Indicators for the Monitoring and Evaluation of the Logic Model
Situation

When Calcutta Kids established the Maternal Health Initiative, health indicators for women and newborns in Fakir Bagan were dismal.Calcutta Kids conducted a baseline survey in 2006: Of the women surveyed over 30% of those who had been pregnant within the past 3 years reported having had a child who died; 14% had not received any antenatal care; 34% did not receive iron-folic acid tablets during pregnancy; 40% of women reported that they did not get more rest then usual during their last pregnancy. Approximately 67% of mothers had an institutional delivery in a private or government hospital (higher than for the urban poor in India at 44%), but still highlighted the necessity to ensure that all women in Fakir Bagan are able to deliver in a health facility. The average birth weight of babies born in Fakir Bagan was 1.8 kg, well under the low birth weight cut of 2.5 kg. Only 8% of mothers initiated breastfeeding immediately after birth while only 28% fed colostrum to their newborn infants. The health indicators and problematic practices were likely to lead to negative health outcomes for both mothers and their young children. These findings strongly supported the urgent need for improved access to health care, health and nutrition counseling, and effective community-based health initiatives.

Intended Impact

The intended impact of the MYCHI Maternal Health Initiative is to reduce maternal and neonatal mortality and morbidity, reduce the total number of low birth weight babies born and increase the birth weight of each baby born. The Maternal Health Initiative intends to ensure that every mother and newborn achieve optimum health and not suffer from lack of essential health services.

Inputs

Community Health Workers
Calcutta Kids currentlyemploys three senior community health workers or Area-in-Charges (AICs) and five community health workers (CHWs) who are from the communities they serve or neighboring areas. Community health workers are the face of Calcutta Kids in Fakir Bagan. Each component of MYCHI is made possible with sustained interaction with Calcutta Kids community health workers. CHWs are trained to advocate for, educate, and assist pregnant women, mothers, and children 0-3 years old with their health care needs.

Management Staff
Calcutta Kids Management Staff for MYCHI include the Program Coordinator and consultant Program Manager. The Program Coordinator has been on staff since the inception of MYCHI. Along with the Director, she facilitated the design and implementation of the program which involved establishing a presence in Fakir Bagan, developing relationships in the community, hiring and training of health workers, procurement of equipment and supplies, and execution of the Initiative. The Program Coordinator organizes the MYCHI staff and the maternal and child health initiatives' activities. In February 2011, a consultant Program Manager was hired to provide direction and technical assistance to MYCHI.

Medical Staff
Calcutta Kids employs a full time doctor and full time nurse at the Calcutta Kids Swastha Kendra (The Calcutta Kids Health Center). It has been a challenge to find a doctor to work in the NGO setting, particularly as most candidates have a private practice or government health care perspective. Our setting as a public health organization focused on preventive care and intensive counseling is unique. Since the inception of MYCHI, we have a male consultant doctor on staff and we hired a female doctor in 2011 to join Calcutta Kids, which has had a tremendous impact on quality of care, particularly for our maternal health initiative.

Training
Calcutta Kids Community Health Workers have undergone rigorous training in-house, as well as training from the Community Development Medicinal Unit (CDMU). They are given refresher trainings regularly by the MYCHI program coordinator and the MYCHI program manager, and the Calcutta Kids doctor.

Health center space
While health care in the slum is available, costs and other factors make it unavailable or undesirable to many residents of Fakir Bagan. Calcutta Kids holds a weekly health camp to provide access to free health care for pregnant women, mothers, and young children in the slum. For a number of years the health camp operated as a mobile outpatient clinic in a space provided by the Welfare Society of Fakir Bagan, but since March 2011 has been held at the Diarrhea Treatment Center (DTC) which offers better infrastructure and logistics. In the next coming months, the DTC will be converted into the Calcutta Kids Swastha Kendra (Calcutta Kids Health Center) in order to better meet the health care needs of women and children in Fakir Bagan.

Community center space
Calcutta Kids has been using a small clubhouse in Fakir Bagan to hold several MYCHI activities including health camp, growth monitoring and promotion (GMP), and community meetings. The space is too small, dark,and cramped to hold these activities in an effective and efficient manner. More importantly, we did not have any ownership over the space. After months of searching, Calcutta Kids has been able to secure a space in the heart of Fakir Bagan to serve as our new community center: Maa O ShishuShiksha Kendra (Mother and Child Learning Center). The center was opened on January 11, 2012 and we are currently transitioning our community-based activities into this center.

Medications and vaccines
Medications and vaccines for MYCHI are procured from the Community Development Medicinal Unit (CDMU). We procure basic medications and supplements needed for health camp and the health center, and vaccines for immunization camp.

Equipment
We have procured medical equipment to provide basic preventive and curative care. For the diarrhea treatment component, we havediarrhea cots, a computer for the clinic MIS, a refrigerator, a generator given the frequent power cuts, Salter scales, height scales for measuring the length of young children, regular scales for older patients, benches for the waiting area, a water purifying machine, and functional kitchen supplies to cook simple food for patients and caretakers. For MYCHI, in addition to the weight and height scales we have adigital Doppler, a stethoscope, a digital BP machine, a manual BP machine, (digital) thermometers, and a nebulizer. For use at GMP, we also have a weighing hooks and pants.

Outputs (Services provided)

Antenatal and postnatal care checkups with the Calcutta Kids doctor
-Percentage of women receiving the appropriate number of routine antenatal care checkups depending on enrollment trimester
-Percentage of women receiving a postnatal care checkup

Women enrolled in the Pregnancy Care Program are required to have at least four routine antenatal care checkups with the Calcutta Kids doctor, based on international guidelines that recommend one routine ANC checkup per trimester plus an additional routine checkup two weeks before the expected date of delivery (EDD). Following delivery, women are required to have one routine postnatal care check up with the Calcutta Kids doctor at 6 weeks postpartum. According to registration time, we monitor number of routine antenatal and postnatal visits to ensure that these recommendations are met.

Antenatal care home visits
-Percentage of women receiving 1 or more antenatal care home visit per month
-Percentage of women receiving the total appropriate number of antenatal home visits during their pregnancies depending on enrollment trimester and time spent in the locality
-Percentage of women receiving counseling on all pregnancy topics during pregnancy during the appropriate trimester

Women enrolled in the Pregnancy Care Program receive a home visit by a senior health worker (Area-In-Charge) each month for monitoring and counseling purposes. At the home visit, the AIC counsels the woman about important antenatal (care) practices such as routine ANC with a skilled health practitioner, taking micronutrient supplements, increased daytime rest and food intake, decreased physical labor, and watching for pregnancy danger signs. The woman receives information on what to expect during labor, delivery and after birth so that she can be wholly prepared for the birth of her child. During each visit the AIC is required to tick off certain type and number of counseling topics on the data collection form to make sure that all topics are covered throughout the pregnancy period.

Monthly growth monitoring
-Percentage of pregnant women attending monthly growth monitoring sessions
-Percentage of pregnant women attending the total appropriate number of growth monitoring sessions during their pregnancies depending on enrollment trimester and time spent in the locality

Women enrolled in the Pregnancy Care Program are requested to attend Calcutta Kids monthly growth monitoring sessions to assess weight gain during pregnancy. Every month the percentage of total pregnant women attending GMP is measured, as is total attendance rate per pregnancy.

Curative Health
-Percentage of non-holiday Tuesdays during which curative health camp sessions occur
Calcutta Kids holds a Health camp for women and children on Tuesday each week. Health camps are rarely cancelled, but are shifted to another day if a holiday falls on at Tuesday. Pregnant and lactating women are encouraged to come attend the Tuesday health camp for routine antenatal care, postnatal care, and sick visits.

Follow up home visits by AICs
-Percentage of curative health session visits that have a follow-up home visit
Following a health camp or other health visit with the Calcutta Kids doctor, one of the Community Health Workers (CHWs) will make a home visit to follow up on patient recovery, medication administration, and provide continued counseling.

Micronutrient supplementation and vaccination
-Percentage of women having had micronutrient (remaining tablets) information recorded at the monthly home visit
-Percentage of women having had recorded tetanus toxoid immunizations at the monthly home visit

Calcutta Kids provides prenatal and postnatal micronutrient supplements, including folic acid, iron, and calcium. Folic acid is given during the entire pregnancy, starting as soon as a woman registers with the Pregnancy Care Program. Iron is started at the 4th month of pregnancy and continues for 3 months after delivery. Calcium is started during the 7th month of pregnancy and continues for 6 months after delivery. During the monthly home visits Area-in-Charges (AICs), are responsible for counting micronutrient tablets remaining with the women, and recording on the data collection form. AICs also record (from the woman's health card) the dates the tetanus toxoid vaccine was administered.

Community meetings
-Percentage of women attending pregnancy meetings per month
-Percentage of women attending the total appropriate number of pregnancy meetings during their pregnancies depending on enrollment trimester and time spent in the locality

Pregnant women are invited to monthly community meetings to discuss topics related to pregnancy and childbirth. The purpose of the meetings is not only to reinforce counseling messages disseminated during the home visits, but more importantly for women to come together as a support group and share stories and experiences during their pregnancy. In order to ensure that women are participating in the meetings and receiving important counseling messages and interaction, attendance rates per month and per pregnancy are measured.

Antenatal Outcomes

Micronutrients are consumed and immunizations are given
-Percentage of women taking all or most of the micronutrients prescribed per month
-Percentage of women taking all or most of the micronutrients prescribed throughout their pregnancies.
-Percentage of women receiving the appropriate number of tetanus toxoid immunizations depending on gravida during pregnancy.

Consumption of micronutrient tablets is calculated based on information collected during the home visits to ensure that women are complying with consumption of prescribed micronutrients.Tetanus toxoid vaccination rates are also measured in order to ensure that all women are receiving the appropriate doses of tetanus toxoid vaccinations during their pregnancy.

Weight gain
-Percentage of women gaining at least 1kg from previous month per month.
-Percentage of women gaining the total appropriate amount of weight during their pregnancies depending on enrollment trimester.

Calcutta Kids advises woman to gain 1 kg in weight per month during pregnancy, in order to achieve the recommended overall pregnancy minimum weight gain of 9-10 kg. Pregnant women enrolled in the Pregnancy Care Program attend a monthly growth monitoring session to ensure that they are gaining weight, and if not, they are counseled on feeding practices including quality and quantity of food during pregnancy. .

Increase in reported positive behaviors
-Percentage of women reporting eating more than pre-pregnancy for the majority of or throughout their second and third trimesters.
-Percentage of women reporting more daytime rest than pre-pregnancy for the majority of or throughout their second and third trimesters.
-Percentage of women reporting less manual labor than pre-pregnancy for the majority of or throughout their second and third trimesters.

Women enrolled in the Pregnancy Care Program are continually counseled on positive pregnancy behaviors during the home visits, curative health visits, and community meetings. Positive pregnancy behaviors including eating more, resting more, and reducing manual labor are monitored and measured to ensure uptake and compliance to the counseling messages, which are crucial for a healthy pregnancy.

Identification and resolution of medical problems
-Percentage of women with danger signs identified during home visits that are referred to the Calcutta Kidsdoctor and access services within 48 hours.
During the monthly home visits with pregnant women, the Area-in-Charge (AIC) monitors the health of the mother and if she is experiencing any danger signs, she is referred to the Calcutta Kids doctor for a medical visit. The danger signs include: high fever(above 102ºF); moderate ankle, body or face swelling; dizziness; excess fatigue; blurred vision; excess vaginal discharge or foul smelling vaginal discharge; painful or difficult urination; persistent headache; any other signals that the AIC feels should be addressed by a doctor.
(Note: If the woman experiences the following danger signs, she is referred to an outside facility, usually the facility where she is registered: convulsions without fever, leak of amniotic fluid, vaginal bleeding, intractable vomiting in the past 24 hours. If women are referred to an outside facility, they are not included in this calculation)

Increase in positive medical pregnancy related behaviors
-Percentage of women who register with a delivery facility within six weeks of registration with Calcutta Kids.
-Percentage of women who have registered with a delivery facility by the time of delivery.
-Percentage of women who have had at least one USG during pregnancy.

Calcutta Kids promotes positive medical pregnancy related behaviors to ensure a healthy pregnancy and delivery. Women enrolled in the Pregnancy Care Program are requested to register with a facility, either a government or private hospital, in which they intend to deliver, as early as possible during pregnancy.

Money is saved for delivery/post-delivery
-Percentage of women enrolled in Delivery Savings Scheme.
-Percentage of women saving in any way for delivery/post-delivery.

The Delivery Savings Scheme was established in early 2011 to provide a savings option for pregnant women (and their families) to provide financial incentive to ensure a facility delivery. A woman who enrolls in the Pregnancy Care Program with the gestational age of 0 to 6 months is entitled to avail the delivery savings scheme of CK. The delivery savings scheme enables women to save money in a safe place and to receive a matched amount from Calcutta Kids of up to 2,000 rupees. The delivery savings scheme ensures that women are able to have an institutional delivery and have enough money for delivery and postpartum expenses. Even if women opt not to join the Delivery Savings Scheme, they are counseled on birth preparedness including saving money for the delivery and post-partum expenses.

Postnatal Outcomes

Increase in facility based deliveries
-Percentage of women that deliver in a facility
Calcutta Kids tries to ensure that every woman enrolled in their program delivers in a facility where she can be assured a safe and clean delivery. The Pregnancy Care Program requires that registration at a facility of the woman's choice as early as possible during pregnancy.

Decrease C-section deliveries
-Percentage of women that have C-section deliveries (goal <20%)
A number of complications during pregnancy and childbirth increase a woman's risk for C-section including placenta previa, placental abruption, uterine rupture, breech position, cord prolapse, fetal distress, failure to progress in labor, cephalopelvic disproportion (CPD), active genital herpes, gestational diabetes, preeclampsia, birth defects, repeat caesarean, and multiple births. Some C-sections can be avoided by preventive measures and early detection of certain conditions that may lead to a C-section outcome. However, many C-sections in India are performed unnecessarily, either for financial gain or by doctor's choice, thus it is a challenge to reduce the C-section rate in our catchment area as we cannot impact any decisions made at the facility level. However we do ensure through preventive care and counseling that danger signs and complications during pregnancy and labor are quickly referred for appropriate care. The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%.

Increase in birth weights
-Percentage of women delivering babies with birthweights of at least 2.5kg.
-Percentage of women delivering babies with birthweights of at least 3.0kg.
-This will be compared between years/seasons; and average birthweight will be calculated.

Low birth weight is defined as a weight of less than 2.5k g (up to and including 2.499 kg), irrespective of gestational age. Twenty eight percent of babies in India are born with low birth weights (NFHS 3). Low birth weight is a major cause of neonatal death. Low birth weight babies can face serious short and long term health consequences.By providing key interventions during pregnancy, Calcutta Kids aims to reduce the rate of low birth weight babies born and increase the birth weight of each baby born in Fakir Bagan.

Increase in positive initial breastfeeding behaviors
-Percentage of women feeding colostrums.
-Percentage of women giving no pre-lacteal feeds.
-Percentage of women initiating breastfeeding within one hour of delivery.

The Maternal and Young Child Health Initiative strongly focuses on exclusive breastfeeding and appropriate feeding of young children. Colostrum, or 'first milk' is critical for the newborn, containing antibiotics that protect against disease and growth factors that help develop the gut. It is nutrient dense and low volume, the ideal first food for a newborn. In India, traditional customs have encouraged women to discard the colostrum and give a pre-lacteal feed of honey or jaggery with ghee to the newborn. As disposal of colostrum and pre-lacteal feeds can adversely affect breastfeeding, MYCHI counsels pregnant women to initiate breastfeeding immediately after delivery, ensuring that newborns are fed colostrum, and discourage giving of a pre-lacteal feed. Information on the three indicators is collected by our health workers during the post natal home visits.

Increase in postnatal checkups after delivery
-Percentage of women receiving the total appropriate number of postnatal home visits by health worker.
-Percentage of women receiving a postnatal checkup within 6 weeks from delivery.

The period immediately following delivery can pose substantial health risks to the mother and the newborn, but until recently more attention has been given to pregnancy and delivery care. Bleeding and infection post-partum account for many maternal deaths, and preterm birth, asphyxia, and infection contribute to two-thirds of neonatal deaths (WHO). Appropriate care during the first days after the delivery can help prevent a great majority of these deaths. Most Calcutta Kids women have an institutional delivery so immediately after delivery the women are cared for at the facility. But as soon as they return home (usually 12-24 hours for normal delivery, 5-7 days for C-section delivery), a Calcutta Kids senior health worker will visit the home immediately to provide home-based care and monitoring for the family. Another visit is conducted one week after the first visit. During these visits, the health worker counsels the new mother, collects delivery, postpartum, newborn care and feeding information, and monitors for any danger signs or poor health in the mother or newborn. If a problem is detected, the mother/newborn are immediately referred to the Calcutta Kids doctor. For all postpartum women, Calcutta Kids requires at least one routine postpartum checkup with our doctor for the new mother and new baby, within 6 weeks of delivery. This is to ensure that the women and newborns that do not necessarily have any apparent health problems are still seen by the doctor for a well visit and counseling.

Increase in positive postpartum behaviors
-Percentage of mothers consuming all or most of the micronutrients prescribed per month.
-Percentage of mothers consuming all or most of the micronutrients prescribed during lactation period.
-Percentage of mothers consuming more food during lactation period.
-Percentage of mothers resting more than usual during lactation period.

Women who have recently given birth are counseled on positive postpartum behaviors during the home visits, routine postpartum checkup, and curative health visits. Positive postpartum behaviors including taking micronutrient supplements, eating more, resting more, and reducing manual labor are monitored and measured to ensure uptake and compliance to the counseling messages, which are crucial for a healthy postpartum period. Calcutta Kids provides postnatal micronutrient supplements iron and calcium. Iron is started at the 4th month of pregnancy and continues for 3 months after delivery. Calcium is started during the 7th month of pregnancy and continues for 6 months after delivery. Consumption of micronutrient tablets is calculated based on information collected by the health workers during the home visits to ensure that women are complying with consumption of prescribed micronutrients.

Impacts

Reduced maternal morbidity
The Maternal Health Initiative provides routine antenatal and postnatal care at the CK Health Center and monthly home visits with pregnant women and mothers. Maternal health issues, danger signs, potential complications are closely monitored and addressed immediately. It is anticipated that these interventions will reduce morbidities that pregnant and postpartum women are facing, particularly those that can be prevented through early detection.

Reduced maternal mortality
Though India has seen a dramatic reduction in maternal mortality rate (MMR) by 59% from 1990 to 2008, the country still has the highest number of women dying from childbirth in the world. India's MMR was 570 in 1990 and is now 230. * Even though the progress is notable, the annual rate of decline is half of what is needed to achieve the MDG 5 target, reducing MMR by 75% from 1990 to 2015. Pregnant women still die from five major direct causes: postpartum hemorrhage, infections, high blood pressure, unsafe abortion, and obstructed labor.* The Maternal Health Initiative provides quality antenatal and postnatal care, and ensures that each woman has access to a safe institutional delivery. Through early detection of potential health problems and complications that may lead to fatal outcomes during pregnancy and postpartum, Calcutta Kids anticipates that the intervention will be successful in reducing maternal mortality in our catchment area.

Reduced neonatal mortality
A child's risk of dying is highest in the neonatal period, the first 28 days of life. About 40% of child deaths under the age of five take place during the neonatal period. During the first month, one quarter to one half of all deaths occur with the first 24 hours of life, and 75% occur in the first week. Three causes account for the majority of neonatal deaths in India: prematurity and low birth weight, neonatal infections, and birth asphyxia and birth trauma. Safe childbirth and effective neonatal care, particularly during the first 48 hours, are essential to prevent these deaths. The Maternal Health Initiative ensures that each woman has access to a safe institutional delivery and provides critical care to the newborn immediately after they come home from the facility. It is anticipated that many newborn deaths can be prevented as a result of Calcutta Kids' intervention.

Benefits

Improved overall health in community
Improved learning capacity
Increased productivity
Reduced poverty
Calcutta Kids' Maternal Health Initiative, as part of the larger Maternal and Young Child Health Initiative (MYCHI), works within the community to empower the local population to understand the importance of maternal and child health. MYCHI provides vital resources to facilitate healthy pregnancy, healthy mothers, and healthy children. As a result of preventive and curative care, health education and counseling, and immunizations, Calcutta Kids anticipates the following benefits of providing their services to the targeted population:
-Decreased maternal and child mortality.
-Increase in average birth weight .
-Decreased incidence of maternal morbidity.
-Decreased child morbidity including respiratory tract infections, diarrheal illness, and vaccine preventable diseases.
-Decreased malnutrition, and decreased prevalence of micronutrient deficiencies.

The women we serve will benefit from a more robust local awareness of maternal and child health best practices and so will the community with whom the women share their knowledge. The anticipated benefits of MYCHI will be instrumental in empowering urban poor mothers and children to achieve optimum health outcomes, which will in turn improve overall health in the community. As a result of optimum health development, these urban poor children will have the opportunity to experience gains in social development and learning capacity similar to those of their economically better off peers. It is anticipated that over the years, the children who have benefitted from the program will grow into young adults with increased productive capacity, and will begin to break the cycle of poverty.

Assumptions

Women will enroll in the Calcutta KidsPregnancy Care Program
Calcutta Kids aims to reach every pregnant woman in its catchment area, Fakir Bagan. Our goal is to enroll every single pregnant woman and ensure that they receive basic antenatal and postnatal care, and have an institutional delivery. Although most women do join our program, we have seen over the years that some women opt not to join our program for various reasons.

Enrolled women will participate fully and avail all services provided
We encourage every woman enrolled in the Pregnancy Care Program to participate fully in our program and avail all the service provided in order to achieve optimum pregnancy, delivery, and postpartum outcomes. We also try to reach women during the first trimester so that they can receive benefits starting early in the pregnancy. However for a variety of reasons, some women enroll in the second trimester or even as late as the third trimester. Furthermore, some women, particularly first pregnancies, go back to the village for delivery. Thus there are a number of challenges we face in making sure our women have a 'complete' Calcutta Kids pregnancy.

External Factors

Cultural practices and beliefs
A number of cultural practices and beliefs in Fakir Bagan can lead to negative health outcomes for mothers during pregnancy and postpartum. It is uncommon for pregnant women to attend routine antenatal care, a practice that may be unfamiliar to their mother-in-laws, the primary decision maker in the household. Too often women will not access care until they have a serious health problem, which can have dire consequences during pregnancy. Many women are told by family to eat less instead of more during pregnancy, and importance is not given to resting or reducing manual labor during the pregnancy. In the postpartum period, it is common practice to discard colostrum, the critical 'first milk' for the newborn, and give a prelacteal feed such as honey or jaggery, which can lead to adverse breastfeeding outcomes. Such practices and beliefs make it a challenge to have sustainable behavior change. We provide intensive counseling and education during home visits and community meetings to increase awareness and change behaviors.

Slum environment
Fakir Baganisa vulnerable slum in terms of location, basic services, occupational hazards, access to health services, education, and gender status. Residents face the burden of a poor drainage system and rampant flooding during the rainy season, becoming exposed to a host of diarrheal and water-borne diseases. The environment is not conducive to positive healthoutcomes, especially for women and young children. Although there is easy availability to health services, these services may be unacceptable and unaffordable to the population. However, we believe that through the provision of preventive care and basic curative health care services, along with intensive counseling and developing strong relationships with the mothers in Fakir Bagan, it is possible to achieve positive health outcomes in this challenging environment.

Lack of community
The catchment area where Calcutta Kids works is more of a geographic definition than a community. The transient nature of the population adds to this feeling, and there is a sense of self interest rather than of building and sustaining a community. While a community might come together to petition the state to develop proper infrastructure, or to work together to find solutions on a large scale, in this population, there are times when even a child crying in the street will not be taken care of by neighbors because of the lack of community. Calcutta Kids is trying to work to reduce the barriers to forming a community and perhaps to encourage a small community among beneficiaries. (Read more about our efforts with community mobilization here.)