Tag Archives: child health

Child Health Counseling Training February

Since the last Calcutta Kids off-site training in May 2011, our staff members have frequently asked, when will we go away again for training? For our staff, training is more than just an opportunity to learn new skills, it is also a special and exciting opportunity to leave the office and their homes to spend a few days away– a much needed break from the daily grind. We held a long awaited training on protocols and child health counseling last week at Monobitan, a training center south of Kolkata in Pailan run by our friends at CINI. The training was a welcome opportunity to take a step back from our day-to-day work and enjoy some fun learning activities.

The first day of training was held on-site in our new community center in Fakir Bagan—Ma o Shishu Shiksha Kendra (MoSSK). The first task was to come up with an entertaining nickname name for each staff member, using an adjective starting with the same letter as their name. The name would be used throughout the training, and it proved to be a great source of amusement. The names ranged from simple— ‘Sincere Sima’ and’ Jumping Jayanta’—to more complex –‘Na sunne ka pasand nahi Nasreen’ (Doesn’t like to hear no Nasreen) and ‘Shundor moner odhikari Sumana’ (Soul with a good heart Sumana).

The goal of the first day’s training was to clarify protocols for program activities held in MoSSK. The day was spent learning about new protocols for Growth Monitoring and Promotion (GMP), our MYCHI Clinic, Immunizations, Nutrition Corner, Community Meetings, and Child Development Corner, all which are now carried out in MoSSK. The team members role-played each of the activities to internalize the protocol and enjoyed playing different parts such as patient, doctor, mother, and counselor.

The next morning the CK team piled into several Tata Sumo trucks and sped through the streets of Kolkata, heading south to our training site in Pailan. After a quick breakfast, we dove into the training sessions on child health. We focused on two new child health topics: Family Planning and Hygiene & Sanitation. They were not unfamiliar topics to our health workers, but they were new in the sense that we were introducing standardized education and training materials for them. Each topic session consisted of a lecture, videos, and the introduction of an innovative counseling technique. After the Family Planning session, Sriya, our AIF Fellow, who has been working on behavior change communication (BCC) for maternal and child health, introduced a technique called Forum Theater  an interactive form of theater that is used to demonstrate problem situations and involves the audience as part of the activity and resolution to the problem.

Chandan and Susmita participating in Forum Theater

Chandan, Malti and Susmita participating in Forum Theater

After the Hygiene & Sanitation lecture, our program coordinator Sumana, who has taken a formal training course on puppetry for community health and awareness, organized a puppet show on the topic performed by the AICs and CHWs in order to demonstrate another creative technique that can be used for counseling and BCC.

PuppetShow

It was incredible to see how quickly our staff members and, in particular, our health workers, adopted the new techniques. Performing both forum theatre and puppet theatre for the very first time, they successfully incorporated essential messages and both identified and found resolution to key problems using these two creative and interactive mediums.

As the day came to an end, the staff took time to enjoy the last bit of sunlight to walk around the gardens and playgrounds of Monobitan, pushing each other on the swings and merry-go-round. In the evening, we did a ‘guess the baby’ game which included showing baby photos of staff members and having to guess who they were. The highlight activity was the eco-friendly newspaper fashion show, where we split into groups by topic—popular female leader, favorite political leader, famous TV advertisement, movie, book, or cartoon character, and Bollywood actor or actress. Each group dressed up one or more models using newspapers and then walked up the runway as a group, using song or dance. It was truly a hysterical experience and brought out the creative side of our team members. Arpita dressed up as the Chief Minister and sang Ekla Chole Re along with her group. Kalyan posed as Rahul Gandhi, and Chandan danced around as the Joker from Mera Nam Joker—much needed laughter therapy for all of us.

NewspaperFasionShow

The next day, the entire day of training was group work, focused on new strategies for BCC including the forum theatre and puppet theatre techniques from the previous day, along with counseling cards, interactive games, poster making, role-play, discussion groups, visual media, and demonstrations. Participants were divided into five groups and given child health topics–PNC and Care of Newborn, Immunizations, Care of Sick Child, Feeding Practices, and Child Growth and Development. All of these topics are familiar to the staff and our health workers already counsel beneficiaries on these topics. However the novel task was to identify key messages, challenges in changing those behaviors, and present solutions in a new counseling medium. Each group presented their topic and form of counseling technique to the rest of the participants, followed by discussion and feedback. All the techniques mentioned were effectively utilized—and at the end of the session, the whole team felt that they had really learned new skills in the BCC arena, and accomplished something very important. We will take this confidence building to our work in Fakir Bagan community, imparting essential health messages through effective delivery tools. The health workers commented how each of them had started at Calcutta Kids with virtually no knowledge of maternal and child health, and now they not only have internalized the information and the messages, but are able to teach the women they work with in new and exciting ways that will truly change the face of counseling and behavior change at Calcutta Kids.

GroupPresentation

As we left Monobitan that evening, I think that each of us felt a sense of triumph, that the training was a success and we came away from it with so much knowledge. We also felt a sense of peace, and sense of togetherness, as I think the training solidified relationships within the organization and really made us feel that we are working towards a common goal. Our Director Noah commented that the training was ‘a memorable few days which not only strengthened our team as a whole but also strengthened each individual working at CKT.’                          —Sumana Ghosh and Danya Sarkar

 

The Art and Science of Diagnosis

A professor from Ohio State e-mailed me the article with the deceivingly understated subject line of all-lower case “fyi.” The Hindu write-up’s headline, though, didn’t mask the shocking contents: “Appalling condition of primary healthcare services” it read. (1) Short and potent, it described the lurid details of a study carried out across the health sector in India, rural and urban, private and public. The details showed a fundamental lack of ability by medical professionals to diagnose even the most common conditions (asthma and dysentery, for example) or ask the most basic questions (whether there was “pain radiation” for an unstable angina). The result was a low rate of diagnosis, whether it was in rural Madhya Pradesh or Delhi.

Overall, healthcare providers provided the correct treatment only 30.4% of the time. (2) Even worse, 41.7% of the time the clinics provided unnecessary or even harmful treatments for “patients” that the research study trained (“from the local community”, the article notes). Many providers, even in public clinics, were unqualified. Medical guidelines and treatment protocols were followed at low rates; providers only asked 33.7% of the recommendations. In Madhya Pradesh, doctors spent 3.6 minutes with patients, while Delhi medical professionals spent a marginally better but still terrible 5.4 minutes. For reference, the Medical Council of India recommends doctors spend at least 10 minutes with each patient. (3)

The article highlighted tough facts that Calcutta Kids has been tackling for years. Through our experiences with the health clinic, we’ve worked to combat the norm of primary health in India: brief, non-comprehensive visits and a disregard for protocols and checklists. We’ve uploaded to the resources section of our website our child health World Health Organization’s IMCI and IMPAC-based Child Health and Pregnancy and Maternal Health protocols and checklists which our doctors are trained and demanded to use. Our two health clinic physicians, Drs. Pal and Sen, work with our management staff to ensure that the protocols we have provided them matches their process for diagnosing patients. See the above-mentioned resources below:

Child Health Protocol (0-2 months)
Child Health Checklist (0-2 months)
Child Health Protocol (2 months to 5 years)
Child Health Checklist (2 months to 5 years)

Pregnancy and Maternal Health Checklist and Protocol

It’s an important process that Calcutta Kids has to do to ensure our beneficiaries get not just quantity but truly quality care. It hasn’t been an easy process to bring in this cultural change into our clinic over the years, but it’s a necessary one. In addition, the creation of standardized protocols ensures a consistent level of care that our beneficiaries can expect, regardless of personnel changes. As Atul Gawande noted in his Harvard Medical School commencement, it’ll require an understanding of a team of healthcare providers- a “pit crew” that includes our health workers- not just the lone cowboy physician:

“The work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.” (4)

Many rightly criticize the low rates of spending on health per GDP in India, ranking 171st out of 175 countries according to a WHO study. (5) But the situation is even grimmer: it is not enough to just increase spending, build more primary health centers or even to write diagnostic protocols at a national level. The groundwork of implementation at a doctor to patient level must be accomplished. At our health clinic, we work on this ground level to make sure that provision of the highest level of primary healthcare is a reality for the mothers and children of Fakir Bagan.–Pranav Reddy

Citations:

  1. Appalling condition of primary healthcare services. The Hindu. R Prasad. December 6, 2012. Retrieved from http://www.thehindu.com/health/medicine-and-research/appalling-condition-of-primary-healthcare-services/article4167677.ece on Jan 1, 2013.
  2. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. J Das, A Holla, V Das, M Mohanan, D Tabak, B Chan. Health Affairs. December 2012. 31(12):2774-84
  3. MCI wants docs to spend at least 10 mins with each patient. The Times of India. K Sinha. September 1, 2011. Retrieved from http://articles.timesofindia.indiatimes.com/2011-09-01/india/29953546_1_opd-patients-doctors on Jan 1, 2013.
  4. Cowboys and Pit Crews. The New Yorker. Atul Gawande. May 26, 2011. Retrieved from http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz2H02jhJMO on Jan 1, 2013.
  5. World Health Statistics 2011 Report. World Health Organization (WHO). 2011; 127-139. Retrieved from http://www.who.int/whosis/whostat/2011/en/index.html on Jan 1 2013.

Gov’t-assisted immunization training

In September, Calcutta Kids organized an immunization training program, which served as a refresher training for some of our team and a new experience for others.  The training was carried out by a colleague in the government sector, Dr. Swagata Mukherjee, the Assistant Medical Officer for the Howrah Municipal Corporation (HMC).  Despite his busy schedule, he volunteered his services to Calcutta Kids during his personal time.  During the training, participants learned about vaccine-preventable diseases and related vaccines, the proper vaccination schedule, and how to technically administer each type of vaccine.  The training comprised of two days of observation at the Municipal Health Center during immunization camps, and three days of theory, observation, and practice in the Calcutta Kids clinic.

Training with Dr. Swagata Mukherjee

The training is one of many steps in the process towards implementing a community-based health care model at Calcutta Kids.  Until recently, our curative health, nutrition care, and immunization components have been held in our health center, Swastha Kendra, situated outside of Fakir Bagan.  During immunizations, vaccines were primarily administered by our nurse under the supervision of our doctor.  But this month we are merging the health center into our community center Ma o Shishu Shiksha Kendra, so immunizations are also transitioning to the new space in the heart of Fakir Bagan.  This is part of our effort to bring cost-effective healthcare solutions closer to the community.

The immunization camp will now be carried out in the community by the area in charges (senior community health workers) and the health assistant-counselors who are now qualified in immunizations as a result of the excellent training they received in September.  Where we once relied on one person to conduct immunizations every week (with the doctor as a back-up), we now have four trained staff members who are proficient in administering immunizations.  This will help ensure that immunizations are even more accessible for the families in Fakir Bagan, and provides Calcutta Kids the capacity to extend our immunization program to neighboring areas, thereby targeting more children in need of immunization.

Laxmi administering vaccinations after the training

Around the world, routine immunizations have reduced and even eliminated many childhood illnesses that once killed and debilitated many children.  Although many vaccine preventable diseases (VPDs) have been controlled, children are still dying from diseases that could be prevented by providing the critical vaccinations during the first few years of life.  The World Health Organization estimated that, every year, 1.5 million children die from diseases that could have been prevented by routine vaccination.  That staggering total represents almost one-fifth of all the children who died worldwide before reaching their fifth birthday. (1)

The Indian National Immunization Schedule includes the following six VPDs: Tuberculosis, Diphtheria, Pertussis, Tetanus, Measles, and Polio. For a child to be considered fully immunized, he or she must have received one dose each of BCG and Measles and three doses of DPT and Polio in the first year of life. There is still much more work to be done in terms of immunization coverage in India: Nationally, less than half (43.5%) of children 12-23 months are fully immunized. West Bengal is faring better than the national average, with 64.3% of children 12-23 months fully immunized. (2)

Waiting for immunizations at the Calcutta Kids clinic. Photography by Brett Cole, November 2012

Immunization in India must be sustained, not only to prevent VPDs, but also to reduce the incidence of measles and tetanus, and eradicate poliomyelitis. India, known as one of the greatest challenges for the global polio eradication campaign, has now been polio free for 18 months. (3) The last reported polio case was in Shahapur village in Howrah district, the same district where Calcutta Kids operates. Sustained immunization and coverage will ensure that polio does not make a comeback to this country.

Calcutta Kids is committed to help sustain immunization coverage in Fakir Bagan by ensuring that every young child in Fakir Bagan is fully immunized and therefore protected against vaccine-preventable childhood illnesses.–Danya Sarkar

1.http://www.who.int/immunization_monitoring/diseases/en/
2.NFHS-3, India and West Bengal Factsheets
3.http://www.un.org/millenniumgoals/pdf/UNGA%20Polio%20Event_Press%20Release%20and%20Quote%20Sheet_Final.pdf

CK Starts Routine Deworming

We introduced an exciting new component to our young child health initiative that we hope will help improve the health status of children in Fakir Bagan.  During our Growth Monitoring and Promotion (GMP) camp this week, Calcutta Kids carried out routine deworming of preschool age children. We have been discussing this idea for several months now after our data analysis showed a high prevalence of worm infestation in a group of malnourished children enrolled in our nutrition pilot program (YChiNG). At the time, we dewormed the children in the YChiNG program, but realized that there were many more children in our catchment area who could benefit from deworming.

Nasreen helping a father give deworming medicine

We were motivated in part by a Government of India mass deworming campaign in New Delhi earlier this year, which included deworming not only school-age children in government schools, but also pre-school age children in ICDS/Anganwadi (government health) centers. During last month’s GMP in Fakir Bagan, we conducted a survey with mothers of children 1-3 years old, asking them to report if their child had an incidence of intestinal worms in the past 6 months. A resounding 43% of mothers answered yes, which reflected a clear need for an intervention.

Intestinal worms, which are pervasive in India, can have devastating effects on a child’s physical and mental growth. In low-income urban areas like Fakir Bagan, where sanitation and hygiene are poor and many children walk around without shoes for protection, the most common type of intestinal worms are soil transmitted helminthes. Once in the body, these parasitic worms feed on host tissues, including blood, leading to a loss of iron and protein. They also hinder the absorption of nutrients. The result is diarrhea, anemia, and malnutrition, all which have a detrimental impact on child health, growth, and development. To counter the negative effects of worms, the WHO recommends periodic drug treatment (deworming) of all children living in endemic areas. (1) Studies have shown that routine deworming of children can have significant positive outcomes on nutrition, growth, and cognitive performance.

A child excited about the new deworming medicine

School-age children are thought to have a high burden of worm infestation. Fortunately, they are easy to reach for deworming because schools serve as pre-established distribution networks. The evidence shows that routine deworming makes a difference. One landmark study showed that deworming can reduce school absenteeism by 25%. Furthermore, children who are regularly dewormed earn over 20% more as adults and work 12% more hours, while those infected are 13% less likely to be literate. (2) Global campaigns now target pre-school age children, who are tougher to reach but also a vulnerable group in terms of exposure to worms. Studies conducted in Indian slums show that there is substantial weight gain in young children (pre-school age) who are dewormed regularly. (3)

Apart from the mass campaign in Delhi this year, which followed mass campaigns in Bihar and Andhra Pradesh a few years back, deworming campaigns have not been widely organized in India. Given that deworming is extremely cost-effective at only a few cents per pill, and provides both short-term and long-term physical and cognitive benefits to a child, India could see great benefits by ramping up state deworming campaigns, which can be effectively carried out through government schools and ICDS/Anganwadi health centers. The WHO includes intestinal worms among “the 17 neglected tropical diseases” which WHO Director General Margaret Chan described as “diseases that are largely silent, as the people affected or at risk have no political voice.”. The WHO launched its “neglected tropical diseases” campaign to raise awareness among policy makers and donors, in hopes of stimulating more action, like deworming campaigns. For Calcutta Kids, this new deworming initiative marks a proactive step to address the “neglected disease” that is most prevalent in our community.

The first round of deworming this week marked the beginning of our commitment to ensure routine deworming every 6 months to each preschool aged child in Fakir Bagan. We reached each of the 311 children between 1-3 years old, but missed some children who had traveled to the village with their families, but they should be covered in future rounds. Between rounds, we will immediately treat any children who present with worms. Parents at the camp were positive about the deworming intervention. The results were telling. In the words of one father, “My child was feeling sick and her stomach was swollen from worms. I am happy that she is now getting medicine to make her better.” – Danya Sarkar

1. http://www.who.int/elena/titles/deworming/en/
2. http://www.dewormtheworld.org/why-deworm/the-evidence-for-school-based-deworming
3. Effects of Deworming on Malnourished Preschool Children in India: An Open-Labelled, Cluster-Randomized Trial. Shally Awasthi, Richard Peto, Vinod K. Pande, Robert H. Fletcher, Simon Read, Donald A. P. Bundy. PLOS Neglected Tropical Diseases, April 2008, Volume 2, Issue 4

The Story of Puja Yadav

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

C-Section Blog Series (4 of 4)

The third part of our C-section blog series focused on the circumstances leading up to Calcutta Kids’ decision to stop partnering with private clinics for facility based deliveries, and instead (a) offer a Delivery Savings Scheme (DSS) which would provide financial assistance for beneficiaries to deliver wherever they prefer; and (b) up the ante on birth preparedness through a new home counseling curriculum. This week’s blog describes that curriculum, provides data on beneficiaries’ usage rates of the delivery savings scheme, and calls attention to the fact that more community involvement is necessary for the delivery savings program to succeed.

Throughout the pregnancies of our beneficiaries, our CHWs visit their homes at least once a month. During the last few months of pregnancy, the visits have become more standardized and focus on the following themes:

  • Danger signs. What to watch out for—especially pain in the lower abdomen, heavy white discharge or bloody discharge. In such cases, pregnant women are advised to go immediately to the facility with which they are registered, and to call their Area in Charge for support
  • What not to worry about: Many women become worried if the gestational age of their child crosses 37 weeks. The CHW’s counsel the women not to worry about this until around 40 weeks at which time they should visit their facility.
  • Preparation: The family is counseled to assure the availability of transportation to the facility regardless of the time of day or night, and to ensure that money is set aside for transport. They are also told what documentation to have ready to take with them to the facility.
  • To C or not to C: Pregnant women and their families are provided with knowledge about C-sections. They are informed of the recognized and accepted indications for C-sections; the potential risks for the mother after a C-section delivery; the potential risks for the mother during her next pregnancy; the immediate risks for the baby during a C-section delivery; and the potential long term risks for a C-section-delivered child.

The CK staff has gone through an intensive training focusing on these themes. (You can see these materials in the resources section of our website or you can click here for the Labor and Delivery Educational Session and here for the C-Section Education Session.)  They also have received refresher training on the labor and delivery process, fetal development, and complications that can occur during labor. And they are equipped with flip charts and other materials to facilitate their home-based counseling with pregnant women.

Delivery Savings Scheme Data:

  • Scheme began in July 2011
  • Since inception, 68 CK pregnant women out of 162 pregnant women in households registered with CK, have enrolled in DSS
  • Of those 68, 45 remain pregnant
    • Of the 45 who delivered, 2 had miscarriages; 29 had normal deliveries, and 14 had c-sections.
    • Of the 45 who delivered, 24 took place in private facilities and 19 took place in public facilities.
  • Currently (July 2012) there are 55 pregnant women involved with Calcutta Kids and 21 are participating in the DSS.

With a DSS user rate of around 40%, the scheme is not working as well as we would like. And the DSS is not working as a replacement for the services being provided earlier through private facilities.

Next week, Calcutta Kids will be holding a number of focus group discussions to try and figure out why it is that more pregnant women are not taking advantage of this scheme. The discussions will be held separately with those who have used the DSS and those who have not. We look forward to sharing what we learn from these discussions in a future blog.

From this data, however, some questions arise: Does this experience coupled with the micro insurance experience indicate that families (a) don’t have surplus cash on hand or (b) aren’t willing to use surplus cash for such a purpose or (c) that the men in the family are not willing to set such money aside for this or (d) there a is basic fear (based on the reality that there is a lot of huckstering that goes on in the slum) that they might never see their money again?

Clearly we have more work to do in facilitating a good option for safe facility-based delivery among our beneficiaries. We are confident that we will be able to find a solution which benefits our beneficiaries while at the same time protecting them—and also Calcutta Kids. -Sumana Ghosh, Danya Sarkar and Noah Levinson

C-Section Blog Series (3 of 4)

In 2007, a young man visited Calcutta Kids from abroad. He was interested in exploring why Calcutta Kids at that time was working with the private health sector rather than the government sector. Instead of explaining the deplorable state of government hospitals and going into the gory details of government bureaucracy, I asked the young man if he might like to join me in visiting a nearby government hospital. He agreed and we hopped into a cycle rickshaw and headed for the hospital.

Fifteen minutes later, we stepped out of the rickshaw, walked into the hospital, and were greeted by a line of stretchers carrying corpses waiting to be picked up by the morgue. We stood there for a few moments trying to get our bearings. When we moved forward, our guest tripped over a large rat that was scurrying across the floor. The young man told me that he now understood why we worked with private hospitals and clinics.

For the most part, our experiences with private clinics and hospitals over the years have been positive ones. Our beneficiaries prefer the private sector as does most of the population of India. And, given the fact that Calcutta Kids was covering the cost of this private hospitalization partially or fully, the beneficiaries were overwhelmingly pleased with this arrangement.

Over the years, however, our understanding of both the private and public health sector in India has evolved, and as we recruited more medical staff on our team, we began to seriously question our exclusive partnership with the private sector.

Part of the evolution in our thinking resulted from a better understanding of C-sections in our area. The rising cost of C-sections our beneficiaries are paying combined with our understanding of the dangers of unnecessary C-sections frightened the Calcutta Kids team and we began to examine our options carefully.

We realized that we were facing two major issues: the first a potential major operational threat to Calcutta Kids; the second an ethical dilemma: Because we have had relationships with particular clinics and were paying the fees for deliveries at these clinics, we were in essence accrediting them; beneficiaries who trusted us throughout their pregnancies were trusting the facilities with which we partnered. This meant, in turn, that if something at these clinics were to go wrong, we would be blamed. Such a situation could create major problems for Calcutta Kids. The ethical dilemma was that since we were paying for the deliveries at these clinics which practiced excessive use of C-sections, we were partially responsible for any deleterious effects of an unnecessary C-section on a mother or child. Was it possible that while we believed we were providing the best possible care for pregnant women and children, we might be exposing them to unnecessary risk?

Below is a brief synopsis of our discussions.

  • We could speak with the private sector clinics, encourage them to follow WHO protocols on the appropriate conditions for C-sections, and then request medical reports for each C-section financed by Calcutta Kids. This option was tried without success. After all, C-sections are increasingly the norm, and the clinics did not want to follow a protocol inflicted upon them by an NGO.
  • We could open our own maternity clinic, although at an exorbitant cost. This was never really an option. Our focus is on nutrition, BCC, and preventive care and that is where it should remain.
  • We could encourage our patients to advocate themselves for normal deliveries unless a C-section is clearly warranted. This we also do but with limited success. Rarely will a poor uneducated family go against the advice of a doctor.
  • We could stop paying for C-sections altogether. But what about those rare cases where C-sections are indeed necessary and families cannot afford them?
  • We could partner exclusively with the government hospitals. But this goes against the preference of our beneficiaries.

Finding none of these options satisfactory, and recognizing the danger to our beneficiaries and to Calcutta Kids, we ended up terminating our formal partnerships with the private sector. What we put in its place is a delivery savings scheme—a financial incentive to ensure a facility-based delivery. 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 beneficiaries then can choose to spend this money at a private clinic (Rs.4000 will likely cover a normal delivery, but not the full cost of a C-section) or they can go to a government hospital where the delivery will be free and use this savings for postnatal care.

Along with the delivery savings scheme, we’ve begun a program of intensive counseling for pregnant women to help assure that they understand all that they need to know about deliveries and can make an educated decision about whether to have a C-section if the doctor recommends one.

The last blog post in this four part series will speak about Calcutta Kids’ experience with the delivery savings scheme as well as the curriculum mentioned above. –Noah Levinson

C-Section Blog Series (2 of 4)

The rise of C-section rates in many parts of the world has triggered a global debate on the use of C-sections, the ideal rate of C-section, and appropriateness of high rates in certain countries. In 1985 the World Health Organization (WHO) recommended a C-section rate of not more than 10-15%. In 2010, they withdrew that guideline and replaced it with a more general statement that, “There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them.” The WHO’s decision to not focus on a universal, evidence-based optimum rate makes sense in light of the difficulties of doing so but, without a specified rate, there is no easy benchmark by which to monitor and interpret the use and potential overuse of c-section deliveries.

When clinically indicated for complications during pregnancy or labor, C-sections greatly improve obstetric outcomes, which in turn improve maternal and child health outcomes. In many developing countries, women have inadequate access to emergency obstetric care leading to preventable maternal and perinatal morbidity and mortality. In such settings, it is essential to strengthen health systems and infrastructure to ensure that C-section services are provided when they are medically indicated and could save lives.

In populations with excessively high C-section rates, on the other hand, there is growing concern about the health and economic consequences when C-sections are performed for reasons other than medical necessity. A C-section is a major surgical intervention that should be carefully considered in light of associated risks that can increase maternal and perinatal morbidities, which include bleeding, infection, blood clots, and increased need for ICU care. C-sections can also have long-term consequences on child health, including increased risk of developing allergies and asthma. (1) Maternal mortality for women undergoing C-sections is four to ten times higher than for vaginal birth. A multi-country study carried out in Latin America indicated that an increase in rates of caesarean delivery is associated with increased use of antibiotics postpartum, greater severe maternal morbidity and mortality, and higher fetal and neonatal morbidity. (2) Another multi-country study carried out in Asia in 2007-8 showed that there was an increased risk of maternal mortality and severe morbidity in women who undergo C-section with no medical indication. (3) Furthermore, in low-income countries with an unmet need for C-section (where women who need C-sections are not receiving them due to inadequate access to obstetric care), the issue of resource drain is important: If C-sections are restricted to only clinical indications and not performed unnecessarily, resources would not be sapped from other sections of the health system.

http://cartoonistsatish.blogspot.in/2009/07/muhurat-c-section.html

Currently, the global C-section rate is about 15%, but there are huge variations in C-section rates across countries and regions in the world. A consistent increase has been seen in the rate of C-section deliveries in most developed countries and in many developing countries including India. Globally, China has the highest rate at an alarming 46% of births being C-section (3); Brazil follows behind at 37% (4). In the United States the rate has been steadily increasing in the past decade and is now at 30%, while in Scandinavian countries it hovers around 20%. In Asia, after China, Vietnam and Thailand have the highest rates with 36% and 34%, respectively. The lowest rate in Asia is Cambodia, with 15%. (3) Although India’s rate is not disturbingly high in the global context, its rate has spiked from 2.2% in 1992-3 to 18% today. Within India, the states of Kerala, Goa, and Andhra Pradesh have the highest rates. In West Bengal the rate rose from 3.3% in 1992-3 to 19% in 2009-10. (5)

There is also a large divide between urban and rural areas, and between public and private facilities. West Bengal as a whole has a C-section rate of 19%; the city of Kolkata’s rate is 33.5% while rural Malda District’s is 2.2%. In Kolkata as in most large Indian cities, the C-section rates in private hospitals are much higher (50% and up) than in public hospitals, which average about 12%. (6) This emerging trend is a classic example of inequalities in access to C-sections in developing countries: It means that in poor, rural areas where there is less access to emergency obstetric care, women who medically need C-sections may not be getting them, while women living in urban areas and going to private hospitals are getting C-sections that may be performed unnecessarily, causing unwarranted risk to the mother and baby.

The trend in rising C-section rates in India and other parts of the world is driven by many reasons factors including, but not limited to:

  • Increase in facility-based deliveries and improved access to emergency obstetric care; improved surgical and anesthetic techniques
  • Doctors’ preference for the procedure due to ease, timing, and financial   incentive compared to vaginal delivery
  • Women’s preference for the procedure to avoid long labor and delivery
  • Over medicalization of childbirth process
  • Lack of information on natural birth options for women
  • Perception of safety of the procedure; casual attitudes about surgery and limited awareness about realities of surgery
  • Increase in heavier women and older women giving birth
  • Increase in multiples (twins, triplets, etc) due to fertility drugs and IVF

How do rising C-section rates affect Calcutta Kids?

Our beneficiaries at Calcutta Kids are very much affected by C-section trends in West Bengal, as their deliveries are taking place in government and private hospitals in Howrah. In the past five years, we have witnessed increasing rates of C-section for women who are participating in our program. In a preliminary analysis of data, our C-section delivery rate has increased from 10% in 2007 to 30.4% in 2012. There may be many contributing factors, including an increase in facility-based deliveries from 67% in 2005 to 90% in 2012. However, we are conducting further analysis to assess these trends and explore the reasons behind them.

Calcutta Kids is not involved in the childbirth process for our beneficiaries and we cannot directly affect any decisions made once a woman has been admitted to the facility, so we do not have any control over C-section rates among our beneficiaries. However, we can take advantage of opportunities during pregnancy to raise awareness about birth preparedness and help a woman understand what she can expect at the facility, including what decisions will be made once the birth process has begun.

Next week’s blog post will cover Calcutta Kids’ experience with facility deliveries and C-sections , followed by a blog post on our work with health workers and pregnant women on birth preparedness and facility delivery. -Danya Sarkar

Citations:

  1. Mode of Delivery Is Associated With Asthma and Allergy Occurrences in Children. Muhammad T.Salam, MBBS, MS, Helene G. Margolis, PhD, Rob McConnell, MD, James A. McGregor, MD, Edward Avol, MS, Frank D. Gilliland, MD, PhD. Annals of Epidemiology, Volume 16, Issue 5, May 2006; 341–346.
  2. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. José Villar, Eliette Valladares, Daniel Wojdyla, Nelly Zavaleta, Guillermo Carroli, Alejandro Velazco, Archana Shah, Liana Campodónico, Vicente Bataglia, Anibal Faundes, Ana Langer, Alberto Narváez, Allan Donner, Mariana Romero, Sofi a Reynoso, Karla Simônia de Pádua, Daniel Giordano, Marius Kublickas, Arnaldo Acosta, for the WHO 2005 global survey on maternal and perinatal health research group. Lancet 2006; 367: 1819–29.
  3. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Pisake Lumbiganon, Malinee Laopaiboon, A Metin Gülmezoglu, João Paulo Souza, Surasak Taneepanichskul, Pang Ruyan,Deepika Eranjanie Attygalle, Naveen Shrestha, Rintaro Mori, Nguyen Duc Hinh, Hoang Thi Bang, Tung Rathavy, Kang Chuyun, Kannitha Cheang, Mario Festin, Venus Udomprasertgul, Maria Julieta V Germar, Gao Yanqiu, Malabika Roy, Guillermo Carroli, Katherine Ba-Thike, Ekaterina Filatova, José Villar, for the World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Lancet 2010; 375: 490–99.
  4. The Role of Nonclinical Factors in Cesarean Section Rates in Brazil. Kristine Hopkins and Ernesto Amaral. Population Research Center, University of Texas at Austin.
  5. Levels and Trends in Caesarean Births: Cause for Concern? Sancheeta Ghosh, K S James. Economic & Political Weekly January 30, 2010 vol xlv no 5.
  6. Telegraph article: To C or not to C?

New Child Development Corner

Despite the sweltering heat in the last couple months, and the impending torrential rains of monsoon, there is a lot going on at Calcutta Kids this summer. In the midst of all the new activities, in mid-May, Calcutta Kids received the wonderful news that we will be receiving a small grant to set up a child development corner in our new community center, from the J. Kirby Simon Foreign Service Trust. We are very excited about this prospect, because a child development corner will allow us to provide a more holistic approach to child growth and development within the larger young child health initiative. In the past six years, we have made remarkable improvements in the nutrition and growth of young children in Fakir Bagan. The average birth weight has increased from a dismal 1.8 kg in 2005 to 2.8 kg in 2011. Indicators of children’s nutritional status have improved greatly– in the past three years, the severe malnutrition rate has fallen by more than half, from 12.3% to 5.5%. However, there is still a lot to do to ensure that children in this urban poor community are able to achieve optimum development.

Calcutta Kids became conscious that in Fakir Bagan slum as in most urban poor settings, young children have little or no access to play and stimulation. There are no playgrounds for children, and although there is a maidan (field) nearby, it is frequented by older children and teens, and usually only boys. Young children (under 3 years old) are often seen sitting passively on a cot or in the doorway, while their mothers are doing domestic work such as cleaning, cooking, fetching water, or part-time factory work such as sewing garments or making zippers. In homes, families rarely have any toys available for the young children, a luxury that many cannot afford.

Play is essential to development because it contributes to the physical, cognitive, social, and emotional well-being of children. In fact, play is so important to optimal child development that it has been recognized by the United Nations High Commission for Human Rights as a right of every child. In this light, Calcutta Kids appreciates the need to create a child development component to ensure this basic right, with the goal of improved cognitive growth and overall development for all our young children in Fakir Bagan.

The child development corner in the community center will be a safe, clean, and stimulating environment for young children to simply play – to create and explore the world with toys, with other children, and with their caregivers. The project will also facilitate parents’ and caregivers’ understanding of the importance of play and stimulation in child development. It is anticipated that this type of play will provide the needed stimulation that will help very young children with both gross and fine motor skills that will allow them to reach appropriate developmental milestones, develop new competencies, and improve cognitive development. It is hoped that this unique early childhood stimulation project will serve as a model for other NGOs in Kolkata who are working in child health in the urban slums.

Stay tuned for more updates on the child development corner which should be fully established by early 2013. –Danya Sarkar

Immunizations – More Than Just a Shot

The immunization program has been a service of Calcutta Kids for many years, but during the last year, we have worked very hard to make it as effective and efficient as our GMP program. There are two primary ways that we have accomplished this; the first is a short multimedia education and counseling session and the second is a system in our database that tracks the immunizations for each child and correctly identifies those who are eligible for that week’s clinic.

Rather than simply telling mothers and caretakers that these immunizations are necessary, we are working to inform our beneficiaries about why these immunizations are important. The short education and counseling session is designed to convey information on both the disease (or diseases) that the immunization is preventing, and on possible side effects. We have already seen mothers taking a larger interest in the immunization program and asking the CHWs about the next session. And for those not taking the initiative, we have an accurate list of all children who should come to the clinic and take the time to remind each household on that list. Take a look at the immunization counseling materials here.

The immunization section of the database has been greatly improved in the past year, and now takes into account the immunizations that have been received and the dates of each immunization received. This is important because many children have missed doses and are therefore off the ideal schedule. For example, a child may have received the first dose of DPT, OPV and Hep-B, but then did not receive the second dose after four weeks, but instead returned after eight weeks. According to the age, the child should be receiving the third dose but in fact, he or she should be receiving the second dose. The system also makes sure that enough time has passed between doses. These two improvements are helping us toward our goal of full immunization for each child that participates in our program. -Dora Levinson