Category Archives: Calcutta Kids Blog

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?

C-Section Blog Series (1 of 4)

For the month of July, Calcutta Kids’ weekly blog will be on the topic of C-section deliveries, and the challenges of working in maternal and child health during a time when C-sections are becoming the norm.

According to a December 2011 article  in the Telegraph, West Bengal “has more Caesarean section deliveries in private hospitals than anywhere else in the country”, and Kolkata has the highest rate at 33.5%. C-sections are convenient for doctors and lucrative for facilities, so doctors are beginning to schedule deliveries regardless of a medical need. Some of the best private hospitals in Kolkata have even removed labor rooms altogether, and only offer the C-section option.

C-section deliveries can lead to serious complications such as hemorrhage, lingering abdominal pain, hernia, blood clots, and long-term effects including a required hysterectomy and even death. C-sections can also impact the child, and can lead to increased incidence of asthma and allergies, as well as possible neurological disorders. In addition, C-sections are expensive and recovery time is often greater than for a vaginal birth. As a public health organization, Calcutta Kids encourages best practices for maternal and child health. This includes safe prenatal care; a vaginal, facility-based delivery (wherever possible); access to comprehensive emergency obstetric and newborn care; exclusive breastfeeding for the first six months after birth, and critical health messages given to the new mother and family.

Through this series, readers can learn more about C-section rates in India and West Bengal, decisions made at the facility level, and our difficulty in having an impact in the delivery room. We will also share what Calcutta Kids is trying to do to empower women through birth preparedness, and welcome your comments and suggestions on ways we can address these challenges. -Margy Elliott

Calcutta Kids in Kathmandu

As one of 21 recipients of the 2009 South Asia Region Development Marketplace Awards to “Innovate for Nutrition” Calcutta Kids was invited to participate in a World Bank sponsored conference titled “Knowledge Sharing Forum on Infant and Young Child Nutrition” which took place in Kathmandu Nepal on June 12th and 13th. I went with our director, Noah to represent Calcutta Kids.

Along with representatives from the other 20 award winning organizations, the forum was attended by nearly two hundred representatives from governments, international NGO’s, and civil society organizations working to alleviate the horrific nutrition indicators which plague South Asia. The forum was also attended by journalists from throughout South Asia with the idea that in order for the public to care about nutrition, media information must be accurate and urgent.

The conference was jointly organized by the World Bank, UNICEF, SAFANSI, and presentations were made by representatives from all those organizations as well as those from organizations such as FAO, CARE, DFID, and the Micronutrient Initiative. It was interesting and fun to meet some of the world famous nutritionists and development workers whose work we regularly use and are inspired by at Calcutta Kids.

While nothing particularly new to those of us committed to improving nutrition, some of the important and shocking truths which we were reminded about and which should be shared whenever possible were:

  • Julie McLaughlin, Sector Manager for Health, Nutrition and Population in the South Asian region of the World Bank informed us that the latest estimates show that over 336 million people in South Asia are facing chronic hunger.
  • It was also discussed that the South Asian region, has the highest prevalence of malnutrition in the world and the child malnutrition in the region is estimated at 46 percent. It is worse than in Sub-Saharan Africa where the corresponding figure is 26 percent.
  • Melanie Galvin, Regional Director of MI, reminded us that that entrepreneurship cannot be possible without healthy population. If the population is deficient of vitamin A and iodine for example, how they can move forward for entrepreneurship?

Noah and I found two of the presentations particularly exciting.

The first by Tina Sanghvi, the Bangladesh senior country director of Alive and Thrive said, “The crisis (of malnourishment) is here and the solution is in our hands”. She continued by saying that the knowledge gap is the main reason of high rates of malnutrition in South Asian countries. Another point she highlighted was that many mothers have no idea that a malnourished mother can also breast feed properly and that is a serious problem. Tina also shared some terrific TV commercials on health messages that Alive and Thrive has created and now show regularly on Bangladeshi television channels. Calcutta Kids was able to get copies of some of these high quality commercials and we plan on using them with our beneficiaries.

The second was by Leslie Elder, Senior Nutrition Speci alist at the World Bank who gave a fantastic presentation on responsible and effective ways to scale up programs. When Calcutta Kids is ready to scales up its programs, the framework that Leslie shared with us will certainly be an invaluable resource. Leslie’s presentation can be found here.

For those of you who might be interested, you can see all the presentations given at the forum by visiting here.

It was a fantastic experience to participate in the forum and to be surrounded by so many people who deeply care about the very same issues we care about at Calcutta Kids. -Sumana Ghosh

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

Swarathma Brings in the Monsoon

I pegged Swarathma as a small time band from a mile away. It was presumptive, sure, naïve even, but it didn’t occur to me that anyone else would play for an NGO in the dusty heat of a slum for free. Little did I know how wrong I was.

When Noah divulged the details to me, I found out that the band is actually something of an Indian phenomenon. Their first album won them Best Band, Best Album, and Song of the Year at India’s most prestigious annual rock awards show. They were on the iconic TV series The Dewarists. They have toured Australia, Britian, and Morocco. And now they were playing for Calcutta Kids.

Back in the old days, for every paid gig they played one for free. They’ve since run out of enough time to keep up the one to one ratio, but when they can they still try to play for those who would not see them otherwise. Thanks to their bassist and spokesman Jishnu’s old friendship with Evangeline, the final concert on the tour to mark the launch of their second album would be in Fakir Bagan.

Weaving around piles of sand and through patches of the road lost in mud, Evangeline and I eventually led their van to Howrah and the impromptu stage that had been miraculously constructed for them. I think the band was almost so impressed as we were, and the juxtaposition of big-band electronics and crumbling-wall school grounds was immensely pleasing.

I picked out a spot in the sea of rickety plastic chairs that bulged at the edges of the colorful canopy above it, and the band sound checked as the crowd filtered in. Chandan and Kalyan lugged some wooden benches out from the school to augment the periphery as it became clear that spectators would outnumber chairs. When all was said and done, a floor of women and children—often balanced on laps or sitting together two to a chair—gazed up at the first bandstand of their lives.

Just before the band went backstage to change into performance attire, their lead singer arrived. No one was going to disappoint the crowd by admitting that he had been missing—the doctors had to knock him out cold at the hospital the night before to put a dislocated shoulder back in—and the band assured us that they could play without him. But after we left him at the hotel and told him to lie low, he just couldn’t. So with a piece of cloth to support his arm (to everyone’s amazement, he even replaced that with a guitar strap when the concert began, strumming away as though nothing had happened), he made it just in time. Security—a graying old man with a stoop and a hard stick—almost wouldn’t let him in. He didn’t have a ticket, after all.

When the band took the stage and plunged into their first song, it seemed to me that an almost tangible incredulousness emanated from the audience. The end of the first number and no more than a sparse acknowledgement of applause underlined the pristine newness of the occasion: the crowd did not know how to react simply because they had never reacted to such a thing before.

Slowly but surely, though, the audience grew less self-conscious and more absorbed by the music. Jishnu has a way of connecting with the floor before him, and in between songs he lightheartedly instructed the crowd in performance manners—when to clap, when to cheer—and introduced the songs that followed, explaining their significance and meaning. On the second song there was little cooperation when he tried to stimulate a clap, but when he motioned for the mothers to lift up their babies in front of them with the chorus of the fourth, there wasn’t a moment’s hesitation. He even seamlessly promoted Calcutta Kids’ new and critical mantra: “A child gaining weight cannot be very sick. A child not gaining weight cannot be very well.”

As the concert went on, the clouds around us darkened, rumbling closer. Just as the mood was reaching unabashed exuberance, the thunder clapped above us and the rain began to fall. At first, no one seemed to know what to do. As soon as it became clear that an inundation was in store, however, the crowd lurched into motion, fleeing either home or into the schoolhouse next door. The band and their helpers scurried to protect the equipment from the blowing rain.

Perhaps unexpectedly to the westerners among us, the deluge did not bring with it a downhearted regret that the concert had been called off before its due course. Instead, the cooling blessing of storm and rain stimulated the same energetic exuberance that had radiated up moments before at Swarathma. As we huddled inside to wait out the downpour, we figured that nature could have given us fifteen more minutes of music. But we agreed that no one could have planned so powerful a coda to the slum’s first concert.—Evan Mullen

Beating the Heat with Mangoes

It’s hot here in Kolkata—incredibly hot. Humidity levels are hovering around 95%, and the mid-day temperatures are reaching as high as 112 degrees Fahrenheit. With such weather, one would expect productivity to reduce, but with so much going at Calcutta Kids these days, productivity remains high and much is being accomplished. I’d like to use this blog post to catch you up on our news and give you snapshots of what is keeping us so busy.

• A new MCPC—Since 2005, we have used the same Mother and Child Protection Card (MCPC) to keep track of the growth of pregnant woman and children; remind families of best healthcare practices; and track their immunization status. Over the past several months we have revised and improved upon these MCPC cards. The changes include updating the growth chart to be consistent with that of the government of India and WHO; sections added for monitoring deworming, home visits, breastfeeding/complementary feeding; and additional space allocated for measles vaccine and for non-CK immunization information. Our Community Health Workers have collected the old MCPC cards from our beneficiaries and are tirelessly transferring information from the old cards to the new cards. 

• Medicine database overhaul—Evan Mullen, our summer intern through the Skolnik Internship Program arrived in Kolkata last week after completing his sophomore year at Yale University. Along with overhauling our medicine database to ensure the most efficient use of medicines, Evan is also working with our doctor, Dr. Mukherjee, on learning and then implementing the WHO/UNICEF-created Integrated Management of Neonatal and Childhood Illnesses (IMNCI ) protocol so that all of Calcutta Kids’ curative care is done following this established protocol.

• Music for our beneficiaries—as part of the launch of their second album, the well-known Bangalore-based band Swarathma will be performing a free concert for the beneficiaries of Calcutta Kids. (This is a real honor for Calcutta Kids and our beneficiaries—the night before, the band will be playing at the most prestigious music club in Kolkata, Tantra, at the Park Hotel.) Especially for the women and children of Fakir Bagan who rarely venture outside the slum, this concert will be a special treat. Our blog next week will be a review of this concert.

• A new HR manual—Having years of HR management experience at the Akanksha Foundation in Pune, the Child In Need Institute in Ranchi, and ITC in Kolkata, Evangeline Ambat has joined Calcutta Kids as a consultant to design a new Calcutta Kids human resources manual. The Calcutta Kids staff has asked for a comprehensive HR manual and we are confident that Mrs. Ambat will be able to deliver this much-needed document.

World Bank Development Marketplace Nutrition Award wrap-up—MYCHI Project Coordinator Sumana Ghosh and CK Director Noah Levinson, are planning their presentation to share in Kathmandu about CK’s experience with the World Bank funded Diarrhea Treatment Center . The conference takes place on June 11th and 12th and is titled “Sharing Lessons from Community Experiences: Improving Infant and Young Child Nutrition”.

• AIF Fellowship transition—this is Margy Elliott’s last week at Calcutta Kids concluding her ten month William J. Clinton Fellowship through the American India Foundation.  Along with building the new Calcutta Kids website, Margy has created a field-level manual for illness assessment and treatment guidance for use by our community health workers, she has been an essential part of designing and implementing our new community mobilization program, she has helped to raise funds for Calcutta Kids, and she is now wrapping up an intensive SWOT (strengths, weaknesses, opportunities, threats) analysis among key CK stakeholders. Margy has become a member of the Calcutta Kids family and we will sorely miss her. That being said, however, thanks to Margy’s marvelous experience at CK, AIF’s Clinton Fellowship Program is providing us with two fellows for the 2012-2013 year. We are excited about welcoming Pranav Reddy, and Sriya Srikrishnan who will begin working with us in September.

So while we are drenched in sweat and continuously drinking plain and coconut water to keep ourselves hydrated, there is one saving grace to this weather— mangoes. For those of you who have experienced the intoxicating flavors of the wide variety of mangoes in India available at this time of year, you’ll understand that the mangoes are almost worth our suffering from this heat. For those of you who have not…you may enjoy reading this New York Times article which nicely explains how fantastic these mangoes really are. -Noah Levinson

Programs to Address Malnutrition

Despite the progress that has been made on other fronts, including infant and child mortality, in India over the last decade, nutrition remains a major public health challenge and nutrition indicators for young children have barely changed. There are many factors that complicate ongoing efforts to implement successful community nutrition programs–including inadequate access to food, unhealthy environment and exposure to infectious diseases, and inappropriate care and feeding practices. Since its inception, MYCHI has targeted the nutritional status of young children in Fakir Bagan during the first 1,000 days of their lives, primarily through preventive care and counseling along with curative care as needed.

The earliest data on nutritional status of children based on weight for age was collected in October 2009. It showed that 33.3% of children 0-3 years old were normal weight, while 32.7% were mildly, 21.6% were moderately, and 12.3% were severely underweight. Two and a half years later, in May 2012, the percentage of severe underweight children has dropped by more than half—from 12.3% to 5.5%, a remarkable success. Data is currently being analyzed to explore the specific factors that have had contributed to the reduction of the severe underweight in our catchment area, but it is clear that the MYCHI approach to deliver key health interventions during pregnancy and young childhood coupled with close counseling, education, and preventive health have made a significant impact in our community.

Although we have made progress, there are still improvements to be made to our child health initiative in order to fully integrate nutrition and growth. This year, we began efforts to systematically address malnutrition and move away from short-term trials, which consumed disproportionate resources and time at the expense of our regular programs. We have made several recent changes to make it easier to monitor and track malnourished children, which we hope will help us reach every child at risk of improper nutrition and growth:

– Early this year, we began generating our lists for monthly home visits by health workers on the basis of the nutritional status of children. Children having a z-score of -3 and below in weight for age (severely underweight) are referred to Swastha Kendra for clinical examination. This also ensures that our health workers have nutrition and growth on their minds as they enter the home of each child and can provide appropriate and intensive counseling to the family.

– At Swastha Kendra the referred child is provided care to resolve any associated medical problems and given supplements for micronutrient deficiencies. Follow up homes visits are carried out by our health workers two days after the doctor’s visit to check up on the child.

– Last month, we designated a space in Swastha Kendra as a nutrition corner, where mothers can freely breastfeed younger children and feed older children when they come for a doctor’s visit. We offer a meal of kichuri and egg in this corner to malnourished children who have been referred by the health workers. The privacy of the corner also enables close counseling with the family.

– Child health community meetings have been re-started in our new community center for mothers of children 0-12 months with an increased focus on complimentary feeding, as we recognize that children begin growth faltering at the time of weaning and introduction of semi-solid foods.

We are optimistic that these changes will enhance MYCHI’s efforts to improve child nutrition in Fakir Bagan. – Danya Sarkar

Walking the Walk

As a fellow with the American India Foundation Clinton Fellowship For Service, I have spent the past nine months working with Calcutta Kids. It has been an incredible experience, and the things I have learned while working here will remain with me throughout my life and career.

One thing that has really impacted me is how this small, but mighty organization is not just one that “talks the talk”. Every day, every employee, every community member is provided with love, compassion, and a sense of humanity that so many organizations may lose as they get caught up in their day-to-day work. “Walking the walk” is what has made Calcutta Kids such a beloved organization in this community. I wish you could see them in action too. Here’s just a sample of the amazing things I’ve seen, which are just a part of Calcutta Kids’ daily work:

– I’ve seen the Community Health Workers in homes, teaching families intimate lessons that will improve their health; teaching mothers how to initiate breastfeeding; and being the first visitor a new mother receives after giving birth.

– I’ve seen technical staff carefully stop programs that turned out to be ineffective in our area.

– I’ve seen the staff embrace a child from the neighborhood, teaching him English, providing him food, and even brushing his teeth when his mother cannot.

– I’ve seen the work in the clinic, where the technical staff knows the names and faces of individual mothers and children.

– I’ve seen mothers come to receive diarrhea treatment, and stay for nap under a fan with her child without any disturbance by the staff.

– I’ve seen severely malnourished children literally being wrapped up in the arms and love of every staff member – from our cleaners to our doctor – as the mother comes daily to learn how to provide proper nutrition for her child.

– I’ve seen management put aside social norms to prove Calcutta Kids values girl children as much as boy children.

– I’ve celebrated with the staff when babies are born with a good birth weight, when our support group started coming to meetings without being called, and when 86 people came to the clinic the day a new immunization was offered (more than 50% increase from an average week of immunizations).

– I’ve joined in concern when unhealthy children come to the clinic, and have seen the staff go to great lengths, sometimes even on the weekends, to ensure the child’s health improves.

Calcutta Kids is not fancy, and we like it that way. Our interventions are simple and heartfelt. The staff prides itself on feeling like family, and the community members are treated like an extension of that family. The facilities are clean and the women are respected. I’m grateful I was able to spend my Fellowship with an organization as sincere and hard working as Calcutta Kids. – Margy Elliott