Baseline Study on Immunization in Rural Jharkhandcortindia.in/RP/RP-2005-1001.pdf · The Universal...

Baseline Study on Immunization in Rural Jharkhand

A Report

Submitted to UNICEF, India

CENTRE FOR OPERATIONS RESEARCH & TRAINING

402, Woodland Apartment Race Course Circle Vadodara 390 007.

Gujarat, India.

research tha t makes a d i f fe rence

PREFACE In order to reduce infant and maternal mortality, the National Population Policy of the country has emphasized the achievement of universal immunization of children, against the six dreaded childhood diseases, and antenatal care of the pregnant mothers. Efforts made by Government of India in this direction are fully supported by UNICEF, whose priority is to ensure that children having limited access to immunization are covered. It has taken up the task of strengthening the routine immunization programme especially in the states where immunization coverage is low. UNICEF thus requested Centre for Operations Research and Training, Vadodara to conduct a baseline survey in selected districts of Jharkhand state to ascertain the level of key indicators of routine immunization programme in these districts. The present report is based on the result of the baseline data obtained from the four districts of Jharkhand. I am sure the findings from this report will guide the program mangers in planning their programme. We take this opportunity to thank the UNICEF officials namely, Dr Vijay Mosses, Dr. James Patterson, Dr. Samresh Sengupta, Dr Vibhavendra Singh Raghuvamshi, and Dr. Madhulika Jonathan for their constant interaction and support at each stage of the study. This study would not have been possible but for the support of all the study districts Chief Medical Officers and the other health officials for sparing their time, we acknowledge their cooperation and support. We are also grateful to all the respondents for sharing their time with us. I wish to put on record my appreciation to all team members and other CORT staff members for their contribution in completing the study with quality and within the stipulated time frame despite the area covered was quite challenging. Prof. M. M. Gandotra, Director 2005 Centre for Operations Research and Training

Study Team

Sandhya Barge P. Swarup Nayan Kumar Yashwant Deshpande Seema Narvekar Jashoda Sharma Premlata Kshatriya

CONTENT

CHAPTER 1: INTRODUCTION Background ................................................................................................................... 1 Objective of the Study................................................................................................... 3 Methodology ................................................................................................................. 3 Questionnaires .............................................................................................................. 4 Recruitment, Training and Fieldwork ........................................................................... 5 Data Entry and Analysis ............................................................................................... 5 Format of Report ........................................................................................................... 5 CHAPTER 2: BACKGROUND CHARACTERISTICS Health Facility .......................................................................................................................7

Primary Health Centre........................................................................................... 7 Sub-centre ............................................................................................................. 8

IEC/Social Mobilization ............................................................................................... 9 Community Level..................................................................................................................9

Background Characteristics of Mothers with Children 12-23 months.................. 9 Background Characteristics of Mothers with Children 0-11 months.........................10

CHAPTER 3: IMMUNIZATION Availability of Vaccines........................................................................................................13

Stock of Vaccines in the Facility .................................................................................13 Status of Vaccines in the Facility.................................................................................15 Status of Vitamin A in Sub-centre ...............................................................................16 Cold Chain Quality .......................................................................................................16 Injection safety..............................................................................................................18 Mode of Collecting Vaccines.......................................................................................18

Accessibility of Immunization Sessions ..............................................................................19 Immunization Sessions.................................................................................................19 Access to Sessions ........................................................................................................20 Access at the Village Level ..........................................................................................20 Health Personnel who Makes the Services Accessible ..............................................22 Linkages with Anganwadi Worker with Access.........................................................22

Utilization and Adequate Coverage .....................................................................................22 Immunization Practice..................................................................................................23 Client Perception of Immunization..............................................................................24 Socio-economic Comparison of Immunization Coverage..........................................25

i

Effective Coverage........................................................................................................ 25 Timing of Immunization ............................................................................................... 27 Review of Immunization Bottlenecks........................................................................... 27 CHAPTER 4: ANTE-NATAL/NATAL AND POST-NATAL Availability of Services.........................................................................................................29 Accessibility of Services.......................................................................................................31

Status of Health Personnel’s Accessible to Community.............................................32 Community Perception on Accessibility of ANC Services........................................33

Utilization of Maternal Services ................................................................................... 33 Full Coverage of ANC by Background Characteristics of Mothers ..........................35 Women’s Perception on Need of ANC Care ..............................................................37 Natal Care......................................................................................................................38 Registration of Birth .....................................................................................................39 Post-natal.......................................................................................................................39

CHAPTER 5: CHILD CARE, BREASTFEEDING AND SUPPLEMENTARY FEEDING Availability ............................................................................................................................41

ORS Packets..................................................................................................................41 Cotrimoxazole Tablets..................................................................................................41

Accessibility ..........................................................................................................................42 Knowledge among Mothers regarding Diarrhoea ......................................................42

Utilization ..............................................................................................................................43 Adequate Coverage ...............................................................................................................44 Effective Coverage................................................................................................................45 CHAPTER 6: SUMMARY AND CONCLUSION Immunization ........................................................................................................................47 Ante-natal, Natal and Post-natal Care ..................................................................................48 Child Care and Breastfeeding/Supplementary Feeding Practice .......................................48 Annexure- I PSU List Annexure-II District-wise status of Immunization by selected Indicators Annexure-III Questionnaires

ii

LIST OF TABLES

Table 1.1: Demographic profile of study area..................................................................2 Table 1.2: Distribution of sample covered by study districts ..........................................4

Table 2.1: Infrastructure of the Primary Health Centre ...................................................7 Table 2.2: Staffing Pattern of the PHC.............................................................................8 Table 2.3: Profile of the SCs .............................................................................................9 Table 2.4: Background characteristics of mother of children 12-23 months ................ 10 Table 2.5: Background characteristics of mothers of children 0-11 months ..................11 Table 3.1: Average position of vaccine doses per facility.............................................. 14 Table 3.2: Reported and calculated stock of vaccines at facility.....................................15 Table 3.3: Position of vaccines in PHCs......................................................................... 15 Table 3.4: Position of vitamin A and vaccine carrier in sub-centres...............................16 Table 3.5: Availability of vaccines and its place of storage ............................................17 Table 3.6: Status of electricity/generator in PHC.............................................................18 Table 3.7: Time required for collection of vaccine and handing of unused vials...........19 Table 3.8: Background of ANMs .....................................................................................19 Table 3.9: Status of immunization sessions......................................................................21 Table 3.10: Health facilities available in the villages ........................................................21 Table 3.11: Distance and mode of accessibility to health facility .....................................22 Table 3.12: Type of vaccines received by children............................................................23 Table 3.13: Status of children Immunization .....................................................................24 Table 3.14: Status of immunization by selected indicators ...............................................25 Table 3.15: Level of ANMs knowledge on immunization................................................26 Table 3.16: Percentage of children who received immunization as per schedule............ 27

Table 4. 1: Status of Iron folic tablets at the PHC.............................................................30 Table 4.2: Status of Iron folic tablets at the sub-centre....................................................31 Table 4.3: Status of DDK in the sub centers ....................................................................31 Table 4.4: Access to health personnel ..............................................................................32 Table 4.5: Opinion of women on accessibility of ANC service......................................33 Table 4.6: Type of ANC services sought .........................................................................35 Table 4.7: Status of ANC services by background characteristics..................................36 Table 4.8: Adequate coverage of ANC services ..............................................................36 Table 4.9: Effective coverage of mothers for ANC services...........................................37

iii

Table 4.10: Opinion of the women regarding need of ANC care .....................................38 Table 4.11: Place of delivery .............................................................................................38

Table 5.1: Status of ORS and Cotrimoxazole at PHC and Sub-centres..........................42 Table 5.2: Knowledge regarding diarrhoea and its management....................................43 Table 5.3: Breastfeeding practice among mothers...........................................................44 Table 5.4: Nutrition pattern among children ....................................................................45 Table 5.5: ANM’s knowledge on breastfeeding and supplementary feed......................45

iv

LIST OF FIGURES

Figure 3.1: Percent of mothers who have immunization card ........................................23 Figure 3.2: Immunization Status ......................................................................................27 Figure 4.1: No. of facilities report/having sufficient stock of IFA tablets .....................30 Figure 4.2: No. of PHCs where delivery conducted........................................................32 Figure 4.3: No. of PHC indicating the trend of deliveries conducted in last one year ..32 Figure 4.4: No. of ANMs trained for conducting delivery .............................................33 Figure 4.5: Percentage of mothers who registered the birth of child..............................39

v

1 Introduction

1.1 BACKGROUND Our country’s National Population Policy 2000 emphasizes on “achievement of universal immunization of children against all vaccines preventable diseases” and has recognized it as one of the National Socio-Demographic Goals for 2010 along with “prevention and control of communicable disease.” This is also re-emphasized in the mission document of the National Rural Health Mission (NRHM). The Universal Immunization Program (UIP), a national programme launched in the country since 1985, desires 100 percent coverage of target population with vaccination against six preventable killer diseases - polio, diphtheria, tuberculosis, pertussis (whooping cough), measles and tetanus, which has helped in reducing the infant mortality rate in India from 104 in 1984 to 66 deaths per 1,000 live births in 2002. Despite some improvement in the infant mortality indicator in the country, the stated goals have not been fully achieved. Wide difference exists in the level of infant mortality across the various states of India. Efforts made by Government of India in striving towards its goals are further strengthened by various international and national agencies joining hands in this initiative. UNICEF an international organization is supporting Government of India’s efforts and is primarily focusing on child care and immunization in this respect. “Vaccination is widely recognized as one of the most powerful and cost-effective public health tools. Often immunization is a child's first - sometimes only - contact with the health system.” - UNICEF Executive Director, Carol Bellamy. Various socio-cultural factors often make it difficult for vaccinators to access children. Some children are excluded from immunization because they come from minority groups or live in deeply impoverished remote areas, where health services may operate poorly. Some communities have religious or traditional beliefs that make them suspicious of immunization. Jharkhand state is one among several states in the country, where immunization coverage has been very low in recent years. As per the NFHS-2 only nine percent of the children had received all vaccinations. At the request of UNICEF and the Government of Jharkhand, a baseline survey was conducted in four districts of Jharkhand namely Deogarh, Godda, Pakur and Sahibgunj by Centre for Operations Research and Training, a multidisciplinary social science research and training organization based at Vadodara, Gujarat. The present report delves in the findings of this baseline survey.


Demographically the population in the study districts ranges betweenPakur to 11,65,000 in Deogarh. These study districts were predominanpercentage urban constitutes only four percent in Godda to 14 percent in Deo Overall the scheduled caste population in the rural areas vary from (Pakur) to 13 percent (Deogarh). Percentage of scheduled tribe in rural areaas 47 percent in Pakur Not much difference exists in the sex ratio of rural and urban areas of thethan half (46 percent) of the population in the rural areas is literate. Female li30 percent in rural areas and 39 percent in urban areas. Table 1.1: Demographic profile of study area

Name of the district Indicators Deogarh Godda Pakur Sahibgu

Population in 000s 1165 1048 702 92Percent of urban 13.7 3.5 5.1 10Percent of Scheduled castes 12.6 8.6 3.3 6Percent of Scheduled Tribes 12.2 23.6 44.6 29Percent of Scheduled Castes in rural areas 13.3 8.7 3.1 5Percent of Scheduled Tribes in rural areas 13.9 24.3 46.6 32Sex ratio in urban 914 926 957 94Sex ratio in rural 926 929 960 95Literacy rate in urban 50.1 43.1 30.6 67Literacy rate in rural 44.1 41.6 28.3 33Literacy rate among urban female 32.0 27.4 20.6 26Literacy rate among rural female 25.2 25.7 18.1 22

Stu

2

7,02,0tly rur

garh.

three ps was a

districteracy i

nj Jha

8 .6 .4 .1 .7 .1 2 0

.6

.4

.6

.3

dy distr

a

es

t.s

r

icts

00 in l, as

rcent high

Less only

khand

29946 11.8 11.8 26.3 12.4 31.0 941 962

53.6 45.7 38.9 29.9

Chapter 1: Introduction

1.2 OBJECTIVE OF THE STUDY The main objective of this baseline survey was to generate base line information on key indicators in the immunization program in rural areas. 1.3 METHODOLOGY The study design adopted for the baseline survey included the multi indicator cluster survey technique. The study was conducted in four districts of Jharkhand selected by UNICEF in consultation with the Government of Jharkhand, which included Deogarh, Godda, Pakur and Sahibgunj. The sampled clusters for the study were limited to the rural areas of the identified districts. 1.3.1 Sampling Method The sample population identified for the study in each district was selected on a two-stage sampling technique. In each district, 30 clusters were selected by using systematic probability proportional to the size (PPS) procedure. The list of selected clusters is given in Appendix A. The study clusters were identified with the following technique: • List of all the rural areas (villages) with the size of population, as per 2001 Census was

prepared for each of the study district. • For identifying the cluster, a class interval was obtained by dividing the total rural

population of the district by 30 (number of cluster to be covered in a district). Using this interval, 30 clusters were selected with a random start of the first cluster.

• Within each cluster, first a center point was identified with the help of villagers. All the households located in the center point were given numbers. One household among these was selected using a currency note. From the first sample household, listing of the subsequent households was carried out clockwise. This process continued till the target sample of eight children between the age of 12-23 months and eight children aged less than a year as on the date of survey, were identified for the interview.

• Large village with geographical spread out was initially divided either by a lane or tola situated geographically in the four direction of the village and numbered. One among these lane/tola was selected by using a number on a currency note. Following this selection of the lane/tola, process of identifying the first sample household from the center of the area was conducted in the same way as discussed earlier in case of smaller villages.

Sample size: From each selected cluster, eight mothers of children aged below one year and eight mothers of children aged 12-23 months were interviewed. In each cluster, therefore 16 mothers were interviewed. In each district, 480 mothers were interviewed comprising of 240 mothers having children below one year of age and 240 mothers who had a child aged 12-23 months. In addition to these in each village, village questionnaire was administered to the village panchayat member or local leader. An attempt was also made to interview the medical officer of the primary health centre and the ANM of the sub-centre in which the selected cluster was located.

3


Table 1.2: Distribution of sample covered by study districts Name of the district Indicators

Deogarh Godda Pakur Sahibgunj Jharkhand

Number of PHC covered 8 7 6 9 30 Number of SC surveyed 7 14 18 9 48 Number of ANMs interviewed 9 14 20 11 54 Number of cluster/village covered 30 30 30 30 120 Number of mothers (0-11 months) interviewed

240

240

240

240

960

Number of mothers (12-23 months) interviewed

240

240

240

240

960

1.4 QUESTIONNAIRES To address the objectives of the study seven different types of tools were used. This includes (i) identification sheet (ii) village questionnaire (iii) mother’s questionnaire i.e. for mothers of children below one year (iv) children questionnaire i.e. for mothers of children aged 12-23 months (v) PHC questionnaire (vi) ANM’s questionnaire and (vii) Sub-centre questionnaire. (i) Identification sheet: This sheet was used to identify the presence of target

population. The name of the head of the household, total member in the household by sex and number of children less than two years of age were listed. If any child was found in the household within the desired age group their name, age and sex was noted and the corresponding questionnaire was administered to the mother of the child. In case if the mother was not available in the household, the reasons for the same were noted.

(ii) Village questionnaire: The village questionnaire was used to collect information from responsible community members in the village like the sarpanch, panchayat member, teacher etc. Through this information on distance to the nearest town, transport facilities available to the village, health facilities available in the village, nearest health facility, providers available and information regarding immunization sessions were collected.

(iii) Tool for mothers of children (0-11 months): This questionnaire collected

information from mothers of children aged below one year. The questionnaire besides collecting information on the background information of the respondents, collected details regarding Antenatal Care (ANC), Postnatal Care (PNC), breastfeeding and supplementary food practices and their opinion on various child health related issues.

(iv) Mother’s questionnaire for children of 12-23 months: This questionnaire was

administered to those mothers who had a child aged 12-23 months. Through this questionnaire, information on the background characteristics of the respondent and the index child, immunization status of the child, and reasons for incomplete or uninitiated immunization was collected. In addition to this, the mother’s opinion on various child health related issues were elicited.

(v) PHC questionnaire: PHC questionnaire collected information from Medical

Officer In-charge of the PHC. This questionnaire collected information on infrastructure, staff position and their training status, obstetric services, supply of vaccine and cold chain equipment, adequate supply of prophylactic drugs, disposable needle and syringes and the correct disposal of needle.

4

Chapter 1: Introduction

(vi) ANM questionnaire: ANM questionnaire collected information from the ANMs - the frontline workers of the government health department. Through this questionnaire information about the population and number of villages covered by the ANM was collected, additional information about her background, job responsibilities and previous training was collected

(vii) Sub-centre questionnaire: Sub-centre is the grass root level public health facility available in India. In this questionnaire information about the number of villages and population covered, infrastructure, distance from the sub-centre to the villages, availability of supplies was collected.

1.5 RECRUITMENT, TRAINING AND FIELDWORK A total of 8 teams were recruited locally in Jharkhand for conducting the survey in four districts. The field investigators included both male and female investigators who had some field survey experience earlier. Each team comprised of two female investigators and one male investigator. One supervisor supervised work for two teams. The training of the field staff was organized at Law College, Patna University, Patna. The training was imparted to investigators at two levels. In the first stage classroom training was given for six days, in the second stage actual field practice was carried out. Senior professionals of CORT were personally involved in giving the training. The teams conducted the field practice in the presence of trainers. Their filled-in questionnaires were thoroughly scrutinized to identify gaps if any, in their understanding. Later they were again briefed. To ensure and maintain the quality of data, entire data collection process in the four districts was monitored by two senior staff of CORT. Data collection was conducted from the last week of June 2005 till July 2005 in the selected districts of Jharkhand. 1.6 DATA ENTRY AND ANALYSIS Completed questionnaires were sent to CORT’s head office at Vadodara for data processing. Activities conducted there included office editing, coding, and computer editing using standard software package. CORT’s computer professional monitored and guided the office editing and data entry. The final data was analyzed by using the SPSS package. 1.7 FORMAT OF REPORT This report is presented in six chapters. The first chapter of the report is introduction which illustrates the background of the study, objectives, methodology, tools used, field work and sample selected and interviewed for this study. The second chapter describes the background characteristic of the target population, while the third chapter discusses the immunization coverage in all study population. ANC/Natal/PNC and breastfeeding/nutrition status are discussed in the fourth and fifth chapter respectively. Summary and conclusions is presented in sixth chapter.

5

2 Background Characteristics

The survey was carried at two levels namely the health facilities and community in Deogarh, Godda, Pakur and Sahibgunj districts of Jharkhand. At the facility level, Primary Health Centre (PHC) and Sub-centre (SC) were surveyed. At the community level, women who had a child between 0 to 11 months and/or in the age group of 12-23 months were interviewed. A brief profile of the health facilities and background characteristics of the study population is discussed in the following section. 2.1 HEALTH FACILITY 2.1.1 Primary Health Centre In the three-tier health system, PHCs play a significant role as they not only provide curative services but also have the responsibility of providing preventive and promotive services in the community. Availability of basic infrastructure and sanctioned staff are essential prerequisites to providing quality services to the community. The study made an attempt to assess the basic infrastructure available at the PHC and its staffing pattern. Among the total 30 study PHCs, 15 PHCs were block PHCs while the rest were additional PHCs. Infrastructure: In the study districts of Jharkhand, 30 Primary Health Centres (PHCs) were covered. Data in Table 2.1 reveals that except for one PHC in Sahibgunj, all the PHCs had their own building. Data on the condition of the PHC building shows that only 23 percent of the buildings were in good condition and the rest of the PHCs needed repairs. Major repair was needed in 37 percent of the 30 assessed PHC buildings. The condition of the building of PHCs in Godda districts was the worst as all the PHCs in this district required minor or major repair. Table 2.1: Infrastructure of the Primary Health Centre (Percentage)

Name of the Districts Indicators Deogarh Godda Pakur Sahibgunj

Total

Ownership of PHC Own Rented

8 -

7 -

6 -

8 1

29

1 Condition of PHC building Good Need minor repair Need major repair

2 3 3

- 5 2

2 2 2

3 2 4

7

12 11

Total number of PHC 8 7 6 9 30


Manpower: Regarding the staffing pattern of the assessed PHCs, data shows that on an average 3 (2.7) doctors/ per facility were found to be in position at the time of survey. On an average, an additional 3 (3.3) doctors per facility were reported to be in position on contract basis. Three quarters (76percent)of the study PHCs had male supervisors. In these PHCs, the mean number of male supervisor was 2.6 per facility, however this varies from 1.3 in Deogarh and Pakur districts to 5.0 in Godda district. Table 2.2 also indicates that on an average four male supervisors per facility in Godda district and two in Sahibgunj district were positioned on contract basis. Twenty-two PHCs (73 percent) had LHV/HA female and the mean number of LHV/HA female was 2.3 per facility. None of the LHV/HA were appointed on contract basis in the study districts. In case of ANM, majority (87 percent) of the PHCs have ANM and on an average around eight ANMs per facility were found to be in position and 3.4 ANMs per facility were reported on contract basis (Table 2.2). Table 2.2: Staffing Pattern of the PHC (Number and Mean)


Total

Average number of Male Doctors per facility In position On contract basis

2.3 3.6

3.0 3.1

2.3 2.8

3.1 3.6

2.7 3.3

Male Supervisor per facility Number of facility having male supervisor Average number in position On contract basis

6

1.3 -

6

5.0 4.0

5

1.3 -

6

2.3 2.0

23 2.6 3.0

LHV/HA Female per facility Number of facility having LHV/HA female Average number in position

6

3.0

7

2.6

4

1.0

5

2.0

22 2.3

ANM (at the PHC) per facility Number of facility having ANM Average number in position On contract basis

7

5.0 3.5

7

7.0 3.8

5

11.4 3.7

7

8.4 2.8

26 7.6 3.4

Total number of PHCs 8 7 6 9 30 Some of the suggestions that emerged from the medical officers regarding infrastructure included

New buildings are needed. Regular maintenance of furniture and buildings should be there Quarters should be provided to all the staff. Generator should be provided with PoL to all the facilities.

Regarding the manpower at the facility most of them stated

Vacant posts should be filled up and sufficient staff should be provided Routine training should be provided to the staff.

2.1.2 Sub-Centre Sub-centre is the first level of the three-tier health system where a male and a female health worker provide the health services at the community level. Information about the infrastructure of sub-centre and availability of IEC materials was gathered and has been presented in Table 2.3.

8

Chapter 2: Background Characteristics

Altogether, 48 sub-centres were surveyed in the study districts. Out of the total, 30 sub-centres had their own building and 33 had a Pucca building. It can be assessed from the table that the condition of the sub-centres was not up to the mark as only seven sub-centres (15 percent) were found in good condition. Electric connection was observed in only four sub-centres and only two sub-centres had regular/continuous supply of electricity. Table 2.3: Profile of the sub-centres (Numbers)


Total

Number of sub-centres having own building having pucca building buildings in good condition

5 6 2

6 8 3

11 12

2

8 7 -

30 33

7 Number of sub-centres in which

electricity connection is currently available electricity supply is regular/continuous

1 -

2 2

- -

1 -

4 2

Number of sub-centres having at least one IEC material available IEC on immunization

3 3

10 10

7 5

3 1

23 19

Number of sub-centres covered in the study 7 14 18 9 48 2.2 IEC/ SOCIAL MOBILIZATION Information at the sub-centre: Out of 48 sub-centres covered in the study area nearly half of the sub-centres had at least one IEC. Only 19 sub-centres had at least one IEC material related to immunization at their centre. The distribution of this varied from one sub-centre in Sahibgunj to ten sub-centres in Godda. Information at the PHC: IEC material displayed at the PHC could be an indirect way of disseminating information about the services available at the PHC. Data gathered on any poster or IEC material displayed in the PHC announcing availability of immunization either in the form of wall poster, pamphlet, charts or painting indicates that 26 PHC out of the total 30 PHC have at least one form of IEC on immunization in their facility. The distribution of these PHCs across the districts was seven each in Deogarh, Godda and Sahibgunj and five in Pakur. 2.3 COMMUNITY LEVEL 2.3.1 Background Characteristics of Mothers with Children 12-23 Months Almost all the mothers interviewed were currently married. Nearly three-fifths of them were Hindu followed by one-fourth Muslims. Two-fifths of the mothers were SC/ST. above three-fourths (79 percent) of the respondents were illiterate. Majority of the respondents were housewives followed by cultivators. Most of the respondent’s husbands were cultivators or daily wage earners. Around one-tenth were skilled workers or running small businesses. Most (80 percent) of the respondents lived in Kachcha houses. This ranged between 88 percent in Pakur district and 73 percent in Godda district. Access to radio was only 15 percent, followed by television (9 percent) and print media (3 percent). To a certain extent access to these media was relatively better in Godda district and least in Pakur district.

9


Table 2.4: Background characteristics of mother of children 12-23 months (Percentages) Name of the Districts Background characteristics

Deogarh Godda Pakur Sahibgunj Total

Marital status Currently married Divorced Widowed

99.6

- 0.4

98.8

1.3 -

99.6

- 0.4

99.2

0.8 -

99.3

0.5 0.2

Religion of head of the household Hindu Muslim Others

69.2 26.7

4.2

61.7 23.8 14.6

51.7 25.4 22.9

55.0 28.3 16.7

59.4 26.0 14.6

Caste SC/ST Others

31.7 68.3

37.5 62.5

46.3 53.7

42.9 57.1

39.6 60.4

Education of mothers Illiterate Literate

76.3 23.7

76.7 23.3

80.4 19.6

82.9 17.1

79.1 20.9

Occupation of mothers Daily wage earners Cultivators Small business Housewife Other

4.2

23.3 0.8

70.4 1.3

1.3

25.4 3.3

66.3 3.7

7.1

22.9 4.2

65.0 1.8

9.6

12.1 3.8

72.1 2.4

5.5

20.9 3.0

68.1 2.5

Occupation of fathers Daily wage earners Cultivators Pvt. Services Govt. services Skilled worker Small business Others

16.7 44.2

5.8 2.9

17.5 11.7

1.2

24.6 44.2

3.3 3.3 9.6 8.8 6.2

31.7 43.8

3.3 1.7 5.8 8.3 5.4

45.0 30.0

3.3 2.1 7.5 9.2 2.9

29.5 40.5

4.0 2.5

10.1 9.5 3.9

Type of house Kachcha Semi-pucca Pucca

79.2 13.8

7.1

73.3 19.6

7.1

87.9

8.8 3.3

80.4 13.3

6.3

80.2 13.9

5.9 Access to media

Exposure to print media Exposure to radio Exposure to T.V.

2.9

14.2 11.7

4.2

21.3 10.8

2.1 8.3 5.8

2.5

17.5 7.9

2.9

15.3 9.1

Total number of mothers of 12-23 months children 240 240 240

240 960

2.3.2 Background Characteristics of Mothers with Children 0-11 Months Almost all the mothers interviewed were currently married. The mean age of the mother interviewed was 24.8 years. Fifty-eight percent of them were Hindus, 27 percent Muslims, 10 percent belonged to Saran and the remaining six percent included Christian, Sikh etc. Caste wise analysis of study population shows that majority (52 percent) of the respondents belonged to other backward community, one-fourth belonged to scheduled tribe, one-tenth belonged to scheduled castes and remaining mothers belonged to other community. Regarding their literacy level more than three-fourths of the respondents were illiterate, while over half of their husbands were also illiterate. Occupation wise nearly 80 percent of the respondents were housewives followed by cultivators (13 percent), while 39 percent of their husbands were cultivators and 34 percent were daily wage earners. Most (85 percent) of the respondent resided in kachcha houses. On an average they had 3.3 live births and 3 living children. The mean age of the last child was 5.9 months.

10

Chapter 2: Background Characteristics

Table 2.5: Background characteristics of mothers of children 0-11 months (Percentages) Name of the Districts Indicators


Marital status Currently married Widow

100.0

-

100.0

-

99.2

0.8

100.0

-

99.8

0.2 Religion Hindu Muslim Saran Others

68.3 27.5

1.3 2.9

62.9 24.2 11.3

1.6

47.9 27.9 17.1

7.1

52.1 28.8

8.3 10.8

57.8 27.1

9.5 5.7

Caste SC ST OBC Other community

17.5 15.0 63.8

3.8

4.6

21.3 56.7 17.5

4.2

39.6 39.6 16.6

14.6 22.1 47.1 16.3

10.2 24.5 51.8 13.5

Education Illiterate Primary Secondary Above secondary

79.2 13.8

6.7 0.3

78.3 12.9

7.9 0.9

80.0 14.2

5.4 0.4

74.6 11.3 11.3

2.9

78.0 13.0

7.8 1.2

Husbands education Illiterate Primary Secondary Above secondary

43.3 29.6 20.8

6.3

49.6 22.1 23.3

5.0

59.6 21.7 14.2

4.6

55.0 16.3 17.9 10.8

51.9 22.4 19.1

6.7 Occupation Daily wage earner Cultivators House wives Others

2.9

14.6 80.4

2.1

0.8

10.0 87.5

1.7

3.8

20.8 70.0

5.4

7.5 7.1

80.0 5.4

3.8

13.1 79.5

4.4 Occupation of Husbands Daily wage earner Cultivators Skilled worker Small business Others

28.8 43.3 12.5

7.9 7.5

27.9 43.8 12.1

8.3 7.9

33.8 41.7

6.3 9.6 8.6

46.3 27.1

7.1 10.4 10.1

34.2 39.0

9.5 9.1 8.2

Type of house Kachcha Semi-pucca Pucca

82.5 10.4

7.1

84.6

7.5 7.9

91.7

5.8 2.5

82.9 11.7

5.4

85.4

8.9 5.7

Average number of total live births Average number of male live births Average number of female live births

3.3 1.6 1.7

3.2 1.6 1.6

3.3 1.5 1.8

3.4 1.6 1.8

3.3 1.6 1.7

Exposure to media Read/listen news paper Hear to Radio See TV

5.0

19.6 13.3

4.6

27.9 13.8

2.9

18.8 6.3

5.4

23.8 17.5

4.5

22.5 12.7

Average number of total children living Average number of male living Average number of female living

3 1.4 1.6

3 1.5 1.5

3 1.4 1.6

3 1.4 1.6

3 1.4 1.6

Total number of mothers of 0-11months children

240 240 240 240 960

11


It is a well known fact that exposure to media plays a vital role in increasing knowledge. Hence data was collected on exposure to media in the study. It was found that only five percent of the respondents read or listened to newspaper, while 23 percent heard radio and 13 percent viewed television. The above findings indicates that though majority of the PHC and SC had their own buildings to a large extent they require repairs. Mothers interviewed from the community were largely Hindus with almost 35 to 40 percent of them belonging to ST/SC, more than three fourths of the women were illiterate and residing in Kachha households.

12

3 Immunization

Success of health programmes depends on the extent of interaction between the service and target population. This interaction ranges over the whole process from making available the services, creating knowledge about the services, providing the services to all, especially the under served and un-reached sections of the community. The interaction therefore ranges from resource allocation to achievement of the desired objectives. According to Tanahashi (1978) to measure coverage of any health programme it is important to evaluate performance broadly in five stages that is availability, accessibility, utilization, adequate coverage and effective coverage. Keeping in line with this, the present study too makes an attempt to understand the reach of the immunization programme in the four study districts of Jharkhand. This chapter initially discusses availability of services followed by the section on accessibility and the utilization component that is the reach of immunization programme in the community. Given this scenario the chapter then tries to assess the adequate and effective coverage for the same. 3.1 AVAILABILITY OF VACCINES Availability and timely supply of all the vaccines is the key component in the immunization programme. An attempt to assess the same was made in the 30 PHCs that were surveyed in the four districts. It may also be pointed out here that the data collection in the district coincided with the `Catch up’ round that was being implemented by the state authorities. As the term indicates this was a drive implemented by the state authorities where the workers had to reach out to children who were so far left out or unreached for immunization. This programme was planned in such a way that health workers reach every village with immunization services, Vitamin A, Iron folic acid tablets and deworming tablets. The catch up round that was ongoing, was the second drive, the first drive had taken place during 7th December 2004 to 7th January 2005. The second drive was launched from 1st June to 7th July and from 15th July to 15 August 2005. 3.1.1 Stock of vaccines in facility For all immunization programmes it is imperative that the PHC has the required stock of the vaccine at the facility. During the survey, data was gathered from the facilities on the position of the available vaccines in the facility. Data was gathered from the facility regarding the availability of stock on the day of the visit. As indicated in Table 3.1, data reveals that there is a wide dispersion in the stock available across the facilities in each district. The average doses available per facility varied from 533 doses for BCG, 669 doses for DPT to as high as 1850 doses for OPV and 1012 doses in case of measles. Not only the stock of the vaccines varies by its type, but its availability also varies across the four study districts as well as among the surveyed facilities within each district. Informal discussions with the concerned officials indicated that in some facilities due to the ongoing catch-up round more vaccines were available in the facilities. For routine immunization programme too, the officials reported that they do not normally encounter problem in receiving the vaccine supply from the district headquarter. Almost all medical officers


reported that in case they request for additional vaccines it was supplied without any problems. Table 3.1: Average position of vaccine doses per facility


Total

BCG No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

422.9 413.7

- 1000

4

768.3 1154.5

- 3000

4

310.0 288.1

- 700

6

611.7 434.2

140 1240

20

532.9 648.4

- 3000

DPT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

472.9 362.5

- 1000

5

1323.3 1058.7

- 2500

3

642.0 818.1

- 2000

3

266.7 535.8

- 1350

17

669.2 789.0

- 2500

OPV No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

1405.7 1200.3

- 3000

6

3303.3 4207.85

80 9000

4

1570.0 2067.5

- 5000

6

1146.7 1155.2

60 2880

22

1849.6 2453.7

- 9000

Measles No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

641.9 982.6

- 2800

6

2410.8 1804.88

200 4275

5

416.0 250.86

115 800

5

540 597.5

- 1470

22

1011.6 1317.6

- 4275

DT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

5

248.6 225.6

- 500

6

1061.7 886.4

150 2500

5

382.0 217.6

200 710

6

570.0 819.6

120 2220

22

560.0 663.7

- 2500

TT No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

345.6 348.4

- 1010

6

3716.7 2115.8

800 6250

5

478.0 356.3

100 1000

5

468.3 470.1

- 1080

22

1246.6 1788.9

- 6250

Total no. of facilities where vaccine stock was observed

7

6

5

6

24

Vitamin A solution (bottles) No. of facilities have stock on the day of visit Mean SD Minimum Maximum

6

209.2 433.0

4 1090

6

205.5 187.1

35 450

3

64.7 72.5

16 148

9

113.2 145.0

4 400

24

154.2 243.5

4 1090

Total number of facilities where stock was observed

7

7

3

9

26

Total number of PHC 8 7 6 9 30 In addition to assessing the stock of the vaccines in the facility, the medical officers were also probed on whether they perceived the available stock to be sufficient for the week or not. As can be observed from Table 3.2, only 15 PHCs to 20 PHCs out of the total 30 PHCs reported the stock to be sufficient.

14

Chapter 3: Immunization

Due to the above dynamics in the collection and distribution of the vaccine stocks, attempt to understand the stock available at the PHC as per the standard norm (that is having required number of vaccines in the facility as per the estimated number of children below one year in the coverage area and considering the number of doses and wastage of the vaccines) was calculated. The number of facilities having the adequate stock of the vaccine was either slightly more (as in case of BCG and Measles) or less (in OPV and DPT) or same (in TT). Table 3.2: Reported and calculated stock of vaccines at facility (Number)


Total

BCG PHCs reported stock available for next week as per calculation

4 3

4 3

3 4

4 6

15 16

DPT PHCs reported stock available for next week as per calculation

5 3

4 4

3 3

2 1

14 11

OPV PHCs reported stock available for next week as per calculation

5 3

4 4

4 4

3 3

16 14

Measles PHCs reported stock available for next week as per calculation

5 4

6 6

4 5

3 4

18 19

TT PHCs reported stock available for next week as per calculation

4 3

6 6

5 4

3 5

18 18

IFA tablet PHCs reported stock available for next week as per calculation

4 2

7 5

2 2

7 1

20 10

Total number of PHC 8 7 6 9 30 3.1.2 Status of Vaccines in the Facility For complete coverage of the target population, it is assumed that vaccines for BCG, OPV, DPT and measles are available with the health facility. Analysis of the same in the 29 facilities that were observed indicates that six facilities did not have any vaccines stored in the facility on the day of the survey. In almost all of these electricity was either not available or not regular. These facilities are spread across all the surveyed districts. Among the 23 facilities in which vaccine was available, 14 of them had all the vaccines in the facility, while nine of them had only partial vaccines. This was true for three PHCs each in Godda, Pakur and Sahibgunj district respectively (Table 3.3). Table 3.3: Position of vaccines in PHCs (Number)


Total

Number Of PHCs surveyed In which no vaccines are available In which vaccine was available on the day of visit In which all vaccines were available In which partial vaccines were available

8 1 7 6 1

7 1 6 5 1

6 1 5 2 3

9 3 6 4 2

30 6

24 17

7

15


Informal discussion with the medical officer of the PHC on the status of vaccine supply in the facility they opined

“Vaccine should be supplied directly at PHC/SC/Immunization session using two wheelers. Did you see Pizza Hut two-wheeler with box? Such kind of two wheelers with cold box fixed to it can be used. In a day two to three villages can be covered by a person easily, as well as the potency of the vaccine will also be maintained, covering remote villages also”

3.1.3 Status of Vitamin A in Sub-centres Out of the 48 sub-centres surveyed only 32 of them had Vitamin A solution on the day of survey (Table 3.4). The average number of bottles available per facility varied from three bottles in Deogarh to eight bottles in Godda. Vaccine carriers were available in all the sub-centres. Table 3.4: Position of Vitamin A and vaccine carrier in sub-centres


Total

Number of sub-centres having Vitamin A solution 3 9 14 6 32 Average number of vitamin A solutions bottles available

3.3 8.4 3.6 4.3 5.1

Number of SCs having vaccine carrier 7 14 17* 9 48 Total number of SCs 7 14 18 9 48 *In one facility the number of vaccines available was not known 3.1.4 Cold Chain Quality For the programme it is essential that not only the PHC should have vaccine but also they should be kept in the cold chain as per their norm. This is essential to ensure the potency of the vaccines. Any deviation from this might influence the potency level of the vaccine and there by effective coverage of the children. As is evident from Table 3.5 though a certain number of PHCs have the vaccines, not all of them are stocking it as per the norm. For instance in 24 PHCs, BCG was available, but as per the norm it has to be kept in ILR and this was evident in only nine PHCs. Storage of DPT and Polio vaccine as per norm was evident in only ten and seven facilities respectively. In case of Measles it was least (two facilities). From the surveyed facilities it may be mentioned that to some extent the situation of the facilities is relatively better in Godda, followed by Deogarh and Pakur, and poor in Sahibgunj.

16


Table 3.5: Availability of vaccines and its place of storage (Number) Name of the Districts Indicators


Number of PHCs where BCG vaccine was kept as per norm in ILR kept in cold box kept in deep freezer Not stored

3 2 1 1

5 1 - 1

1 3 1 1

- 6 - 3

9 12

2 6

DPT vaccine was kept as per norm in ILR kept in deep freezer kept in cold box not stored kept in vaccine carrier

4 - 2 1 -

5 - 1 1 -

1 - 2 2 1

- - 4 5 -

10

- 9 9 1

Polio vaccine was kept as per norm in deep freezer kept in ILR kept in cold box not stored kept in vaccine carrier

2 2 2 1 -

3 2 1 1 -

2 -

1 2 1

- - 6 3 -

7 4

10 7 1

Measles vaccine was kept in deep freezer as per norm kept in ILR kept in cold box Vaccine not stored Vaccine carrier

- 4 2 1 -

2 3 1 1 -

- 1 3 1 1

- - 6 3 -

2 8

12 6 1

Total number of PHCs 8* 7 6 9 30* * In one facility observation was not possible For the storage of vaccine effectively either in ILR and/or deep freezer it is imperative that the PHC should have regular supply of electricity or generator facility. Analysis of the same indicates (Table 3.6) that 21 PHC did mention that they have an electricity connection. The distribution of this varied from three in Sahibgunj to seven in Deogarh. However, only seven of them reported that they had regular supply of electricity. Average hours for which electricity was available in the other PHCs was around four hours during the day and three hours in the evening/nights. On the day of data collection in the facility electricity was available in only seven PHCs, which however were not the same as those who reported regular supply of electricity. Out of the total 30 PHC surveyed, only 17 of them had a generator facility, among which only 12 were in working condition. Source of funds to manage the fuel for the generator was the government in nine PHCs, two of them reported UNICEF fund and six of them managed it from other source. On an average, generators would have to run an on average 3-4 hours a day to make up the required 8 hours day power supply. In two districts, there is less than 4 hours of mains power supply a day, making it difficult to make up the balance power requirement using a generator set.

17


Table 3.6: Status of electricity/generator in PHC Name of the Districts Indicators


Number of PHC having electricity connection having regular supply

7 3

6 2

5 2

3 -

21

7 Average hours of electricity available

in a day during evening or night

4.3 3.3

3.0 2.8

3.7 3.3

5.0

-

3.8 2.8

Number of PHCs having electricity on the day of visits

2 2 1 2 7

Number of PHCs having generator in working condition not in working condition

6 5 1

5 5 -

- - -

6 2 4

17 12

5 Source of fund for POL of generator

Government fund UNICEF Others

5 - 1

1 1 3

- - -

3 1 2

9 2 6

Total number of PHCs 8 7 6 9 30 3.1.5 Injection Safety ANMs should have access to syringes/needles for immunization. Out of 54 ANMs, 28 reported that they use disposable syringes, while 25 ANMs reported the use of Auto-disabled (A.D.) syringe for non-BCG immunization injections. Only one ANM from Sahibgunj reported that she used sterilized needles. For providing BCG vaccination, 39 ANMs reported that they use A.D. syringe, while 21 reported that they use disposable syringes. Except for one ANM in Pakur, all 53 ANM had heard and seen A.D. syringes. Regarding disposal, 28 of them mentioned that they bury the used AD syringes in a pit. Some of the other response given included - burn it (7), thrown out (5), cut the hub and bury (2), cut the hub and throw it away (1) etc. 3.1.6 Mode of Collecting Vaccines The supplies reach the Block PHC/ PHC weekly rather than monthly due to the problems in electricity supply and availability of cold chain. These were usually supplied by Tuesday evening and the ANM collects the same for the routine immunization programme to be held on Wednesday. The time required for collection by the ANM from the PHC till its actual utilization in the immunization session, differs across the facilities. In most cases, ANMs collect the vaccine from the PHC on Tuesday and take it to the immunization session the next day from her residence. The mode of carrying the vaccine from the PHC till it is utilized for immunization was understood from the ANM. Forty-six ANM out of the total 54 did mention that they go and get the vaccine from the PHC. Four ANM reported that they send some one to the PHC to collect the vaccine, and the remaining ANMs reported that the PHC delivers the vaccine at the sub-centre or the immunization session. Fifty-three of them did also mention that the vaccine was carried in thermocol, vaccine carrier/ice box. Probing into the time required from collection of vaccines to administering it to the child was reported to be nine hours. Minimum time was reported two hours and the maximum time reported was 24 hours. District wise the average time varied from eight hours in Pakur, to nine hours in Deogarh and ten hours each in Godda and Sahibgunj. Given this situation, it

18


needs to be ascertained whether the cold chain for the vaccine is actually adequately maintained or not as per the norm. All the ANMs were asked what they do with the unused vials, if any. Forty-eight ANMs out of 54 reported that they return the same to the PHC. Probing further on the partially used vials 26 ANMs reported that they throw it away and 22 ANMs reported that they return the same to PHC. Table 3.7: Time required for collection of vaccine and handling of unused vials

Name of the Districts Indicator Deogarh Godda Pakur Sahibgunj

Total

Time to Collect Vaccines until Use (Hrs) Average Standard deviation Minimum Maximum

9.0 5.9 3.5

18.0

9.7 6.8 4.0

24.0

7.6 3.9 3.0

18.0

9.7 5.8 2.0

20.0

8.8 5.4 2.0

24.0 Unused vials is (number)

Disposed Returned to PHC Used

- 8 1

-

14 -

-

20 -

2 6 3

2

48 4

Number of ANMs 9 14 20 11 54 3.2 ACCESSIBILITY OF IMMUNIZATION SESSIONS In addition to the availability of essential vaccines, it is essential that the same are accessible to the community through planned, fixed immunization sessions. An attempt has been made to understand this at various level of the health facility as well as village level, in the following discussion. 3.2.1 Immunization Sessions Details were gathered from the ANM regarding how they plan and conduct immunization sessions in their area. Thirty-nine ANMs reported that they have fixed day immunization. While nine ANMs mentioned that they follow work plan for immunization programme. The remaining ANM mentioned that they inform the AWW and take their help in organizing the immunization sessions. Table 3.8: Background of ANMs


Total

Number of ANMs covered 9 14 20 11 54 Number of ANMs received field training 2 9 12 7 30 Number of ANMs staying in the quarter - 1 1 4 6 Number of ANMs in the SC head quarter villages - 3 2 2 7 Number of ANMs having fixed days immunization 7 10 15 7 39 Average number of villages having more than 1000 population

covered by ANM in which immunization sessions was conducted in last three months

3.8

3.4

2.7

2.6

4.2

3.6

4.5

2.9

3.8

3.1 Average number of villages having less than 1000 population

covered by ANM in which immunization session was conducted in last three months

6.3

6.1

4.4

3.9

9.3

9.0

6.3

2.6

6.9

5.9

19


3.2.2 Access to Sessions All the ANMs were asked about the number of villages where they conduct immunization sessions in a month. Analysis of the same indicates that on an average an ANM had to cover a little less than four villages where population was more than 1000 and around seven villages having less than 1000 population covers five villages for immunization. Further, probing on the coverage of villages for immunization sessions and thereby to assess whether the ANMs actually covers only the large size village or also the smaller villages wherein usually the accessibility is difficult. Data reveals that in the last three months, on an average ANMs conducted immunization session in three villages which had more than 1000 population, that is around 82 percent while six villages which had less than 1000 population were also covered which was a coverage of almost 86 percent of their assigned villages. Among the four study districts coverage of the villages by ANM was less in Sahibgunj district when compared to other three districts (Table 3.8). Conducting these routine immunization sessions in the villages, ANMs do encounter various kinds of problems which are apparently both at the facility level as well as in the community (Box 1). In continuation to this the ANMs were also asked how they motivate mothers to come to the immunization sessions. A positive attitude and motivation of the ANM will equip her to have strategies to reach to the mothers. Some of the strategies used include: providing detailed information, house to house visits etc. (Box 2)

BOX 1 Problems encountered in conducting routine

immunization session

• People are mainly illiterate; it is difficult to convince them

• People believe that due to immunization, children get temperature, wound

• Some people believe this is from government and hence vaccines are not of good quality

• There are problems in bringing the vaccine from the PHC

• Certain villages do not have transport facility and hence difficult to reach them, in rainy season the condition of the roads worsen

• No sitting arrangement at the facility, no support staff available

• Electricity and water problem

BOX 2 Strategies used to motivate mothers to come to

immunization clinic

• Talk about the importance of the disease it prevents

• Explain that it is for the health of the child • Go house to house and explain • Use Anganwadi worker, trained dai, local

person for disseminating information • Show the card and explain • Follow up mothers at home

3.2.3 Access at the Village Level Out of the 120 villages and hamlets surveyed, immunization sessions were reported to be conducted in 102 villages (Table 3.9). In almost one-third of the villages, these sessions were held at the anganwadi centre. This was 53 percent in Godda district and ten percent in Deogarh district. Some of the other sites used for immunization sessions included school (16 percent) and the sub-centre (13 percent). Regarding the frequency at which these sessions were conducted, one-third of them did mention that it is held once in a month. However, the response from 40 percent of the villages is worrisome as the frequency mentioned varies between two to three months, less frequently and rarely. Further probing on whether the place of immunization is accessible to all the sections of the community. Only in two villages some section of the community did not have accessibility to the immunization session.

20


Table 3.9: Status of immunization sessions Name of the Districts Indicators


Percentage of villages in which immunization session conducted

83.3

93.3

90.0

73.3

85.0

Place where the immunization sessions are held (percentage)

Sub-centre School Anganwadi Sarpanch’s house Any household in the village Other

6.7 26.7 10.0

- 16.7 23.3

6.7 10.0 53.3

- 3.3

20.0

26.7 10.0 33.3

- -

20.0

10.0 16.7 33.3

3.3 -

10.0

12.5 15.8 32.5

0.8 5.0

18.3 Frequency at which sessions conducted (percentage)

Once in a week Once in a month Once in 2-3 months Less frequently Rarely Other

6.7

23.3 10.0 10.0 30.0

3.3

6.7

43.3 6.7

10.0 23.3

3.3

13.3 40.0

6.7 20.0 10.0

-

6.7

30.0 6.7 6.7

16.7 6.7

8.3

34.2 7.5

11.7 20.0

3.3 Immunization place accessible to all sections of the community (percentage)

80.0

90.0

90.0

73.3

83.3

Total number of villages 30 30 30 30 120 Related to the accessibility of the services is also accessibility of the health facilities in these villages, which were also analyzed. In Jharkhand, 120 villages were surveyed. The average distance to nearest town among the surveyed villages was found to be 12.4 kms. Almost half of the villages (69) did not have any health facilities available within their village; while the sub-centre/PHC contributed 30 percent (36 villages), private doctors were available in 21 percent (25 villages) of the villages (Table 3.10). Among the four districts comparatively more villages in Sahibgunj did not have any health facility. Health committees were there only in 12 percent of the villages. For 53 percent of the villages, a sub-centre was the nearest government health facility while for 41 percent of the villages, PHC was the nearest public health centre. Twenty villages reported that the nearest government health facilities were not accessible in all the seasons. Table 3.10: Health facilities available in the villages


Total

Average number of traditional birth attendants available 1.2 2.1 1.4 2.1 1.7 Average number of medical shops available 0.3 0.7 0.4 0.7 0.5 Health facilities available in the village (percentage)

None Sub-centre Primary health centre Private doctor ANM visits the village Other

50.0 20.0

6.7 26.7 23.3

-

46.7 20.0

3.3 26.7 13.3

3.3

46.7 40.0

- 23.3 16.7

3.3

63.3 26.7

3.3 6.7

23.3 -

51.7 26.7

3.3 20.8 19.2

1.7 Percentage of villages have any health committee 20.0 6.7 13.3 6.7 11.7 Nearest government health facility (percentage)

Sub-centre Primary health centre Community health centre District hospital Other

56.7 33.3

3.3 3.3 3.3

50.0 40.0

- 10.0

-

53.3 43.3

- 3.3

-

50.0 46.7

- 3.3

-

52.5 40.8

0.8 5.0 0.8

21


The average distance to the nearest govt. health facility was found to be nine kilometers (Table 3.11). It varied from four kms each in Deogarh and Godda to 17 kms in Pakur. Access to these health facilities was mainly on foot followed by bicycle. In 112 villages there was no bus facility to nearby health facility. Table 3.11: Distance and mode of accessibility to health facility


Total

Average distance to the nearest government health facility (in kms)

3.5

3.9

16.8

13.3

9.4

Mode of accessibility to the health facility (percentage) Bus/minibus Private vehicle Train On bicycle On foot Other

3.3

26.7 3.3

86.7 93.3 26.7

10.0 30.0

- 76.7 83.3 16.7

3.3

33.3 -

90.0 86.7 26.7

10.0 30.0

3.3 90.0

100.0 30.0

6.7

30.0 1.7

85.8 90.8 25.0

Total 30 30 30 30 120 3.2.4 Health Personnel who makes the Services Accessible As per the norm each Auxiliary Nurse Midwife (ANM) has certain areas assigned to her. She is responsible for the care and management of health services in this area with special emphasis to the health of the pregnant mothers and children. During the study a total of 54 ANMs were interviewed. Brief characteristic of the interviewed ANM’s is given in Box 3.

BOX-3 Characteristic of ANMs

• Mean age of ANM s was 39 years • Average population covered was 10,717 • Eleven ANMs were provided with quarter • Six ANMs were actually staying in the quarters • Twenty-two ANMs reside in neighboring village • Average distance from sub-centre to residence

was 9 kms

3.2.5 Linkages with Anganwadi Worker with Access Villages do have an Anganwadi worker who is in constant touch with the community especially mothers with young children. Contact with her by the ANM should make the immunization services more accessible to the community. It was in this context that the ANM were asked whether they have advance tour programme and share it with Anganwadi workers. Fifty ANMs responded positively, among these 46 (85 percent) of them did mention that they do share their advance tour programme with the Anganwadi worker. Three ANMs from Pakur and one from Godda reported that they do not share the program. Such positive linkages at the village level should help in increasing the accessibility to immunization services. 3. 3 UTILIZATION AND ADEQUATE COVERAGE It is well established that by vaccinating children against the six killer diseases, infant mortality and morbidity will decline. Hence in the study area status of immunization of children aged 12-23 months was collected. As per the study design 240 mothers of children aged 12-23 months were interviewed from each selected districts.

22


3.3.1 Immunization Practice In the study area 240 mothers of children aged 12-23 months were interviewed. Information on each of the vaccine, whether provided or not, if provided at what age it was provided, source of immunization, etc. was collected.

Figure 3.1: Percent of Mothers who have Immunization Card

33.8 36.3

47.1

39.2 39.1

0

10

20

30

40

50

60

Deoghar Godda Pakur Sahibgunj Total

As observed from figure 3.1 only 39 percent of the mothers reported having immunization card. This was highest at 47 percent in Pakur and lowest (34 percent) in Deogarh. Regarding the utilization of immunization services, as the data in the Table 3.12 indicate immunization coverage varied across the vaccines and across the districts. Analyzing the same vaccine wise shows that only 43 percent of children had received BCG vaccination. Among the four districts, the proportion of children who received BCG was lower in Deogarh than the other districts. Regarding DPT coverage, around 40 percent of the children had received DPT 1, while 28 percent and 21 percent received DPT 2 and 3 respectively. This shows a drop out of 19 percentage points from the first to the third dose. Coverage of this vaccination was lowest in Deogarh, but the drop out from the first to the third dose was highest in Pakur district. The percentage of children who received polio '0' shows that only 15 percent of the study population had received it. This was comparatively lower in Godda district. The coverage of Polio I dose to III dose decreased from 45 percent for Polio I dose to 28 percent for Polio III. This shows a drop out of 16 percentage points. This drop out was higher in Pakur district than in other districts. About 37 percent of the children in the study area had received Measles vaccination. If we look into Vitamin A Prophylaxis, about 43 percent of the children had received the same. Thus in the study area two-third of children received atleast one vaccine. Table 3.12: Type of vaccines received by children


Total

Percentage of children received BCG 35.0 45.0 45.8 45.4 42.8 Percentage of children received

DPT I DPT II DPT III

31.7 21.3 14.2

47.1 34.2 26.3

40.8 29.6 21.7

38.3 27.5 22.1

39.5 28.1 21.0

Percentage of children received Polio ‘O’ Polio I Polio II Polio III

14.2 39.6 31.3 24.6

10.8 53.3 43.3 35.8

17.1 46.3 32.9 26.7

15.8 40.4 32.1 32.1

14.5 44.9 34.9 28.4

Percentage of children received Measles 32.1 40.0 38.3 36.3 36.7 Percentage of children received Vit. A (1 dose) 40.0 44.2 47.5 39.2 42.7 Total number of children (12-23 months) 240 240 240 240 960

It is important to provide all vaccines to a child, providing one vaccine is not enough as the child has to be provided with all the four vaccinations and vitamin A prophylaxis for adequate protection.

23


The data (Table 3.13) indicates that in the study area only 15 percent of the children were fully immunized. This varies from 10 percent in Deogarh district to 18 percent each in Godda and Sahibgunj district. The percentage of partially immunized children was 66 percent. In other words, the immunization programme had at some point or the other had reached these children, but had failed to contact them for the required subsequent doses. Thirty four percent of surveyed children have still not been reached for any vaccination. This was highest at 41 percent each in Deogarh and Sahibgunj districts and lowest at 24 percent in Godda district. Table 3.13: Status of children immunization (Percentage)

Name of the Districts Percentage of children who received Deogarh Godda Pakur Sahibgunj

Total

No Immunization 41.3 24.2 30.8 41.3 34.4 At least one immunization 58.8 75.8 69.2 58.8 65.6 Complete immunization 10.4 17.5 12.9 17.9 14.7 At least one immunization +Vit ‘A’ 59.6 77.1 72.5 60.8 67.5 Complete immunization + Vit ‘A’ 9.6 17.1 11.7 15.8 13.5 Total number of children (12-23 months) 240 240 240 240 960 Taking into consideration the Immunization Plus Programme, if we look into the status of complete immunization of children with vitamin A , the percentage drops marginally to 14 percent, while the partially immunized increases slightly, apparently because only Vitamin A was given. 3.3.2 Client Perception of Immunization Accessibility to health facility even if it is available will be under utilized if the users are not aware of the problem. In the case of immunization, if mothers do not have the required knowledge on the need of getting their children immunized, it might act as a barrier. In light of this, as per the study design 240 mothers who had delivered 12 months prior to the date of survey were interviewed. In addition to other details, their knowledge about immunization was also assessed. Knowledge of Immunization All the respondents were asked if they were aware that to protect children from disease they should be immunized. Data indicates that about 70 percent of the mothers were aware about it. All these mothers who were aware about immunization were further asked about the source of their information. Twenty seven percent of the respondents reported that ANM/Health workers were their source of information. Nine percent mentioned that they came to know about immunization through Anganwadi worker. Fifteen percent of the mothers came to know about immunization through their family members. All those mothers who mentioned that they do not know about immunization were asked whether they know that on certain days health workers come and provide injections/ and put drops in the children mouth. About 15 percent reported positively.

24


BOX 4 Reasons for not immunizing

• Not aware about immunization • Not aware of the place of immunization • Immunization not carried out in the village • Child was not keeping well • Child was not at home • Lack of money/ it cost money

Reasons for not immunizing: All the 330 mothers who had not given any immunization to their child were asked the reasons for the same. Analysis of the same indicates varied kind of response. Some of the main reasons includes that they were not aware about immunization, they do not perceive the need of immunizing the child as the child was healthy, facility not available in the village etc. Overall the reasons do point out the need to address the community on the importance of immunization and remove the misconceptions regarding it. They will have to be told where and when the same are available. Simultaneously the access issues also needs to be strengthened. 3.3.3 Socioeconomic Comparison of Immunization Coverage Further analysis of the socio-economic characteristics of children not immunized, partially immunized, and fully immunized is presented in Table 3.14. It is evident from the table that percent of completely immunized children was lower among Muslim population as compared with Hindu and other religious groups. (District by district break-downs are annexed.) Status of immunization improves with the education level of mother. As complete immunization of children was 31 percent when the child's mother was literate while the same was only 10 percent for illiterate mother. While analyzing the data with exposure to any media, complete immunization was 31 percent among those who were exposed to any media while it was only 11 percent among those who were not exposed to any media. Similarly complete immunization in villages where immunization sessions were held was 15 percent while it was 13 percent in villages where no sessions were held. Chi-square test shows relation between religion, education of mother, exposure to media, availability of health facility within the village, availability of immunization sessions in the village and immunization to be highly significant.

Table 3.14: Status of immunization by selected indicators Back ground characteristics

Percent Not immunized

Percent Partially Immunized

Percent Completely Immunized

Total

Mothers religion χ2 42.42 Hindu 28.6 52.6 18.8 570 Muslims 46.8 48.8 4.4 250 Others 35.7 47.9 16.4 140 Education level of mothers χ2 83.15 Illiterate 40.1 49.7 10.3 759 Literate 12.9 55.7 31.3 201 Exposure of mothers to any media χ2 54.56 Exposed to any media

19.3 49.4 31.3 176

Not exposed to any media

37.8 51.3 11.0 784

Health facility within the village χ2 35.26 Available 55.6 31.3 13.2 144 Not available 30.6 54.6 15.0 816 Immunization session in the village χ2 35.26 Yes 30.6 54.4 15.0 816 No 55.6 31.3 13.2 144 Total 34.4 50.9 14.7 960

3.4 EFFECTIVE COVERAGE Correct and complete knowledge of immunization will help the ANM in reaching out her services to the target group effectively. In case of immunization, it is essential that the ANM is aware about the disease which the vaccine prevents, number of doses a child should receive to be completely protected, age at which the first dose of immunization

25


should be given and the route of administration. Analysis of the same is presented in Table 3.15. It is evident that not a single ANM was having the correct knowledge on the details of all immunizations. Forty-seven of them had correct knowledge on the details for at least one immunization. It is therefore essential to ensure that the ANMs have the requisite information, as it will strengthen them to provide the services adequately. In addition to the details of the vaccines, ANMs were also asked whether they were aware about the conditions that are contraindications for vaccination. In this case too, as the data (Table 3.15) indicates 24 and 23 ANMs were having the wrong knowledge that immunization should not be given to a pre-term/low birth weight baby and a child suffering with mild diarrhoea respectively. However, 37 of them had correct knowledge that seizure following previous immunization was contraindication. Informal discussions with some ANM on this topic here revealed that

“In case a child has fever/cold or any other health problem we are reluctant to immunize the child, because parents relate the occurrence of temperature/diarrhoea to immunization and in such situation they blame us and come to beat us. What can we do? The doctor is not there in the facility always, so where will we take the child for treatment? Hence in such situation we do not immunize the child and ask the mother to bring the child later”.

The above verbatim clearly indicates that though the ANM might have the correct knowledge, due to lack of backup support she does not want to take any chance with the community, as her position is at stake. Table 3.15: Level of ANMs knowledge on immunization (Number)


Total

Number of ANMs correctly knows the name of all the six diseases which the vaccine prevents the number of doses for each of the four vaccines the schedule of the first dose for all four vaccines route of administration of vaccines

1 8 2 5

- 8 2 6

- 12

7 7

- 6 5 3

1 34 16 21

ANM has correct knowledge on the name of disease prevented, no of doses, age of first dose and route of administration for

BCG OPV DPT Measles

8 4 1 6

7 3 0

11

14 2 0 6

6 2 1 2

35 11

2 25

Number of ANMs who correctly knows all the details of All the four vaccinations Knows about at least one vaccination

0 9

0

14

0

16

0 8

0

47 Number of ANMs reporting the conditions are contra indication for vaccination

Pre-term/low-birth weight Mild diarrhoea Seizure following previous Immunization Minor low grade fever

5 3 7 4

8 6 9 4

7 9

13 13

4 5 8 4

24 23 37 25

Total number of ANM 9 14 20 11 54

26


3.5 TIMING OF IMMUNIZATION The data analyzed shows that even though 43 percent of children received BCG only 13 percent received BCG within one month of age. Similarly only 13, 9 and 7 percent of children received DPT 1,2 and 3 as per schedule. While looking into Polio 16, 12 and 9 percent of children received Polio I, II and III doses respectively as per schedule. Only seven percent of children received measles as per schedule. Further analysis of data shows that only six percent of children got all three doses of DPT as per schedule, and nine percent received all three doses of polio as per schedule. Over all, only two percent of children received all vaccines as per schedule. Table 3.16: Percentage of children who received immunization as per schedule


Total

Percentage of children received BCG within one month DPT I within one month DPT II in 2nd and 3rd month DPT III in 3rd and 4th month Polio ‘O’ within 15 days Polio I in 1&2nd month Polio II in 2&3rd month Polio III 3&4th month Measles in 9th month

9.6 7.5 5.0 3.8

13.2 16.3 11.7

9.6 6.3

15.1 15.5 11.6

9.1 9.8

19.6 14.6 10.4

6.7

11.7 13.8

9.2 7.1

12.6 14.2

8.7 6.7 5.8

16.7 14.2

8.3 6.7

16.0 15.0 12.1 10.0

7.9

13.0 12.7

8.5 6.6

12.1 16.2 11.8

9.2 6.7

3.6 REVIEW OF IMMUNIZATION BOTTLENECKS

Figure: 3.2 Immunization Status

80

50

64

15

2

0 20 40 60 80 100

Percentage of PHCs having vaccine

Percent of villages reporting regularsession

Percent ochildren had anyvaccination

Percent of children completelyimmunized

Percent of children immunized atright age

Percent

Hence, understanding the immunization services in the study district in terms of its availability (vaccines in the PHC), accessibility (villages reporting regular immunization sessions), utilization (children received at least one vaccination), adequate (children received complete vaccination) and effective coverage (children received complete immunization as per schedule), as seen from the figure here, apparently there is a wide gap between the supply of vaccines and timely full immunization. Though the programme has reached out to nearly two thirds of the target population, it has not been successful to follow this population for follow-up services, hence the biggest bottlenecks appear to be in tracing drop-outs and ensuring correct timing of immunization. Initial contacts of the service should be utilized to inform the community about the need of subsequent services available and importance of it.

27

4

Ante-natal/Natal and Post-natal

Infant mortality rate is an important indicator as it reflects the status of survival of children. Part of the infant mortality rate is the neo-natal mortality, which constitutes almost two-thirds of all deaths during infancy. These deaths can be best avoided if deliveries are held in hospitals under medical supervision. This study made an attempt to understand the situation of ante-natal, natal and post-natal services sought by 960 mothers spread across four study districts of Jharkhand. The mothers interviewed for the study had a child less than twelve months as on the date of survey. This chapter presents the findings from the same. As in the earlier chapter, in this case too an attempt has been made to understand the natal services by taking the minimum bottleneck approach of Tanahashi, this basically includes understanding of the services in terms of: availability of services, accessibility, utilization, adequate and effective coverage. As per the information available in the study tools, each of these components have been assessed for ante-natal, natal and post-natal care. 4.1 AVAILABILITY OF SERVICES Iron Folic tablets: As per national norms all pregnant women should consume at least 100 IFA tablets during pregnancy. Hence, availability of these IFA tablets in the facility becomes crucial.

Out of the 30 PHCs surveyed, 26 PHCs had stock of IFA tablets on the day of data collection. This included the presence of both large (100 mg) and small tablets (50 mg). The average stock available at the PHC was 10,698 tablets and 13,312 for large and small size tablets respectively. The availability of these tablets varies widely across the facilities. On the day of visit there were certain facilities which did not have any stock, while the maximum number ranged even up to 60000 and 208000 for large and small size tablets respectively.


Table 4.1: Status of Iron folic tablets at the PHC Name of the Districts Indicator


Number of PHC stock IFA large tablets small tablets

7 7

77

33

9 9

2626

Stock of IFA tablets large (on the day of survey) Average number Standard deviation Minimum Maximum

16098.622480

060000

11773.112382

030000

16335.328288

249000

3783.1

4920 0

13000

10698.316105

060000

Stock of IFA tablets small (on the day of survey) Average number Standard deviation Minimum Maximum

645.61287

03410

12203.716746

040000

9668.016742

029000

25239.9

68665 0

208000

13311.841195

0208000

Total number of PHC 8 7 6 9 30 Medical officers were asked whether the available quantity was sufficient for the next week. This was affirmed by only 20 PHCs. Analysing the sufficiency of IFA stock available in the facility as per the norm, only 10 PHCs out of 30 PHCs had sufficient stock. Sufficiency of IFA stock per week was calculated considering the number of pregnant women per thousand population including the pregnancy wastage and the women should consume minimum 100 tablets during pregnancy. District wise variation in the reported and calculated stock is indicated in Figure 4.1. Except for Pakur district, in all the other districts the calculated stock is much less than the reported stock.

Figure 4.1: Number of Facilities Report/Having Sufficient Stock of IFA Tablets

8

7

6

9

4

7

2

7

2

5

2

1

0 2 4 6 8 10

Deogarh

Godda

Pakur

Sahibgunj

Total PHC Reported sufficient stockCalculated sufficient stock

In the three tier health system, sub-centres at the lowest level are relatively more accessible to the community. Assessing the same stock in the 48 sub centers surveyed, data reveals that 40 sub-centers had large IFA tablets with an average stock of 5,507 tablets per facility. Whereas, 36 sub-centre had small IFA tablets with an average number of 4,307 tablets per facility. In this case too there was a wide dispersion in the stock available at the facility, for instance the distribution for large tablets ranged from minimum five to maximum 32,000, while the same for small tablets was one to 20,000. Overall, the data does indicate that to a large extent stock is available at the sub-centre level too.

30

Chapter 4: Ante-natal/Natal and Post-natal

Table 4.2: Status of Iron folic tablets at the sub-centre Name of the Districts Indicator


Number of sub-centre stock IFA large tablets small tablets

7 4

13 13

13 12

7 7

40 36

Stock of IFA tablets large (on the day of survey) Average number Standard deviation Minimum Maximum

3414.3 5208.1

100 15000

8576.9 9389.4

1000 32000

3145.4 2817.7

400 9000

6286.4 6420.9

5 15000

5507.4 6780.9

5 32000

Stock of IFA tablets small (on the day of survey) Average number Standard deviation Minimum Maximum

3512.5 5054.8

50 11000

6077.0 7365.0

1 20000

2482.5 2356.3

400 7000

4600

5566.2 50

13000

4306.7 5498.9

1 20000

Total number of Sub-centre 7 14 18 9 48

Disposable delivery kits (DDK): In the absence of institutional delivery it is essential to maintain at least the five cleans and use the delivery kits for home deliveries. Availability of these disposable delivery kits therefore becomes an important factor to ensure clean and safe delivery. Information was gathered on the situation of disposable delivery kits supplied to the sub-centre in the previous twelve months and the stock available on the day of visit. It was found that only 14 sub-centres had received a supply of DDK in the past one year. But on the day of survey just 9 sub-centres had DDK in stock. On an average, there were 25 DDKs on the day of visit to the facility. However there is a wide dispersion of this availability across the facilities, which varied from a minimum stock of one DDK to a maximum of 83 DDK. Table 4.3: Status of DDK in the sub centers


Total

Number of sub centers that had Received DDK in the past 12 months DDK on the day of visit

2 1

7 5

5 3

0 0

14

9 Stock of DDK

Average number Standard deviation Minimum Maximum

30

- 30 30

35.8 34.5

5 83

6.0 7.8

1 15

- - - -

25.2 28.7

1 83

Total number of sub centers 7 14 18 9 48 4.2 ACCESSIBILITY OF SERVICES Deliveries conducted: Deliveries conducted at the health facility helps to ensure a safe delivery for the mother and child in case of any complication to the mother or the newborn child the same can be attended to immediately. Out of 30 PHCs surveyed only 19 PHCs were conducting delivery. An attempt was made to understand the volume of deliveries conducted in these facilities. From the seventeen facilities for which the data was reported, on average ten deliveries were conducted per facility in three months. Comparing this data of the last three months that is March ’05 to May’05 with the same time frame in the year 2004, it was observed (Figure 4.3) that in ten facilities the number of deliveries conducted has decreased, whereas in seven it has increased.

31


Figure 4.3: No. of PHC indicating the trend of Deliveries Conducted in last

One Year

2

4

1

7

4

21

3

10

0

2

4

6

8

10

Deoghar Godda Pakur Sahibgunj Total

no. of PHC where deliveries conducted increasedno. of PHC where deliveries conducted decreased

Figure 4.2: No. of PHCs where Delivery Conducted

7 6

24

19

02468

10121416182022

Deogh

ar

Godda

Pakur

Sahibg

unj

Total

*

* for 2 PHC data was not available

Distance to health facility: While availability of the services in the facility is important, iis equally important that they are located within reasonable reach of the target populationwho should benefit from it. As discussed in the earlier chapter the average distance tonearest health facility was 12 km. and this distance was more in Deoghar. The averagetime to cover this distance varied from 40 minutes in Sahibgunj to an hour in Deogarh. 4.2.1 Status of Health Personnel’s Accessible to Community Facility level: The presence of doctors and/or Para medics in the health facility for twentyfour hours has an implication on the utilization of services. This is possible only whenthey are staying in the close vicinity of the facility. Study made an attempt to understandthis. As Table 4.4 indicates in 20 PHCs (two-thirds) it was reported that at least one doctoresides within PHC compound. This was six each in Deogarh and Godda and four each inPakur and Sahibgunj. In 11 and 16 PHCs at least one LHV/female health assistant and aANM respectively were staying within the PHC premises. Table 4.4: Access to health personnel


Total

In the facility Number of PHC where at least

one doctor resides in PHC compound LHV/female health assistant reside in PHC compound ANM

6 2 4

6 4 7

4 3 3

4 2 2

201116

Number of PHC 8 7 6 9 30In the village Number of villages having at least

one traditional birth attendant one qualified doctor (MBBS) within village

10 0

19 4

14 0

19 1

625

Total number of villages 30 30 30 30 120 Village level: In rural area, typically traditional birth attendants conduct deliveries ahome. TBAs can be trained in using DDK and help to ensure a clean delivery. But are theyreally available in all the villages? From the data collected from the study villages (Table4.4), it was found that in almost half (62) of the villages out of the total 120 surveyedtraditional birth attendants were available. Eleven villages each in Godda and Sahibgundid not have any birth attendant staying within the village, where as in Pakur and Deogarh

32

t

-

r

t

, j


relatively more villages (16 and 20 respectively) did not have a traditional birth attendant. For deliveries in such village, birth attendant were mainly drawn upon from the neighbouring villages. The presences of qualified doctor was still worse as only four villages in Pakur and one village in Sahibgunj had at least one MBBS doctor staying in the village. ANM trained for conducting delivery: Given the accessibility of the ANM with the community, an ANM who has been trained for conducting delivery will be beneficial to the community. Findings from the 54 ANMs interviewed reveals that only 22 ANMs had received this training in the last three years (Figure 4.4). All of them had found the training to be useful.

Figure 4.4: No. of ANMs Trained for Conducting Delivery

4 6 7 55

813

6

0

5

10

15

20

25

Deoghar Godda Pakur Sahibgunj

Trained Not trained 4.2.2 Community Perception on Accessibility of ANC Services At the community level all the mothers who had delivered in the twelve months prior to the survey were asked to opine on certain statements related to their opportunity, ability and motivation to seek services during pregnancy. Anlaysis of the same is presented in Table 4.5. Only 46 percent of the mothers mentioned that care for pregnant women was available within 30 minutes of walking distance from their house. This varied from 40 percent in Godda district to 56 percent in Pakur district. However a lesser percentage (39 percent) agreed that a healthcare provider who provides information on care during pregnancy was available within 30 minutes. Table 4.5: Opinion of women on accessibility of ANC service


Total

Percentage of women Agreed that care for pregnant woman are available within 30 min walk Agreed that a health care provider who provides information on care during pregnancy is available within 30 min walk

44.1

34.2

40.4

33.7

55.9

49.6

45.0

37.6

46.4

38.7

Total number of women 240 240 240 240 960 4. 3 UTILIZATION OF MATERNAL SERVICES Details regarding ANC services sought were collected from 960 mothers. As Table 4.6 reveals only 37 percent of the mothers reported that they had ANC checkups. In other words the majority, two-thirds of the women did not seek or receive any ANC services. This percentage varied from 46 percent in Deogarh to 31 percent in Godda. As per the recommended norm, a pregnant woman should undertake a minimum of three check-ups. However, as the data indicates only 16 percent of the women reported that they had undergone three or more check ups. From the programme point of view it is also important that the woman should receive her first check up in the first trimester of pregnancy. Only

33


20 percent of all the women surveyed had done this. Just three percent of the women had gone for check up in the third trimester. Probing further on the source of ANC checkups, data shows that 22 percent of them had their checkups from private doctors and only eight percent got their checkups at government hospitals. Two percent each availed the services from PHC and Sub-centre. Two percent of the women also availed the services from RMP, quacks, etc. Mothers need more iron during pregnancy and in India anaemia is a common and major ailment among pregnant and lactating women. Among the study population a little more than two-fifths (44 percent) of the mothers were given IFA tablets. NFHS –2 reported this to be 33 percent. However, only 13 percent of mothers reported that they had received 100 + IFA tablets. In other words, those women who do receive the IFA tablets do not receive the total amount as per the required norm. Thirty percent of the mothers did report that they had consumed all the tablets received. The percentage of women who consumed more than 100 tablets was eight percent. This data does indicate that to a large extent women do consume IFA tablets provided they receive the same. Hundred and forty-two women who had not consumed all the IFA tablets that they had received were asked why they had not taken all the tablets. Varied reasons were mentioned for the same (see box 1). The reasons indicate that these women and their immediate family members should be sensitised on the need of consuming iron folic tablets during pregnancy.

BOX 1 Reasons for not taking IFA

• Due to side effects/ there were health problems• The tablet tastes bad/ it smells • Feel bad/nauseating after taking tablet • Forget to take • Relatives, in-laws object to my taking • No use of taking the tablet • Child will become big

Compared to the above services sought during ANC, the coverage of tetanus toxoid injection was encouraging. Three-fourth of the women had received at least one TT injection, while 63 percent had received two or more TT injections. This is again an increase over the data reported in NFHS-2, which was 51 percent for the state. Among the four study districts, the coverage was highest in Deogarh district and lowest in Pakur district. Informally it was learnt that most of these women received the TT injection from rural medical practitioners in and around the village. Considering the motivation of the women to take TT injections and the role of RMPs in providing this, strategies should be worked out as to how these RMPs can play a role in the program, as they are located at the grass root level and are accessed by the community.

34


Table 4.6: Type of ANC services sought (Percentage) Name of the Districts Indicator


Percentage of women had at least 1 ANC check up 46.3 31.3 37.9 32.1 36.9 Number of ANC checkup sought by mothers

1 2 3 and above Don’t remember

12.9 11.3 21.3

0.8

9.6

12.1 10.0

0.4

7.5

10.4 18.8

1.3

10.0 10.0 12.9

-

10.0 10.9 15.7

0.6 Percent of mothers who went for 1st check ANC in

First trimester Second trimester Third trimester

25.4 17.0

3.7

20.0

9.2 2.9

18.8 16.7

0.0

26.1 11.6

3.8

20.4 13.6

3.2 Source of ANC Checkups

Sub-centre PHC Govt. Hosp. Private Doctor Others Don’t remember

2.9 2.5 4.6

34.2 -

2.1

0.4 1.7 5.8

20.8 2.1 0.8

3.8 2.1

13.3 16.3

2.1 0.4

2.5 2.5 6.7

17.1 3.3 0.4

2.4 2.2 7.6

22.1 1.9 0.9

Iron folic tablet given Percent of mothers who were given Iron folic tablet Percent of mothers who got 100+ or more IFA tablets Do not remember

Iron folic tablet consumed Percent of mothers consumed all the tablets Percent of mothers who consumed 100 or more tablets

45.0

10.4

0.4

31.7

7.1

41.3

15.8

-

27.5

10.0

43.3

9.6

-

30.4

6.7

47.5

14.9

-

28.8

8.3

44.3

12.9

0.1

29.6

8.0 Tetanus toxoid injection

Percent of mothers received one TT Percent of mothers received 2 or more TT

79.2 71.3

78.8 65.8

67.9 54.6

77.5 60.4

75.8 63.0

Total number of women 240 240 240 240 960 4.3.1 Full Coverage of ANC by Background Characteristics of Mothers As promotion of maternal and child health has been one of the important components of the family welfare programme, it is essential that a pregnant woman should receive at least three ante-natal check ups, at least one tetanus toxoid injections and receive at least 100 IFA tablets. A pregnant woman receiving all these components is considered as having received `full ANC’ services, any services received lesser than this would be `partial ANC’ and those who have not received any services mentioned earlier are considered as `no ANC’. These data indicate that only three percent of the women had received full ANC services, 77 percent of the mothers had received some or the other services required during ANC, whereas 20 percent of the mothers had not been reached for any services during pregnancy. Analysing the same data by the background characteristic of the women, data shows that four percent of Hindus had complete ANC care while it was around six percent for other category and nil for Muslims (Table 4.7). Chi-square analysis shows religion has significant relation with ANC care (p<.01). Similarly, if we look into ANC care by education, the percentage of women having received complete ANC care was nine percent in the case of literate women and two percent in the case of illiterate women. Twenty three percent of the illiterate women and eight percent illiterate women had not taken any services during pregnancy. Further, availability of health facility within village also has significant relation with percentage of mothers who had full ANC check-ups. The

35


presence of either PHC, sub-centre or a private doctor in the village was considered as health facility available in the village. Table 4.7: Status of ANC services by background characteristics Back ground characteristics

Percent Not received any ANC

Percent Partially Received ANC

Percent Received full ANC

Total

Religion χ2 42.20 Hindu 15.5 80.4 4.1 555 Muslims 19.2 80.8 0.0 260 Others 35.2 59.3 5.5 145 Education χ2 44.71 Illiterate 22.8 75.4 1.7 749 Literate 7.6 83.9 8.5 211 Health facility within the village χ2 13.54 Available 15.4 80.0 4.6 456 Not available 23.2 74.8 2.0 504 Total number of women 19.5 77.3 3.2 960 As discussed earlier, ANC service should at minimum consists of minimum of three ANC check-ups, at least one TT injection and 100 IFA tablets during pregnancy. Taking this as adequate coverage, the data was re-analysed to understand the coverage of pregnant mothers with respect to each component as well as taking all the three components together. Among the three components of ANC services the percentage of women seeking tetanus toxoid injections was the highest. Women need to be equally sensitised on the importance of going to health facility for ANC checkup and receiving IFA tablets. Considering all the three components together, it emerges that only three percent of the women have been adequately covered for all the said services. Though 53 percent of the women have received at least one adequate services, the percentage decrease to 21 percent when two services are considered together. Table 4.8: Adequate coverage of ANC services

Name of the Districts Particulars Deogarh Godda Pakur Sahibgunj

Total

Percentage of women who Went for 3 or more ANC visits Received 100+ IFA tablets Received at least one TT injection

21.3 10.8 79.2

10.0 15.8 78.8

18.8

9.6 67.9

12.9 15.0 77.5

15.7 12.8 75.8

Number of ANC services adequately taken by women

No ANC care taken Taken ANC service but inadequate Any one adequate service Any two adequate service Any three adequate service

14.2 4.6

55.0 22.5

3.8

18.3 1.7

57.5 20.4

2.1

27.1 3.8

45.8 19.6

3.8

18.3 3.8

53.8 20.8

3.3

19.5 3.4

53.0 20.8

3.2 Total number of women 240 240 240 240 960 Though the programme has identified a minimum services package for ANC, the woman would benefit if among her three visits to the health facility the first one is within first trimester, has received 1/2 TT injections and consumed 100 or more IFA tablets. Taking these three components individually and together to understand effective coverage the data was re-analysed. As observed from Table 4.9 effective coverage for visit to the health facility was only 11 percent. This was 15 percent in Deogarh and eight percent in

36


Godda. The percentage of women who consumed more than 100 IFA tablets was lowest at seven percent in Pakur and ten percent in Godda. Coverage for tetanus toxoid injection was also relatively better in Deogarh at 71 percent but lowest in Pakur district at 55 percent. Analysing all these three components together, the data reveals that only 50 percent of the women have been effectively covered for at least one service, this drops down substantially to 13 percent for two effective services and only two percent of the women have actually been covered effectively for all the services. A wide gap exists between the utilization of various services, which is essential to be bridged. Table 4.9: Effective coverage of mothers for ANC services

Name of the Districts Particulars Deogarh Godda Pakur Sahibgunj

Total

Percent of mothers who had effective first visit in first trimester and three visit to health facility consumed 100 or more IFA tablets received two TT injections

15.0 7.1

71.3

7.9 10.0 65.8

11.3 6.7

54.6

8.8 8.3

60.4

10.7 8.0

63.0 Percent of mothers effectively covered

Did not receive any ANC Received ANC but ineffective Any one effective service Any two effective service Any three effective service

14.2 12.5 55.0 16.7

1.7

18.3 13.8 53.3 13.3

1.3

27.1 15.9 44.2 10.4

2.5

18.3 19.6 48.8 11.3

2.1

19.5 15.4 50.3 12.9

1.9 Total number of women 240 240 240 240 960 4.3.2 Women’s Perception on Need of ANC Care The study further reveals that only two-fifths (40 percent) of the women agreed that the community worries about services during pregnancy. In other words to a large extent pregnancy continues to be perceived as a natural physiological phenomena not requiring any special care. Understanding the ability of the rural women to seek services, 53 percent of the women did respond that their in-laws have influence on their health seeking behaviour during pregnancy. This was highest at 60 percent in Sahibgunj. Only 39 percent of the women agreed that women seek services from health provider during pregnancy. Further only 36 percent of the women disagreed that only man decides whether his wife can seek services during pregnancy. In other words almost two-thirds of them depend on the husband’s decision regarding this. Given the scenario only 45 percent of the women agreed that they can take the services during ANC. This was highest at 55 percent in Deogarh and least at 34 percent in Sahibgunj. Seventeen percent of the women did report that their family members are against seeking any health services during pregnancy.

37


Table 4.10: Opinion of the women regarding need of ANC care (Percentage) Name of the Districts Indicator


Disagreed that in the community nobody worry about ANC

40.9

44.6

33.0

41.3

39.8

Agreed that in-laws have influence on women seeking services during pregnancy Agreed that most of women seek services from health provider during pregnancy Disagreed that it is only the man can decide whether his wife should seek services during pregnancy

48.4

44.2

45.8

50.4

35.0

37.1

51.3

38.8

30.9

60.4

39.6

40.4

52.6

39.4

36.0 Agreed that she can take all the services during her Pregnancy Agreed that their family member against to ANC services

54.6

19.2

40.0

12.1

39.6

12.5

33.8

25.9

44.5

17.4

Total number of women 240 240 240 240 960 4.3.3 Natal Care Place of delivery and type of birth attendant who attend the delivery, are the two important factors influencing maternal and neonatal mortality. It is safest to have delivery in an institution with appropriate medical facility. Delivery in a hospital also ensures newborn care and therefore, can reduce the incidence of infant mortality substantially. In the study area, only nine percent of births were institutional and almost half of these were in private hospitals. It may be noted that while in Deogarh, institutional deliveries were mainly in private hospitals, in Pakur, government hospital was mainly utilized. Statistical analysis of socio-economic characteristics of the women with the place of delivery found no significant relation. Table 4.11: Place of delivery (Percentage)


Total

Place of Delivery Institutional SC PHC Govt. Hospital Private Hospital / Maternity Home Home

8.7

- -

0.8 7.9

91.3

11.6

3.3 -

2.9 5.4

88.3

8.3

- 0.8 7.1 0.4

91.6

6.3

- 0.4 3.8 2.1

93.7

8.7 0.8 0.3 3.6 4.0

91.2 Home deliveries conducted by

Traditional birth attendant / Dai Family members/neighbours ANM/Nurse Doctor Others

82.5

5.4 1.7 1.7 0.4

82.5

1.7 0.8 2.1 0.8

84.2

4.6 0.4 1.3 0.4

76.7 11.3

0.4 0.8 1.3

81.5

5.7 0.8 1.5 0.8

Percentage of home deliveries in which DDKs are used 3.8 5.4 3.8 5.8 4.7 Reasons for not going to health facility

Not necessary Not customary Cost too much Too far/no transport Better care at home Others

34.6

0.8 21.3

6.3 24.2

5.1

30.0

0.4 19.2

3.3 29.2

5.9

37.5

- 12.9

5.0 27.9

7.5

26.7

1.7 28.8

5.0 21.7

8.4

32.2

0.7 20.5

4.9 25.7

6.5 Total number of women 240 240 240 240 960

38


A little more than nine out of ten (91 percent) deliveries continue to take place at home. The percentage of home deliveries attended by trained personnel that is either a doctor or ANM/nurse was only two percent. The percentage of home deliveries attended by doctor or ANM was lowest in Sahibgunj and Pakur. In 82 percent of the cases it was the traditional birth attendant who conducted the delivery. Earlier it was observed that though all the villages do not have traditional birth attendant staying within the village, those staying in the adjoining village are called for during delivery. In Sahibgunj this was still lower at 77 percent, as family members/neighbours conducted the delivery in 11 percent of cases. All those mothers whose last delivery took place at home were asked whether DDK was used or not. Only five percent of the mothers reported that DDK was used in the delivery.

All those women who did not have institutional deliveries were probed for the reason as to why they did not go to the health facility. The most common reason that emerged included: did not feel the necessity for the same (32 percent), better care at home (26 percent) and cost too much for institutional delivery (21 percent). 4.3.4 Registration of Birth All the mothers were probed on whether they had registered the birth of their child. Only six percent of the mothers confirmed this. It was as low as one percent in Deogarh and highest at 10 percent in Pakur (Figure 4.5).

Figure 4.5: Percent of mothers who registered the birth of child

1.3 2.1

10.48.3

5.5

0

5

10

15

Deoghar Godda Pakur Sahibgunj Total Post-natal During the post-natal period the new mother and baby are vulnerable to new set of risks. As per the norm a health worker should visit the mother at her home at least within a week of delivery. Data collected on this from the study indicates that, health workers visited only four percent of mother’s within 10 days after delivery. Visits by health workers were marginally better in Sahibgunj as compared to other districts. Table 4.12: Post-natal follow up


Total

Percent of mothers visited by health worker within 10 days after delivery

3.3

2.9

3.3

4.6

3.5

Day of visit On the same day of delivery Within one day after delivery 2-5 days After 5th day Do not remember

0.8

- 1.3 0.4 0.8

0.4 2.1 0.4 0.8 0.4

0.4

- 2.1 0.8

-

2.5 0.4 1.3 0.4

-

1.0 0.6 1.3 0.6 0.3

Total number of women 240 240 240 240 960 The health workers visited only one percent of the mothers on the same day of delivery. This negligible percentage points out the absences of adequate coverage to mothers for PNC. As per the norm a minimum of three visits by the health worker is required within 40 days, with the first visit being on the same day of delivery.

39

5 Child Care, Breastfeeding and Supplementary Feeding

Malnutrition, directly or indirectly, accounts for more than 50 percent of all deaths during infancy and early childhood. It is often thought that malnutrition is due to inadequate food intake resulting from poverty and deprivation. However, ignorance about feeding of the newborn and young infant and certain cultural practices associated with child’s nutrition play an important role in malnutrition. Acute respiratory infections (ARI) and diarrhoea are the major causes of death among infants and children. Both these illnesses are preventable but life threatening unless timely treatment has been initiated. This chapter makes an attempt to understand the breastfeeding practice and supplementary feeding practices among the surveyed mothers. It also understands the availability of ORS and Cotrimoxazole in the facility and the level of knowledge among the mothers. Each of these have been analysed based on whether it constitutes a component of availability, accessibility or utilization 5.1 AVAILABILITY ORS packet: All the PHCs and sub-centres were assessed for the availability of ORS packets and cotrimoxazole tablets, the basic requirement for treatment of diarrhoea and ARI that should be available at the facility. It was found that 25 out of 30 PHCs surveyed (83 percent) had stocks of ORS packets with an average 550 packets of ORS available. There were at least 102 packets in Pakur PHC and highest number was 752 and 753 packets each in Godda and Deogarh PHC respectively. Similarly out of 48 SCs covered 39 sub-centres (81 percent) had ORS packets. On an average each sub-centre had 99 ORS packets. The stock of ORS was more (222) in Sahibgunj sub-centre compared with other sub-centres of other districts surveyed. There were 21 packets in Deogarh sub-centre. Thus, there exists a wide dispersion in the stock availability at different facilities. Cotrimoxazole tablets: Regarding the availability of cotrimoxazole tablets, this was available in 25 out of 30 PHCs and 20 out of 48 sub-centres surveyed. The average stock of cotrimoxazole tablets available at the PHCs was 4,364 varying from 667 tablets in Pakur districts PHCs to 10,775 tablets in Godda district PHCs. Similarly, the average stock of cotrimoxazole tablets in sub-centre was found to be on an average 320, that ranged from 77 tablets in the sub-centres of Deogarh district to 550 tablets in the sub-centres of Godda district. Thus, the average stock of cotrimoxazole tablets availability varied widely across both these facilities (PHC and sub-centre) and the districts.

Strengthening Immunization Plus in Jharkhand

Table 5.1: Status of ORS and cotrimoxazole at PHC and Sub-centres Name of the district Indicator


Number of PHCs Having ORS packets Average no. of ORS packets Standard deviation Having cotrimoxazole Average no. of cotrimoxazole Standard deviation

7

753.1 950

7

2200 4380

7

751.7 802

7

10775 26174

3

102.0 171

3

666.7 1155

8

362.8 926

8

2033.6 5643

25

549.7 836

25

4363.8 14225

Total number of PHCs 8 7 6 9 30 Number of Sub-Centres Having ORS Average number of ORS packets Standard deviation Having cotrimoxazole Average no. of cotrimoxazole Standard deviation

7

20.9 11.5

3

76.7 37.9

12

104.8 100.7

8

550.0 627.6

12

57.5 52.1

6

215.3 392.0

8

222.1 517.4

3

214.0 249.4

39

99.2 240.7

20

320.2 478.6

Total number of Sub centre 7 14 18 9 48 5.2 ACCESSIBILITY For health interventions delivered at the household, knowledge among mothers rather than contacts/visit by the health workers is often the requirement to ‘access’ a particular service. In this section we assess the knowledge of mothers of key household health interventions for diarrhoea. Knowledge among Mothers regarding Diarrhoea Diarrhoea is one of the major childhood illnesses, which can be easily prevented provided the management of the same begins at home as soon as the child passes the first loose motion. Hence in the study area, all the mothers (with children 12-23 months old) were asked about the signs of severe diarrhoea (when the child should be taken to a health worker). Eighty-one percent of mothers reported about frequent watery motions, while half of the mothers reported about frequent vomiting. Eight percent reported blood in motions, followed by feeling thirsty and not taking any food and water. Around 11 percent of mothers reported that they do not know any signs of diarrhoea. No knowledge about the signs of diarrhoea varied from 8 percent in Pakur district to 15 percent in Godda district. Further probing on when a child suffers from diarrhoea, whether he/she should continued to be fed with the same amount of liquid diet during diarrhoea or should the child be fed with less or more than normal liquid. About 45 percent of mothers reported that the baby should be given less fluid than before diarrhoea, while 45 percent correctly reported that the baby should be provided with either the same or more fluids than normal. About eight percent of mothers reported that they don’t know about it. In addition to giving increased amounts of fluids, mothers should continue to feed the child even during diarrhoea. Around 2.5 percent of them reported that the baby should not be given any food. Seventy two percent of mothers reported that the child should be given less food than what is given before diarrhoea. Only 18 percent mothers correctly opined that child should be given same or more food as before diarrhoea. Eight percent of the mothers said that they don’t have any knowledge about it.

42

Chapter 5: Child Care, Breastfeeding and Supplementary Feeding

Table 5.2: Knowledge regarding diarrhoea and its management (Percentage) Name of the districts Indicators


Signs of Diarrhoea Frequent watery motions Frequent vomiting Blood in motions High fever Feel thirsty Not taking any food and water Others Do not know

78.8 53.8

3.8 9.2 7.9 3.8 2.1 8.7

84.2 50.4

3.8 4.2 5.8 5.8

- 15.1

85.0 47.9

4.2 9.2 0.8 4.2 2.1 7.9

75.0 46.3

4.2 8.8 3.8 4.6 3.8

11.3

80.7 49.6

4.0 7.8 4.6 4.6 2.0

10.8 Opinion on liquid diet during diarrhoea None Less than before diarrhoea Same as before diarrhoea More than before diarrhoea Do not know

0.8

41.7 9.2

39.2 9.2

0.4

42.5 5.0

44.6 7.5

1.7

49.2 10.8 31.7

6.7

2.9

47.9 9.2

30.0 10.0

1.5

45.3 8.5

36.4 8.3

Opinion on feeding during diarrhoea None Less than before diarrhoea Same as before diarrhoea More than before diarrhoea Do not know

1.3

73.8 15.0

3.8 6.3

1.7

69.2 15.4

6.3 7.5

1.7

73.3 13.8

2.5 8.8

5.4

72.1 8.3 5.0 9.2

2.5

72.1 13.1

4.4 7.9

Percent of women aware of ORS Place from where ORS can be availed From ANM/SC PHC Chemist Doctor Others

49.6

2.5 0.4

37.9 1.3 7.5

52.1

3.3 2.1

39.2 2.9 4.6

41.3

4.2 0.4

32.9 2.5 1.3

40.8

4.2 3.3

26.3 3.8 3.3

45.9

3.5 1.6

34.1 2.6 4.2

All the mothers were asked whether they know about ORS. It was found that 46 percent of the mothers were aware about it. All these mothers, who were aware about it, were asked from where one can get ORS; 74 percent of these mothers (34 percent of all mothers) said it can be availed from a chemist, while ANM/sub centre was mentioned by only 11 percent (3.5 percent of all mothers). Others opined that ORS can be obtained from doctors or other sources such as anganwadi worker, home preparation etc. 5.3 UTILIZATION Initiation of breastfeeding: All the mothers who had delivered a child in the 12 months prior to the survey were asked when they initiated breastfeeding to their child. It was found that only 19 percent of mothers initiated breastfeeding within two hours of birth. This was highest (25 percent) in Pakur district. Another one-fourth of the mothers reported that they initiated breastfeeding within a day of delivery. Around two-fifths (40 percent) of the mothers initiated breastfeeding between the first and the third day, whereas about 15 percent mothers reported that they breastfed their child only after 3 days. One percent of the mothers did not breastfeed their children. Feeding colustrum is important to a baby as it increases the immunity power of the child. Hence in the survey mothers were asked whether they squeeze out the yellow milk before initiating breastfeeding to the baby as it is generally followed in certain cultural practices. Around 41 percent of mothers reported that they squeezed out the yellow milk before initiating breastfeeding to their child. It varied between 31 percent in Godda district

43


and 47 percent in Sahibgunj district. Probing into the reasons for the same, milk is dirty (11 percent), it is our custom (10 percent) and it is harmful to baby (10 percent) were some of the common reasons mentioned. Other reasons mentioned included relatives, in-laws, asking to do so, removing initial milk will increase the production of milk and dai advising them to do so. Almost all mothers (98 percent) reported that they are currently breastfeeding their child. Table 5.3: Breastfeeding practice among mothers (Percentage)

Name of the district Indicator Deogarh Godda Pakur Sahibgunj

Total

Initiation of breast feeding Immediately/ within two hrs. of birth 2- 6 hrs of birth 7-12 hrs 13-24 hrs 1-3 days After 3 days Not breastfed

16.3

7.9 4.2 7.5

49.6 13.8

0.8

18.3

9.2 9.2

10.8 37.9 13.8

0.8

24.6

9.2 5.0 8.8

35.4 15.8

1.3

17.5 11.3

6.7 11.3 35.8 17.1

0.4

19.2

9.4 6.3 9.6

39.7 15.1

0.8 Percent of mothers squeeze out yellow milk 44.2 30.8 40.8 47.1 40.7 Reasons Dirty milk Customary Harmful to baby Relatives asked to do so Others No response

10.4 12.5

8.8 9.6 3.3 3.8

8.3 7.1 6.7 6.2 2.9 4.6

11.3 10.4 10.4

3.4 6.7 1.3

14.2 11.7 15.4

5.4 3.8 1.3

11.0 10.4 10.3

6.2 4.1 2.7

Percent currently breast feeding 97.1 98.3 98.8 99.6 98.4 Total number of women 240 240 240 240 960 5.4 ADEQUATE COVERAGE Exclusive breastfeeding: Exclusive breastfeeding means that except for breast milk no other food or fluids, including water and pre-lacteal feeds, should be given to a child from birth to six months. Feeding anything other than breast milk, including water, is not only unnecessary but is also harmful as it increases the risk of infection. Analysing breastfeeding practices of children under six months, the data shows that 73 percent of the children are currently being breastfed. Six percent of these children were exclusively breastfed for four months. The survey data was reanalysed for the children above six months to understand the percentage of children who were exclusively breastfed. Analysis of the data shows that among the children aged above 6 months about 30 percent of children were breastfed exclusively for 6 months and above, while 72 percent of children received exclusive breastfeeding for four months. On an average, it emerges that mothers breastfeed the child exclusively for slightly more than four months. It was found that, on an average, they gave water to the baby at 4.9 months of age. The average age when they were given liquid food was six months. Supplementary feeding practice indicates that only 55 percent of the children received semi-solid/mushy food on the previous day of the survey. Similarly the percentage of children who received fruits and green leafy vegetables was only seven and 12 respectively.

44

Chapter 5: Child Care, Breastfeeding and Supplementary Feeding

Table 5.4: Nutrition pattern among children Name of the district Indicator


Percentage of children 0-6 months of age breast-fed

Exclusively from birth until survey Exclusively on previous day of survey

80.2 80.2

73.2 80.4

75.2 85.0

63.0 75.0

72.6 80.2

Total number of children (under six months) 91 97 113 108 409 Percentage of children 6-11 months exclusively breastfed for:

Four months Six months

71.8 26.2

75.5 27.3

69.3 24.4

70.5 40.9

71.9 29.6

Average months the children aged more than 6 months

breastfed exclusively was given water

4.3 4.7

4.4 4.8

4.3 5.0

4.6 5.3

4.4 4.9

Mean age at (in months) which children above six months

were given liquid food (other than water and breast milk) were given semi-solid food

6.1

6.8

6.0

6.5

5.9

6.7

6.1

6.9

6.0

6.7 Percentage of children aged above 6 months on the previous day had

Green leafy vegetables Mean number of times

12.1 2.3

13.3 2.1

11.0 1.9

12.9 1.8

12.3 2.0

Fruits Mean number of times

6.0 1.9

7.0 1.7

4.7 1.5

8.3 1.1

6.5 1.5

Semi-solid Mean number of times

56.3 2.2

59.4 2.1

55.9 1.9

48.5 2.0

55.2 2.0

Total number of children (6-11 months) 149 143 127 132 551 5.4 EFFECTIVE COVERAGE Skill/Knowledge among ANM: Auxiliary nurse midwives are the paramedical health persons who directly interact with the community at the grass root level. They are the first hand information providers on health related matters to the community. Hence in the present study ANMs were asked, when should a mother start breastfeeding her newborn baby. Thirty-nine out of the 54 ANMs responded that breastfeeding should start within one hour. Further analysis of the ANMs responses shows that as per their perception mothers should initiate breastfeeding on an average 4.9 hours after delivery. This duration was more in Pakur (8.0 hours) and Deogarh (7.4 hrs) while it was less in Godda at around one hour. Table 5.5: ANM’s knowledge on breastfeeding and supplementary feed (Number)

Name of the district Indicator Deogarh Godda Pakur Sahibgunj

Total

Number of ANMs reporting baby should be breastfed Within an hour Average hours when mother should initiate Baby should be given supplementary feed Before 4 months 4-6 months 6+months

8 7.4

- 3 6

13 1.1

1 6 7

11 8.0

-

10 10

7 1.9

- 6 5

39 4.9

1

25 28

Total number of ANM 9 14 20 11 54

45


They were also further probed at what age a child should be given supplementary feeding. One ANM reported that the baby should be given supplementary feeding before 4 months, while 25 and 28 ANMs reported that it should be between four to six months and after six months respectively.

46

6 Summary and

Conclusion Multi-indicator cluster survey was conducted in four districts namely Deogarh, Godda, Pakur and Sahibgunj of Jharkhand state. In each district 30 clusters were selected by using PPS procedure. The clusters identified were in the rural areas of the identified districts. Within each cluster, eight mothers each of children aged 0-11 months and 12-23 months were surveyed. In addition to this a village questionnaire was filled. Public health facilities, which included the PHC and the sub-center within the cluster was also identified and surveyed. In the process 30 PHC and 48 sub-centers were surveyed. A further 54 ANMs across the study districts were interviewed. The data collection period did coincide with the catch up round of immunization that was on going in the state. As discussed in the earlier chapters, the major findings, which emerged from this were as follows: IMMUNIZATION

Twenty-four out of the 30 PHC surveyed had vaccines available in the facility on the day of the survey. However, only in 17 of them were all vaccines available.

Wide disparity was found in the quantum of the stock available at the facility.

This availability could also be due to the catch up round that was ongoing. The sufficiency stock for one week as per norms was found to be in 16 facilities for BCG, 14 facilities for OPV, 11 facilities for DPT and 19 facilities for measles. Tetanus toxoid was found to be sufficient in 18 facilities.

To maintain the vaccine potency it should be kept in either ILR or in deep freezer

as the required norm of the vaccine. However, only in 9 PHC and 10 PHC were BCG and DPT vaccines respectively kept as per norm, whereas polio and measles vaccines were properly kept in 7 PHC and 2 PHC respectively.

Electricity supply was reported to be regular in only seven PHCs. Whereas

generator facility in working condition was reported from only 12 PHCs.

Of the total 120 villages surveyed, immunization sessions were reported from 102 villages. However, the frequency of these sessions varied across the villages.

Fifteen percent of children 12-23 months surveyed were fully immunized Thirty

four percent of the children had not received any immunization; 66 percent had received at least one immunization. Thirty nine percent of the mothers had immunization card. Only two percent of the children received all the vaccines as per schedule.


Statistical test shows a statistically significant correlation between religion,

education of mother, exposure to media, availability of health facility and immunization session within the village and immunization.

ANTE-NATAL, NATAL AND POST NATAL CARE

Twenty-six PHC and 40 sub-centers had IFA large tablets on the day of survey. Wide disparity was observed in the stock availability at the facility.

Only nine sub-centers had DDKs at the facility on the day of the survey, although

14 of them had received the same in the last 12 months.

Nineteen PHCs were conducting deliveries. On an average, ten deliveries were conducted per facility in the last three months. Formal training in delivery was received by only 22 ANMs.

Percentage of women who received at least one ANC check up was 37. Twenty

two percent of the total women had received this check up from private doctors. Only 44 percent of the women had received IFA tablets but only 13 percent had received more than 100 tablets. Consumption of these tablets was only eight percent for more than 100 tablets. Sixty three percent of the mothers received at least two tetanus toxoid injection.

Percentage of women who received complete ANC care (three check up, one TT

and received 100 IFA tablets) was three percent. Twenty percent of the mothers had not received any services where as 77 percent had received some or the other service. Statistical analysis reveals significant relationship of ANC services with religion, mothers’ education and availability of health facility within the village.

Institutional deliveries were only nine percent, with the majority of the deliveries

being conducted at home by traditional birth attendants. Follow up for post-natal care was only for four percent as per the norm of 3 visits within 10 days of delivery.

CHILD CARE AND BREAST FEEDING/SUPPLEMENTARY FEEDING PRACTICE

Twenty-five PHC (out of 30 PHC) and 39 sub-centres (out of 48 sub-centers) had ORS packets on the day of survey. However a wide disparity was found in the quantum of stock across the facilities.

Eighty one percent of the mothers considered `frequency of watery motion’ as the

sign of severe diarrhoea. The other signs were mentioned by lesser percentage. Correct knowledge on the practice of giving same or more liquid and the same or more food during diarrhoea was known to less than half of the mothers.

Nineteen percent of the mothers initiated breastfeeding within two hours of

delivery. The practice of discarding colostrums before breastfeeding was followed by around 41 percent of the mothers.

48

Chapter 6: Summary and Conclusion

Seventy-two percent of surveyed children 6-11 months were exclusively breastfed for 4 months; however at 6 months, exclusive breastfeeding coverage drops to 30%. The average months for which the child was exclusively breastfed was slightly over four months, with water being initiated after fifth month. Over half of ANMs had correct knowledge on the timing of initiation and length of exclusive breastfeeding, however, knowledge of correct timing of supplementary feeding was considerably less.

From the above discussion it may be inferred that to a certain extent the health facilities do have the requisite stock, however given the condition under which it operates, it is essential to understand and ensure that the potency of the vaccine is maintained, Efforts should be made to reach out to all section of the community and take even the first contact as the opportunity to enlighten the beneficiary on the need of subsequent contacts and repeat contacts with the health services. Contacts for antenatal and post-natal care need to be strengthened.

49

Deoghar District, Jharkhand (based on Census 2001) Total Population 1,005,539 (Rural only) Clusters 30 Size 33518 Random number 0.373 Starting cluster 29989

Cluster Value Block Village Population Households 1 29,989 Deoghar Chhota Manikpur 372 75

2 63,507 Deoghar Sankari 1,262 219

3 97,025 Deoghar Karmatanr 274 40

4 130,543 Deoghar Bisunpur 827 136

5 164,061 Mohanpur Lorhia 686 112

6 197,579 Mohanpur Bhairwatanr 986 172

7 231,097 Mohanpur Chakarman 1,136 188

8 264,615 Mohanpur Jamuniya 758 131

9 298,133 Sarwan Kordiha 381 55

10 331,651 Sarwan Banbariya 1,943 273

11 365,169 Sarwan Khajuriya 398 56

12 398,687 Sarwan Binjha 1,556 240

13 432,205 Devipur Kolharia 374 53

14 465,723 Devipur Ghonghadih 226 39

15 499,241 Devipur Manda Mundi 351 63

16 532,759 Madhupur Patwabad 2,202 322

17 566,277 Madhupur Nawadih 938 177

18 599,795 Madhupur Lodhna 219 30

19 633,313 Karon Mahajori 1,050 159

20 666,831 Karon Pathraul 3,281 573

21 700,349 Karon Upar Bilriya 844 128

22 733,867 Karon Karo 4,396 759

23 767,385 Sarath Munda 779 120

24 800,903 Sarath Murgabani 312 55

25 834,421 Sarath Goplaraedih 511 88

26 867,939 Sarath Raotara 724 117

27 901,457 Palojori Ghormara 137 24

28 934,975 Palojori Shekhar Nawadih 715 106

29 968,493 Palojori Kanki 2,201 312

30 1,002,011 Palojori Malandi 470 82

Godda District, Jharkhand (based on Census 2001) Total Population 1,010,931 (Rural only) Clusters 30 Size 33698 Random number 0.519 Starting cluster 5046 Cluster Value Block Village Population Households

1 5,046 Meherma Borma 2,347 367

2 38,744 Meherma Sukhari 1,955 340

3 72,442 Meherma Dasu Chakla 983 160

4 106,140 Meherma Rajan 1,571 262

5 139,838 Thakur Gangti Hira Khutahari 1,523 247

6 173,536 Thakur Gangti Lensirsa 299 48

7 207,234 Boarijor Chhota Darma 523 105

8 240,932 Boarijor Bhadria 980 200

9 274,630 Boarijor Basdiha 1,796 319

10 308,328 Mahagama Sarbhanga 1,363 231

11 342,026 Mahagama Parsa 4,367 702

12 375,724 Mahagama Ramchandarpur 189 35

13 409,422 Mahagama Semarkita Ghat Bhandaridih 1,098 211

14 443,120 Mahagama Chichohari 841 143

15 476,818 Pathargama Chengai 713 123

16 510,516 Pathargama Jamnikola 2,804 478

17 544,214 Pathargama Sundarmor 708 129

18 577,912 Pathargama Maheshpur 1,003 175

19 611,610 Pathargama Ghat Rampur 550 95

20 645,308 Godda Gangta 202 42

21 679,006 Godda Bhadrahi Mal 1,169 184

22 712,704 Godda Pathwara 440 80

23 746,402 Godda Jamua 1,211 231

24 780,100 Godda Banka Ghat 2,582 494

25 813,798 Poreyahat Ratanpur 1,578 297

26 847,496 Poreyahat Naudiha 3,006 558

27 881,194 Poreyahat Dhobai 697 133

28 914,892 Poreyahat Raghunathpur 1,426 294

29 948,590 Poreyahat Bankati 413 80

30 982,288 Sundarpahari Pakeri 162 34

Pakur District, Jharkhand (based on Census 2001) Total Population 665,635 (Rural only) Clusters 30 Size 22188 Random number 0.900 Starting cluster 16373 Cluster Value Block Village Population Households

1 16,373 Litipara Kaldam 498 121

2 38,561 Litipara Asanbani 251 46

3 60,749 Litipara Jamkandar 413 97

4 82,937 Litipara Phulpahari 1,783 324

5 105,125 Amrapara Dumarchir 799 172

6 127,313 Amrapara Jamugaria 1,586 315

7 149,501 Hiranpur Sundarpur 2,296 455

8 171,689 Hiranpur Bartola 2,465 415

9 193,877 Hiranpur Torai 2,120 280

10 216,065 Pakaur Kalidaspur 2,270 443

11 238,253 Pakaur Gosainpur 254 47

12 260,441 Pakaur Nandipara 250 44

13 282,629 Pakaur Ishakpur 2,991 494

14 304,817 Pakaur Manikpara 3,419 531

15 327,005 Pakaur Manirampur 5,882 954

16 349,193 Pakaur Pirthinagar 7,190 1,038

17 371,381 Pakaur Jhikarhati 16,357 2,683

18 393,569 Pakaur Kismat Kadamsai 2,286 386

19 415,757 Maheshpur Baramasia 966 186

20 437,945 Maheshpur Tulsipur 859 170

21 460,133 Maheshpur Kaira Chatar 771 164

22 482,321 Maheshpur Murgadanga 594 120

23 504,509 Maheshpur Kharakdangal 538 98

24 526,697 Maheshpur Ratanpur 463 88

25 548,885 Maheshpur Dharamkhanpara 1,933 344

26 571,073 Maheshpur Arjundaha 769 152

27 593,261 Pakuria Mahuligaipathar 422 78

28 615,449 Pakuria Lakhipokhar 1,102 217

29 637,637 Pakuria Angargaria 365 73

30 659,825 Pakuria Bannagram 1,255 273

Sahibgunj District, Jharkhand (based on Census 2001) Total Population 829,639 (Rural only) Clusters 30 Size 27655 Random number 0.882 Starting cluster 21193 Cluster Value Block Village Population Households

1 21,193 Sahibganj Ganga Parshad 21,035 3,681

2 48,848 Sahibganj Makhmalpur 8,518 1,244

3 76,503 Mandro Chhota solbandha 931 177

4 104,158 Mandro Simra 1,271 280

5 131,813 Borio Jetkekumarjori 773 165

6 159,468 Borio Khairwa 919 203

7 187,123 Borio Marichak 784 144

8 214,778 Barhait Patkhasa 1,384 311

9 242,433 Barhait Bhagnadih 1,262 248

10 270,088 Barhait Chhuchi 2,777 524

11 297,743 Barhait PanchkatiyaBazar 1,867 373

12 325,398 Taljhari Dhanbad 933 177

13 353,053 Taljhari Hisiganj 783 170

14 380,708 Rajmahal Mukimpur 3,748 704

15 408,363 Rajmahal Kozigaon 601 114

16 436,018 Rajmahal Bamangawan 1,704 334

17 463,673 Rajmahal Jamnagar 12,264 2,029

18 491,328 Udhwa Jonka 3,768 697

19 518,983 Udhwa Phudkipur 2,318 449

20 546,638 Udhwa Mansachandi (Chhit) 710 151

21 574,293 Udhwa Palasgachhi Diara 9,409 1,388

22 601,948 Udhwa Pranpur 5,361 797

23 629,603 Pathna Jhiktia 1,197 215

24 657,258 Pathna Sahri 2,081 427

25 684,913 Pathna Sibapahar 2,070 457

26 712,568 Barharwa Barharwa 11,260 2,091

27 740,223 Barharwa Kankjol 2,139 474

28 767,878 Barharwa Dhatapara 370 72

29 795,533 Barharwa Mirjapur 6,309 1,094

30 823,188 Barharwa Chhota Sonakar 231 49

Back ground characteristics Percent Not

Immunized Percent Partially Immunized

Percent Completely Immunized

Total

Deogarh Religion χ2 6.64 Hindu Muslims Others

14.0 12.1 30.0

80.5 87.9 70.0

5.5 0.0 0.0

164 66 10

Education χ2 4.10 Illiterate Literate

16.3

6.0

80.5 88.0

3.2 6.0

190 50

Health facility within the village χ2 4.45 Available Not available

16.7 11.7

77.5 86.7

5.8 1.7

120 120

Total 14.2 82.1 3.8 240 Godda Religion χ2 5.30 Hindu Muslims Others

15.2 24.1 22.6

81.5 75.9 77.4

3.3 0.0 0.0

151 58 31


21.3

7.7

77.7 86.5

1.1 5.8

188 52


10.8 25.8

85.8 73.3

3.3 0.8

120 120

Total 18.3 79.6 2.1 240 Pakur Religion χ2 20.97 Hindu Muslims Others

24.3 19.4 41.4

73.0 80.6 48.3

2.6 0.0

10.3

115 67 58


32.3

6.3

65.6 83.3

2.1

10.4

192 48


21.3 34.6

72.8 64.4

5.9 1.0

136 104

Total 27.1 69.2 3.8 240 Sahibgunj Religion χ2 20.70 Hindu Muslims Others

9.6

21.7 37.0

85.6 78.3 58.7

4.8 0.0 4.3

125 69 46


21.2

9.8

78.2 78.7

0.6

11.5

179 61


10.0 22.5

87.5 73.8

2.5 3.8

80

160 Total 18.3 78.3 3.3 240

Date post:	27-Jul-2020
Category:	Documents
Upload:	others
View:	9 times
Download:	0 times

Baseline Study on Immunization in Rural Jharkhandcortindia.in/RP/RP-2005-1001.pdf · The Universal...

Documents