Building an enabling environment for improving the uptake of family planning in high mortality settings: lessons from Jharkhand and
Orissa, India.
Rajendra Mahapatra1, Rajkumar Gope1, Shibanand Rath1, Suchitra Rath1, Swati Roy, Vijay Singh, Aparna Bajpai1, Rajesh Kumar Sinha1, Nirmala Nair1, Prasanta Tripathy1, Audrey Prost2
1-Ekjut, Plot no556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, INDIA,
2-UCL Centre for international Health and development, Institute of Child Health , University college London.
1.Introduction
• High Infant mortality is consistently associated with high fertility…parents who have lost a child
expect to have more children than do similar parents who have not. 1
• Child survival generate various distinct but closely interrelated changes in reproductive behavior. 2
• In the Ekjut trial conducted in three bordering districts of two eastern Indian states (Jharkhand &
Orissa) with a population of 228000 from 2005 to 2008 there was a reduction in newborn mortality
rate by 45% (OR:0.55 95%CI: 0.45-0.67). 3
• The baseline newborn mortality was 58/1000 livebirths which remained unchanged in the control
areas.
• The reduction was through a participatory learning and action approach of mobilizing communities
through women’s groups (n=244),each group benefitting a population of 468.
•The women’s group had successfully addressed neonatal and maternal health problems in the trial
period and after the trial period (2009 - 2010), they decided to take up childhood issues for children
under five and issues related to women’s health.
CHILDHOOD AND
WOMEN”S ISSUES
Number of
groups (244)
Childhood diarrhoea
108
Immunization
86
Measles
56
Low birth weight, Malnutrition &
worms
157
Childhood Pneumonia
56
Malaria
139
Family Planning
103
Anaemia
54
Tuberculosis
50
Abortion
46
Retained placenta
27
Postpartum haemorrhage
22
Domestic violence
21
HIV/AIDS
14
1. World Development Report 1990 , Page-82, New York: World Bank
2.Fertility Behaviors and Their Costs,HNP-2007- http://www.dcp2.org/file/159/fertilityregulationsfinal.pdf)
3. Tripathy et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial.
The Lancet 2010; 375: 1182-1192
3.Prospective Surveillance System
2.Study setting
• 70% of mothers were from indigenous community+
Select one key informant
per 25O households
• 40 % were below the poverty line+
• 70 % non-literate+
Pay informant incentive to identify births and
deaths to women of reproductive age
• 60 % had little or no land+
Interviewer visits informant monthly to
collect list of identifications
• 30 % had no ANC+
• 85% of births were home deliveries+
Interviewer verifies identifications
and pays informant
3 % contraception usage#
STUDY AREA+
INDICATORS
JHARKHAND*@
ORISSA*@
INDIA*
Maternal Mortality Ratio(100,000 live births)
668
371
358
301
NMR (per 1000 live births)
58*
49
45
39
Crude Birth Rate
30+
29
23
23
2.32
1.89
2.7
-
Total Fertility Rates (15-49 years)@
Interviewer interviews once at six weeks
after delivery
Women who are interviewed are
‘snowballed’ for other identifications
Data presented in this poster is from the prospective
surveillance system by Ekjut between 2005 to 2010 (still
ongoing), whereas data on contraception was collected
between 2009 – 2010.
* SRS data, @NFHS-III-2005-6,+ Ekjut baseline data 2005, # Ekjut data 2009-10
4. Mother’s age of marriage ( n = 30490)
5.Age at first pregnancy ( n = 30490)
64.9
70.0
60
60.0
47.9
50
% age of mothers
50.0
% age of Mothers
Interviewer collects identifications from
government records every month
40.0
31.0
30.0
20.0
10.0
3.9
0.2
0.0
Don’t Know
<=19Yrs
20-30Yrs
6. Duration between last 2
pregnancies (n = 11660)
40
30
20
10
3.9
0.4
0
>30Yrs
Don’t Know
7. Number of Previous
pregnancies ( n = 30490)
47.8
<=19Yrs
8. Heard of any FP
method (n = 8825)
20-30 Yrs
9. Heard of which contraception
methods (n=4291) Year 2009-10
54%
>3 & <4 years
Cap/Diaphrag
m
2%
No
> 2 & <3 years
>1 &< 2 years
25%
One year or less
21%
Emergency
Contrceptives
0%
Condom
25%
Male
Sterilisation
4%
Pill
17%
Female
Sterilisation
10%
Yes
Only one pregnancy
>30 Years
Did not Know
0
5
10
15
20
25
30
35
First
pregnancy
% age of mothers
10. Unmet need for contraceptivesWomen & Men ( n = 18813)
85
% of Male and Female
85
7
8
6
8
Wanted a Not wanted Not wanted Wanted a Not wanted Not wanted
baby
this time
at all
baby
this time
at all
Female
Male
1-3
pregnancies
4 or more
pregnancies
0
20
40
60
Ever heard of contraceptives
IUD
12%
Injection
17%
Herbal Pill
13%
11. Discussion
• In underserved areas with high early marriages and high newborn mortality there is inadequate
information on family planning methods
•Community mobilisation, by empowering women improved several neonatal and maternal health
indicators and 103 groups have identified Family planning as a priority issue for discussion in their
group meetings
• During the Ekjut trial while the home care practices improved, the supply side was wanting with
marginal year-to-year improvement
•While community mobilisation in our settings has created an enabling environment for interest in
family planning, improved supply and better health services will enable families to exercise their family
planning choices.