The results have been divided into two sections: results from the rapid assessment survey at baseline, and end-line qualitative assessments. Besides, the analysis of the data obtained from the MIS has been shown.
3.1 Rapid assessment survey at baseline
A total of 240 women from Banda and 236 from Kaushambi participated in the survey. The mean age of the women was 27 years. Approximately 66% and 81% of the respondents were illiterate (cannot read and write) in Banda and Kaushambi, respectively. Only 4% of women were working under the MGNREGA scheme in Banda. Overall, the socio-economic and demographic characteristics of the women were poor, and the practices of early marriage and early childbearing was rampant. Although both the districts had poor indicators, Kaushambi seemed to have a higher burden of poverty, illiteracy, and unemployment as compared to Banda. The complete quantitative data from the baseline has been shown in supplementary Table 1 and supplementary Table 2. The qualitative analysis was broadly divided into three key themes, namely, awareness and utilization of MCH services, support from family (husbands or mothers-in-law) and utilization of MGNREGA scheme by women (Table 3). Some of the key issues highlighted during qualitative analysis were poor literacy about the importance of antenatal check-ups, family planning methods, newborn and childcare, and dissatisfaction with the government health services, etc. among women.
3.2 Management Information System data and End line analysis
The socio-demographic characteristics of the intervention population tracked through MIS is shown in Table 4. Most of the women in Banda (90%) and Kaushambi (85%) attended at least 60% of the education sessions. Around 39% of women in Banda and 35% of women in Kaushambi registered in MGNREGA, and 94% and 80% of them had worked in the MGNREGA also respectively (Table 5). Nearly 24% of women had opened accounts as well as registered in MGNREGA (Table 6). The progress tracked through MIS at three-time intervals (after the first 15 months, middle 12 months, and last eight months) has been shown in supplementary figure 1. The complete analysis of the qualitative data collected at the end line is detailed through nine themes.
Peer educators reported that the training conducted by the outreach workers was useful and engaging because different infotainment materials were used such as posters, videos, role-plays, and songs, etc. for discussions on the topics. Frontline workers in their interviews affirmed about the high quality of the training and workshops:
Very good training was given by project staff using different techniques like magic shows, dhol (drums), TV shows. (An AWW during IDI)
The training was good. Information about all the government schemes was provided. They answered our queries and explained things through poster or TV (shows). (An ANM during IDI).
- Perceived changes in the awareness of women about MCH and government health schemes
Women during FGDs informed that their awareness about MCH increased post-intervention. Mothers-in-law understood their responsibilities for supporting and caring for their daughters-in-law during pregnancy. They knew about the emergency helpline number for ambulance, he importance of childhood immunization, and family planning. ANM and ASHAs reported that the awareness of the women about health care services had increased. Most of the women coming to their facilities for antenatal care knew about maternity benefit schemes (Janani Suraksha Yojna, JSY). ASHAs helped women to open accounts in banks for the transfer of the money received under the scheme and had encouraged these women for daily savings and keeping the money in piggy banks.
Now, all of us go to the hospital for delivery. ASHA bahu comes and takes us to the hospital and care for us. She calls the vehicle (ambulance), and then we go to the hospital. (A woman during FGD)
Peer educators had counselled women on the importance of breastfeeding and maternal nutrition during pregnancy and lactation. Peer educators had accompanied these women to the facilities for further support on many issues such as family planning methods, adequate latching during breastfeeding, and misconceptions regarding immunization, etc. Peer educators perceived that the utilization of most of these services had increased post-intervention.
- Perceived change in the utilization of health services by marginalized women
Outreach workers and frontline workers had faced challenges in mobilizing marginalized women to avail of health services. Some of the major challenges that prompted low utilization of health services among marginalized women included illiteracy, poverty, ignorance, lack of women empowerment, traditional beliefs or misconceptions, and long distances between villages and the health facility. The outreach worker and frontline workers succeeded in mobilizing such women for the intervention through repeated meetings and counselling of their family members. There was a wide gap in the service utilization rates between women from non-marginalized and marginalized families. However, this gap had decreased between the two groups after the intervention as revealed in FGDs with ASHA and IDIs with medical officers, ANM, and AWW.
- Perceived improvement in economic independence of women
The money earned after getting work under MGNREGA or saved from daily savings was deposited in the bank account by the women. These savings had helped women investing money at times of need, such as starting their work, in emergencies for the medical treatment of their family members, education of their children, etc. Outreach workers and village sarpanchs endorsed this improvement in social mobility and the financial status of women in the communities. An increased number of women and people have been linked to the MGNREGA scheme, and they received work for a minimum of 50–100 days. This has improved not only the status of the women in the family but also their decision-making power. Women revealed that they have become more confident in resolving their health and family issues.
After being associated with MAMTA, I was encouraged by family members and neighbors to go outside and work. I worked at a place where my neighbors were also working; both got the opportunity to work under MGNREGA. (A woman during FGD)
After the intervention, I could perceive the change in the nutritional practices of women. Women have become more caring for their children and maintain hygiene. (A PRI member during IDI)
- Perceived change in gender equity norms in the communities
Gender disparities regarding access to education, adequate nutrition, and mobility prevailed in the communities. Outreach workers had educated communities about the importance of girl’s education, and a nutritious diet for women and girls through magic shows, plays, and community-based events such as 'Saas Bahu Sameelan’ (meetings with mothers-in-law and daughters-in-law at a common platform).
People did not like a girl child in our village. My husband asked my mother-in-law not to give me food because I delivered a baby girl in my previous pregnancy. However, the project has changed people’s mindset. MAMTA staff educated us about the benefits of a girl child and to continue their education and let them earn name and fame. People now don’t consider a difference between a male and a female child. (A woman during FGD)
ASHAs perceived a positive change in the attitude of men towards their wives. Ration cards (subsidy cards) were issued in women’s name. All the subsidies and incentives from maternity benefit schemes or MGNREGA were transferred into women’s accounts. ASHA did not find any reported case of female feticide in the last six months from the date of the interview. Village sarpanch recalled a play organized by outreach workers based on female feticide and preventing the killing of a girl child. Husbands received education on gender equality and the need to educate girls through magic shows.
I do agree that if the girls are educated, they will know their rights. And now, emphasis should be laid on educating more and more girls. When girls are educated, they will get to know their rights. Hence, education is very important. I do agree that there should be no discrimination between girls and boys. The MAMTA staff had explained me that one should not go for the gender identity test of the fetus. In the craze of having a baby boy, I have seen people have given birth to 6 girls. (A husband during IDI)
Because of the project, I have observed a change in the attitude of my husband. Earlier I was not allowed to go outside anywhere except for defecation. However, after my husband attended meetings taken by MAMTA staff, I have noticed a change in his behavior. I could go and move around in my village, and my husband did not mind. I could talk to people easily, chit-chat with other ladies. So, I have got this kind of freedom. (A woman during FGD).
- Perceived changes in the functioning of village health sanitation nutrition committees (VHSNC)
PRI members had reported that they were not clear about their role in VHSNC before and became aware of the processes after the intervention. They had started to participate actively in the meetings to facilitate the processes of government schemes. The meetings were conducted monthly and decided to judiciously use the fund (INR Rs. 10,000) to provide health-related facilities in the village. The fund account was operated and maintained jointly by Gram Pradhan and ANM. In the past, lack of effective communication or coordination between VHSNC members and ANM had resulted in the cancellation of the meetings, which resolved after the intervention. Issues most commonly raised during such meetings included hygiene in the villages, facilitating access to the MGNREGA scheme by the women and people from marginalized communities, and immunization of under–5 children.
There is a committee controlled by ANM and Gram Pradhan to give more facilities to mothers. We channelized funds for cleanliness and support to the poor families who could not bear the expenses related to the delivery of a woman. In some cases, money was collected through group charity. Outreach workers always encouraged women for better health services. (A Gram Pradhan during IDI)
- Perceived change in the livelihood opportunities of the women
Women were engaged in small cottage industries like poultry, goat rearing, grocery store, etc. Some women’s groups opened stitching centres to give training to the girls on stitching and embroidery. Such women’s groups had linked women to other schemes such as Rajiv Gandhi Mahila Vikas Pariyojna (Women Development scheme). The money earned from the new job was spent on starting a small new business. Peer educators extended their support to women during the ‘Demand for Work (Kaam Mango Abhiyan) campaign’, and helped them in opening bank accounts. PRI members informed that women were told that they could work under MGNREGA and earn Indian Rupees (Rs.) 156 (3USD) for working 8 hours a day. Women were also informed that they could borrow money at a low-interest rate from the group’s bank account to start a new venture. Mothers-in-law raised concerns over poor maintenance of widow pension scheme by the Government officials. In the ‘Demand for Work’ campaign, group meetings were called by MGNREGA staff to give information about the scheme.
- Experiences and perceptions of peer educators towards changes in women’s uptake of MCH services
Peer educators did home visits, built rapport with family members, and organized sessions with women in the communities. They demanded more training on issues such as national family health insurance scheme, and refresher training on the other issues. Sessions elaborating on women’s reproductive health and rights, financial literacy, and postpartum care were difficult to discuss by peer educators. As a result of prevailing notions and misconceptions, it was difficult to obtain consent from the families for engaging their women in different activities. However, the use of IEC tools such as magic shows, demonstrations, interactive meetings with husbands or mothers-in-law, collective decision-making and feedback mechanisms were some of the key strategies that helped in mobilizing communities for greater engagement in activities and bringing change in women’s health practices. An increase in perceived self-respect, confidence, and improved access to government health schemes was noticed among peers. Peer educators helped VHSNC in monitoring services in the communities for improvement in their quality of work.
We had observed service delivery points like Anganwadi centres and sub-centres to assess the availability of different materials. (Peer educators from FGD)
- Health service providers’ perception about change in communities’ uptake of health services
ASHA reported increased access to maternal health services by women. However, the consumption of iron-folic acid tablets and vaccination were perceived to be poor. ANM opinioned that despite hard-core interventions (sessions and meetings), the uptake of family planning and postnatal care services by the women were poor in the communities. There was a scope of improvement in the intervention including advocating for the availability of adequate resources in the health centres such as a stethoscope, weighing machine, regular supply of iron-folic acid tablets, and vitamin A capsules, etc. Two key issues highlighted by medical officers as needed to uplift the health situation of marginalized women were adequate nutrition and education (schooling). A change was noticed in the functioning of frontline workers, including need-based planning, timely planning for services, and an inclusive approach to prioritize the health needs of marginalized women.
The key issues of women from marginalized families included poverty, migration, and pressure on females to earn a livelihood, lack of education, ignorance, social outcasts, poor transport facilities, more belief in quacks or traditional healers than registered practitioners. superstitions, parda pratha, etc. (A medical officer during IDI)