The results have been divided into three sections: results from the rapid assessment survey at the baseline, the analysis of the data obtained from the management information system and end-line qualitative assessments.
3.1 Rapid assessment survey at baseline
A total of 476 young married women, 240 from Banda and 236 from Kaushambi, who were pregnant or had a child less than three years of age responded to the quantitative questionnaire. The mean age of the women was 27 years. Approximately 66% and 81% of the women were illiterate (could not read and write) in Banda and Kaushambi, respectively (Supplementary Table 1). Overall, the socio-economic and demographic characteristics of the women were poor. Less than 50% of the women were aware of anemia, maternity benefit schemes, postnatal care, safe places for abortion and the MGNREGA scheme (Supplementary Table 2). More than three-fourth of the women did not receive 3 or more antenatal check-ups in both districts. The institutional delivery rate was 78% and 64% in Banda and Kaushambi, respectively. Only 23% of women in Banda and 13% in Kaushambi were using any family planning method at the time of the survey. Around 40-46% of women had bank accounts and less than one-third of the women were registered for the MGNREGA scheme. Only 13% of women in both districts had ever worked under the MGNREGA scheme.
Although both districts had poor socio-economic indicators, Kaushambi found to have a higher burden of poverty, illiteracy, and unemployment as compared to Banda. The qualitative analysis was broadly divided into three key themes, namely, awareness and utilization of maternal and child health services, support from family (husbands or mothers-in-law) and utilization of the MGNREGA scheme by women (Table 3). Some of the key issues highlighted during qualitative analysis were poor knowledge about the importance of antenatal check-ups, family planning methods, newborn and childcare, and dissatisfaction with the government health services, and limited access to the MGNREGA scheme among women.
3.2 Management Information System data
The socio-demographic characteristics of the intervention population tracked through the management information system 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 were registered under the MGNREGA scheme, and 94% and 80% of them had also worked in the MGNREGA scheme, respectively (Table 5). Compared to the baseline, all the six outcomes improved among women at the end of the intervention (management information system data) except for possession of a bank account in Kaushambi (Table 5).
Nearly 24% of women had opened accounts as well as were registered in the MGNREGA scheme (Table 6). The progress tracked through the management information system at three-time intervals (after the first 15 months, during the middle 12 months, and in the last eight months) has been shown in Supplementary Figure 1.
3.3. End line assessment
The complete analysis of the qualitative data collected at the end line is broadly divided into six themes.
1) Perceived changes in the awareness and utilization of maternal and child health services by women
Women during FGD informed that their awareness about maternal and child health increased post-intervention. Most of the women coming to their facilities for antenatal care knew about maternity benefit schemes. They knew about early newborn care practices, the importance of early and exclusive breastfeeding, and a minimum gap of three years between two pregnancies.
Midwives, community health workers and VHSNC members reported that the awareness of the women about health care services had increased. Mothers-in-law understood their responsibilities of supporting and caring for their daughters-in-law during pregnancy. They knew about the emergency helpline number for the ambulance, the importance of childhood immunization, and family planning.
Now, all of us go to the hospital for delivery. ASHA bahu comes and takes us to the hospital and cares for us. She calls the vehicle (ambulance), and then we go to the hospital. (A woman during FGD; community health worker is called ASHA in the community)
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 VHSNC member during IDI)
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 resolving misconceptions regarding immunization. Peer educators perceived that the utilization of most of these services had increased post-intervention. One noticeable change highlighted in the interviews was that the demand for health services from the communities had increased.
Outreach workers and community health 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 to the health facilities. The outreach worker and community health 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 at the baseline study between women from non-marginalized and marginalized families. However, this gap had decreased between the two groups after the intervention as revealed in interviews with community health workers, midwives, and medical officers.
2) Perceived improvement in economic independence in the households and livelihood opportunities for women
Women who worked under the scheme felt financially strong and independent. 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. Being an earning member of the family, such women could voice their demands and take decisions for family and self.
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)
Women were engaged in jobs other than MGNREGA, such as small cottage industries like poultry, goat rearing, and grocery stores. Some women’s groups opened stitching centers to give training to the girls on stitching and embroidery. Such women’s groups had linked women to other schemes for women development. The money earned from the new job was spent on starting a small new business.
After being associated with MAMTA, I started a stitching center. I used to train other girls. Recently, I have another embroidery and stitching center. (A woman during FGD)
Outreach workers and VHSNC heads endorsed this improvement in social mobility and the financial status of women in the communities. An increased number of women and people were linked to the MGNREGA scheme, and they received work for a minimum of 50-100 days. VHSNC members informed that women were told that they could work under MGNREGA and earn 156 INR (3USD) for working eight 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. Community health workers 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.
Peer educators extended their support to women during the ‘Demand for Work (Kaam Mango Abhiyan) campaign’, and helped them in opening bank accounts. In the ‘Demand for Work’ campaign, group meetings were called by the MGNREGA staff to give information about the scheme.
Other perceived changes
3) 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 on 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 the mindset of people. 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 the difference between a male and a female child. (A woman during FGD)
Community health workers perceived a positive change in the attitude of men towards their wives. Ration cards (subsidy cards) were issued in women’s names. All the subsidies and incentives from maternity benefit schemes or MGNREGA were transferred into women’s accounts. Community health workers did not find any reported case of female foeticide in the last six months from the date of the interview. The VHSNC head recalled a play organized by outreach workers based on female foeticide 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 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 to me that one should not go for the gender identity test of the fetus. Craving to have a boy, I have seen people giving birth to six 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 the 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).
4) Perceived changes in the functioning of Village Health Sanitation Nutrition Committees (VHSNC)
The VHSNC 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 (10,000 INR) to provide health-related facilities in the village. The fund account was operated and maintained jointly by the VHSNC head and midwife. In the past, lack of effective communication or coordination between VHSNC members and the midwife had resulted in the cancellation of the meetings, an issue which was 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-five-year-old children.
There is a committee controlled by the midwife and VHSNC members 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. MAMTA staff always encouraged women for better health services. (A VHSNC head during IDI)
5) Peer educator’s experiences from the project and perceptions towards changes in the community
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 postnatal care were difficult to discuss by peer educators. 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 for discussions on the topics.
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 communication tools such as magic shows and 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 centers and sub-centers for health services by midwives to assess the availability of different materials. (Peer educators from FGD; Child development centers are called Anganwadi centers in villages)
6) Health service providers’ experiences from the project and perception about changes in communities
Community health workers and midwives 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), and TV shows. (A community health worker 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). (A midwife during IDI).
Community health workers reported increased access to maternal health services by women. However, the consumption of iron-folic acid tablets and child immunization were perceived to be poor. Midwives 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 centers 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 community health 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, etc. (A medical officer during IDI)