l To understand the community needs, behaviors and perception for MNH Iin urban poor settings.

l To explore various factors (both demand and supply side) affecting care seeking for MNH.

l To assess the preparedness of the urban health system for providing MNH services at various levels of care in terms of infrastructures at various levels of care, HR availability and capacity, logistics, drugs & equipment, referral, recording & reporting, supervision, gove r n a n c e a n d f i n a n c i a l modalities.

Objectives of the Study

DE

MA

ND

SU

PP

LY

Conceptual Framework

Pune City Profile

Gaps in service provision – outreachl Not enough Link workers / ASHAs on ground (120/564)l AWW is the first point of contact. But, poor coordination with ICDS ~

between departmentsl Lack of uniform system for implementation of Urban Health and Nutrition Day(UHND) covering entire cityl Lack of morbidity surveillance and hence late identification and referral of maternal and neonatal morbidityl Lack of uniform system for periodic house visiting, surveillance and monitoring (not in JD of any worker) – hence no follow up

informal at grassroots without formal agreements

Gaps in service provision – utilization of public facilitiesl

l Underutilization of the Govt. schemes – JSY, JSSK, 108 servicesl Poor linkage between primary and secondary / tertiary level facilitiesl Lack of defined population coverage by Urban Primary Health Centres (UHPC)l People were unaware about which services were being provided and wherel Lack of in house diagnostic services at all levels

Under utilization of primary care and major load of MNH handled by secondary and tertiary facility

Gaps in service provision – institutional capacitiesTraining

Management capacities

l

l No dedicated training institution for the urban health and Health and Family Welfare Training Centre (HFWTC), District Training Team (DTT) utilized by rural health training

l Lack of micro planning (top-down approach) l Monitoring and review are facility based rather than population based l No quality assurance mechanisms; Indian Public Health Standards (IPHS) standards for NUHM - lost in files

No system for assessing training needs and capacity building plan

Gaps in service provision – HR, recruitment & workflowl

l No fixed salary or incentives for the outreach staffl Staff on contractual basis – no accountability l No uniformity in recruitment of ASHAs under various schemes and delayed recruitment of ASHAsl Difficulty in retention of ASHAs

Vacant scheduled posts - poor salary structure for Specialists, MOs

l

at Privatel ANC services predominantly limited to enrolment only. Concerns about package of services and qualityl Delivery predominantly in government facilities and limited to tertiary facility and few secondary facilities (undue burden

on tertiary).l Large number of mothers / newborns receive PNC visit within 24 hrs. at facility (due to more than 48 hrs. stay in facility).

However, PNC following facility discharge (home based) significantly poor. l Care seeking for sick newborn is high and predominantly from private sector.l Rationalization of specialist HR services; training on the basic maternal and newborn care are need of the hour.l All the facilities require functional linkages with the primary facilities on one hand and tertiary facilities on the other handl Need to urgently activate outreach sessions, community processes.

ANC was mainly self initiated and equal number go to public and private facilities. However, JSY incentives not available

Conclusions

Maternal and Newborn HealthSituation of

in Urban Slums of PuneKey Findings2016

3.12 million*

Slums566

SlumPopulation1.15 Mn*

(33%)

Density ofPopulation

6500 personsper sq. km.**

LiteracyRate (%)

89.6*

DecadalGrowth Rate

50.08 **

Source: *Census ’11; **City Development Plan, PMC, 2006 - 12

56

15

Existing Urban Health Infrastructure:

Source: http://populationfoundation.in/wp-content/uploads/2015/09/Pune-City-Urban-Health-Profile.pdf

Acknowledgements

This Situation Analysis was carried out by Save the Children's Saving Newborn Lives (SNL) Program in collaboration with the Pune Municipal Corporation (PMC) and the National Health Mission — Government of Maharashtra. The team extends its sincere thankfulness to the National Health Mission— Government of India for the constant encouragement and support. The team is grateful to the National Technical Advisory Group constituted under the program for its continuous inputs and guidance. Acknowledgement goes to all the study participants (recently delivered women, their families; the slum communities, and representative members and organizations; frontline workers, health care providers and staff in the public and private healthcare system; the Municipal Corporation and State Government Officials) who spared their time and enthusiastically participated in the study. The SNL Program is funded by the Bill & Melinda Gates Foundation.

For Further Information, Contact

Saving Newborn Lives, Save the Children1st & 2nd Floor, Plot No. 91, Sector 44, Gurugram- , Haryana

Phone : +91-124-4752000 E-mail: snl@savethechildren.in Website: www.savethechildren.in122003

75.047.6

31.6

20.3

35.7

39.6

16.828.9

4.7

15-19 Years (64) 20-24 Years (286) 25-29 Years (187)

Study Coverage Geographical Coverage

Results

1 2 3 4 or more

Pregnancy Outcomes

l 25% of RDWs currently in their teens had already experienced multiple pregnancies

l By the age 24 yrs., over 50% RDWs have already had more than one pregnancies

l 70% of the women aged 25-29 yrs. had experienced more than 2 pregnancies

Number of Pregnancy by Age

Once Twice Three & more

N=601

Antenatal Care (ANC) Registration & Services

l A b o u t 6 5 % w o m e n received first ANC before

th4 month

l 15% received first ANC th

session as late as in the 9 month

Place of Ante-natal Examinations

Awareness of Danger Signs in Pregnancy

l

headache and oedema of face/ hands/ legs, most cited symptoms of danger signs

l In case of any danger signs during pregnancy, around one- third would consult a private sector facility

Severe abdominal pain,

N=601

N=601

0%

40%

50%

30%

20%

10%

03 Public Facility

02 Public Facility

01 Public Facility

FrontlineWorkers

Pvt. Hospital

Pvt. Doctor

Others(e.g, LocalProvider)

NotRegisteredAnywhere

21.0

31.1

0.5 1.2

44.1

24.0

5.42.2

N = 601

N = 601

l Pregnancies were frequently registered with Private Hospitals (44%)

l Only 1.7% women registered e i t he r w i th f ron t l i ne workers or at primary health facilities

0%

20%

40%

60%

Immediate Newborn Care

MedicalCollege Hospital

TertiaryHospital

MaternityHome/UFWC

Dispensary/UHP

PrivateHospital/

Clinic

NGO/ TrustHospital

At Home(Visit by doctor/other health care

provider)

Other

Place of Delivery

l Majority of deliveries conducted in private hospital and tertiary care public facilities.

l Those who have not delivered in the govt facilities, cited ‘poor quality of service’, and ‘husband/ family didn’t allow’ as the main reasons.

l Only 10% availed any govt. vehicle for delivery.

l Around 30% deliveries are C-section deliveries ~ Govt.: 20% and Pvt.: 40%

Self Reported Complications During Delivery

l

delivery complications referred to a higher up facility

l 62% of the RDWs never landed up in the referral facility they were referred to, cited it was unnecessary to visit the referred facility

41% of RDWs who had

N=601

l Less than 2.5 kg – 20%

l Huge amount of clustering at 2.5 kg implicating that the recording was 2.5 kg irrespective of their actual weight.

Birth weight recorded

No. of Children

Act

ual W

eig

ht

of

Ch

ild

(K

gs.

)

N= 586

Pre-discharge Counseling

l

signs or critical aspects of newborn care

l Limited discussion of family planning (need or methods)

l The three most popular topics were breast feeding, nutrition and routine immunization

Little discussion on danger

0%10%20%30%40%50%60%70%80%90%

100%

Imm

unis

atio

n

Nut

ritio

us fo

odfo

r M

othe

r

Bre

ast F

eedi

ng

Kee

p B

aby

War

mno

t STS

or

KM

C

Del

ayed

Bat

hing

Um

bilic

al C

ord

Car

e

Ski

n to

Ski

n/

Kan

garo

o M

etho

d

Dan

ger

Sig

ns/

Sym

ptom

s fo

rN

ew B

orn

Bir

th C

ontr

ol/

Fam

ily P

lann

ing

Dan

ger

Sig

ns/

Sym

ptom

s fo

rM

othe

r

88.5 88.0 83.9

63.455.9

46.135.6 35.4 33.3

25.8

N= 586

l Registration of pregnancy usually in the first trimester, but actual ANC starts in the second trimester

l ANC services at outreach almost non-existent; Uptake of ANC was mostly self-initiated

l ANC counselling was reportedly mostly on early initiation of breast feeding and regarding financial preparation

l Awareness on danger signs and pregnancy complications was poor amongst pregnant women

Gaps with respect to Antenatal Care

0%

20%

40%

60%

80%

100%

Baby cried/ breathedeasily immediately

after birth

Baby wiped (dried) as soon as it was born

Breast feeding within1 hour of birth

Something applied to thecord immediately after

cutting

99%

76%

30%

53%

N= 586

l High out of pocket expenditure in private sector deliveries.l Little or no awareness about the entitlement based services (JSY, JSSK), hence, poor

uptake of the same.l Role of health workers was minimal - rarely sought at the time of delivery. l Referral compliance for complications during labour was poor.l Only 30% initiated breast feeding within first hour of child birth.

Gaps with respect to Delivery Services

N=601

Exposure to Health Issues through Community Meetings

Source of Counseling

ANM MAS MembersAWW Link Worker / ASHA

Post natal check up of the mother Post natal check up of the newborn

l

l Outreach of PNC services by ANM was non-existent.Less than 50% women and newborn had received post-discharge follow up

Source of consultation regardingANC, delivery or PNC needs

Pri

vate

H

osp

ital

/N

ursi

ng

Pri

vate

Doct

or

Pha

rmac

y/C

hem

ist

Dis

pens

ary/

M

ater

nity

Hom

e

Dis

tric

tH

osp

ital

Oth

ers

N=601

Main reason behing visiting a private facility

N=335

Source of Information regarding MNH Services

HealthPersonnel

FamilyMembers/Relatives

AWWTV/Radio

News-paper/

Magazine

Posters/Pamphlets

ANM

N=601

Motherreceived any PNC(N=601)

Received more than

2 PNC visits (N=251)

Received first

check upwithin 24 Hrs

(N=251)

Received PNCat the Health

Facility(N=251)

PNCat the

UNHD(N=251)

PNCat

Home(N=251)

0%

90%

100%

80%

70%

60%

50%

40%

30%

20%

10%

48%

39%

64%

98%

1% 0%

Newbornreceivedany PNC(N=601)

Check up for more than

2 times(N=253)

Received firstcheck up

within 24 Hrs(N=253)

Check up atthe facility(N=253)

Check up atthe UHND(N=253)

0%

90%

100%

80%

70%

60%

50%

40%

30%

20%

10%

45%49%

87% 90%

1%

0%

10%

20%

30%

40% 35.2

29.6%

19.7%

12.7%8.5% 7.0%

4.2%1.4%

N=71

OthersFever Poor Sucking

or Feeding

Yellow Palms/Soles/ Eyes

Child has difficult/

Fast breathing

Baby too smallor born too early

Baby feels cold

Red swollen eyes/

discharge

Unconciousness

7.0%

1.4%

None of the above

Pathways to Careseeking 1 2 3 4

Symptoms in Sick Newborns as reported by RDWs

l

l 93% Families sought treatment ; 74% had taken their child to a private facility and 29% to district hospital

Among 601 RDWs, 12% (N=71) had experienced at least one danger signs in their baby in the first month

N=35

Primarily, AWW doing nutritional counselling (93%), promotion of WASH practices (68%), newborn care and breastfeeding (65%).