January 2015 | Debjani Ray

Women of steel: the sahiyas of Seraikela

Tata Steel embarked on its Maternal and Newborn Survival Initiative or Mansi in 2009 in Jharkhand’s Seraikela block. In just five years, the project has helped build an army of women health workers, sahiyas, who are delivering outstanding results

Tara Mahato went into labour early on the morning of December 9, 2013. Around 10am, she delivered a girl. As is a custom in many parts of India, Tara was at her mother’s home for the birth, in village Gangpur of backward Seraikela block in Seraikela-Kharsawan district of Jharkhand, India.

Though it is safer for women to deliver in hospitals, Tara’s parents, like many in rural India, preferred a home birth. They called a midwife, and the sahiya of Gangpur Rupam Mahato to help. In Jharkhand, a sahiya or friend is a trained health worker sent by the government to offer guidance and care to pregnant women. In remote areas of Jharkhand, a sahiya is often the first point of contact for pregnant women. Thanks to the training received through the Maternal and Newborn Survival Initiative (Mansi) run by Tata Steel Rural Development Society (TSRDS), sahiyas are looked up to as saviours.

Trained under Project Mansi, sahiyas extend care to mothers and newborns
In Tara’s case, though half an hour had passed since the birth, things were not as they should have been. She was in discomfort; her stomach was swollen and there was no sign of the placenta yet, a mass of tissue that is expelled by the body soon after birth of the child. Rupam started on an oil massage to help Tara discharge the placenta. After 15 minutes or so, the placenta came out as an unexpectedly large mass of tissue. Nobody knew what to do with it —the midwife was too scared to make a second move, and Rupam, for all her training and experience, hadn’t seen anything like it before.

Despite her nervousness, Rupam worked up the courage to take a decision. “Forty-five minutes had elapsed since the birth, yet there was no relief for the mother. There was a lot of pressure on me to save the mother. Something had to be done,” she says, sitting in her house in Gangpur, recalling the events of a year ago. The midwife suggested that she use a blade to cut the placenta, but Rupam knew the risks, so she tore open the placental covering gently with her hands, bit by bit. Inside was a baby boy. It wasn’t moving, and the umbilical cord was wound around its neck.

The sahiya quickly pulled out a portable mucous extractor from her toolbox and cleared the baby’s airway. Soon there was a small hiccup from the baby, followed by a soft cry. The boy had been saved. “He’s a healthy boy and he’s going to turn one in December,” she smiles.

Seraikela appears at the bottom of the pile in any measurement of socio-economic indicators — be it the infant mortality, per capita income or nutrition level. Today, due to the efforts of sahiyas and TSRDS, there’s been a 32.7 percent reduction in neonatal mortality and a 26.5 percent reduction in infant mortality in the region.

A collaborative effort
When Tata Steel decided to embark on the Mansi initiative under the auspices of Tata Steel Rural Development Society, the infant mortality rate (IMR) or the number of children dying within a year of birth in Seraikela was 60 per 1,000 live births. Also high was the neonatal mortality rate (NMR) or the number of infants dying within 28 days of birth. In comparison, Kerala and Goa had IMRs of 12 and 11 respectively.

The reasons for Seraikela’s poor performance in community health were many. The terrain is inhospitable — there are places the administration does not visit for months. Government health systems are either defunct, too far away or cost too much to visit. Since one trip to the hospital was so much trouble, a return visit was out of the question. Hence there was no supportive medical care, which is why new mothers and infants did not get medical attention when they needed it most. Despite all the incentives the government gave through the Janani Suraksha Yojana to encourage women to deliver babies in hospital, most people preferred home births. It was in this scenario that Tata Steel decided to implement the concept of home-based neonatal care — and Mansi was launched.

Mansi is the brightest jewel in Tata Steel’s corporate social responsibility (CSR) crown. It is a unique project — a multi-collaborative association between the Jharkhand government, Tata Steel, funding agency America India Foundation (AIF), Gadchiroli-based NGO Search, and the community — specifically formed to reduce infant and maternal mortality rates in Seraikela.

“We realised that the government health system was not making any impact. Doctors were not there, facilities were not enough, and often far from the village. Besides, transport was not available to reach health centres quickly,” says Biren Bhuta, chief of CSR, Tata Steel. “We were clear from the start that we would not run a project parallel to the government’s. Rather, we would use the existing government machinery to deliver a social benefit. We found a good model in the home-based neo-natal care model implemented through Search, an NGO run by Dr Abhay and Dr Rani Bang in Gadchiroli, Maharashtra. This model was based on training the women health workers chosen by the government to deliver home-based care to pregnant women and newborns.”

Focused approach
Tata Steel decided to implement Mansi on a scale where it could see real impact. “Instead of 10 villages, we decided to take up an entire block — the administrative block of Seraikela consisting of 167 villages with a population of 80,000,” says Mr Bhuta. The first step was to find out what were the prime causes of infant and maternal deaths. For this, Tata Steel decided to follow the Total Quality Management or TQM approach. “Our surveys revealed that 96 percent of deaths happened in the neo-natal stage. We realised that is the stage we need to focus on,” says Dr PC Mohapatra, head of family initiatives and health at Tata Steel.

The three most common causes that resulted in 80 percent of deaths at the neo-natal stage were asphyxia, in which the umbilical cord wraps itself around the baby’s neck, low birth weight resulting in hypothermia and sepsis which is a respiratory infection. Therefore, it was decided that the sahiyas would be trained to tackle these first.

Mansi is headed by a programme manager who has a coordinator under him. The 167 villages are divided into 4 zones and each zone has a zonal coordinator responsible for around 45 villages. When the project began, Tata Steel and its partners conducted many meetings to get the buy-in of district and state health officials, block officials with the National Rural Health Mission, panchayat heads, etc. It was found that elected representatives would play a key role in changing cultural beliefs.

To bring healthcare to the doorstep of the people of Seraikela, mobile clinics, as many as 31, were sent to different villages. The medical team would arrive at an appointed date and time for trimester check-ups, ante natal check-ups (ANC), immunisation, etc. Later, the number of clinics was reduced to allow people to reach out to the existing government setup. TSRDS decided to retain clinics only in hard-to-reach areas.

The people who train health workers in the state were taken to Gadchiroli to expose them to the home-based neo natal care model. They came back and taught the sahiyas. Training was regular and the sahiyas were even graded on the basis of their grasping power and their performance on the field. This proved to be a real challenge because many of these sahiyas did not know to read and write.

Today, sahiyas have been trained to fill up at least three detailed forms for every case they take up, and it is a triumph for the trainers to see them capture and explain data so well.

On the field
The sahiya’s first job on the field is to track women from the time they become pregnant. They are taught to assess the mother’s health, calculate the expected date of delivery and fill all the information in forms. Sometimes, the sahiya might get someone in her family to do it, but mostly she fills the forms on her own. Being part of Mansi has given her the knowledge and confidence to do so. During each visit, the sahiya checks whether the expecting mother is taking her iron and folic acid tablets, and counsels the woman to opt for a hospital birth. She also hands the would-be mother a phone number to get in touch during emergencies. The phone number is linked to a call centre through which the pregnant woman can ask for Mamata Vahan (ambulance facility for pregnant women) at the onset of labour.

Mamata Vahans, put in place by the state government, take the woman to the nearest hospital in case she chooses to give birth in a hospital. The contact number for calling the Mamata Vahan is visible all around the block — painted on houses, near schools, and near tubewells.

Each sahiya is given a kit which comprises among other things a thermometer, a mucous extractor, a weighing machine, a warm wrap and blanket and a disinfectant. In 2012, due to the advocacy by the Mansi team, the Jharkhand government decided to add more power to the sahiya’s toolbox in the form of a bottle of cotrimoxazole syrup and permission to give it to newborns to reduce chances of infections.

It was a big achievement for the sahiyas, and an acknowledgment of the impact of Mansi. After the child is born, the sahiya continues to make her home visits till the 42nd day, checking on the health of the baby and the mother, recording their temperatures, weight and other vital signs and filling the data in forms. She also teaches the mother correct breastfeeding techniques, advises her on the right diet and if needed, refers the mother or baby to a hospital for further treatment.

“We created an HR structure and the project is monitored very tightly. There is a lot of rigour on timeliness of data, accuracy, strict compliance with protocols because we are talking about human lives,” says Bipin Rawat, the programme manager for Mansi. Support for a yearly evaluation comes from Search, through what is known as a Vital Rate Survey. It is a census survey, a comprehensive household-based count in which project managers go to every household in the block and get data.

Apart from this, there is monthly data, monthly and quarterly progress reports recording the number of births, deaths, reason for deaths etc. There are about 70 in-process indicators that are recorded by the Mansi team every month.

From rigour to results
The rigour and the constant training of the sahiyas have yielded the expected results. Almost every process indicator has improved —today women undergo three ante natal checkups, and are more aware of what to eat and what to avoid during pregnancy. More children are being weighed at birth and mothers of underweight children are being taught to give proper nutrition. This has resulted in more healthy children. Also, hospital births have shot up, by 50 percent. So impressed was the Jharkhand government with the impact of Mansi — the reduction in neonatal mortality and infant mortality that it wrote to Tata Sons complimenting Tata Steel for the initiative and asking them to scale up the project across the state. And that’s exactly what Tata Steel is going to do. It will work with its partners in Jharkhand — AIF and Search and scale up the project from one block in Seraikela-Kharsawan to eight blocks, covering half a million people. Two more blocks under west Singbhum will also come within the ambit of Mansi. More lives will be saved, and more people will be empowered.

The takeaways
In the book of good works, Mansi will occupy pride of place, mainly for three things: for bringing the government, a business house, a funding agency, an NGO and the community to work together and succeed in delivering a social benefit; for demonstrating that it makes sense to use business processes to solve social problems because a ‘managed project’ is more efficient and focused on results.

But most important of all for proving to the world that people, no matter where they come from, are capable of bringing about change. Mr Bhuta says, “The sahiyas are the stars of the project. They get immense pride and satisfaction from saving lives. People look up to them as saviours.”