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Public Health

A case narrative of birth preparedness; safe delivery and essential newborn care behaviours practiced by poor family of Ardhaya village; Agra, U.P.

What made ‘Anjali’, a Low Birth Weight baby, gain weight in 3 months

Case studies of PD commercial sex workers

Miss KT's Story

K. T. is 19 years old and is the eldest of four siblings ( three girls and one boy). She comes from Mandalay. Her father died of liver cirrhosis. Since then her mother is selling seasonal food at the market and is unable to support the family. So K. T. dropped out of school when she passed 7th standard and entered the sex trade to help her family.

She lost her virginity with her first boy friend whom she dated for 2 years. During that relationship she had unprotected sex and knew nothing about condoms. She started working as a commercial sex worker 3 months ago and works every day.

She met her first broker who sent her to a brothel house at 8 miles Junction, where she worked for one month. There her clients volunteered to use condoms. After that, she was sent to Ma Sein (female pimp) by another broker.

She started using condoms after she met with her most recent Madam who told her to use condoms whenever she is having sex, especially with foreigners, to prevent getting AIDS. Therefore she has been using condoms systematically during her sex work, except for three occasions when her Myanmar clients brought her to their homes and could not purchase condoms because they were unavailable in the neighborhood or it was late at night.

She always uses a condom with foreigners especially with Taiwanese who use double condoms whereas Thai, Japanese and European clients use only one. She has now a second boyfriend, who has been her client for two months and uses condoms whenever they have sex.

Specific factors which enable her to practice this unusual behavior

Since she was young, she has seen information about AIDS on television. When she married, she was afraid to get this disease from her husband. Her recent pimp told her about a driver she knows who has HIV/AIDS. Since then Kay Thawe always uses a condom to prevent this disease. She also takes three months Depo-Provera injection for contraception. Her pimp chooses clients for her and she has never chosen drunkards or a client who asked for oral sex. But she has had to perform this unusual sexual behavior twice and used condoms on both occasions. She has never been asked to perform anal sex.

She does not worry about being arrested since her pimp has protection from a captain in the army who is responsible for the area where the night club is located.

Action to overcome problems engendered by unusual behavior

She said the word "condom" to a foreigner who did not want to use a condom and he agreed to wear it. She says that "she has a disease" to Myanmar clients who refuse to wear a condom and most of them comply. When some clients still refuse to wear it, she threatens to give their money back and not go through the contract. They usually give in. She has never been beaten or threatened when she has asked clients to use condoms. Nor has she experienced having a client requesting to have unprotected sex for extra-money. On one occasion, she has found herself with multiple Myanmar clients instead of one but was able to negotiate for everyone to wear condom and got extra money for each one. She is willing to come and meet with PD team at PSI.

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Case studies of PD commercial sex workers

Kyawt Kyawt Htwe's Story

Kyawt Kyawt Htwe is 20 years old, from Mandalay, and has one elder and younger brother. She has short hair and wears a white T-shirt and a blue flower print long skirt the night of the interview. She is open and friendly. Her father is selling automobiles' accessories and getting enough money for their family.

Factors that push her to the sex work

She said she was persuaded to go into the sex trade by her girlfriend, a divorcee and a sex worker who had many debts. Kyawt Kyawt said she felt sorry for her and wanted to help her. She came with her to Yangon and joined the sex work. She told her parents that she was working in Yangon. When she lost her virginity, she received one lahk kyats (100,000) and gave half of it to her Madam. She works 10 days and rests 10 days, thus has about 14 clients per month. She has no boyfriend but has a regular client who always uses a condom whenever they have sex.

In 1998, she attended a training course about HIV/AIDS taught by Red Cross at a school. There she learned that it could be transmitted sexually without condom protection. She has never known someone who has HIV/AIDS.

She uses a condom because she is afraid of the transmission of AIDS and she knows that AIDS has no cure. She also knows that condoms can be used for contraception. She takes a three months Depo-Provera injection for contraception. Her Madam taught her how to use condoms and provides her with condoms which she keeps in her locker at the night club. She is afraid to die early if she gets this disease and she thinks she is too young to die.

Action to overcome problems engendered by unusual behavior

She always tells all her clients to use condoms and guests always keep condoms. Before going to the Hotel, she asks her clients whether they brought the condom or not and accepts only the client who brought it. If she learns that her client did not really bring condoms to the Hotel, she insists that he calls a waiter to buy condoms. However, she has had sex without condoms on two occasions with two Chinese clients. One client brought her to his home and neither of them had condoms on hand and could not buy it near his house. The other client brought her to a hotel and when she asked him to use a condom through the waiter, he was very angry and strongly refused to use it. It was too late to go back home and she had no money to give him back. The waiter told her that this time she had better have sex with him because he was really angry. Since that incident she asked her Madam not to choose a foreigner for her because of the language barrier.

She finds it easier to negotiate with Myanmar clients. If they refuse to use condoms, she can explain by saying: "Aren't you afraid to get a disease? I may have a disease, why waist your reputation for a few minutes of pleasure?” Or, “Big brother, you also do not know whether you get a disease or not, I request you to use a condom because no one is sure." She does not need to persuade them too much, they accept to use condoms easily.

One day, a regular customer was over, drunk and fussy, and refused to use the condom. She told him if he did not want to use it, she was going to hit him and then she really hit him. He was not angry and said nothing because he knew her very well.

On another occasion, one client still refused to use the condom although she had pleaded with him. So she gave him his money back and went back to her house by a Hotel taxi. Unlike other Madams or pimps who always punish the girls who come back empty handed by exhorting money from them, her Madam has never blamed her for not fulfilling a transaction. For her, money is not as important as keeping her girls healthy.

K. K. T. rents a taxi with her own money. She has never had multiple partners and abnormal sexual practices. Her Madame chooses clients for her such as a Myanmar customer who is cleaned and wealthy so she can negotiate condom use easily. She also has regular customers. Therefore, she has had few customers who could be counted with fingers.

Ideas for "community based" action for behavior change in the community

Having learned more about condom usage from PD team at first screening meeting, she already talks to her friends about HIV/AIDS and advises them to use condom whenever having sex. She cannot give any suggestion to PSI but she is willing to help other girls and is interested in meeting with the PD team at PSI. She suggested that a good way for training sex workers about condom usage and negotiation would be in groups of women who share the same Madame or pimp.

Her dream is to stop doing this work and get a higher education.

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Case studies of PD commercial sex workers

In-depth interview with Madame Ma Ma S. (PD female pimp)

Her real name is S.. S.. M... Her father died when she was 13 years of age. She is the second to last among her 8 siblings. Her family was very poor previously.

She worked as a supervisor in a wool garment factory for 3 years and in an OMO washing powder factory for 1 year. She separated from her boyfriend because her mother did not approve of their plan to marry. She became very depressed. She learned about a night club through a friend. She had been working as a sex worker for three days when she met Captain Aung San Lynn, who is in charge of the area where the club is located. She fell in love with him and he suggested her to become a Madame. Hence she went to Mandalay to look for girls and found some girls with the help of her friend.

Current situation of the work

She charges clients about 8,000 kyats per girl and she nets about 5000 kyats. She provides her girls with dresses, food and shelter, health care, the taxi fair and night club entrance fees. Most of all she provides their security. She always chooses the clients for them. She never chooses a drunkard man, a man with poor appearance or does not look healthy. A client must pay the fees for the girls at the club and she gives money to the girl for emergency. She asks clients the telephone number or the name of the place where they plan to bring her girls beforehand. If one of her girls faces any problems such as the client who does not want to use a condom or does not allow her girl to come back home without having sex with him, she goes there, explains and solves the problem. She has never cut allowance to a girl who came back without money because her client refused to use condom.

Concerns about HIV/AIDS

She is afraid to get this disease because she lives with these girls. Therefore, she explained to them about this disease and always tells them to use a condom. If a girl has had sex without condoms, she instructs her to clean her private part (vagina) with a tooth-paste. She makes a roll of condoms which can fit inside the make-up case and a lip-stick. So, nobody can find them easily. Sometimes, she also provides a condom for the clients who did not bring it.

She is willing to work with PSI on a training for the girls. She said it may be difficult to organize girls from other Madames and pimps. They might think that she persuaded their girls. She suggests that training be done at PSI's office, because if it is in the club nobody wants to listen. She thought that the girls who are free-lance were dangerous and had a different character from girls affiliated with madames or pimps. According to her, they are alcoholic, gamblers and drug-users. It might be difficult to organize them. Sometimes they give a lot of trouble to the Madames and some have been arrested because of the free lance girls have tipped the police. She does not know what topics should be covered by the training. She said she did not want to continue this work. After saving some money, she wants to be a "Yogi"(who practices religious meditation).

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Grandmothers as Positive Deviants: PD Grandmothers become maternal-child health counselors

Author: Vani Sethi, PhD Fellow, Lady Irwin College, New Delhi (Edited)

This intervention-control study is being conducted in 7 socio-economically backward villages within ‘Achhnera' Integrated Child Development Services (ICDS) community development block in district Agra, Uttar Pradesh. The baseline study (June-Nov, 2004) for current practices and key influencers established beyond doubt that grandmothers are key influencers of newborn care and breastfeeding practices and not all of them are barriers as generally cited in literature. During the PD process of identifying PD families and their practices, grandmothers emerged as key facilitators for these positive deviant practices. This resulted with PD grandmothers being motivated to form a community counselor group in the intervention villages.

Since Dec 04, a grandmother network (“named Bal Gopal Seva Mandal by them) comprising of 24 grandmothers from positive deviant families has been working voluntarily as village health workers (VHWs) to improve maternal-newborn-infant health. Traditional Birth Attendants (TBAs), grass-root level ICDS workers support them in this initiative. The grandmothers, TBAs and ICDS workers received an initial capacity building training (Dec, 04-Feb, 05) through bimonthly meetings to share what they know and together enhance their technical and communication skills in influencing behavior adoption towards improved newborn care and breastfeeding behaviors. Together we developed the key messages and methods of communicating these messages effectively. The outcome of which was a pictorial flip book, which is now being used by the grandmothers in counseling families.

In the intervention villages, grandmothers as VHWs support 20-30 households in their neighborhood. If there is a pregnant woman in the household, the grandmother counsels the family members using a pictorial flip book during home visits, ensures that the pregnant woman comes to monthly group meetings, assist immunization sessions, provides the family with a delivery kit (now we have started preparing home-based delivery kits together)> In case of emergency, she escorts pregnant women to the nearby health facility, assists delivery and conducts weekly postnatal visits until their infant is 6 months of age. She is also being trained to monitor behavior change through pictorial monitoring formats developed. Nutritional status (weight and length), diarrhea and ARI prevalence in infants born is being monitored on monthly basis by the researcher using WHO guided procedures. Monthly meetings with the grandmother group to collectively solve problems we face in our work using the AAA approach.

Change: Today the scenario in the intervention villages is very different. There has been a significant improvement in behavior adoption towards appropriate antenatal care, delivery, newborn care, TT and childhood immunization. Also, exclusive breastfeeding rates are improving. Birth weights have improved and more and more babies now roly-poly.

Grandmothers host a monthly meetings (Mahila Mandal) when they sing health songs based on their own folk songs, sit and prepare delivery kits. You would be glad to learn that they have involved out of school adolescent girls too in their Mandal and are teaching them garment stitching (all free of cost). The change for betterment has begun. More and more influential people of the village are getting involved in this group and voicing the grandmothers opinions. For example the village head has banned the use of non-iodized salt in their villages and has regularly started participating in the grandmothers meetings.

The grandmothers are a treasure of knowledge. They have developed more than 20 health songs and I have been able to capture their songs in form of a book but since they are illiterate we together thought of recording their songs in form of an audiocassette that can be disseminated to as many as people. These days we are all practicing for the same.

Overall, not only has this grandmother group gained recognition from their community because of their work they have also been able to break caste barriers. Given below are two success stories:

Anguri Amma- grandmother gains recognition and respect from her community

On the 2nd April 2005, in a village named nanglamansa, ‘Parvati', pregnant lady of her cluster was experiencing labour pains near mid-night. Anguri Amma, a 65-year-old lady, and one of the members of the grandmother group in the village was the first to be informed. She quickly woke from her sleep, called Urmila, the ‘dai' (TBA in local terminology). She assisted the Urmila in delivery and ensured that 5 cleans of delivery were maintained. “I did not allow the baby (girl) to be bathed, inspite of Parvati's MIL insisting. I said- now no one is allowed to bathe the baby, if you insist you will have to go to prison” she said. Urmila weighed the baby with the weighing machine given to her, the baby weighed 2.8 kgs. They wrapped the baby, checked for hypothermia using human touch method and helped the mother initiate breastfeeding.

“Parvati's family brought me green bangles to thank me for my work. They have started giving me more respect now. They offer me tea, first they never used to let me in their home but now they make me sit and patiently hear my health messages when ever I visit them”, she concluded. TAnguri Amma not only motivates but also escorts pregnant women of her cluster to the government health facility, a 4 kms walk from the village. When her husband advises her not to attend the monthly meetings she says- “You send your grandchild to school and you pay a fee, I get to learn new things without even paying a fee, I will definitely go”. She mentions that now people in her village have started respecting her even more. “They say I will go to heaven after I die because I am doing seva (social work)”, she smiles.

Grandmothers break caste barriers as they accept the ‘Dai' as a member of their group.

The ‘Dai', a harijan, considered the lowest caste in Hindu mythology. In the village, she cleans drains in front of homes and gets one ‘roti' from each home on daily for these efforts.

Strangely although considered as a near untouchable and not allowed in the house beyond the courtyard, she is the first one to touch the baby. She is the one who ties and cuts the cord, cleans the baby and her role in promoting safe delivery and essential newborn care cannot be overestimated.

Although the grandmother group recognized her role, the grandmothers who were Thakurs and Pundits (considered higher castes in the village) were initially not willing to allow the ‘Dais' to sit with them during group meetings. “They are low-caste and unholy”, they emphasized. Moreover the group meetings were held in the temple, a place where the ‘Dais' entry was restricted but the only place where the grandmother chose to meet. As the intervention begun, the grandmothers complained that at the time of delivery the 5 cleans were not practiced. “The ‘Dais' are not practicing these behaviors, all our efforts are in vain, and the ‘Dais' also need to told all things we know”. Slowly, the grandmothers from ‘Thakur' caste allowed the ‘Dais' to attend meetings with them. Today people from all castes are allowed in the temple. They sit and sing together including the harijan ‘Dais', all for the good cause of improving the health of infants and mothers in their village.

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Stories of Positive Deviant families in an Afghan refugee camp

Shazia's Story

Shazia is a six month old baby and the second daughter of Fazal Mohammed, a driver. His family lives in the Afgan refugee camp 5, located in Haripur, Pakistan.

Shazia's mother used the BHU (basic health Unit) antenatal services twice during her pregnancy, and followed the advice she got there for her headaches. She got 2 Tetanus shots and planned to be delivered by a private nurse called Gulalai.

When the labor pain came at 31 weeks she was prepared with her mother-in-law at her side. They spread a clean plastic sheet on the floor and the nurse took out the soap, blade and thread. Because it was summer, the room was very hot. When the baby was delivered, they waited for the placenta to come out. Then the nurse tied the umbilical cord at two points and asked the mother to cut the cord for fear of getting dirty….The mother-in-law provided warm water and washed the newborn and put on some clothes. The mother said that this baby looked similar to the first born but cried weakly. They did not apply anything on the cord but the mother checked it every day because the baby was so small.

After washing her hands and breasts with soap, the mother started breastfeeding her baby. However, the newborn was so weak that it could not suck. So the Lady Health Visitor (LHV) was called and advised the mother to squeeze her milk into a spoon and feed the newborn that way.

They followed her advice for 3 days and then decided to go to a specialist because the baby was so small. The doctor gave her an injection. The baby started to suck. Because the baby had jaundice her father bought a taweez, or paper amulet, to protect her. After 10 days, the baby‘s sucking was strong and her health improved steadily. During this time, the mother breastfed the baby frequently, every hour. She also treated the baby for constipation by adding nawnahal to her breast milk. The husband has been very supportive and congratulated his wife and thanked God for giving him a daughter. He often takes his baby daughter in his arms despite his mother's disapproval: “Don't spoil the baby by picking her up all the time. She will miss you.” To ensure the mother some rest, he also takes care of the older daughter when he is at home.

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Stories of Positive Deviant families in Bagra village

Tausif's Story

Tausif is a small, 51-day old newborn compared with his cousin born the day before last December. Tausif‘s fragile and short life has already beaten many odds, as the story about his entry into this world will demonstrate. He is the second child and first son of Fatma. She is a shy, small illiterate young woman who told her story with help from her eager and talkative mother-in-law.

During her 4th month of pregnancy, she developed abdomen pain and was diagnosed as suffering from appendicitis and had an appendectomy. She went twice for antenatal check-up during her pregnancy on her 4th & 8th month when she felt delivery pain. She received 2 tetanus shots as well.

At the beginning of her 8th month, she suddenly felt delivery pain. Her mother-in-law went to a neighbor to seek advice because the delivery pains came early. She was advised to drink green tea to stop the pain. However, shortly thereafter she delivered her baby by herself on her bed, while her worried husband rushed out to get a car to take her to the hospital. Luckily, the old dai arrived in time to cut the umbilical cord with a bamboo stick, tied the cord with a thread, and performed the usual postpartum rituals (gutti, cleaning the newborn, etc.). When the husband came back with the car, the dai suggested that it was unnecessary to take the mother and newborn to the hospital.

Because of his very small size, the premature newborn could not suck his mother's milk. So the family fed him green tea and goat milk for the first night and the next two days. At that time, the baby was put to his mother's breast and breastfeeding was initiated. The colostrum was given and the baby was exclusively breastfed. On the 25th day, he was given his first bath and green tea was given to him to keep him warm.

When the baby was 30 days, he got sick and stopped sucking, could not lie down, and his ribcage was painful to the touch. The family started a home treatment of egg yolk and green tea for a day or two. They consulted a private doctor, who diagnosed the baby as suffering from “hasba.” He gave them medication for “hasb,” but the mother-in-law was not convinced that the diagnosis was accurate because the baby did not have blue fingertips. She decided that the baby was suffering from pneumonia, advised the mother to discontinue treatment and sought a second doctor's advice. He gave her a different medicine. In addition to this medication, the mother-in-law purchased mustard oil, blew a prayer on it and massaged the baby's chest with it 3 times a day for 4 days, wrapping the baby's chest tightly with bandages in between massages. During this illness the baby was breastfed by his mother. The baby is currently breastfed on demand with no additional foods or liquids. He has totally recovered from the illness and is making steady, albeit slow, progress.

The mother-in-law says, “Mother's milk is very ‘nurrowa,' healthy for the baby.”

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Stories of Positive Deviant families in Bagra village

Aqsa's Story

Mr. Khan Nawaz is a driver, father of an eleven-month-old thriving, former premature baby girl, Aqsa (delivered during seventh month). This was the second pregnancy, which was successful, as his wife had a miscarriage in the first pregnancy. Khan Nawaz's wife received five antenatal check ups and two-tetanus toxoid vaccinations, as he didn't want to take any risk keeping the last miscarriage in view. His wife had bleeding during the fifth month of pregnancy. He took her to a Lady Doctor (in Haripur) for a checkup, considering bleeding a danger sign for both baby and the mother. He and his mother extended a helping hand to his wife from the fifth month of the pregnancy, as he wanted to avoid the chances of miscarriage this time.

“Taking care of wife during pregnancy and after delivery is my religious obligation, if I don't care for her, who else will do that”.

He took charge of almost all the domestic chores himself except the cooking so that no family member (mother and sisters) could raise a finger on his wife that she is taking rest at an early stage in the pregnancy. He increased her diet (including milk and fruit) during pregnancy to provide the required energy to his wife and ensure the healthy baby. He started saving money from the third month of the pregnancy and saved Rs.12000.00, considering that an emergency can happen at any stage of the pregnancy. In the middle of the 7th month, his wife had labor pain and he rushed her to the hospital where she delivered a premature baby girl.

“Delivery at hospital saved lives of both mother and premature baby who could not have survived otherwise. My struggle and help of Allah enabled me to save both lives. If I would not have done that, my relative would have blamed me for any mishap”.

The family realized that the baby was very weak and needed a special care. She was wrapped in warm cloths and handed over to the mother soon after the delivery. She was given ghutti only once (ghutti is a tradition). The baby was given colostrum, considering it very healthy and energetic for a newborn. The baby was too small to suckle the breast milk so the family gave the expressed breast milk with the help of spoon for the first few days until she started suckling. The baby was exclusively breastfed for six months without water, as mothers' milk was believed a complete food for the baby. He learned from the doctor and television that mothers' milk has no alternative. The family didn't give bath to the baby for many weeks. The baby was wrapped in warm cloth, kept in a warm room and only her face was shown to the relatives so that she could not get cold. No body was allowed to touch or pick the baby so that she may not have any problem. He got his baby weighed regularly from the hospital on weekly/fortnightly basis for three months. His wife took complete rest for three months after the delivery so that she could take care of the weak baby properly.

“We knew that the premature baby required special care and attention and only a mother can provide such care. If she continued the routine domestic errands like cooking and washing, she would not have been able to provide the required attention to such a small baby”.

His mother really supported him in carrying out all the domestic activities during this period. He increased diet of his wife i.e. desi ghee (purified butter), milk and fruit after the delivery to make her healthy so that she could produce enough breast-milk for the child.

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