Bangles of health

Ghazipur district, indeed much of Eastern Uttar Pradesh (UP), is known for its high rates of infant mortality and maternal mortality. The Annual Health Survey, 2011, reported that 45 out of the 70 districts of UP report an Infant Mortality Rate (IMR) of 65 per 1,000 live births. The national IMR average is 44. Of the 44 districts, 24 report very high IMRs between 80 and 100. IMR is a sensitive health indicator, and has a direct bearing on the Maternal Mortality Rate (MMR).

Prabha (27) belongs to the low income Bindwalia Gram Panchayat in Ghazipur district. She is expecting her fourth child in a few months; her previous three deliveries had taken place at home without major medical intervention or attention. Thanks to the number of pregnancies that Prabha has had, she was identified as a high risk pregnant woman (HRP) in the second month of her pregnancy and was given a red bangle to wear on her left hand.

Known as the ‘choodi’ (bangle) model, this unique marker system was introduced so that women who are more likely to die at childbirth are identified early, and given appropriate attention and care. Dr Anand Chaudhuri, a public health consultant who conceived and designed the model, says, “The primary motive was to place women at the centre of the model, and get them interested in their own well-being. From our previous research and programming experience, we felt a need to make a woman feel precious, especially in these geographies that are plagued by feudal and patriarchal mind-sets.”

The Trusts are supporting and handholding a major Community Health Action Programme implemented by Faizabad-based organisation, PANI, alongside five community-based organisations. The programme attempts to plug the many structural failures of the public health system in Eastern UP, particularly in relation to maternal and infant health. The ground partners, such as Grameen Vikas Sansthan, based in Ghazipur district, procure bangles of four different colours, and hand them over to the auxiliary nurse and midwife (ANMs).

An appropriate coloured bangle is given to the women, who are told of its significance, and the importance of wearing it. Orange, white, and green bangles are given to pregnant women to wear on their right hands, on the completion of each antenatal check-up. This works as a surveillance tool. Red bangles are given to high-risk pregnant women, and are meant to be worn on their left ands, so as to facilitate tracking, special care, and counselling. The bangle enables the band of health workers, namely, community health workers, accredited social health activists (ASHAs) and ANMs to keep track of the high-risk pregnant women in their districts, and also allows them to be updated on the progress of their pregnancies. The core rationale of the choodi model is to increase surveillance and track high-risk pregnancies, so that interventions can be made at the optimal stages.

“Aside from being an important surveillance system to the cadre of health care workers, doctors and nurses, the choodis, particularly the red one given to high-risk pregnant women, sends out an important message to the family that she needs to be given special care during this important period. Care at the individual and household level is seen as crucial,” says Jagdish Giri of PANI, who oversees the implementation. He adds that the colours of the bangles have been chosen from the colours of the national flag to emphasise that “women are our national treasures”. Community health workers monitor the work of the ‘swasthya sakhis’ (health friends), run behavioural change interventions, track pregnancies and work with adolescent girls. These ‘sakhis’ (‘friends’) are mostly high school educated, though some of them have a college education. They’re trained in basic maternal and child health concepts, and shoulder the responsibility of transmitting these concepts to the community at large.

Prabha is not the only one who is being tracked throughout her pregnancy. Reeta Devi, in her late 20s, belonging to the Bindwaliya Gram Panchayat in Ghazipur district is expecting her fifth child in about six months. With multiple pregnancies and low haemoglobin levels, Reeta has been identified as a high-risk pregnant woman and also wears a red bangle on her left hand. She also wears an orange bangle on her right hand, to signify that she has completed her first ANC (antenatal check-up).

The swasthya sakhi assigned to Reeta’s gram panchayat visits her at home, and checks on whether she has been having her supplementary iron tablets and a suitable diet. Thanks to continuous monitoring on the part of the swasthya sakhis and due diligence and compliance in eating an iron-rich diet, supplemented by iron tablets and prescribed bed rest, Prabha has also managed to shed her high-risk status.

(All identities have been changed)