Maternal, Newborn and Child Health Care (MNCH) Service

An initiative of UBINIG with rural healthcare providers

Introduction
Despite significant efforts in maternal health care by the government and the NGOs, Bangladesh continues to remain high among the countries having high maternal mortality rate. The present rate of maternal mortality is 194 per 100,000 live births showing that Bangladesh could not achieve the MDG target of 143 per 100,000 live births by 2015. However, the decline in MMR from 322 in 2001 to 194 in 2010, a 40 percent decline in nine years was significant achievement. Now the new goals are set for Sustainable Development Goals (SDG). The 17 new SDGs, also known as Global Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

The SDG are also set to end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births by 2030.

It is an unacceptable fact that women die at the time of child birth. Although this is preventable, maternal causes account for 14% of all the causes of deaths among women of reproductive age. According to Bangladesh Maternal Mortality Survey, 2010 hemorrhage and eclampsia are the dominant direct obstetric causes of death, together responsible for more than half of the MMR followed by Obstructed or prolonged labor (7%) and abortions (1%). Indirect obstetric causes of deaths account for about a third (35%) of maternal deaths. These preventable causes of deaths can be dealt with through effective measures at individual and community level.

The neonate mortality is very much associated with maternal and child health. Bangladesh has 24 neo nate deaths per 1000 live births , in numbers it accounts for 76,722 neo nate deaths. The infant mortality rate has also declined considerably; from 87/1000 live births in 1990 to 43/1000 in 2011 .

The services provided by the healthcare providers are very crucial at the time of child delivery. At the national level, only 26.9% of women are delivering in a facility, mostly in private sector (15.1%) at public hospitals (11.8%) and others facility (2%). The rest (about 71%) are delivered at home. About 2.4 million women deliver at home. The Demographic Health Survey also shows that only 21% of all births were delivered by a doctors and 6.1% by nurse, midwife, auxiliary nurse, which includes qualified doctors, nurses, midwives, paramedics, family welfare visitors (FWVs) and community skilled birth attendants (CSBAs). The rest are looked after by Traditional Birth attendants known as Dais. It is a reality at present and will remain so for the years to come that women, particularly rural poor women will deliver babies at home with the help of the traditional birth attendants, locally known as Dai Mas.

Researchers do not find any systematic review or study about the causes of maternal deaths in Bangladesh. In this regard a study conducted by ICDDR’B at Matlab is cited with major causes of maternal death, using a combination of record review and field interviews. The major causes of maternal mortality were hemorrhage (20%), complications of abortion (18%), eclampsia (12%), violence and injuries (9%), concomitant medical causes (9%), postpartum sepsis (7%), and obstructed labor (6.5%) .

The causes of maternal deaths are matters of great concern for the country. However, prevention of the causes that leads to the deaths is not dealt with a holistic approach that involves the families, community and the healthcare providers.

General scenario of child birth and maternal health services

WHO has compiled the vital statistics for maternal and perinatal health for South East Asia region. For Bangladesh the annual number of births is 3.5 million and annual number of maternal deaths is 5,200 as of 2013. The maternal mortality ratio is 170 per 100,000 live births. About 71% of babies are delivered at home, 11.8% in public hospitals and 15.1% in private hospitals . In terms of services providers only 21% are qualified doctors, 6.1% are nurse, midwife and auxiliary nurse, and the majority 72.4% are at the hands of traditional birth attendants or by family members. That means the home deliveries (71%) are usually assisted by the traditional birth attendants (72.4%). The maternal health workforce needed for maternal healthcare is insufficient. There are only 33,061 nurse, midwife and auxiliary nurses, 802 obstetricians and gynecologists and the rest qualified doctors are general physicians 53,603 who have to attend other healthcare services. The other human resources for maternal healthcare include medical as¬sistants, pharmacists, medical technologists, family welfare visitors, community-based skilled birth at¬tendants, family welfare assistants, and health assis¬tants. All these workforces cannot deal with the real causes of maternal deaths, but they can help in monitoring of the health conditions of the pregnant women and provide some medicines. The health facilities include District Hospitals under Health Services Wing (59), Maternal and Child Welfare Centers under Family Planning Wing (97), Union Health and Family Welfare Centers under Family Planning Wing (3478). The other higher level facilities are only available in the Medical Colleges and the Capital City Dhaka.

The maternal healthcare includes Antenatal Care (ANC), Basic Essential Obstetric Care (BEOC), Comprehensive Essential Obstetric Care (CEOC), Maternal and Child Health Care (MCHC) and Post Natal Care (PNC). The Antenatal Care is provided in almost all UHFWC, MCWC, UHC and district hospitals. The Basic Essential Obstetric Care (BEOC) is available in only few UHFWC, in MCWCs and in most UHCs. Comprehensive Essential Obstetric Care (CEOC) is not available in UHFWCs. But it is available in 62 MCWCs, 77 UHCs and in the district hospitals. That means pregnant women who needs CEOC have to go mostly to the district hospitals for the comprehensive obstetric care. The field based health and family planning workers have training on BEOC (6 months) and at the hospitals nurses have midwifery training of 1 year and Medical Assistants or the Sub-Assistant Community Medical Officers (SACMO) provide BEOC services at the Union level health facilities. An UNFPA initiative resulted in 600 certified midwives, nurse-midwives who completed a six-month post-basic training, have already been posted to sub-district level health facilities in late 2015.

Reality of institutional child deliveries

Based on the real facts about the facilities and the human resources it is not possible for all women who give birth to go to a facility for the services. Even if they want to go there are many other factors that determine the accessibility to the services such as distance to the facility, availability of the transportations and other social and economic factors. It is also not the government’s intention to have all the child deliveries to be institutional. It is neither possible nor recommended. The concern is the child deliveries should be with skilled hands and that it should be safe. Having births at home has been going on for years and it has not been found to be the cause of maternal mortalities. In fact maternal deaths are happening at the hospitals or clinics when it is handled with unskilled hands. In the newspapers the reports on deaths due to wrong treatments of women at delivery are found frequently for private clinics and even government hospitals. The reports are only made when there is violent reaction from the patients guardians happen. In one hospital alone there were 11 maternal deaths during 2015. In the private clinics the patients were supposedly under gynecologist treatment, yet the deaths occurred due to ‘negligence’ or wrong treatment. Other such cases remain unreported. This only indicates that women are not necessarily safe to give birth at the clinics and hospitals.

The issue of maternal mortality is presently looked at mainly from the point of view of the availability of “skilled” healthcare providers at the time of child delivery and at postpartum period. A medicalised care is provided during this time. But a woman who is pregnant needs services and advice from early period throughout the pregnancy and in the postpartum period. This needs intensive care and proper nutrition.

Cost involved in maternal health care

In the government hospitals the admission fee is Tk.15 and the patients’ family has to buy the medicines. If any cesarean operation is needed it is provided free, but the medicines have to be purchased. In the private hospitals, the normal delivery costs Tk. 5000-Tk.6000 and for cesarean section Tk. 15,000 to Tk. 20,000 is needed at the district level hospitals.

Daima: The Maternal Healthcare providers outside the formal medical system

The vast number of women living in the rural areas and in the poorer section of the urban areas cannot receive services from the public health facilities and from the private hospitals. Several NGOs also provide maternal health care services with as price or free of cost. There is not enough supply of trained human resources for providing maternal healthcare services. However, traditionally the 71% of the home deliveries are attended by the Traditional Birth Attendants.

In Bangladesh, the Traditional Birth Attendants, (locally known as Dai Ma) play a significant role and help the majority of pregnant women (over 71%) at the time of their delivery . First of all, they are living within the community and are known to the families of pregnant women who need their services. This is a socially accepted relationship which does not have any financial transaction for services, and the Dai Ma is a respected person and her advice is taken with much importance. Their role is acknowledged in the global discourse on maternal health service providers. According to wikipedia, “Traditional birth attendants are often older women, respected in their communities. They consider themselves as private health care practitioners who respond to requests for service. The focus of their work is to assist women during delivery and immediately post-partum”. [wikipedia]. TBAs may not have any formal training on how to attend pregnant women. Many are highly experienced in well woman care including how to recognize and respond appropriately to complications of pregnancy.

Historically, Traditional Birth Attendants (TBA) have operated outside of the formal healthcare delivery structure. The TBA role in the community should not be overlooked; they are highly respected members and proven assets in addressing poor maternal outcomes.

Though the Dai Mas do not have any formal training in any institution, they have a system of training through apprenticeship in close association with long experienced Dais. They learn about Ante-natal care (ANC), child delivery and Post Natal Care (PNC) and about child health care.

Community maternal health care – an initiative of UBINIG

UBINIG’s interaction with the rural communities since 1990s found that there are a great number of traditional birth attendants or the Dai Mas living in the village who take care of women during pregnancy and help them at child birth. The rural women, particularly poor women, do not have access to healthcare facilities. UBINIG identified various reasons for poor access including transport, non-availability of health professionals and as women many of them found difficulties to move. To access government health care, villagers have to travel a minimum of 4 to 6 kilometers to the nearest health centers. Women find it difficult to access health services outside their villages. They face mobility restrictions because of their gender. In addition, the transportation cost to visit even the nearest government health centers puts a financial burden on their impoverished families. Furthermore, many women have experiences of non-availability of health personnel at the government health centers and are also reluctant to trust their health care to people they do not know.

UBINIG has been working with the biodiversiy-based farmers, known as Nayakrishi farmers, and came in contact with the Traditional Birth Attendants, called the Dai Mas and started networking with them. UBINIG received small grants from Action Aid, UK and Global Fund for Women, USA for running the Dai Ma Networks in different areas of the country.

UBINIG in its work on health issues, found the role of Dais as very important in the healthcare structure in rural areas and even in the poorer section in urban areas. Although they are serving to the majority of women, their services are not recognized. On the contrary, they are blamed for the reproductive health problems, particularly for maternal mortality and unsafe abortion. UBINIG’s work with the Dais for last 20 years have shown that the Dais possess knowledge of the body as well as social aspects of the women they are related to. They do not relate to the women they serve as ‘clients’ or customers, but they serve these women as their responsibility and a humanitarian service. Therefore, they do not charge money for their services, nor do they say no, if they are called at midnight. They are always available to help those who are in need of their services. Usually the Dais belong to the poor class, often the widows. In response to this, the community provides them with clothing and food when they need. The rich and better off families give them gifts after a child is born, particularly if the child is a son.

But at the government level and also at the rapidly changing ‘modernised’ social level, the Dais are not recognized, -- neither for their service, nor for their knowledge. Socially, culturally and psychologically Dai’s are indispensable in the life of rural women. They also combine herbal treatment for gynecological problems as well as care for infants. They command profound knowledge in plants, animals and local bio-diversity. They take care of pre-natal and post-natal health care of the mother and child, therefore she is ‘mother’ in a very significant sense; they are not merely ‘birth attendants’ as development agencies call them in English. The ‘mothering’ of the child they perform in continuous care relations establishes a bond with children in the community. They are respected and there are many stories and folk songs to celebrate this relation.

The Dais know about how to preserve biodiversity at the village level, since they deal with plants that are not in use in normal condition. Medicinal values of plants are related to the habitat. They also talk about nutrition and food requirements of mother and children. UBINIG formed a network of Dais having a membership of over 400 and has been raising the question of proper recognition of Dais and also helping them coping with the newer health situations caused by various external factors including application of pesticides, use of harmful contraceptives etc. The Dais want to learn about some new aspects of health problems such as diabetes, blood pressure etc. which they find during pregnancy stage of women. The issue of recognition of the Dais and their knowledge in the health care system is a crucial issue but has been denied because they are seen negatively in the context of modern health care and its inability to assess the value of indigenous knowledge practices that cannot be provided by any other way.

A Dai conference along with women healers and women farmers was organized in 7-9 December 2006 with support from PWRDF. This conference brought 100 Dais from all over Bangladesh and they will meet with over 200 farmers and women healers in Tangail and Dhaka.

With this experience of working with Dais, in early 2012, UBINIG took the project called ‘Improving access of maternal and child health care’ in partnership with Primate’s World Relief and Development Fund (PWRDF) under the Maskuka Initiative of the Canadian Government. For this purpose, UBINIG selected 130 villages in 23 Upazila under 15 districts, where the women of reproductive age, pregnant women and children under 5 (U5) had very little access to government health service delivery system. In order to address these challenges and increase access to MNCH care for women and children living in the selected 130 villages, UBINIG trained 664 Traditional Birth Attendants known as Dais constructed 35 DaiGhors in 15 districts. Dai Ghors provide advisory services to the women in reproductive age group, pregnant women, children under 5, developed a referral system, custom designed 35 tricycle vans and 10 boats to serve as ambulances for referrals to government health facilities, and run community meetings and awareness sessions on maternal, new born and child health (MNCH), nutrition and gender issues.

UBINIG also recorded that the government health professionals have occasional visits from the government Health and Family Planning Services who conduct immunization campaigns.

The initiative capitalized on the space and place Dais have occupied in their communities for years. It addressed not just the technical aspects of MNCH, particularly related to pregnancy and child birth, but also the social issues that impact the health and well being of mothers and their children. It built on the decades of practical experiences the selected Dais had and increased their effectiveness by helping them to improve their skills and develop new skills to provide basic pre and post natal care and safer home delivery, recognize danger signs of pregnancy complications and the importance of getting urgent and appropriate medical care for such cases, make referrals to the appropriate government health centers, understand the importance of hygiene and nutrition , challenge gender discriminations and harmful traditions and practices that have negative consequences on mothers and children.

A pivotal and innovative part of the effort are the DaiGhors --- centers, run by a management committee of 5 senior, skilled Dais as focal points for the Dais' operational and advisory activities. Each DaiGhors served 3 to 5 villages and was managed by 2 Dais at a time on a rotational basis from the five Dais..

The DaiGhors are open from dawn to late afternoon every day of the week. They provided basic pre and post natal care and nutritional advice to women of reproductive age, pregnant women and children U5. They also offered the space for government health officials to carry out the EPI (Expanded Program on Immunization) sessions.

In terms of the use and effectiveness of the DaiGhors, the initiative demonstrated investment by the community for the success and sustainability of the DaiGhors as centers where women can receive care as well as get connected to the government health systems---the same systems which as individuals the majority of the women in the project villages would not have had the confidence and the trust to seek out.

During the period January 2012 – June 2015, the trained Dais attended to 4,741 home deliveries (out of 5,943 pregnant women). All deliveries were at the women's homes. The Dais were able to identify 1,501 problem pregnancies (32%), convince the women and their families on the importance of seeking medical help and refer them to government hospitals for institutional care.

The 35 DaiGhors registered a significant increase in the number of pregnant women attending ante and post natal care at the union and upazila level government health facilities. By the end of June, 2015, total 34,381 pregnant mothers had received at least four check-ups during their pregnancy where their weight was monitored and their blood pressure taken by trained Dais and associates and had received ante and post natal care at the union and upazila health facilities. This was a 58% increase from the 23,000 target set at the initial stage of the effort. The pregnant women had also improved their nutrition by implementing the Dais' nutritional advice which was geared to their specific health needs and their socio-economic conditions.

In addition to the pregnant women referred to hospitals for institutional care, the Dais referred a total 9,701 patients to government-run community clinics, union health centers, upazila health complexes, district level government hospitals, and government maternity clinics. A few cases were also referred to divisional government hospitals. The referred included 3,832 women of reproductive age, 1,879 pregnant women and 3,990 children less than five years of age.

The tricycle and boat ambulances were used by 13% of the pregnant women referred by the Dais to government institutions at the upazila and district levels while 5 percent used other modes of transportation. The main reason for the low usage of the ambulances was that the union and upazila level health institutions which are closer to the villages are ill equipped to handle high risk deliveries. These were handled at the district level--a distance too far for non-motorized modes of transportation.

The effectiveness of the community awareness sessions which included monthly mothers' meeting, men's meeting and community meeting is evident in the number of villagers who can now recognize some of the danger signs of pregnancy and the type of food pregnant women need to consume for a healthy pregnancy and a healthy baby. Lack of basic health awareness is one of the major factors contributing to illnesses and even deaths. On the other hand, positive behavior changes and increased awareness (in this case on MNCH) are significant contributors to the sustainability of results. It is therefore empowering to villagers living in the project villages to have 83 percent of the mothers now able to recognize at least two of the known danger signs during pregnancy. A similar percentage of mothers and fathers are also now able to report at least 2 types of healthy foods that should be part of the diet of a pregnant woman and lactating mother.

Similarly, the initiative registered impressive results in the level of community awareness of gender and women's health. 48 percent of the male community leaders could identify two gender issues that impact women's reproductive health and 62 percent of the women and men who attended gender awareness sessions showed a very good understanding of gender and MNCH.

General situation of Nutrition

Nutrition is a very important indicator of general health status of people, and more importantly for the nutritional status of children and the pregnant women. Generally, the food intake in terms of calories has increased. The UN Food and Agricultural Organization (FAO) estimates that in 1993, the average Bangladeshi had access to 2,000 calories per day, whereas today that number has increased to 2,450 calories.

It is well understood that self sufficiency in food production is a national priority mostly expressed as food security. Bangladesh has achieved significant progress in the cereal production, particularly in rice. Food grain production has more than doubled during 1980 -2013 and has grown at the rate 2.61% per year. Rice grown in 71% gross cropped land constitutes 97% food grain production, grown at the rate 2.74% per year. Self sufficiency of food grain production is around 98.8%. The majority of farmers are engaged in rice production throughout two major seasons of the year.

Structurally, two starchy foods -cereals and potatoes constitute 78% of total production. In terms of meeting nutritional needs for people, the picture is not very encouraging. Production of Non food grain commodities such as pulses, oilseeds and fruits has reduced. Over 70% of the pulses and 66% of the edible oil requirements are currently imported, which were originally grown by the farmers. For the common people, traditionally the two most important non -cereal foods were fish and pulses, which are less available.

Food availability has reached the level of normative consumption requirement of 2318.3 kilo calorie per capita per day. But this calorie intake consists of 77% cereal, 18% non - cereal and 4% animal food. Out of the total 2318.3 K. cal received per capita per day from all food items in 2010, 1617.2 K.cal was contributed by cereals in which rice alone contributed 1436.2 K.cal. The other major calorie contributing food groups were edible oils (184.1 K.cal), vegetables (89.1 K.cal), potato (68.2 K.cal), fish (66.1 K.cal), condiments and spices (67.9 K.cal), pulses (50.2 K.cal), milk and milk products (27.4 K.cal), sugar/gur (33.5 K.cal), meat & poultry/egg (33.8 K.cal), fruits (31.1 K.cal) and miscellaneous items (49.9 K.cal) (Household Income and Expenditure Survey, 2010).

The Millennium Development Goal, Bangladesh Progress Report quoted the 'State of Food Insecurity (SOFI) 2014' jointly prepared by the FAO, IFAD and WFP, Bangladesh has reduced 27.3 percent of the number of people undernourished within 1990-92 to 2012-14 (from 36 million in 1990-92 to 26.2 million in 2012-14). According to UN estimates, proportion of population below minimum level of dietary energy consumption has reduced from 32.8 percent in 1991 to 16.4 percent in 2015. Similarly, according to the Global Hunger Index (GHI) Report 2014, Bangladesh has improved its rank to 57th from 68th position in 2012, which was 70th position in 2011. From the 1990 GHI to the 2014 GHI, 26 countries reduced their scores by 50 percent or more. (MDG, Bangladesh Progress Report, 2015).

However, malnutrition and under-nutrition is rampant, especially among small holder and landless farmers. The year's Global Nutrition Report (GNR), 2016 shows that the rate of stunting -- low height for age -- is still high at 36.1 percent and wasting remains high at 14.3 percent, far above the global target of five percent in Bangladesh. The report reveals 43.5 percent Bangladeshi women in their reproductive age are anemic.

Nutrition intervention from the Dai Ghors

Women receive nutrition advice about the food that available in their areas through farmers, homestead garden and from uncultivated sources. However, UBINIG introduced a model for Dai Mas to disseminate their acquired knowledge regarding nutritional requirement to the pregnant mothers and the relevant community. This idea was derived from the food pyramid or diet pyramid, a pyramid-shaped diagram representing the optimal number of servings to be eaten each day from each of the basic food groups. [American Heritage Dictionary Entry: food pyramid". Ahdictionary.com. Retrieved 2015-02-05]. However, the Pyramid developed by the Dai Mas is locally contextualized and has taken its own independent form according to the needs of the women in the rural areas. This Nutrition Pyramid was exercised as part of the training of Dais on nutrition since 2013 in which they shared their own knowledge and practices. These are not abstract model, and assumed a local character and are still evolving. The DaiGhors practices Nutrition Pyramid as opposed to Food Pyramid.

Nutrition Pyramid

The Nutrition Pyramid has five vertical compartments of specific categories of food items. The base compartment of the pyramid represents energy or the staple food in the diet, in the form of rice, wheat and other cereals. The second compartment from below represents varities of leafy greens and vegetables. The third compartment has fruits. The Fourth compartment has proteins in the form of fish, meat, lentils pulses, egg, milk, oil & fats. The top compartment has sugar, salt, spices, sweets etc.

The Dai Mas place iron rich vegetables as very important nutrition advice because they can identify the anemic conditions among women, particularly among those who are pregnant. In addition they have to deal with a lot of women in reproductive age as well as those who are over 45 years complaining about waist pain, bone aches etc. most likely to have osteoporosis. Now a day because of health education through radio and television, the Dai Mas are aware about the diabetes and hypertension. They know of many edible medicinal plants used as food. They also know what not to be taken as food if a woman suffers from such diseases.

The items in the pyramid have balanced nutrition with specific food that are available locally with seasonal variations and special requirements of pregnant and lactating mothers.

Nutrition Plate

Knowledge about Nutrition Pyramid is not enough when necessity arises to contextualize the individual cases of food intake by socio-economic differences. Women receiving advice on nutrition through a pyramid can understand the need, but one cannot ensure the effective utilization of the knowledge without showing exactly what is on the plate.

To arrange a poor family the nutrition plate the Dai Mas face challenge as their economic condition does not support her to have those foods. The knowledge they get for nutrition has to be translated into food availability according to their requirement. Dai Mas try to use food sources that are uncultivated and can be availed by the poorer families. With the knowledge of appropriate nutrition in those uncultivated food the families can meet the specific requirement of nutrition. They understand that it is not enough to know about generalized uncultivated food but to know specifically about nutrition contents and also in relation to their nutritional deficiencies.

The Complementary Role of Nayakrishi

There are Seed Huts in many areas with DaiGhors. Here they interact with the Nayakrishi farmers to produce food crops that are particularly needed for the pregnant women specially those who suffer from complications of anemia, osteoporosis, diabetes, hypertension etc.

The pregnant mothers and children are more vulnerable to toxic chemical contaminants associated with industrial farming. The Dai Ghors are built to develop synergy with Nayakrishi practicing without the use of any pesticides or chemical fertilizers. Dai Mas also belong to the farming families, therefore they provide the linkage with the Nayakrishi Seed Huts that are available in their villages or from Nayakrishi farmers. They encourage the families of the pregnant women and with infant children to have kitchen garden for safe and nutritional food crops. In addition, the families can earn extra income that can help meet the costs needed for treatment of pregnant women.

A Summary of Dai Ghor works

The maternal and child health services are at the top priority for the healthcare facilities. However, it remains an open call to the beneficiaries who have to come to the facilities to receive the services required by the pregnant women and their new born babies. The DaiGhors have made a difference between receiving and providing the services.

What the Dai Ghors do in general?

• Register all the women in 4 to 5 villages under each Dai Ghor who are pregnant.
• Register all the Dai Mas that look after the pregnant women in each village.
• Register the pregnant mothers indicating the status of their health;
• Ensuring 4 anti-natal check up including recording of weight, blood pressure, status of nutrition and any other complication. If there is anything found negative, Dais take initiative to address them and if the situation is beyond their control, they do refer and accompany her to reach nearest govt. hospital;
• Newborn and children under 5 years are well looked after by DaiGhors. The Dais record the health status of each child since immediate after his/her birth and ensure to grow well. If necessary they also refer and accompany them to reach the nearest govt. hospital to treat any complication;
• Total 23 DaiGhors have been selected by National Immunization Program as Immunization Center. Dais are very active to ensure so that all children under 5 years are properly immunized. They also keep records. The Dais mobilize the parents for immunization and also accompany the children the to DaiGhors for immunization;
• Organize the Dai Mas to gather in one centre so that they can share their experiences with each other and learn;
• Dai ghors also become the place to make contact with the government healthcare providers;

Each DaiGhors organize Mothers meeting in every month. Pregnant mothers, women in reproductive age, elderly women, adolescent girls, Dais join the sessions. A wider range of issues are addressed in these sessions. It includes personal hygiene, water and sanitation, problems of reproductive health, how to protect adolescent girls and boys mentally and physically, food and nutrition, nutrition pyramid and plate, how to take preventive measure for seasonal diseases, how to produce nutritious and safe vegetable;

Each DaiGhors organizes both Community and Male members meetings on quarterly basis. The meetings inform the activities, progresses and challenges of each DaiGhors. The farmers, community leaders, local govt. representatives, teachers, traders and people from other occupation join the meetings. It gives an ownership among the community and male members to own the DaiGhors. They also extend their cooperation when necessary;

How Dai ghors play a role in Hard to reach areas?

The problems in hard to reach area differ from other places, so, each DaiGhors in hard to reach area mapping them and identify the strategies collectively;

• Because of bad communication in the rainy season, the Dais plan to organize most of the social activities in dry season;
• Like other areas, they ensure service, referral in a same manner round the year;
• In river char area, the Dais keep good relation with the fishers to get boat service for referral;
• In hilly area, the relation with horse-cart and push cart owner is maintained properly to get service for referral;
• Because of hard to reach area, the relation with the community people is maintained respectfully to ensure assistance from them;

What will happen if the Dai ghors are not there

• The collectivity of Dais will be affected. The Dais will act individually and their collective skill and knowledge-base will not act;
• Now a pregnant mother is looked after and treated under collective decision, however, if there is no DaiGhors the system will be lost;
• Each DaiGhors is governed by a management system, so the problems of a pregnant mother is taken under that system, but if there is no DaiGhors, the spirit is lost;
• Food and nutrition is major task of each DaiGhors, which is the most vital issue of maternal and child, but if there is no DaiGhors, these issues will be ignored;
• Each DaiGhors ensure at least 4 anti-natal check up, but in the absence of DaiGhors, this process will be dis-functional;
• DaiGhors ensures the referral system in a systematic way, but in absence of DaiGhors, there will no such systematic effort;
• Each DaiGhors keeps the updated information about the facilities including health man-power available in the nearest govt. hospital, if there was no DaiGhors, it was absolutely impossible to keep such records;
• The Dais have good reputation and relation with the govt. health manpower including Family Welfare Visitors, Physicians, Health Assistant and it has been possible because of the good and effective role of DaiGhors;
• Because of effective and positive role of DaiGhors, the attitude of male members towards Maternal and Child Health has been positively change, but in absence of DaiGhors the change would not be possible
• Because of essential service of DaiGhors and intensive follow up for pregnant mother, the rate of normal delivery has been increased;
• All DaiGhors ensure to inform all pregnant mothers, elderly women and male members of each family about the danger signs of a pregnant mother and the children under 5 years old;
• Because of effective role of DaiGhors, the Dais are now socially acknowledged and more respected;
• The activity of DaiGhors reduced the rate of early marriage, dowry and violence against women;

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7. WHO, World Health Statistics 2014
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9. Demographic Health Survey 2011

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