Case Management

By Abhishek Tiwari

Case management involves tracking all pregnant women and then their children till the age of two. The first and perhaps most important step in case management is the identification of the pregnant mother. Traditional birth attendants (TBA's) initiate the process of identification and subsequent registration of the pregnant mother. Upon registration the mother is evaluated for her risk potential. If she is identified as an "at risk" pregnancy then she is referred to a referral unit that closely monitors all high risk pregnancies. Additionally the women are also encouraged to come to CINI for at least three ante-natal checkups. During the ante-natal checkups the women are given iron and folic acid supplementation; tetanus and other immunizations; their weights, BP, hemoglobin count, and other health indicators are also recorded; and pregnancy related counseling is given. Post- pregnancy activities, which are the responsibility of the TBA if it is a home delivery, of the case management approach include community based management of obstetrical emergencies; weighing the child within 48 hours of birth (if it is a home delivery); initiation of breast feeding; and registration of the birth. The TBA's are given a token amount of Rs. 30 for following established CINI protocol for home deliveries.

The use of TBA's is an example of how CINI uses indigenous human resources to facilitate its program activities. CINI provides training to indigenous medical practitioners like the TBA's, MPW's and quack doctors. Additionally training is also give to adolescent peer educator, male & female peer educators, teachers, and opinion molders (i.e. panchayat members, local leaders, etc.). The idea is to upgrade the skills and knowledge base of these individuals so an authentic pool of information is created within each community. Subsequently this engenders an enabling environment within the community, which allows behavior change communication (BCC) strategies to work at the family and individual level. In other words by educating and training key figures within the community CINI legitimizes its messages and activities at the family and individual level; people are a lot more receptive to BCC messages if they see important local figures propounding the same ideas.

Case management also includes the management of obstetrical emergencies.

To ensure a safe delivery during such emergencies CINI has identified the potential impediments that may compromise the family's ability to take the woman to the hospital. The first and most important step in managing such emergencies is recognition of the problem. The local dai's and family members have been educated to recognize the danger signals during delivery. The second step involves addressing the potential obstacles that may prevent the actual transportation of the woman to the hospital. These obstacles include lack of transportation, insufficient finances and lower status of the woman. CINI has identified a local person with access to a vehicle who will be called upon in such emergencies for transportation. This individual will later be compensated, for his services, either by CINI or the family. In case of financial difficulties CINI either loans the money to the families or arranges for a low interest loan from the panchayat or some other entity. The marginilization of the Indian woman is one of the root causes of many health problems faced by women throughout their lives. CINI addresses this through community based gender education (i.e individual and family counseling, videos, etc), which is usually mediated by the local panchayats. CINI also provides in-kind help to other needy members of their project areas. This may include the free or subsidized provision of vaccines & medicines; of ambulance transport; and of clinical or hospital care.

CINI also encourages women to go for at least three post natal checkups. Often many public health programs do not disseminate knowledge that allows mothers to establish appropriate child care practices. In many cases it is not the availability of food or the accessibility to health care that is culpable for malnutrition or other illnesses. Instead issues that pertain to food security within the household, traditional practices of child rearing, an insalubrious environment, and time allocated for care of child are to blame for the various ailments, including malnutrition, that befall the child during the first few years of life. The CINI staff addresses these issues by counseling the women on topics that pertain to breast feeding, weaning, birth spacing and proper care of the infant. The growth and health status of the new born infant is monitored monthly using health cards. This is a process that continues until the child is two years of age. CINI is trying to convince the government primary health care centers to maintain similar records, especially on the number and type of family planning services used.

Another important part of its case management strategy is the referral system. Health workers are continually informing their clients within the communities about how to avail the appropriate government, and in some cases private, health facility or service. This system also tackles the problem of high risk pregnancies by identifying and subsequently referring 'at risk' women to the 'high risk pregnancy' management unit (see diagram).The basic idea behind the referral system is that all individuals should have access to the appropriate medical help, education, etc. based on a needs assessment of that individuals health status and practices.

Behavior Change Communication (BCC)

Behavior change communication, simply put, tries to inculcate the adoption of healthier behaviors or health related skills by increasing individual, family and community awareness and knowledge through health education. The BCC approach tries to increase awareness about important issues relevant to the mother and child and also attempts to bring about greater inter-personal communication within the family and the community. The behavioral messages stress the importance of good nutrition during pregnancy and lactation, the importance of reducing workload and increasing rest, and the importance of appropriate birth spacing. If the woman is having her second or third child she and/or her husband are urged to go for sterilization. However, there is still a great deal of resistance to these procedures, for a variety of reasons including religious proscriptions and superstition, in the communities.

The health workers verbally check the degree of compliance with their recommendations during each visit. The individual attention given to each woman and her family by the health worker demand reciprocity in the form of greater accountability for behavior change at the individual and family level. The same messages are also reinforced at the community level by peer health counselors & indigenous medical practitioners (who themselves were targeted for BCC) and at the institutional level by physicians and other health personnel. When a family or woman, new to CINI, is educated, their amenability to the recommendations made by CINI staff is high because the education takes place within a larger framework, in this case the community whose other families and key figures have been sensitized using similar messages, that is conducive to the desired behavior change.

To facilitate the process of behavior change CINI workers carry out various activities which include: regular home visits in which case workers interact with not only the pregnant woman but also her family; periodic group meetings with women in the community; nutrition demonstrations; issue based discussions among peer groups to whom CINI provides technical support and BCC material; and institute based counseling. Additionally CINI staff also develops indigenous community resources through regular interaction and orientation sessions with the panchayat members and training of village "quack" doctors.

The CINI staff uses various educational materials and techniques to ensure internalization of health messages. Videos, tapes, posters, books, and board games are just some of the educational materials used by CINI for behavior change communication. In addition, there are the various counseling sessions with the case workers, physicians, nutritionists and other relevant personnel that increase the likelihood of behavior change and subsequent improvement in health status. One such successful method involves the use of a fictional character - Champa - whose various gender specific experiences, i.e. menstruation, adolescence, marriage and pregnancy, throughout her life are depicted in a series of videos. Women and/or girls of all ages can identify with Champa as they vicariously share her various experiences and in the process internalize the various health related messages that are embedded throughout the videos. The Champa videos, apropos to pregnancy, discuss the do's and don'ts of pregnancy, safe pregnancy, pre and post natal care, family spacing, personal hygiene and safe sex practices. The videos have been found to be remarkably effective in inducing behavior change because they highlight certain negative behaviors, such as gender biases, that are perpetuated unconsciously by the family or community.

A very important component of the BCC strategy is the emphasis on male and mother-in-law involvement. Sometime it is necessary to target the husband and/or the mother-in-law, in lieu of the mother, to achieve the desired changes. Often the mother is not in control of her finances, food, or work load. Experience has shown that better results are achieved when the welfare of the child is emphasized instead of the mother. By appealing to the paternal instincts of the father or the maternal (or grandmotherly) instincts of the mother-in-law the CINI case-workers have achieved a greater level of compliance with their recommendations. Since most Indian families are patriarchal, male involvement and support during the pregnancy is a necessity. All husbands are thus encouraged to come with their spouses for the antenatal checkups. Once at CINI, they are counseled by male peer educators about proper care for the mother and child during and after the pregnancy. By holding the father directly responsible for the fate of his unborn child, case workers have been able to create a greater sharing of the household workload, increase the quality and quantity of woman's diet, ensure ante-natal check ups and increase emotional support for the woman.

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