The strategy of training ASHA workers in best practices in child health and natal care has helped the Sure Start project to up its success rate

"The birth of a new life should bring happiness and joy to the family, but lack of basic knowledge and facilities often restricts the event to anxiety and concern,” according to Dr Kranti Rayamane, maternal and newborn health expert at PATH, an organisation working on health issues. In 2005, PATH initiated the Sure Start Project aimed at ensuring the health and safety of mothers and newborns through behaviour change and community action. In a seven-year initiative, it has been working towards this goal in rural communities of Uttar Pradesh and among settlements of disadvantaged sections in Maharashtra's sprawling cities.

"Our only aim was to bridge the defence in the availability of infrastructure available and the lack of any human recourse development. The changes we seek are not abrupt or imposed. We train Accredited Social Health Activists (ASHAs) who are chosen from the community who in turn encourage community leaders, health workers, family members, and pregnant women to adopt best practices to improve health outcomes," Dr W.Sita Shankar, Director maternal and child health and natal care said.

In Uttar Pradesh, Sure Start works with the National Rural Health Mission and its ASHAs to promote healthy pregnancy practices for mothers in 5,520 villages. In Maharashtra, Sure Start implemented the project in selected slums of seven cities (Mumbai, Navi Mumbai, Nanded, Nagpur, Solapur, Pune, Malegaon).

The project carried out intensive activities including door-to-door surveillance for pregnancy through menstrual surveillance tools to ensure early registration of pregnancy, need-based Behavior Change Communication (BCC) for women and families, distributing printed health materials and using street theatre performances to promote healthy pregnancy, safe delivery and newborn care messaging.

Over the last two years, there has been a perceptible increase in the percentage of women registering their pregnancy within 12 weeks --from 41 per cent in 2008 it has gone up to 54 per cent in 2011. Institutional deliveries are also up from 78 per cent in 2008 to 88 per cent in 2011in the seven Maharashtrian cities. Sure Start works with 95 partners in Uttar Pradesh and Maharashtra, with the project funded by the Bill & Melinda Gates Foundation.

The key to the difference that the project has made is its ability to communicate and monitor. Issues are different in the urban – rural landscape, but they all fall under the same arch of logic and counselling. “Policy makers cannot wash their hands off by throwing money or creating infrastructure as a solution to problems that need to be solved by creating better communication and awareness. You can make a school but what if no one wants to go there,” asked Tarun Vij, PATH's country programme director.

He explained that in rural areas the challenge is the lack of medical conditions and opinion makers need to be influenced, in most cases mothers- in laws and sarpanch leaders. However, in the case of Maharashtra, which has the largest urban population in the country there were a different set of issues. “Drastic change in immigration and drift from the traditional lifestyle has changed the social structure, often leading to nuclear families where women have an additional burden of contributing economically. Outreach to the community is the most basic aim of the programme, no matter how many hospitals are made, unless the families are convinced of the practices, there is no use of the infrastructure…Communities have an innate capacity to find solutions to problems they face, we only need to catalyse them by training someone from among them. The snowballing effect takes place when women respond to the story of another woman's healthy delivery. This is the best way to spread an idea.” Mr. Vij said.