Accredited Social Health Activists (ASHAs) are empowering women like Rani Burman living in Madhya Pradesh, India, to seek a better tomorrow. The Challenge Initiative for Healthy Cities (TCIHC) supports local governments in Indian states like Madhya Pradesh to strengthen the capacity of urban ASHAs to provide quality family planning counseling and referrals to meet the needs of women like Rani. 

"I was flying on my new scooty; my dreams were turning into reality. Life was a Bliss! All thanks to Pooja Didi. Yet I clearly remember the day when Pooja Didi first visited me. I was eating only rice. She had asked, 'Why are you eating only rice? You have small children; you must eat a healthy and balanced diet.' My eyes had welled up and she sat there quietly. Once I felt better, I shared that ever since the birth of my second daughter financial hardships increased for us. My husband and in-laws wanted a male child so my husband did not spare money for us; instead, he spends most of his earnings on alcohol. Today I at least had rice to eat. Pooja Didi comforted me and left with a promise to return."

From that day, she would visit me often, sometimes to give iron-folic tablets or to immunize my children or to just inquire about my health. One day, she cited her example and encouraged me to work and earn for the family. I told her that I had completed my secondary education but my husband does not like the idea of my working outside of the house. Didi jolted me to think of making a change in the drudgery of my life. One afternoon, when Didi came, my husband was home. She checked about children's health and started a conversation around the importance of family planning and also prodded upon the idea of my working outside of the house. She reasoned without fear that these two decisions will only make life better for us. My husband was moved. A few days later, I asked my husband if I could look for a job. To my surprise, he gave his nod. I soon found one and gradually found a better one as a receptionist at a hospital. Pooja Didi was elated!"

Financial independence boosted my confidence. I started expressing myself. I told my husband that I know that the family desires to have a male heir but given that we already have two daughters and our income is also not sufficient to support this current family of six members including his parents. Thus, we must do something about family planning as we cannot bear the cost of upbringing one more child. My husband approved and asked me to inquire all about family planning from ASHA Didi. Next time, when Pooja Didi visited us, she explained all the family planning choices and clarified our doubts. We decided to adopt a permanent family planning method as we wanted to be free."

These two decisions have changed my life. Not only am I free from the constant pressure of producing a male child but I have become independent too and also gained respect from my family and society. I am determined that my daughter will do advanced studies and become a doctor or a police officer. I have learnt not to fear life but to live life."

To learn more about the impact of urban ASHAs and how to adopt or adapt this high-impact approach, check out Enabling Urban Accredited Social Health Activists.

For reading this story on TCI University please visit https://tciurbanhealth.org/tcihc-urban-tale-asha-helps-woman-move-beyond-just-surviving-to-live-life-to-the-fullest/You can read all previous stories also athttps://tciurbanhealth.org/topics/india-urban-tale/.

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

The Challenge Initiative for Healthy Cities (TCIHC) in India worked strategically through its adolescent and youth sexual and  reproductive health (AYSRH) program to reach first-time parents with informed-choice counseling and modern contraceptive services over a six-month period ending June 2019 in five cities in Uttar Pradesh (Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi). 

The first step was to make sure young first-time parents were visible, so they can receive appropriate services, including contraception, so TCIHC coached and mentored active urban Accredited Social Health Activists (ASHAs) to identify them from their urban health index registers (UHIR). This effort included coaching to make sure the ASHAs knew how to complete their UHIRs, develop lists of women based on age and parity (i.e., number of children), and devise a priority list of young first-time parents. At the same time, TCIHC worked to overcome provider bias to ensure providers and facility staff were aware of the latest medical guidelines and had accurate knowledge on all the methods available for young first time-parents at both the facility (medical-officer-in-charge and staff nurse) and community level (ASHA worker). "

Studies have shown that low parity can be a barrier to accessing some family planning methods. Data from the Urban Reproductive Health Initiative (URHI) found that 90% of the providers restricted access to female sterilization and intrauterine contraceptive device (IUCD) based on the number of children that a client has. Of this, 65% of doctors required a client to at least have one child and 63% of all traditional birth attendants believed that a woman can opt for an IUCD only if she had two children or more. As a result, a plan was devised to conduct whole site orientation (WSO) - a TCIHC proven approach - on adolescent-friendly services at urban primary health centers (UPHCs) in the five cities. Following this, the TCIHC team garnered support from city health teams to organize special fixed day static (FDS) services - another TCIHC proven approach - for first-time parents. These efforts significantly increased contraceptive uptake among first-time parents, aged 15-24, as illustrated in Figure 1. Forty-one percent of all women aged 15-24 accepting a family planning method at a UPHC were first-time parents, across the five TCI AYSRH cities, as compared with 28% in the 26 TCIHC-supported cities implementing TCI's proven family planning solutions in Uttar Pradesh, Madhya Pradesh and Odisha with no special focus on AYSRH.

Upon learning about the AYSRH impact, many of the TCI cities implementing family planning only informally began adding AYSRH activities. As a result, these cities also began to exhibit increased results in reaching women 15-24 years and referring them to FDS (Figure 2). While TCIHC AYSRH cities still reached more young women, ages 20-24, (50.3%) than TCI family planning only cities (42%), the fact that there is not a large gap between the two different city groups speaks to the scalability of the AYSRH approaches.

For reading this story on TCI University please https://tciurbanhealth.org/reaching-first-time-parents-in-the-tcihc-supported-youth-friendly-cities-of-uttar-pradesh/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

Shahnaz lives in the Lavkushnagar slum in Uttar Pradesh with her husband Nasruddin. Tailoring is their livelihood, but it offers a meager and insecure income. Shahnaz is very familiar with hardship and has faced many challenges since childhood. 

"I lost my father when I was merely nine years old. My mother, due to low income, couldn't take care of seven children. Hence, as a result of social pressure, she arranged my marriage. I never went to school. I got married at the age of 12 and I conceived soon after my first menstrual period."

Shahnaz had her first child by the time she was 13. Since then, she has added two more children to her family and experienced four miscarriages. The pregnancies, births and miscarriages have taken a toll on Shahnaz's health.

Her husband Nasruddin assumed it was her responsibility to take care of things like family planning and, unfortunately, they never spoke about it. Soon, Shahnaz was pregnant again with twins. In the eighth month of pregnancy, she experienced heavy bleeding and was rushed to a hospital where both were stillborn. The hospital bills were more than she and Nasruddin could afford, so they had to borrow 10,000 rupees for her treatment. Life became tougher still for Shahnaz as she struggled to pay for food and medicine. By the time she turned 28, Shahnaz found the courage and determination to do something about family planning. She decided that the next time an Accredited Social Health Activist (ASHA) knocked on her door, she would not ignore her and miss the opportunity to find out about about family planning method choices. Ultimately, she met with a TCI-coached ASHA and decided to adopt female sterilization as her method of choice. Shahnaz is no longer stressed by the fear of becoming pregnant again.

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

Shahnaz is now learning how to read and write from her son. She is also saving some money for the future. Like Shahnaz, thousands of women in India wish to space or limit their family size but are either unaware of or do not have access to family planning choices.

This is why state and city governments in Indian states like Uttar Pradesh are strengthening the capacity of urban ASHAs, with TCIHC's support, to provide quality family planning counseling and referrals to meet the needs of women like Shahnaz.

To learn more about the impact of urban ASHAs and how to adopt or adapt this high-impact approach, check out Enabling Urban Accredited Social Health Activists.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-urban-tales-family-planning-offers-new-beginnings-for-young-mothers-in-india/You can read all previous stories also athttps://tciurbanhealth.org/topics/india-urban-tale/.

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visithttps://tciurbanhealth.org/india-toolkit/and https://tciurbanhealth.org/topics/india/.

In Shahjahanpur, Uttar Pradesh, monthly meetings between Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives used to take place centrally at the office of the Chief Medical Officer (CMO). But because Shahjahanpur has 94 ASHAs and 25 ANMs, the CMO felt that these meetings were often too crowded, chaotic and unproductive. 

The Challenge Initiative for Healthy Cities (TCIHC) recommended that these meetings be moved to the urban primary health center (UPHC) level to limit the number of participants, ensure better engagement of ASHAs and ANMs with other facility staff, provide more regular reviews of data and discuss course corrections. Shahjahanpur's CMO readily agreed and now the meetings are held in UPHCs and family planning indicators are improving."

"I [have] attended 10 such meetings at UPHCs and noticed a surmountable difference," the CMO said. "With a limited number of ASHAs and ANMs, I noticed they were paying attention to the proceedings of the meeting."

The Deputy CMO also witnessed this transformation, and pointed to the following three changes that have taken place:

ASHAs feel more comfortable sharing issues they face in their work. Those who were shy were not able to speak in front of the large audience in the meetings at the CMO office.

The UPHC Medical Officer can now coach the entire UPHC team on method choices for family planning and clarify myths and misconceptions related to them.

Regular UPHC-specific data reviews helps identify issues that need to be addressed, such as supply stock outs.

The Medical Officer In Charge (MoIC) of the Lodhipur UPHC also said holding meetings at the UPHCs was the right move.

"Now, we can review the ASHA diary and Urban Health Index Register ... and FP uptake has increased," said the MOIC. "Earlier, we would know only by the end of six months or one year as to what the performance is but now we know every month."

This active, regular review of data has helped ASHAs better focus their efforts (see chart below), identify areas where coaching support is needed, provide a platform for recognition of high-performing ASHAs, expedite more timely payment processing and unlock funds from the Ensuring Spacing at Birth (ESB) scheme of the Government of India, which was not previously utilized by urban ASHAs.

Moving the location of the monthly ASHA-ANM meetings to UPHCs is proving to be a successful approach across all 31 TCIHC-supported cities. More than 6,000 urban ASHAs are now taking part in such meetings.

For reading this story on TCI University please https://tciurbanhealth.org/moving-data-review-meetings-to-uphcs-in-shahjahanpur-improves-family-planning-service-delivery/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.