Lohardaga, India—Dr. Kiran Marandi works at the District Hospital in Lohardaga, one of the poorest areas of Jharkhand, with most of its population living in rural areas and engaged in subsistence farming. With 353 villages in the district and more than 36,000 families living below the poverty line, progress is slow and severely challenged because of heavy Naxalite (a militant communist group) activity. No private hospitals exist, making residents solely dependent on government-run facilities, especially the District Hospital. Dr. Marandi, 50, works here by choice. “Though my family is in Ranchi [the state capital], I chose to serve in Lohardaga, as it needs a doctor much more than the city,” she says.
Last year, Dr. Marandi was invited to attend a postpartum family planning/postpartum intrauterine contraceptive device (PPFP/PPIUCD) training course along with Sister Binderswari—a nurse-midwife from the same facility. Organized by the Government of Jharkhand, the three-day course was supported by the U.S. Agency for International Development’s Maternal and Child Health Integrated Program (MCHIP), which provided technical assistance for the training. MCHIP is partnering with the state government to strengthen PPFP services in Jharkhand, a state challenged by poor health indicators.
Every year, 42 infants die for every 1,000 infants born alive, and, of the 100,000 mothers who give birth to a live baby, 278 die. The total fertility rate is 3.0; only about 30 percent of the state’s women use any method of contraception. In addition, there is a high unmet need for family planning (35 percent), which is much higher in the postpartum period.
Dr. Marandi was excited to attend the PPFP/PPIUCD training because of its potential to help increase the contraception coverage among postpartum women in the district. This intensive training included:
- Awareness-building on the importance of the postpartum period and the various family planning methods available
- Introduction to PPIUCD as a viable option that increases the basket of PPFP choices for women
- Hands-on training on the new technique of PPIUCD insertion
- Orientation on a system to check for the eligibility of clients
- Practical PPIUCD insertion training with anatomical models and then clients
- Training on effective counseling skills
“It was what we were looking for,” recalls Dr. Marandi. “I had seen too often women delivering at our facility, going back home and returning within six months with another pregnancy. Most of them did not want to get pregnant so soon, but had failed to adopt a family planning method on time.” Part of the reason, she believed, was the fact that the hospital was sending women home from the facility without a family planning option in hand. “But now, with PPFP/PPIUCD, we could change that,” she adds.
Determined to start PPIUCD services at their facility, Dr. Marandi and Sister Bindeswari, a nurse-midwife whose dedication matches the doctor’s, set off to get the site ready for service provision. “At the time that we attended the PPIUCD training by MCHIP, no one had even heard of PPIUCD at our facility. The entire district was not providing such services,” says Dr. Marandi. “It was a very new concept for my colleagues and staff. I faced problems in convincing them… It took me two to three months to get the program up and running, and arrange for all the instruments required for service provision. It was hard at the beginning.”
Sister Bindeswari recalls feeling dejected at times. “When we wanted to start providing PPIUCD services at our facility, people would refuse to accept it. We thought our training would go to waste. Sometimes they [clients] would say no even on the table [before getting the IUCD inserted]. People started talking among each other. Sahiyas [community health workers] were not able to convince them to accept these services,” she says.
Dr. Marandi understood why: “When the providers themselves had many apprehensions, how could they counsel clients to adopt the PPIUCD services?”
But the two women were confident in the benefits of PPIUCD as an effective PPFP choice and were determined to make a change.
The supportive supervision provided by the MCHIP team kept them going. “A method like PPIUCD allows a woman to have birth control in her own hands,” says Dr. Marandi. “It is not a permanent method, yet it is long acting. These are big advantages for the women who come to us—who are mostly from the poor households.” Sister Bindeswari agrees, saying, “Using a family planning method like PPIUCD keeps a woman tension free.”
Today, the program is running successfully at the District Hospital in Lohardaga, with other providers also trained and performing this service. The administrative and clinical staff have seen the benefits of PPFP for themselves and are working as a well-integrated team today.
“We’ve come very far in the last year,” says a proud Dr. Marandi, who comes from a tribal community. So far, 227 women have already received PPIUCD services1. Now, women who have accepted PPIUCD [services] bring in their friends and family members to get counseled. A satisfied client who is happy with her choice and faces no problems is the best recommendation.
“We need to be sincere to the client and screen them properly. This is very, very important. We need to understand the client and see what suits her best. We also tell our clients that they can come to us anytime to clarify any doubts,” says Dr. Marandi, who has been trained by MCHIP to be a trainer of PPFP/PPIUCD services.
The physician and midwife also stress effective counseling at every stage as an essential ingredient of program success—right from the antenatal ward to early labor and postpartum ward.
These two providers are an inspiration. Despite working in such difficult conditions and against all odds, they have made a success of providing family planning services to the women who need it most. “The life of a woman in this community is hard. When, because of a service we provide, she feels happy and smiles, I know I need to continue doing what I do,” says Sister Bindeswari.
Dr. Marandi adds, “It was my desire to serve the poor and underserved people of my country that made me enter this profession. Even after 22 years of service, the same urge keeps me going and prompts me to strive harder.”
 Data as of September 2012