With the mission of “Reaching the last mile with a community-centric primary healthcare program” PANI as ‘resource hub organization’ implemented an innovative Bangle marker system for high-risk pregnant women in rural India to substantially prevent maternal mortality. The scheme is unique because of its intertwining with the culture and resulting in high levels of efficacy, having a tremendous impact on the health of mother and child.

About the Organization:

PANI (People’s Action for National Integration-PANI) is a leading development organization, based in Ayodhya (Faizabad) of Uttar Pradesh, India; incorporated under Societies Registration Act XXI, 1860 and legally complaint and professionally managed organization. It was founded by a group of Gandhian social activists in 1986 & registered in 1989. PANI envisions itself as a medium for building an inclusive society that prospers in harmony with its surroundings. PANI’s MISSION is to empower people so that they have greater control over their life situations and take responsibility to make a world that is mutually rewarding. PANI has its own Theory of Change and Strategic Plan that highlights their work across five main verticals- (i) Gender & Governance (ii) Integrated Child Development (iii) Health, Nutrition & WASH (iv) Food Security & Livelihood (v) NRM & Climate Change. The organization has already forged strong alliances at the local, national, and international levels. PANI has created a network of 469 grassroots level NGOs/CSOs. PANI has acquired certificates for its transparency from Guide Star India, good governance from Credibility Alliance, and process validation from Charities Aids Foundation. Currently, PANI is implementing its various development projects in 19 districts of Uttar Pradesh and in 1 district of Himachal Pradesh and directly outreaching 10 Lakhs households. 

Maternal healthcare initiative by PANI in Uttar Pradesh, India 

With the mission of “Reaching the last mile with a community-centric primary healthcare program” PANI as ‘resource hub organization’ implemented a community healthcare service delivery program named Eastern UP Health Initiative between April 2013 to March 2017 in 22 blocks of 9 districts of Eastern Uttar Pradesh with 21 implementing grassroots level organizations. This program outreached extensively 462 Village Panchayats (1120 revenue villages) and covered 2,57,713 HHs and 12,51,990 population. This program was jointly implemented with the Tata Trusts’ technical as well as financial inputs. The goal of the program was “ To Improve Maternal, Adolescent, and Child health status in Community.” There were two specific objectives- (i) To build the capacity of the community to run a health initiative on primary healthcare with a focus on maternal and child health and (ii) To establish a primary and secondary health service mechanism at the community level. The program components were totally aligned with the Ministry of Health and Family Welfare-MoHFW’s RMNCH+A (Reproductive, Maternal, Neonatal, Child Health + Adolescent) approach. 

Context 

The mandate comes from Sustainable Development Goal- No.3: Ensure healthy lives and promote well-being for all of all ages. The first two targets are as under.

3.1) by 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births

3.2) by 2030 end preventable deaths of newborns and under-five children

The situation of maternal and newborn healthcare services is abysmal at the base of pyramid. The comparative health indicators of India, UP and Eastern UP are as under.

Key Maternal and Child Health Indicators:


 IMR  Neo- natal Mortality Rate  Under Five Mortality Rate  MMR 
India  57  39  74  212 (As per SRS-2011) 
Uttar Pradesh  68 49 90 258

Source of data: India: NFHS-4 : 2015-16  Uttar Pradesh: AHS : 2012-13

Key Maternal and Child Health Indicators- Eastern UP:

District  IMR  Neo- natal Mortality Rate  Under Five Mortality Rate  MMR 
Ambedkar Nagar  72  55  90  451 
Ghazipur  82  66  102  346 
Mau  76  58  97  385 
Pratapgarh  88  66  113  442 
Varanasi  78  53  101  346 
Azamgarh  79  60  95  385 
Basti  84  62  109  412 
Maharajganj  87  69  110  354 
Siddarthnagar  87  69  118  403 

Source of data: AHS (2011-12)

Bangle Marker System-Innovative intervention model for maternal healthcare 

 The bangle marker system for pregnant women is started with the objective to let woman as well as family members and key grassroot functionaries (ASHA, ANM and AWW) understand status of her antenatal care and imbibe the importance of additional precautionary care in case of a status being diagnosed as a High Risk pregnancy (HRP) as per the standard clinical criteria set by the national guidelines. Women are made to wear particular coloured bangle on her right hand post her Ante Natal Care (ANC) check up so that looking at the colour of bangle, one would come to know about no. of ANCs she has undergone and information on current stage of pregnancy. Colors of bangles have been chosen from our national flag signifying women are as our national treasure.

 How does this marker system work?

  • Orange color bangle on the right hand of pregnant women whose first ANC is completed.
  • White color bangle on the right hand of pregnant women whose first and second ANC both are completed
  • Green color bangle on the right hand of pregnant women whose all first, second, and third ANC are completed.
  • Red color bangle in the left hand of High-Risk Pregnant women

Protocol to operationalize bangle marker system:

The Eastern UP health initiative model ignited community action to track a total of 65,923 pregnant women, over a period of three years for an end to end care ( Registration of pregnancy, ensuring at least 3 Antenatal checkups, care for high-risk women, ensure institutional deliveries, and strive for better pregnancy outcomes). Women CBOs (Nari Sanghs) are monitoring the regularity and quality of maternal healthcare by VHND and health sub-center in their respective villages. Primary healthcare delivery points-health sub-center and VHND and Aganwari center are now responsive and providing maternal healthcare services carefully.

  • Ensuring that bangle is put on the hand of pregnant women in presence of ANM, ASHA, and AWW on Routine Immunization Day, VHND, or when a pregnant woman is going to health sub-center/PHC/CHC for ANCs.
  • This marker system is made well known to all in community and frontline health service providers (ANM, ASHA, and AWW, doctors, and staff of PHC/CHC) so that they could easily identify pregnant women to ensure care, services, and regular follow-up. 
  • There must be high attention/focus on high-risk pregnant women to remove her red color bangle as soon as possible by timely referral and treatment and ensure their institutional delivery.

The Bangle Marker System ensures at least 3 ANCs timely with quality parameters and gives high attention to High Risk Pregnant (HRP) women. This system is a community-based monitoring tool that is used by a women CBO named Nari Sanghs. This tool gives high visibility to the intervention in the community. 

Outcome/impact created by the intervention 

As per the DLHS III data, 65% of pregnant women in UP receive any ANC. This implies out of expected 25 pregnancies per 1000 population, pregnancies getting registered at the State public health system are 16 pregnancies per 1000 population. (If Crude birth rate is considered as 22 births per 1000 population, the state has been able to register only 14 pregnancies per 1000 population for ANC services.) In Eastern UP health program blocks, with community action, the local public health system has been able to register 18 pregnancies per 1000 population.

As per the Annual Health survey 2012-13, institutional deliveries in UP are 68%. In the Eastern UP health program, more than 90% of institutional deliveries are reported.

The maternal mortality ratio in Uttar Pradesh is near to 300 per one lakh live births. In other words, 3 women are dying per 10,000 live births. In the Eastern UP health program, statistical inferences from the project data show that 2 women died per 10,000 live births.

Challenges in the operationalization of this innovative intervention:

Initially, there were operational challenges, as in a community, wearing a white colored bangle was not easily accepted. In local culture, a woman would wear white bangles on her husband’s death. Hence, it took quite a time to convince women that they are not being requested only to wear a white colored bangle, but that along with her usual bangles.  

Scope of replicability/scalability

The bangle marker system is an innovation implemented as a community marker system, to ensure tracking for pregnant women to ensure basic antenatal services. Importantly it served to easily identify high-risk, pregnant women, for healthcare providers and also induced the behavior change aspect in the woman who was at risk, reinforcing a thought that she needs to be out of the risk and for that additional care was required. In a context where masses in eastern UP villages are still ignorant, inadequately aware of basic entitlements and checkups during the antenatal period, such community-rooted model would be very essential to bring in awareness and behavior change in beneficiaries along with the frontline service providers. This model has a high potential of replicability in Asian countries as well as also in other countries with some customization.  

About the Author:

Jagdish Giri is Head-Programs at PANI (People’s Action for National Integration), a leading development organization based in Uttar Pradesh state of India. He has been working with PANI since 2001 with mission to empower poor and marginalized sections of society to fight the socio-economic