Community-Based Postpartum Care Services in MotherNewBorNet Member Programs

Transcription

1 T h e E x t e n d i n g S e r v i c e D e l i v e r y ( E S D ) P r o j e c t Community-Based Postpartum Care Services in MotherNewBorNet Member Programs O c t o b e r

2 Acknowledgements On behalf of the Extending Service Delivery (ESD) Project, the authors would like to acknowledge the technical expertise and contributions of all the individuals who were involved in the development and preparation of the survey questionnaire and the report, Communitybased Postpartum Care Services in MotherNewBorNet Member Programs : Ilham Siddig for her input to the initial draft of the survey questionnaire Malay Kanti Mridah for helping ESD contact the MotherNewBorNet members Marjorie Koblinsky for review of the draft survey questionnaire Veronique Dupont for data entry, data analysis and review of the survey questionnaire and report Carla White for review and guidance of the survey questionnaire and report Jeanette Kesselman for review of the report Maija Kroeger and Kristen Barba for editing and formatting the report In particular, ESD is grateful to the MotherNewBorNet members for taking the time to answer the survey questionnaire and share with us their valuable experiences to improve communitybased postpartum care programming. Last but not least, ESD would like to acknowledge USAID/Washington - Maureen Norton and Rushna Ravji - for their continued support and guidance. May Post and Elsa Berhane

3 List of Abbreviations and Acronyms ANC ANMW BF CB PPC CHV CHW CmSS CMW DOTS EPI FABM FCHV FP HMIS HSP HV KMC LBW LHW MW NGO PHC PNC PPC PPFP PPH RH SDU STI TBA VHV Antenatal Care Auxiliary Nurse Midwife Worker Breastfeeding Community-based Postpartum Care Community Health Volunteer Community Health Worker Community Support System Community Midwife Directly Observed Treatment Short-course Expanded Program on Immunization Fertility Awareness-based Methods Female Community Health Volunteers Family Planning Health Management Information System Health Sector Program Health Volunteers Kangaroo Mother Care Low Birth Weight Lady Health Worker Midwife Nongovernmental Organization Primary Health Care Postnatal Care Postpartum Care Postpartum Family Planning Postpartum Hemorrhage Reproductive Health Safe Delivery Unit Sexually Transmitted Infection Trained Birth Attendant Village Health Volunteer

4 Table of Contents Executive Summary... 5 I. Introduction... 7 II. The Survey Purpose Methodology The Respondents... 8 III. Survey Results: Major Findings General Background Provision of Postpartum Care Services Provision of Newborn Care Promising and Best Practices in Postpartum Care Challenges/Issues/Barriers Monitoring and Evaluation Improving Community-based Postpartum Care and Postpartum Family Planning Windows of Opportunity for Pospartum Family Planning Counseling Lessons Learned IV. Highlights of Findings V. Recommendations for Further Improvement VI. Conclusion Annex 1: List of Survey Respondents Annex 2: 2007 Survey Questionnaire Annex 3: 2005 Survey Findings... 43

5 Executive Summary This report compiles results from a survey conducted in the summer of 2007 that aimed to identify, document, and share information on the status of community-based postpartum care and postpartum family planning services implemented by MotherNewBorNet member organizations in the Asia Near East region. This survey is a follow-up to a similar study conducted in 2005 aimed primarily at documenting the status of community-based postpartum care provided by 13 USAID bilateral projects in the Asia Near East region. For the current survey, a structured questionnaire was sent electronically to 50 individuals representing member projects and organizations within the MotherNewBornNet, of which 28 responded. The questionnaire covered the following topics: project background, provision of postpartum care services, newborn care, best and promising practices, challenges faced, monitoring and evaluation, recommendations for improvement, and lessons learned. Overall, 68% of respondents reported providing community-based postpartum care and 84% reported postpartum care visits within the first three days following delivery. Regarding newborn care, early and exclusive breast-feeding was the most utilized promising and best practice, reported by 89% of respondents. Seventy-five percent (75%) of respondents reported counseling on postpartum contraception, with counseling on contraceptive pills occurring most frequently (57%). At the policy level, 50% of respondents cited lack of funds and lack of priority given to postpartum care programs as key barriers to implementation of postpartum care (PPC) programs. At the service delivery level, 61% of respondents cited lack of training in postpartum care as the primary barrier to adequate implementation of postpartum care programs. Finally, 68% of respondents reported that postpartum care was not considered a priority for the family, with 64% citing community norms as barriers. Three common models of community-based PPC exist in the field, based on an extensive review of published and unpublished literature covering the 1970s through March When asked about the model that best described their PPC services, the majority (18/19) cited Model 3, i.e., home visits by community workers with referral or health facility support. The provider (community health workers/volunteers with an education level of 10 th grade) to population ratio reported by respondents in this model ranged from 1:60 to 1:5000. Based on survey findings, select prioritized strategic recommendations are as follows: A priority recommendation is to increase service providers knowledge and skills related to essential PPC services that must be provided at a minimum, including timing and frequency of postpartum visits and postpartum family planning. To that end, a consensus needs to be reached among international organizations and postpartum advocates for a prototype essential integrated PPC minimum package (similar to the essential newborn care package and focused antenatal care package). At the community level, a key recommendation is to improve community support for PPC, through strengthening social mobilization and community involvement activities to increase community/families awareness, demand and use of PPC, particularly in areas where PPC is not considered a priority by the family, and PPC is not considered a community norm. Improving the skills of community health workers and traditional midwives in provision of select integrated PPC including early PPC home visits and postpartum family planning information is also recommended, given that home-based deliveries and home-based postpartum 5

6 care remain the norm. Integration of postpartum family planning (PPFP) into focused antenatal care, PMTCT services and other MCH consultations such as immunizations, well-baby clinics will also be important to make PPFP a component of comprehensive health care. At the policy/advocacy level, a priority recommendation is to continue advocacy for PPC among policy makers to update national guidelines and protocols on integrated PPC: to include essential components of integrated PPC including who will provide PPC, where and when, and what skills are needed.; and to ensure that postpartum family planning is included in all appropriate communication and counseling protocols and guidelines. Identifying a basic list of minimum standard indicators which can be adopted/ adapted by national Ministries of Health for use by their field workers is also key to standardize monitoring, evaluating and tracking delivery of integrated PPC services. 6

7 I. Introduction The postpartum period is one of the most vulnerable [periods] for both mother and newborn, yet often neither health programs nor mothers and families recognize this vulnerability. For mothers, death at delivery, immediately thereafter, and during the following week accounts for more than 60% of the estimated 529,000 annual maternal deaths. More than 4 million neonatal deaths occur every year and about 50% of these are within 72 hours of delivery (The World Health Report, 2005). Add to this mounting death toll, the stillbirths that alone total nearly 3.3 million annually. Most of this burden of death occurs among women in developing countries who lack skilled care during labor, at delivery and in the immediate postpartum period. These numbers are large. Nearly half of women in developing countries deliver without any skilled birth care and less than a third are estimated to have any postpartum care (PPC) Introduction to MotherNewBorNet Website A literature review commissioned by the CATALYST Project 2 in 2004 titled, Integrated Community-based Postpartum Care: An Urgent Unmet Need 3, revealed that there is a critical lack of programmatic information concerning integrated community-based PPC. The literature review was complemented by a survey 4 in 2005, conducted by the CATALYST Consortium Project, to assess the status of community-based PPC service delivery in USAID bilateral projects in the Asia and Near East (ANE) region. The 2005 survey found that PPC was not considered a priority among policy makers or families; facility-based routine PPC was not common; and counseling on PPC was neglected by health workers. Complete findings from the 2005 survey are included in Annex 3. This 2007 survey is a follow-up to the 2005 survey (Annex 3) to document the status of community-based PPC and postpartum family planning activities implemented by MotherNewBorNet member projects in the ANE region. II. The Survey 1. Purpose The Extending Service Delivery (ESD) Project conducted a survey in the summer of 2007 to identify, document and share information on: 1) status of community-based PPC and postpartum family planning services (PPFP) implemented by member organizations and 2) successful practices and approaches related to PPC implemented by MNBN 5 member organizations in the CATALYST Consortium ( ) was a global RH/FP project funded by the Office of Population and Reproductive Health, Bureau for Global Health of the United States Agency for International Development. 3 Koblinsky, Marjorie Community-based Postpartum Care: An Urgent Unmet Need. 4 Post, May Status of Community-Based Postpartum Care Services: Analysis of Survey Findings. CATALYST Consortium. Survey report prepared for the first meeting on community-based postpartum care network, April 24-26, 2005, Dhaka, Bangladesh. 5 MotherNewBorNet, a network established in 2005 to improve maternal and neonatal health at the community level. It is currently hosted by ICDDR, B: Center for Health and Population Research with financial assistance from USAID. ( 7

8 ANE region. The information generated by the survey will be disseminated to the MotherNewBorNet members, USAID, and interested ESD partners, to share successful approaches in community-based postpartum care (CB PPC), lessons learned and recommendations from the field to improve CB PPC. 2. Methodology A structured questionnaire (Annex 2) was prepared and finalized with input from USAID/Washington, ACCESS-FP, and MotherNewBorNet and sent electronically to 50 individuals who represent member projects and organizations in the MotherNewborNet. Survey questions covered the following areas: General Project(s) Background; Provision of PPC Services; Provision of Newborn Care; Best and Promising Practices in PPC; Challenges/Issues/Barriers; Monitoring and Evaluation; Improving CB PPC and Postpartum Family Planning; and Lessons Learned to Date. 3. The Respondents A total of 28 individuals (Annex 1) representing 19 countries and 34 projects completed the survey indicating a response rate of more than 50 percent. See Annex for the complete list of respondents. III. Survey Results: Major Findings **PLEASE NOTE: 1) For questions that specify CHECK ALL THAT APPLY, the answer may exceed 100 %. 2) Survey responses are reported as articulated/received from the field. 1. General Background The general background section covers information on project type (based on program focus) and project category, as well as information on home-based deliveries and attendance at homebased deliveries in the project intervention areas. Project Type/Program Focus Among the 28 who responded, the majority (89% or 25/28) described their projects as maternal and newborn health. Other common project types included primary health care, child survival and child health and reproductive health/family planning. Two respondents identified their project as Other and specified a focus on child survival and tuberculosis (TB) control (DOTS). See Figure 1. 8

9 Figure 1. Project Types Represented in the Survey Sample % of Respondents MNH PHC CS/CH RH/FP MNH=Maternal and Newborn Health; PHC=Primary Health Care; CS/CH=Child Survival/Child Health; RH/FP=Reproductive Health/Family Planning Project Category Project categories included rural health, urban health, public sector/ private sector and NGOs. The majority (64% or 18/28) of the MotherNewborNet survey respondents categorized themselves as NGOs. The majority (61% or 17/28) focused on rural health. See Figure 2. Figure 2. Project Categories Represented in the Sample % of Respondents NGOs RH UH Pub Sec (gov't) 11 Pr Sec (commercial) NGOs=Non-governmental Organizations; RH=Rural Health; UH=Urban Health; Pub Sec=Public Sector; Pr Sec=Private Sector Home Deliveries in Project Intervention Areas On average, 70% of births are delivered at home in project intervention areas. This finding is based on 82% (or 23/28) citing a documented source and 11% (or 3/28) citing general knowledge. The overall reported responses for home deliveries ranged from 26% home deliveries in Swaziland (BASICS-Repositioning PPC in an HIV Environment Project) to 92% in Bangladesh (the Radda-Plan Joint Project). 9

10 Attendance at Home-Based Deliveries Ten percent of births delivered at home were reported to be assisted by skilled birth attendants. This finding is based on 54% (or 15/28) citing a documented source and 4% (or 1/28) citing general knowledge. On the other hand, 37% of births delivered at home was reported to be assisted by traditional birth attendants (TBAs). This finding is based on 61% (or 17/28) citing a documented source and 4% (or 1/28) citing general knowledge. 2. Provision of Postpartum Care Services The majority of respondents (68% or 19/28) reported providing CB PPC while 32% (9/28) reported not providing CB PPC services for the reasons listed below: No funding/resources for outreach/home visits at the community 33% (3/9) Health care workers too busy to conduct outreach/home visit 22% (2/9) Not considered a priority by the project 22% (2/9) Not considered a priority by the family/community 11% (1/9) Not considered a priority by the government 11% (1/9) Identification of Postpartum Women for Postpartum Care Services Postpartum women are identified by various categories of community-based service providers: TBA, nurse-midwife, village doctor, paramedic, female community health volunteer (FCHV), Lady Heath Worker (LHW), etc. Likewise, the protocols and approaches used by MotherNewborNet member programs to identify postpartum women varied, as listed below. The following are different approaches and different categories of community-based workers used to identify postpartum women in the community: Community Health Workers (CHWs) o The CHWs register all pregnant women and track the mothers from antenatal care (ANC) to postnatal care (PNC). o Women are identified by trained LHWs, who are responsible for a certain number of households, have records of pregnant women and know when deliveries take place in their catchment areas. Community/Village Health Volunteers (CHVs) o Female community health volunteers (FCHVs) map their community and identify pregnant women. They follow up by probable delivery dates. o FCHVs keep a pregnancy register, follow up with pregnant women and provide postpartum visits. o FCHVs maintain a pregnancy register and are deployed to identify postpartum mothers on a regular basis in the catchment areas they are responsible for. o Village health volunteers (VHVs) visit postpartum women in their para (section of a village) within 24 hours postpartum. 10

11 o VHVs identify pregnant women and motivate them to go to the health care center for ANC. Paramedics o Project-trained paramedics conduct home deliveries and provide postpartum services at home. o Paramedics maintain a family register in which they have detailed information on couples and delivery checklists to ensure PPC. Traditional Birth Attendant o TBA and CHV identify postpartum women and report to a community forum called the Ward Health Community. o TBAs and local volunteers are asked to report any pregnancy that comes to their notice. Other o Pregnancy surveillance and follow up. Timing of Postpartum Visits The majority of PPC visits occur in the first three days of delivery. Eighty-four percent (16/19) of respondents reported that PPC services are provided in the first 72 hours after birth (days 1-3), followed by 79% (15/19) in the first week postpartum (days 1-7), followed by 63% (12/19) in the first 24 hours (immediate postpartum). Only 53% (10/19) reported PPC visits at six weeks postpartum, presumably because the woman went to a health facility for PPC. Figure 3. When PPC Services Are Provided % of Respondents First 24 hrs 72 hrs PP First week PP 6 weeks PP 0 Time of Service Thirty seven percent (7/19) of respondents (also) checked Other. These responses were: 8-14 days after delivery; days after delivery; days after delivery; 28 th day after delivery; and six months after delivery. 11

12 There appears to be a need for providers to have and know how to provide a standard package of essential PPC services (similar to focused ANC or essential newborn care package) including the timing of PPC visits in the community. Location of Postpartum Care Provision All respondents (19/19) reported that home-based PPC is a component of their program. The figure below provides a breakdown of the reported location of PPC provision. Since respondents were requested to check all that apply, one can presume that PPC services are provided in more than one site. Figure 4. Where PPC Services Are Provided % of Respondents Home Health Center/ Hospital Community Health Clinic Twenty-one percent of respondents (4/19) cited Other in reference to PCC service locations. Their responses included mini-clinic in slum and satellite clinic. Models of Community-based Postpartum Care Based on a review of published and unpublished literature covering the 1970s through March 2004, three common models of community-based PPC exist in the field (although there are many variations on these 3 models). 6 Model 1: Home visits by professional health care providers: a health care professional conducts a home visit to a postpartum woman. Model 2: Home visits by community workers: a non-professional community worker visits women in their homes but little or no referral provided. This model has been primarily used for newborn care home visit programs rather than maternal health programs. Model 3: Home visits by community workers with referral or health facility support: Community workers visit women in their homes, and referral or health facility support is provided. (This model blends Models 1 and 2.) When asked about the model that best described their PPC program activity, the majority (18/19) cited Model 3. The provider to population ratio (CHVs and CHWs with an education level of 6 Koblinsky, Marjorie Community-based Postpartum Care: An Urgent Unmet Need. 12

13 10 th grade) reported by respondents in this model ranged from 1:60 to 1:5000. Among respondents citing their program as Model 1 (home visits by professional health care providers), the provider: population ratio reported varied from 1:1300 (for trained paramedics) to 1: 3000 (for midwives) to 1: 10,000 (for community midwives).the least-cited model (3/19) was Model 2 (home visits by community workers). A provider-population ratio of 1: households for community volunteers was reported by one respondent under this model. Training of Providers The majority of respondents reported that their service providers have been trained in delivery of PPC. Among those whose providers received training in PPC, the majority also reported that PPFP was included as part of the training. It is important that all service providers are trained in provision of postpartum care, i.e., all elements of PPC similar to training service providers in essential components of ANC (focused ANC) and newborn care. Integrated PPC involves care for both the mother and the newborn. Equal attention must be given to training service providers in elements of care for both, focusing on: the first 24 hours; first week postpartum; six weeks postpartum; and for PPFP six months postpartum and one year postpartum. PPFP counseling should be an essential element of PPC training. 3. Provision of Newborn Care The majority of respondents were familiar with the essential components of newborn care during the postpartum period. The following table indicates that provision of essential newborn care was administered by a substantial number of respondents. The most frequently cited newborn care component was early and exclusive breastfeeding. Figure 5: Essential Components of Newborn Care Provided by Respondents Essential Newborn Care Components Respondents Providing This Component Early and exclusive breastfeeding 79% (22/28) Cord care 75% (21/28) Thermal protection 71% (20/28) Monitoring (e.g., for warmth and breathing) 68% (19/28) Immunization 64% (18/28) Eye care 57% (16/28) Resuscitation 54% (15/28) Other 39% (11/28) Other essential newborn practices reported include: identification of danger signs, first dose of antibiotics, and referral; delayed bathing; Kangaroo Mother Care (KMC) for small babies as well as drying; gestational age assessment at the health care center's safe delivery unit (SDU); neonatal sepsis scoring for sepsis risk assessment and referral from SDU; assessment and management of neonatal infections; and special care for low birth weight (LBW) baby. 13

14 4. Promising and Best Practices in Postpartum Care All respondents (28/28) reported application/utilization of one or more of WHO and USAID accepted practices (i.e., best and promising practices) to improve maternal and newborn outcomes during the postpartum period. Reported promising and best practices utilized by respondents (in descending order) were: counseling for immediate and exclusive breastfeeding (89% or 25/28); monitoring for newborn emergencies (such as inability to breath and to suck, very small size, signs of sepsis) (82% or 23/28); counseling on postpartum contraception (75% or 21/28); monitoring for signs of a postpartum obstetric emergency (such as retained placenta, eclampsia, postpartum hemorrhage, etc.) (71% or 20/28); and providing PPC in the first three days (68% or 19/28) counseling on using an effective family planning method of choice continuously for 24 months before trying to become pregnant again (54% or 15/28) Counseling on postpartum contraception While the majority (75% or 21/28) of the respondents reported counseling on postpartum contraception, the content of counseling varied by method as shown in the Figure 6 below. Counseling on pills was reported by 57% (16/28) of the respondents, whereas only 21% (6/28) reported counseling in fertility awareness-based methods (FABM). Figure 6. Counseling on Postpartum Contraception by Method FABM=Fertility Awareness Based Methods (natural FP methods including Standard Days Method); LAM= Lactational Amenorrhea Method * Other responses included: surgical ligation; Norplant; tubectomy; vasectomy; implants; permanent methods; Norplant and VSC; counseled to go to health facility for FP services and (if eligible) permanent sterilization. 14

15 Referral for Postpartum Family Planning The majority of respondents (64% or 18/28) reported that the programs they manage refer clients to public sector facilities for family planning services, followed by referral to private sector facilities (32% or 9/28). Eleven percent (3/28) did not refer clients because methods were reported to be provided by CHWs. Other Successful/Effective Practices for Improved Maternal and Newborn Health In addition to adopting accepted promising and best practices, when asked about other successful interventions implemented by their projects that had a positive effect on maternal and newborn health, 12 of the 28 respondents (43%) reported other practices. Their responses have been grouped in categories listed below: Presence of referral mechanisms Home visits Community care starting from antenatal period Establishing community support systems Focusing on activities valued by the family Other Figure 7 lists the detailed responses including reported results from the practices. Figure 7. Other Successful/Effective Practices for Improved Maternal and Newborn Health COUNTRY/ PROGRAM ACTIVITY RESULTS Presence of Referral Mechanisms Bangladesh/ Marie Stopes Clinic Society Successful referral mechanisms. Increase ANC visits and institutional delivery. Bangladesh/ Training of Community-based Skilled Birth Attendants Referral on basis of danger signs. Reduction of neonatal death and disabilities. Bangladesh/ Maternal, Neonatal and Child Health Initiative Successful referral linkage between facility and community. Care seeking behaviors improved and number of complicated cases attended in the facility increased. Bangladesh/ Lutheran Aid to Medicine in Bangladesh (LAMB) Integrated Health and Development Program Bangladesh/ Radda-Plan Joint Project Home Visits VHVs visit women who have home deliveries within hours of delivery even if they haven't done the delivery. They refer on to the SDU for danger signs of mother or baby. They are considering a pictorial referral card for use by VHV's to monitor appropriateness of referral and to facilitate feedback. Home visits by CHWs play an important role. They discuss early and exclusive breastfeeding, immunization, birth spacing, family planning methods, and nutrition with mothers. In cases of referred case, TBAs usually present with mother/child at the referral center. Not yet documented should be able to have documentation on referral mechanisms and maternal/newborn outcomes end of Reduced maternal and infant mortality and morbidity. Swaziland/ Repositioning PPC in a Highly Prevalent HIV Environment Community Care Starting from Antenatal Period Promotion of early visits starting at ANC; assessment/care/counseling for mother and baby in the same encounter. N/A 15

16 COUNTRY/ PROGRAM ACTIVITY RESULTS Nepal/ Community-based Maternal and Neonatal Care FCHVs identify and register women from the time of pregnancy and provide counseling to pregnant woman on postpartum family planning from the time of pregnancy. Health care providers are updated on maternal and newborn health issues, and health facilities are strengthened to provide services. needed to take place. Bangladesh/ Community- Based Intervention to Reduce Neonatal Mortality Bangladesh/ Safe Motherhood Promotion Project (SMPP) Bangladesh/ NSDP Negotiation-based customized approach for antenatal counseling and education, community-based identification and management of possible newborn sepsis. Establishing Community Support Systems Through Community Support System (CmSS), postpartum women are referred to betterequipped facility immediately for saving the mother s and neonate s lives. This is done by collective efforts organized under an umbrella of CmSS (a unity of that community regarding Safe Motherhood). NSDP community volunteers identify community support system under the intervention of birth preparedness and identify complicated cases for early referral. Women receive basic information on and services in pregnancy, delivery and postpartum period at community level. They are counseled on basic care and services Significant change in community behavior and practices regarding maternal and newborn care, reduction in neonatal mortality. Lives of both mothers and neonates are saved by immediate referrals. Community became satisfied and motivated by these efforts and encouraged to act proactively. This is a new project so the numerical results weren t available. But considering the previous project achievement, we can say that it is possible to save lives of both mothers and neonates. Increased referral cases at facility. Nepal/ Morang Innovative Neonatal Intervention (MINI) Focusing on Activities Valued by the Family Weighing the baby is valued by the family and may be a good entry point and helps to raise Appears that families are more likely to seek awareness about the risks for the LBW babies. care for their babies when they are sick. Nepal/ MINI Bangladesh/ Saving Newborn Lives 1 Other Birth reporting or registration is also an important thing that the FCHV/health promoter can do when visiting the home. Piloting sentinel hospital registers. Impression is that this makes the baby s life more valued. Newborn admission and deaths from sentinel hospital registers have been incorporated into routine HMIS findings from the pilot process and will be used to revise other facility based admission registers. 5. Challenges/Issues/Barriers Respondents reported a number of challenges and barriers to implementing their PPC programs. Policy Level At the policy level, barriers most commonly cited were: lack of funds/resource allocation and not considered a priority. (See Figure 8.) 16

17 Figure 8. Reported Challenges at the Policy Level Reported Challenges % of Respondents Lack of funds/resource allocation 50% (14/28) PPC is not considered a priority at the policy level. Examples provided: Too many competing priorities. PPC did not receive the attention that ANC did and the National Maternal Health Policy did not emphasize immediate postpartum newborn care. Considered an extra burden for the FCHVs (by central level staff but not the FCHVS themselves). Other policy-related challenges: Inefficiency of government system to deliver programs although policy tends to be good. No clear defined roles and responsibilities for nurses and midwives (in terms of provision of care). No accountability for poor performance. Civil unrest. HMIS does not collect information on immediate postnatal period. 50% (14/28) 21% (6/28) Service Delivery Level At the service delivery level, the challenges most commonly cited were, health care providers not sufficiently trained in PPC (61% or 17/28), and health care providers not sufficiently trained in newborn care (61% or 17/28). The following table includes all the service delivery level challenges listed in descending order. Figure 9. Reported Challenges at the Service Delivery Level Reported Challenges % of Respondents Health care providers not sufficiently trained in PPC. 61% (17/28) Health care providers not sufficiently trained in newborn care. 61% (17/28) No funds/resources for supervision of outreach providers. 43% (12/28) Difficulty in finding just-delivered/postpartum women. 39% (11/28) No funds/resources for outreach visits. 29% (8/28) Health center/post considered too far by the family for postpartum checkups. 32% (9/28) No time. 7% (2/28) Other Lack of awareness and importance of PPC. Culture of seclusion following birth women and their infants don't come to clinics. Understaffing and shortage of trained personnel including midwives. 29% (8/28) Frequent rotation and turnover of trained personnel. Lack of minimal equipment and supplies. Not considered an essential health care service both by the family and health workers. Lack of trust in the health care system. Lack of recognition of the value/importance of PPC and newborn care. Difficult in accessing services geographic barriers, civil unrest and lack of transport. 17

18 Community Level At the community level, the two challenges that were most commonly cited were not considered a priority by the family (68% or 19/28) and not considered as a community norm (64% or 18/28). The following table includes all the reported community-level challenges, listed in descending order. Figure10: Reported Challenges at Community Level Reported Challenges % of Respondents Not considered a priority by the family 68% (19/28) Not considered a community norm 64% (18/28) Community level providers not trained in PPC provision 43 % (12/28) Community level providers not trained in newborn care provision 43% (12/28) Postpartum care provided at home by family member(s) who include the following (in different combinations): Mother-in-law and sisters-in-law; Mother, mother-in-law, sister, grandmother; Mother, mother-in-law; Mother in-law, mother, sister; Mother in-law, mother, relatives; Mothers, mothers-in-law; sisters-in-law, at times the husband too; Newborn care by mother and other caretaker. 32% (9/28) Other: Lack of qualified community level practitioners (health volunteers are trained to give basic postpartum and newborn assessment, but they are not trained health care providers. Their main role is to encourage breast-feeding, check for problems (abnormal discharge, fever, small/sick baby) and provide referrals. Religious and cultural customs bar postpartum women from leaving the home until 11 days after birth (in most of the societies). There is poor referral link with the facilities. 21% (6/28) 6. Monitoring and Evaluation Four projects reported not having monitoring and evaluation indicators for the following reasons: Monitoring not considered necessary (one project) Need training and guidance to develop monitoring indicators and data collection system (two projects) Project has not been initiated (one project) The majority (75% or 16/21) reported that their projects monitor their PPC activities. In sum, there were nearly 50 different indicators reported used for monitoring PPC activities 18

19 among which only two were related to family planning. The indicators reported are below, as organized by focus area: Postpartum Visits 1. Number/percentage of postnatal cases visited within 24 hours of delivery 2. Percentage of mothers and newborns receiving PPC at each recommended interval from skilled personnel 3. Number of women and newborn receiving PNC visit at home within 72 hours and complications identified 4. Number of women receiving PPC 5. Percentage of mothers and newborns that are visited by FCHVs within three days 6. Percentage of newborns attended within 24 hours 7. Percentage of newborns attended within seven days 8. Percentage of women receiving a home visit by a VHV within 48 hours of birth 9. Visit made by patient within 42 days after delivery 10. Percentage of mothers receiving PNC within 3-7 days of delivery 11. Percentage of mothers with an infant under one year who say they received PNC within 3-7 days of delivery 12. Percentage of mothers receiving PNC who were counseled in at least two danger signs 13. Number of babies and mothers visited within 3, 7, and 28 days Maternal and Newborn Care 14. Response to maternal complication 15. Response to newborn complication 16. Number of newborns with signs of bacterial infections; treatment completion rates 17. Percentage newborns with possible sepsis managed 18. Percentage of newborns for whom bathing is delayed for at least 24 hours 19. Percentage of LBW babies receiving KMC care 20. Number of babies and mothers identified with danger signs and referred to health facility for treatment and care 21. Number of LBW babies receiving four follow-up visits 22. Percentage of newborns who were bathed after three days 23. Percentage of newborns who had nothing applied to the umbilical stump 24. Number of women receiving PPC 25. Cord care, eye care, breathing, thermal care, any infection, immunization, breast-feeding, birth spacing, maternal health condition 26. Number LBW babies Family Planning Counseling and Methods 27. Percentage of postpartum mothers counseled on FP by FCHVs during post-natal period 28. Percentage of women who leave first postpartum visit with a FP method Breastfeeding 29. Percentage of colostrums intake 30. Percentage of newborns who were not given any pre-lacteals 31. Percentage of newborns who are exclusively breastfed 32. Percentage providers demonstrating to the mother the appropriate breastfeeding practice 19

20 Morbidity and Mortality 33. Incidence of birth asphyxia 34. Birth asphyxia related mortality 35. Incidence of selected maternal morbidity 36. Maternal mortality during postpartum period 37. Keeping record of 0-5 year's child mortality 38. Birth trauma Training and Counseling 39. Percentage of health workers trained in PPC 40. Quality of counseling for PPC 41. Percentage of providers counseling on relevant issues: exclusive breastfeeding, postpartum contraception, EPI (Source: NSDP QMS & MIS Indicators) 42. PPC service delivery skills Other 43. Percentage of women enrolled in the program based on expected pregnancies 44. Compliance with referral 45. Percentage with primary postpartum hemorrhage 46. Percentage of postpartum sites that teach community about danger signs, breastfeeding, FP 47. Number births recorded (and subset recorded within 72 hours) 48. Percentage of mothers who know at least two danger signs after delivery 7. Improving Community-based Postpartum Care and Postpartum Family Planning 7.1 Improving Community-based Postpartum Care (CBPPC) In response to the question, What is needed to improve community-based postpartum care? 71% (20/28) gave recommendations for improvement (See below for recommendations.) 25% (7/28) responded don t know 4% (1/28) checked not applicable Recommendations for Improving CB PPC Based on the responses, four main areas for improvement were identified: 1) advocacy and policy; 2) training; 3) service delivery and supervision; and 4) community involvement and mobilization. Specific recommendations from respondents by area include: Advocacy and Policy o Improve policy environment. o Convince policy makers that postpartum care is important. o Provide national PNC guidelines on: defining PNC care and components; when to do PNC care; who will provide PNC and where; what skills are needed for providing PNC. o Design an attractive package for PPC. o Include PPC in the job description for FCHVS, MCHWs, etc. o Allocate resources for (postpartum) outreach visits. 20

21 Training o Train a mix of service providers and provide logistic support. o Increase local-level trained service providers. o Need for sufficient community-based trained health workers. o Build capacity of CHW. o Orient CHW and community-based distributors. o Provide training and refresher training for CHWs and TBAs. o Train community volunteers. o Increase number of qualified CHWs. o Provide training on the essential components of PPC. Service Delivery and Supervision o Integrate PPC with all existing services like newborn care, FP services, etc. o Minimize communication/information gap between community/users and service providers so that there is understanding of the available resources, opportunity of services, etc. o Motivate health workers through supportive supervision. o Orient and put on board public health officers/technicians who will oversee and supervise CB PPC and PP FP. o Provide good referral linkages. o Promote high coverage of contact between the mother and the newborn and the health system, be it at home or at facility. Community Involvement and Mobilization o Increase families' understanding of the importance of the postpartum period for mother and baby with appropriately targeted PPC messages and interventions. o Increase community awareness about importance and use of PNC services. o Educate communities on benefits of postpartum visits. o Encourage women to make postpartum clinic visits within three days of child birth. o Support communities to establish transport and finance systems for women experiencing danger signs. o Educate and counsel women on PP FP and where to get services. o Social mobilization, community involvement. o Orient key members of the community-based organizations on PP FP. 7.2 Improving Postpartum Family Planning Reasons cited by respondents for not providing FP counseling routinely during postpartum care are in figure 11 below. The top three reasons were: 1. Family planning is not considered a priority by the woman/family (57% or 16/28). 2. Focus is on the newborn in the postpartum period (54% or 15/28). 3. Health care workers have not been trained in FP counseling (39% or 11/28). 21

22 Figure 11: Reasons for Not Providing FP Counseling Routinely during Postpartum Care Reported Reasons % of Respondents Family planning not considered a priority by the woman/family 57% (16/28) Focus is on the newborn in the postpartum period 54% (15/28) Health care workers have not been trained in FP counseling 39% (11/28) Family planning counseling not considered a priority by the health care worker 32% (9/28) Health care workers do not have informational materials on FP 29% (8/28) Family planning services are not easily available to refer postpartum women for family planning methods 25% (7/28) Health care workers have biases against family planning 14% (4/28) Postpartum period is not an appropriate time for family planning counseling 11% (3/28) Other 21% (6/28) Don t know 7% (2/28) Reasons reported under Other were as follows: Resources (providers and materials) o Lady Health Workers are mostly young and unmarried and therefore do not feel comfortable talking about FP issues; o Midwives are shy/embarrassed and don't always know what terminology to use; o Health care workers are not trained to focus on FP counseling during PPC; o Current materials used for community education are too technical and not easily understood. Culture and gender o Women lack decision-making power on FP; o Health care workers are afraid to discuss FP with some clients because of fear that they will tell their husbands who oppose FP use; o Misunderstanding of religious injunctions on FP. Misconceptions o Women /families think that a woman cannot get pregnant again until she starts menstruating. Recommendations for Improving Postpartum Family Planning Recommendations provided by respondents to improve PP FP are organized into three levels: policy level, service delivery level, and community level. Policy Level (68% or 19/28) At the policy level, recommendations focused on development and revision of existing national guidelines, standards and protocols. Responses included: PP FP should be a part of the postpartum package. Develop or revise existing national guidelines, standards, and protocols to include PP FP. Include PNC visits in national standards, packages and make way for volunteers to provide these services and collect information on early PNC visits (home based). Implement early initiation of postpartum visits. Include PP FP in reproductive health (RH) policy and guidelines, spelling out what methods can be provided, when and by what cadre of health care worker. 22

23 Promote HTSP as part of the countries RH guidelines. Provide support from the Ministry of Health by availing policy and guidelines for use by service providers and supervisors at all levels of care. Policy should advocate incorporation of FP counseling with PPC counseling. Other: o Develop standard messages. o Advocate for importance of postpartum family planning. Service Delivery Level (86% or 24/28) At the service delivery level, recommendations were varied. They included training and supervision, integration of services, counseling, access to FP methods, advocacy at the service delivery level, and improved data management to strengthen quality of care. Specific responses included: Training and supervision o Ensure sufficient trained health personnel. o Provide feedback on monthly reports by LHWs. o Emphasize the issue in the training curriculum. o Provide more supportive supervision for community birth attendants o Train service providers and their supervisors on PPC and PP FP: apply cascade training approach to orient those working in maternity, antenatal, child welfare, postpartum and family planning clinics. o Should make training of PPC available to health workers and service providers. o Need training, supportive supervision and regular supplies. o Continue to reinforce the importance of PP FP in other trainings and interactions with health workers. o Train staff to provide PNC visits and care both at home, outreach and facilities. o Train health care workers to educate and counsel women on PP FP (including LAM). o Train health care workers on commodity management and provision of clinical services. Integration of services o Provide one-stop services and ensure more skilled providers. o Integrate PP FP into different services, e.g., welfare clinics, PNC, in/outpatient departments, etc. Counseling o Develop culturally relevant materials for the midwives to work with when they are doing counseling. o Improve counseling and education during antenatal visits. o Encourage and ensure CHWs give FP counseling to users at the community level. o Strengthen counseling during antenatal period, to make people understand the importance of PP FP, involving husband/mother, mother-in-law during counseling. o Provide private space for counseling. FP logistics and access to FP methods o Provide appropriate method mix. o Need well trained staff, better monitoring, and adequate logistic support. o Ensure adequate FP instruments and inputs for meeting needs of FP users. 23

24 o Provide seed stock of FP commodities to trained staff and facilities. o Ensure availability of supplies. o Improve supply side including quality of care. o Determine what methods are acceptable and how they can be made more accessible. Advocacy at the service delivery level and promotion of messages o Initiate promotion of FP services at ANC clinic. o Place more emphasis on the importance/impact of proper PPC. o Include adequate PNC messages. Monitoring and improved data management to strengthen quality of care o Indicators should include PP FP service delivery issues. o Strengthen the FP register so that the management information system can track gaps in this sector and make decisions immediately and accurately. o Strengthen HMIS to capture information on PP FP use. Community Level (79% or 22/28) At the community level, respondents listed IEC/training, community involvement and mobilization, strengthening outreach serves, and FP logistics and referral. Specific responses include the following: IEC o Implement IEC strategies for promotion of HTSP emphasizing risks of short spacing and benefits of recommended timing and spacing. o Develop education/promotion materials that use language that is easily understood by the lay person. o Implement more awareness building initiatives and functional community support systems. o Make the community aware of its importance. o Increase awareness of importance of PNC and create a demand for it. o Build awareness of FP in this period. Training o Community worker should also receive training on PP FP; o CHW should be trained more on counseling on FP methods, exclusive breast-feeding and immunization. Community involvement and mobilization o Involve key local female leaders; o Community mobilization on importance of pregnant mothers attending antenatal clinics, including hospital delivery and postpartum assessment; o Community participation; o Include topic in mothers group discussions; include other family members (mothers-inlaw, husbands) in open discussion; o Mobilize the community to place greater importance on PP FP and encourage the use of PP FP among the target population. o Mobilize communities to recognize danger signs occurring in the postpartum period; o Strengthen community financing and transport systems for emergencies. 24

25 Strengthening outreach services o Outreach/mobile ANC, PPC, FP and immunization services. o Mobilize existing CHWs and volunteers to give more attention in tracking postpartum patients, helping raise awareness among families, give proper care, and refer (if necessary) to appropriate facilities. o Identification of delivery at home, assessment/counseling by CHVs on PP FP and its use; o Support outreach by CHWs; o Ensure household visit by trained community worker. Referrals o Strengthen the referral system within the community during postpartum period; o Availability of good referral linkage along with awareness-raising of community people on PPC. Other o Revitalize the services of public health officers and technicians on community education focusing on importance of pregnant mothers attending antenatal clinics, including hospital delivery and postpartum assessment; o Public health officers and technicians need to improve follow up for defaulters, for example, in cases where a mother does not bring her child back for immunization or she did not show up at the maternity on or about her expected date of delivery. 8. Windows of Opportunity for Postpartum Family Planning Counseling Almost all (96% or 27/28) respondents reported that the ideal window of opportunity for PP FP counseling is both before and after delivery. Eighty nine percent of respondents (25/28) reported that the ANC clinic was the ideal place before delivery, and 85% (24/28) reported that the home was the ideal place post-delivery. The following illustrates all possible windows of opportunity to provide PP FP counseling, listed in descending order. Figure 12. Windows of Opportunity for Postpartum FP Counseling (Pre-delivery) % of Respondents Ante-natal clinic Home FP clinic Other Point of service 25