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Community-based maternal/ newborn care
Nepal Family Health Program
Technical Brief #10
The main emphasis of community-based maternal and neonatal care (CB-MNC) has been to significantly increase coverage of a minimum package
of high-impact, cost-effective,
community-based interventions with the potential for significant population-level mortality impact over the short-to-medium term. The package was, to a considerable extent, based on existing service elements and other recent experiences in Nepal, but includes some innovative components. The CB-MNC package was intended to be:
• In principle, implementable at scale
Female Community Health Volunteer (FCHV) counseling
a mother-in-law on maternal care.
• Eventually fully integrated with other maternal
and child health (MCH) activities, community-
based integrated management of childhood illnesses (CB-IMCI) and ongoing training
Countries that have made real head-way in
initiatives, etc. In the three initial districts, the
reducing maternal and neonatal mortality have
generally done so by significantly increasing the
related activities e.g., ‘iron-intensification’ and
proportion of deliveries done under skilled birth
attendance. Such an effort is underway in Nepal
and the Nepal Family Health Program (NFHP) has
Selective rather than full continuum-of-care (focusing on specific interventions with the
contributed to it, for example, through strengthening basic emergency obstetrical care
(BEmOC) services. However, reducing mortality
• Initially closely documented and monitored, to
through increased use of skilled delivery services is
enable us to learn lessons and progressively
refine the approach for greater impact and ease
Nepal and we do not expect large gains quickly.
The Nepal Family Health Program has piloted a
To achieve impact the intervention requires:
package of primarily community-based inputs with the goal of improving maternal and neonatal
• A high level of uptake of appropriate
outcomes. This work was implemented under the
household-level practices (behavior change).
leadership of the Ministry of Health and
• Prompt & appropriate treatment-seeking
Population, Family Health Division (FHD) and District (Public) Health Offices (D(P)HO) in the
districts of Banke, Jhapa and Kanchanpur.
• Availability of appropriate services (access/
Implementing partners included Nepal Family
Health Program (USAID), JHU/HARP-GRA (Johns Hopkins University), ACCESS Project (SC/US & JHPIEGO), PLAN, and USAID (funder).
In the table below, ten main goals
associated sets of activities are outlined (the first seven have been implemented in all three districts; the last three in selected districts).
Household practice/ service utilization goals:
1. Receive key antenatal ‘clinical’ interventions
1. • Demand creation through counseling / health
education provided by Female Community Health
Volunteers (FCHVs), with complementary behavior
• Provision of services through existing channels (peripheral health facilities, outreach clinics, FCHVs), • Monitoring/ supervision, logistics and policy review.
2. • FCHV-provided counseling (individual/ group),
appropriate care for danger signs
leveraging household social support (with BCC and
community mobilization) and providing specific
• Provision of quality emergency services (site strengthening). • Monitoring/ supervision (e.g. tracking commodity stock status).
3. Use appropriate essential newborn care
3. FCHV (plus Trained Traditional Birth Attendant
household practices (clean blade, surface and
(TTBA) in some settings)—provided counseling/
hands; stimulate, dry, wrap, quick to the breast,
4. Plan for, seek and receive skilled birth
4. Site-strengthening, mapping/ inventory of service-
quality emergency obstetrical care
delivery-points, FCHV-provided health education—
referral information given (with BCC/ community mobilization as in 3, above).
5. Early detection/ prompt treatment of post-
5. Health worker/ FCHV orientation, supervision/
partum/ neonatal danger signs, targeting sepsis
monitoring, logistics, site-strengthening (for treating
(community outreach for case detection
early post-natal home visit and referral).
6. Early initiation & exclusive breastfeeding
6. FCHV-provided health education/counseling (with
post-partum home-visit assessment), supervision/ monitoring (with BCC, community mobilization).
Receive postpartum iron.
7. FCHV orientation, logistics, supervision.
8. Appropriately use misoprostol (matri suraksha
8. Logistics (procurement, distribution, control system),
) for preventing postpartum hemorrhage
training/ orientation for health workers (including
if not delivering with skilled birth attendance
FCHVs), counseling pregnant women (by FCHVs,
other health workers), supervision/ monitoring.
9. Low-birth-weight babies
9. Policy clearance, on-the-ground formative research
early postpartum home visit & receive risk-
(KMC), health worker orientation (including FCHVs),
reducing interventions (kangaroo-mother-care,
logistics (for new commodities), FCHV-provided
KMC/ skin-to-skin, breast-feeding assessment/
counseling, Kanchanpur only, done under ACCESS project).
10. Births registered
through early postpartum home 10. Orientation—health worker/ local government,
Note that although this includes all the main activities, it is not an exhaustive list.
Summarizing the three main sets of
B. Strengthening existing services
, including minor
renovations/ repairs and provision of training and
A. Community-level antenatal contact
equipment for selected Basic Emergency Obstetric
Care (BEOC) sites; service mapping/ inventory for
pregnant women and household decision-makers,
mainly by Female Community Health Volunteers
complications (pregnancy-related, delivery-related,
(FCHVs) and, where appropriate, by Trained
postpartum and neonatal); logistical and other
Traditional Birth Attendants (TTBAs), focusing on
monitoring. In Banke, there was a separate activity
strengthening expanded program of immunization
Seeking specific antenatal services (e.g., TT,
(EPI) services and increasing community support
iron, de-worming, etc.) from FCHVs or other
Seeking skilled attendance at delivery (or
C. Postpartum home visits
by FCHVs (and
Emergency Obstetric Care (EOC)), including
sometimes TTBAs), within the first two-three days,
Recognizing and promptly seeking care for
—(case detection) looking for
danger signs (including locality-specific
danger signs (neonate—following CB-IMCI
information on where to go for care; FCHV to
protocol; mother—questioning on danger signs)
address obstacles to prompt care-seeking).
Performing essential new-born household care
practices (clean delivery, appropriate cord-care,
• Counseling/ negotiation
(especially on essential
temperature control, breastfeeding—early and
newborn care & breastfeeding, recognition of
danger signs—but also including EPI & FP).
Seeking immunization and postpartum family
Informing FCHV soon after delivery, to trigger
In specific districts
there have been other elements
covered by the postpartum home visit, notably: •
FCHVs use this antenatal health education contact
Recovery of misoprostol/matri suraksha
and documentation of its use.
Birth recording to support civil registration;
Misoprostol (matri suraksha chakki
• in Kanchanpur
In Kanchanpur, counseling/health education has
(implemented under the ACCESS Project)—for
been implemented somewhat differently from the
those found to be low birth-weight on initial
Package key-chains are given to pregnant women
and where the approach depends more heavily on
individual counseling. In Kanchanpur, this
A follow-up home visit around day five-six
assess feeding and reinforce counseling).
(mothers-in-law, sisters-in-law) as well as
CB-MNC – Next Steps
Uses a more active, group-based, participatory,
problem-posing/solving pedagogy (based in
(including monitoring provisions) to make it
Activity (MIRA) approach which was piloted
intervention in Nepal’s national community-
In addition to counseling/ health education, there
based neonatal/ safe-motherhood approach.
• Possible addition of new technical elements,
community mobilization support (including radio
e.g., chlorhexidine for cord stump care, early
drama serial, etc.) in each of the three districts. In
neonatal vitamin A dosing, calcium to be added
Banke, there has been additional activity targeting
to antenatal care for prevention of eclampsia,
marginalized communities to raise awareness of
development of more effective screening and
care for pregnancy-associated night-blindness.
CB-MNC Program Framework
Around birth/ delivery
for danger signs
This technical brief is one of a series seeking to capture key lessons learned from the USAID/ Nepal bilateral project,
the Nepal Family Health Program (367-00-02-00017-00), 2001 - 2007. The document was produced with support
from the American people through the U.S. Agency for International Development.
The views expressed in this document do not necessarily reflect those of USAID.
The Nepal Family Health Program is implemented by JSI Research & Training Institute, Inc.,
in collaboration with EngenderHealth, JHPIEGO, Johns Hopkins University/ Center for Communication Programs
(JHU/CCP), Save the Children, Nepal Technical Assistance Group (NTAG), Management Support Services (MASS),
Nepal Fertility Care Center (NFCC) and, for a period, CARE and ADRA.
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