Community-based maternal/ newborn care

Nepal Family Health Program
Technical Brief #10
Community-Based Maternal/
Neonatal Care
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, largely 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 using the 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- BACKGROUND
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 and 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- attendance/ quality emergency obstetrical care
delivery-points, FCHV-provided health education— with specific 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 through
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). 7. Receive postpartum iron.
7. FCHV orientation, logistics, supervision. 8. Appropriately use misoprostol (matri suraksha 8. Logistics (procurement, distribution, control system), chakki) 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 identified through
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 1. Seeking specific antenatal services (e.g., TT,
(EPI) services and increasing community support iron, de-worming, etc.) from FCHVs or other 2. 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, 3. Recognizing and promptly seeking care for
Assessment—(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). 4. 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). 5. Seeking immunization and postpartum family
6. 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 chakki and documentation of its use. ƒ Birth recording to support civil registration; Misoprostol (matri suraksha chakki) (in • in Kanchanpur—low-birth-weight package 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
Postpartum/ neo-natal
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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