Increasing women's access to safe delivery through health service quality improvement and health promotion in Nawalparasi

Green Tara Nepal (GTN) has been implementing AmplifyChange for Increasing women's access to safe delivery through health service quality improvement and health promotion. AmplifyChange is a fund that aims to empower young people, men and women to realise their sexual and reproductive rights. AmplifyChange is pooled fund supported by Danida at the Ministry of Foreign Affairs in Denmark,

the Ministry of Foreign Affairs of the Netherlands, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, and the Viiv Foundation. The donors have contracted Mannion Daniels Limited to deliver AmplifyChange. MannionDaniels is working in a consortium with the Global Fund for Women (GFW) and African Women’s Development Fund (AWDF) to manage AmplifyChange.

AmplifyChange supports civil society and grassroots organisations (CSOs) to advocate for and promote better sexual and reproductive health and rights, working in countries where the needs are greatest.

Project Background:

Access to comprehensive maternal health is one of the health rights of women. Nevertheless, women continue to have a high risk of death and illness during pregnancy, delivery and/or postpartum period because of many preventable causes. The coverage indicators for maternal, neonatal and child health interventions such as contraceptive prevalence, antenatal care, skilled attendance at birth, postnatal care, case management of sick children are still low in Nepal. Primary and secondary care are deficient in Nepal, and where services exist, the reasons for their underuse are complex. Since 2006, Nepal has addressed supply of health care in remote rural areas by setting up Birthing Centres (BCs) in underserved areas. Yet data indicates most maternal improvements are within privileged groups while marginalised groups not accessing services; more than 70% of women in the Nawalparasi district still give birth at home, and 67% had no postnatal check up by a health worker (GTN baseline 2013).

Nawalparasi district has 21 Birthing Centers, local government sponsored facilities providing safe deliveries with nurses, most of which are under utilised. Whilst Nepal has in place a system of using Female Community Health Volunteers (FCHVs) to provide outreach and education in each area, training is ad-hoc with no mentoring. The District Health Office also does not support FCHVs to collect vital data, and has no system for screening women for maternal depression, despite the fact that suicide is now the no. 1 cause of maternal death (16%) in Nepal.

Green Tara Nepal’s  Project titled “Increasing women's access to safe delivery through health service quality improvement and health promotion” will work towards   access to comprehensive reproductive health services, sexual health of young people and girls challenging stigma, discrimination, attitudes and laws. Therefore, the main focus of the project will be to support equitable access to Reproductive Health Services by mobilising local health care workers and volunteers to conduct health promotion to marginalised women of childbearing age and their families to support use of under utilised Birthing Centres. The project confronts discrimination by empowering women and the local community to understand the health and human rights of women. Approx 1/3 of our target will be newly married and expectant adolescents under age 21.

Overall, the project aims to create equitable access and use of maternal health services among marginalised ethnic and tribal women with access to rural Birthing Centres (BCs) in Nawalparasi through the addition of health promotion (HP) services and improved collection and use of vital data in the target areas. services, and nationally to advocate for training and use of HP for all primary health care providers.

Problems identified in the Project area

§ Primary and secondary care is deficient in Nepal, and where services exist, the reasons for their underuse are complex. Since 2006, Nepal has addressed supply of health care in remote rural areas by setting up Birthing Centres (BCs) in underserved areas. Yet data indicates most maternal improvements are within privileged groups with marginalised groups not accessing services; more than 70% of women in the target areas still give birth at home, and 67% had no postnatal check up by a health worker (GTN baseline 2013).

§  Nawalparasi district has 21 BCs, local government sponsored facilities providing safe deliveries with nurses, most of which were under-utilised. Partly this is due to lack of strategic planning in deciding the location of BCs (of the 21 in the area, many are clustered).  Also health care providers in Nepal receive almost no training in Health Post, and have not previously been expected to conduct outreach, home visits etc.

§  Whilst Nepal has in place a system of using Female Community Health Volunteers (FCHVs) to provide outreach and education in each area, training is ad-hoc with no mentoring. There exists a lacking of support to FCHVs to collect vital data, and has no system for screening women for maternal depression, despite the fact that suicide is now the no. 1 cause of maternal death (16%) in Nepal.

§  Each BC is managed by a local management committee, and most of these don’t meet regularly and don’t conduct social audits or discuss quality service improvements (GTN data 2015). This leads to failure in local health systems government to run effective and high quality SRH services for women.

Objectives:

Overall aim of this project is to promote continuum of care from pregnancy to post-partum period aim to reduce maternal and infant mortality in the target population.  Specific objectives are:

·      Strengthen ANC, PNC, neonatal, child health and family planning services.

·      Strengthen PHC/ORC and immunization services in the facility and outreach sites.

·      Increase promotive health behaviours of the community people through mobilisation of community groups such as mothers groups, adolescent groups meetings.

·      Organise social mobilisation and advocacy activities.

·      Establish birthing facilities in the local health post.

·      Establishing a prompt and proper referral services for emergency and complicated cases.

Approach/strategies

·      Need based program planning and management addressing the gaps

·      Active engagement of local stakeholders from planning phase

·      Align with existing system considering sustainability of the programme

·      in partnership with DHO, health posts and local health facility and management committee

Major Activities:

Activity 1: CAPACITY BUILDING FOR HEALTH PROMOTION (START UP AND PREPARATION)

The objective of this activity is to improve local health systems governance, and use of data for maternal and neonatal health programme.  Each BC is managed locally by a Health Facilities Operations Management Committee (HFOMC) made up of local volunteers, health workers and government officials. The funding includes training for the HFOMCs to improve inclusive management (whilst women and Dalits are required to be on the HFOMC, to conduct social mapping and use data to discuss and improve services. GTN staff and nurses share data and support local women to bring concerns and questions.   Major activities under training and capacity development are:

·           Conduct training on health promotion, participatory group facilitation, training to GTN staff and key board members on, FCHVs

·           Training of FCHVs on SRHRs and health indicators

·           Training of HFOMC on SRHRs and health indicators

·           Refresher training on health promotion and participatory group facilitation for GTN staff and key board members

ACTIVITY 2: SUPPORT FOR HEALTH STRENGTHENING SERVICES AT BIRTHING CENTERS

Green Tara Nepal will provide technical support and support of nursing staff to operate birthing centers.  This support will remain in strengthening nursing care in the facilities.  Major activities under this theme include;

·           Identify 2 Birthing Centers (BCs) for intervention in consultation with DHO

·           Meet with Health Facilities Operations Management Committee at selected BCs to introduce project and conduct orientation

·           Recruit ANMs for birthing centers

·           Supply equipment and minor renovations as per needs assessment

·           Support one ANMs per health facility for running SRH services

ACTIVITY 3: SCALING-UP EVIDENCE BASED HEALTH PROMOTION (NEEDS ASSESSMENT, BASELINE STUDY AND  FINAL EVALUATION)

To collect and use data on maternal mortality and use of health promotion to improve SRH services in Nepal.  The evaluation design measures proof of concept of the health promotion (HP) strategy using Community Health Promoters (CHPs) and FCHVs at the target Birthing Centres (BCs).  These data will be entered regularly and used to produce policy briefs and papers that will be published in int'l health journals. Major activities are;

Baseline Study

·      Produce Study design and sampling for controlled before and after study

·      Conduct baseline data collection in intervention and control VDCs and data input and analysis

Review, monitoring and advocacy of SRH services

·      Conduct quarterly reviews of data with district and local health management staff and implement quality improvements/recommendations

·      Social Audits for accountability of the birthing center

·      Conduct rapid mid-term evaluation (process evaluation)

·      Compilation of case studies

·      Project review meetings between health facility, VDC and GTN staff

Endline assessment

·      Conduct endline assessment to assess target vs achievement (tool design, data collection, data entry and report writing)

·      Dissemination of findings at district level

·      Dissemination of findings at national level for evidence-generation and national level policy advocacy works

ACTIVITY 4: COMMUNITY BASED HEALTH PROMOTION WORKING WITH WOMEN AND THEIR FAMILIES

The project focuses to improve knowledge, behaviour and use of maternal health services among marginalised and vulnerable women with access to Birthing Centres.   The key to improving access to SRH services at BCs is to educate and empower the women who are currently not using those services using a consistent health promotion approach that engages and empowers the most marginalised to use and quality services. The project will staff each target BC with a Health Promoter (HP), a woman living in the area who will champion HP. The HP will be responsible for a catchment area of 2 VDCs including the one with the BC. HPs and FCHVs will identify women newly moved in with husband (often adolescents who have minimal info about pregnancy); and newly pregnant women. They will invite these women to join a monthly group, and conduct home visits to those who can't. They will also invite their motherin- law (often the main decision maker regards health) to attend a separate monthly group. Groups will focus on topics such as preparation for birth, good nutrition, depression, family planning and GBV and empowerment. Major activities include;

·      Mother's group and Mother-in-laws groups formation to get input from the community on SRHRs issues

·      Facilitate monthly health promotion groups for pregnant women, mother-in-laws and husbands

·      Conduct home visits to newly pregnant and extremety isolated/vulnerable women to recruit to groups and to support access to BCs

ACTIVITY 5: IMPLEMENTATION OF HEALTH PROMOTION FOR DEMAND CREATION AND STRENGTHENING HEALTH SERVICES

Major activities under this theme are;

·      Conduct social and operational mapping of working location to identify and outreach to  target women

·      Solicit feedback from local women about BC facilities and \

·      Coordinate with HFOMC for use of capacity building funds for BC improvements.

Key achievements

•       The programme is still in the beginning phase

•       All the process of approval and preparation are completed

•       Engagement of local stakeholders from the beginning of the programme

•       Started strengthening services both at community and grassroots level