SAFE MOTHERHOOD STRATEGY DESIGN MEETING

DISH II PROJECT SAFE MOTHERHOOD STRATEGY PREPARED 1 – 2 MARCH 2001 TABLE OF CONTENTS Strategic Goal & Audiences ...………………………………………….. 2 Background ……………………………………………………………… 2 Service Delivery Strategy ……………………………………………… 6 Strategic Approaches to Implement Improved MH Services ……….. 9 Communication & Promotion Strategy ……………………………….. 10 Message and Media Plan I for Women 18 – 35 Years Old …………… 10 Message and Media Plan II for Men and Older Women ..…………… 13 Message and Media Plan III for Service Providers .…………………. 14 Workplan ..……………………………………………………………….. 15 1 DISH II PROJECT SAFE MOTHERHOOD STRATEGY PREPARED 1 – 2 MARCH 2001 Goal  To increase utilisation of maternal health (MH) services with emphasis on assisted deliveries and postnatal care. Audiences   Primary: Women of reproductive age (18-35) living in rural areas of the DISH districts. Secondary: Husbands, partners, mothers and mothers-in-law of primary audience; health workers at facilities that serve them; TBAs and traditional healers in their communities. Background: Despite efforts to improve the quality of services, and evidence showing that antenatal care and delivery assistance services in the DISH districts has improved, utilisation of those services remains very low. Postnatal services are essentially restricted to immunisation of infants at 6 weeks postpartum and rarely include examination of the mother. Underutilisation appears to be due to negative perceptions among the public about the quality and cultural acceptability of these services as well as traditional beliefs and practices that prevent women from using these services. What we know about Antenatal Care Services (ANC):               Communities want to care for pregnant women, and do what is thought to protect the woman during this vulnerable period. Most pregnant women come at least once during a pregnancy to get a card, just in case they have a problem during labour and need to come back. Most women come after first trimester for first ANC visit. ANC is provided by a variety of cadres--Nursing Aides, Nurses, Midwives, Clinical Officers, Medical Officers. Service providers are perceived as “unfriendly” and usually do not give clients information they need, especially about danger signs during pregnancy and where they should deliver. No pregnancy tests available. Long waiting times; short consultations. ANC is mostly a promotive and preventive service. No standard “package” of services/clients often leave without drugs. Most public facilities don’t have ANC cards available. Clients not followed-up at home by service providers. ANC inaccessible in many rural areas. Antenatal providers rarely assure the client of confidentiality; and mothers fear lack of confidentiality No waiting area for husbands at antenatal facilities. 2              Many men and women do not know what takes place during antenatal care. ANC providers give 2 tetanus injections every pregnancy regardless of total number of times the woman already had it. Mothers do not bring immunisation cards to ANC so providers cannot know how many times they have already received tetanus toxoid. ANC is affordable for most people. In many facilities, ANC is offered 1 or 2 days a week and waiting clients are delayed by health education talk; and the service is usually only available in the mornings while clients prefer coming in the afternoons. Clients and their families do not know their rights as clients. Birth planning and emergency preparedness rarely done. Usually, there is little or no contact between health care providers and client’s husbands. Midwives in rural health facilities are often young, yet most women prefer older birth attendants. Privacy provided during examination. Equipment available. Service providers’ attitudes are improving. Antenatal care guidelines are widely available but not often followed. What we know about Delivery Assistance at Health Facilities                    Most rural women deliver by TBAs. There are “lucky” people in some communities who are preferred for delivery. TBAs/private midwives accompany their clients to health facilities when they are referred. Mothers fear lack of confidentiality. Many midwives have training in Life Saving Skills (LSS). Clients fear having unnecessary C-sections. Clients are offered no physical support during labour. Services perceived to be unfriendly. Clients are not assisted through the process; they often go through labour alone. Lack of credit facilities at public facilities. Women deliver on their backs, when they prefer to deliver squatting or kneeling. Distance to health units often far. Lack of trust in health providers. Lack of cleanliness in labour wards at large facilities. No security at night. Bring your own: beddings, lighting, food, and water. Not all facilities are always open 24 hours a day. Many health facilities lack emergency obstetric drugs, and some essential supplies (e.g. gloves, jik) Herbs, massage and taking home the placenta are not allowed. 3       Mothers are advised not to bathe newborns or feed them anything but breast milk. At health facilities, you do not have to travel for emergency care. Referral system is not very smooth (mothers often resist referral) Skilled manpower is available in most facilities but inadequate in numbers. Many Health Centre IVs are not staffed or equipped to attend to emergency obstetric cases. All hospitals, Health Centres III and IV open 24 hours a day, 7 days a week for delivery assistance. What we know about Post-Natal care (from birth to 6 weeks after birth)          60% of maternal deaths occur during the first week after birth. Yet most women do not leave their homes during first week. Most women do not go for postnatal care (PNC). Few health workers offer post-natal services, even when mothers come to health facilities during the postpartum period. Post-natal services are not known to the community. Guidelines for PNC in place and providers trained. Providers focus on 6 week PNC visit, not on first day or 1-week visit. May need to offer early PNC at home since mothers stay home. Community knows a woman needs care after delivery, but to them good care means staying indoors and not travelling. What we know about the Community Knowledge about maternal health and safe motherhood        Do not know importance of using sterile instruments to cut umbilical cord. Poor understanding of pregnancy, ANC, delivery, PNC services. Poor knowledge of pregnancy danger signs. Fetal development poorly understood. Poor understanding of importance of ANC, PNC, assisted deliveries. Do not know causes of miscarriage, postpartum psychosis and eclampsia. Do not know what to do in case of emergency. Beliefs  Food taboos during pregnancy.  Pregnancy is a woman’s matter.  TT causes abortion.  Polio is caused by drug use during pregnancy.  Infidelity during pregnancy causes complications of L & D.  Women in early pregnancy are attractive, warm and promiscuous.  Placenta needs to be disposed of properly or the child will be unlucky, sickly or die; mother becomes infertile. 4          Pregnant women may not cross roads or sit on chairs where others have been sitting. Infidelity by pregnant women can cause miscarriage, child gets rash. Herbs can prevent and treat syphilis. Some believe it is cowardly to opt for hospital delivery. Giving boiled herbs to newborn will clear his digestive tract. Babies should be bathed in herbs immediately after birth. Herbs during pregnancy can soften pelvic bones. If a woman hates someone in the family, the baby will resemble that person. If a man jumps over a pregnant woman’s legs, it is as good as having sex with the woman, and the baby will resemble that man. Practices  Feed mother special diet after birth.  Paternity tests.  Baby stays with mother after birth.  Staying indoors for one week or more after birth.  Cut umbilical cord with a piece of leaf or knife.  Deliver stooping, squatting or kneeling and holding onto a pole.  Bury placenta.  During labour, begin preparing for baby.  Use herbs to cure most pregnancy related discomforts.  Make loud noise or sing song to “wake” new born.  Compress uterus immediately after delivery.  Dispose of colostrum and give baby something else to drink.  Give mothers a gift after birth.  Husband is told of pregnancy very early.  Pregnancy is confirmed by TBA or mother-in-law after missing 2 periods.  A mother who cries or yells during labour is beaten and scolded.  Massaging mother after birth.  In some cultures, husbands have sex with wives immediately after delivery. Attitudes/perceptions  Need to establish paternity.  Negative attitudes towards women who have miscarriages or obstructed labour.  Clients don’t like being “ordered around”.  Men think women nag a lot when pregnant.  Men and women fear health facilities, they think providers don’t care, are rude.  Prefer assistance during delivery with someone they know present.  Arrive late in labour at health facilities out of fear that nurses will not take them seriously if they take long to deliver.  Providers think clients don’t want to listen to instructions, don’t follow instructions, are uncooperative, patients don’t want to be referred. 5  Clients only value health care if they get drugs or treatment. Gender roles  Men do not do some housework even when the woman is in labour.  Men control money and decisions concerning health during pregnancy.  The less educated a woman is, the less power she has in a relationship.  Men are concerned about health of pregnant women and their child.  Women play a central role in pregnancy and child birth (TBA, in-laws) SERVICE DELIVERY STRATEGY Specific Objectives: By the end of September 2002 1. Increase the proportion of clients served within 30 minutes of arrival by 50%. Improve provider communication skills and attitudes through training on the job. Increase percentage of clients who are aware of their rights by 50%. Ensure availability and accessibility of service guidelines at all service delivery points. Include maternity services in outreaches. Ensure 100% of service providers discuss birth plans with mothers during history taking. Strengthen sites for emergency obstetric care, through training and supply of equipment supplies Ensure that 100% of service delivery points establish a functional referral system (through working with the community). Assist 100% of sites to be flexible towards client’s harmless cultural practices and beliefs. Encourage 100% of sites to accept the policy that allows women in labour access to physical support (husband or relative). Ensure 80% of sites comply with standard infection prevention practices. Work with HM/QA component to ensure regular availability of emergency drugs. Adopt WHO recommendations of 3 post natal visits. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 6 STRATEGIES FOR IMPROVING ANC SERVICES Long Waiting Time  Together with the DHT, empower trained nursing assistants to perform ANC tasks Health unit in-charges to:       Deploy trained nurses to provide ANC services Sensitise the community about availability of daily ANC services Provide radio, audio/or video tape messages for waiting ANC clients Encourage the policy of first come, first serve. Provide patient information materials and news letters in appropriate languages (while waiting) Encourage husbands/partners to participate in ANC activities. Client Provider Interaction   Organize whole site orientation to client’s rights Hold periodic focus group discussions with the community to obtain feedback on quality of services (specifically primary and secondary target audience) Improve service provider communication skills. Educate the clients and the community about their rights as clients Organize quarterly client exit interviews, and provide suggestion boxes to obtain client feedback. Participate in monthly LC meetings and other community activities that take place at the health units and obtain feedback. Remind the clients about the importance of bringing their cards to the health units especially TT cards.      Service Delivery Guidelines    Ensure availability of enough copies of Policy Guidelines and Service Standards at each health facility Orient service providers to the use of the Guidelines. Assess the utilization of the Service Guidelines and work with the site staff on its use. 7 Increasing Access To ANC Services    Expand weekly outreaches to include ANC services Mobilize existing community resource persons to assist with home visits. Estimate the number of likely users in the catchment area and use the information for planning purposes. Birth Planning And Emergency Preparedness    Service provider should discuss birth and emergency plans with the client and spouse. Encourage the client to discuss her birth plans with the husband or relatives and bring feedback to the service provider. The service provider should sensitize the client and relatives about danger signs in pregnancy and childbirth and signs of labour. STRATEGIES FOR IMPROVING ASSISTANCE DURING LABOUR AND DELIVERY  Be flexible towards harmless cultural practices and beliefs. Allow the client to choose the delivery position she feels is comfortable for her. Avoid unnecessary shaving of pubic hair and episiotomy. Educate the client and relatives about the dangers of washing the baby immediately after birth Educate clients and relatives about the value of colostrum. Accept external use of herbs (that is not ingested orally) but discourage use of herbal pessaries. Educate the clients and relatives about the side effects of herbal pessaries. Assist with massage of the back during labour - - - Physical Support During Labour   Allow the woman in labour to have a relative of her choice to assist her during labour. Keep the woman and her relatives informed of labour progress and need for surgical intervention where necessary. 8 Infection Prevention   Ensure availability of JIK, other detergents, and other protective materials in the facility. Assess compliance with standard infection prevention practices during support supervision. Logistics Management   Ensure availability of emergency drugs and supplies. Maintain an appropriately equipped and accessible emergency tray. Referral     Ensure that clients are well informed about the need for referral. Strengthen referral sites by supply of essential equipment and materials. Train staff in emergency obstetric care and life saving skills. Work with the community to provide/mobilize emergency transport system and funding. STRATEGIES FOR IMPROVING POSTNATAL CARE     Create awareness of the danger signs during post-natal period especially the first week. Promote three post-natal visits (within 6 hours, at 6 days and at 6 weeks) Empower nursing assistants to follow up clients at home during the first week postpartum. Provide information on family planning and immunization of baby and mother to complete her tetanus toxoid doses. STRATEGIC APPROACHES TO MATERNAL HEALTH SERVICES 1. IMPLEMENT IMPROVEMENTS IN Training : Continue training nurses, midwives, clinical officers to provide ANC, PCN. Train Medical Officers in emergency obstetric care 9 (EOC) at selected referral sites; train midwives in life saving skills (LSS). 2. Training follow up: 3. 2 weeks after training 4 weeks after training Regular support supervision Support supervision and on-job training to update trained providers to new emphases. Special issue of Health Matters to address client’s rights and distributed to health facilities. Special newsletters for service providers outlining key issues concerning client friendly maternal health services. Client education posters/pamphlets Clients rights Danger signs in pregnancy Danger signs in labour and puerpium Record health education information on audio tapes and distribute to sites with audio cassette players. 4. 5. 6. COMMUNICATION AND PROMOTIONAL STRATEGIES There will be three audiences for communication messages. Each will have slightly different messages, approaches and media materials. The strategies are described for each audience. Audience # 1: Women aged 18-35 living in rural areas of DISH II districts Objective: To increase awareness of the risks involved during pregnancy and the puerperium and the importance of having birth preparedness plans. Key promise: If you know the risks involved in childbearing and have a birth preparedness plan, you will have a safer delivery and will be more likely to have a healthy baby. Message points:   Description of services to expect during ANC, PNC and delivery at a health facility. Risks during pregnancy, labour and delivery and during postpartum period: Pregnancy: 10 1. 2. 3. 4. 5. 6. 7. 8. Antepartum hemorrhage (bleeding) Anaemia Malaria Pre-eclampsia Ectopic pregnancy STDS/HIV Miscarriage Premature birth Labour & Delivery: 1. 2. 3. 4. 5. 6. Obstructed labour Eclampsia Bleeding (hemorrhage) Ruptured uterus Still birth Malpresentation Postpartum: 1. 2. 3. 4. 5. 6. Bleeding Infection Retained placenta Fistulas or prolapse Mastitis Problems with baby (e.g syphilis, gonococcal eye infection, respiratory tract infection, jaundice, UTI, low birth weight/prematurity)        When delivered in a health facility, some problems with newborns can be corrected early. Locations of ANC, PNC, delivery assistance (rainbow over the yellow flower for ANC and PNC) Importance of postnatal care, especially during the first week. Danger signs during pregnancy, delivery, postnatal period Danger signs for new born babies Describe a birth preparedness plan and how to make one. Address misconceptions that stop women from using services: Crossing roads, standing in doorways, sitting where another has been sitting does not affect pregnancy Reassure that privacy and confidentiality is maintained at health facilities 11     Infertility, miscarriage and difficult labour are not the result of infidelity. Explain possible causes of miscarriage and difficult labour. When delivering at a health facility, you can tell the health provider how you would like to dispose of the placenta. Preparing for the baby before birth will not adversely affect the child. Use testimonies from couples who have prepared for childbirth. Generally speaking, it is not a good practice to drink or eat or take herbal pessaries/mixtures during pregnancy, labour or delivery or to give them to babies. They can cause premature labour, ruptured uterus and diarrhea. Babies can be born asphyxiated. Health providers are well-trained in maternity care and are concerned about the mother’s and baby’s health. Health facilities that provide delivery assistance are equipped to handle most obstetric emergencies and the midwives and doctors have been trained to do so. They know when it is beyond their capability and where to refer. Feel free to ask questions and discuss your pregnancy with the health provider. They will listen to you and help you. Communication with your husband about your pregnancy not only when you need something.     Media and Materials:   Copies of RH IEC Working Group borchures about safe motherhood for distribution. Radio spots on:  Risks of pregnancy, labour & delivery, postpartum period  Birth preparedness planning  Services available when delivering at a health facility; the advantages of delivering at a health facility Drama script for use by districts Health Matters issue on safe motherhood (including a list of facilities with delivery assistance Messages on “Olujegere Lw’obulamu” and “Orujegyere Rw’amagara” radio programmes Poster and calendar “Nze N’owange” community radio programmes (add Runyankole programme on Radio West) Birth preparedness plans for use with clients adapted from RCQHC and translated to vernacular       12 Audience # 2: Rural men 20-45 years old and older women 50 years and older living in DISH II districts. Communication objective: To convince the audience of the importance of antenatal care (ANC), delivery at health facilities and postnatal care (PNC), and developing a birth preparedness plan together with their pregnant wives/daughters. Key promise: If you ensure that women attend antenatal care, deliver at health facilities, go for postnatal care, and prepare plans for childbirth, you will be protecting the lives of your women/daughters and their children. Message points:  Services have improved now. Things have changed. Providers are better trained and facilities are better equipped.              Describe antenatal, delivery and postnatal services. Delivering at health facilities is safer than delivering at home. Describe a birth preparedness plan and why it is important. Danger signs during pregnancy, labour, and postpartum period. Danger signs in new born babies Risks during childbirth, pregnancy and postnatal period. Locations of antenatal, postnatal and delivery services (antenatal and postnatal care available where you se the rainbow over the yellow flower). Health workers are well trained and concerned about the woman and her baby. You can rely on them to take good care of her. Men should discuss pregnancy and childbirth with their wives and provide emotional support. Testimonies from couples who made plans and followed them. Counter misconceptions as for women There is no medical reason to restrict some foods during pregnancy. Fish, eggs and salt plus chicken can be safely eaten during pregnancy. Generally speaking, pregnant women, women in labour and new born babies should not be given herbs to eat. Women should not be given herbal pessaries. They can cause premature labour, ruptured uterus or diarrhea. Babies can be born asphyxiated. 13 Media and Materials:  DISH centerpiece TV programme(s) translated to vernacular  Identify other videos including “Three Visits” that can be shown in communities  Health Matters issue on safe motherhood, including the role of the father, aunties, and mothers in law  “Olujegere Lw’obulamu” and “Orujegyere Rw’amagara” radio programme episodes  Radio spots for men and mothers-in-law  Identify radio talk shows for men and incorporate safe motherhood messages Audience # 3: Health providers offering maternal health services in DISH II districts, public NGOs or private Objective: To increase the proportion of health providers who offer “client friendly” maternal health services and assists ANC clients prepare birth plans. Key promise: If you offer “client friendly” maternal health services and assist ANC clients prepare birth plans, you will be respected, recognized and appreciated by the community and your superiors. Message points:  Qualities of client friendly services: Waiting time less than 1 hour. Emergencies attended to immediately Observes infection prevention Encourage client questions Ensures privacy and confidentiality Provides correct and updated information about pregnancy, labour and delivery Treats clients and respectfully regardless of clothing, culture, level of education. Understands local cultural practices and adapts services as much as possible (e.g. delivery position, placenta-to-go). Welcomes husband and relatives during delivery Clean facility Open 24 hours/days, 7 days/week. 14 - - -        Why and how should providers get feedback about services from the communities they serve. Benefits of and how to prepare birth plans with all ANC clients. The dangers to the mother during the first 6 hours and first 6 days after childbearing; and the need for postnatal care. Testimonies from satisfied clients. Examples of places that provide client-friendly services. Location for emergency obstetric (EOC) referrals How to plan for emergency transportation. Media and Materials  Self-instructional materials for use during training and support-supervision on: 1) client friendly maternal health services, and 2) birth preparedness planning. Certification upon completion.  Desk/table chart reminding providers about client-friendly maternal health services  Provider magazine or newsletter  Lists of facilities offering delivery assistance and emergency obstetric care in each district for posting in health facilities  “I care about you” badges for providers  In each district, work with 2 health facilities—one level 3 and one level 4 health centre to get community perspective of maternal health services and rearrange services to be more client friendly. Document process and share with other health facilities  Beginning with these model “client friendly” services, train Community Resource Persons (CORPS) and PDCs to do birth preparedness planning follow-up with clients  Organize regular reproductive health outreaches that include birth preparedness planning and other antenatal services. 15