Process Evaluation of Community Based-Maternal and Neonatal Care Program in Rural Nepal

Abstract

Introduction: Most community-based maternal health and newborn (MNH) programs rely upon community health workers (CHWs) as a bedrock strategy to educate and counsel pregnant women and their family members. Both types of educational approaches that are used in these types of programs as well as the content of the educational packages have been refined and experimented with in research and programmatic contexts in Nepal over the past several years. With regards to package content, traditional antenatal health education content has expanded to include topics that are now often classified as birth preparedness. Community-level MNH programming has reached an important juncture as the Nepal MOH and its partners are in the process of investing heavily in an educational strategy—the Birth Preparedness Package, or BPP— that seeks to improve the health status of mothers and newborns. The BPP has been pilot-tested in a modest number of districts and has shown some initial promise to improve intermediate health outcomes such as client knowledge and utilization of health services as well as preparation for obstetric emergencies. However, antenatal health education and the BPP in Nepal would benefit from further study and experimentation—including possible revisions to the BPP strategy and tool package—before decisions regarding the standardization and roll-out of the BPP are contemplated. The Community-Based Maternal and Neonatal Care (CB-MNC) project, implemented by the government of Nepal with the support of the Nepal Family Health Program (NFHP), has incorporated the BPP as a central program strategy in three districts (Banke, Jhapa and Kanchanpur) where the CB-MNC is being implemented. The NFHP is currently considering how an alternative antenatal educational approach might be used in order to scale up the pilot program to the entire country. The main activities such as providing antenatal counseling/health education, strengthening of existing facility-based services and post-partum home visits were implemented in all the three districts. Other specific activities such as distribution of Misoprostol to prevent post-partum hemorrhage (Known in Nepali as matri suraksha chakkior MSC, low-birth-weight package, emphasis on post-partum health assessment and birth registrations were implemented in one or more districts. The birth registration package was implemented in both Banke and Kanchanpur in order to register births through early post-partum home visit and low-birth-weight package was implemented in Kanchanpur and the post-partum health assessment was implemented only in Jhapa in order to detect and promptly treat neonatal danger signs. The MSC (3 tablets of Misoprostol to prevent post-partum hemorrhage) component was implemented in Banke district only. The CB-MNC therefore provides an outstanding opportunity to use process evaluation to (1) gain a fuller understanding of how antenatal health education takes place at the community-level through the BPP as well as to (2) design and implement alternative, sustainable models of community-based antenatal health education and document how they are implemented and how members of the community perceive and use them.