EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santénet2 – 2013)

8/22/2019 EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santnet2 2013)

1/42

EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE

COMMUNITY LEVEL


2/42

Page 2USAID/Santnet2 is implemented by RTI International under contract No. GHS-I-01-07-00005-00, in partnership with CARE

International, CRS, PSI, IntraHealth International and, DRV.

TABLE OF CONTENTS

ACRONYMS ................................................................................................................................................... 3

EXECUTIVE SUMMARY ................................................................................................................................. 5

BACKGROUND5

ASSUMPTION.7

GOALS OF THE STUDY

General objective..7

Specific objectives.7

Expected results.7

METHODOLOGY

Study type..8

Study zone.8

Selection criteria of communes..9

Study length..9Study population9

Study activities.10

Principles stages of the study11

LIMITATIONS OF THE STUDY14

RESULTS

Capacity building of the actors15

Support of the organization of community emergency evacuation system18

Qualitative results19

Register indicators of service utilization..24

DISCUSSION

Recognition of danger signs and referrals27

Comparisons of the indicator changes ..28

Implementation of solidarity funds and evacuation systems.29

RECOMMANDATIONS32

ATTITUDES TOWARD THE CONTINUATION OF THE PROGRAM32

SCALING OF THE PROGRAM33

Results33

Community emergency evacuation system.33

Service utilization35

CONCLUSION40

ANNEX.41


3/42



ACRONYMS

ANC Antenatal Care

CHD 1 Centre Hospitalier du District niveau 1 (District Hospital Center, Level 1)

CHD2 Centre Hospitalier du District niveau 2 (District Hospital Center, Level 2)

CHU Centre Hospitalier Universitaire (University Hospital Center)

CHV Community Health Volunteer

CME Complexe Mre Enfant (Mother Child Health Complex)

CSB Centre de Sant de Base (Basic Health Center)

DHS Demographic Health Survey

ONE Obstetrical and neonatal emergency

c-IMCI Community based Integrated Management of Childhood Illnesses

C-ONE Community-based care for obstetrical and neonatal emergencies

GM Group of Men

HC House Call

HF Health Facility

HMIS Health Management Information System

HO Health Official

IFA Iron and Folic Acid

IPT Intermittent Preventive Treatment

KMs Kaominina Mendrika salama

MES Medical Evacuation System

NA Not Available

NGO Non-Governmental Organization

LLIN Long-Lasting Insecticidal Net

PoNC Postnatal Consultation


4/42



PW Pregnant Women

SDC Social Development Committee

SP Sulfadoxine Prymethamine

SSI Semi-Structured Interview

ST Support technician

USAID United States Agency for International Development


5/42



I- EXECUTIVE SUMMARYThe C-ONE project helps the community prevent possible dangers before, during, and after childbirth,

both for pregnant women and newborns. In general, the perception of the population stays positive for

an extension of practices in excellence.

Another point that was evoked during the course of the study was the importance of partnering the

public and private sectors in reinforcing the capacities of the CHVs. Investment at the community levelcomes through the partnerships of NGOs and Fokontany.

It is important to recognize the importance of the CDS and to request the help of Health Officials. Their

support is needed in the stimulation of the request and the offer of services at a community level.

Reinforce the capacity of the CHVs to address the first delay: the delay in the decision to seek a

referral.

Reinforce the role of the CDS to address the second delay: the delay in the transfer or in the

medical evacuation.

Families, communities have a better understanding of obstetrical and neonatal emergencies afterinformation, awareness raising and adoption of appropriate attitudes for maternal and child health.

Community knowledge and understanding of danger signs, late decision making with all its negative

impacts and obstetrical and neonatal emergencies enable decision making for all engagement.

Community capacity to recognize danger signs and referral of all complication cases has increased.

Community engages to manage evacuation systems by defining action plans to set up means of

transport, solidarity funds to support emergency cases.

Community engagement consists of:

Organization, management and setting up responses at the commune level to NEO cases. Rapid

referral of emergency cases and capacity of appropriated health centers managers are improved

to reduce all risk factors to maternal and child mortality. Setting up local transport system and

solidarity fund based of common funds to facilitate transfer of ill people and support transport

and medical fees are resolved through community common engagement.

CHV and CCDS training on recognizing danger signs among pregnant women and new-born

enables to raise awareness among families and community to help them adapt a decision making

attitude in timeframe to evacuate cases to health centers, to receive appropriate treatment and

to mobilize community to set up local and adapted transport means to situations and finally

constitution of solidarity fund or family funds adjusted to community needs.

It should be noted that CHV can sensitize pregnant women, families and communities during their home

visits or during discussions, public awareness raising sessions or community meetings and assisted by

CCDS members.

Results of the study confirmed that the majority of pregnant women and families could recognize

danger signs among pregnant women and new born. The transmission of CHV message was efficient

event for cases among people of low education.


6/42



CHV capacity to monitor pregnancy early enough enables referral of pregnant women to ANC at the

beginning of the first quarter. Awareness of women on advantages and services offered during ANC

increases women knowledge on necessity to get service package within health centers (CSB).

CHV referral of emergency cases linked to pregnancy was improved by community responses to NEO.

Between 2009 and 2010, indicators have changed a lot concerning ANC and referred deliveries that have

increased. Community awareness raising conducted by CHV combined with IFA distribution to pregnantwomen have enable more and more women to get IFA and have been referred to malaria.

II- BACKGROUNDThe extent of maternal and newborn mortality indicates a major developmental failure. Worldwide,

more than 500,000 women die each yearapproximately one per minuteduring pregnancy, during

childbirth, or shortly following childbirth. In addition, every year there are 4 million stillborns and 3

million premature newborn deaths. This means that, annually, maternal morbidity and a lack of quality

care cause 7.5 million deaths. About 5 million of these deaths are linked to AIDS, tuberculosis, and

malaria.

In Madagascar, approximately 8 women die every day from pregnancy complications, before childbirth,

during childbirth, or post-partum. In other words, each month, maternal deaths are equivalent to those

of a 747 airplane crash.

In 1997, 2003, and 2008, the ratio of maternal mortality in Madagascar has remained fairly consistent

(source: DHS 1997, 2003 and 2008); there were, respectively, 488, 469 and 498 maternal deaths for

every 100,000 live births. The ratio of infant mortality, based on these same studies, has declined; there

were, respectively, 40, 32, and 24 infant deaths for every 100,000 live births.

The Millennium Development Goals target of reducing maternal mortality by three quarters and that of

child mortality by two thirds by 2015, brought the countries of the world to invest in new energies and

new resources its efforts to provide maternal health services equitable.

The reduction of maternal and neonatal mortality is one of the Malagasy Government's priorities.

In fact, people often face a series of barriers that restrict access to appropriate care:

- Low decision latitude of women,- Insufficient and inappropriate transportation,- Difficult geographic accessibility of health facilities,- Difficulty of communication between villages and health centers

These constraints cause delays in access to emergency services which can cost the lives of women and

newborns.

The Roadmap for the reduction of maternal and neonatal mortality 2005-2015 is the framework of

actions for the reduction of maternal and neonatal mortality in Madagascar.


7/42



The main strategies recommended were then respectively the updating and strengthening the policy

and organizational program, improving the quality of services in maternal and neonatal care including

family planning, strengthening the referral system, and improving communication on maternal and

neonatal care, and improving the practices of families and maternal and neonatal care at home

This study is to experiment the promotion of community partnership to address This study experiments

the promotion of community partnerships to address obstetric and neonatal emergencies at ONE within

the community if communities assume part of the responsibility for ONE, the collaboration between

health services, NGOs, and community structures can be reinforced, which should help reduce

inaccessibility to ONE and lead to improved maternal and infant health.

The results of this study will guide the implementation of a monitoring system within 800 KM salama to

improve strategies and make available the necessary resources to meet the identified weaknesses

regarding ONE to reduce the rate of maternal and neonatal mortality in Madagascar.

III- ASSUMPTIONThere are three key strategies to use when working to decrease maternal and infant mortality in

childbirth:

1. Family planning2. Childbirth assistance by a trained professional3. Emergency obstetrical and neonatal care (ONE)

Within the realm of the third strategy, populations face many possible barriers that may limit access to

ONE. For instance:

Ignorance of danger signs and limited female decision-making power.

Insufficient and inadequate transportation system.

Limited geographic accessibility to health facilities.

Limited functionality of the communication system between villages and health centers.

These various constraints lead to delays in access to emergency services that can cost the lives of

women and newborns. When examining the question of why mothers and infants die during the

process of childbirth, there are three main points of delay to address in which all obstacles fall:

1. A delay in the decision to seek consultation.2. A delay in transportation.3. A delay in the administration of care.

This study focuses on enabling communities to address the first two delays.


8/42



IV- GOALS OF THE STUDYThe goal of this study is to help reduce maternal and neonatal mortality by promoting a partnership AT

the community level to respond to obstetric and neonatal emergencies.

IV.1. GENERAL OBJECTIVE

Evaluate the role of the community in the response to obstetric and neonatal emergencies anddetermine the strategies for large scale intervention implementation.

IV.2. SPECIFIC OBJECTIVES

Inventory of abilities supported in SONU at all levels of the health system and at the end of theintervention

Measure the perceived changes concerning the attitudes of families and communities in the decision-making process and the organization of transportation for suitable evacuations during ONE in the

intervention and control zones.

Analyze the determining factors in the communitys capacity to respond to obstetrical and neonatalemergencies.

Make recommendations for the future implementation of obstetric and neonatal emergency care ATthe community level (C-ONE).

IV.3. EXPECTED RESULTS

At the family, community, and CHW level, a better understanding of obstetric and neonatalemergencies, and an adoption of suitable behavior regarding family health.

Increased capacity of the community and of families to recognize complications. Increased capacity of the community to manage a system for emergency evacuations.

V- METHODOLOGYThis study is a combination of qualitative and quantitative research, including:

- Focus group and structured interviews with CHVs, SDC, PW, and GM.- Structured interviews with those in charge of childbirth in each of the communes involved in the study.- Statistical analysis of the CSB, CME, CHD1, and CHD2 registers.

V.1. STUDY TYPE

This is a quasi-experimental study with a control group.

V.2. STUDY ZONE

- The study took place in Marovoay, Ambato Boeny, and Mahajanga II districts in Boeny region.- The study was conducted in 23 communes divided into three groups:

Group 1: KM salama communes activities with UON-c

Group 2: KM salama communes activities without UON-c

Group 3: non-communes KM salama and in which there are no activities UON-c


9/42



Table N1: List of communes to the study

DISTRICT COMMUNES

GROUP 1

(10 communes)

MAHAJANGA II Belobaka

Boanamary

Ambalakida

Betsako

MAROVOAY Antanambao AndranolavaAmbolomoty

Tsararano

Ankazomborona

Marovoay Banlieu

Marosakoa

GROUP 2

(7 communes)

AMBATO-BOENY Ankijabe

Andranofasika

Anjiajia

Tsaramandroso

Ambondromamy

Andranomamy

Manerinerina

GROUP 3

(6 communes)

MAROVOAY Manaratsandry

Anosinalainolona

Maroala

MAHAJANGA II Ambalabe befanjava

Antanambao manarenja

Maromiandra

Groups 2 and 3 constitute the control sites of the study.

V.3. SELECTION CRITERIA OF COMMUNES

- Existence of a reference and counter reference system- Ability of CBS to provide SONU services- Presence of community structures- Intervention area of technical and financial partners and strengthening SONU community activities- For the control sites: Communes with the same socio-demographic criteria and infrastructure as the

intervention sites

V. 4. STUDY LENGTH

- The study lasted 18 months- Period of collection data for the study: from October 2009 to March 2011.

V.5. STUDY POPULATION

- Community Health Volunteers- Women and members of their families, including men- Members of the Social Development Committees (SDC) and local authorities (mayors, heads of the

fokontany, etc.) in the KM salama communes.

- CHU, CHD, and CSB service providers.


10/42



V.6. STUDY ACTIVITIES

The proposed study entailed six principal types of activities

1. Preparation PhaseThe study preparation consisted primarily of courtesy visits to the administrative authorities,

decentralized services of the region, medical districts, and communes.

These visits are conducted in order to inform them of the study that would be conducted in their locality

and obtain their engagement. This phase facilitate the implementation of the studys activities. During

these visits, regional health directors, heads of SSDs, heads of the CSBs and mayors of the communes

were approached.

2. Investigators TrainingA training of investigators took place in December 2009 in order to conduct a survey at the CSB level to

gather basic data and create an inventory of the ONE services offered at health facilities. The collection

of these base figures was completed after the preparation for the study and the collection of CSB service

data.

The training was based on filling out survey cards, focus group management, and note-taking. The

trainees were also given important notes on the study protocol.

3. Data CollectionInterviews of the health providers in the intervention zones and control zones

In order to collect data on the performance of health facilities in ONE, a basic survey was conducted

with the service providers within the health facilities at all levels within both of the intervention zones

and the control zones: CSB1 and CSB2 at commune level, CHD at district level, and Mahajangas

CHU/CME. The analysis of this information helped identify the strengths and weaknesses of each

intervention zone in terms of ONE.

Document review

The first purpose of the document review was to simply update the statistics of obstetric and

neonatal complications and maternal deaths, and to comment on the community reactions vis--vis

for obstetric and neonatal emergency systems.

Next, it was necessary to review the registers of hospitals, CSB, and CHD, looking specifically at

obstetric and neonatal services. A similar analysis was conducted with the CHVs on the response of

the population to obstetrical and neonatal emergencies.

The data before and after the intervention was compared in order to document any changes; the

same data was collected again during the final evaluation, using the same data collection tools as that

of the initial survey, in order to measure the change in the functionality level of ONE services offered.

Confirmation of Data Conformity


11/42



Follow-up and support sessions took place four times a year with the SDC and the CHVs in the KMs

communes (Groups 1 and 2). In these sessions, the support technicians worked with community

actors in the application of a C-ONE system and checked the impact of this system on the community

in general. Any problems encountered and their solutions were discussed.

4. Data Processing and AnalysisProcessing

The focus groups and various interviews were recorded with the help of a dictaphone, and the discussions

were transcribed and translated into French. The discussion group transcriptions were processed

manually, sentence by sentence and question by question, in order to extract all the ideas discussed and

to examine each objective of the study.

Analysis

Analysis were conducted in order to determine the results and to highlight recommendations for a

suitable strategy in the future.

- Analysis of results by group type. This analysis was conducted to see the similarities orconvergences and differences between each player and category considered.

- Analysis of the structured interview data.5. Final ReportThe final report identifies the gaps between the planned activities and the actual implementation during

the study. The preliminary results were discussed with the principal stakeholders. The participants

analyzed to what extend the studys hypotheses and expected results were confirmed. The participants

also identified supplemental analysis needed to better explain the results vis--vis the hypotheses.

The primary conclusions and recommendations for future implementation have been reproduced anddisseminated. The final report is in a format to be shared with other organizations and partners of the

public and private sector interested in using the same model in their intervention zones. It helps inform

and guide the Ministry of Health in the application of the lessons learned and results obtained from the

implementation of this model.

V.7. PRINCIPLE STAGES OF THE STUDY

1. CHVs Capacity building1.1.Training

Profile of the trainersThe trainer pool was composed of supervisors, support technicians, and medical personnel. The

majority held a high school diploma minimally. Doctors and midwives had further education.

Length of the trainingo Duration: 2 dayso Participants: CHVso Number of CHV trained: 126 (50 in Mahajanga II and 70 in Marovoay)


12/42



Training contentThe training focused largely on:

- Research on pregnant women in the villages- Importance of ANC and the general plan for childbirth, especially in regard to:

the existence of solidarity funds and community-based means of transportation

the definition of childbirth

the advantages of childbirth at a health center

the recognition of danger signs in pregnant women and newborns

the importance of safe motherhood, care, and early follow-ups

- Measures to be taken in case of emergency by all actors involved and their respective roles, how topromote public awareness in target groups, negotiation, group discussion using brochures and

booklet, and the procedures for using the health management information system (HMIS).

1.2.Supervision System of supervision

The supervision of the CHVs activities was carried out through different levels and by multiple people

who each had their own specific roles, according to the following diagram:

Figure 1: Supervision system

RTI/Santenet2

Supervisor NGO

Supporttechnician

CSB/CDS

CHVs

Independenttrainers

NGO


13/42



This diagram shows the supervision of the CHVs by the SDC and officials from the CSB and SSD, and the

NGOs support technician. This support technician is supervised in turn by the NGOs supervisor. The

independent trainers supervise the CHVs during trainings (twice each year). All is overseen by the heads

of the project at the NGO (ZETRA) and by RTI/Santnet2.

The respective roles of the different actors in the system of supervision is described in Annexe 1

2. Support of the organization of community emergencyevacuation system (community solidarity funds and

means of transportation).

To evaluate the CHW and SDC activities in relation to the action

plans, and to evaluate the implication of the community in

response to ONE, follow-up activities were done during the

monthly reviews in order to reinforce the capacity of both CHVs

and SDC to work with their communities to resolve problems

linked to referral systems and solidarity funds.

Photo1 : modle de moyen de transport (pirogue), Betsako

3. Final evaluationFollowing the investigator training, surveys were conducted with structured interviews with the persons

in charge of childbirth in the communes of the study (27 health professional trainings) and also AT the

CHU/CME Mahajanga, CHD2 Marovoay, and CHD 1 Ambato-Boeny in order to find indicators of services.

Focus groups were also carried out.

Focus groups40 focus groups in 10 communes are performed. The table below illustrates the focus group

participants:

Table 2: Focus Groups

Group participants Number Involved

CHVs 90

SDC Members 80

Pregnant Women 56

Group of Men 56

Extended interviews with those in charge of childbirthMeetings took place directly with each selected individual and the investigators. A total of 27 structured

interviews took place in the studys communes.


14/42



Stretchers are very difficult to accept

for the majority of the population.

Theyre meant for the dead

(CHV, 40 years old, primary school educated,

Antanambao Andranolava, Marovoay).

Register consultationsThe registers of consultations in 27 communes in the three districts of intervention were consulted to

see the results for the indicators related to pregnant women and newborns. Registers of consultations

at the CHD2 of Mahajanga II, the CHD1 of Ambato Boeny and the CME of the CHU Mahajanga were also

consulted.

VI- LIMITATIONS OF THE STUDY1- Constraints during the execution of the study

o Security problems on the ground produced a negative impact on the ease and thepsychological state of the research team conducting the interviews, and also required

obligatory regrouping of the team and drastic security measures, like finding a guide and

using a public school for lodging.

o The problem of inaccessibility in certain intervention zones with breaks over days of workclearly had an influence on the planning of the study. Consequently, it was decided that the

communes Mariarano and Bekobay (both within the Mahajanga 2 district) needed to be

removed from the list of communes to be used in the study.

2- Incompatibility of the methods with local habits and customsUsing a stretcher carried on the soldier of two individuals is not compatible with the local habits and

customs. People consider stretchers to be reserved for the dead. A majority of the communities,

therefore, need better transportation system.

This implies that there is still a need to educate

and work with certain communities on their

evacuation systems.

3- Difficulties in solidarity fundimplementation

For certain communesabout 3 out of 10the

communities had trouble implementing solidarity

funds because of challenges finding people to place in charge of the management of funds, a pre-

existing lack of trust relating to the management of public funds, and the challenging of fixing the

contribution amount to be given by the community.

4- Measuring improvementOne limitation in this study is in improvement measurements. The measurements are dependent on the

number of complications that occur. Variations in the number of complications from one year to

another or from one zone to another could skew the results. Because it is impossible to control the


15/42



CHV PROFILE

Male 44%

Female 56%

Years in school 7

Median age 40 years

Single 17%

In union 83%

number of complications, it is helpful to use other aspects of the study when analyzing the results, such

as interviews and focus groups. For instance, even if a commune has few complications, the impact of

the study can still be determined by examining the ability of CHVs and pregnant women to recognize the

danger signs presented by pregnant women and newborns. In the future, the impact of this limitation

could be reduced by increasing the number of communes being studied.

VII- RESULTSVI.1. CAPACITY BUILDING OF THE ACTORS

1. Profile of the Community HealthVolunteers

In general, all of the CHVs had already worked in the health

domain, including maternal and child health. Some CHVs

did mosquito net public awareness, community care for

illnesses in children under 5 years of age, hygiene, prenatal

consultations, STIs and HIV/AIDS work, and worked with

pregnant women and the PCIME-C.

2. Community health volunteers competency: Recognition by CHVs of Pregnant woman andnewborn danger signs

86% of CHV recognized pregnant women danger signs and 94% the newborn danger signs.

CHV immediately recognize seven pregnant women danger signs out of 12 (58%). These symptoms are:

Pale or icteric mucous membranes, Cuts and wounds, Intense pain in the lower belly and back, Fever,

Hemorrhage, Uncotrollable vomiting and Convulsions.

They did not recognize failure to gain weight and vaginal discharges as pregnant women danger signs.

About knowledge of CHVs concerning the newborn danger signs, they immediately recognized the

majority of danger signs presented in newborns but needed help identifying one sign: redness or

swelling at the base of the umbilical cord.


16/42



Figure 2: Recognition by CHVs on the danger signs presented by pregnant women.

0%

20%

40%

60%

80%

100%

120%

Recognition by CHVs on the danger signs

presented by pregnant women

Spontaneous response

YES

Assited response

YES

Did not know


17/42



Figure 3: Recognition by CHVs on the danger signs presented by pregnant women.

3. SUPERVISION

The quantitative survey of CHVs revealed the participation of public and private entities in the system of

supervision. The following table summarizes the percentage of CHVs according to the entities which

supervise their activities.

Table 3: Entities overseeing supervision

Person in charge of supervision Number of CHV with

positive response

%

NGO personnel 60 87.3

Health personnel 27 12.5

Comit de Dveloppement Social

(Kaominina Mendrika)3 2

None 1 0.9

87.3% of the CHVs affirmed that supervision is assured by NGO personnel, at namely that of ZETRA.

This organization has a widespread structure in the communities for the implementation of the project.

43.5% of the CHVs spoke of the participation of the health personnel in the system of supervision.

94%83%

97%83%

50%

89%

3% 6% 3% 6%

39%

8%2%11%

0%11% 11% 3%

0%20%40%60%80%100%

120%

Refusal to

breastfeed

Lethargic Hyperthermia

or hypothermia

Difficulty

breathing

Redness or

swelling at the

base of the

umbilical cord

Vomiting

Recognition by CHWs of the danger signs

presented in newborns.


YES

Assited response

YES

Did not know


18/42



V.2. SUPPORT OF THE ORGANIZATION OF COMMUNITY EMERGENCY EVACUATION SYSTEM (community

solidarity funds and means of transportation).

1. Communication Means for Discussing Community-Based Obstetric and NeonatalEmergency Care

Community gatherings provide opportunities to spread C-ONE messages. 66.7% of the CHVs used them

to communicate the presence of this project. The advantage in this approach is that the presence ofcommunity leaders validates the legitimacy of the message. 12.4% of the CHVs were interested in

speaking AT festivities; however fairs and festivals offer few opportunities for CHVs to speak. Only 6.7%

of the CHVs took advantage of religious gatherings to speak on the importance of C-ONE. Using posters

was only possible when other organizations (cultural, social, health, etc.) were also being displayed.

2. Materials Used for Public Education91% of CHVs used a technical poster relating to mothers and newborns. The CHVs also used other

materials for additional support, like mother-child pamphlets.

Tableau 4: Transportation system

DISTRICT COMMUNE Number of

fokontany with

transportation

system

Number total of

fokontany

TYPE

Mahajanga 2 Belobaka 9 9

- Car

- Taxi-brousse

- Charette

- Stretcher

Boanamary 4 4

Betsako 4 4

Ambalakida 4 4

Marovoay Ambolomoty 7 7

marovoay banlieu 2 2Marosakoa 9 9

Ankazomborona 9 9

Tsararano 5 5

Antanambao

Andranolava

7 7

TOTAL 60 60


19/42



Tableau 5: Solidarity funds

District Commune Fokontany Type Operating

adhesion

Number of

Membership

Mahajanga 2 Belobaka 8 Monthly

subscription

Women older

than 18 years

Not available

Boanamary 3 Monthly

subscription

(Ar 300)

Women older

than 18 years

Not available

Betsako 3 Monthly

subscription

Women older

than 18 years

Not available

Marovoay Ambolomoty 7 Monthly

subscription

(Ar 200)

Women older

than 18 years

180 persons

Marovoay

banlieu

2 Monthly

subscription

Women older

than 18 years

95 persons

Marosakoa 8 Monthly

subscription

Per household 44 households

TOTAL 31

All the fokontany included in the study have established a transportation system for ensuring pregnant

women reference in case of emergency.

However, only half of them have constituted a solidarity fund at the end of the study.

Figure 4: Transportation system and solidarity funds implementing in the study zone

100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

89% 75% 75%0%

100% 100% 89%

0% 0% 0%0%

20%40%60%80%

100%120%

Transportation system and solidarity funds

implementing in the study zone in 2010

% of fokontany with transportation system % of fokontany with solidarity funds


20/42



The mothers will no longer have

difficulty coming to the CSB 2

(Head of fokontany, Andakalaka,

Marovoay Banlieu, 61 years old) If the mothers are in good health, the children

can all go to school, and in that way we will

overcome illiteracy

(Mayor, Ambalakida, 44 years old)

The presence of communal funds in a locality allows the community not to worry about the population

in case of medical emergency, and it also reinforces the motivation and consolidates the organization of

the community.

The women who benefited (10 pregnant women) could not have survived if an evacuation system had

not existed in their locality.

The population in general found the presence of communal funds to be important, and requested

extension into other communities and targets.

V.3. QUALITATIVE RESULTS

Almost all of the actors involved,

including community leaders, CSB

leaders, and NGO officials, agree

that the application of C-ONE is

effective.

They think that the program

contributes fighting against

poverty and improving the family

economy.

A woman with no complication of

pregnancy due to the effect of

childbirth unprepared reduces

unforeseen expenses.

Photo2 : chantillon focus group des femmes enceintes (Marovoay Banlieue)

1. Benefits in relation to mother and child healthThe improvement of the health of mothers and newborns is a

major advantage according to the mayors interviewed. This is

because of better health and a removal of fears related to giving

birth at the CSB.

The reduction of infant mortality was also

evoked, due to an improvement in child

education.

Indeed, according to community officials, the populations good health would become a pillar for fast

development and for the durability of the commune.


21/42



We (pregnant women) organized a trip

to the CSB with the CHVs every

Wednesday for prenatal consultations

right up until childbirth like in the case of

our friends

(Pregnant woman, 31 years old, secondary

school educated, Vololona, Ambalakido,

Mahajanga 2).

At the hospital, there are too many

people, and its difficult to really

understand explanations. At home

its calm and quiet and you can

really listen well

(Pregnant woman, 26 years old, primary

school educated, Ankazomborona).

Its good because these are peoplecoming from the society

(Head of fokontany, 48 years old,

Ankazomenavony, Belobaka)

If everyone can work, poverty will

be reduced. The commune will have

financial autonomy and that would

automatically involve development

(Man, 44 years old, Betsako)

2. Perception of CHVs PublicEducation Work

The majority of pregnant women, men, and SDC

members generally approved of the importance of

the messages given by the CHVs after their training.

- Easy access to health informationThere are numerous advantages to collaborating

with CHVs. According to the majority of the studys

targets, CHVs were able to work with individuals and

educate the public in their homes. House calls also created an occasion for detailed explanation,

eliminated group influence on individual decisions, and ensured confidentiality to the discussion.

According to health officials, better access to health information

gives women more opportunities to get exposed to the

information, and increases the rate of external consultations.

- Friendly relationsCHVs are people coming from the society itself, so they are familiar

with the population. This familiarity with the population allows for

friendly and confidential relations, and thus there is no obstacle

between the CHVs and the targets during the public education and

the explanations of the messages.

At home we can ask all the questions that

worry us

(Pregnant woman, 28 years old, secondary school

educated, Boanamary).


22/42



We are convinced of the importance

of early care for pregnant women and

prenatal consultations and the

recognition of danger signs as well as

the importance of implementation of

transportation system for evacuations

after a story shared by the CHVs after

training, the story of [Rabary andMartine]

(Letozy, PW, 29 years old, secondary school

educated, Antanambao Andranolava).

The public education from the CHVs

was well received by the community.

When its a woman, she is considered

a midwife, and when its a man, he is

taken for a doctor; whatever they say

is taken seriously

(Doctor, Ambolomoty).

Its good to use CHVs; because they

were trained well, they can educate

well

(Head of fokontany, 43 years old,

Beronono, Marosakoa).

What the CHVs do is goodtheyre different from midwives,

they explain a lot of things, they do meetings and house calls, the

midwives are far away

(Pregnant woman, 18 years old, secondary school education,

Manerinerina).

3. Successful public education and CHV credibilityWhile the CHVs are from the community itself, they are also

capable, because they have received the training necessarily to

educate the public and answer any questions the targets might

ask. They are credible, according to all of the pregnant women

and the SDC and the majority of technicians, the CHVs were even

considered essentially health personnel.

4. Persuasiveness of the CHVsDuring focus groups, the majority of participants

spoke well of the persuasiveness of the CHVs.

Other ideas related to the CHVs also came out of this

study, including the following:

- The majority of focus group participants (92%)mentioned the effectiveness of public awareness

for large groups of the community.

- A minority of participants also mentioned theimportance of the presence of the CHVs in the

community. Their presence helps create a sense of

security.

5. Proximity to servicesBecause the CHVs come

from the communities,

they live in the same

villages as the targets.Therefore, the targets do

not need to travel to

learn more about healthy

pregnancies. This is

especially true because

the distance separating certain villages from health centers can be dozens of kilometers, while the only

means of transportation can rely largely on traveling by foot or by oxcart.


23/42



The presence of CHVs would be a solution to problems affecting more isolated regions.

6. Pregnant women competencyThe percentage of pregnant women knowing pregnant women danger signs and the newborn danger

signs is the same (77%).

They immediately recognized half of pregnant women danger signs: cuts and wounds, intense

headaches, uncontrollable vomiting, intense pain, fever and hemorrhage.They did not mainly recognize 2 danger signs: failure to gain weight and pale or icteric mucous

membranes.

About knowledge of CHVs concerning the newborn danger signs, they immediately recognized the half

of newborn danger signs: lethargic, vomiting, and hyperthermia or hypothermia.

CHV did not recognize the refusal to breastfeed as a danger sign in newborns.

Figure 5: Recognition of danger signs by pregnant women.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Recognition of danger signs by pregnant women.


YES

Assited response

YES

Did not know


24/42



Figure 6: Recognition by pregnant women of danger signs presented by newborns

V.4. REGISTER INDICATORS OF SERVICE UTILIZATION

1. General ServicesThe results of indicators are much higher in areas implementing KM salama with or without

implementation of the activity UON-C. But this is much more visible in the group implementing KM

salama and UON-c

Table 6: Evolution of indicators in the three groups

Group1: C-ONE and KMs (10communes)

Indicators 2009 2010 Variations

1stANC 2,869 2,860 -0.3%

2 or more ANC 3,448 3,498 1.5%

ANC Total (4ANC) 3,162 3,270 3.4%

VAT2 or more 2,875 2,475 -13.9%

IPT1 2,676 2,793 4.4%IPT2 2,585 2,629 1.7%

PregnantWomen(PW)who took IFA 2,753 3,107 12.9%

Childbirth 2,673 2,600 -2.7%

32%

73%

63%

29%

20%

68%

25%

9%

23%

45%

63%

13%

43%

18%14%

27%

18% 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Refusal to

breastfeed

Lethargic Hyperthermia

or hypothermia

Difficulty

breathing

Redness or

swelling at the

base of the

umbilical cord

Vomiting

Recognition by pregnant women of danger

signs presented by newborns


YES

Assited response

YES

Did not know


25/42



Group2 : KMs not C-ONE (7communes)

Indicators Before KMS

(2009)

During KMS Variations

1stANC 4,073 3,972 -2.5%

2 or more ANC

5,000 5,059

1.2%

ANC Total (4ANC)5,845 5,934

1.5%

VAT2 or more

4,825 4,382

-9.2%

IPT1

3,511 3,604

2.6%

IPT2

3,228 3,275

1.5%

PregnantWomen(PW)who

took IFA 4,812 4,249

-11.7%

Childbirth

3,432 3,268

-4.8%

Group3 : Not C-ONE and not KMS (9COMMUNES)

Indicators 2009 2010 Variations

1stANC 1,245 741 -40.5%

2 or more ANC 1,786 1,498 -16.1%

ANC Total (4ANC) 308 287 -6.8%

VAT2 or more 964 658 -31.7%

IPT1 1,241 860 -30.7%IPT2 328 406 23.8%

PregnantWomen(PW)who

took IFA

717 457 -36.3%

Childbirth 456 293 -35.7%


26/42



Figure 7: Evolution of indicators at CSB level in the 3 groups

2,869

3,448

3,162

2,8752,676

2,5852,753 2,673

2,860

3,4983,270

2,4752,793 2,629

3,107

2,600

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

1st ANC 2 or moreANC

ANC Total(4 ANC)

VAT2 etplus

IPT 1 IPT 2 PregnantWomen

(PW) who

took IFA

Childbirth

2009 2010

Evolution of indicators in Group 1

4,073

5,000

5,845

4,825

3,5113,228

4,812

3,432

3,972

5,0595,934

4,3823,604 3,275

4,249

3,268

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1st ANC 2 or more

ANC

ANC Total

(4 ANC)

VAT2 et

plus

IPT 1 IPT 2 Pregnant

Women

(PW) who

took IFA

Childbirth

Before KMS 2009 During KMS

Evolution of indicators in group 2


27/42



2. Referred Cases, Solidarity Funds, and Transportation SystemsIn 2010, there are few solidarity funds set up in the communes and the health evacuation system established are

under used by communities

Table 7: Comparison of referred cases, solidarity funds and transportation systems in 2009 and 2010

Pregnant womenreferred presented

danger signs

Newborn referredpresented danger

signs

# of solidarityfunds

implementing

# of cases using thetransportation

system

implementing

2009 2010 2009 2010 2009 2010 2009 2010

Groupe 1 69 74 2 2 0 6 0 9

Groupe 2 105 107 65 33 0 1 0 0

Groupe 3 18 13 0 0 0 0 0 0

The results of the study show that:

- In 2010, 6 out of 10 communes have implemented solidarity funds in group 1, but the use of thetransportation system implemented is still low compared to referrals.

- In group 2: referred cases are much higher than in the other 2 groups, but only one commune hasconstitutes a solidarity funds. None referred case has uses the transportation system implemented.

- In group 3: no solidarity fund and no evacuation system were established.

1,245

1,786

308

964

1,241

328

717

456

741

1,498

287

658

860

406457

293

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1st ANC 2 or more

ANC

ANC Total

(4 ANC)

VAT2 et

plus

IPT 1 IPT 2 Pregnant

Women

(PW) who

took IFA

Childbirth

2009 2010

Evolution of indicators in Group 3


28/42



VIII- DISCUSSIONVIII.1. RECOGNITION OF DANGER SIGNS AND REFERRALS

It was noted during the study that it can be effective to have CHVs educate the public in pairs. But most

importantly, it was noted that the effectiveness of the awareness raising was not dependent on the

gender or CHW type (Mother CHVs or Child CHVs); during the interviews it was clear that all

communication channels can be used to good effect, like home visits, mass public education, technical

posters distributed by the CDS, and periodic meetings with the CDS.

The majority of the CHVs (86%) and more than two thirds of pregnant women (77%) were able to

recognize the danger signs presented by pregnant women and newborns. This result demonstrates the

competence of AC to transmit the messages to the targeted population. Note that almost half of the

pregnant women have very minimal education.

That being said, there are still gaps in the recognition of the danger signs presented in pregnant women.

23% of pregnant women interviewed did not recognize women pregnancy and newborn danger signs.

This may be due in part to the lack of tools in the possession of pregnant women, mothers and

caregivers. Without tools as a memory aid, they have difficulty in retaining messages.

VII.2. COMPARISONS OF THE INDICATOR CHANGES BETWEEN 2009 AND 2010

1- Group 1 : communes implementing KM salama and C-ONE approach Compared to the previous year, the number of pregnant women monitored during their first ANC, those

having received VAT2 injection and those having delivered at CSB were reduced for the 3 groups (focus

groups and witness group) during 2010. But this variation is a lot lower in the communes implementing

KMsalama and community-based ONE at the same time.

This situation is linked to the positive results on awareness activities conducted by CHV and to the mothersbelief on the importance of early management of maternal and new born health.

It is notable that following repeated awareness efforts by the CHVs, prenatal consultations took

places earlier, more pregnant women took IFA, and more women were able to give birth at the CSB.

For certain communes, the community decided to construct a hut to lodge the families of the

pregnant women in order to reduce the costs and increase the motivation to give birth at a medical

center and stay for two days.

Following the sensitization by the CHVs and supported by the community distribution of IFA in 2 communes(Belobaka and Boanamary), an increase of 13% was detected in women taking IFA compared to the previous

year (2009).

2- Group 2 : communes implementing KM salama approach


29/42



Public education is very important

in our community but I work alone.

I am in charge of both the CSB and

childbirth. The population is too big

for only one person in charge of

health; therefore we request the

presence of community health

volunteers to help us(Chief of the

CSB2 Manaratsandry, Marovoay).

These results are more or like similar to group 1. The number of pregnant women coming to CSB for

their first ANC was reduced during 2010 (3% of reduction) compared to the number of ANC 2 and the

number of total ANC has increased to 1% for ANC2 and 2% for total ANC.

Also, the number of women having delivered at CSB have decreased by 5% compared to results in 2009.

For childbirth it was noted that in certain communes, in particular the commune Manerinerina,

pregnant women were not amply convinced of the importance of giving birth at a medical center. This

situation can be explained by two possibilities:

- The CHVs, for fear of disturbing local practices, did not amply educate the pregnant women on goingto medical centers for childbirth. In these cases, it is necessary to educate not only the pregnant

women, but also the community in generalin particular the parents or officials who have authority

in rural zones.

- There was not enough education, or the means or methods used by the CHVs for public educationwere not effective enough.

3- Group 3 : communes not KM salama and not implementing C-ONE activitesAll indicators linked to ANC and delivery have decreased. 41% of

ANC1, 16% for ANC 2 and more, 7% for total ANC and 36% for

delivery . This could be explained by the lack of public education and

community mobilizations in these communes.

Reduction of results is due to the furthermost of health centers and

the impact of political crisis.

VII.3. IMPLEMENTATION OF SOLIDARITY FUNDS AND EVACUATION SYSTEMS

1. For communes with C-ONE and KMs (Group 1)Case 1: Existence of solidarity funds and existence of transportation system (car, dugout canoe, or others

depending on the particular village)

In this case, communes, more specifically seven communes (see Table 4),set up solidarity funds, and in

the event of an emergency had transportation system available for the population, like a car or a dugout

canoe. Following ONE education from the CHVs and SDC, these seven communes each established an

ONE action plan for their respective communities. Provisions for the solidarity funds and transportation

system were taken during the community meeting (fivoriam-pokonolona.)

For the solidarity funds, the members were mostly female. These female members were older than 18

years, and decided themselves the amount of the contribution to pay. The cost varied from one

community to another, but was generally between 200 and 300 Ariary per person per month.


30/42



Among the members were health and CDS officials who ensured the maintenance of the funds along

with the other members. Generally speaking, members seemed convinced of the importance of the

existence of evacuation systems to medical centers, and actively participated in the contribution. That

being said, public awareness is always necessary in certain localities.

Transportation systems were generally managed by men. Certain men even proposed carrying the

women by a stretcher on the shoulders of two men. Other localities relied instead on cars and dugout

canoes. These cars and dugout canoes were offered by different individuals of the village who, thanks

to a spirit of solidarity, were willing to contribute to the cause.

The fuel was taken care of by the members and was paid for with money from the solidarity funds.

Case 2: Use of transportation system but not communal funds.

In this second case, the action plan put in place by communities did not necessarily require the existence

of communal funds. Transportation system in case of emergency, however, did exist. Essentially, in

communes like the rural Ambalakida, before the implementation of the C-ONE project, there already

existed transportation system like oxcarts or cars that individuals volunteered to be used by the

population in case of emergency.

This was also the case for the commune Ankazomborona, where there were no communal funds, but

thanks to public awareness sessions with transportation cooperatives in the locality, the cooperatives

accepted to makes their car available in case of emergency.

In this second case, a couple of problems exist. First, the cost of the fuel, which would generally be paid

by the person wanting to use the car. And second, the car or oxcart could be unavailable AT times when

needed.

Case 3: Integration of the system already in place.

Using transportation system from an ex-Angap project in the commune Marosakoa, the car from the

park is always available for the community when needed, and especially during emergencies. In this

commune there is an association for protecting the environment in the national park Ankarafantsika,

and the majority of the population over 18 years of age are members. After a meeting on C-ONE, the

people decided to increase normal contributions in order to really prepare for obstetric and neonatal

emergencies. In other parts of the commune which are not accessible by car, transportation system like

oxcarts was already in place.

In all, it was found that among the ten communes focused on with UON-C in the study, seven have put

communal fund systems in place that are already functioning, overseeing 54 communities throughout

the intervention communes. 54 out of 65 communities (or 83%) have an evacuation system in place. 74

different cases of obstetric complications were referred by the CHVs. Of the 74 referrals to the CSB2, 10

pregnant women (or 13.5%) were transferred there using a system that was put in place through this

study.

2. FOR COMMUNES WITH KMS BUT NOT C-ONE (GROUP 2)


31/42



We needanimators like in other communes to help us, because, considering the lack of

personnel, we have difficulty accomplishing our work, especially since our district is very vast.

The populations are accustomed to giving birth with the matriarchs. Moreover, people here

dont want the person in charge of childbirth to a man, which I am, which explains the

progressive decrease in numbers of women who get prenatal consultations and the number

of women giving birth

(Childbirth official, Ambalabe Befanjava, Mahajanga 2).

In the 7 communes included in this group, the commune of Andranofasika district of Ambato Boeny is

the only one that could set up solidarity fund. No transport system for emergency evacuation has been

set up in these communes.

In general, for the seven communes that received KMs intervention in the study but not C-ONE, the

prenatal consultations and the IPT 1 and 2 increased progressively. Childbirths decreased similarly

women taking IFA at the CSB decreased due to stock shortages of IFA coming from the SSD in Ambato-

Boeny.

According to an in-depth survey, in all of the KMs communes, the number of pregnant women and

mothers going to the CSB increased. This can be explained by the positive impact of the public

education.

3. Communes with neither KMs nor C-ONE (Group 3)In the 6 communes included in this group, noone of them could set up even one solidarity fund nor a

transport system for emergency system.

De mme comme spcifi plus haut, la plupart des indicateurs lis la CPN et laccouchement ontaccus une baisse de 2009 a 2010. Ceci est du a linsuffisance de sensibilisations de la population.

In conclusion, results show positive effects of implemented activities in the KM salama communes. KM

salama. KM salama approach objective is to strenghten local actors skills in order to encourage them

taking care of their health.

Communitys engagement and different community actors to take care of their health is stronger in

communes implementing KM salama approach.

IX- RECOMMENDATIONS1. Reinforce community engagement in the implementation of a medical evacuation system.


32/42



2. Integrate the C-ONE training into the CHW training and make sure the supervisors integrate it intothe management of the CHVs. The implementation of the system needs to take into consideration:

a- Human resources (CHVs, CDS, pregnant women, transportation personnel, health personnel)b- Financial resources (communal funds)c- Material resources (stretchers, oxcarts, dugout canoes, cars, bush taxis)

3. Organize an appropriate evacuation system.4. Determine transportation systems when necessary.5.

Create communal funds larger than necessary, and take care of the eventual use of funds for healthtraining. In order to ensure the functionality of the system implementation:

a- Institutionalize the statutes to be set up.b- Support local responses as solutions to identified problems.c- Find local solutions for resource mobilization.

X- ATTITUDES TOWARD THE CONTINUATION OF THE PROGRAMAlmost all of the actors involved wanted to continue the C-ONE program.

1. COMPATABILITY OF THE PROGRAMTable 17: Percentage of C-ONE reception

PERCEPTION OF THE COMMUNITY# %

VERY RECEPTIVE 31 30

RECEPTIVE 52 58

NOT RECEPTIVE 22 12

Total 90 100.0

This opinion could be connected to the effective education of those involved in the project.

2. PROXIMITY TO SERVICEAll of the arguments mentioned above relating to the proximity to services were reiterated by all the

players as a crucial motivation for the continuation of the program.

3. THE EFFECTIVENESS OF THE INTERVENTION OF THE CHVSAccording to those involved, measurements would need to be taken if the program were to continue.

According to the leaders of the CSB, the trainings would need to be amplified in content and frequency

to give the CHVs the capabilities necessary in the accomplishment of their responsibilities. Those in

charge of childbirth in each commune would also need to be trained in order to facilitate the follow-ups.

The CHVs need more technical support from the technicians and supervisors. According to the CHVs,

the administrative authorities like mayors and heads of fokontany need to be involved, not only for

signing documents, but also for taking part in the training and popularization of C-ONE.

A good communication and education campaign for all levels should go hand in hand with the

continuation of the program. Everyone involved agreed on the importance of the program but the


33/42



necessity of good education on the implementation of communal funds and transportation systems for

each commune. To do this, the CHVs could use house calls, public meetings, and media.

XI- SCALING C-ONE PROGRAMThe promising results from the study enable the project to scale up C-ONE programme in the other

project intervention communes. The objective is to reduce maternal and child mortality rate.

CHV are trained with community integrated service packages to ensure maternal and child care. Their

trainings started in July 2010 at the region level, after the broadcast of evaluation study results on

community response to C-ONE.

The project has trained CHV at first on early detection of pregnancy enabling referral of pregnant

women to CSB for early antenatal care. Pregnant women were informed on all packages of services

offered to motivate them to come at least four times before prior to delivery for a better preparation to

maternity. IFA uptake advantages during 180 day were also shared and instructed to CHV who are

raising awareness on IFA uptake by pregnant women to reduce anemia among pregnant woman and

improve her nutritional status. Danger signs and referrals of emergency cases were instructed to CHV

awareness raising was made to community to recognize them and the impact of the delay as well as the

importance of setting up means of transport and solidarity funds to an immediate evacuation.

CCDS members were then trained on NEO and on community mobilization for manage all cases.

Community meetings enable setting up of community action plans on setting up evacuation health

systems at the community level and organization and management of the systems. Community was

mobilized on solidarity fund according to the established needs, status and management returning to

community decisions.

La mise en place de ces plans pour les urgences a convaincu la famille, la communaut car elles ont

connu et compris limportance dune prise en charge temps, dune prparation aux ventuellesdpenses pour la maternit, dune rduction des risques lis aux urgences.

RESULTS

I- COMMUNITY EMERGENCY EVACUATION SYSTEM (Transportation system and solidarity funds)Up to now, around 99% of communes (792 communes) are known to have set up community evacuation

systems. 6,388 fokontany have their functional system. To date, 7,812 people have benefited from the

evacuation systems, including 3,471 pregnant women and 1,272 newborns In addition, 3,069 other

people benefitted from an evacuation system.

Even if the Malagasy culture puts in priority help in front of hardships, setting up systems was done with

a high commitment among community because of their knowledge and their understanding of the

importance of the evacuation systems and the impacts of any delay to make decision, impacts of

evacuation delay and lack of any plan to resolve financial difficulties for emergency cases.


34/42



In almost all the communities, system was set up with a solid organization, without any issue on lack of

time or unnecessary resources. Humanitarian assistance is almost volunteer; a rotation system is

systematic to accompany sick people in need.

Set up funds help to resolve families worries to different medical costs, transport costs and assistance

during stay in hospitals. There is almost no refusal for any emergency need because everyone thinks

that this could happen to any other family.

There are some cases where community is aware that if the evacuation system is not established,

charges related to the accompanying families can surely overlap those necessary to the patient medical

costs. That is why their commitment to put in place a very effective system with rotation so that all

people accompanying patients are efficient and reliable to all evacuation needs.

Even in any system like the filanjana, the boat or the shaw, community always recognize that these

systems are a great need for them, and this is the timeliness acknowledgment of emergency cases and

the decision making on time that can resolve their helpless situations. Established solidarity funds are of

great help to any desesperate cases and reduce worries or refusals to join specialized centers.

Community identified systems remain strong and benefit a strict follow up because CHV and CCDS

members are more and more convincing and their awareness raising is seen as undeniable truth. Few

CHV reach to accompany women to CB or hospital, which is really encouraging families and facilitate theevacuation. CCDS members role is to follow up communities established systems and assist for their

application.


35/42

Region Number of

CHVs

trained

Total number

of communes

Number of

communes

with Health

emergency

system

Total number

of fokontany

Number of

fokontany with

Health

emergency

system

Number of

pregnant

women

referred using

transportation

system

Number of

newborns

referred using

transportation

system

Number of

other persons

referred using

transportation

system

LAOTRA MANGORO 436 55 37 291 0 0 0 0

MORON'I MANIA 493 44 17 127 91 27 4 63

NALAMANGA 497 33 11 229 178 44 0 10

NALANJIROFO 868 51 13 402 355 157 111 339

NDROY 1,088 38 29 299 77 49 0 7

NOSY 417 51 42 290 77 14 1 26

TSIMO ANDREFANA 1,001 78 4 229 82 49 32 81

TSIMO ATSINANANA 461 41 29 125 108 44 11 44

TSINANANA 819 69 29 92 82 21 16 49

OENY 294 18 18 106 93 52 12 55

AUTE MATSIATRA 1,533 84 34 260 169 44 18 51

HOROMBE 229 23 0 147 0 0 0 0

TASY 286 20 5 45 45 13 0 27

AVA 676 45 20 308 220 55 43 102

AKINANKARATRA 807 70 68 498 162 104 12 38

ATOVAVY

TOVINANY

1,092 80 40 240 212 144 55 211

TOTAL 10,997 800 396 3,688 1,951 817 315 1,103

Source : Social Quality Reports, February 2013


36/42

II. SERVICE UTILIZATION

II.1 Results of communes Group 1 (implementing KM salama and ONE)

Awareness raising activities and referral conducted by community health volunteers contribute to the

increase of ANC services and delivery at CSB.

This frequency was reduced in 2012 both at the CHV level and CSB. This may be due to negative impact of

long lasting political crisis in Madagascar.

Tableau 9: Evolution of CHVs and CSB indicators (2010-2012) in the communes group 1

Indicators Year 2010 Year 2011 Year 2012

CHVs CSB CHVs CSB CHVs CSB

ANC referred 7,180 8,650 762 8,580 311 2,540

Childbirth referred 2,312 1,501 211 1,715 96 1,450

IFA referred 2,234 112 61

IFA managed 4,496 693 536

Pregnant women

referred for ITP

796 92 50

Pregnant women

with danger signs

referred

535 29

52

Awarenees raising

(Number of people)

890,922 9,360 6,103

The number of referred cases to CSB for ANC and delivery by CHV has increased from 2010 to 2011.Results show a decrease in 2012. However, results follow the same trend at the CSB level.


37/42



The table below shows evolution of cases referred by CHVs and the service utilization at CSB level in

2010 2012

Figure 8: ANC at CSB level and pregnant women referred by CHVs for ANC

Figure 9: Childbirth at CSB level and pregnant women referred by CHVs for childbirth

8,650 8,580

2,540

547 762 311

0

2,000

4,000

6,000

8,000

10,000

2010 2011 2012

ANC at CSB level and pregnant women

referred by CHV for ANC(2010 - 2012)

ANC at CSB level Pregnant women referred by CHV to CSB for ANC

1,5011,715

1,450

136 211 96

0

500

1,000

1,500

2,000

2010 2011 2012

Childbirth at CSB level and pregnant

women referred by CHVs for childbirth

(2010 - 2012)

Childbirth at CSB level Pregnant women referred by CHV to CSB for childbirth


38/42



The next figures show CHVs contribution in ANC and childbirth at CSB level

Figure 10: CHVS contribution in ANC

Figure 11: CHVS contribution in Childbirth

II.2 Results of other KM salama

Activities results on maternal and new born health in the other KM salama communes having set up the

program show a yearly reduction of the number of people going to CSB in terms of ANC and delivery

whereas CHV referrals increase.

The following table shows evolution of referrals conducted by CHV and CB use of services from 2010 to

2012.

8,650 8,580

2,5406%

9%

12%

0%

2%

4%

6%

8%

10%

12%

14%

0

2,000

4,000

6,000

8,000

10,000

2010 2011 2012

NumberofANC(CSB)

CHVs contribution in ANC

(2010 - 2012)

ANC at CSB level CHVs contribution

1,501

1,715

1,450

9%

12%

7%

0%

2%

4%

6%

8%

10%12%

14%

1,300

1,400

1,500

1,600

1,700

1,800

2010 2011 2012

CHVs contribution in Childbirth

(2010 - 2012)

Childbirth at CSB level CHVs contribution


39/42



Le tableau ci-dessous montre lvolution des rfrences effectues par les AC et lutilisation de services

des CSB de 2010 2012

Tableau 10: Evolution of CHVs and CSB indicators in other KM salama (2010-2012)

Indicators Year 2010 Year 2011 Year 2012

CHVs CSB CHVs CSB CHVs CSB

ANC referred 11,180 314,435 22,545 303,185 28,767 257,008

Childbirth referred 3,844 107,321 8,823 100,639 10,288 83,955

IFA referred 3,072 4,264 7,819

IFA managed 7,430 14,197 11,338

Pregnant women

referred for ITP

1,161 1,756 14,003

Pregnant women withdanger signs referred

784 991 827

Awarenees raising 1,341,931 1,756,820 1,225,499

Figure 12: ANC at CSB level and referred by CHVs in other KM salama

314,435 303,185257,008

11,180 22,545 28,767

0

100,000

200,000

300,000

400,000

2010 2011 2012

ANC at CSB level and pregnant women referred

by CHVs for ANC(2010 - 2012)

ANC at CSB level Pregnant women referred by CHV to CSB for ANC


40/42



Figure 13: Childbirth at CSB level and referred by CHVs in other KM salama

CHV contribution in terms of ANC and delivery, the rate increases progressively by year. For ANC,

this rate has doubled in 2 years (from 6% in 2010 to 12% in 2012). As for deliveries, the rate has raised

three times (from 4% in 2010 to 12% in 2012).

The following figures show the level of CHV contribution in terms of ANC and delivery at the CSB level

Figure 14 : CHVS contribution in ANC

107,321100,639

83,955

3,8448,823 10,288

0

20,000

40,000

60,000

80,000

100,000

120,000

2010 2011 2012

Childbirth at CSB level and pregnant

women referred by CHVs for childbirth

Childbirth at CSB level Pregnant women referred by CHV to CSB for childbirth

6%

9%

12%

0%

2%4%

6%

8%

10%

12%

14%

0

2,000

4,000

6,000

8,000

10,000

2010 2011 2012

NumberofANC(CSB)

Contribution of CHVs in ANC

(2010 - 2012)

ANC at CSB level CHVs contribution


41/42



Figure 15: CHVS contribution in Childbirth

XII- CONCLUSIONActivities conducted under the ONE program contributed to the increase of people going to the health

centers seeking for ANC and delivery services enable to have an impact on 2 determining factors of

maternal and child mortality which are late decision to seek for medical checkup and to evacuate.

CHV play also a key role in screening danger signs and population awareness raising for the use of

services.

More than 90% of CHV working in the 800 KM salama communes were trained. Results show a better

knowledge and understanding of mothers and families about danger signs among pregnant women and

new born.

CCDS members engagement is very important as community leaders. They play a very important role to:

- demand stimulation- quality improvement of health services at the CSB level and at the community level- community awareness raising to set up solidarity funds and means of transport to ensure health

evacuation.

Community based health services could not be sufficient unless they are connected to the formal health

system and get their support.

Community appropriation to the management of NEO is very important.

However, challenges need to be resolved in setting up means of transport and solidarity funds in all

fokontany and communes. Also, means of transport set up are still used in a very low level by the

community. Is the number of complication still limited or should we strengthen awareness raising

activities?

ANNEX 1: Respective roles of the different actors in the system of supervision

1- The roles of the CHVsCounting the pregnant women and newborns in the community.

4%

9%

12%

0%

5%

10%

15%

0

20,000

40,000

60,000

80,000

100,000120,000

2010 2011 2012

Contribution of CHVs in Childbirth

(2010 - 2012)

Childbirth at CSB level CHVs contribution


42/42

Sensitize pregnant women and their families to recognize the danger signs and risk factors in

order to ensure quick referrals to emergency obstetric and neonatal care at a medical

facility.

Sensitize pregnant women and their families to change their behavior in favor of safe

motherhood and to promote newborn-specific care (prenatal consultations, follow-up with

the prenatal care packet, childbirth at a hospital, immediate breast-feeding, assuring

thermal protection of the newborn, umbilical cord and skin hygiene, vaccination, post-natal

consultations, etc.).Teaching the community about implementing local transportation systems and solidarity or

communal funds in order to remove the first and second delays.

Public awareness on families adhering to the systems taught.

Perform home visits to follow-up with the pregnant women and newborns.

Filling management tools

Submitting a monthly report to the CSB according to the reports canevas.

Discussing with the SDCs and the NGOs support technicians, and the consultant when

problems.

2- The roles of the Comit de Dveloppement Social (CDS)The CDS members include: the mayor, the heads of the fokontany, COSAN representatives, the head

of CSB, and leaders of other local associations. The committee is a body used for coordination and

for follow-up on all health activities AT the commune level in the communities. Within the

framework of C-ONE, their roles include:

Facilitating the censuses of pregnant women and newborns in the communities.

Helping identify transportation systems.

Ensuring that C-ONE activities were included in the communes action plan.

Following up the action plan.

Ensuring the monitoring and supervision of the CHVs.

Following up on the solidarity funds and the implementation of evacuation systems tomedical centers.

3- The roles of the NGO support techniciansOrganizing and facilitating C-ONE trainings.

Supporting the SDC in the supervision of the CHVs: assisting and managing the CHVs in their

activities (home visits, checking the data collected in the motoring sheets of the pregnant

women and newborns).

Following up on the solidarity funds and the implementation of evacuation systems to

medical centers.

Supporting the CHVs in routing data to the SDC.

Collecting data from the CSB during monthly reviews.Compiling data within the CSB and forwarding the data centrally.

EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santénet2 – 2013)

Documents

Transcript of EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santénet2 – 2013)