Improving Family Panning Services Through Training and Capacity Building of Frontline Workers of Maternal and Newborn Health

Care Program in a Low-Resource Area of Rural Bangladesh

(Healthy Fertility Study)
Salahuddin Ahmed1 & 2, Jaime Mungia2, Saifuddin Ahmed1, Catharine McKaig2, Amnesty LeFevre1, Ahmed Al-Kabir3, Anne Pfitzer2 and Abdullah Baqui1 1Johns Hopkins School of Public Health; 2 Jhpiego; 3Shimantik

International Conference on Family Planning

ADDIS ABABA, ETHIOPIA November 14, 2013
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Background: Bangladesh and Sylhet Division

Selected FP indicators, Bangladesh and Sylhet, BDHS 2007 and 2011
BDHS 2007 Bangladesh Unmet FP need CPR (any method) 17% 56% Sylhet 26% 31% BDHS 2011 Bangladesh 14% 61% Sylhet 17% 45%

TFR
Birth Intervals <24 months <36 months

2.7

3.7

2.3

3.1

15% 37%

26% 57%

12% 32%
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19% 47%

Evolution of MNH Packages: Projahnmo, Bangladesh

Designed a community-based maternal and newborn care intervention package and evaluated the effectiveness of the package using a cluster randomized design A home care package which involved CHW antenatal and postnatal home visits and management of sick newborn reduced NMR by 34% (Baqui et al., Lancet, 2008)

Healthy Fertility Study: Integrated model of PPFP & MNH

Newborn care

Postpartum FP counseling and contraceptive distribution

Study Objectives
To design and develop integrated community-based PPFP and MNH program and evaluate the intervention package:
Feasibility and effectiveness-

exposure to key messages contraceptive prevalence, method mix at different postpartum points optimum birth interval adverse pregnancy outcome

Study Design
Study sites: eight unions in two sub-districts in Sylhet district, Bangladesh
Non-Random Allocation Intervention unions: four Enrolled women: 2247 Comparison unions: four Enrolled women: 2257

Enrollment of women during <8 months of pregnancy Intervention clusters: MNH plus FP during ANC and Postpartum visit Comparison clusters: MNH ONLY during ANC and Postpartum visit

Follow the cohort through pregnancy to 36 months postpartum

Intervention Delivery Strategy

1. Capacity strengthening:

Training Orientation

2. Community-based advocacy and behaviour change communication approach:

Household level through Community Health Workers (CHW) Community level through Community Mobilizers Facility level through Service Providers
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Community Health Workers (CHWs)

Young woman with grade 10 education from the local community Training received:
MNH: 21 days HTSP, PPFP &

LAM: 3 days FP methods including Injectables: 4 and 1/2 days

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CHW Counselling Topics and Timing

FP integrated with MNH program Additional

Messages
ANC Newborn Care, EBF Return to fertility LAM and transition, EBF HTSP FP methods Visit to facility

During pregnancy

Day 6 postpartum

Day 29-35 postpartum

Month 2-3 & 4-5 PP

Community and Facility Level Intervention Delivery Strategy

One male and one female Community Mobilizer for 20,000 population. Key activities of the Community Mobilizers include:

Conduct advocacy meetings with community leaders, religious leaders, teachers and their wives Facilitate targeted male/female group meetings Conduct one-to-one visits to develop role models on LAM

Male community meeting by CM; Photo credit: Salahuddin Ahmed

Key activities of GOB/NGO providers at the facility level include:

Provide postnatal care Counsel about PPFP methods including LAM Provide FP methods

Facility; Photo credit: Salahuddin Ahmed

Selected Baseline Characteristics of Participant Women by Study Arm

Intervention (n=2247) Comparison (n=2257) P-value

Womens age1
Womens education (in years of schooling)1 Husbands education1 Parity1

26.5 (24.9-28.1)
4.5 (4.0-5.0) 4.1(3.2-5.0) 2.2 (2.0-2.3) 2135 (95.0) 112 (5.0) 18.0%

26.6 (25.7-27.5)
4.1(3.4-4.8) 4.0 (3.0-5.0) 2.2 (1.9-2.5) 2080(92.2) 177(7.8) 21.1%

0.753
0.026 0.783 0.653

Religion
Muslim Hindu/other Ever contraceptive use before the index pregnancy
1 Data

0.270 0.022

are means (95% confidence intervals)

Contraceptive Prevalence Rate was Higher in the Intervention Arm at Each Visit Round
50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%
3 months 6 months 12 months 18 months 24 months 30 months 36 months

47%

46%

42% 36%
37% 34% 27% 18% 11% 35%

44% 37%

45% 39%

Intervention

Comparison
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Contraceptive Prevalence Rate was Higher in the Intervention Arm at Each Visit Round
50% 45% 40% 35% 30% 27% 47% 46%

42% 36%
37% 34% 35%

44% 37%

45% 39%

25% Statistically significant improvement in the contraceptive use rate in the intervention area 18% 20% during the high risk period of first 24 months after delivery 15% -- 18% ever user before the index pregnancy to 46% at 24 months postpartum 11% -21% ever user before the index pregnancy to 35% at 24 months postpartum 10% 5% number of new users and a trend towards increased early adoption High 0%
3 months 6 months 12 months 18 months 24 months 30 months 36 months

Intervention

Comparison
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LAPM Use Rates Were Higher In The Intervention Arm

50%

45% 40%
35% 30% 25% 20% 15% 10% 5% 0% Intervention Intervention Intervention Intervention Intervention Intervention Comparison Comparison Comparison Comparison Comparison Comparison Intervention Comparison

3 months LAM

6 months Pill Condom

12 months Injectables

18 months IUD /Implants

24 months Sterilization

30 months

36 months

Withdrawal or periodic abstinence

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Contraceptive Cumulative Adoption Probability Was Higher in The Intervention Arm [with and without LAM]
1.00 1.00

All modern methods

LAM excluded

0.75

Probability

0.50

0.25

0.00

9 12 15 18 21 24 27 30 33 36 Months since delivery Intervention Control

0.00

0.25

0.50

0.75

9 12 15 18 21 24 27 30 33 36 Months since delivery Intervention Control

P <0.001

P <0.001

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Inequity in Contraceptive Use Was Reduced by Intervention

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Birth to Pregnancy Interval Was Higher in The Intervention Arm

0.00 0.10 0.20 0.30 0.40 0.50

Hazards ratio: 0.79; 95% CI: 0.70-0.89

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18 24 Months since delivery Control

30

36

Intervention
Wilcoxon P = 0.001

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Effect of Integration on MNH Care: Selected Newborn Care practices by Study Arm
Intervention (%) 50.4 Comparison (%) 44.1

Drying and wrapping of newborn within 10 minutes of delivery Initiation of Breastfeeding within 30 minutes

56.6

46.8

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Duration of Exclusive Breastfeeding by Study Arm

1.00

Duration of exclusive breastfeeding by study arm

0.00

0.25

0.50

0.75

3 analysis time Intervention 18 Control

Lessons Learned
1. Feasibility of integration of PPFP within a community-based MNH program 2. Effectiveness of the model in increasing modern method use during extended postpartum period 3. No notable negative effect on the delivery of MNH services. 4. The promotion of LAM had a positive effect on duration of exclusive breastfeeding. 5. Pregnancy spacing and its health benefits accepted in religiously conservative settings
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THANK YOU
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