1. 1 Healthy Fertility Study Integrating Family Planning within a Community- Based Maternal and Neonatal Health Program in Sylhet, Bangladesh September 4, 2013

2. Presentation Outline  Study context and background  Study objectives, design, sites and timeline  Intervention, intervention delivery strategy and IEC materials  Data collection schedule 2

3. Study Context BDHS 2007BDHS 2011 BangladeshSylhetBangladeshSylhet Unmet FP need 17%26%14%17% CPR (any method) 56%31%61%45% TFR2.73.72.33.1 Birth Intervals <24 months15%26%12%19% <36 months37%57%32%47% 3 Selected FP indicators, Bangladesh and Sylhet, BDHS 2007 and 2011

4. Evolution of MNCH packages in Sylhet: Projahnmo in 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)  Trained CHWs can safely assess, classify and treat sick newborns using parenteral antibiotics at home (Baqui et al., PIDJ, 2009)  A postnatal home visit on day 1 or 2 of birth was associated with about 2/3 rd lower neonatal mortality (Baqui et al., BMJ, 2009)

5. Healthy Fertility Study: Integrated model of PPFP & MNH 5 Newborn carePostpartum FP counseling and contraceptive distribution

6. Study Objectives Primary:  To integrate PPFP in to a community-based MNH program and evaluate the intervention package on: exposure to key messages, knowledge of contraceptive methods and healthy timing and spacing of pregnancy and its benefits, contraceptive prevalence, method mix at different postpartum points and optimum birth interval  To assess the strengths and limitations of integrating FP into an ongoing community-based MNH care program 6

7. Study Objectives (Cont.) Secondary  To evaluate intervention impact on adverse pregnancy outcome 7

8. 8 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

9. 9 Study Sites  Sylhet district  Zakiganj & Kanaighat Upazila (sub district)  Intervention area: 4 unions : Manikpur, Kajalshar, Jhingabari & Dakshin Banigram  Comparison area : 4 unions : Sultanpur, Kholachara, Purbo Dighirpar & Paschim Dighirpar Union is the lowest administrative unit with 25,000 population and a primary health facility

10. Study Timeline 10 20072008 2009 2010201120122013 Dec 07: Launched in four unions Jul 08: Expanded another four unions Jul 09: Started household dispensing of pills and condoms Jul 09: Enrolment completed Mar 11: Started household dispensing of follow up doses of Injectables Jan 11: PP 12 months survey completed Jan 13: PP 36 months survey completed Sep 13: Outcome analysis completed Jan 12: PP 24 months survey completed

11. 11 Intervention Delivery Strategy 1.Capacity strengthening:  Training  Orientation 2.Community-based advocacy and behaviour change communication approach:  Household level through Community Health Workers (CHW) Household level through Community Health Workers (CHW)  Community level through Community Mobilizers Community level through Community Mobilizers  Facility level through Service Providers Facility level through Service Providers

12. 12 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: 4 and 1/2 days

13. 13 CHW Counselling Topics and Timing FP integrated with MNH programAdditional MessagesDuring pregnancy Day 6 postpartum Day 29-35 postpartum Month 2-3 & 4-5 PP ANC √ Newborn Care, EBF √√√ Return to fertility √√√ LAM and transition, EBF √√√√ HTSP √√√√ FP methods √√ Visit to facility √√√√

14. Example of IEC Materials: Birth Spacing and Breastfeeding

15. Example of IEC materials: Return to Fertility 15

16. Example of IEC Materials: Postpartum Care

18. Example of IEC Materials: LAM 18

19. Example of IEC Materials: LAM 19

20. 20 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 Key activities of GOB/NGO providers at the facility level include:  Provide postnatal care  Counsel about PPFP methods including LAM  Provide FP methods Male community meeting by CM; Photo credit: Salahuddin Ahmed Facility; Photo credit: Salahuddin Ahmed

21. Coordination with GOB and Other NGO Programs  HFS-CHWs referred clients to FWC, UHC for LAPM  CHWs and FWA/FPI/FWV: coordination meeting every month - collect methods from GOB  CHWs make active referral for sterilization  Project staff attend monthly GOB- NGO coordination meeting at upazila and district level  Joint field visit Referred women at UHC; Photo credit: Salahuddin Ahmed CHW-FWA monthly coordination meeting at FWC; Photo credit: Dipika 21

22. 22 Data Collection

23. Collection Schedule Follow up at PP monthsData collection BeginningEnd BaselineDec 2007June 2009 3 monthsSep 2008Mar 2010 6 monthsApr 2009Jul 2010 12 monthsJun 2009Jan 2011 18 monthsSep 2009Jul 2011 24 monthsJan 2010Jan 2012 30 monthsJun 2010Jul 2012 36 monthsJan 2011Jan 2013 23

24. 24 JHSPH ACCESS-FP /MCHIP Government of Bangladesh Shimantik and CDPA Study Partners Funded by USAID

25. 25 THANK YOU http://dx.doi.org/10.9745/GHSP-D-13-00002