1 Healthy Fertility Study Integrating Family Planning within a Community- Based Maternal and Neonatal Health Program in Sylhet, Bangladesh September 26, 2013

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

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

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)

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

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 birth interval  To assess the strengths and limitations of integrating FP into an ongoing community-based MNH care program 6

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

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 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

Study Timeline 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 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 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 CHW Counselling Topics and Timing FP integrated with MNH programAdditional MessagesDuring pregnancy Day 6 postpartum Day 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 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

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 15

16 Data Collection

Collection Schedule Follow up at PP monthsData collection BeginningEnd BaselineDec 2007June monthsSep 2008Mar monthsApr 2009Jul monthsJun 2009Jan monthsSep 2009Jul monthsJan 2010Jan monthsJun 2010Jul monthsJan 2011Jan

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

19 THANK YOU