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Date/Time: Thursday, November 14, 2013 Session: 2.2.

11 Family Planning and Quality of Care

Improving family planning services through training and capacity building of frontline workers of maternal and newborn health care program in a lowresource area of rural Bangladesh
Author(s): Salahuddin Ahmed, MCHIP/Jhpiego, Jaime Mungia, Jhpiego, Catharine McKaig, Jhpiego, MCHIP Amnesty Lefevre, Abdullah Baqui, Johns Hopkins University, Bloomberg School of Public Health

Abstract Type: Research Abstract Topic: Innovations in contraceptive service delivery Significance/background Evidence shows that community based newborn programs are effective in reducing neonatal mortality in low resource settings; however, there have been no significant efforts to integrate Family Planning (FP) services within these programs. We describe an innovative intervention delivery strategy for an area of rural Bangladesh where 90% of births occur at home, and demonstrate how promotion of FP can be effectively integrated into a community based maternal and neonatal health (MNH) intervention package and through the same frontline worker. Main question/hypothesis To test the effect of family planning integration with a community-based MNH program on improving postpartum contraceptive usage and continuing through the second year postpartum. Methodology We implemented the study in two sub-districts of Sylhet district in northeastern Bangladesh. Community health workers (CHWs), one per 4000 population, visited women in their homes two times during the antenatal period and four times during postpartum periods in MNH program. Both study groups received a basic package of MNH information and services through CHWs; the intervention group received additional FP information and community-based services during counseling visits. Male and female Community Mobilizers (CM) organized advocacy and community meetings with pregnant and postpartum women, their mothers-in-law, husband, community influential persons including religious leaders, their wives; and identified postpartum women to serve as role models on LAM in intervention area. Using a quasi-experimental design, a cohort of 4504 pregnant women, 2247 in intervention and 2257 in comparison arms, were followed from December

2007 to December 2012. Quantitative data were collected from the consented cohort longitudinally from pregnancy to 36 months postpartum at eight time points. We included all women in this analysis who had live birth or in case of multiple births at least one live birth and a surviving child in respective cross-sectional analysis. Results/key findings Counseling coverage by CHWs during pregnancy (99.4% vs. 99.6%; p>0.1) and within first week of delivery (86% vs. 89%; p>0.1) were similar in both arms. Contraceptive acceptance rate was significantly higher in intervention areas compared to comparison areas, at all measured time points following delivery: at three months postpartum (36% vs. 11%; p<0.01), six months (37% vs. 18%; p<0.01), 12 months (42% vs. 27%; p<0.01) and 24 months (46% vs. 35%; p<0.01) with significant changes in the method mix over time. The probability of all method adoption was 2.5 times higher in the intervention arm compared to the control arm during 24 months postpartum period (adjusted hazards ratio =2.49; 95% confidence interval: 2.27-2.74). The acceptance of sterilization was also significantly high in intervention arm compare to control arm during 24 months postpartum period (3.4% in intervention vs. 2.2% in comparison; p <0.05). The intervention also increased equity in FP coverage. Exclusive breastfeeding at three (58% vs. 47%; p<0.01) and five months postpartum (40% vs. 25%; p<0.01) were significantly higher in intervention arm. Home delivery rate was similar in both arms (89.5% in intervention vs. 91.3% in comparison arm). Drying and wrapping of newborn within 10 minutes after birth was 50.4% in intervention arm and 44.1% in comparison arm. Initiation of breastfeeding within 30 minutes after birth was also higher in intervention arm (56.6% vs. 46.8%; p<0.01). Knowledge contribution This model has demonstrated the feasibility of integrating FP into a community-based MNH intervention considering factors such as CHWs workload, supervision and promotion of MNH services. The promotion of LAM showed positive breastfeeding practices. The community-based provision of information and services has demonstrated a significant increase in contraceptive use during postpartum period; more women used contraceptives during the first 24 months postpartum period, preventing pregnancies that have the highest risk for the mother and newborn and prevent adverse pregnancy outcome for subsequent pregnancy. It is also notable that in a religiously conservative setting, the study generated significant community support for FP as a component of MNH through its emphasis on pregnancy spacing and its health benefits. This innovative model can be effectively replicated in low resource settings in South Asia and Africa where home deliveries are high and there is a need for community-based MNH and FP services. Maternal and newborn health programs should consider integrating family planning as a service component to improve use of family planning services and providing an opportunity to improve overall maternal and newborn health.

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