Effectiveness of Community-based Primary Health Care: A Participatory Discussion of Program Implications MARY CAROL JENNINGS

1. Community-Based
Primary Health Care:
Maternal Health
Dr. Mary Carol Jennings, MD, MPH
CORE Group, Portland OR
May 19, 2016

2. Objectives
Context
Methods
Describe: strategy-intervention package-indicator-effectiveness
Post-Partum Hemorrhage example

3. WHO Global Health Observatory Data, 2016
WHO 2016 Trends in maternal mortality
44% decrease
2.3% decrease per year
216 / 100,000 LB (2016)

4. 0
50
100
150
200
250
2015 2020 2025 2030
Ratio(per100.000LiveBirths)
Figure. Global Maternal Mortality
Ratio, 2015 actual to 2030 SDG goal
6-7% decrease per year
Goal 70 / 100k LB
WHO 2016 Trends in maternal mortality

5. ATTENDED BY WHOM?

6. 51% of women in low-income
countries deliver with a skilled
attendant
WHO Maternal Mortality Fact Sheet 348,November 2015

7. Prevent 50%
Prevents 7%

8. Montagu, Yamey, Visconti, Harding, Yoong, PLoS One 2011; 6(2): e17155
> 50% at home

9. Equity

10. Maternal Health - Methods
153 articles
Computerized
database

11. ALL
MATERNAL
DEATH
HEMORRHAGE
27%
Say, Chou, Gemmill, Tuncalp, Moller et al., Lancet Global Health 2014
2/3
PPH

12. Overall

13. Address
Medical
Complications
of Pregnancy
Coordinate and
Provide
Routine
Maternal Care
Capacity
Development
Total Reports
Number of Times Reported 483 714 78 1298
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
0
200
400
600
800
1000
1200
NumberofInterventions
Number of Interventions Extracted From Reports

15. 33% Most
Frequent
(9%)

16. 29
PPH
Prevention Detection Treatment

17. 61
2 3 5
4
PPH Report Selection Criteria
6
123 5
4PPH

18. PPH Reports
Kapungu 2013
A community-based continuum of care model for the prevention of postpartum hemorrhage in rural Ghana. Kapungu
CT, Mensah-Homia J, Akosah E, Asare G, Carnahan L, Frimpong MA, Mensa-Bonsu P, Ohemeng-Dapaah S, Owusu-
Ansah L, Geller SE. International Journa of Gynecology and Obstetrics, vol 120 (2013), pp156-159, ISSN 0020-7292.
Kumar 2012
Kumar V, Kumar A, Das V, Srivastava NM, Baqui AH, Santosham M, Darmstadt GL; Saksham Study Group. Community-
driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India. Int J Gynaecol
Obstet. 2012 Apr;117(1):48-55
Prata 2012
Ndola Prata, Clara Ejembi, Ashley Fraser, Oladapo Shittu, Meredith Minkler. Community mobilization to reduce
postpartum hemorrhage in home births in northern Nigeria. Social Science & Medicine. 2012(74): 1288-1296
CB-MNC-Nepal 2007
McPherson R, Baqui A, Winch P, Ahmed S, Hodgins S. Community-based maternal and neonatal care program
(CB-MNC): Summative report on program activities and results in Banke, Jhapa and Kanchanpur districts from
September 2005 - September 2007. December 2007 (CB-MNC Nepal)

19. Evidence

20. • Community sensitization
• Create linkages between traditional birth attendants and
health providers (Community Health Extension Workers)
• Ask women to involve CHEWs and TBAs together in their
delivery plan
KAPUNGU
• Use a behavior change management approach to shift
community norms
• Involve men and decision-makers; empower women and
consider equity of care delivery
• Base intervention on culture and tradition
• Use less-skilled cadres to supplement skilled providers, and
involve skilled providers
• Focus on prevention and care-seeking themes
• Combine community-based with facility-based strategies
• Combine increases in maternal health coverage with health
systems strengthening
KUMAR
• Involve men
• Community mobilization
• Pregnancy surveillance
• Use traditional birth attendants to link to the "formal"
health system (midwives and facility-based providers)
• Create a new, literate group of "health promoters"
selected by the community to implement health
promotion
• Address lack of pharmacies and drug supply chain
PRATA
• Communicate health messages through multiple channels
• Use Female Community Health Volunteers (FCHVs) to
promote interpersonal communication
• Mobilize communities
• Create demand for basic commodities (e.g., misoprostol)
• Provide basic commodities and health services during home
visits
• Promote facility-based delivery for complications and
emergency care
CB-MNC-NEPAL

21. • Community sensitization
• Create linkages between traditional birth attendants and
health providers (Community Health Extension Workers)
• Ask women to involve CHEWs and TBAs together in their
delivery plan
KAPUNGU
• Use a behavior change management approach to shift
community norms
• Involve men and decision-makers; empower women and
consider equity of care delivery
• Base intervention on culture and tradition
• Use less-skilled cadres to supplement skilled providers, and
involve skilled providers
• Focus on prevention and care-seeking themes
• Combine community-based with facility-based strategies
• Combine increases in maternal health coverage with health
systems strengthening
KUMAR
• Involve men
• Community mobilization
• Pregnancy surveillance
• Use traditional birth attendants to link to the "formal"
health system (midwives and facility-based providers)
• Create a new, literate group of "health promoters"
selected by the community to implement health
promotion
• Address lack of pharmacies and drug supply chain
PRATA
• Communicate health messages through multiple channels
• Use Female Community Health Volunteers (FCHVs) to
promote interpersonal communication
• Mobilize communities
• Create demand for basic commodities (e.g., misoprostol)
• Provide basic commodities and health services during home
visits
• Promote facility-based delivery for complications and
emergency care
CB-MNC-NEPAL

22. PromoteSensitize, Mobilize
Link
Promote

23. 1. Campaign comprised of messages on safe motherhood,
importance of facility delivery, early PPH diagnosis, when
to transfer to facility for emergency, and messages
preparing for future phase 2 misoprostol distribution
2. Train primary healthcare providers, traditional birth
attendants (TBAs) and Community Health Extension
Workers (CHEWs) on safe motherhood practices and to
use blood collection drapes at every home delivery
3. Create incentives and expectation for TBAs and CHEWs
to work together to attend deliveries and implement
intervention KAPUNGU
1. Implementation of a behavior change intervention focused
on changing high-risk home-based neonatal care practices
that also impact women's health
2. Traditional community health workers (CHWs) make home
visits, identify pregnant women and deliver the behavior
change intervention through 2 ANC & 2 PNC home visits,
community meetings and folk-singing
3. CHW messaging promotes: ANC and obstetric/newborn
care-seeking from a qualified provider, birth preparedness
(prepare delivery room, select birth attendant, and save
money for emergency), and immediate breastfeeding
(along with newborn-specific care behaviors) KUMAR
1. Education campaign on birth and hemorrhage
preparedness (organize community dialogues and drama
productions to promote messages around bleeding after
delivery, facility delivery, and correct misoprostol use)
2. Recruit new cadre of literate Community Oriented
Resource Persons (CORPs) to promote
intervention/practices
3. Recruit and train traditional birth attendants (TBAs) and
CORPs to counsel women on campaign messages
4. Create a community-based misoprostol distribution
mechanism using "drug keepers“ PRATA
1. Female Community Health Volunteers (FCHVs) make
antenatal visits and promote behaviors such as attended
delivery and recognition/response to danger signs and
hemorrhage
2. FCHVs dispense misoprostol (one district), and run
community mobilization activities (street drama, radial
drama, wall murals)
3. FCHVs make postnatal home visits to collect unused
misoprostol and to provide other counseling, commodities
or services CB-MNC-NEPAL

24. 1. Campaign comprised of messages on safe motherhood,
importance of facility delivery, early PPH diagnosis, when
to transfer to facility for emergency, and messages
preparing for future phase 2 misoprostol distribution
2. Train primary healthcare providers, traditional birth
attendants (TBAs) and Community Health Extension
Workers (CHEWs) on safe motherhood practices and to
use blood collection drapes at every home delivery
3. Create incentives and expectation for TBAs and CHEWs
to work together to attend deliveries and implement
intervention KAPUNGU
1. Implementation of a behavior change intervention focused
on changing high-risk home-based neonatal care practices
that also impact women's health
2. Traditional community health workers (CHWs) make home
visits, identify pregnant women and deliver the behavior
change intervention through 2 ANC & 2 PNC home visits,
community meetings and folk-singing
3. CHW messaging promotes: ANC and obstetric/newborn
care-seeking from a qualified provider, birth preparedness
(prepare delivery room, select birth attendant, and save
money for emergency), and immediate breastfeeding
(along with newborn-specific care behaviors) KUMAR
1. Education campaign on birth and hemorrhage
preparedness (organize community dialogues and drama
productions to promote messages around bleeding after
delivery, facility delivery, and correct misoprostol use)
2. Recruit new cadre of literate Community Oriented
Resource Persons (CORPs) to promote
intervention/practices
3. Recruit and train traditional birth attendants (TBAs) and
CORPs to counsel women on campaign messages
4. Create a community-based misoprostol distribution
mechanism using "drug keepers“ PRATA
1. Female Community Health Volunteers (FCHVs) make
antenatal visits and promote behaviors such as attended
delivery and recognition/response to danger signs and
hemorrhage
2. FCHVs dispense misoprostol (one district), and run
community mobilization activities (street drama, radial
drama, wall murals)
3. FCHVs make postnatal home visits to collect unused
misoprostol and to provide other counseling, commodities
or services CB-MNC-NEPAL

25. Emphasize
Attended
and Facility
Delivery
Create Inter-Cadre Partnerships
Community
Distribution
of Commodities:
Misoprostol
Blood collection drapes
CHW
home
visits
CHW-run
Communication
Campaigns

27. Maternal
Mortality
Maternal
Morbidity
Coverage of
Key Health
Intervention
Health System
Strengthening
Other Metric Total
Number of Reports 32 29 120 32 51 153
[CELLRANGE][CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
0
20
40
60
80
100
120
140
160
NumberofReports
Indicator Category
Number of Indicator Categories Used by Reports

28. Maternal Mortality
Skilled Attendant
Facility Delivery
Maternal Morbidity PPH-specific intervention

29. PPH-specific intervention
Community misoprostol distribution
Immediate post-partum breastfeeding
Blood collection drapes

30. Maternal Mortality
Skilled Attendant
Facility Delivery
Maternal Morbidity PPH-specific intervention

31. WITH WHOM?

33. To achieve accelerations in maternal mortality
We must work in communities AND in facilities

34. Next Up:
Neonatal Health
Child Health
Equity
Strategies

35. Discussion Questions
How can we use these findings to improve our own NGO programs?
How can our findings on equity and community strategies be used to
strengthen maternal/neonatal/child health program implementation?
How could we use these results to make a case for investment in
community based approaches for maternal/neonatal/child health?

36. PPH Reports
Kapungu 2013
A community-based continuum of care model for the prevention of postpartum hemorrhage in rural Ghana. Kapungu
CT, Mensah-Homia J, Akosah E, Asare G, Carnahan L, Frimpong MA, Mensa-Bonsu P, Ohemeng-Dapaah S, Owusu-
Ansah L, Geller SE. International Journa of Gynecology and Obstetrics, vol 120 (2013), pp156-159, ISSN 0020-7292.
Kumar 2012
Kumar V, Kumar A, Das V, Srivastava NM, Baqui AH, Santosham M, Darmstadt GL; Saksham Study Group. Community-
driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India. Int J Gynaecol
Obstet. 2012 Apr;117(1):48-55
Prata 2012
Ndola Prata, Clara Ejembi, Ashley Fraser, Oladapo Shittu, Meredith Minkler. Community mobilization to reduce
postpartum hemorrhage in home births in northern Nigeria. Social Science & Medicine. 2012(74): 1288-1296
CB-MNC-Nepal 2007
McPherson R, Baqui A, Winch P, Ahmed S, Hodgins S. Community-based maternal and neonatal care program
(CB-MNC): Summative report on program activities and results in Banke, Jhapa and Kanchanpur districts from
September 2005 - September 2007. December 2007 (CB-MNC Nepal)

37. Intervention Category
# Times
Reported
Percentage*
(of 153)
Percentage**
(of 1298)
Address Medical Complications of Pregnancy 483 -- 37.2
Screen for high-risk pregnancy 49 32.0 3.8
Mental health 4 2.6 0.3
Screen/monitor gestational diabetes 10 6.5 0.8
Maternal weight/height/nutritional status 39 25.5 3.0
Micronutrients 32 20.9 2.5
Monitor/control blood pressure/hypertension 12 7.8 0.9
Prevent/detect/(pre)/eclampsia 14 9.2 1.1
Prevent/detect/treat anemia 26 17.0 2.0
Prevent/detect/treat hemorrhage 29 19.0 2.2
Detect/treat complications of pregnancy† 42 27.5 3.2
Detect obstetric complications 52 34.0 4.0
Abortion and post-abortion care 4 2.6 0.3
Detect/treat infection/sepsis 20 13.1 1.5
Prevent HIV 25 16.3 1.9
Treat HIV/AIDS 12 7.8 0.9
Prevent STI/reproductive tract infection 11 7.2 0.8
Treat STI / Reproductive tract infection 7 4.6 0.5
Prevent tetanus 34 22.2 2.6
Treat tetanus 6 3.9 0.5
Prevent syphilis 2 1.3 0.2
Treat syphilis 0 0.0 0.0
Prevent malaria 31 20.3 2.4
Treat malaria 22 14.4 1.7

38. Intervention Category
# Times
Reported
Percentage*
(of 153)
Percentage**
(of 1298)
Coordination and Provision of Routine Care 741 -- 57.1
Primary health care 65 42.5 5.0
Antenatal care 121 79.1 9.3
Immunizations 43 28.1 3.3
Develop birth plan 41 26.8 3.2
Promote facility-based delivery 61 39.9 4.7
Promote/use trained attendant at delivery 81 52.9 6.2
Train/support/use traditional birth attendants 57 37.3 4.4
Assist or provide kit for safe delivery 39 25.5 3.0
Referal for care of obstetric complications 53 34.6 4.1
Immediate postpartum breastfeeding 41 26.8 3.2
Post-partum care, as home visit or other 80 52.3 6.2
Family planning, including immediate postpartum 55 35.9 4.2

39. Intervention Category
# Times
Reported
Percentage*
(of 153)
Percentage**
(of 1298)
Social-Economic Capacity Development 78 -- 6.0
Micro-credit/savings groups 6 3.9 0.5
Conditional cash transfers 5 3.3 0.4
Women's empowerment 40 26.1 3.1
Participatory women's groups 27 17.6 2.1
*Percentage out of 153 assessments included
**Percentage out of 1298 total interventions reported

40. Why include a maternal component?

41. WHO Global Health Observatory, 2012 data

42. MMR < 20
MMR > 300
WHO, GA Map Server 2015; WHO Maternal Mortality Fact Sheet 348,November 2015

43. PPH definition
Reports that quantified post-partum hemorrhage used the
standard definition of measured blood loss greater than
500mL (Kapungu 2013) (Fauveau 1990)

44. Intervention Packages
Number of
Interventions
Number of
Reports
Percent (of
153)
One 3 2.0
Two 10 6.5
Three 13 8.5
Four 11 7.2
Five 14 9.2
Six to Ten 59 38.6
Eleven to Fifteen 23 15.0
Sixteen and More 20 13.1
Total 153 100.0
Table 2. Number of different interventions
assessed in the same report

45. • (not a slide)

46. 73%
DIRECT
ALL
MATERNAL
DEATH
Say, Chou, Gemmill, Tuncalp, Moller et al., Lancet Global Health 2014

47. Indicators
Processes:
12/120 coverage of a key health service
Outcomes:
14/62 maternal morbidity