CRS Nicaragua ORPresentationThe role of menduring partner’spregnancy,delivery andpost-partum/neo-natal periodsElena McEwan...
Matagalpa Department in North-CentralNicaragua
Project Context• Post-conflict area.• Male dominatedhouseholds, domesticviolence.• Traditionally men makedecisions in thei...
Problem01020304050men together womenWho makes the decisionPregnancyBirthFor newborn
Father-Focused Counseling:Fathers gain knowledgeand skills about maternaland child careIncreases joint decisionmaking abou...
Approach using a men lens to identifytheir readiness to probe new behaviors.
OR phases• Formative Research• Summative Research
Formative ResearchPhase 1: Formative Research• To identify key factors, perceived benefits, barriers thatinfluence men beh...
Formative researchPhase 2:Probing phaseTo develop anapproach toimplement andmonitor the BCCinterventions topromote behavio...
% Behaviors practiced by menCollected firewood and water 76Supported wife with household work 100Took care of newborn and ...
Formative ResearchPhase 3:StrategyLaunching andImplementationTo carry out a small-scale pilot testing ofthe intervention,i...
OR Objectives• To assess men’s knowledge in recognizingdanger signs during pregnancy, labor anddelivery, post partum and n...
Summative ResearchObjectives• Intervention arm: 20 target communities• Control arm: 20 communities (within the100 communit...
Summative Researchmethods• Study methodology: The project conducted two types ofsurveys as part of the baseline: KPC and q...
Men’s knowledgedanger sings duringpregnancy01020304050607080FeverAbdominalpainHeadacheEdemaVaginalbleedingBlurredvisionFev...
Men’s knowledge dangersigns during Labor anddelivery010203040506070HeadacheFeverHemorrageProlongeddeliveryRetentionofthePl...
Men’s knowledge danger signsduring postpartum period010203040506070HemorrageFeverHeadacheAbdominalpainBlurredvisionSmellyv...
Men accompanied wifeto ANC010203040506070Case Control2010 yes2012 yesp=0.025
Men accompanied wifeto HFs for newborncare010203040506070Case Control2010 yes2012 yesp=0.738
Men who participated in thedelivery of their child010203040506070Case Control2010 yes2012 yesp=0.451
Results050100150200250300350400Matiguás Rio BlancoNumberofDeliveriesInstitutional Deliveries2008 comunidades del Proyecto2...
Innovative dimensions of theintervention• The systematic approach of using a men lens• Identifying willingness, barriers a...
Best practices• Engaging key stakeholders during project cycle• Implementing Behavior Change Communicationat household, co...
Challenges, lessonslearned• Formative research phase took longer than expected• Probing phase was from July 2009/June2010,...
Humanizing Institutional Care:MoH health staff capacity-buildingactivitiesFather-Focused Counseling:Equipping and Training...
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The Role of Men during Partner’s Pregnancy, Delivery and Post-Partum/Neo-Natal Periods_Elena McEwan_4.25.13

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  • This OR will be aimed at measuring if behavior change activities with men may contribute to decreasing the first barrier in recognizing and deciding to access timely obstetric and neonatal emergency care and secondly to better understand men’s attitudes about their perceived role, their perception of authority and of family well-being. On the providers’ side, the CSP will strengthen the services by providing MoH staff new skills to diagnose and treat obstetric and newborn emergencies, by re-structuring the health services to become more culturally sensitive, and by including new indicators in the MoH health’s information system to record the number of pregnant women seeking care with their partners and the number of men who asked questions regarding their wives’ health during care. The CSP will also improve the coordination between health units and community structures to improve timely referrals.
  • Goal: Contribute to the reduction of maternal and neonatal morbidity and mortality by 2012.Target groups: 41,428 women of reproductive age and 25,861 children under five years oldGrant Period: September 30, 2008 to September 30, 2012Nicaragua located in Central America, is the second poorest country in Latin America. Its population is rural, isolated roads difficult to access during the rainy season. This is a post conflict area. It was the center of the civil war during the eighties. The literacy rate among adults is low at 67%, with women on average attending 2.4 years of school and men 3.2 years. Nearly all families earn their livelihood from small-scale agriculture or through intermittent day labor on estates of large land-owners who raise cattleThe average wage for those working in the target area as agricultural laborers is less than $2.00 a day and work is only sporadic. Most of the communities are not along these paved roads and many are far off in the mountains, accessible only on foot or by mule or horse.
  • Why the approach for the first element is innovative?  The systematic process of engaging men taking into consideration different variables, for example that this is a post-conflict area, male dominated households, domestic violence); to design the approach using a men lens to identify their perceptions, beliefs, roles, readiness to probe new behaviors (willingness, barriers, and enablers) at different levels: household, community and health facilities. This approach could be applicable to other post conflict settings.How does it work? The most important innovation was the involvement of men in their wives’ pregnancy and subsequently in their families’ health. The methodology used was an adaptation of the Trials Improved Practices; where the Behavior Change Counselors (BCC) work face to face with men to agree on the behaviors the men will try to practice; the BCC counselors do follow up visits to assess if the men are practicing the behaviors, encourage its adoption, and identify barriers if the men did not practice the behaviors.   The BCC counselors will address the barriers and continue working with the men until the behaviors are adopted. The behaviors selected by listing the ones that would contribute to addressing delay No 1. A small group of men were invited to participate in the probing phase. The men practiced the behaviors at home, and the 10 behaviors that were practices more than 70 percent of the time practice were selected for inclusion in the behavior change strategy that was implemented in 20 communities. 
  • Increasing awareness among men in regards to recognizing danger signs during pregnancy and new born periods, and by Motivating them to make joint decisions with their wives will result in boosting seeking care during obstetric and newborn emergencies in a timely manner, and An increase in ANC, institutional deliveries; therefore improving maternal and newborn health. 5 card our approach: three  levels of intervention: households, community and health facilities How does it improve upon current approaches?The innovation was drafted from the perception of men, using a male lens.  The intervention included assessment to determine the knowledge of the men, and perceived enablers and barriers to men engaging in their families’ health. Information given by the men was used to tailor the intervention to decrease the barriers at different levels.  For example, there were two behaviors that some men could not practice without the support from the health staff; accompany the wife to the antenatal and delivery rooms. In these cases the project negotiated with the health staff to allow the husbands to be present during the care and included them in the service delivery (able to answer questions, receive counseling, etc)The overall plan is to implement with the MOH a complete “package” of household, health units and community activities, taking care to contain costs and labor intensiveness within the reality of the MOH. This innovation is disruptive in two ways. It provides a more central role to the husband, while not excluding women; and it brings emergency care maternal to the home, thereby decreasing the time to initial treatment, and giving families extra time to reach referral facilities. It is disruptive in that it will provide access to emergency care to women in remote areas that previously have not had access to it, thus ‘enlarging the market/reach’ of the intervention. It is also disruptive in that it brings new stakeholders into emergency maternal care, namely husbands and community-based providers
  • Individual and group interviews (FGDs)Questionnaires designs and field testingTraining staff in interview and facilitation techniquesPlanning of field work to gather informationParticipation of 80 men which partners were pregnant, 36 men with children under 40 days old and under two, 16 men which wives were in the postpartum period, and their wives.During the interviews and FGDs were identified a list of behaviors, enablers and barriers. It also provided a better understanding of the men’s role regarding their families, decision making norms regarding seeking care and their role in their wives pregnancy, partum and post partum. With respect to the protocol developed by NicaSalud called formative research, it included applying the behavioral changes methodology, which contains six implementation phases; although for preparing the innovation the protocol grouped the activities of these six phases into three phases of application detailed as follows: Diagnostic Phase, BCC counselors’ recruitment phase and strategy implementation phase. The peer methodology was developed during the innovation. In the first phase men’s current behaviors and the barriers to behavioral change were identified. This process was considered necessary as it provided an assessment of the gender situation in the beneficiary families
  • Innovation - Engaging Men to Improve Care-Seeking was carried out in 20 communities with technical assistance from NICASALUD. The innovation followed a “Trials in Improved Practices” design where behaviors were identified, practiced then an analysis carried out by men to determine which were the most feasible. The approach includes 7 behavior modification strategies. Using a cascade training model, first the field agents from Caritas were trained and they then trained 61 Behavior Change Agent (BCA) volunteers. Three BCAs were trained in each community to work with men to negotiate behavior change for improved MNC. They use venues such as sporting events as educational opportunities, as well as face to face counseling methods to negotiate behavior change.In the second phase the BCC counselors were recruited; the community strategies to be promoted were constructed with the information provided in the first phase; and the communication materials were validated by different actors, including MINSA, the promoters and project staff. At that time the monitoring instruments were also designed. These activities were done through a continuous consultation process with the community agents.
  • 25 men in three municipalitiesMen with pregnant women’Men whose wives where in last two weeks of pregnancy: behavior 1,2Anecdote about the wife didn’t want to go back and wash the baby’s clothes after one months of probing phaseThe husband convinced it was important to participate in the ANC came to the H/U but the doctor didn’t let him inThe H/U staff brainstorming how to declare “husband friendly units”. “welcome all me who love their wives”
  • Subsequently, the BCC counselors were selected and trained in the methodology, and given that the majority of the male beneficiaries have a low level of schooling attractive laminates were designed that represented the men’s role in caring for the maternal-infant health. These laminates were previously validated with them to see if their message could be precisely understood and the men’s behavior could be negotiated.The negotiation of behavioral changes was the frame of reference for the BCC counselors to be able to gradually achieve changes recognizing their role in the family. In this process, a community census was done that identified the men with children under two years old and pregnant women, which were the selection criteria for being a beneficiary of the strategy. To train in the Change of Men’s Behavior Innovation Strategy, the community promoter was selected from within the community through a community assembly managed by MINSA and the project personnel. In this assembly the activities of the project and how it would benefit the community were laid out.Once the men were recruited, the activities of “changes” were generated through three phases conducted on the ground by the promoter of the changes, to wit: Phase of assessment, negotiation and follow-up that involves new “negotiations and awards” as he surmounts the task assigned and the natural cycle he lives with his partner, during her pregnancy, delivery, post partum and/or care of the newborn. As part of the strategy of attracting potential negotiators, various groups of men grouped into baseball teams were provided with sports equipment for the purpose of this mechanism becoming an “activity hook” in the spaces so as to develop chats on health “with men and for men.”
  • A sample of 194 participants was selected, which was the baseline sample. In this sample 97 men with their respective partners were from the case communities and the other 97 men with their respective partners were from the control communitiesSurveys, interviews and focus groups were done during the information-gathering process. The survey was applied simultaneously to male and female couples, getting simultaneous responses to the same questions from the vision of both the men and the womenIn the FE were added communities that have not received interventions. They included 9 communities from the 3 municipalities studied during the 2010-2012 period.Focus Groups: Semi-structured interview guideQuantitative techniques. KPC applied to 568 people, of whom 50% (284) are men and the other 50% (284) women from the different communities in the 3 municipalities.To conduct this process the team was made up of 15 survey takers and 4 supervisors from CIES-UNAN.On the ground and at the base of operationObservation of the survey taker’s development by the supervisorReview and correction of the questionnaires and lists of errors and inconsistenciesThe survey was processed in the SPSS statistical package. SPSSbecause it is the most adapted to the information system created as part of the project actions. The qualitative questions were processed in an Excel matrix. For purposes of this study a univariate and bivariate analysis was done.
  • To assess men’s knowledge in recognizing danger signs during pregnancy, labor and delivery, post partum and new born periods.
  • To measure health outcomes in increasing maternal and newborn care.
  • In innovation communities, the percentage of women who sought ANC care with their husbands increased (Bl-43%, FL 64%) and it was higher than that of the control communities (Bl-47%, Fl-39%)
  • In innovation communities the percent of men who accompanied their wives to HFs for newborn care increased (Bl-55%, Fl-78%) and this was a much greater increase than that in the control communities (Bl-35%, Fl-46%
  • In innovation communities there was a significant increase in men who participated in the delivery of their child (Bl-49%, Fl-60%) and this difference was not evident in control communities (Bl-47%, Fl-45%).
  • 8 card why is effective: show dataDefining success: Objectives and research questions - The objectives investigated through the experimental plan will be:To assess the coverage and quality achieved from the introduction of the three project components (fathers’ clubs, community health volunteers, health facilities) on maternal and newborn care practices, prompt referral for skilled facility care for complications, facility delivery, and quality care in health facilities.To assess the effect of the three project components on social factors affecting health including engagement of fathers in maternal health and intimate partner violence.To assess the level of adoption of behaviors at the household level resulting from implementation of the three project components.To assess the pattern of care seeking, referrals to health facilities, and degree of compliance with referral.To assess qualitatively the social causes of mortality, and the extent to which the household and community-level interventions are addressing these social causes .Methods/Results monitoring
  • Key question that they judges may ask: Why Nicaragua;Responses:Nicaragua even though is not the poorest country in the world, it has marginalized and underserved populations with similar characteristics and dynamics as other countries in Latin America.  Our innovation could be adapted for those settings to benefit vulnerable populations.  It has the potential to be applicable to Latin America and beyond The project area has conditions to demonstrate that it works. The environment is favorable to implement it, refine it, measure it, document it and share it with larger communityCRS as a global organization can share the innovation and promote its adaptation in other countries in Africa  and Asia with similar characteristics and dynamics.
  • How could the government take it (the proposed intervention) over? CRS has been working on sustainability by engaging  the MoH in the project design, implementation, Monitoring and evaluation of the current project.The same strategy will be used  in the new proposal by Engaging the MoH at the SILAIS and Municipal levels and other stakeholders in the planning, implementation, evaluation and documentation of the innovation Sharing lessons learned and best practices with  the Ministry of Health from neighboring municipalities (SILAIS). Current project have documented the first phase of the innovation and developed implementation guidelines for its adoption in other areasJoining working groups at the national level during the technical review meetings aiming to influence obstetric and newborn national guidelines. CRS and the local MoH (SILAIS) will share the documentation, revise and adapt it for other municipalities and SIALAIS to implement it.Sharing documentation report and implementation guidelines with NGOs and other Government organizations to encourage  its adoption/adaptation in their current and future programs. Sustainability at the household, community and health staff levels will continue by promoting new actionable behaviors at these levels, and providing a supportive environment to ensure principal groups probe, adopt and advocate new behaviors. For example:At the household levels decision- makingAt the community level, mobilization of community health structures At the facility levels by establishing systems and providing resources for health staff to practice new skills and at the same time become most respectful of communities beliefs and culture
  • (over18 months), indicators already increasedthey could not devote enough time to follow up with the men they were counseling.
  • The Role of Men during Partner’s Pregnancy, Delivery and Post-Partum/Neo-Natal Periods_Elena McEwan_4.25.13

    1. 1. CRS Nicaragua ORPresentationThe role of menduring partner’spregnancy,delivery andpost-partum/neo-natal periodsElena McEwan, MDSTA/Team LeaderCatholic Relief servicesCore Group Spring MeetingBaltimore, MD
    2. 2. Matagalpa Department in North-CentralNicaragua
    3. 3. Project Context• Post-conflict area.• Male dominatedhouseholds, domesticviolence.• Traditionally men makedecisions in their families.
    4. 4. Problem01020304050men together womenWho makes the decisionPregnancyBirthFor newborn
    5. 5. Father-Focused Counseling:Fathers gain knowledgeand skills about maternaland child careIncreases joint decisionmaking about careseekingSupports expecting andpost partum wife withmore householdresponsibilitiesImproves healthybehaviors of householdmembersbefore, during, and afterbirthHypothesisReduces harmful gender norms thatprevent women from accessing timelyobstetric and newborn care servicesImproves family-level self-referral andcommunity-level referrals to appropriateinstitutional health services and increasesdemand for these servicesImproves antenatal care, institutionaldeliveries, and ultimately healthierpregnancies and newborns
    6. 6. Approach using a men lens to identifytheir readiness to probe new behaviors.
    7. 7. OR phases• Formative Research• Summative Research
    8. 8. Formative ResearchPhase 1: Formative Research• To identify key factors, perceived benefits, barriers thatinfluence men behaviors regarding making jointdecisions to seeking care and their involvement in theirwives and children health, and• To ascertain their willingness to adopt new behaviorsand how liable they are to practice them.
    9. 9. Formative researchPhase 2:Probing phaseTo develop anapproach toimplement andmonitor the BCCinterventions topromote behaviorsand develop draftBCC materials
    10. 10. % Behaviors practiced by menCollected firewood and water 76Supported wife with household work 100Took care of newborn and older children day and night 71Fed older children 98Made joint decision with wife to stay at the maternity waiting homeseven days post partum75Found someone to take care of the house when they sought care athealth units80Accompanied wife to ANC and ask questions during care 66Accompanied wife during labor and delivery 50Source: Formative research monitoring
    11. 11. Formative ResearchPhase 3:StrategyLaunching andImplementationTo carry out a small-scale pilot testing ofthe intervention,includingassessment reactionto draft BCCmaterials.
    12. 12. OR Objectives• To assess men’s knowledge in recognizingdanger signs during pregnancy, labor anddelivery, post partum and new born periods.• To determine if participating men change theirbehaviors concerning health care seekingdecisions and taking care of their family’shealth.• To measure health outcomes in increasingmaternal and newborn care.
    13. 13. Summative ResearchObjectives• Intervention arm: 20 target communities• Control arm: 20 communities (within the100 communities where the CSP isbeing implemented).• CIES conducted a baseline, midtermand a final surveys to measure changesin the population.
    14. 14. Summative Researchmethods• Study methodology: The project conducted two types ofsurveys as part of the baseline: KPC and qualitative studies.This information was used to prioritize seeking care indicatorsthat the project wanted to increase• Study population: Men from the rural area and their partners(pregnant or with children under two years old).• Inclusion criteria: Men from the rural area whose partners arepregnant, are post partum or have children under two years old.• Sampling methodology: All men and their partners who fit theabove-described criteria and are participating in the behavioralchange activities.
    15. 15. Men’s knowledgedanger sings duringpregnancy01020304050607080FeverAbdominalpainHeadacheEdemaVaginalbleedingBlurredvisionFeverAbdominalpainHeadacheVaginalbleedingBlurredvision2010 2012CasoControlNo intervenention
    16. 16. Men’s knowledge dangersigns during Labor anddelivery010203040506070HeadacheFeverHemorrageProlongeddeliveryRetentionofthePlatentaHeadacheFeverHemorrageProlongeddeliveryAbnormalpresentationRetentionofthePlatenta2010 2012CasoControlNo intervention
    17. 17. Men’s knowledge danger signsduring postpartum period010203040506070HemorrageFeverHeadacheAbdominalpainBlurredvisionSmellyvaginaldischargeHemorrageFeverHeadacheAbdominalpainBlurredvisionSmellyvaginaldischarge2010 2012CaseControlNo intervenidas
    18. 18. Men accompanied wifeto ANC010203040506070Case Control2010 yes2012 yesp=0.025
    19. 19. Men accompanied wifeto HFs for newborncare010203040506070Case Control2010 yes2012 yesp=0.738
    20. 20. Men who participated in thedelivery of their child010203040506070Case Control2010 yes2012 yesp=0.451
    21. 21. Results050100150200250300350400Matiguás Rio BlancoNumberofDeliveriesInstitutional Deliveries2008 comunidades del Proyecto2008 comunidades sin el Proyecto2011 comunidades del Proyecto2011 comunidades sin el Proyecto
    22. 22. Innovative dimensions of theintervention• The systematic approach of using a men lens• Identifying willingness, barriers and enablersfor key stakeholders probe new behaviors.• Creating a supportive environment for men athousehold, community and facility levels• This approach could be applicable to otherpost conflict settings with similar householddynamics.
    23. 23. Best practices• Engaging key stakeholders during project cycle• Implementing Behavior Change Communicationat household, community and health facilitylevels.• Sharing innovation progress (lessons learnedand best practices.)• Influencing the sub national obstetric andnewborn program• Documenting and sharing innovation results withpartners NGOs, and other governmentalorganizations
    24. 24. Challenges, lessonslearned• Formative research phase took longer than expected• Probing phase was from July 2009/June2010, andOR baseline was done until June, 2010• The need to include health staff in BCC for men topractice some behaviors at the facility level• “contamination of control communities” difficult toavoid due to other project interventions (c-BPS)• Family and labor commitments of the BCCcounselors,• Some BCC counselors emigrated for economicreasons
    25. 25. Humanizing Institutional Care:MoH health staff capacity-buildingactivitiesFather-Focused Counseling:Equipping and Training CHWs: to1) evaluate pregnancy risks, 2) refer toinstitutional care & 3) first respondersto obstetric and neonatal healthemergenciesSalubristas organize community birthplanning and implement obstetric andnewborn emergency transport teams(ETTs)Fathers gain knowledgeand skills about maternaland child careMoH health staff gain technicaland managerial skills provide animproved environment formothers, fathers and familiesIncreases joint decisionmaking about careseekingSupports expecting andnew mothers with morehouseholdresponsibilitiesImproves healthybehaviors of householdmembersbefore, during, and afterbirthHealth services providehigh-quality and cultural-sensitive maternal andchild careCommunities with birthplans, functioning referralsystems for Maternal WaitingHouses (MWHs)Care Intervention Impact ModelSupporting Women in Timely Care Seeking for Maternal and Neonatal HealthReduces harmful gender norms thatprevent women from accessing timelyobstetric and newborn care servicesImproves family-level self-referral andcommunity-level referrals to appropriateinstitutional health services and increasesdemand for these servicesImproves quality of antenatalcare, institutional deliveries, and ultimatelyhealthier pregnancies and newbornsCommunication Coordination

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