EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santénet2 - 2013)

EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL
TABLE OF CONTENTS
ACRONYMS ................................................................................................................................................... 3 EXECUTIVE SUMMARY ................................................................................................................................. 5 BACKGROUND5 ASSUMPTION.7 GOALS OF THE STUDY General objective..7 Specific objectives.7 Expected results.7 METHODOLOGY Study type..8 Study zone.8 Selection criteria of communes..9 Study length..9 Study population9 Study activities.10 Principles stages of the study11 LIMITATIONS OF THE STUDY14 RESULTS Capacity building of the actors15 Support of the organization of community emergency evacuation system18 Qualitative results19 Register indicators of service utilization..24 DISCUSSION Recognition of danger signs and referrals27 Comparisons of the indicator changes ..28 Implementation of solidarity funds and evacuation systems.29 RECOMMANDATIONS32 ATTITUDES TOWARD THE CONTINUATION OF THE PROGRAM32 SCALING OF THE PROGRAM33 Results33 Community emergency evacuation system.33 Service utilization35 CONCLUSION40 ANNEX.41
USAID/Santnet2 is implemented by RTI International under contract No. GHS-I-01-07-00005-00, in partnership with CARE International, CRS, PSI, IntraHealth International and, DRV.
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ACRONYMS
ANC CHD 1 CHD2 CHU CHV CME CSB DHS ONE c-IMCI
Antenatal Care Centre Hospitalier du District niveau 1 (District Hospital Center, Level 1) Centre Hospitalier du District niveau 2 (District Hospital Center, Level 2) Centre Hospitalier Universitaire (University Hospital Center) Community Health Volunteer Complexe Mre Enfant (Mother Child Health Complex) Centre de Sant de Base (Basic Health Center) Demographic Health Survey
Obstetrical and neonatal emergency

Community based Integrated Management of Childhood Illnesses
C-ONE
GM HC HF HMIS HO IFA IPT KMs MES NA NGO LLIN PoNC
Community-based care for obstetrical and neonatal emergencies

Group of Men House Call Health Facility Health Management Information System Health Official Iron and Folic Acid Intermittent Preventive Treatment Kaominina Mendrika salama Medical Evacuation System Not Available Non-Governmental Organization Long-Lasting Insecticidal Net Postnatal Consultation Page 3
PW SDC SP SSI ST USAID
Pregnant Women Social Development Committee Sulfadoxine Prymethamine Semi-Structured Interview Support technician United States Agency for International Development
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I-
EXECUTIVE SUMMARY
The C-ONE project helps the community prevent possible dangers before, during, and after childbirth, both for pregnant women and newborns. In general, the perception of the population stays positive for an extension of practices in excellence. Another point that was evoked during the course of the study was the importance of partnering the public and private sectors in reinforcing the capacities of the CHVs. Investment at the community level comes through the partnerships of NGOs and Fokontany. It is important to recognize the importance of the CDS and to request the help of Health Officials. Their support is needed in the stimulation of the request and the offer of services at a community level.
Reinforce the capacity of the CHVs to address the first delay: the delay in the decision to seek a referral. Reinforce the role of the CDS to address the second delay: the delay in the transfer or in the medical evacuation.
Families, communities have a better understanding of obstetrical and neonatal emergencies after information, awareness raising and adoption of appropriate attitudes for maternal and child health. Community knowledge and understanding of danger signs, late decision making with all its negative impacts and obstetrical and neonatal emergencies enable decision making for all engagement. Community capacity to recognize danger signs and referral of all complication cases has increased. Community engages to manage evacuation systems by defining action plans to set up means of transport, solidarity funds to support emergency cases. Community engagement consists of:
Organization, management and setting up responses at the commune level to NEO cases. Rapid referral of emergency cases and capacity of appropriated health centers managers are improved to reduce all risk factors to maternal and child mortality. Setting up local transport system and solidarity fund based of common funds to facilitate transfer of ill people and support transport and medical fees are resolved through community common engagement. CHV and CCDS training on recognizing danger signs among pregnant women and new-born enables to raise awareness among families and community to help them adapt a decision making attitude in timeframe to evacuate cases to health centers, to receive appropriate treatment and to mobilize community to set up local and adapted transport means to situations and finally constitution of solidarity fund or family funds adjusted to community needs.
It should be noted that CHV can sensitize pregnant women, families and communities during their home visits or during discussions, public awareness raising sessions or community meetings and assisted by CCDS members. Results of the study confirmed that the majority of pregnant women and families could recognize danger signs among pregnant women and new born. The transmission of CHV message was efficient event for cases among people of low education.
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CHV capacity to monitor pregnancy early enough enables referral of pregnant women to ANC at the beginning of the first quarter. Awareness of women on advantages and services offered during ANC increases women knowledge on necessity to get service package within health centers (CSB). CHV referral of emergency cases linked to pregnancy was improved by community responses to NEO. Between 2009 and 2010, indicators have changed a lot concerning ANC and referred deliveries that have increased. Community awareness raising conducted by CHV combined with IFA distribution to pregnant women have enable more and more women to get IFA and have been referred to malaria.
II-
BACKGROUND
The extent of maternal and newborn mortality indicates a major developmental failure. Worldwide, more than 500,000 women die each yearapproximately one per minuteduring pregnancy, during childbirth, or shortly following childbirth. In addition, every year there are 4 million stillborns and 3 million premature newborn deaths. This means that, annually, maternal morbidity and a lack of quality care cause 7.5 million deaths. About 5 million of these deaths are linked to AIDS, tuberculosis, and malaria. In Madagascar, approximately 8 women die every day from pregnancy complications, before childbirth, during childbirth, or post-partum. In other words, each month, maternal deaths are equivalent to those of a 747 airplane crash. In 1997, 2003, and 2008, the ratio of maternal mortality in Madagascar has remained fairly consistent (source: DHS 1997, 2003 and 2008); there were, respectively, 488, 469 and 498 maternal deaths for every 100,000 live births. The ratio of infant mortality, based on these same studies, has declined; there were, respectively, 40, 32, and 24 infant deaths for every 100,000 live births. The Millennium Development Goals target of reducing maternal mortality by three quarters and that of child mortality by two thirds by 2015, brought the countries of the world to invest in new energies and new resources its efforts to provide maternal health services equitable. The reduction of maternal and neonatal mortality is one of the Malagasy Government's priorities. In fact, people often face a series of barriers that restrict access to appropriate care: Low decision latitude of women, Insufficient and inappropriate transportation, Difficult geographic accessibility of health facilities, Difficulty of communication between villages and health centers
These constraints cause delays in access to emergency services which can cost the lives of women and newborns.
The Roadmap for the reduction of maternal and neonatal mortality 2005-2015 is the framework of actions for the reduction of maternal and neonatal mortality in Madagascar. Page 6
The main strategies recommended were then respectively the updating and strengthening the policy and organizational program, improving the quality of services in maternal and neonatal care including family planning, strengthening the referral system, and improving communication on maternal and neonatal care, and improving the practices of families and maternal and neonatal care at home This study is to experiment the promotion of community partnership to address This study experiments the promotion of community partnerships to address obstetric and neonatal emergencies at ONE within the community if communities assume part of the responsibility for ONE, the collaboration between health services, NGOs, and community structures can be reinforced, which should help reduce inaccessibility to ONE and lead to improved maternal and infant health. The results of this study will guide the implementation of a monitoring system within 800 KM salama to improve strategies and make available the necessary resources to meet the identified weaknesses regarding ONE to reduce the rate of maternal and neonatal mortality in Madagascar.
III-
ASSUMPTION
There are three key strategies to use when working to decrease maternal and infant mortality in childbirth:
1. 2. 3. Family planning Childbirth assistance by a trained professional Emergency obstetrical and neonatal care (ONE)
Within the realm of the third strategy, populations face many possible barriers that may limit access to ONE. For instance:
Ignorance of danger signs and limited female decision-making power. Insufficient and inadequate transportation system. Limited geographic accessibility to health facilities. Limited functionality of the communication system between villages and health centers.
These various constraints lead to delays in access to emergency services that can cost the lives of women and newborns. When examining the question of why mothers and infants die during the process of childbirth, there are three main points of delay to address in which all obstacles fall:
1. 2. 3. A delay in the decision to seek consultation. A delay in transportation. A delay in the administration of care.
This study focuses on enabling communities to address the first two delays.
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IV-
GOALS OF THE STUDY
The goal of this study is to help reduce maternal and neonatal mortality by promoting a partnership AT the community level to respond to obstetric and neonatal emergencies. IV.1. GENERAL OBJECTIVE Evaluate the role of the community in the response to obstetric and neonatal emergencies and determine the strategies for large scale intervention implementation. IV.2. SPECIFIC OBJECTIVES

Inventory of abilities supported in SONU at all levels of the health system and at the end of the intervention Measure the perceived changes concerning the attitudes of families and communities in the decisionmaking process and the organization of transportation for suitable evacuations during ONE in the intervention and control zones. Analyze the determining factors in the communitys capacity to respond to obstetrical and neonatal emergencies. Make recommendations for the future implementation of obstetric and neonatal emergency care AT the community level (C-ONE).
IV.3. EXPECTED RESULTS

At the family, community, and CHW level, a better understanding of obstetric and neonatal emergencies, and an adoption of suitable behavior regarding family health. Increased capacity of the community and of families to recognize complications. Increased capacity of the community to manage a system for emergency evacuations.
V-
METHODOLOGY
This study is a combination of qualitative and quantitative research, including:

Focus group and structured interviews with CHVs, SDC, PW, and GM. Structured interviews with those in charge of childbirth in each of the communes involved in the study. Statistical analysis of the CSB, CME, CHD1, and CHD2 registers.
V.1. STUDY TYPE This is a quasi-experimental study with a control group. V.2. STUDY ZONE
The study took place in Marovoay, Ambato Boeny, and Mahajanga II districts in Boeny region. The study was conducted in 23 communes divided into three groups: Group 1: KM salama communes activities with UON-c Group 2: KM salama communes activities without UON-c Group 3: non-communes KM salama and in which there are no activities UON-c
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Table N1: List of communes to the study

DISTRICT MAHAJANGA II COMMUNES Belobaka Boanamary Ambalakida Betsako Antanambao Andranolava Ambolomoty Tsararano Ankazomborona Marovoay Banlieu Marosakoa Ankijabe Andranofasika Anjiajia Tsaramandroso Ambondromamy Andranomamy Manerinerina Manaratsandry Anosinalainolona Maroala Ambalabe befanjava Antanambao manarenja Maromiandra
GROUP 1 (10 communes)
MAROVOAY
AMBATO-BOENY GROUP 2 (7 communes)
MAROVOAY GROUP 3 (6 communes) MAHAJANGA II
Groups 2 and 3 constitute the control sites of the study. V.3. SELECTION CRITERIA OF COMMUNES
Existence of a reference and counter reference system Ability of CBS to provide SONU services Presence of community structures Intervention area of technical and financial partners and strengthening SONU community activities For the control sites: Communes with the same socio-demographic criteria and infrastructure as the intervention sites
V. 4. STUDY LENGTH
The study lasted 18 months Period of collection data for the study: from October 2009 to March 2011.
V.5. STUDY POPULATION

Community Health Volunteers Women and members of their families, including men Members of the Social Development Committees (SDC) and local authorities (mayors, heads of the fokontany, etc.) in the KM salama communes. CHU, CHD, and CSB service providers.
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V.6. STUDY ACTIVITIES The proposed study entailed six principal types of activities
1. Preparation Phase
The study preparation consisted primarily of courtesy visits to the administrative authorities, decentralized services of the region, medical districts, and communes. These visits are conducted in order to inform them of the study that would be conducted in their locality and obtain their engagement. This phase facilitate the implementation of the studys activities. During these visits, regional health directors, heads of SSDs, heads of the CSBs and mayors of the communes were approached.
2. Investigators Training
A training of investigators took place in December 2009 in order to conduct a survey at the CSB level to gather basic data and create an inventory of the ONE services offered at health facilities. The collection of these base figures was completed after the preparation for the study and the collection of CSB service data. The training was based on filling out survey cards, focus group management, and note-taking. The trainees were also given important notes on the study protocol.
3. Data Collection Interviews of the health providers in the intervention zones and control zones In order to collect data on the performance of health facilities in ONE, a basic survey was conducted with the service providers within the health facilities at all levels within both of the intervention zones and the control zones: CSB1 and CSB2 at commune level, CHD at district level, and Mahajangas CHU/CME. The analysis of this information helped identify the strengths and weaknesses of each intervention zone in terms of ONE. Document review The first purpose of the document review was to simply update the statistics of obstetric and neonatal complications and maternal deaths, and to comment on the community reactions vis--vis for obstetric and neonatal emergency systems. Next, it was necessary to review the registers of hospitals, CSB, and CHD, looking specifically at obstetric and neonatal services. A similar analysis was conducted with the CHVs on the response of the population to obstetrical and neonatal emergencies. The data before and after the intervention was compared in order to document any changes; the same data was collected again during the final evaluation, using the same data collection tools as that of the initial survey, in order to measure the change in the functionality level of ONE services offered. Confirmation of Data Conformity
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Follow-up and support sessions took place four times a year with the SDC and the CHVs in the KMs communes (Groups 1 and 2). In these sessions, the support technicians worked with community actors in the application of a C-ONE system and checked the impact of this system on the community in general. Any problems encountered and their solutions were discussed. 4. Data Processing and Analysis Processing The focus groups and various interviews were recorded with the help of a dictaphone, and the discussions were transcribed and translated into French. The discussion group transcriptions were processed manually, sentence by sentence and question by question, in order to extract all the ideas discussed and to examine each objective of the study. Analysis Analysis were conducted in order to determine the results and to highlight recommendations for a suitable strategy in the future. - Analysis of results by group type. This analysis was conducted to see the similarities or convergences and differences between each player and category considered. - Analysis of the structured interview data. 5. Final Report
The final report identifies the gaps between the planned activities and the actual implementation during the study. The preliminary results were discussed with the principal stakeholders. The participants analyzed to what extend the studys hypotheses and expected results were confirmed. The participants also identified supplemental analysis needed to better explain the results vis--vis the hypotheses. The primary conclusions and recommendations for future implementation have been reproduced and disseminated. The final report is in a format to be shared with other organizations and partners of the public and private sector interested in using the same model in their intervention zones. It helps inform and guide the Ministry of Health in the application of the lessons learned and results obtained from the implementation of this model.
V.7. PRINCIPLE STAGES OF THE STUDY

1. CHVs Capacity building 1.1. Training Profile of the trainers The trainer pool was composed of supervisors, support technicians, and medical personnel. The majority held a high school diploma minimally. Doctors and midwives had further education. Length of the training o Duration: 2 days o Participants: CHVs o Number of CHV trained: 126 (50 in Mahajanga II and 70 in Marovoay)
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Training content
The training focused largely on:

Research on pregnant women in the villages Importance of ANC and the general plan for childbirth, especially in regard to: the existence of solidarity funds and community-based means of transportation the definition of childbirth the advantages of childbirth at a health center the recognition of danger signs in pregnant women and newborns the importance of safe motherhood, care, and early follow-ups Measures to be taken in case of emergency by all actors involved and their respective roles, how to promote public awareness in target groups, negotiation, group discussion using brochures and booklet, and the procedures for using the health management information system (HMIS). 1.2. Supervision System of supervision
The supervision of the CHVs activities was carried out through different levels and by multiple people who each had their own specific roles, according to the following diagram:
Figure 1: Supervision system
RTI/Santenet2
NGO
Supervisor NGO
Independent trainers
Support technician
CSB/CDS
CHVs
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This diagram shows the supervision of the CHVs by the SDC and officials from the CSB and SSD, and the NGOs support technician. This support technician is supervised in turn by the NGOs supervisor. The independent trainers supervise the CHVs during trainings (twice each year). All is overseen by the heads of the project at the NGO (ZETRA) and by RTI/Santnet2. The respective roles of the different actors in the system of supervision is described in Annexe 1
2.
Support of the organization of community emergency evacuation system (community solidarity funds and means of transportation).
To evaluate the CHW and SDC activities in relation to the action plans, and to evaluate the implication of the community in response to ONE, follow-up activities were done during the monthly reviews in order to reinforce the capacity of both CHVs and SDC to work with their communities to resolve problems linked to referral systems and solidarity funds. Photo1 : modle de moyen de transport (pirogue), Betsako
3. Final evaluation
Following the investigator training, surveys were conducted with structured interviews with the persons in charge of childbirth in the communes of the study (27 health professional trainings) and also AT the CHU/CME Mahajanga, CHD2 Marovoay, and CHD 1 Ambato-Boeny in order to find indicators of services. Focus groups were also carried out.
Focus groups
40 focus groups in 10 communes are performed. The table below illustrates the focus group participants: Table 2: Focus Groups Group participants CHVs SDC Members Pregnant Women Group of Men Number Involved 90 80 56 56
Extended interviews with those in charge of childbirth
Meetings took place directly with each selected individual and the investigators. A total of 27 structured interviews took place in the studys communes.
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Register consultations
The registers of consultations in 27 communes in the three districts of intervention were consulted to see the results for the indicators related to pregnant women and newborns. Registers of consultations at the CHD2 of Mahajanga II, the CHD1 of Ambato Boeny and the CME of the CHU Mahajanga were also consulted.
VI-
LIMITATIONS OF THE STUDY

1- Constraints during the execution of the study o Security problems on the ground produced a negative impact on the ease and the psychological state of the research team conducting the interviews, and also required obligatory regrouping of the team and drastic security measures, like finding a guide and using a public school for lodging. The problem of inaccessibility in certain intervention zones with breaks over days of work clearly had an influence on the planning of the study. Consequently, it was decided that the communes Mariarano and Bekobay (both within the Mahajanga 2 district) needed to be removed from the list of communes to be used in the study.
2- Incompatibility of the methods with local habits and customs
Using a stretcher carried on the soldier of two individuals is not compatible with the local habits and customs. People consider stretchers to be reserved for the dead. A majority of the communities, therefore, need better transportation system. This implies that there is still a need to educate and work with certain communities on their evacuation systems.
3- Difficulties in solidarity fund implementation
Stretchers are very difficult to accept for the majority of the population. Theyre meant for the dead
(CHV, 40 years old, primary school educated, Antanambao Andranolava, Marovoay).
For certain communesabout 3 out of 10the communities had trouble implementing solidarity funds because of challenges finding people to place in charge of the management of funds, a preexisting lack of trust relating to the management of public funds, and the challenging of fixing the contribution amount to be given by the community.
4- Measuring improvement
One limitation in this study is in improvement measurements. The measurements are dependent on the number of complications that occur. Variations in the number of complications from one year to another or from one zone to another could skew the results. Because it is impossible to control the
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number of complications, it is helpful to use other aspects of the study when analyzing the results, such as interviews and focus groups. For instance, even if a commune has few complications, the impact of the study can still be determined by examining the ability of CHVs and pregnant women to recognize the danger signs presented by pregnant women and newborns. In the future, the impact of this limitation could be reduced by increasing the number of communes being studied.
VII-
RESULTS
CHV PROFILE Male Female Years in school Median age Single In union 44% 56% 7 40 years 17% 83%
1. Profile of the Community Health Volunteers
VI.1. CAPACITY BUILDING OF THE ACTORS
In general, all of the CHVs had already worked in the health domain, including maternal and child health. Some CHVs did mosquito net public awareness, community care for illnesses in children under 5 years of age, hygiene, prenatal consultations, STIs and HIV/AIDS work, and worked with pregnant women and the PCIME-C.
2.
Community health volunteers competency: Recognition by CHVs of Pregnant woman and newborn danger signs
86% of CHV recognized pregnant women danger signs and 94% the newborn danger signs. CHV immediately recognize seven pregnant women danger signs out of 12 (58%). These symptoms are: Pale or icteric mucous membranes, Cuts and wounds, Intense pain in the lower belly and back, Fever, Hemorrhage, Uncotrollable vomiting and Convulsions. They did not recognize failure to gain weight and vaginal discharges as pregnant women danger signs. About knowledge of CHVs concerning the newborn danger signs, they immediately recognized the majority of danger signs presented in newborns but needed help identifying one sign: redness or swelling at the base of the umbilical cord.
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Figure 2: Recognition by CHVs on the danger signs presented by pregnant women.
Recognition by CHVs on the danger signs presented by pregnant women

120% 100% 80% 60% 40% 20% 0%
Spontaneous response YES
Assited response YES
Did not know
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Figure 3: Recognition by CHVs on the danger signs presented by pregnant women.
Recognition by CHWs of the danger signs presented in newborns.

120% 100% 80% 60% 40% 20% 0% 94% 83% 97% 83% 50% 39% 11% Redness or swelling at the base of the umbilical cord Did not know 89%
3% 2% Refusal to breastfeed
6%11% Lethargic
3% 0% Hyperthermia or hypothermia
6%11% Difficulty breathing
8% 3% Vomiting
Spontaneous response YES 3. SUPERVISION
The quantitative survey of CHVs revealed the participation of public and private entities in the system of supervision. The following table summarizes the percentage of CHVs according to the entities which supervise their activities. Table 3: Entities overseeing supervision Person in charge of supervision NGO personnel Health personnel Comit de Dveloppement Social (Kaominina Mendrika) None Number of CHV with positive response 60 27 3 1 % 87.3 12.5 2 0.9
87.3% of the CHVs affirmed that supervision is assured by NGO personnel, at namely that of ZETRA. This organization has a widespread structure in the communities for the implementation of the project. 43.5% of the CHVs spoke of the participation of the health personnel in the system of supervision.
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V.2. SUPPORT OF THE ORGANIZATION OF COMMUNITY EMERGENCY EVACUATION SYSTEM (community solidarity funds and means of transportation). 1. Communication Means for Discussing Community-Based Obstetric and Neonatal Emergency Care
Community gatherings provide opportunities to spread C-ONE messages. 66.7% of the CHVs used them to communicate the presence of this project. The advantage in this approach is that the presence of community leaders validates the legitimacy of the message. 12.4% of the CHVs were interested in speaking AT festivities; however fairs and festivals offer few opportunities for CHVs to speak. Only 6.7% of the CHVs took advantage of religious gatherings to speak on the importance of C-ONE. Using posters was only possible when other organizations (cultural, social, health, etc.) were also being displayed.
2. Materials Used for Public Education
91% of CHVs used a technical poster relating to mothers and newborns. The CHVs also used other materials for additional support, like mother-child pamphlets. Tableau 4: Transportation system DISTRICT COMMUNE Number of fokontany with transportation system 9 4 4 4 7 2 9 9 5 7 60 Number total of fokontany TYPE
Mahajanga 2
Marovoay
Belobaka Boanamary Betsako Ambalakida Ambolomoty marovoay banlieu Marosakoa Ankazomborona Tsararano Antanambao Andranolava TOTAL
9 4 4 4 7 2 9 9 5 7 60
- Car - Taxi-brousse - Charette - Stretcher
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Tableau 5: Solidarity funds District Commune Fokontany Type Operating adhesion Women older than 18 years Women older than 18 years Women older than 18 years Women older than 18 years Women older than 18 years Per household Number of Membership Not available Not available
Mahajanga 2
Belobaka Boanamary
8 3
Monthly subscription Monthly subscription (Ar 300) Monthly subscription Monthly subscription (Ar 200) Monthly subscription Monthly subscription
Betsako
Not available
Marovoay
Ambolomoty
180 persons
Marovoay banlieu Marosakoa TOTAL
95 persons
8 31
44 households
All the fokontany included in the study have established a transportation system for ensuring pregnant women reference in case of emergency. However, only half of them have constituted a solidarity fund at the end of the study. Figure 4: Transportation system and solidarity funds implementing in the study zone
Transportation system and solidarity funds implementing in the study zone in 2010
120% 100% 80% 60% 40% 20% 0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
89%
75%
75%
100% 0%
100%
89% 0% 0% 0%
% of fokontany with transportation system
% of fokontany with solidarity funds
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The presence of communal funds in a locality allows the community not to worry about the population in case of medical emergency, and it also reinforces the motivation and consolidates the organization of the community. The women who benefited (10 pregnant women) could not have survived if an evacuation system had not existed in their locality. The population in general found the presence of communal funds to be important, and requested extension into other communities and targets.
V.3. QUALITATIVE RESULTS
Almost all of the actors involved, including community leaders, CSB leaders, and NGO officials, agree that the application of C-ONE is effective. They think that the program contributes fighting against poverty and improving the family economy. A woman with no complication of pregnancy due to the effect of childbirth unprepared reduces unforeseen expenses.
Photo2 : chantillon focus group des femmes enceintes (Marovoay Banlieue)

1. Benefits in relation to mother and child health
The mothers will no longer have difficulty coming to the CSB 2

(Head of fokontany, Andakalaka, Marovoay Banlieu, 61 years old)
The improvement of the health of mothers and newborns is a major advantage according to the mayors interviewed. This is because of better health and a removal of fears related to giving birth at the CSB. If the mothers are in good health, the children can all go to school, and in that way we will overcome illiteracy
The reduction of infant mortality was also (Mayor, Ambalakida, 44 years old) evoked, due to an improvement in child education. Indeed, according to community officials, the populations good health would become a pillar for fast development and for the durability of the commune. Page 20
2.
Perception of CHVs Public Education Work
The majority of pregnant women, men, and SDC members generally approved of the importance of the messages given by the CHVs after their training.
Easy access to health information
We (pregnant women) organized a trip to the CSB with the CHVs every Wednesday for prenatal consultations right up until childbirth like in the case of our friends
(Pregnant woman, 31 years old, secondary school educated, Vololona, Ambalakido, Mahajanga 2).
There are numerous advantages to collaborating with CHVs. According to the majority of the studys targets, CHVs were able to work with individuals and educate the public in their homes. House calls also created an occasion for detailed explanation, eliminated group influence on individual decisions, and ensured confidentiality to the discussion. At the hospital, there are too many people, and its difficult to really understand explanations. At home its calm and quiet and you can really listen well
(Pregnant woman, 26 years old, primary school educated, Ankazomborona).
According to health officials, better access to health information gives women more opportunities to get exposed to the information, and increases the rate of external consultations.
At home we can ask all the questions that worry us

(Pregnant woman, 28 years old, secondary school educated, Boanamary).
Friendly relations
Its good because these are people coming from the society
(Head of fokontany, 48 years old, Ankazomenavony, Belobaka)
If everyone can work, poverty will be reduced. The commune will have financial autonomy and that would automatically involve development
(Man, 44 years old, Betsako)
CHVs are people coming from the society itself, so they are familiar with the population. This familiarity with the population allows for friendly and confidential relations, and thus there is no obstacle between the CHVs and the targets during the public education and the explanations of the messages.
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3.
Successful public education and CHV credibility
The public education from the CHVs was well received by the community. When its a woman, she is considered a midwife, and when its a man, he is taken for a doctor; whatever they say is taken seriously
(Doctor, Ambolomoty).
While the CHVs are from the community itself, they are also capable, because they have received the training necessarily to educate the public and answer any questions the targets might ask. They are credible, according to all of the pregnant women and the SDC and the majority of technicians, the CHVs were even considered essentially health personnel.
Its good to use CHVs; because they were trained well, they can educate well
(Head of fokontany, 43 years old, Beronono, Marosakoa).
4.
Persuasiveness of the CHVs
During focus groups, the majority of participants spoke well of the persuasiveness of the CHVs. Other ideas related to the CHVs also came out of this study, including the following:
The majority of focus group participants (92%) mentioned the effectiveness of public awareness for large groups of the community. A minority of participants also mentioned the importance of the presence of the CHVs in the community. Their presence helps create a sense of security.
We are convinced of the importance of early care for pregnant women and prenatal consultations and the recognition of danger signs as well as the importance of implementation of transportation system for evacuations after a story shared by the CHVs after training, the story of [Rabary and Martine]
(Letozy, PW, 29 years old, secondary school educated, Antanambao Andranolava).
5.
Proximity to services
Because the CHVs come What the CHVs do is goodtheyre different from midwives, from the communities, they explain a lot of things, they do meetings and house calls, the they live in the same midwives are far away villages as the targets. Therefore, the targets do (Pregnant woman, 18 years old, secondary school education, not need to travel to Manerinerina). learn more about healthy pregnancies. This is especially true because the distance separating certain villages from health centers can be dozens of kilometers, while the only means of transportation can rely largely on traveling by foot or by oxcart.
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The presence of CHVs would be a solution to problems affecting more isolated regions.
6. Pregnant women competency
The percentage of pregnant women knowing pregnant women danger signs and the newborn danger signs is the same (77%). They immediately recognized half of pregnant women danger signs: cuts and wounds, intense headaches, uncontrollable vomiting, intense pain, fever and hemorrhage. They did not mainly recognize 2 danger signs: failure to gain weight and pale or icteric mucous membranes. About knowledge of CHVs concerning the newborn danger signs, they immediately recognized the half of newborn danger signs: lethargic, vomiting, and hyperthermia or hypothermia. CHV did not recognize the refusal to breastfeed as a danger sign in newborns. Figure 5: Recognition of danger signs by pregnant women.
Recognition of danger signs by pregnant women.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Did not know
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Figure 6: Recognition by pregnant women of danger signs presented by newborns
Recognition by pregnant women of danger signs presented by newborns

80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 63% 43% 32% 25% 9% 18% 23% 14% 45% 29% 27% 20% 20% 13% 63% 68%
18%
Refusal to breastfeed
Lethargic
Hyperthermia or hypothermia
Difficulty breathing
Redness or swelling at the base of the umbilical cord Did not know
Vomiting
V.4. REGISTER INDICATORS OF SERVICE UTILIZATION 1. General Services
The results of indicators are much higher in areas implementing KM salama with or without implementation of the activity UON-C. But this is much more visible in the group implementing KM salama and UON-c Table 6: Evolution of indicators in the three groups Group1: C-ONE and KMs (10communes) Indicators 1stANC 2 or more ANC ANC Total (4ANC) VAT2 or more IPT1 IPT2 PregnantWomen(PW)who took IFA Childbirth 2009 2,869 3,448 3,162 2,875 2,676 2,585 2,753 2,673 2010 2,860 3,498 3,270 2,475 2,793 2,629 3,107 2,600 Variations -0.3% 1.5% 3.4% -13.9% 4.4% 1.7% 12.9% -2.7%
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Group2 : KMs not C-ONE (7communes) Indicators 1stANC 2 or more ANC ANC Total (4ANC) 5,845 VAT2 or more 4,825 IPT1 3,511 IPT2 3,228 PregnantWomen(PW)who took IFA Childbirth 3,432 3,268 4,812 3,275 -11.7% 4,249 -4.8% 3,604 1.5% 4,382 2.6% 5,934 -9.2% Before KMS (2009) 4,073 5,000 During KMS 3,972 5,059 1.5% Variations -2.5% 1.2%
Group3 : Not C-ONE and not KMS (9COMMUNES) Indicators 1stANC 2 or more ANC ANC Total (4ANC) VAT2 or more IPT1 IPT2 PregnantWomen(PW)who took IFA Childbirth 2009 1,245 1,786 308 964 1,241 328 717 456 2010 741 1,498 287 658 860 406 457 293 Variations -40.5% -16.1% -6.8% -31.7% -30.7% 23.8% -36.3% -35.7%
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Figure 7: Evolution of indicators at CSB level in the 3 groups

4,000 3,500 3,000 2,500 2,000 3,498 1,500 1,000 500 0 1st ANC 2 or more ANC Total ANC (4 ANC) VAT2 et plus IPT 1 IPT 2 Pregnant Childbirth Women (PW) who took IFA 2,860 3,270 2,475 2,793 2,629 3,107 2,600 2,869 3,448 3,162 2,875 2,676 2,585 2,753 2,673
Evolution of indicators in Group 1
2009
2010
7,000 6,000 5,000 5,000 4,073 4,000 3,000
Evolution of indicators in group 2

5,845 4,825 3,511 5,934 5,059 3,972 4,382 3,604 4,249 3,275 3,268 4,812 3,432
3,228
2,000 1,000 0
1st ANC
2 or more ANC
ANC Total (4 ANC)
VAT2 et plus
IPT 1
IPT 2
Pregnant Childbirth Women (PW) who took IFA
Before KMS 2009
During KMS
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2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 741 1,245 1,786 1,498
Evolution of indicators in Group 3
1,241 964 860 658 308 287 406 328 717 457 456 293
1st ANC 2 or more ANC Total VAT2 et ANC (4 ANC) plus
IPT 1
IPT 2
Pregnant Childbirth Women (PW) who took IFA
2009
2010
2.
Referred Cases, Solidarity Funds, and Transportation Systems
In 2010, there are few solidarity funds set up in the communes and the health evacuation system established are under used by communities Table 7: Comparison of referred cases, solidarity funds and transportation systems in 2009 and 2010
Pregnant women referred presented danger signs
Newborn referred presented danger signs
# of solidarity funds implementing
# of cases using the transportation system implementing 2009 0 0 0 2010 9 0 0
Groupe 1 Groupe 2 Groupe 3
2009 69 105 18
2010 74 107 13
2009 2 65 0
2010 2 33 0
2009 0 0 0
2010 6 1 0
The results of the study show that: - In 2010, 6 out of 10 communes have implemented solidarity funds in group 1, but the use of the transportation system implemented is still low compared to referrals. In group 2: referred cases are much higher than in the other 2 groups, but only one commune has constitutes a solidarity funds. None referred case has uses the transportation system implemented. In group 3: no solidarity fund and no evacuation system were established.
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VIII- DISCUSSION
VIII.1. RECOGNITION OF DANGER SIGNS AND REFERRALS
It was noted during the study that it can be effective to have CHVs educate the public in pairs. But most importantly, it was noted that the effectiveness of the awareness raising was not dependent on the gender or CHW type (Mother CHVs or Child CHVs); during the interviews it was clear that all communication channels can be used to good effect, like home visits, mass public education, technical posters distributed by the CDS, and periodic meetings with the CDS. The majority of the CHVs (86%) and more than two thirds of pregnant women (77%) were able to recognize the danger signs presented by pregnant women and newborns. This result demonstrates the competence of AC to transmit the messages to the targeted population. Note that almost half of the pregnant women have very minimal education. That being said, there are still gaps in the recognition of the danger signs presented in pregnant women. 23% of pregnant women interviewed did not recognize women pregnancy and newborn danger signs. This may be due in part to the lack of tools in the possession of pregnant women, mothers and caregivers. Without tools as a memory aid, they have difficulty in retaining messages.
VII.2. COMPARISONS OF THE INDICATOR CHANGES BETWEEN 2009 AND 2010 1- Group 1 : communes implementing KM salama and C-ONE approach Compared to the previous year, the number of pregnant women monitored during their first ANC, those having received VAT2 injection and those having delivered at CSB were reduced for the 3 groups (focus groups and witness group) during 2010. But this variation is a lot lower in the communes implementing KMsalama and community-based ONE at the same time.
This situation is linked to the positive results on awareness activities conducted by CHV and to the mothers belief on the importance of early management of maternal and new born health.
It is notable that following repeated awareness efforts by the CHVs, prenatal consultations took places earlier, more pregnant women took IFA, and more women were able to give birth at the CSB. For certain communes, the community decided to construct a hut to lodge the families of the pregnant women in order to reduce the costs and increase the motivation to give birth at a medical center and stay for two days.
Following the sensitization by the CHVs and supported by the community distribution of IFA in 2 communes (Belobaka and Boanamary), an increase of 13% was detected in women taking IFA compared to the previous year (2009). 2- Group 2 : communes implementing KM salama approach
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These results are more or like similar to group 1. The number of pregnant women coming to CSB for their first ANC was reduced during 2010 (3% of reduction) compared to the number of ANC 2 and the number of total ANC has increased to 1% for ANC2 and 2% for total ANC. Also, the number of women having delivered at CSB have decreased by 5% compared to results in 2009. For childbirth it was noted that in certain communes, in particular the commune Manerinerina, pregnant women were not amply convinced of the importance of giving birth at a medical center. This situation can be explained by two possibilities:
The CHVs, for fear of disturbing local practices, did not amply educate the pregnant women on going to medical centers for childbirth. In these cases, it is necessary to educate not only the pregnant women, but also the community in generalin particular the parents or officials who have authority in rural zones. There was not enough education, or the means or methods used by the CHVs for public education were not effective enough.
3- Group 3 : communes not KM salama and not implementing C-ONE activites
Public education is very important in our community but I work alone. I am in charge of both the CSB and childbirth. The population is too big for only one person in charge of health; therefore we request the presence of community health volunteers to help us (Chief of the CSB2 Manaratsandry, Marovoay).
All indicators linked to ANC and delivery have decreased. 41% of ANC1, 16% for ANC 2 and more, 7% for total ANC and 36% for delivery . This could be explained by the lack of public education and community mobilizations in these communes. Reduction of results is due to the furthermost of health centers and the impact of political crisis.
VII.3. IMPLEMENTATION OF SOLIDARITY FUNDS AND EVACUATION SYSTEMS 1. For communes with C-ONE and KMs (Group 1)
Case 1: Existence of solidarity funds and existence of transportation system (car, dugout canoe, or others depending on the particular village) In this case, communes, more specifically seven communes (see Table 4), set up solidarity funds, and in the event of an emergency had transportation system available for the population, like a car or a dugout canoe. Following ONE education from the CHVs and SDC, these seven communes each established an ONE action plan for their respective communities. Provisions for the solidarity funds and transportation system were taken during the community meeting (fivoriam-pokonolona.) For the solidarity funds, the members were mostly female. These female members were older than 18 years, and decided themselves the amount of the contribution to pay. The cost varied from one community to another, but was generally between 200 and 300 Ariary per person per month.
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Among the members were health and CDS officials who ensured the maintenance of the funds along with the other members. Generally speaking, members seemed convinced of the importance of the existence of evacuation systems to medical centers, and actively participated in the contribution. That being said, public awareness is always necessary in certain localities. Transportation systems were generally managed by men. Certain men even proposed carrying the women by a stretcher on the shoulders of two men. Other localities relied instead on cars and dugout canoes. These cars and dugout canoes were offered by different individuals of the village who, thanks to a spirit of solidarity, were willing to contribute to the cause. The fuel was taken care of by the members and was paid for with money from the solidarity funds. Case 2: Use of transportation system but not communal funds. In this second case, the action plan put in place by communities did not necessarily require the existence of communal funds. Transportation system in case of emergency, however, did exist. Essentially, in communes like the rural Ambalakida, before the implementation of the C-ONE project, there already existed transportation system like oxcarts or cars that individuals volunteered to be used by the population in case of emergency. This was also the case for the commune Ankazomborona, where there were no communal funds, but thanks to public awareness sessions with transportation cooperatives in the locality, the cooperatives accepted to makes their car available in case of emergency. In this second case, a couple of problems exist. First, the cost of the fuel, which would generally be paid by the person wanting to use the car. And second, the car or oxcart could be unavailable AT times when needed. Case 3: Integration of the system already in place. Using transportation system from an ex-Angap project in the commune Marosakoa, the car from the park is always available for the community when needed, and especially during emergencies. In this commune there is an association for protecting the environment in the national park Ankarafantsika, and the majority of the population over 18 years of age are members. After a meeting on C-ONE, the people decided to increase normal contributions in order to really prepare for obstetric and neonatal emergencies. In other parts of the commune which are not accessible by car, transportation system like oxcarts was already in place. In all, it was found that among the ten communes focused on with UON-C in the study, seven have put communal fund systems in place that are already functioning, overseeing 54 communities throughout the intervention communes. 54 out of 65 communities (or 83%) have an evacuation system in place. 74 different cases of obstetric complications were referred by the CHVs. Of the 74 referrals to the CSB2, 10 pregnant women (or 13.5%) were transferred there using a system that was put in place through this study.
2. FOR COMMUNES WITH KMS BUT NOT C-ONE (GROUP 2)
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In the 7 communes included in this group, the commune of Andranofasika district of Ambato Boeny is the only one that could set up solidarity fund. No transport system for emergency evacuation has been set up in these communes. In general, for the seven communes that received KMs intervention in the study but not C-ONE, the prenatal consultations and the IPT 1 and 2 increased progressively. Childbirths decreased similarly women taking IFA at the CSB decreased due to stock shortages of IFA coming from the SSD in AmbatoBoeny. According to an in-depth survey, in all of the KMs communes, the number of pregnant women and mothers going to the CSB increased. This can be explained by the positive impact of the public education.
3. Communes with neither KMs nor C-ONE (Group 3)
In the 6 communes included in this group, noone of them could set up even one solidarity fund nor a transport system for emergency system. De mme comme spcifi plus haut, la plupart des indicateurs lis la CPN et laccouchement ont accus une baisse de 2009 a 2010. Ceci est du a linsuffisance de sensibilisations de la population. We need animators like in other communes to help us, because, considering the lack of personnel, we have difficulty accomplishing our work, especially since our district is very vast. The populations are accustomed to giving birth with the matriarchs. Moreover, people here dont want the person in charge of childbirth to a man, which I am, which explains the progressive decrease in numbers of women who get prenatal consultations and the number of women giving birth
(Childbirth official, Ambalabe Befanjava, Mahajanga 2).
In conclusion, results show positive effects of implemented activities in the KM salama communes. KM salama. KM salama approach objective is to strenghten local actors skills in order to encourage them taking care of their health. Communitys engagement and different community actors to take care of their health is stronger in communes implementing KM salama approach.
IX1.
RECOMMENDATIONS
Reinforce community engagement in the implementation of a medical evacuation system.
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2.
3. 4. 5.
Integrate the C-ONE training into the CHW training and make sure the supervisors integrate it into the management of the CHVs. The implementation of the system needs to take into consideration: a- Human resources (CHVs, CDS, pregnant women, transportation personnel, health personnel) b- Financial resources (communal funds) c- Material resources (stretchers, oxcarts, dugout canoes, cars, bush taxis) Organize an appropriate evacuation system. Determine transportation systems when necessary. Create communal funds larger than necessary, and take care of the eventual use of funds for health training. In order to ensure the functionality of the system implementation: a- Institutionalize the statutes to be set up. b- Support local responses as solutions to identified problems. c- Find local solutions for resource mobilization.
X-
ATTITUDES TOWARD THE CONTINUATION OF THE PROGRAM
Almost all of the actors involved wanted to continue the C-ONE program.
1. COMPATABILITY OF THE PROGRAM
Table 17: Percentage of C-ONE reception PERCEPTION OF THE COMMUNITY VERY RECEPTIVE RECEPTIVE NOT RECEPTIVE Total # 31 52 22 90 % 30 58 12 100.0
This opinion could be connected to the effective education of those involved in the project.
2. PROXIMITY TO SERVICE
All of the arguments mentioned above relating to the proximity to services were reiterated by all the players as a crucial motivation for the continuation of the program.
3. THE EFFECTIVENESS OF THE INTERVENTION OF THE CHVS
According to those involved, measurements would need to be taken if the program were to continue. According to the leaders of the CSB, the trainings would need to be amplified in content and frequency to give the CHVs the capabilities necessary in the accomplishment of their responsibilities. Those in charge of childbirth in each commune would also need to be trained in order to facilitate the follow-ups. The CHVs need more technical support from the technicians and supervisors. According to the CHVs, the administrative authorities like mayors and heads of fokontany need to be involved, not only for signing documents, but also for taking part in the training and popularization of C-ONE. A good communication and education campaign for all levels should go hand in hand with the continuation of the program. Everyone involved agreed on the importance of the program but the Page 32
necessity of good education on the implementation of communal funds and transportation systems for each commune. To do this, the CHVs could use house calls, public meetings, and media.
XI-
SCALING C-ONE PROGRAM
The promising results from the study enable the project to scale up C-ONE programme in the other project intervention communes. The objective is to reduce maternal and child mortality rate. CHV are trained with community integrated service packages to ensure maternal and child care. Their trainings started in July 2010 at the region level, after the broadcast of evaluation study results on community response to C-ONE. The project has trained CHV at first on early detection of pregnancy enabling referral of pregnant women to CSB for early antenatal care. Pregnant women were informed on all packages of services offered to motivate them to come at least four times before prior to delivery for a better preparation to maternity. IFA uptake advantages during 180 day were also shared and instructed to CHV who are raising awareness on IFA uptake by pregnant women to reduce anemia among pregnant woman and improve her nutritional status. Danger signs and referrals of emergency cases were instructed to CHV awareness raising was made to community to recognize them and the impact of the delay as well as the importance of setting up means of transport and solidarity funds to an immediate evacuation. CCDS members were then trained on NEO and on community mobilization for manage all cases. Community meetings enable setting up of community action plans on setting up evacuation health systems at the community level and organization and management of the systems. Community was mobilized on solidarity fund according to the established needs, status and management returning to community decisions. La mise en place de ces plans pour les urgences a convaincu la famille, la communaut car elles ont connu et compris limportance dune prise en charge temps, dune prparation aux ventuelles dpenses pour la maternit, dune rduction des risques lis aux urgences.
RESULTS
ICOMMUNITY EMERGENCY EVACUATION SYSTEM (Transportation system and solidarity funds)
Up to now, around 99% of communes (792 communes) are known to have set up community evacuation systems. 6,388 fokontany have their functional system. To date, 7,812 people have benefited from the evacuation systems, including 3,471 pregnant women and 1,272 newborns In addition, 3,069 other people benefitted from an evacuation system. Even if the Malagasy culture puts in priority help in front of hardships, setting up systems was done with a high commitment among community because of their knowledge and their understanding of the importance of the evacuation systems and the impacts of any delay to make decision, impacts of evacuation delay and lack of any plan to resolve financial difficulties for emergency cases.
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In almost all the communities, system was set up with a solid organization, without any issue on lack of time or unnecessary resources. Humanitarian assistance is almost volunteer; a rotation system is systematic to accompany sick people in need. Set up funds help to resolve families worries to different medical costs, transport costs and assistance during stay in hospitals. There is almost no refusal for any emergency need because everyone thinks that this could happen to any other family. There are some cases where community is aware that if the evacuation system is not established, charges related to the accompanying families can surely overlap those necessary to the patient medical costs. That is why their commitment to put in place a very effective system with rotation so that all people accompanying patients are efficient and reliable to all evacuation needs. Even in any system like the filanjana, the boat or the shaw, community always recognize that these systems are a great need for them, and this is the timeliness acknowledgment of emergency cases and the decision making on time that can resolve their helpless situations. Established solidarity funds are of great help to any desesperate cases and reduce worries or refusals to join specialized centers. Community identified systems remain strong and benefit a strict follow up because CHV and CCDS members are more and more convincing and their awareness raising is seen as undeniable truth. Few CHV reach to accompany women to CB or hospital, which is really encouraging families and facilitate the evacuation. CCDS members role is to follow up communities established systems and assist for their application.
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Region
Number of CHVs trained
Total number of communes
Number of communes with Health emergency system 37 17 11 13 29 42 4 29 29 18 34 0 5 20 68 40 396
Total number of fokontany
Number of fokontany with Health emergency system 0 91 178 355 77 77 82 108 82 93 169 0 45 220 162 212 1,951
Number of pregnant women referred using transportation system 0 27 44 157 49 14 49 44 21 52 44 0 13 55 104 144 817
Number of newborns referred using transportation system 0 4 0 111 0 1 32 11 16 12 18 0 0 43 12 55 315
Number of other persons referred using transportation system 0 63 10 339 7 26 81 44 49 55 51 0 27 102 38 211 1,103
ALAOTRA MANGORO AMORON'I MANIA ANALAMANGA ANALANJIROFO ANDROY ANOSY ATSIMO ANDREFANA ATSIMO ATSINANANA ATSINANANA BOENY HAUTE MATSIATRA IHOROMBE ITASY SAVA VAKINANKARATRA VATOVAVY FITOVINANY TOTAL
436 493 497 868 1,088 417 1,001 461 819 294 1,533 229 286 676 807 1,092 10,997
55 44 33 51 38 51 78 41 69 18 84 23 20 45 70 80 800
291 127 229 402 299 290 229 125 92 106 260 147 45 308 498 240 3,688
Source : Social Quality Reports, February 2013
II. SERVICE UTILIZATION II.1 Results of communes Group 1 (implementing KM salama and ONE) Awareness raising activities and referral conducted by community health volunteers contribute to the increase of ANC services and delivery at CSB. This frequency was reduced in 2012 both at the CHV level and CSB. This may be due to negative impact of long lasting political crisis in Madagascar.
Tableau 9: Evolution of CHVs and CSB indicators (2010-2012) in the communes group 1 Indicators Year 2010 CHVs ANC referred Childbirth referred IFA referred IFA managed Pregnant women referred for ITP Pregnant women with danger signs referred Awarenees raising (Number of people) 7,180 2,312 2,234 4,496 796 535 CSB 8,650 1,501 Year 2011 CHVs 762 211 112 693 92 29 52 890,922 9,360 6,103 CSB 8,580 1,715 Year 2012 CHVs 311 96 61 536 50 CSB 2,540 1,450
The number of referred cases to CSB for ANC and delivery by CHV has increased from 2010 to 2011. Results show a decrease in 2012. However, results follow the same trend at the CSB level.
The table below shows evolution of cases referred by CHVs and the service utilization at CSB level in 2010 2012 Figure 8: ANC at CSB level and pregnant women referred by CHVs for ANC
ANC at CSB level and pregnant women referred by CHV for ANC (2010 - 2012)
10,000 8,000 6,000 4,000 2,000 0 547 762 2,540 311 8,650 8,580
2010 ANC at CSB level
2011
2012
Pregnant women referred by CHV to CSB for ANC
Figure 9: Childbirth at CSB level and pregnant women referred by CHVs for childbirth
Childbirth at CSB level and pregnant women referred by CHVs for childbirth (2010 - 2012)
2,000 1,501 1,500 1,000 500 0 2010 Childbirth at CSB level 2011 2012 136 211 96 1,715 1,450
Pregnant women referred by CHV to CSB for childbirth
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The next figures show CHVs contribution in ANC and childbirth at CSB level Figure 10: CHVS contribution in ANC
CHVs contribution in ANC (2010 - 2012)

10,000 Number of ANC (CSB) 8,000 6,000 4,000 2,000 0 8,650 8,580 14%
12% 9% 6%
2,540
12% 10% 8% 6% 4% 2% 0%
2011 CHVs contribution
2012
Figure 11: CHVS contribution in Childbirth
CHVs contribution in Childbirth (2010 - 2012)

1,800 1,700 1,600 1,500 1,400 1,300 2010 2011 Childbirth at CSB level 2012 CHVs contribution 1,715
12%
9%
1,501 1,450
7%
14% 12% 10% 8% 6% 4% 2% 0%
II.2 Results of other KM salama Activities results on maternal and new born health in the other KM salama communes having set up the program show a yearly reduction of the number of people going to CSB in terms of ANC and delivery whereas CHV referrals increase. The following table shows evolution of referrals conducted by CHV and CB use of services from 2010 to 2012.
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Le tableau ci-dessous montre lvolution des rfrences effectues par les AC et lutilisation de services des CSB de 2010 2012 Tableau 10: Evolution of CHVs and CSB indicators in other KM salama (2010-2012)
Indicators
Year 2010
Year 2011
Year 2012
CHVs ANC referred Childbirth referred IFA referred IFA managed Pregnant women referred for ITP Pregnant women with danger signs referred Awarenees raising
CSB
CHVs
CSB
CHVs
CSB
11,180 3,844 3,072 7,430 1,161 784
314,435 107,321
22,545 8,823 4,264 14,197 1,756 991
303,185 100,639
28,767 10,288 7,819 11,338 14,003 827
257,008 83,955
1,341,931
1,756,820
1,225,499
Figure 12: ANC at CSB level and referred by CHVs in other KM salama
ANC at CSB level and pregnant women referred by CHVs for ANC (2010 - 2012)
400,000 300,000 200,000 100,000 0 2010 ANC at CSB level 2011 2012 11,180 22,545 28,767 314,435 303,185 257,008
Pregnant women referred by CHV to CSB for ANC
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Figure 13: Childbirth at CSB level and referred by CHVs in other KM salama
Childbirth at CSB level and pregnant women referred by CHVs for childbirth
120,000 100,000 80,000 60,000 40,000 20,000 0 2010 Childbirth at CSB level 2011 2012 3,844 8,823 10,288 107,321 100,639 83,955
Pregnant women referred by CHV to CSB for childbirth
CHV contribution in terms of ANC and delivery, the rate increases progressively by year. For ANC, this rate has doubled in 2 years (from 6% in 2010 to 12% in 2012). As for deliveries, the rate has raised three times (from 4% in 2010 to 12% in 2012). The following figures show the level of CHV contribution in terms of ANC and delivery at the CSB level Figure 14 : CHVS contribution in ANC
Contribution of CHVs in ANC (2010 - 2012)

10,000 14%
Number of ANC (CSB)
8,000 6,000 4,000 2,000 0
12% 9% 6%
12% 10% 8% 6% 4% 2% 0%
2011 CHVs contribution
2012
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Figure 15: CHVS contribution in Childbirth
Contribution of CHVs in Childbirth (2010 - 2012)

120,000 100,000 80,000 60,000 40,000 20,000 0 15%
12% 9% 4%
2010 2011 Childbirth at CSB level 2012 CHVs contribution 10% 5% 0%
XII-
CONCLUSION
Activities conducted under the ONE program contributed to the increase of people going to the health centers seeking for ANC and delivery services enable to have an impact on 2 determining factors of maternal and child mortality which are late decision to seek for medical checkup and to evacuate. CHV play also a key role in screening danger signs and population awareness raising for the use of services. More than 90% of CHV working in the 800 KM salama communes were trained. Results show a better knowledge and understanding of mothers and families about danger signs among pregnant women and new born. CCDS members engagement is very important as community leaders. They play a very important role to:
demand stimulation quality improvement of health services at the CSB level and at the community level community awareness raising to set up solidarity funds and means of transport to ensure health evacuation.
Community based health services could not be sufficient unless they are connected to the formal health system and get their support. Community appropriation to the management of NEO is very important. However, challenges need to be resolved in setting up means of transport and solidarity funds in all fokontany and communes. Also, means of transport set up are still used in a very low level by the community. Is the number of complication still limited or should we strengthen awareness raising activities?
ANNEX 1: Respective roles of the different actors in the system of supervision

1- The roles of the CHVs Counting the pregnant women and newborns in the community.
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Sensitize pregnant women and their families to recognize the danger signs and risk factors in order to ensure quick referrals to emergency obstetric and neonatal care at a medical facility. Sensitize pregnant women and their families to change their behavior in favor of safe motherhood and to promote newborn-specific care (prenatal consultations, follow-up with the prenatal care packet, childbirth at a hospital, immediate breast-feeding, assuring thermal protection of the newborn, umbilical cord and skin hygiene, vaccination, post-natal consultations, etc.). Teaching the community about implementing local transportation systems and solidarity or communal funds in order to remove the first and second delays. Public awareness on families adhering to the systems taught. Perform home visits to follow-up with the pregnant women and newborns. Filling management tools Submitting a monthly report to the CSB according to the reports canevas. Discussing with the SDCs and the NGOs support technicians, and the consultant when problems. 2- The roles of the Comit de Dveloppement Social (CDS) The CDS members include: the mayor, the heads of the fokontany, COSAN representatives, the head of CSB, and leaders of other local associations. The committee is a body used for coordination and for follow-up on all health activities AT the commune level in the communities. Within the framework of C-ONE, their roles include: Facilitating the censuses of pregnant women and newborns in the communities. Helping identify transportation systems. Ensuring that C-ONE activities were included in the communes action plan. Following up the action plan. Ensuring the monitoring and supervision of the CHVs. Following up on the solidarity funds and the implementation of evacuation systems to medical centers. 3- The roles of the NGO support technicians Organizing and facilitating C-ONE trainings. Supporting the SDC in the supervision of the CHVs: assisting and managing the CHVs in their activities (home visits, checking the data collected in the motoring sheets of the pregnant women and newborns). Following up on the solidarity funds and the implementation of evacuation systems to medical centers. Supporting the CHVs in routing data to the SDC. Collecting data from the CSB during monthly reviews. Compiling data within the CSB and forwarding the data centrally.
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EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL (Santénet2 - 2013)

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EMERGENCY OBSTETRIC AND NEONATAL CARE AT THE COMMUNITY LEVEL

Obstetrical and neonatal emergency

Community-based care for obstetrical and neonatal emergencies

PW SDC SP SSI ST USAID

GOALS OF THE STUDY

IV.3. EXPECTED RESULTS

This study is a combination of qualitative and quantitative research, including:

Table N1: List of communes to the study

GROUP 1 (10 communes)

AMBATO-BOENY GROUP 2 (7 communes)

MAROVOAY GROUP 3 (6 communes) MAHAJANGA II

V.5. STUDY POPULATION

V.7. PRINCIPLE STAGES OF THE STUDY

The training focused largely on:

Figure 1: Supervision system

Extended interviews with those in charge of childbirth

LIMITATIONS OF THE STUDY

2- Incompatibility of the methods with local habits and customs

VI.1. CAPACITY BUILDING OF THE ACTORS

Figure 2: Recognition by CHVs on the danger signs presented by pregnant women.

Recognition by CHVs on the danger signs presented by pregnant women

Spontaneous response YES

Assited response YES

Did not know

Figure 3: Recognition by CHVs on the danger signs presented by pregnant women.

Recognition by CHWs of the danger signs presented in newborns.

6%11% Difficulty breathing

Spontaneous response YES 3. SUPERVISION

Assited response YES

- Car - Taxi-brousse - Charette - Stretcher

Marovoay banlieu Marosakoa TOTAL

% of fokontany with transportation system

% of fokontany with solidarity funds

Photo2 : chantillon focus group des femmes enceintes (Marovoay Banlieue)

The mothers will no longer have difficulty coming to the CSB 2

Perception of CHVs Public Education Work

At home we can ask all the questions that worry us

Successful public education and CHV credibility

Persuasiveness of the CHVs

Recognition of danger signs by pregnant women.

Spontaneous response YES

Assited response YES

Did not know

Figure 6: Recognition by pregnant women of danger signs presented by newborns

Recognition by pregnant women of danger signs presented by newborns

Spontaneous response YES

Assited response YES

V.4. REGISTER INDICATORS OF SERVICE UTILIZATION 1. General Services

Figure 7: Evolution of indicators at CSB level in the 3 groups

Evolution of indicators in Group 1

7,000 6,000 5,000 5,000 4,073 4,000 3,000

Evolution of indicators in group 2

ANC Total (4 ANC)

Pregnant Childbirth Women (PW) who took IFA

Before KMS 2009

Evolution of indicators in Group 3

1st ANC 2 or more ANC Total VAT2 et ANC (4 ANC) plus

Pregnant Childbirth Women (PW) who took IFA

Referred Cases, Solidarity Funds, and Transportation Systems

Pregnant women referred presented danger signs

Newborn referred presented danger signs

# of solidarity funds implementing

# of cases using the transportation system implementing 2009 0 0 0 2010 9 0 0