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Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community-Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi-country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions.
We designed community‐based intervention packages to improve access, coverage, quality, and/or efficiency of maternal and neonatal health services, with emphasis on nutrition interventions, in four countries in Africa building on existing platforms. The methodological approach had four steps (Figure 1): Summary of steps in designing Community‐Based Maternal and Neonatal Health and Nutrition (CBMNH‐N) projects in Ethiopia, Kenya, Niger, and Senegal. MoH = Ministry of Health; ANC = antenatal care; PNC = postnatal care; IFA = iron folic acid The four countries; Ethiopia, Kenya, Niger, and Senegal were selected for the demonstration projects based on the following considerations: countries with high maternal mortality indices; countries where Nutrition International already had a presence and therefore ongoing collaboration with the Ministry of Health (MoH); political will to improve antenatal care and nutrition; countries with a cadre of community‐based personnel (Table 1) who would be the agents to deliver the community‐based intervention packages or equipped for tasks that are traditionally not in their domain. In all four countries, the interventions were at the primary health care level that is identified as the community, health post, health centre, and dispensary (Table 1). Terminology used for health system and cadres of health workers in the four countries Note. The specific region within each country was selected in collaboration with each MoH based on a combination of factors including MoH priority based on documented or perceived need for additional services; and existence of a local partner with capacity to work in that region, including ability to ensure the safety of project implementation and evaluation teams. The four regions presented with different needs and contexts. To get the commitment of stakeholders to the CBMNH‐N model at national, regional, and local levels, a series of meetings were held at different levels to explain the project objectives in the different countries. Nutrition International coordinated these meetings with the objective of getting stakeholder engagement and ownership through an iterative and collaborative process of project design and implementation. The process of project leadership and stakeholder involvement growing into aligned stakeholder commitment also involved establishment of project coordination committees or teams that would provide administrative, management, technical, and supportive supervision roles at all levels. In some cases, these teams met at a scheduled regular basis throughout the project life and were vital in providing quality assurance of the implementation process and ensuring that the project plans and implementation approaches were of technically high quality and in line with national technical guidelines. These teams also ensured that all relevant implementing partners’ work was well coordinated and they resolved project challenges throughout the project life. We anticipate that these teams will also have the responsibility of synthesizing the impact analysis results at country level and advising the MoH on the adoption for scale up of the components of the CBMNH‐N model. In all four countries, the MoH was considered the main implementing partner supported by other partners responsible for specific components. We selected partners already successfully engaged in components of the CBMNH‐N package that was proposed in each country context. The survey teams were composed of competent researchers in various disciplines relevant to maternal health and nutrition with experience in designing and conducting epidemiological studies and a track record for publications. Nutrition International was responsible for coordination and synergy among partners. Embedding theory driven approaches to programme implementation and evaluation is well described in public health literature (Loechl et al., 2009; Rawat et al., 2013). To track how the CBMNH‐N project would achieve impact, it was important to develop an overall logic model (De‐Regil, Pena‐Rosas, Flores‐Ayala, & Del Socorro Jefferds, 2014; Figure 2) and detailed country logic models (Figures 3, ,4,4, ,5,5, ,6)6) that explain the specific country context and how components of the interventions are linked with each other and with the ultimate outcome of reducing maternal and neonatal morbidity and mortality. Approaches described in CBMNH‐N logic models were hypothesized to ultimately reduce maternal and neonatal morbidity and mortality in the four countries. We identified ways to bridge gaps in the provision and utilization of maternal and neonatal health services. Quantitative key performance indicators along with frequency of collection of the indicators were defined to match the different levels of the key components of the logic model and were measured to track progress and change associated with the project interventions. Qualitative approaches included formative assessments that were used to design culturally appropriate behaviour change interventions. Behaviour change communication (BCC) strategies within our CBMNH‐N projects included social mobilization, interpersonal communication, branding, and use of promotional materials, dramas, scripts, and skits. The duration and intensity of the strategies used were not identical across the countries but depended on the type of behaviour being changed, the barriers and enablers identified through formative research and the social and cultural context. The formative research will be reported elsewhere. Overall Community‐Based Maternal and Neonatal Health and Nutrition (CBMNH‐N) programme theory using CDC/WHO generic logic model. CDC = Centers for Disease Control and Prevention; WHO = World Health Organization; SBCC = Social and Behavior Change Communication; MNHN = Maternal Neonatal Health and Nutrition; BCC = behaviour change communication; IFA = iron folic acid; CHW = community health workers; TBA = Traditional Birth Attendant; HEW = Health Extension Worker; ASC = Agent de Sante Communautaire; ANC = antenatal care; PNC = postnatal care Ethiopia: Reducing maternal and neonatal morbidity and mortality through supporting Ethiopia’s health extension programme to increase access to quality maternal, neonatal, and nutrition services. MNHN = Maternal Newborn Health and Nutrition; MoH = Ministry of Health; ANC = antenatal care; PNC = postnatal care Kenya: Reduce maternal and neonatal morbidity and mortality in Kenya through improving care and nutrition for women at risk during pregnancy through a novel community–facility linkage programme. PRONTO = Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno; MoH = Ministry of Health; ANC = antenatal care; PNC = postnatal care Niger: Reducing maternal and neonatal morbidity through health facility strengthening and community mobilization. CHV = Community Health Volunteer; IFA = iron folic acid; ANC = antenatal care Senegal: Reducing maternal and neonatal morbidity and mortality through the development and piloting of a comprehensive maternal and newborn community health policy for Senegal. IFA = iron folic acid A key characteristic of the CBMNH‐N project was a rigorous monitoring and evaluation system as part of the design of the project. In order to measure improvements in inputs and outcomes along the implementation pathway as outlined in the project logic models, we highlight in this section what we identified as the rationale for selection of key performance indicators based on an evidence informed programme model using proven interventions (Bhutta et al., 2013). Uptake of the interventions is described as utilization of one or more components of the CBMNH‐N package and was assessed by measuring changes in key performance indicators. It is well known that ANC is more beneficial in preventing adverse pregnancy outcomes when received early in the pregnancy and continued through delivery (Klemm et al., 2011). WHO recommends that a woman without complications should have at least four ANC visits, the first of which should take place during the first trimester (Lincetto, Mothebesoane‐Anoh, Gomez, & Munjanja, 2013). Quality and uptake of ANC were key components in each of the projects and we developed indicators to capture the status of these components. These include percentage of mothers attending one or more antenatal visit; percentage of mothers attending four or more antenatal visit; percentage of mothers receiving first antenatal visit during the first trimester; percentage of mothers who received advice about the importance of having ANC visit; percentage of mothers who received advice about when to start the ANC visit; and percentage of mothers who received advice about the importance of having at least four ANC visits. Daily oral IFA supplementation is recommended as part of the ANC to reduce the risk of iron deficiency, maternal anaemia, and low birthweight. Pregnant women are advised to take IFA supplements during pregnancy for at least 90 days to prevent anaemia and other complications (WHO, 2012a). Through formative assessments in each of the four countries, we identified barriers to IFA supplementation and developed country‐specific BCC material that was used by the relevant implementing partner in each country to educate women at both health facility and informal and formal community encounters. We also ensured there was adequate IFA supplements after facility supply chain assessments identified shortages by including stop gap procurement as part of our package to ensure no stock outs during the project life. Indicators measured include percentage of mothers who took any IFA supplements during the pregnancy; percentage of mothers who took IFA supplement during the latest pregnancy for ≥ 90 days; percentage of mothers who received advice on IFA supplements; percentage of mothers who received advice on IFA supplements from health care personnel; percentage of mothers who received advice on IFA supplements during postnatal visit; and percentage of mothers who knew at least one benefit of consuming IFA supplement. It is recommended that children be put to the breast within an hour of birth and should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health (WHO, 2014). Through formative research, we identified key influencers of the mother in each country context, who we then involved in BCC relating to protecting, promoting, and supporting breastfeeding. Indicators measured included percentage of mothers whose infants were put to the breast early (within 1 hr) after delivery; percentage of mothers whose < 6 months infants had exclusive breastfeeding status; percentage of mothers who received advice on early initiation of breastfeeding; and percentage of mothers who received advice on exclusive breastfeeding. WHO recommends that delayed umbilical cord clamping (not earlier than 1 min after birth) should be performed during the provision of essential neonatal care for improved maternal and infant health and nutrition outcomes (WHO, 2014). Delayed umbilical cord clamping was incorporated into the training curriculum of health workers in Ethiopia, Kenya, and Senegal. The indicator we measured was the percentage of mothers who knew the benefit of delayed cord clamping. Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infection that can cause morbidity and mortality to either the mother or the baby. Increasing the number of deliveries in the health facilities is an important factor in reducing health risks to both the mother and the child; the specific mechanism to reduce risks of delivery was adapted to the policy of each country. In Kenya, where the policy advocates for facility based deliveries, one major component of the CBMNH‐N project was redefining the roles of Traditional Birth Attendants (TBAs) to birth companions. TBAs who originally delivered women at home were motivated through the CBMNH‐N interventions to accompany women to the health facility for delivery. In Afar region of Ethiopia, where the health system context allowed, the project equipped heath care providers at the health posts by training them as birth attendants to deliver women at the health post. Bridging the personnel gaps in health facilities is in line with the WHO guidance on optimizing health workers roles through task shifting (WHO, 2012b). In Senegal, community health workers (CHWs) were trained to conduct delivery for low risk deliveries; while in Niger, no specific intervention was specified. Indicators measured included percentage of mothers whose delivery was facility‐based; percentage of mothers who delivered with the assistance by facility‐based health personnel; percentage of mothers who delivered with the assistance by community‐based health personnel/who delivered at home; and percentage of mothers who delivered with the assistance by TBAs. Appropriate care during the postnatal period is an important determinant of the well‐being of mothers and their newborns. WHO has provided recommendations on timing of discharge from a health facility after birth, number and timing of postnatal contacts, home visits for PNC, and content of PNC for newborn (assessment of the baby, exclusive breastfeeding, and cord care; WHO, 2013a). Indicators measured included percentage of mothers who received PNC from facility‐based health personnel; and percentage of mothers who received PNC from community‐based health personnel. Strengthening the evidence base on how to effectively deliver maternal and neonatal health and nutrition interventions requires programmes or complex public health interventions that are well designed, implemented, and evaluated. The CBMNH‐N project engaged rigorous plausibility evaluation designs (Habicht, Victora, & Vaughan, 1999). All countries implemented quasi‐experimental pre–post non‐randomized intervention studies with comparison groups. It was not logistically feasible to conduct randomized controlled trials; nonetheless, these less robust yet rigorous designs were implemented to maximize our ability to evaluate the impact of the various components of the CBMNH‐N project on knowledge and practices related to maternal and neonatal care and to inform scale‐up (Kung'u et al., 2018). Routine monitoring and evaluations were implemented in each country with the intent of estimating the overall public health impact of the project and facilitating the compilation of evidence and lessons learnt for potential of similar programmes in other regions of the country or other countries.
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