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Improvement of maternity and child health services in rural Bangladesh: an experimental project
Public Health (1988), 102, 355-358
Improvement of M a t e r n i t y and Child Health Services in Rural Bangladesh: an Experimental Project Shafiqur Rahman MBBS, DPH, Dr PH (Berkely California)
Fazilatun Nessa MSS (Economic & Political Science) Diploma in Population Research (UK) Operation Researcher, International Centre for Diarrhoeal Disease Research, Bangladesh
Bangladesh Fertility Research Programme Bangladesh Medical Research Centre Mohakali, Dakar 12. BANGLADESH
This study was undertaken in an upazila (large rural administrative district) of Bangladesh to seek ways of improving the uptake of Maternity and Child Health Services. Substantial improvements were obtained. In the year prior to the study Traditional Birth Attendants conducted 47.2% of deliveries: after the training they conducted 87.8% of all deliveries in the area. Evaluation of their performance showed a substantial improvement. The number of satellite clinics rose from 1 to 71. There was a marked increase in uptake of antenatal and postnatal care and of tetanus immunisation. During the project 134 community meetings were held, and those proved helpful in clarifying issues and decision making. Knowledge of and use of oral rehydration therapy improved dramatically, and contraceptive practice also benefited. Introduction Maternal and Child Health Services were integrated with Family Planning activities of Bangladesh in 1975 with a view to reducing high levels of maternal, infant and childhood mortality and morbidity, and bringing down the total fertility rate from the present 5.8 to 4.1 by the year 1990. ~ However, observations in the rural areas revealed that the actual delivery of M C H services was not optimum. In 1982, a study was conducted in the districts o f Jessore and Tangail to find out the determinants of utilisation of M C H services and their effect on contraceptive behaviour. This was the second phase o f a survey started in 1981, and the findings of the previous survey were used as baseline data. Methods Four Unions o f Jhikargacha Upazila of Jessore District were selected as the experimental area and 2 Unions as control based on random sampling. The experimental area differed from the control area in better supervision and continuing training program of the field workers, and planned educational and field activities in the former. The study was implemented in 2 parts. In the first part training was given to the TBAs, TBA trainers and Field Workers. Community leaders also received a 3-days' orientation © The Societyof Community Medicine, 1988
356
Shafiqur Rahman and Fazilatun Nessa
course in maternal and child health care and services. The second part consisted o f delivery of services through a three tier approach; by static clinics at Union Health & Family Welfare Centre, by satellite clinics at ward levels, and by domicilliary visit. The static clinics provided ante- and postnatal care, child care up to the age of 5, contraceptive advice and supply, treatment of minor ailments and routine education program. Similar services were provided through satellite clinics held once a month at selected places in the wards. Home visits were made by FWVs twice a week during which they provided advice on healthy living, care during pregnancy, child care, nutrition, contraception, immunisation, preparation and use o f oral rehydration solution. Pregnant mothers were immunised with Tetanus Toxoid through the U & F W C and satellite clinics. Community participation was ensured through revival and formation o f M C H and FP Committee, education and orientation of members o f organised leaders o f the villages and holding o f community meetings. Results
There was a remarkable improvement in the knowledge and skill of the TBAs after training (Table I). Acceptability o f the trained TBAs by the community almost doubled, the TBAs being responsible for conducting 47.2% of the deliveries before training as compared to 87.8% after training. Whereas, before the training program, the TBAs did not have any role in referring women for TT, after the program they were responsible for 41.3 % o f the referrals. The neonatal death rate among babies delivered by TBAs was 40.5/1,000 live births as compared to the national figure of 70.92/1,000. In the experimental area, the maternal death rate was also found to be lower at 4/1,000 live births. The number of satellite clinics held increased markedly. A total of 71 such clinics were held during the study period as compared to none before. During the project period 134 community meetings were held as compared to a very small number before. These meetings were helpful in decision making for utilisation o f Maternal and Child Health Services, Extended Programme of Immunisation, Rehydration, Oral Therapy and clarifying issues on utilisation of M C H care, etc. The mothers were also educated regarding preparation and use of ORS by the field workers during home visits. At the end of the project, they had a very satisfactory knowledge of the regime. The utilisation care and postnatal care services also increased several fold (Table II). A total o f 1,114 women were provided with antenatal services during the project, whereas the corresponding pre-project figure was 262. Similarly 786 women received postnatal care during the project compared with 113 in the preceding year. The Educational programs o f the U H & FWC, satellite clinics and home visits led to a 28% improvement in uptake o f child care. A similar improvement was also observed in treatment of general ailments. There was a remarkable increase in acceptance of TT, whereas during the last year before implementation o f the project only 33 pregnant women received the first and 12 women the second dose o f TT. The numbers rose to 1,063 and 785 respectively for the first and second doses during the project year (Table III). Conclusions
The performance o f maternal and child health and family planning programs can be greatly improved at little cost. Job training for the workers and their proper supervision, regular home visits of clients by field workers and FWVs and incorporation of the activities of
Maternity and Child Health Services in Rural Bangladesh Table I
Proceedings improvement of knowledge and skill of TBAs after training
Topics
Pre-Training Good
I. Hand washing 2. Preparation for delivery 3. Advice to mother on breast feeding, hygiene condition and nutrition 4. Cutting of cord 5. Knowledge and skill of conducting safe delivery
Table II
-
-
10.0%
Post-Training
Fair
Poor
Good
Fair
10.0%
90.0%
80.0%
20.0%
10.0%
90.0%
50.0%
40.0%
10.0%
100.0% 10.0%
80.0%
60.0% 10.0%
10.0% 50.0%
30.0% 50.0%
20.0%
80.0%
50.0%
20.0%
30.0%
Poor
Number on antenatal and postnatal care by sources of services and by study period Antenatal
UH&FWC SC Home visits Total
Table III
357
Postnatal
Pre-project
During project
Pre-project
During project
227 6 29 262
453 440 221 1,114
91 -22 113
289 210 287 786
Progress report on EPI in the project area for August 1983 to June 1984 (pre-study period) and August 1984 to June 1985 study
Vaccine TT (To pregnant women) DPT Polio DT BCG Measles
Pre-project period 1983-84
Project period 1984-85
45 947 947 710 160 110
1,848 619 619 1034 7l 32
2,919
4,223
358
Shafiqur Rahman and Fazilatun Nessa
TBAs in clinics were the key elements in our experiment. The Upazila Health & Family Planning Officer and the T h a n a Family Planning Officer played important roles by initi~tting and coordinating the activities of the field workers through regular meetings. Delivering services close to the clients' homes and involvement of the c o m m u n i t y as a whole were the other positive factors in improvement and acceptance o f M C H care.
References 1. Country paper on health for all by year 2000, Bangladesh. Presented in joint UNICEF/WHO meeting, June, 1980. 2. Ahmed, A. U. Mortality and Health Issues Analysis of Mortality Trends and Patterns in Bangladesh, United Nations 1986 P-19. 3. Ibid Ahmed, A. U. P-37.
Glossary 1. UH & FPO 2. FPO 3. FWV
4. MA 5. DD 6. CS 7. UH & FWC 8. THC 9. FWA 10. FPA 11. Union 12. Upazila
Upazilla Health and Family Planning Officer. A medical graduate. The Head of Health and Family Planning programme in the upazila. Family Planning Officer. At least a college graduate, having 12 15 years of experiences in working in the FP programme. Family Welfare Visitor--Female, high school graduate, trained for 18 months in MCH, FP, treatment of minor ailments, certified by Nursing Council. Working in FP programme for 5-10 years. Medical Assistant--High school graduate, trained for ½ year in diagnosis and treatment of disease, MCH, FP, sanitation, etc. Deputy Director Family Planning (District Head of FP programme). Civil Surgeon--Medical graduate. District Head of Health Programme. Union Health and Family Welfare Center, provides comprehensive health care services to about 20,000 rural population. Thana health complex A thirty-one bedded Hospital in rural area, serves a population of 200,000. Family Welfare Assistant. Full time Family Planning field workers for a population of 6,000. Female, have read at least up to class VIII with an initial training of one month. Family Planning Assistant--Male, high school graduate, supervises FWAs. They had initial training of one month. Lowest tier of administrative unit, having a population of 20,000. Main administrative unit in rural area, having a population of 200,000.7 8 Unions make an upazila.
Improvement of M a t e r n i t y and Child Health Services in Rural Bangladesh: an Experimental Project Shafiqur Rahman MBBS, DPH, Dr PH (Berkely California)
Fazilatun Nessa MSS (Economic & Political Science) Diploma in Population Research (UK) Operation Researcher, International Centre for Diarrhoeal Disease Research, Bangladesh
Bangladesh Fertility Research Programme Bangladesh Medical Research Centre Mohakali, Dakar 12. BANGLADESH
This study was undertaken in an upazila (large rural administrative district) of Bangladesh to seek ways of improving the uptake of Maternity and Child Health Services. Substantial improvements were obtained. In the year prior to the study Traditional Birth Attendants conducted 47.2% of deliveries: after the training they conducted 87.8% of all deliveries in the area. Evaluation of their performance showed a substantial improvement. The number of satellite clinics rose from 1 to 71. There was a marked increase in uptake of antenatal and postnatal care and of tetanus immunisation. During the project 134 community meetings were held, and those proved helpful in clarifying issues and decision making. Knowledge of and use of oral rehydration therapy improved dramatically, and contraceptive practice also benefited. Introduction Maternal and Child Health Services were integrated with Family Planning activities of Bangladesh in 1975 with a view to reducing high levels of maternal, infant and childhood mortality and morbidity, and bringing down the total fertility rate from the present 5.8 to 4.1 by the year 1990. ~ However, observations in the rural areas revealed that the actual delivery of M C H services was not optimum. In 1982, a study was conducted in the districts o f Jessore and Tangail to find out the determinants of utilisation of M C H services and their effect on contraceptive behaviour. This was the second phase o f a survey started in 1981, and the findings of the previous survey were used as baseline data. Methods Four Unions o f Jhikargacha Upazila of Jessore District were selected as the experimental area and 2 Unions as control based on random sampling. The experimental area differed from the control area in better supervision and continuing training program of the field workers, and planned educational and field activities in the former. The study was implemented in 2 parts. In the first part training was given to the TBAs, TBA trainers and Field Workers. Community leaders also received a 3-days' orientation © The Societyof Community Medicine, 1988
356
Shafiqur Rahman and Fazilatun Nessa
course in maternal and child health care and services. The second part consisted o f delivery of services through a three tier approach; by static clinics at Union Health & Family Welfare Centre, by satellite clinics at ward levels, and by domicilliary visit. The static clinics provided ante- and postnatal care, child care up to the age of 5, contraceptive advice and supply, treatment of minor ailments and routine education program. Similar services were provided through satellite clinics held once a month at selected places in the wards. Home visits were made by FWVs twice a week during which they provided advice on healthy living, care during pregnancy, child care, nutrition, contraception, immunisation, preparation and use o f oral rehydration solution. Pregnant mothers were immunised with Tetanus Toxoid through the U & F W C and satellite clinics. Community participation was ensured through revival and formation o f M C H and FP Committee, education and orientation of members o f organised leaders o f the villages and holding o f community meetings. Results
There was a remarkable improvement in the knowledge and skill of the TBAs after training (Table I). Acceptability o f the trained TBAs by the community almost doubled, the TBAs being responsible for conducting 47.2% of the deliveries before training as compared to 87.8% after training. Whereas, before the training program, the TBAs did not have any role in referring women for TT, after the program they were responsible for 41.3 % o f the referrals. The neonatal death rate among babies delivered by TBAs was 40.5/1,000 live births as compared to the national figure of 70.92/1,000. In the experimental area, the maternal death rate was also found to be lower at 4/1,000 live births. The number of satellite clinics held increased markedly. A total of 71 such clinics were held during the study period as compared to none before. During the project period 134 community meetings were held as compared to a very small number before. These meetings were helpful in decision making for utilisation o f Maternal and Child Health Services, Extended Programme of Immunisation, Rehydration, Oral Therapy and clarifying issues on utilisation of M C H care, etc. The mothers were also educated regarding preparation and use of ORS by the field workers during home visits. At the end of the project, they had a very satisfactory knowledge of the regime. The utilisation care and postnatal care services also increased several fold (Table II). A total o f 1,114 women were provided with antenatal services during the project, whereas the corresponding pre-project figure was 262. Similarly 786 women received postnatal care during the project compared with 113 in the preceding year. The Educational programs o f the U H & FWC, satellite clinics and home visits led to a 28% improvement in uptake o f child care. A similar improvement was also observed in treatment of general ailments. There was a remarkable increase in acceptance of TT, whereas during the last year before implementation o f the project only 33 pregnant women received the first and 12 women the second dose o f TT. The numbers rose to 1,063 and 785 respectively for the first and second doses during the project year (Table III). Conclusions
The performance o f maternal and child health and family planning programs can be greatly improved at little cost. Job training for the workers and their proper supervision, regular home visits of clients by field workers and FWVs and incorporation of the activities of
Maternity and Child Health Services in Rural Bangladesh Table I
Proceedings improvement of knowledge and skill of TBAs after training
Topics
Pre-Training Good
I. Hand washing 2. Preparation for delivery 3. Advice to mother on breast feeding, hygiene condition and nutrition 4. Cutting of cord 5. Knowledge and skill of conducting safe delivery
Table II
-
-
10.0%
Post-Training
Fair
Poor
Good
Fair
10.0%
90.0%
80.0%
20.0%
10.0%
90.0%
50.0%
40.0%
10.0%
100.0% 10.0%
80.0%
60.0% 10.0%
10.0% 50.0%
30.0% 50.0%
20.0%
80.0%
50.0%
20.0%
30.0%
Poor
Number on antenatal and postnatal care by sources of services and by study period Antenatal
UH&FWC SC Home visits Total
Table III
357
Postnatal
Pre-project
During project
Pre-project
During project
227 6 29 262
453 440 221 1,114
91 -22 113
289 210 287 786
Progress report on EPI in the project area for August 1983 to June 1984 (pre-study period) and August 1984 to June 1985 study
Vaccine TT (To pregnant women) DPT Polio DT BCG Measles
Pre-project period 1983-84
Project period 1984-85
45 947 947 710 160 110
1,848 619 619 1034 7l 32
2,919
4,223
358
Shafiqur Rahman and Fazilatun Nessa
TBAs in clinics were the key elements in our experiment. The Upazila Health & Family Planning Officer and the T h a n a Family Planning Officer played important roles by initi~tting and coordinating the activities of the field workers through regular meetings. Delivering services close to the clients' homes and involvement of the c o m m u n i t y as a whole were the other positive factors in improvement and acceptance o f M C H care.
References 1. Country paper on health for all by year 2000, Bangladesh. Presented in joint UNICEF/WHO meeting, June, 1980. 2. Ahmed, A. U. Mortality and Health Issues Analysis of Mortality Trends and Patterns in Bangladesh, United Nations 1986 P-19. 3. Ibid Ahmed, A. U. P-37.
Glossary 1. UH & FPO 2. FPO 3. FWV
4. MA 5. DD 6. CS 7. UH & FWC 8. THC 9. FWA 10. FPA 11. Union 12. Upazila
Upazilla Health and Family Planning Officer. A medical graduate. The Head of Health and Family Planning programme in the upazila. Family Planning Officer. At least a college graduate, having 12 15 years of experiences in working in the FP programme. Family Welfare Visitor--Female, high school graduate, trained for 18 months in MCH, FP, treatment of minor ailments, certified by Nursing Council. Working in FP programme for 5-10 years. Medical Assistant--High school graduate, trained for ½ year in diagnosis and treatment of disease, MCH, FP, sanitation, etc. Deputy Director Family Planning (District Head of FP programme). Civil Surgeon--Medical graduate. District Head of Health Programme. Union Health and Family Welfare Center, provides comprehensive health care services to about 20,000 rural population. Thana health complex A thirty-one bedded Hospital in rural area, serves a population of 200,000. Family Welfare Assistant. Full time Family Planning field workers for a population of 6,000. Female, have read at least up to class VIII with an initial training of one month. Family Planning Assistant--Male, high school graduate, supervises FWAs. They had initial training of one month. Lowest tier of administrative unit, having a population of 20,000. Main administrative unit in rural area, having a population of 200,000.7 8 Unions make an upazila.