EVALUATION EVALUATION OF ENCOURAGING POSITIVE PRACTICES FOR IMPROVING CHILD SURVIVAL, EAST MAMPRUSI, GHANA, WEST AFRICA Karunesh Tuli and Sandra Wilcox November 2015 This publication was produced at the request of the United States Agency for International Development. It was prepared independently by the project’s final evaluation team. Evaluation of Encouraging Positive Practices for Improving Child Survival, East Mamprusi, Ghana, WEST AFRICA November 2015 Innovation Category Cooperative Agreement Number: AID-OAA-A-11-00042 DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government CONTENTS CONTENTS ................................................................................................................................................. 3 ACRONYMS ................................................................................................................................................... 4 EVALUATION PURPOSE AND EVALUATION QUESTIONS .............................................................................10 EVALUATION PURPOSE ...........................................................................................................................10 EVALUATION QUESTIONS .......................................................................................................................10 PROJECT BACKGROUND ..............................................................................................................................12 EVALUATION METHODS AND LIMITATIONS ...............................................................................................16 FINDINGS, CONCLUSIONS AND RECOMMENDATIONS ...............................................................................19 FINDINGS .................................................................................................................................................19 CONCLUSIONS .........................................................................................................................................28 RECOMMENDATIONS .............................................................................................................................29 ANNEXES .....................................................................................................................................................31 I. List of Publications and Presentations Related to the Project II. Project Management Evaluation (Optional) III. Work Plan Table IV. Rapid CATCH Table V. Final KPC Report VI. Community Health Worker Training Matrix VII. Evaluation Scope of Work VIII. Evaluation Methods and Limitations IX. Data Collection Instruments X. Information Sources XI. Disclosure of Any Conflicts of Interest XII. Statement of Differences (If applicable) XIII. Evaluation Team Members, Roles, and Their Titles XIV. Final Operations Research Report XV. Stakeholder Debrief PowerPoint Presentation XVI. Project Data Form XVII. Other Optional Annexes 4 ACRONYMS 5A Fives Alive! AED/GSCP Academy for Educational Development’s Ghana for Sustainable Change Project (USAID funded) ANC Antenatal Care AR Annual Report BCC Behavior Change Communication BF/EBF Breastfeeding/Exclusive Breastfeeding BL Baseline BMC Baptist Medical Center C4D Communication for Development (UNICEF) CBA Community-Based Agent CBIS Community-Based Information System CETS Community Emergency Transport System CDO Community Development Officer CHAG Christian Health Association of Ghana CHPS Community-Based Health Planning and Services CHC Community Health Committee CHV Community Health Volunteer CHO Community Health Officer CIMACS Community-Led Initiative for Mother and Child Survival CIS Community Information System CoC Council of Champions C-PreS Community Pregnancy Surveillance CRS Catholic Relief Services CSPs Community based Surveillance Programs DA District Assembly DDHS Director District Health Services DHMT District Health Management Team DIMS District Information Management System DIP Detailed Implementation Plan DOTS Directly Observed Treatment Short course ECOWAS Economic Community of West African States EL Endline EMD East Mamprusi District EmOC Emergency Obstetrical Care ENA Essential Nutrition Actions ENC Essential Newborn Care EPPICS Encouraging Positive Practice for Improving Child Survival FE Final Evaluation 5 FP Focal Person FGD Focus Group Discussion FtF Feed the Future GDHS Ghana Demographic and Health Survey (2008) GHI Global Health Initiative GHS Ghana Health Services HHs Households Hb Hemoglobin HDM Household Decision Makers HF Health Facility HFA Height for Age HIRD High Impact Rapid Delivery HIS/HMIS Health Information System/Management Information System HMNCCs Healthy Mothers and Newborn Care Committee HW / CHW Health Workers / Community Health Workers IFA Iron Folic Acid IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate IPTp Intermittent preventive therapy (Pregnancy) IPT3 Intermittent preventive therapy (3 doses of SP) IRS Indoor Residual Spraying ITN/LLIN Insecticide Treated Net/Long Lasting Insecticidal Nets IYCF Infant and Young Child Feeding KPC Knowledge Practice and Coverage Survey LAM Lactation Amenorrhea Method LAQS Lot Quality Assurance Sampling LOE Level of Effort MAMAN Minimum Package for Mothers and Newborns MAF MDG Accelerated Framework MCH Maternal Child Health MD/MW Medical Doctor/Midwife M&E Monitoring and Evaluation MDG Millennium Development Goals MICS Multi-Indicator Cluster Survey MIS Malaria Indicator Survey MIP Malaria in Pregnancy MMR Maternal Mortality Ratio MMT Modified Motor Tricycle MNC Maternal and Newborn Care MN/N Maternal, Newborn and Nutrition MNCH Maternal, Newborn and Child Health MOH Ministry of Health MOP Malaria Operational Plan (PMI) NNMR Neonatal Mortality Rate 6 NR Northern Region OR Operations Research PRABs Practices, Rituals, Attitudes and Beliefs PD/PDI Positive Deviance/Positive Deviance Inquiry PDM Positive Deviant Mothers PDQ Partnership Defined Quality PMI Project Management Institute PMTCT Prevention of Mother to Child Transmission of HIV PRA/PLA Participatory Rural Appraisal/Participatory Learning and Action P/L M Pregnant/Lactating Mothers PP Post-Partum Care QA Quality Assurance RF Results Framework RHFA Rapid Health Facility Assessment RTI Research Triangle Institute SBCC Social Behavior Change Communication SD Sub-district SO Strategic Objective TA Technical Assistance TBA/TTBA Traditional Birth Attendant/Trained TBA TT Tetanus Toxoid (Immunization) UDS University for Development Studies UNICEF United Nations Children’s Fund USAID United States Agency for International Development WFP United Nations World Food Program WRA Women of Reproductive Age 7 Evaluation, Purpose, And Evaluation Questions The final evaluation assessed the performance of the EPPICS maternal and child survival project. The evaluation assessed:  To what extent did the project accomplish and/or contribute to the goals and objectives stated in the Detailed Implementation Plan?  What were the key strategies and factors, including management and partnership issues that contributed to what worked or did not work?  Which elements of the project have been or are likely to be sustained or expanded (for example, through institutionalization or policies)?  What are stakeholder perspectives on the implementation of operations research, and how did the operations research study affect capacity, practices, and policy? Project Background EPPICS was designed to improve maternal and newborn health in the East Mamprusi district of northern Ghana through the components of Maternal and Newborn Care (60%), Nutrition (30%), and Malaria in Pregnancy (10%). EPPICS was launched in 2011, with a target of 51,000 direct beneficiaries including women of reproductive age and children 0-59 months. The project combined health facility and community based strategies to: improve geographic access to health services through provision of modified motor-tricycles as rural ambulances; reposition traditional birth attendants as “link providers” to health facilities for skilled assisted childbirth; and modify practices, rituals and beliefs (PRABs) to remove barriers to health seeking behaviors. In Sakogu sub-district, EPPICS created Councils of Champions (CoCs) in each community comprised of the chief, and women and religious leaders. CRS worked in close partnership with Ghana Health Services (GHS) to implement EPPICS. An expectant mother in Bongbini poses in front of her community’s Wall of Good Health, which shows progress towards improved maternal neonatal practices. Photo: CRS Key Findings: Maternal and Newborn Care indicators improved from baseline to endline: Four plus antenatal care visits increased by 18%; use skilled assisted deliveries increased by 33% and postnatal care for newborn within first two days increased by 52%. The Wall of Good Health is a creative tool used to track and pictorially present at least two key MNC indicators in each project community. The Council of Champions (CoC) strategy is useful for addressing challenging PRABs related to MNC service uptake – women were 2.9 and 1.7 times more likely to use ANC within first trimester and early PNC respectively in communities with CoC. Modified Motor-tricycles made statistically significant contributions to skilled assisted deliveries in the target communities from a baseline of 23% to 78% at endline. Evaluation of the Encouraging Positive Practices for Improving Child Survival Project - Executive Summary November 2015 The EPPICS project was funded by the US Agency for International Development through the Child Survival and Health Grants Program, 2011-2015. 8 In September 2015, a four-person evaluation team conducted the final evaluation (see Annex XIII for a list of members). The team visited project sites in EMD (sub-districts: Gambaga, Nalerigu, Sakogu, Jawani and Tamboku) and also talked with staff and partners in Gambaga, Tamale, and Accra districts. The team first reviewed findings from the knowledge, practice, and coverage (KPC) surveys and other studies commissioned by the project to determine what further questions it wanted to answer during the field evaluation. The team then used qualitative methods to assess the project and answer these questions through interviews, group discussions, and observations. One of the limitations of this report is that the FE evaluator who conducted the qualitative field review with CRS staff and project stakeholders was unable to complete the report; a second evaluator finished the report using data and information collected by the previous consultant. Findings and Conclusions: Key Findings: A review of the KPC findings shows that EPPICS improved on most of its performance indicators (see Annex V for complete report): (1) Pregnant women who registered for and use antenatal care at the health facilities within the first trimester increased from a baseline of 50% to 74% at endline; (2) four plus antenatal visits among pregnant women showed statistically significant increase from 63.9% to 82%.; (3) birth preparedness (setting aside money to pay for emergency transport, getting clean clothes to wrap baby etc) increased from 16% at baseline to 41% at endline; (4) skilled assisted deliveries showed statistically significant rise from 43% to 76% at baseline and endline respectively; (5) knowledge of danger signs in pregnancy increased from 81% at baseline to 86% endline while knowledge of delivery danger signs increased from 69% to 72% at baseline and endline respectively; (6) knowledge of post￾partum danger signs increased from 77% baseline to 87% endline while knowledge of neonatal dangers increased from 72% baseline to 80% endline; (7) the use of health facilities for postnatal care within the first two days of delivery showed statistically significant improvement from 32% baseline to 84% endline; (8) uptake of two or more dozes of tetanus toxoid increased from 64% baseline to 71% endline; (9) the portion of mothers who slept under long lasting insecticide nets with their babies increased from 16% at baseline to 43% at endline; (10) early initiation (within the first 30 minutes after delivery) of breastfeeding increased from 50% at baseline to 75% at endline; (11) exclusive breastfeeding of infants within the first 6 months of age showed statistically significant increase from 47% at baseline to 70% at endline; (12) the proportion of children age 6-23 months fed according to a minimum of appropriate feeding practices showed statistically significant increase from 55% at baseline to 78% at endline; (13) severe stunting reduced from 17% at baseline to 5% at endline. At the time of the final evaluation, many of the project activities were being scaled up or expanded. For example, with support from CRS and GHS, the community was able to offer Community Pregnancy Surveillance and targeted education (C-PreS) sessions. CRS and GHS have also worked to scale up repositioning TBAs as Link Providers as well as the Council of Champions strategies in six new districts in northern Ghana with an expected 100,000 beneficiaries with funds from a US based Foundation. Also, the Walls of Good Health methodology was shared at the ECOWAS meetings in 2012 and CRS Ghana has supported CRS Niger and Burkina Faso with integration in their child survival projects. The EPPICS project strategies contributed in making the East Mamprusi District transform from the worst to the best performing district in the Northern Region from 2011 to 2014. To address the socio-cultural barriers to accessing health services, the project developed innovative operations research (OR). As part of the OR, EPPICS developed community-led approaches to target 9 challenging socio-cultural practices in 44 communities through creation of a Council of Champions in intervention communities. The CoCs are composed of the 5-7 most influential individuals in the community and are trained to engage with household decision makers, and work to modify challenging MNC PRABs. COC members had a strong influence on the improvement of early ANC attendance and increase in institutional births (See Annex XIV for details). The OR study provided insight into how SBCC through empowered community leaders can positively influence access to and utilization of quality MNC services, leading to improved health outcomes for families. Conclusions: The EPPICS project as designed was implemented in full and has made positive contributions to improvements in all MCH indicators in EMD over the last four years. The deployment of combined health facility and community based strategies may have accounted for these improvements. The strategies found to be most promising include: the ‘’Walls of Good Health’’, repositioning TBAs as Link Providers, the Council of Champions, and the Quality Improvement Methods in health facilities. These strategies have already been adopted by Ghana Health Service and are being scaled up in 6 other districts with technical support from CRS. The EPPICS design designated GHS staff as the lead implementers while CRS project staff provided technical support. This design not only contributed to the positive gains recorded by the project but also ensured that project interventions will be sustained beyond the life of the project. Recommendations: The evaluation team proposes the following recommendations to CRS, GHS and USAID: Ghana Health Services/Ministry of Health  Facilitate the use EPPICS design as a reference model for future MCH interventions that target the health of women and children in similar context.  To improve referrals between the CHPS compounds and next level of care, GHS should invest in scaling up the use of modified motor tricycles (MMTs) as a promising and cost effective strategy.  EPPICS strategies should be integrated into the current MDG Accelerated Framework (MAF) strategy for Ghana and post MDG policies for MCH and should also support the scale up of Walls of Good Health, Council of Champions, Modified Motortricycles, Repositioning TBAs as Link Providers and Quality Improvement Methods. Catholic Relief Services  CRS should collaborate with other USAID funded MCH interventions in Ghana such as Systems for Health to scale-up EPPICS strategies that will benefit the other regions and should explore funding to document and share guidance on how to implement each strategy for adoption in similar settings. United States Agency for International Development (USAID)  CRS and GHS should be supported to document and share ‘’How to Implement’’ these strategies including the Council of Champions strategy for adoption in other USAID funded projects.  Future USAID maternal health projects should invest more of their resources in improving staffing and supplies at health facilities. 10 EVALUATION PURPOSE AND EVALUATION QUESTIONS EVALUATION PURPOSE The purpose of this final evaluation (FE) is to assess performance of the CRS-led Encouraging Positive Practices for Improving Child Survival (EPPICS) project and to make the findings/results available to various audiences including the Ghana Health Service and Ministry of Health (MOH) of other countries. The findings are expected contribute evidence relevant to global initiatives such as the Global Health Initiative and Feed the Future.1 Also, the FE provides an opportunity for all project stakeholders to take stock of accomplishments to date and to listen to the beneficiaries at all levels (Health Centers, CHPS compounds etc.), including mothers and caregivers, other community members and opinion leaders, health workers, health system administrators, local partners, other organizations, and donors. The FE Report will be used by the following audiences as a source of evidence to help inform decisions about future program designs and policies: In-country partners at national, regional, and local levels (e.g., MOH and other relevant ministries, district health team, local organizations, communities in project areas).  USAID (CSHGP, Global Health Bureau, USAID Missions), and other CSHGP grantees.  The international global health community. The FE report will be posted for public use at http://www.mchipngo.net and the USAID Development Experience Clearinghouse at https://dec.usaid.gov. The CSHGP grant included funding for hiring of the FE evaluator. In order to assure independence of the evaluation, the evaluator was selected by CRS but approved by USAID. USAID also reviewed the Scope of Work and the final report is being submitted to USAID at the same time that it is sent to CRS. EVALUATION QUESTIONS The final evaluator and the evaluation team will use existing data collected or compiled during the life of the project, as well as additional data reviewed during the evaluation to answer the following questions: 1. To what extent did the project accomplish and/or contribute to the strategic objectives and Intermediate Results stated in the detailed implementation plan (DIP)?  Describe the extent to which the project was implemented as planned, any changes to the planned implementation, and why those changes were made.  How were results achieved? If the project improved coverage of high-impact interventions simultaneously, what types of integration enabled this? Specifically, refer to community based 1 For more information on these two initiatives, visit http://www.usaid.gov and http://www.feedthefuture.gov. 11 strategies and approaches and construct a logic model describing inputs, process/activities, outputs, and outcomes.  Document high impact interventions and its potential for scalability 2. What were the key strategies and factors, including management and partnership issues that contributed to what worked or did not work:  What were the contextual factors such as socioeconomic factors, gender, demographic factors, environmental characteristics, baseline health conditions, health services characteristics,2 and so forth that affected implementation and outcomes?  What capacities were built, and how?  Were gender considerations incorporated into the project at the design phase or midway through the project? If so, how? Are there any specific gender-related outcomes? Are there any unintended consequences (positive and negative) related to gender? 3. Which elements of the project have been or are likely to be sustained or expanded? e.g., through institutionalization or policies  Analyze the elements of scaling-up and types of scaling-up that have occurred or could likely occur (dissemination and advocacy, organizational process, costs and/resource mobilization, monitoring and evaluation using the Expand Net resource for reference).3 4. What are stakeholder perspectives on the OR implementation, and how did the OR study affect capacity, practices and policy? 2 See Table 1 in the document here: http://heapol.oxfordjournals.org/content/20/suppl_1/i18.long 3 http://expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Step%20Guide%20published.pdf 12 PROJECT BACKGROUND Over the past decade, Ghana Health Service (GHS) and its Development Partners (USAID, UNICEF and WHO among others) have been implementing evidence-based interventions including the free maternal health policy, an expansion of the health infrastructure as well as investments in human resources for health. In spite of these efforts, set targets for Ghana’s health related Millennium Development Goals (MDG) four (Reduce Child Mortality) and five (Improve Maternal Health) were all missed. Though the institutional maternal mortality ratio fell from 216 per 100,000 live births in 1990 to 144 per 100,000 live births in 2014, it fell short of the MDG target of 54 per 100,000 live births in 2015. Though under-5 mortality rate improved from 122 per 1,000 live births in 1990 to 60 per 1,000 live births in 2014, it still fell below the MDG target of 40 per 1,000 live births4. Though there has been positive progress in MNCH indicators generally, these MNCH indicators in the Northern Region reflect significant challenges (See table 1 comparing indicators of the Northern Region, East Mamprusi District (EMD) and national level). Most of the GHS efforts have focused on improving health facility based services (supply side) using evidence based interventions, but gaps remained on the community/household level (demand side) in terms of improving service delivery as well as in overcoming harmful practices, rituals, attitudes and beliefs (PRABs) that prevent care seeking. Research shows that most of the neonatal deaths in high mortality regions are due to preventable and behavior modifiable causes. However, the extent to which prevention measures can reduce neonatal mortality is not clear. A study in EMD, which explored women’s knowledge of neonatal danger signs, revealed that even where the quality of antenatal care is consistent with World Health Organization (WHO) Guidelines, many women still have limited knowledge of neonatal danger signs. The study also shows that low utilization of services, such as supervised deliveries and post-natal care continue to persist even where financial and geographic access is adequate.5 This low utilization of services in EMD was attributed to PRABs that jeopardize maternal and child health and result in delays in seeking prompt care at health facilities. CRS partnered with the Ghana Health Services (GHS), through the EPPICS project to improve local PRABs related to pregnancy and newborn care, and encourage strengthening of civil society structures in order to empower local communities to advocate for improved MNCH services in the district. The project population is presented in table 2 below. 4Ghana Millennium Development Goal Report, 2015 5Exploring Women’s Knowledge of Newborn Danger Signs: A Case of Mothers with under Five Children. Public Health Research. 2014 Table 1: Pre-EPPICS MNCH/N Indicators EM, NR and National Indicator EM* NR** Ghana** Supervised delivery 48 35.5 48.2 Antenatal visits (1st trimester) 30 49 55 Antenatal visits(4+) 46 58 78 IPT2+ 51 33 44 ITN use (pregnant women) 36 45 Height for age -2 SD 39 31 28 Weight for age -2 SD 30 29 14 WRA (any anemia) 59 59 * EM GHS Annual Report 2010; **Ghana Statistical Service et al, Districts MICS Report, 2009 13 Table 2 Project population of East Mamprusi Beneficiaries* Total Total Population 139,606 Total Neonates 2,887 Infants aged 0–11 Months 5,584 Children 12 -23 Months 5,747 Children 24 -59 Months 16,1485 Children aged <5 Years 27,921 Women of Reproductive Age (15–49 years) 30,713 Total Beneficiaries 58,634 Expected Pregnancies 5,584 Community Health Workers or Volunteers (CHWs), Disaggregated by Sex Males=235 Females=275 Health Facilities (Hospital to Sub Health Post) 12 Community-Based Structures (e.g., Village Development Committees [VDCs]) 175 *Source: District Health Information System II, Ghana Project and OR Design. East Mamprusi District was selected as the project site out of 5 potential districts in the Northern Region (NR). This decision was reached from discussions with the GHS Regional Director for NR based on high rates of maternal, newborn and infant mortality, stunting rates and low utilization of MNC services. Another factor included the previous positive work relationship between the GHS and CRS in that district, a very supportive DHMT and the suitability of the district for implementing and testing the project innovation. The project design including the results framework (see figure 1 below) was developed jointly with the DHMT with input from GHS and partners including regional level staff at UNICEF and PMI. PMI and GHS see MIP as a priority that needs to be addressed at the community level due to low IPT uptake and low LLIN utilization. The project goal and strategic objectives were to contribute to sustainable maternal/newborn morbidity/mortality reduction in East Mamprusi District by 2015. They entailed particularly:  SO1: East Mamprusi District has improved maternal and neonatal health outcomes  SO2: Families have increased access to quality maternal and neonatal services The key project strategy has been to scale up community led strategies that enhance MNCH/N practices and service utilization. Technical interventions included: Maternal and newborn care (60%), Nutrition (30%) and Malaria in Pregnancy (10%). The social and BCC strategies at household and community level were key for achieving SO1 and its IRs. Community mobilization supports achievement of SO2 and IRs. To address the three delays that contribute to MNC morbidity and mortality,6 the BCC strategy was employed including working with community members for effective response to MNC 6 1) Recognizing harmful practices and danger signs, 2) decision making and seeking care, and 3) diagnosing and providing timely care. 14 complications. The third delay was addressed by strengthening GHS capacities and quality of care at the health facilities. Operations Research (OR) Design: As noted above, the high maternal and neonatal death rates in East Mamprusi are attributed to household PRABs well as non-recognition of danger signs and lack of timely decisions to access services, which all increase risks of obstetric complications. Low institutional deliveries also have negative impacts on early initiation of BF and cord care7. The ability of the health system to provide timely interventions is mediated by challenging PRABs of mothers/ fathers, chiefs, religions leaders and others who control the birthing practices in rural Ghana. To address this, CRS, together with University for Development Studies (UDS) designed an OR to test an innovation that targeted challenging PRABs through creation of a council of champions (CoC) in each intervention community. The CoCs are composed of the 5-7 most influential community members who are trained and regularly supervised by the project. These individuals have a strong influence in the improvement of early antenatal attendance as well as institutional childbirths. Partnership/ collaboration: From the conceptualization, design and field level implementation stages of EPPICS, GHS and the UDS have played strategic roles. As a lead implementer of field level activities, GHS has contributed in the training of community-based agents, monitoring and supervision of project activities as well as coordinated and led the overall provision of services and interventions being promoted by the EPPICS Project. Additionally, GHS has coordinated with other relevant organizations including Presby Health Services and the Baptist Medical Centre who run a number of health facilities which were all beneficiaries of the EPPICS interventions. SEND Foundation collaborates with GHS- East Mamprusi for the implementation of Family Planning activities at the community level. The UDS has been instrumental in the design, execution, documentation and dissemination of the OR component of the EPPICS Project. EPPICS Project activities were designed to contribute to Ghana’s MOH MNCH/N policies, and also, the USAID Health Program’s Global Health Initiative (GHI) which is all focused on contributing to MDGs 4 and 5 and beyond. EPPICS has enjoyed great collaboration with USAID-Washington and USAID Ghana Mission. Over the life of the project USAID’s Ghana Mission has supported EPPICS in various ways: USAID was part of the official launch of the EPPICS Project on site; the Director and MCH Advisor of the Health and Population Bureau conducted three separate monitoring and support visits to the field. Additionally, CRS Ghana has always participated in USAID Ghana’s Implementing Partners Meetings where lessons learned and best practices are shared as part of project updates. EPPICS’ technical intervention areas (maternal and newborn care, nutrition and malaria) are in consonance with USAID Ghana’s Health Sector Strategy (Strategic Objective 7- Health status of Ghanaians is improved)8.The project was positioned to contribute towards achieving Intermediate Results 3 (improved nutritional status of women and children) of the USAID funded Feed the Future initiative in Ghana which commenced a few months before the closure of EPPICS. 7 Wuni A (2009) Determinants of use of MCH services among women of reproductive age in West and East Mamprusi. Northern Health Monitor 8USAID Ghana Strategic Plan for the Health Sector (2009 -2013) http://pdf.usaid.gov/pdf_docs/PDACP753.pdf 15 Figure 1.1 EPPICS Results Framework Goal To contribute to improved maternal and neonatal health outcomes in East Mamprusi district by 2015. Strategic Objective (SO 1) Improved knowledge and positive health practices among pregnant and lactating women Strategic Objective (SO 2) Increased access to maternal and neonatal services IR 1.1: Increased knowledge & skills on positive health behaviors among pregnant & lactating mothers IR 1.2: Increased knowledge of seeking obstetric emergency & newborn care among pregnant & lactating women & household decision makers IR 1.3: Improved nutritional practices among pregnant, lactating women & newborns Strategies/Activities IRs 1.1. 1.2 and 1.3 - Community Mobilization and capacity building: 1. Organize and train community health workers and provide skills for post-partum care for TBAs 2. Facilitate preparation of birth plans among pregnant women and their partners 3. Organize and equip Emergency Transport and establish a referral system 4. Engage community and the district assembly in the establishment of emergency transport plans - Behavior Change Communication 1. Establish and facilitate the functioning of community pregnancy surveillance and targeted education session 2. Establish functional Council of Champions 3. Establish Healthy Mothers and Newborn Care Committees 4. Foster the provision of counseling during home visits 5. Print and distribute T-Shirts with targeted messages 6. Broadcast key messages using the community radio 7. Train GHS staff in the application of Positive Deviant strategy to maternal/newborn care (MNC) services - Community Health Information System 1. Support community members to construct and manage Giant scoreboards 2. Train CHVs, TBAs in data recording, analysis and reporting. - Operations Research and Quality Assurance 1. Develop and test innovative approaches for improving uptake of MNC services 2. Train TBAs in counseling skills 3. Monitor of community volunteers. -Improve maternal and neonatal nutrition practices 1.Train health staff, CHVs and TBAs to promote ENAs 2. Form/revitalize Breastfeeding Mother-to-Mother support groups 3.Support/promote deworming activities for pregnant women 4.Train health staff and CHVs in nutrition counseling IR 2.1: Improved MNC & ENA skills among Community Health Volunteers & TBA IR 2.2: Strengthened partnership between Community structures & health facilities IR 2.3: Improved quality of MNC at public & private health facilities Strategies/Activities IRs 2.1., 2.2., and 2.3: - Community Mobilization and sensitization: 1. Organize and reposition TBAs as Link Providers 2. Establish/strengthen linkages between CHVs, TBAs and Health Facilities, - Quality Assurance: a. Health facility level 1. Capacity building programs for health staff through trainings, coaching sessions and mentoring 2. Provide facilitative supervision 3. Establishment of QA teams in all the health facilities 4. Provisions of MNC guidelines and protocols 5. Re-activate management meetings of DHMTs and SDHMTs b. Community level 1. Train TBAs and CHVs in EoMC, ENAs and identification of danger signs during pregnancy/delivery/postpartum period/newborns and maternal nutrition 2. Provisions of tools and working gears for TBAs - Improve partnership 1. Conduct annual reflection forums for stakeholders- District Assembly members, Chiefs, Decentralized government agencies, etc. - Strengthen Referrals 1. Establish functional two-way referral system Facilitative supervision 2. Supervise project activities at the community and facility level 16 EVALUATION METHODS AND LIMITATIONS One of the limitations of this report is that the FE evaluator who conducted the qualitative field review with the CRS staff and project stakeholders was unable to complete the report, so another evaluator was asked to write it. This second evaluator did not participate in the field evaluations so has been dependent upon project documents, an incomplete draft from the first evaluator and communications with CRS staff and project stakeholders to complete the report. Evaluation Methods: In the second half of September 2015, over a ten-day period, a four-person evaluation team conducted the final evaluation of the Child Survival project (see Annex XIII for a list of members). Members of the team visited project sites in East Mamprusi district (sub-districts: Gambaga, Nalerigu, Sakogu, Jawani and Tamboku) and held discussions with project staff and partners in Gambaga, Tamale, and Accra districts. The team reviewed the findings of knowledge, practice, and coverage (KPC) surveys and other studies commissioned by project staff in the district (see Annex1 for a list of documents). In addition, the evaluation team used qualitative information – non-numeric and opinion-based – to assess the project. The evaluation team used a small number of interviews, group discussions, and observations to supplement existing information. Interviewers and discussion facilitators conducted a few unhurried sessions, probing for answers and meetings with other individuals and women’s/community groups. In particular, the evaluators sought answers to an important question: “Why?” For example, when surveys showed that the prevalence of low weight-for- age (an indicator of malnutrition among children) had decreased in East Mamprusi, the team brought this positive finding up for discussion in meetings with project staff and partners in Tamale and Accra to explore possible reasons for the decline. The methods used by the evaluation team include:  Discussions with project team members  Review of project documents including the KPC survey and OR reports and community based data forms on the Walls of Health  Group discussions with mothers  Interviews with community members  Interviews with project partners  Observations of patient-provider interactions  Exit interviews with patients  Investigation of maternal death in Gambaga sub-district  Review of referrals to hospital in Nalerigu 17 Group discussions were conducted by two experienced data collectors (Bachelor degree holders) who have facilitated such sessions for the project before. Working together, they facilitated the discussions (in Mampruli, the local language) and took notes (rotating the two roles in a series of discussions). Group discussion topics included antenatal care, delivery (transport, place, and birth attendant), infant feeding practices, use of bed nets, and opinion about project activities. Group discussion facilitators (Raymond Atariba and Sumaila Nambe) also conducted a participatory diagramming exercise to explore the roles played in deliveries by family members, community members, transportation providers, health care providers, and health facilities. Interviews with health facility staff explored a number of topics related to the provision of services for antenatal, delivery, and post-partum care, including the following: number, qualifications, and responsibilities of staff; availability of equipment and medicines (and stock-outs of medicines); cost of consultation, procedures, and treatment; use of services (number of patients and waiting periods); thoughts about improving services; and opinions about project activities. While an important theme of the evaluation was project performance as assessed through the KPC surveys, the team also examined other issues related to the project. These included project accomplishments, project strategies that worked (or did not) including the review of community based data forms from Healthy Mothers and Newborn Care Committees (HMNCCs) on their Walls of Health, results of the operations research study and, continuation or expansion of activities. (See annex XIV for the number, location and timing of interviews and group discussions.) Data Quality and Use: In general, there were no significant problems with the KPC baseline and Final evaluations. The findings were used consistently by the project to focus the project training and BCC activities. An issue regarding the design of the OR project, which the project staff concedes, concerns the selection of case/intervention and comparison sub-districts. It turns out that the intervention/study district had only one health facility while the control district had 5. This may account for the discrepancy in findings in the final OR report where women in the intervention communities were 50 percent less likely to deliver in a facility than women in the comparison communities. According to project staff there was violence in the intervention district that caused the facility midwife to leave the district and as a result, women did not go there for deliveries. Unfortunately, there were no other facilities in this sub-district for women to seek delivery services. Another OR issue was with the council of Champions (CoC). Because the Council was composed of 5-7 high level leaders in each community, it was sometimes hard to keep their CoC activities separate from the comparison communities. This is because the leaders, especially the Chiefs were so excited about what they were doing that they shared the information with other communities who then began listening to the Chiefs. So there may have been contamination of the comparison communities as well. Another data issue became apparent during the internal mid-term review conducted by the headquarters Senior Technical Advisor for Health. During her review the GHS reported a very high number of stillbirths and the rate had not decreased over time. She advised the GHS to review their data and determine where the women lived. The analysis found that most of the mothers of stillbirth babies were from neighboring districts and had not participated in the different SBCC interventions being implemented by GHS and CRS. Once this was done, they discovered that the actual number of stillbirths in East Mamprusi District was much lower than originally calculated. 18 One of the successes of the EPPICs project is how it assisted the GHS improve their HIS system. The project provided training and mini I-pads and cell phones to improve health information/data collection, analysis and timely transmission from the district facilities to the DHMT, who then pass it on to the national level. The project also shared their community-based HIS (CIS) using the walls of health to collect data and improve demand by communities for better data and follow-up. This community data was a useful comparison with the facility data regarding deliveries. 19 FINDINGS, CONCLUSIONS AND RECOMMENDATIONS FINDINGS The main finding of the evaluation team is that improvements have occurred in maternal and child health in East Mamprusi District over the last four years. This section will address the evaluation questions in the scope of work. 1. To what extent did the project accomplish and/or contribute to the Strategic Objectives and Intermediate Results stated in the Detailed Implementation Plan? Table 3 presents the summary of inputs, activities and outputs related to the S.O.s and I.Rs is presented below. Table 3: Summary Table of Inputs, Activities, and Outputs That Contributed to Key Outcomes Strategic Objective (SO 1): Improved knowledge and positive health behaviors among pregnant and lactating women Project Inputs Activities Outputs Outcomes Fuel, funds and Logistics Conducted community Sensitization on project strategies Sensitized project communities on EPPICS strategies 240 mobilized and sensitized on all EPPICS strategies communities in FY13 Formed and trained Community Pregnancy Surveillance and Targeted MNC education sessions (C-PreS) sessions C-PreS formed in 240 communities C-PreS session contributed to improved MCNH knowledge awareness and service uptake among Pregnant women and lactating mothers Behavior Change Communication (BCC) Materials Funds/Logistics for trainings and Workshops 480 Positive Deviant Mothers9 trained in SBCC Positive Deviant Mothers positioned to facilitate C-PreS session for pregnant and lactating mothers Increase in percentage of births attended by skilled personnel (from 43% to 76%) Essential newborn care increased from 12% at baseline to 52% at endline Exclusive breastfeeding increased from 47% at baseline to 70% at endline Post-natal checkup for the newborn increased from 30% at baseline to 80% at endline 480 Traditional Birth Attendants and Traditional Medical Practitioners repositioned as Link Providers 480 Link Providers facilitate referrals of women and point of labor and delivery as well as postnatal mothers to health facilities Modified Motor Tricycles (MMTs) as Rural Ambulances Provided 4 MMTs to remote communities to facilitate access to health facilities for pregnant women and newborn emergencies Increased access to skilled assisted care among women in remote communities. The 4 MMTs reached 40+ communities 9 These are mothers who inspite of their locations and conditions have been able to uptake MNC services in line with the recommendations of GHS: Presented at antenatal clinic within first trimester, made four plus ANC visits, used skilled professionals for childbirth, exclusively breastfeed infant and ensured that the infant was fully vaccinated against vaccine preventable diseases. Has good communication skills to provide educational support to peers 20 Long lasting Insecticide Nets (LLINs) Collaborated with GHS and Networks (USAID funded project ) to continuously distribute and improve LLIN use among Pregnant and Lactating mothers 17,368 pregnant and lactating mothers communities benefited from the package Increased use of LLINs by pregnant and lactating mother from 42% at baseline to 71% at endline Strategic Objective 2 Families have increased access to quality and use of maternal and neonatal services by 2015 Funds/Logistics for trainings and Workshops Trained Health staff (midwives and nurses) in Emergency Obstetric Care (EmOC, Essential Newborn Care (ENC) and Essential Nutrition Action(ENA) Midwives/Nurses trained in EmOC, ENC and ENA and have been deployed to provide services in all 11 health facilities Improved knowledge and skills health staff ENC and ENA, Improved MNC services are being provide in all the 11 health facilities and 240 outreach points Increase in percentage of health facilities in which interviewed health worker reported receiving any training in maternal and neonatal care in the last twelve months (from 71% to 100%) MNC Guidelines and Protocols Developed/Reproduced MNC related protocols/guidelines for distribution to all health facilities All relevant MNC guidelines/protocols are available and used in all the health facilities Increased percentage of health facilities with guidelines on delivery care (from 14% to 100%) Cements, Paints and funds Facilitate the construction of Alaafia Gooma- Walls of Good Health/ community giant scoreboard (CGS) 240 Alaafia Gooma – walls of Good Health/Community Giant scoreboards constructed Community members actively participate in the monitoring of key MNC indicators Training designs/Funds and logistics Form and train quality assurance teams for health facilities Five member quality assurance teams formed and trained for each of the 11 health facilities 10 health facilities provided with functional QA teams and are working to improve quality of MNC services Cross cutting activities: Innovation – Operations Research Funds and Logistics for Operations Research Identified, trained and support the operations of 200 Council of Champions (CoC) in 44 communities in the intervention arm of the OR CoCs in 44 communities deployed and supported to influence Household Decision Makers The 200 CoCs visited and engaged 13,632 and 15,152 Household Decision Makers and Caregivers respectively to influence them and support prompt uptake of health services by pregnant and lactating mothers Developed CoCs manual and provided orientation for 200 CoCs members Documentation of OR Activities/Data collection An average of 6 key Practices, Rituals, Attitudes and Beliefs challenging to the uptake of MNC were modified/eliminated Conduct baseline, midterm and final evaluation of the OR in both intervention and comparison arms The three study reports were conducted and are available for use to replicate the strategy or to influence policy The CoC strategy researched and documented to inform policy on community engagement for enhance uptake of maternal and child health services 21 The goal of the EPPICS project was to contribute to sustainable maternal/newborn morbidity/mortality reduction in East Mamprusi District by 2015. The objectives were to improve maternal and neonatal health outcomes and to increase access to quality MNC services for all families in EMD. A review of the KPC results shows that EPPICS improved all of its indicators (see Annex IV and V for complete report). The endline (EL) KPC survey found a statistically significant increase in the proportion of mothers of children 0-23 months received 4 or more ANC visits (82%) against baseline (BL) value (63.9%). Also statistically significant is the increase in proportion of women who accessed ANC during their first trimester from 50% (BL) to 74% (EL). Ninety percent indicated they were satisfied with their treatment by health staff though 10% did say they were abused by HF staff, generally this meant they were exposed to yelling. Baseline focus group discussions with communities revealed that abuse by HF workers was one of the reasons women went to facilities for ANC but not for deliveries. Seventy-one percent of women at EL received tetanus toxoid compared with 64% at baseline. Skilled birth attendance showed a statistically significant increase to 76% at EL from 43% at baseline. Postnatal care for children within two days after birth had a statistically significant increase from 30 % (BL) to 83% (EL). Postpartum care for mothers also showed a statistically significant increase from 32% (BL) to 82% (EL). Overall 95% of mothers were checked by health provider at endline compared to 86% at BL. There was an increase in children 0-5 months breastfed in the previous 24 hours (47% BL- 70% EL). Likewise exclusive breastfeeding (EBF) of children 0-5 months showed a statistically significant increase from 47% at BL to 70% at EL. At baseline only 50% of children were immediately breastfed after birth but this increased to 75% by the EL. The proportion of children’s mothers who reported to have had clean cord care showed statistically significant increase from 22% (BL) to 73% at EL. The use of clean delivery kits during birth of youngest child by mothers with children 0-23 months also showed statistically significant increase from 65% at BL to 95% at EL. Knowledge of danger signs at BL also increased at EL (delivery danger signs 69-72%, pregnancy danger signs 81% - 86%, postpartum danger signs – 77% BL – 87% EL, neonatal danger signs 72% at BL- 80% at EL). Some of EPI indicators example immunization levels for measles, DPT1 either did not increase or stayed the same, but childhood immunization was not a focus of the project. ORT use for children 0-23 months with diarrhea showed a statistically significant increase from 48% at BL to 65% at EL. Appropriate care seeking for pneumonia also showed a statistically significant increase from 45% at BL to 63%. The percentage of households that treat water effectively grew from 4% to 33% and appropriate hand-washing practices rose from 28% at BL to 46% at EL. Knowledge of PMTCT increased from 36% at BL to 65% at EL. ITN use of children 0-23 months showed a statistically significant increase from 42% at BL to 71% at EL. IPTp however, decreased by 59% at BL to 58% at EL. This was attributed to the shortage of Suphurdoxine Pyramithamine (SP) as a result of procurement challenges that was made worse by the fire that gutted the Central Medical stores of Ghana in 2013. The proportion of children fed according to minimum appropriate infant feeding practices (WHO) increased at a statistically significant 55% at BL to 78% at EL. The percent of children who 0-23 months who ate vitamin and iron rich food, fortified food and dairy increased by 4% to 10% points. Those eating vitamin A rich foods dropped slightly (from 76% to 72%). Children eating animal source food also decreased from 72% to 54%. This drop was attributed to the seasonal difference during which the two surveys were conducted. The BL was conducted during the latter part of dry season where families had 22 access to animal source foods from bush-hunting, whereas the EL was conducted during the rainy season. In general, the project was implemented as planned but there were a few nested interventions:  Four Modified Motor Tricycles (MMTs) served twenty clusters of communities as rural ambulances to address challenge of limited geographic access to health facilities. From April, 2012 to September 2015, the MMTs had served 2,894 pregnant women, 3,022 mothers with newborns/children and 754 other emergency medical conditions. Each MMT averagely recorded 212 transport events with a cost per event at $5±.5 on the average. The fee was divided to cover fueling-$3.3±.2, maintenance- $1±.2 and driver/link provider motivation fee-$0.7±0.1. Total fuel and maintenance requirements of each MMT were approximately $22- $35/month. The MMT made a statistically significant contribution to skilled assisted deliveries in the target communities from a baseline of 23% to 78%.  EPPICS staff investigated and established a key cause of the level of child under-nutrition and wasting (30%) to be a rapid repeat birth rate, with little spacing. As a result, the Lactational Amenorrhea Method (LAM) as well as birth control using cycle beads and calendars was promoted. EPPICS first piloted the cycle bead method in 4 large communities and then expanded it to all the communities along with its exclusive breast feeding strategy in the project district. There is now demand for cycle beads from neighboring districts.  In EMD, CRS found that 24 different forms for data collection were filled manually on a monthly basis. On average, each health facility serves 30 communities. Manual completion and submission of these data forms to the district level took considerable time (2 days to deliver the forms), money and risks. CRS addressed these challenges by supplying the sub-districts with mini iPads and digitized forms along with training on how to use them. These iPads not only facilitated transmission of data to the district office improving timeliness and data completeness but also reduced absenteeism. Health providers no longer had to travel long distances and spend hours per day filling out forms while patients were waiting for services. An assessment by the District Health Information Officer indicated that timeliness of data reporting had improved greatly since the system was installed in year 2 of the project. The system has been adopted by the GHS that uses cell phones to capture data and ensure real time data collection for better management of health delivery issues in the district. 2. What were the key strategies and factors, including management and partnership issues that contributed to what worked and did not work? At community and household levels, EPPICS combined tested strategies from earlier projects to link communities with GHS facilities by providing support networks to promoting the uptake of maternal and newborn care services. Key strategies included:  Community Pregnancy Surveillance and targeted Education Session (C-PrES): C-PrES aimed at improving the knowledge of pregnant women and lactating mothers on MNC. In all, EPPICS engaged a total of 64,244 pregnant women and lactating mothers and supported them to increase the MNC health knowledge and practices. On the average, 25 women pregnant women or lactating mothers were constituted into groups and received for MNC education covering a wide range of themes including: important of antenatal care and uptake of related services, 23 healthy birthing practices with emphasis on institutional deliveries, essential newborn car, IPT intake, use of LLINs, danger signs, postpartum check, maternal and child nutrition. A total of 480 trained Positive Deviant Mothers10 were engaged to facilitate C-PreS sessions in each community over the life of the project. This strategy contributed to SO1 for EPPICS: Improved knowledge and positive health behaviors among pregnant and lactating women. Examples of some status of some MNC knowledge indicators as at endline against baseline are: knowledge of danger signs at BL increased at EL (delivery danger signs 69-72%, pregnancy danger signs 81% - 86%, postpartum danger signs – 77% BL – 87% EL, neonatal danger signs 72% at BL- 80% at EL). Also knowledge about the risk associated with births to pregnancy intervals less than 24 increased from 35% baselines to 54% at endline.  Re-positioning traditional birth attendants as Link Providers as partners in skilled care: To encourage early and frequent ANC, promote maternal nutrition in pregnancy, support skilled assisted deliveries and to discourage home deliveries, 480 TBAs were identified, trained and repositioned to play a new role as Link Providers in all the 240 communities. Link providers accompany pregnant/postpartum women to facilities and assist with the health facility deliveries. TBAs also doubled as providers and teachers on essential newborn care when babies are born at home, promoted uptake skilled post-partum and newborn care and accompany mothers and babies to a facility within 24 hours after a home birth for postnatal and newborn checkups. This strategy contributed in strengthening partnership between community structures and health facilities, Key outcomes that benefitted directly from this strategy is significant increase in skill assisted deliveries from 43% at baseline to 76% at endline while post-natal visit for newborn health increase significantly from 30% at baseline to 83% at endline. The strategy praised by the GHS during the evaluation concerns how TBAs have become key MNC stakeholders in rural communities. The Link Providers showed no resistance as the engagement process still guaranteed them their original incentives of fowls and soap even after linking a pregnant women to health facility for childbirth  Creation of Healthy Mothers and Newborn Committees (HMNCCs) – HMNCCs were comprised of influential community members including men and women, TBAs, CHVs, THs, grandmothers, religious leaders etc. The HMNCC’s tasks included mobilizing communities to develop birth plans including transport expenses, engaging fathers to support birth plans and supporting pregnant mothers in seeking early ANC and nutritional behaviors, influencing women’s behaviors through women leaders. The also led communities to construct and managed the walls of good health. This strategy assisted in enhancing the operations of the community health planning and service (CHPS) compounds as the HMNCCs also doubled as the Community Health Committees and worked directly with the Community Health Officers in charge of the CHPS compounds. 10 These women 1) registered early for ANC, 2) used skilled delivery and 3) employ newborn care practices known to prevent MN deaths. Experience shows that these mothers have good access to households, and are good face-to-face peer counselors 24  Using CBIS for Community Motivation and Feedback with “Walls of Health”: In public health it is often difficult to present health data to communities where literacy levels, especially among women, are low. The FE team found the Alaafia Goomni “Wall of Health” to be an ingenious solution for this. The walls are made of mud, plastered and painted and often stand on the roadside. They are a little taller than a man and as broad as a car. The wall displays data on 2 health indicators, chosen from a menu of indicators by community members. Ten holes at the top of the wall hold ten colored sticks, green and red. To use these, for example, the percentage of births attended by skilled providers out of the total is calculated; say 60% - in which case six green sticks and 4 red sticks are on the wall. There are walls in all 240 communities. The team found the Walls to be a great strategy for the community to monitor MNC indicators. The members become involved in collecting and analyzing community data and progress. The walls have been adapted as a Score Card for monitoring MNCH indicators at facilities. The FE team did raise concerns regarding upkeep of the walls. The team visited one community where the wall had collapsed and not been rebuilt and heard of other instances where this had occurred. However, the chiefs and community members in areas visited did say that that they did and would repair damaged walls. One of the FE team was also concerned about privacy for individuals in small communities who might fall in the “red” area, but the rest of the team believed because the communities were large enough and since individuals were not singled out, that privacy was protected.  Nutrition Interventions: These were integrated into most MNCH and delivery activities. The project uses Essential Nutrition Actions (ENA) for health facility (HF) training and community SBCC activities. Specific behaviors include BF initiation in the first hour and colostrum, nutrition during pregnancy and lactation, anemia prevention, lactation management, and birth spacing. ENA is key for improving birth outcomes and decreasing low birth weight. As part of this strategy, Mother to Mother Breastfeeding Support Groups were revitalized. The groups support early initiation of EBF and introduction of complementary feeding at 6 months. Baseline assessments determine knowledge of these as well as the Lactational Amenorrhea method for birth spacing and then based on their knowledge; integrate them into the Community Pregnancy Newborn Surveillance and Education sessions. Key outcomes included a significant increase of exclusive breastfeeding from 47% at baseline to 70% at endline.  Health Service Quality Improvement at the CHPS and Health Facility level: To ensure that service provision match’s client’s expectation, EPPICS formed and trained Quality Improvement Teams in all the 12 targeted health facilities including the CHPS compounds. The QITs provided a platform for reflection on the quality of services provided – analyze such issues and take decisive and prompt action to swiftly address challenges. Community members were part of the QITs and through these, EPPICS assisted communities to advocate for services from healthcare providers and held them accountable for quality services being provided. Additionally EPPICS focused on health manpower, health staff attitudes, and supply chain management challenges faced by NR and EMD. EPPICS filled the gaps by linking the formal health service to communities and by improving skills of CHVs and TBAs and building volunteer support to regularly visit households with pregnant/lactating mothers. 25  Council of Champions (CoC): The ability of the formal health system to provide rapid MNC interventions is mediated by challenging practices, rituals, attitudes and beliefs (PRABs) of key household decision makers: husbands, mothers- and fathers-in-law. Chiefs, Magazias, Traditional Birth Attendants/Medical Practitioners and Religious Leaders are the custodians of these PRABs and also dominate the obstetric and gynecologic scene in much of the rural districts of Ghana. EPPICS regrouped a total of 200 (5 – 7 per community) most influential people to serve on the community CoC and to help address/promote PRABs related barriers/enforcers to health seeking behavior. A total number of 13,632 Household Decision Makers (HDM) were engaged by 200 CoCs in 42 communities. Also, a total of 15,152 mothers/caregivers were visited by the CoCs within the period of implementation. In all eight key challenging and four key positive PRABs were identified and work on with the support of the CoCs. The modification and reinforcement of such PRABs facilitated improvement of key MNC indicates. Gender considerations were upheld in the design of EPPICS. The HMNCCs for managing and updating the Walls of Health required that the membership be gender balanced. The QA teams always solicited feedback from women as well as men as each viewed situations differently. The transport committees always included women as their opinions concerning transport to facilities were valued. This was important as traditions dictate that the husbands decide where the baby should be born. There is also a belief that if a mother has been faithful to her husband then she has a safe home delivery but if she delivers in an HF, it is because she has been unfaithful. Part of the committee’s work was to make sure that pregnant mothers were given a choice/ voice once the dangers of home births were understood. On partnership, project staff noted during the review that EPPICS facilitated great coordination between CRS and the GHS. Unlike other similar interventions by other GHS partners, CRS ensured that the GHS was heavily consulted and involved in the design of the project, taking ownership at all levels. CRS claims that much of the success of this partnership is due to the district director who took over just as the project was starting. Compared to other NGOs where project staff led the implementation, CRS ensured that GHS lead implementation of activities at all levels. GHS continues to commit staff (12 Quality Assurance Teams and 7 district and regional Focal Persons, 11 nurses), time and effort as part of the in-kind contribution to lead/support the six EPPICS field staff in the implementation of activities at all levels. This partnership, which is based on trust, often sees CRS and GHS jointly conducting activities including monitoring visits with facilitative support at the 12 health facilities and 240 communities. One of the concerns mentioned by the FE external evaluator was the disparity in staffing levels between the sub-districts. One hospital at Nalerigu has three doctors plus 2-3 part-time doctors, 4/5ths of the districts nurses and half of the midwives. The 4 other facilities have one midwife and maybe a nurse. The FE team members that were there at the beginning of the project noted that over the past four years the facilities have improved in terms of cleanliness and water supply. 3. Which elements of the project have been or are likely to be sustained or expanded? The evaluation team established from the GHS partners that the following strategies of EPPICS are being/already scaled up and or sustained: Community-managed C-PreS education strategy, Repositioning TBAs as Link Providers, Council of Champions, Modified Motor tricycles, Quality Improvement Teams, the Walls of Good Health. Other specific examples are as follows: 26  With support from CRS and GHS the community managed C-Pres education strategy is being scaled up in six new districts in northern Ghana by the GHS and is expected to benefit over 100,000 beneficiaries.  Due to the documented achievements of using TBAs as link providers for referrals of pregnant women/newborns to facilities, and the resulting increase in skilled deliveries, CRS has leveraged $2.6 million to scale up this strategy in 6 more districts, to reach an estimated 85,000 women and children. This strategy has now been adopted by the GHS and is being scaled-up in the rest of the 21 districts of the Northern Region of Ghana.  The Walls of health have been recognized as a useful intervention outside Ghana. CRS Ghana shared the methodology at the ECOWAS meetings in 2012. Some countries showed interest in this strategy and asked CRS / Ghana to help them replicate it in their countries. CRS staff traveled to Niger and Burkina Faso to support this expansion of the MNC methodology.  Interventions such as the use of iPad Minis to improve data collection and Natural Family Planning Methods using the Standard Days Method together with other EPPICS project strategies contributed in making the East Mamprusi District the best performing district in 2014. This is a dramatic improvement since it was recorded as the worst performing district in 2010. The table 4 below presents EPPICS’ most effective and promising community-based strategies in terms of impact. The table presents corresponding unit costs for scale up. Table 4: Costs per Unit of EPPICS’ Most Effective Strategies Promising Strategy Numbers involved Total Cost incurred in USD Cost per unit in USD Additional information Custodians PRABs repositioned Council of Champions for MNC 200 $6,914 $35 This includes 4 days of training CoCs including using SBCC materials Modified Motor Tricycles (MMTs) 4 $9,000 $2,250 This includes a 1 day training of MMT drivers Repositioning TBAs as Link Providers 480 $38,985 $81 This cost includes a 1 day training and provision of material incentives including raincoats, flashlights and wellington boots Walls of Good Health for CBIS 240 $33,375 $139 This excludes community support in building the walls but includes cement for concrete reinforcement, paint and picture illustrations as well as training of management committees 4. What are stakeholder perspectives on the OR implementation, and how did the OR study affect capacity, practices and policy? The OR project, like the EPPICS project, had the overall aim to contribute to sustainable reduction in maternal/newborn morbidity/mortality in East Mamprusi District by 2015. The operational research 27 (OR) sought to improve knowledge, modify PRABs to maternal and newborn health care through an innovative approach using the “Council of Champions” (CoCs) (see background for details). The final OR report11 (see annex XIV) concluded through the difference-in-difference analysis, comparing the changes over time for intervention households and comparison households, an improvement in respect to all outcome measures was noted except health facility delivery due to constraints with skilled health providers. The results showed that more pregnant women in the intervention communities received adequate prenatal care (defined as having initiated ANC in first trimester and made at least 4 visits) than the comparison communities. Women from the intervention communities were 2.9 times more likely to initiate first ANC visit early in pregnancy (AOR=2.95 (CI: 2.01-4.34) than the comparison communities. Women from the intervention communities were 1.7 times more likely to utilize postnatal care services at least twice in the first week of delivery compared to women from the comparison communities (AOR=1.74, CI: 1.28-2.37). Women who received more ANC services were 1.9 times more likely to seek postnatal services in the first week of delivery compared to those who received less than seven visits. The intervention improved essential newborn care practices (breastfeeding, safe cord care, optimum thermal care, and improved neonatal feeding). These findings demonstrated the power of council of champions to effect change in behaviors around maternal and newborn care. The prevalence of at least one wrong MNCH belief was lower in the intervention than the comparison communities (33.9% versus 50%). Generally, mothers in the intervention communities were more knowledgeable about danger signs during pregnancy, delivery, postpartum and neonatal periods than their counterparts in the comparison communities. Women in the intervention communities were 50% less likely to deliver in a health facility, compared to their counterparts in comparison communities. The intervention was unable to effect positive changes in health facility delivery because of external influences that prevented the availability of the midwife to render services (see background section for discussion). Unfortunately, there was only one facility in the intervention sub-district, so the mothers had no other place to go. This site selection was a weakness in the design of the OR strategy as the control sub-district had several facilities. The District Health Directorate of GHS with support from OR Investigators and CRS was able to share the OR results at the GHS/ Northern Region Annual Performance Review meeting and at the National level at the USAID System for Health meeting. The MoH/GHS in northern region has adopted the Council of Champions as a novel strategy to be implemented in 20 additional districts as part of the Millennium Accelerated Framework for Maternal Health. Additionally, GHS/MoH is working with USAID/Systems for Health for implementation of the CoC strategy in five of Ghana’s 10 regions. Also, MoH/GHS’s Northern Regional Health Directorate is working with CRS to develop a policy brief for revision of the MNC implementation policy at the sub-district and community levels. As part of the FE, the MoH/GHS District Director of Health Services and the GHS Regional Focal Person for the EPPICS saw the CoC strategy as very promising in addressing current bottlenecks for uptake of MNC services. To them, it’s a shortcut for addressing suboptimal MNC indicators and its 11 M.Saaka, P.A.Aryee, M. Ali, R. Kuganab-Lem. “Engaging Community Leaders as “Council of Champions” to improve uptake of maternal and newborn health services in East Mamprusi District, Northern Ghana. Endline Survey Report. August 2015 28 consequent effect on maternal and child survival in the region. Additionally, the Local Government representatives and the Chiefs interviewed as part of the FE were very complementary regarding GHS’s role in using the CoCs to address the low utilization of MNC services. The head Chief noted that the CoC strategy has taken the engagement of community leaders in health service delivery to the next level and his subjects (sub-chiefs) now see health delivery especially at the community and health facility levels as collective responsibilities. In conclusion, the OR established that engaging custodians of PRABs and repositioning them to influence household decision makers assisted to modify challenging MNCH/N related PRABs and enforced the positive PRABs which subsequently contributed to improved uptake of MNCH/N services in the intervention sub-district. CONCLUSIONS Catholic Relief Services, Ghana Health Service, and numerous committed community volunteers have implemented a great project in East Mamprusi. In the short span of four years, population-based indicators – most notably, skilled attendance at childbirth – have improved substantially in the district. The key EPPICS strategies which contributed to this success include: The Walls of Health, Repositioning TBAs as Link Providers, C-PreS, Modified Motor Tricycles (MMTs), Council of Champions and Quality Improvement Methods. The Walls of Health, an innovative strategy used by the project to display health data and to engage communities in setting health priorities, is being expanded to other Northern districts and to other West African countries. The C-Pres education strategy is also being expanded to other Northern Region districts by the GHS, as is using TBAs as Link Providers. C-PreS, MMTs, Council of Champions and the OIMs have been scaled up by GHS and CRS into six additional districts. In addition the use of iPad minis to improve data collection and reporting and the introduction of natural family planning methods along with these other EPPICS strategies are making huge improvements in the quality of health care in the region. Another improvement encouraged by the project’s quality of care objectives is that local health officials investigate maternal deaths thoroughly and offer clear recommendations to prevent such deaths in the future. Members of the evaluation team were impressed with the dedication displayed by dozens of individuals in the district to the cause of maternal and child health, their willingness to discuss systemic and specific problems, and their ability to find creative solutions to resource constraints. Catholic Relief Services is now implementing a successor project in East Mamprusi and neighboring districts, serving a larger population and replicating elements of the Child Survival project such as those above and the three-wheeled motorcycle ambulance. The use of health services by women and children in the project area has improved in recent years and East Mamprusi was recognized as the best-performing district in the Northern Region in 2014. Sincere efforts to improve service quality are continuing and this part of Ghana is poised for further, and rapid, gains in health service use and in health status. 29 RECOMMENDATIONS Table 5: Recommendations Consistent with Major Findings and Conclusions Findings Conclusion Recommendation Action Who Is Responsible Improvements in MNC indicators: Both rapid and non-Rapid CATCH indicators improved considerably. Deployment of combined health facility and community based strategies is key to effecting desired impact on MNC The design of the EPPICS experience should be a reference for future MCH interventions that targets the health of women and children CRS should document and share how to guide on the replication of EPPICS with other stakeholders CRS, GHS, Christian Health Association of Ghana (CHAG) and other actors Promising scalable strategies: A number of the strategies including the repositioning TBAs as Link Providers, Constituting Community leaders into Council of Champions, Alaafia Goomni –‘’Walls of Good Health’’, Modified Motor￾tricycles and Quality Improvement Methods in health facilities made significant contributions to the success of the EPPICS Project EPPICS innovative strategies have proven to be effective in addressing MNC challenges in East Mamprusi District and in similar contexts Ghana Health Service and the Ministry of Health should coordinate with Catholic Relief Services to scale up such strategies in all districts of Ghana USAID should support CRS to document and share ‘’How to Implement’’ these strategies for adoption in other USAID funded projects CRS should take the lead in organization and dissemination meeting to introduce these innovative strategies to all the major actors in MNCH programming CRS, GHS, CHAG and other actors USAID, CRS Adoption of the Council of Champions strategy is useful for addressing challenging practices, rituals, attitudes and beliefs (PRABs) related to MNC service uptake. The CoC strategy has proved useful in facilitating the modification of challenging PRABs that hinder acceptance and utilization of MNC services and also served as a constructive strategy for facilitating healthy engagement of community leaders with household decision makers USAID should support CRS to document and share ‘’How to Implement’’ the CoC strategy for adoption and use on other USAID funded MCH projects CRS should make frantic efforts in reaching out to USAID and other USAID funded MNCH projects to advocate for inclusion of CoCs in areas where PRABs appears as key barriers to MNC service utilization CRS, USAID 30 Findings Conclusion Recommendation Action Who Is Responsible Management and Partnership with GHS: The EPPICS Project Model has been very successful in promoting partnership between health service providers and users. This design not only contributed to the positive health gains recorded but also promotes sustainability EPPICS Model supports sustainability of MNCH interventions GHS should be encouraged to adopt and expand the EPPICS Project Model in partnership with other MCH programming actors for improved success CRS should develop basic marketing materials to showcase this model for adoption GHS, MoH and Partners The EPPICS Project created a great demand for formal MNC services. However there are limited human resources especially midwives, to optimally meet the demand for MCH services in some sub￾districts Human Resource for Health (HRH) is key to health system strengthening Additional Human Resources for Health are required to enhance the human resources based within the rural districts Future maternal health projects should consider investing more of their resources towards improving staffing and supplies at health facilities. GHS and MoH The Modified Motor tricycles (MMTs) piloted by EPPICS seemed to have proven cost effective and capable of improving referrals for MNC emergencies in rural settings MMTs is a cost effective approach to bridging geographic access related gaps for rural communities GHS should invest in scaling up the use of MMTs in rural areas to improve referrals within rural districts GHS and CRS should work on a business model that will encourage private persons/organizati on to invest in this area Ghana Health Service CRS 31 ANNEXES I. List of Publications and Presentations Related to the Project II. Project Management Evaluation (Optional) III. Work Plan Table IV. Rapid CATCH Table V. Final KPC Report VI. Community Health Worker Training Matrix VII. Evaluation Scope of Work VIII. Evaluation Methods and Limitations IX. Data Collection Instruments X. Information Sources XI. Disclosure of Any Conflicts of Interest XII. Statement of Differences (If applicable) XIII. Evaluation Team Members, Roles, and Their Titles XIV. Final Operations Research Report XV. Stakeholder Debrief PowerPoint Presentation XVI. Project Data Form XVII. Other Optional Annexes 1 ANNEXES I. List of Publications and Presentations Related to the Project 2 II. Project Management Evaluation 3 III. Work Plan Table 4 IV. Rapid CATCH Table 10 V. Final KPC Report 12 VI. Community Health Worker Training Matrix 172 VII. Evaluation Scope of Work 173 VIII. Evaluation Methods and Limitations 188 IX. Data Collection Instruments 189 X. Information Sources 190 XI. Disclosure of Any Conflicts of Interest 191 XII. Statement of Differences (If applicable) 194 XIII. Evaluation Team Members, Roles, and Their Titles 195 XIV. Final Operations Research Report 196 XV. Stakeholder Debrief PowerPoint Presentation 230 XVI. Project Data Form 240 XVII. Other Optional Annexes 245 2 ANNEX I. LIST OF PUBLICATIONS AND PRESENTATIONS RELATED TO THE PROJECT 1. Ali M (2015), "Medical transport for women and children in rural settings: modified motor￾tricycle as a promising option," Ending Preventable Child and Maternal Deaths in Ghana, National Health Research Dissemination Symposium 2015, Accra, Ghana, 27-28 May 2015. 2. Ali M (2015), "Repositioning traditional birth attendants as link providers improves uptake of maternal and child health services in rural Ghana," Ending Preventable Child and Maternal Deaths in Ghana, National Health Research Dissemination Symposium 2015, Accra, Ghana, 27- 28 May 2015. 3. Adondiwo A (2014), Integration of Community Emergency Transport System with repositioning Traditional Birth Attendants as Link Providers improves skilled assisted childbirth in northern Ghana, Presentation at the Core Group Meeting, Double Tree Hotel, Washington DC 4. Ali M and Adondiwo A (2014) Application of Positive Deviance Concept in a Rural District of Ghana Improves Feeding Practices for Newborns and Infants. Poster Presentation at the Africa Nutrition Epidemiology Conference, Ghana Institute of Management and Public Administration, Ghana 5. Bliss K and Streifel C, (2014) Improving Maternal, Neonatal, and Child Health in Ghana. http://csis.org/files/publication/141118_Bliss_ImprovingHealthGhana_Web.pdf 6. Ali M and Zakaria I (2013) Community Giant Scoreboards: Rallying communities and measuring maternal and child health outcomes in Ghana. A presentation made at the GHS Annual Health Performance Review Meeting, Bolgatanga, Ghana 7. Ali M (2012), Community involvement in nutrition data collection, analysis and use for decision making –A paper presented at the 13th ECOWAS Nutrition Forum in Ouagadougou, Burkina Faso 3 ANNEX II. PROJECT MANAGEMENT EVALUATION With a small team of around half a dozen staff members, the project implemented a large number of interventions to reduce maternal and newborn mortality in East Mamprusi. Working with Ghana Health Service, University for Development Studies, the USAID Ghana Mission and the Baptist Medical Center as well as Community-based Agents, the team was able to amplify the human resource base available for project activities through the use of hundreds of community members who volunteered their time and energy. The table below presents project partners and their roles Partners Roles/Level of Involvement Community Members/Community￾Based Agents Volunteered their time, support and services in the capacities of Link Providers, Management of Community Emergency Health Systems, the Community Giant scoreboards/Walls of Good Health among others Ghana Health Service Revitalized District Health Management Team (DHMTs and SDHMT management meetings. Advocated for funds to support training and supervision of CHWs and TBAs. Garnered support and leadership from District and Regional officials for activities targeting MNC services. Engaged communities, Council of Chiefs and religious leaders to champion and improved the use of MNC services Trained Cadre of Health Professionals in key project strategies Monitored and supervised project activities Catholic Relief Services Provided Technical support on key project strategies Coordinated transfer of funds and logistics for timely activity implementation Stationed field officers at the sub-district to augment HR capacity of GHS to monitor and supervise project activities and the health facility and community levels University for Development Studies Designed, implemented and document the Operations Research component of the EPPICS Support in the baseline and final Health Facility Assessments USAID Ghana Mission Support with the joint monitoring and supervision of project activities Provided platforms and opportunity to CRS to showcase best practices and lessons learned implementing project activities The evaluation team was impressed with the dedication of staff members to public health work. As one member of the staff put it, “it is a joy to work on maternal and child health. “The team met with volunteers who have worked for years on a range of preventive health interventions, including vaccination drives, the guinea worm eradication campaign, the filariasis control program, and programs to improve the health of mothers and children. The design of EPPICS which facilitate posting of field officers with qualifications at the levels of Bachelors with experience in community mobilization activities worked to enhance the achievement of project objectives. In the midst of HR shortage, the officers complemented the monitoring supervisory roles of GHS so well so that no project activity was delayed. Equally the officers worked with GHS to provide quality support to community based agents working on different strategies of the EPPICS project. This provided a healthy synergy that support in improving MNC indicators in East Mamprusi as established in the final KPC report 4 ANNEX III: WORK PLAN ATTACHMENT H : WORK PLAN & TRAINING PLAN Topic/ objectives Location Number of participants Duration of training/ activity Facilitators Year 1 Year 2 Year 3 Year 4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q 4 PRE - IMPLEMENTATION Hiring EPPICS staff Tamale N/A 2 months CRS staff Purchasing equipment Tamale/Ac cra N/A Over 1 quarter CRS staff DIP development (writing & workshop) Tamale 35 people 4 days CRS STA & 1 RTA￾health & 1 EPPICS Respond to DIP Review Gambaga 20 people 1 month RTA-Health & EPPICS PM & CRS HPM Inauguration of the Project Gambaga Invited Guests/Com munity Members 1 day CRS-GHS Project overview for DHMT members & EPPICS project staff Gambaga 1 batch, 27 (13+14) people 1 day EPPICS Project Manager & CRS Program Manager ASSESSMENTS (FOR BASELINE, MIDTERM, FINAL EVALUATION) KPC (including MIP) - Training, survey & data collection EM district 30 communities *20 respondents 2 months EPPICS staff & external consultant & GHS Qualitative studies (PDI, Formative research) EM district 30 communities 1 month EPPICS staff & GHS 5 Nutrition Program Design Assistant tool EM district 27 people 1 week CRS STA/RTA Rapid Health Facility Assessment & PDQ assessment (Training CRS staff & Roll - out of assessment) HF & comm unities 7 HFA + 14 communitie s for PDQ 3 weeks EPPICS staff & STA Evaluations (mid - term & Final) EM/Tamale 30 communities *20 respondents 2 months External consultant MONITORING & EVALUATION Training EPPICS staff & UDS on data quality and collection Gambaga 15 people 3days CRS STA Partner Annual Reflection meetings with representative s from EPPICS groups Gambaga 31 people 1 day EPPICS Project Manager & CRS Program Manager EPPICS M&E system established in partnership with GHS/DHMT members Gambaga 1 batch, 6 staff 4 days CRS RTA - M&E, EPPICS M&E staff, and GHS staff Develop/revise monitoring tools for the project Gambaga 5 staff 3 weeks EPPICS M&E staff LQAS - Training (of EPPICS & GHS staff) and roll -out EM 20 groups 7 weeks CRS RTA -M&E 6 Ensuring EPPICS data for objectives/indi cators are integrated in the community and district HIS EM N/A Ongoing over 1 year EPPICS & GHS staff Construction of Giant Scoreboards EM Community & EPPICS staff 3 months EPPICS staff Ongoing data collection EM EPPICS staff & GHS Ongoing EPPICS staff Ongoing EPPICS joint monitoring & facilitatitive support visits (with GHS) EM EPPICS staff & GHS Ongoing EPPICS staff Support visits from region & headquarters EM EPPICS staff & CRS staff Ongoing CRS Staff & EPPICS staff Sending annual reports to USAID EPPICS program manager Once a year EPPICS staff & CRS Staff OPERATIONS RESEARCH (OR) Planning OR with UDS Tamale 1 month University of Developm ent Studies OR plan submitted to USAID N/A N/A UDS & EPPICS/CR S staff OR plan revised Tamale 1 month UDS & EPPICS/CR S staff OR plan approved by USAID N/A N/A USAID OR data collection EM Over 2 years UDS & EPPICS staff OR activities target and EM Over 2 years UDS & EPPICS staff 7 control communities Data analysis Tamale Over 6 quarter s UDS & EPPICS staff OR status update for annual & MTE reports Tamale 1 month UDS & EPPICS staff Results shared with GHS, USAID partners National & interna tional Over 2 years UDS & EPPICS/CR S staff Develop OR report Tamale 1 month UDS & EPPICS/CR S staff Reporting on lessons learned from the OR and recommendati on for scale - up Tamale/Ac cra 1 month UDS & EPPICS/CR S staff WORKSHOPS / ACTIVITIES FOR PROJECT IMPLEMENTATION / COMMUNITY MOBILZATION Community entry and mobilization/ sensitization training (includes setting up groups) EM 1 batch, 24 people 3 days EPPICS Project Manager & District Communit y Mobilizatio n Officer Develop SBCC strategy and package (messages) Tamale 22 people Over 1 month EPPICS staff & GHS Develop community work plans Tamale 22 people Over 1 month EPPICS staff & GHS Develop training materials Tamale 22 people Over 1 month EPPICS staff & GHS 8 Action Plan response to MTE recommendati ons Tamale 22 people 3 days EPPICS staff & GHS Sustainability planning, assessment & action plan Tamale N/A Ongoing EPPICS Staff & GHS Organize stakeholders meeting with donors, selected ministries, INGOs, etc. (mini -summit) - results sharing, lessons learned and sustainability Tamale 30 people Annual EPPICS staff Share nutrition lessons learned with FtF in Northern Region TBD TBD Annual EPPICS staff Exchange visits with CIMACS operational district CIMACS district s 5 people 1 week EPPICS staff & GHS Dissemination of results at CORE group & in CRS HQ Baltimore, USA 1 person 2 weeks EPPICS program manager Midwives are trained in: EmOC First Aid & ENC Baptist Medica l Centr e 22 5 days Local consultants (2 from Teaching Hospital in Tamale) 9 Midwives train TBAs in EmOC First Aid & ENC Clustered at HF 480 TBAs 3 days Midwives & EPPICS Staff Engagements/Mee ting with Council of Champions EM - Innova tion Comm unities Council of Champions Ongoing Training/orientati on for HMNC EM 1680 community members 10 days per field agent EPICCS staff ToT for EPPICS field staff (incl HF staff) on ENA & LAM for the PD mothers Gambaga 2 batches, 20 people 3 days EPICCS staff EPPICS staff train CHVs/TBAs, GHS for PD mothers training (this includes ENA & LAM) Sub - district level 480 CHVs/TBAs 3 days EPPICS staff & GHS Staff CHVs/GHS training TBAs & PD mothers Communit ies 5 sub -districts 2 days EPPICS staff & GHS Staff PD mothers implement SBCC strategies EM 240 groups 1 day PD mothers HMNCs training/Orien tation EM 1680HMNC members 1 day EPPICS Staff & GHS 10 ANNEX IV. RAPID CATCH TABLE Indicator Baseline Estimate (%) Final Estimate (%) Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child 63.9 82* Percentage of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of the youngest child 64 71 Percentage of children age 0-23 months whose births were attended by skilled personnel 43 76* Percentage of children age 0-23 months who received a post￾natal visit from an appropriately trained health worker within two days after birth 30 83* Percentage of mothers of children age 0-23 months who are using a modern contraceptive method 22 35 Percentage of children age 0-5 months who were exclusively given breast milk the day prior to the interview 47 70 Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 55 78* Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 74 78 Percent of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 95 89 Percent of children aged 12-23 months who received the first dose of diphtheria, tetanus, and pertussis vaccine (DTP1) according to the vaccination card or mother’s recall by the time of the survey 96 95 Percent of children age 12-23 months who received the third dose of diphtheria, tetanus, and pertussis vaccine (DTP3) according to the vaccination card or mother’s recall by the time of the survey 95 94 Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 10 17 11 Indicator Baseline Estimate (%) Final Estimate (%) Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night 42 71* Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 48 70.7* Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 48 63 Percentage of households of children age 0-23 months that treat water effectively 4 33 Percentage of mothers of children age 0-23 months who live in a household with soap at the place for hand washing 28 46* Percentage of children age 0-23 months who are underweight (- 2 standard deviations for the median weight for age, according to World Health Organization/National Center for Health Statistics reference population) 43 11.2* Notes: * Denotes that final estimates are statistically significantly different from the Corresponding baseline estimates 12 ANNEX V. FINAL KPC REPORT 13 FINAL REPORT Knowledge, Practice and Coverage Survey Encouraging Positive Practices for Improving Child Survival (EPPICS) Project, Ghana October 2015 East Mamprusi District, Northern Ghana Funded by the United States Agency for International Development Bureau for Global Health Office of Health, Infectious Disease, and Nutrition Grant No. AID-OAA-A-11-00042 14 Table of Contents TABLE OF CONTENTS 14 LIST OF TABLES 16 LIST OF FIGURES 16 LIST OF ABBREVIATIONS 17 EXECUTIVE SUMMARY 19 BACKGROUND AND INTRODUCTION 23 PURPOSE OF THE ASSESSMENT 24 BACKGROUND - BRIEF DESCRIPTION OF THE EPPICS PROJECT 25 GOAL AND OBJECTIVES OF EPPICS 27 METHODS 27 STUDY SITE................................................................................................................................................................. 27 KPC INDICATORS .........................................................................................................................................................28 QUESTIONNAIRE DEVELOPMENT......................................................................................................................................28 SAMPLING DESIGN .......................................................................................................................................................28 TRAINING OF DATA COLLECTORS.....................................................................................................................................29 DATA COLLECTION 29 DATA ANALYSIS 30 RESULTS 30 DEMOGRAPHICS ..........................................................................................................................................................32 CORE INDICATORS 32 RAPID CATCH INDICATORS ...........................................................................................................................................33 Maternal and Newborn Care Indicators .............................................................................................................36 Antenatal Care (ANC) Coverage .........................................................................................................................36 First ANC in the first trimester of pregnancy ......................................................................................................37 Mothers satisfaction and abuse during ANC ......................................................................................................37 Perception of abuse during delivery ...................................................................................................................38 Tetanus Toxoid Immunization ............................................................................................................................38 Skilled Birth Attendance .....................................................................................................................................38 Post-Natal Visit to Check on Newborn Health ....................................................................................................38 Post-Natal Visit to Check on Mother Health ......................................................................................................39 Breastfeeding and Infant and Young Child feeding ............................................................................................39 Current Contraceptive Use among Mothers of Young Children .........................................................................39 NON-RAPID CATCH INDICATORS ...................................................................................................................................39 Maternal and Newborn Care Indicators .............................................................................................................39 Quality Antenatal Care for Pregnant Women ....................................................................................................42 Intermittent Preventative Treatment of Malaria in Pregnancy (IPTp) ...............................................................42 Iron Tablets for Pregnant Women ......................................................................................................................43 Immediate Breastfeeding of Newborns, feeding colostrum and pre-lacteal feeds ............................................43 HIV testing during pregnancy .............................................................................................................................43 Thermal care (immediate drying and wrapping) ...............................................................................................44 Clean cord care and clean cord cutting ..............................................................................................................44 15 Birth preparedness and clean birth kit ...............................................................................................................44 Trained delivery attendants ...............................................................................................................................44 Care during delivery ...........................................................................................................................................45 Care of child when mother is away ....................................................................................................................45 Knowledge of MTCT of HIV and PMTCT of HIV ..................................................................................................45 Knowledge of Post-Partum Danger Sings and Neonatal Danger Signs ..............................................................45 Prevention and control of major childhood diseases .........................................................................................46 DISCUSSION 51 IMMUNIZATIONS..........................................................................................................................................................51 MATERNAL AND NEWBORN CARE: ...................................................................................................................................51 Antenatal Care (ANC) .........................................................................................................................................51 First ANC in the First Trimester of Pregnancy .....................................................................................................51 Newborn Care ....................................................................................................................................................52 Skilled Birth Attendance .....................................................................................................................................52 Clean cord cutting ..............................................................................................................................................53 Post-natal visit to check on newborn health: .....................................................................................................53 Post-Natal Visit to Check on Mother ..................................................................................................................54 Mothers satisfaction and abuse during ANC ......................................................................................................54 Perception of abuse during delivery ...................................................................................................................54 Contraceptive use ...............................................................................................................................................55 NUTRITION................................................................................................................................................................. 55 Breastfeeding and Infant and Young Child feeding ............................................................................................55 Micronutrients ....................................................................................................................................................56 MALARIA ...................................................................................................................................................................56 HEALTH FACILITIES .......................................................................................................................................................57 ANNEX 1: KPC ENDLINE SURVEY QUESTIONNAIRE 58 ANNEX 2: RAPID CATCH INDICATORS 93 MATERNAL AND NEWBORN CARE ...................................................................................................................................93 BREASTFEEDING AND INFANT AND YOUNG CHILD FEEDING...................................................................................................93 VITAMIN A SUPPLEMENTATION ......................................................................................................................................93 IMMUNIZATION...........................................................................................................................................................93 MALARIA ...................................................................................................................................................................93 CONTROL OF DIARRHEA ................................................................................................................................................93 ACUTE RESPIRATORY INFECTIONS....................................................................................................................................94 WATER AND SANITATION ..............................................................................................................................................94 ANTHROPOMETRICS .....................................................................................................................................................94 ANNEX 3: COMPLETE INDICATOR LIST 95 ANNEX 4: INDICATOR TABULATION PLAN 98 ANNEX 5: LIST OF COMMUNITIES 116 ANNEX 6: PERCENTAGE DISTRIBUTION OF VARIABLES 121 ANNEX 7: SUMMARY OF BASELINE AND ENDLINE INDICATORS 163 16 List of Tables TABLE 1: SAMPLE CLUSTER COMMUNITIES.......................................................................................................................31 TABLE 2 RAPID CATCH INDICATORS AT BASELINE AND ENDLINE ................................................................................................. 33 TABLE 3 NON-RAPID CATCH INDICATORS FOR MATERNAL AND NEWBORN CARE .......................................................39 TABLE 4: INDICATORS ON PREVENTION, CONTROL AND TREATMENT OF MAJOR CHILDHOOD DISEASES, AND GOOD HYGIENE PRACTICES .............................................................................................................................................46 TABLE 5: BASELINE AND ENDLINE ANTHROPOMETRIC INDICATORS ..................................................................................47 TABLE 6: IMMUNIZATION STATUS AND VITAMIN A SUPPLEMENTATION.............................................................................48 List of Figures FIGURE 1: FIRST ANC VISIT BY MONTH OF PREGNANCY...........................................................................................................37 FIGURE 2: COMPARISON OF ENDLINE AND BASELINE NON-RAPID CATCH INFANT BREASTFEEDING INDICATORS................................. 43 FIGURE 3: OTHER NON-RAPID CATCH INDICATORS ON KNOWLEDGE OF MOTHERS ON MTCT HIV, DANGER SIGNS OF PREGNANCY, DELIVERY, POST-PARTUM AND NEONATAL DANGER SIGNS ................................................................................................46 FIGURE 4: COMPARISON OF ENDLINE AND BASELINE INDICATORS ON IMMUNIZATION STATUS AND VITAMIN A SUPPLEMENTATION ........50 FIGURE 5: GENERAL KPC EPPICS PROJECT BASELINE AND ENDLINE RAPID CATCH INDICATORS .....................................................50 17 List of Abbreviations ANC Antenatal Care BMC Baptist Medical Center CCM Community Case Management CHAG Christian Health Association of Ghana CHN Community Health Nurses CHN Community Health Nurse CHV Community Health Volunteer CHV Community Health Volunteer CIS Community Information System CMAM Community Management of Acute Malnutrition CoC Committees of Champions CRS Catholic Relief Services CSHGP Child Survival and Health Grants Program DPT Diphtheria, Pertussis, and Tetanus EM East Mamprusi EmOC Emergency Obstetric Care EmOC Emergency Obstetric Care ENA Essential Nutrition Actions ENC Essential Newborn Care EPPICS Encouraging Positive Practices for Improving Child Survival FGD Focus Group Discussion GHS Ghana Health Service HIV Human Immunodeficiency Virus HMNC Healthy Mother and Newborn Committees HQ Headquarters IDI In-depth Interview IPTp Intermittent Presumptive Treatment ITN Insecticide-Treated Net IYCF Infant and Young Child Feeding KPC Knowledge, Practice, and Coverage LB Live Birth M & E Monitoring and Evaluation MDG MICS Millennium Development Goal Multiple Indicator Cluster Survey MNC Maternal and Newborn Care MNCH Maternal, Neonatal and Child Health MNCH/N Maternal Newborn Child Health and Nutrition MOH Ministry of Health MTCT Mother-to-Child-Transmission MAMAN Minimum Activities for Mothers and Newborns NGO Non-governmental Organization 18 NHRC Navrongo Health Research Centre NR Northern Region NRC Non-Rapid CATCH Indicator ORT Oral Rehydration Therapy PMP Project Monitoring Plan PMP Project Monitoring Plan PMTCT Prevention of Mother-to-Child-Transmission PNC Postnatal Care RC Rapid CATCH Indicator RCH Reproductive and Child Health RING Resiliency in Northern Ghana SP Sulfadoxine-Pyrimethamine TBA Traditional Birth Attendant TT Tetanus Toxoid UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization WRA Women of Reproductive Age 19 INTRODUCTION TO THE KPC The 2015 Knowledge, Practices and Coverage (KPC) study is the second conducted for the Encouraging Positive Practices for Improving Child Survival (EPPICS) project. This KPC is intended to measure changes since the 2011 baseline. The 2015 KPC survey was conducted by the Navrongo Health Research Centre (NHRC) in conjunction with CRS staff. This report highlights key findings of an endline survey on knowledge, practices and coverage of maternal, neonatal and child health conducted in the Mamprusi East District of the Northern Region of Ghana. The survey provides endline indicators to establish a district level progress on access and utilization of maternal, neonatal and child health (MNCH) services in the district. The progress report aims to provide insights into project outcomes and subsequently the final project evaluation. BACKGROUND The East Mamprusi District (EMD) is one of the poorest districts in the Northern Region. The population of the district is 139,000, representing 5% of the region’s total population, 68% of whom are rural. The district has a total of 13,895 households and average household size is 8.6 persons per household. The total fertility rate in EMD is 3.6, slightly higher than the regional average of 3.5. Thirty-three percent of the population 11 years and above are literate and 67 % are non-literate. However, the proportion of literate males is higher (39 %) than that of females (27.5%). About 86% of households in the district do not have toilet facilities. Islam is the most dominant religion (59.2%) while Christian and traditional African religion constitute (37.9%) of the population. The goal of the EPPICS project was to contribute to sustainable maternal/newborn morbidity/mortality reduction in EMD by 2015. The objectives were to improve maternal and neonatal health outcomes and to increase access to quality maternal and neonatal services for all families in the district. METHODS USED Key Findings:  Marked improvement of deliveries that were supervised by trained health personnel (doctor, midwife, nurse etc.) (76% compared to 43% at baseline)  Significant increase in clean cord care of children at birth (73% compared with 22% at baseline)  Demonstrated improvement in post￾natal care for children aged 0-23 (from 30% at baseline to 83% at the endline)  Postpartum care for mothers saw a significant rise (32% at baseline compared to 82% at the endline) Knowledge, Practices and Coverage Study Executive Summary 20 The assessment was carried out using the standard KPC questions, which are specifically designed for community-based NGO programming. The questionnaire was drafted by CRS HQ staff with inputs from the NHRC. Questions were drawn from the Rapid CATCH, the Malaria, the Nutrition (breastfeeding and IYCF), the Maternal and Newborn Care, and the Anthropometry Modules. The 30 cluster sampling protocol was followed and yielded a total of 328 interviews with women with children less than two years. Average age of the survey respondents was 28 years (SD 6.3). The majority of the survey respondents (71%) had never been to school. Most of those who had been to school had an average of 6.6 years of schooling. Almost all the respondents (98.8%) were married at the time of the survey. In terms of religious practices, the majority of respondents were Muslims (53.4%) and Christians (44.2%). On many demographic indicators the characteristics of the 2015 survey respondents are similar to those of the baseline survey. In both cases, majority of respondents have never attended school. Mampruli is the most common language, and male headship of households is predominant. In majority of the households the father of the index child was living in the same household as the child on the day of interview. FINDINGS The endline (EL) KPC survey found a significant increase in the proportion of mothers of children 0-23 months who received 4 or more ANC visits (82%) against the baseline (BL) value (63.9%). The proportion of pregnant women who accessed ANC services in the first trimester increased significantly from 50% at baseline to 74% at endline. As to whether mothers were satisfied with the conduct of the health workers when they went for ANC services, the majority (90%) indicated satisfaction of the conduct of health staff. However, a few (10%) reported that they were abused either by being ignored, yelled at or insulted. On perceptions of abuse of mothers during delivery, only 7% reported that they were abused and out of those who said that they were being abused the major form of abuse they reported was that they were being yelled at (67%). Concerning maternal and newborn care, the proportion of deliveries with clean cord cutting increased marginally from 80% at baseline to 82% after project implementation. The results also indicate that 71% of women reported receiving tetanus injection at endline compared to 64% at baseline. Skilled attendance at childbirth significantly increased at endline (76%) compared to baseline (43%). There was also a significant improvement in post-natal care for children aged 0-23 at endline (83%) compared to baseline (30%). Also, postpartum care for mothers increased significantly from baseline (32%) to endline (82%). Overall, 95% of mothers were checked at the endline by either a health care provider or a trained traditional birth attendant compared to 86% at baseline. The proportion of children age 0-5 months exclusively breastfed had a significant increase at endline (70%) compared to baseline (47%). On the other hand, the proportion of children fed according to a minimum of appropriate feeding practices increased from 55% [95%CI (45%-65%)] at baseline to 78% [95%CI (70%-86%)] at the endline, and this is statistically significant at 95% confidence level. When mothers were asked whether or not they received quality ANC, the results showed an increase from 37% at baseline to about 51% at the endline. Only half of the children sampled (50%) were reported to have been immediately breastfed at baseline, this has improved at the endline with about three quarters (75%) of children being put to the breast immediately after birth. Also the proportion of children who were fed colostrum after birth increased slightly from 96% at baseline to 98% at endline. 21 The percentage of children that had clean cord cutting at birth increased from 80% at baseline to 82% at the endline, the proportion who reported to have had clean cord care increased significantly from baseline (22%) to endline (73%). Also thermal care non-Rapid CATCH indicators all had significant coverage at baseline, and therefore, did not show any improvement at the endline. For instance, the proportion of children who were dried immediately after birth increased marginally from 96% at baseline to 97% at the endline. Similarly, there was no difference in the coverage of children who were wrapped immediately after birth (96% vs 96%) and those who were dried and wrapped immediately after birth (95% vs 95%) between the baseline and at endline. There was an improvement on deliveries that were supervised by trained health personnel (doctor, midwife, nurse etc.) from 43% at baseline to 76% at the endline. All three Immunization Rapid CATCH indicators at the endline did not show any improvement over the indicators recorded at baseline. Measles vaccination coverage reduced from 95% at baseline to 89% at the endline. Coverage for DTP1 also showed some marginal decrease of 1% from the proportions recorded at baseline. RECOMMENDATIONS Antenatal Care GHS: The package of services provided for pregnant women during ANC determines the quality of ANC services. The increase in coverage of ANC attendance especially in the first trimester of pregnancy should provide opportunity to health care providers to improve on the package of ANC service provided to pregnant women in the district. There is also the need to encourage women to continue attending ANC to improve on their health and pregnancy outcomes. EPPICS: The gain by the project is commendable. Any opportunity for GHS to continue roll-out of social behavior change communication activities to sustain the gains made is encouraged. ANC in First Trimester GHS: The community liaison with the CHV should be encouraged towards the identification of potential mothers during the early months of pregnancy and encouraging them to go for ANC services. EPPICS: Performance in ANC attendance in the first trimester of pregnancy has been encouraging. Perception of abuse during ANC and delivery GHS: Even though there is a high level of satisfaction about the conduct of health staff, more still needs to be done since GHS seeks to maintain high levels of professional conduct and customer satisfaction. EPPICS: Results in this indicator has been encouraging. Newborn Care GHS: Continue with the practice of supporting and guiding mothers and caregivers to immediately wrap and dry the newborn, and to ensure that babies are not bathed within 24 hours according to service protocols. Also, mothers should be encouraged to put their babies to breast immediately after birth. Providers should counsel and educate mothers during ANC, delivery and post-partum care visits about the importance of thermal care and early initiation of breast milk. EPPICS: Overall, there were improvements in essential newborn care practices at the end of project intervention. While systems and structures are in place to sustain the gains of EPPICS in East Mamprusi, 22 CRS and other actors should continue to search for opportunities that will facilitate the scale-up of the EPPICS strategies to other districts in Ghana However, there is need for sustainability or scale-up of community mobilization programs to sustain and further improve on these gains. Delivery Care/Skilled Birth Attendants GHS: Skilled delivery indicators can further be improved by continued collaboration with community health volunteers and TBAs and all stakeholders. EPPICS: There have been appreciable levels of improvements in these indicators, an indication that intervention packages for these indicators were well executed. Clean cord cutting GHS: Health workers should continue with the practice of clean cord cutting as it is an important method of preventing mother and child from infection and enhancing their health. EPPICS: Achievement has been very remarkable. Post Natal Care-Child for mother and child GHS: Though there was improvement in home visits, postpartum and postnatal visits by community health officers, this should be encouraged to further improve the health of newborns in the district. EPPICS: The improvements in post-natal care is another plus in the efforts of the EPPICS project towards improving maternal and child health in the East Mamprusi district and a very remarkable achievement of post-natal care for mothers with the efforts of project staff. Nutrition GHS: Even though a lot of progress has been made on exclusive breastfeeding and infant and young child feeding practices, more work needs to be done to further improve on the nutritional status of children in the district. Educating women on the importance of exclusive breastfeeding and proper child feeding practices during ANC, post-partum/post-natal care, immunization and growth monitoring outreach activities should continue. Health care providers should document Vitamin A supplementation on health cards of children. The promotion of the use of iodine fortified salt or supplementation of iodine should continue. EPPICS: Very good achievement for improving on exclusive breastfeeding and infant and young child feeding practices in the district. There was some improvement in the availability of iodized salt in households compared to baseline indicators, but this is still low. 23 Background and Introduction Over the past 15 years, Ghana’s maternal mortality rate decreased from 570 deaths per 100,000 live births in 2000 to 380 deaths per 100,000 live births in 2013. The under-five mortality rate decreased from 103 deaths per 1,000 live births in 2000 to 72 deaths per 1,000 live births in 2012. In contrast, neonatal mortality has risen from 30 deaths per 1,000 live births in 2008 to 32 deaths per 1,000 in 2013. Newborn deaths account for 40 percent of under-five mortality in Ghana1. Despite the progress Ghana has made in terms of MNCH indicators, the country’s indicators are still worse than other countries with similar socioeconomic profiles and health care spending levels. While Ghana has made considerable strides toward meeting MDGs 4 and 5 in the southern regions of the country, health indicators in northern Ghana, particularly the Northern Region reflect significant challenges. Research has shown that most of the neonatal deaths in high-mortality regions are due to preventable and behavioral modifiable causes. However, the extent to which preventive measures could reduce neonatal mortality is not widely explored. A study in the East Mamprusi District, which sought to explore women’s knowledge of neonatal danger signs, revealed that even where the quality of antenatal care is standard as recommended by the World Health Organization (WHO), many women still have limited knowledge regarding neonatal danger signs. The study, therefore, recommends that as part of health education and sensitization, women should be taken through danger signs prior to their discharge from hospital so that they can easily detect danger signs and seek early health care. It is further shown that low utilization of available health services, such as supervised deliveries and post-natal care continue to persist even where financial and geographic access is deemed adequate.2 Against this backdrop, the United States is working in partnership with the government of Ghana, with other bilateral donors, and with multilateral and nongovernmental organizations to implement a range of interventions aimed at improving MNCH outcomes, with a new emphasis on the northern regions. One of such programs is the Encouraging Positive Practices for Improving Child Survival (EPPICS) project being implemented in the East Mamprusi District of the Northern Region by CRS. The EPPICS project seeks to address social and cultural barriers to access and utilization of MNCH services. Another intervention is the Resiliency in Northern Ghana (RING) project. The RING project seeks to provide direct funding to Northern Region district assemblies to support families, particularly women of reproductive age and children under-five who face food insecurity, to improve their health and nutritional status. RING promotes access to education about nutrition, water quality and hygiene; provides women with access to livestock and other domestic animals to enhance their economic prospects; and promotes active men’s involvement in family care activities.3 1 Improving Maternal, Neonatal, and Child Health in Ghana, Centre for Strategic and International Studies Report, 2014 2 Exploring Women Knowledge of Newborn Danger Signs: A Case of Mothers with under Five Children. Public Health Research 2014 3 Improving Maternal, Neonatal, and Child Health in Ghana, Centre for Strategic and International Studies Report, 2014 24 Purpose of the Assessment The main purpose of the endline study is to establish a district level progress status on access and utilization of MNCH services in the East Mamprusi district of Northern Ghana. The survey will contribute to providing insight to the project outcomes. Results of this study will be provided to the external independent evaluator for EPPICS to be used to finalize the methodology for the final project evaluation. Results will also help determine to what extent each specific objective, as per the indicators set out in the original Project Monitoring Plan (PMP) have been achieved and validate if the activities within the project design were sufficient in scale and scope in order to achieve the desired outcome/results. Finally, the results will highlight opportunities from EPPICS that CRS and GHS could leverage to respond to additional funding opportunities. Specifically, the study seeks to:  Establish to what extent the prevailing health and contributing social conditions, and health and nutritional problems including diseases affecting women of reproductive age, newborns and children under the age of five years have improved over the past four years.  Determine whether there have been any marked changes regarding the levels of knowledge, attitudes and practice towards maternal, newborn and child health and access as well as utilization of MNCH services in the targeted communities over the project period.  Determine whether there have been any marked changes in the levels of knowledge, attitudes and practice towards issues and access to child health services in the targeted communities over the project period.  Assess the current capacity of communities and community structures and GHS partners to continue to address and participate in issues related to MNCH services in the targeted communities and if so, highlight if there is any major attribution to the EPPICS project.  Assess the extent to which EPPICS interventions have supported in building the capacity of communities to link with frontline health providers/services in the detection and management of childhood illnesses including appropriate infant feeding practices.  Determine the capacity of Ghana Health Service staff and stakeholders to sustain or institutionalize EPPICS Project best practices in the target communities.  Identify and document key learning points for sharing with stakeholders in health and government beyond the project close out. 25 Background - Brief Description of the EPPICS Project Governments and stakeholders in developing nations strive to reduce maternal mortality by 75% by 2015 in accordance with the MDGs.4 In spite of national strides to change health policies and strengthen health services to meet MDGs 4 and 5 in Ghana, maternal and infant mortality and morbidity remain much higher in the Northern Region (NR) than in the rest of the country. Ghana Health Services (GHS) and their partners are implementing high-impact, evidence-based interventions to improve the situation. Most of their efforts have focused on health services only at the facility level. However, high level of maternal and neonatal deaths in East Mamprusi (EM) district have been attributed to: household beliefs and rituals that jeopardize the health of pregnant women and their unborn children and result in delays in seeking ANC, recognition of danger signs (in both the mother and newborn) to make timely decisions to seek care at health facilities, and a low percentage of institutional deliveries. The Catholic Relief Services (CRS) is partnering with the Ministry of Health (MOH) and the Ghana Health Services (GHS), through the EPPICS project to improve local socio-cultural beliefs and practices related to pregnancy and newborn care, and encourage the strengthening of civil society structures in order to empower local communities to advocate for improved MNCH services in the district. The EPPICS project targets 51,000 women of reproductive age and children under-five years in the East Mamprusi district. By addressing social and cultural barriers to access and utilization of MNCH services, EPPICS engages and repositions traditional birth attendants and family members to help ensure pregnant women seek prenatal care and are prepared to go to a clinic for delivery with a skilled attendant. Some of the activities of EPPICS include collaboration with community leaders to oversee the operation of motorcycle ambulance that can be used to transport pregnant women to the site for delivery if they present signs of complications once they go into labor. Apart from that, EPPICS collaborates with community volunteers who oversee monthly reporting on the percentage of deliveries attended by skilled health care workers through the use of the Community Giant scoreboards, a tool that displays MNCH indicators in colorful signs at the community5 Generally, the NR lags behind in maternal, neonatal and child health in many respects. The region recorded the second highest institutional maternal mortality ratio (174/100,000LBs) and neonatal deaths (8.1/1000LBs), according to the 2013 annual reproductive and child health review report.6 Supervised delivery is a key indicator for the health sector in Ghana as well as for achieving the MDGs 4 and 5. However, the Northern Region recorded the lowest skilled delivery (46.8%) only ahead of the Volta region (43.4%) in the year under review. Also it is expected that pregnant women attend at least four antenatal care visits for women with uncomplicated pregnancies. This is in line with national policy which also recommends a minimum of four visits per client, with the first visit in the first trimester. Thus while 4Kuganab Lem R and Yidana A (2014) Exploring Women Knowledge of Newborn Danger Signs: A Case of Mothers with under Five Children. Public Health Research 2014 5 Bliss K and Streifel C (2014) Improving Maternal, Neonatal, and Child Health in Ghana, Centre for Strategic and International Studies Report, 2014 6 Ghana Health Service, Annual Reproductive and Child Health Report, Ghana Health Service, 2013. 26 the national average visit was 4.0% the Northern Region recorded the least of 3.3%. In contrast, the northern Region recorded the highest postnatal care (89.7%) in the 2013 review year of Reproductive and Child Health7 In the East Mamprusi district, neonatal deaths are attributed to asphyxia, low birth weight/prematurity and infections; and reported stillbirths are increasing. Pregnant women, especially first-time mothers, do not have the power to make decisions themselves whether or not to use skilled health services. A UNICEF study found that 68% of mothers trusted skilled health professionals, and identified key decision makers in the use of MCH services as mothers-in-law/fathers-in-law, especially at the time of delivery and complications. The study also found that health workers’ negative attitudes contributed to choosing TBA-assisted delivery instead of skilled services.8 The Catholic Relief Services investigated several factors related to access and use of MCH services in a NR district and found that even when geographic and financial access were adequate, socio-cultural and traditional practices were still significant barriers to receiving key evidence-based MNCH/N services. GHS and the Christian Health Association of Ghana (CHAG) administer formal health services in 7 health facilities, 6 with 24/7 capacity for deliveries and 4 that have vehicles for transport, but there are still many times when transport is not available. Regional GHS also reports that attempts to address emergency transport problems have “been a miserable failure.” CHAG facilities include the Baptist Medical Center (BMC), a referral hospital and the only facility with capacity for EmOC and ability to care for sick or premature newborns. There are plans for the construction of a fully-equipped hospital in the district capital. District health staff shortages, particularly staff capable of performing skilled deliveries, are severe; each facility averages only 50% of staff they need according to GHS standards9. Many GHS doctors assigned to work in the NR never report for duty. GHS has begun to train Community Health Nurses (CHNs) to become midwives but the effort has been slow. Community Health Volunteers (CHVs), usually two per community, serve as the outreach and surveillance arm of GHS, linked to the Sub district level. Many have been in place for decades and they are respected members of the community. GHS, supported by UNICEF, has extended their role to include Community Case Management (CCM) of Childhood Illness that was expanded from Home Base Management of Malaria to include zinc for diarrhea and antibiotics for pneumonia in children over 6 months of age. CHV have also begun to provide Community Management of Acute Malnutrition (CMAM) with support of UNICEF. 7 GHS Annual RCH, 2013 8 UNICEF C4D Five Key Health and Hygiene Final Report, 2010 9 CRS Ghana CSHGP Technical Application 27 Goal and Objectives of EPPICS To contribute to sustainable maternal/newborn morbidity/mortality reduction in East Mamprusi District of Northern Region of Ghana by 2015. SO1: East Mamprusi District has improved maternal and neonatal health outcomes SO2: Families have increased access to quality maternal and neonatal services The key project strategy was to scale up a promising approach to community-led improvements in MNCH/N practices and service. Technical interventions included: Maternal and Newborn Care (60%), Nutrition (30%) and Malaria in Pregnancy (10%); an integrated minimum package of interventions at communities, households and facilities by applying MNCH and Nutrition services that are included in the MAMAN Framework; Essential Newborn Care (ENC); and Essential Nutrition Actions (ENA). At the Community Level, the project intended to scale-up a motivational community mobilization strategy using Healthy Mother and Newborn Committees (HMNC), Positive Deviant Inquiry and, as part of the community information system (CIS), the Giant Community Scoreboards for communities to track progress on process indicators and provide feedback to community members. At the Health Facility, CRS and GHS carried out activities to improve health staff counseling skills to improve quality in health worker-client communication in response to gaps identified in the project Five Alive, such as inconsistent messages and disrespect toward pregnant women. The Innovation was intended to test new approaches to overcome barriers and influence household and community practices using the overall project strategy as the foundation. Committees of Champions (CoCs) for mothers and babies were formed and trained. The CoCs consisted of Chiefs, “Queen Mothers” and Imams/Pastors. All formative research questions were related to the overriding question: “How can the most influential community members change the advice given to pregnant women and new mothers within households that result in positive MNCH/N behaviors and health care-seeking?” Improved MNCH services, including achieving progress in MDGs 4 and 5, are priorities of the MOH and GHS national policies, and they have identified overcoming negative cultural practices as essential in achieving these goals. The project targeted 26,881 Women of Reproductive Age (WRA) and 24,431 Children under 5 years of age living in East Mamprusi (EM) District, Northern Region (NR) of Ghana. Methods Study Site The study was conducted in the East Mamprusi District of Northern Region. The district is divided into five sub-districts that cover approximately 300 rural sparsely-located settlements with 200-500 inhabitants.10 East Mamprusi District is one of the poorest districts in the Northern Region. The 10 Exploring Women Knowledge of Newborn Danger Signs: A Case of Mothers with under Five Children. Public Health Research 2014 28 population of East Mamprusi District is 139,603 representing 4.9 percent of the region’s total population. The district has a rural population of 81,850, representing 67.6 percent.11 Total Fertility Rate is 3.6 which is slightly higher than the Regional average of 3.5. The General Fertility Rate is 102.6 births per 1000 women aged 15-49 years and a Crude Birth Rate (CBR) of 23.0 per 1000 population. The district has a household population of 119,596 with a total number of 13,895 households. Average household size in the district is 8.6 persons per household. A little above half (57.4%) of the population aged 12 years and older are married. In terms of age stratification, four out of five females 25-29 years (84.8%) are married compared to a little above half of males (59.1%). Thirty-three percent of the population 11 years and above are literate and 67.0 percent are non-literate. However, the proportion of literate males is higher (39.0 %) than that of females (27.5%). About 86% of households in the district do not have toilet facilities. Islam is the most dominant religion (59.2%) while Christian and traditional African religion constitute (37.9%) of the population KPC Indicators All Rapid CATCH indicators were included in the survey. The standard questions were asked and the standard tabulation plan was followed. The Rapid CATCH indicators are listed in Annex 2. As mentioned above, the survey also included questions from the Maternal and Newborn Care, and the Nutrition KPC modules. These questions were used to calculate the indicators listed in Annex 3. The definition of these indicators, the tabulation plan and the STATA commands or formulas used to calculate the values are listed in Annex 4. Questionnaire development The assessment was carried out using the standard KPC questions, which are specifically designed for community-based NGO programming. The questionnaire was prepared to report on the set of Rapid CATCH indicators plus other indicators relevant to the project priorities. The questions were in English and all data collectors were required to be fluent in both the local language and English. The questionnaire was drafted by CRS HQ backstopping staff and further refined by project staff and the NHRC acting as the consultant. Questions drawn were from the Rapid CATCH, the Malaria, the Nutrition (breastfeeding and IYCF), the Maternal and Newborn Care, and the Anthropometry Modules. Also, the indicators of the EPPICS Monitoring and Evaluation Plan were reviewed, and additional questions were added to the KPC questionnaire to match the set of indicators of the EPPICS M&E plan and to ensure that the key interventions (Maternal and Newborn Care (60 %), Nutrition (30 %) and Malaria (10 %.) was reflected. The final survey questionnaire had 109 questions and took about one hour to administer (see Annex 1). Sampling design To achieve the objectives of the endline assessment, we employed quantitative methods for data collection. Quantitative data are critical in establishing current levels of knowledge, practices and coverage related to maternal, neonatal and child health care and the socio-demographic factors associated with maternal and newborn health practices. However, they do not provide explanations for the observed behavior. 11 GSS PHC District Analytical Report-East Mamprusi District, 2014 29 The thirty cluster sampling design was used. This design provides for listing of all communities in the East Mamprusi district with their respective populations (see Annex 6). From this list the clusters were selected using probability proportional to size (PPS). Thus, larger communities had a greater chance of having more clusters than smaller ones, and since communities were listed by their sub-district, larger sub-districts had more clusters. This strategy allowed for the distribution of interviewees (mothers/caregivers and young children) in the sample which also mirrored the distribution of mothers in the general population. To have for most indicators a precision of +/- 10%, at least 10 mother/child units in each cluster were sampled. But taking into consideration errors in the interviewing and data entry process, 11 interviews were conducted in each cluster. Training of Data Collectors The data collectors were recruited locally from the study district while staff of CRS supervised the data collection process. The selection of the field staff was based on a combination of the following: qualification, previous experience with KPC and other health related data collection, ability to speak the local language, familiarity with or residence in the intervention district. Recruitment of the data collectors was done by CRS while a team from NHRC trained field staff for data collection. A three-day training workshop was organized for the field staff; the content of the training covered the aims and objectives of the study, role and responsibilities of interviewers and supervisors, techniques of interviewing, ethics of data collection, community entry strategies and informed consent procedures. Data collectors were also given comprehensive training on the data collection instruments and how to do the household listing. As part of the training, field practice (pre-test) was conducted to assess the skills and competencies of trainees before commencement of data collection. The survey teams were deployed and assigned to clusters depending on their language skills. Field staff included data collectors, supervisors who were selected from CRS staff and field coordinators from NHRC who monitored the data collection process. Data Collection After the training of the interviewers and field-testing of the data collection instruments, the interviews were carried out from August 22-August 26, 2015. Data collection took place in 30 clusters covering the five sub-divisions of the district. At least five clusters were selected in each sub-district but more clusters were covered in sub-districts that had more communities. For purposes of conducting interviews in an orderly manner to representativeness of data across the study area, the field staff were put into six teams made up of 3 members (2 data collectors and 1 supervisor) to collect data across the 30 clusters selected for the study. (See list of communities and sub-districts in Annex 5). There was also a team of three members from the consulting firm (NHRC) who monitored field activities to ensure that high quality data was collected. The supervisors assisted the data collectors to locate sampled interview locations and starting households for interviewing. They also reviewed the questionnaires to identify possible inconsistencies or missing data. Where inconsistencies or missing data were identified, they immediately took steps to ensure that such inconsistencies were corrected and/or the missing data obtained. On a daily basis the 30 supervisors met with their teams and reviewed the completeness of questionnaires as well as discussed issues related to the survey and gave feedback to ensure data accuracy. They also observed interviewers during the administration of questionnaires to ensure that they were asking the right questions and recording data correctly. Data Analysis The data was double entered and validated using EPI Data 6.1. Data was then transferred into STATA version 11 (STATA Corporation, College Station, Texas) for cleaning and analysis by Monitoring and Evaluation Specialist of the Navrongo Health Research Center. He was also the lead trainer, supervised the data entry process and facilitated data control and management issues. Indicators were calculated using the standard tabulation plans which were provided in the KPC modules and differences in indicators at baseline and endline were established. To account for cluster sampling, a Design effect (D) of 2 was assigned to calculate standard deviations and confidence levels of each indicator. Some baseline and endline indicators are presented graphically for easy comparison. Results A total of 328 interviews were conducted in the 30 clusters sampled. Table 1 shows the distribution of the interviews conducted in each cluster: 31 Table 1: Sample Cluster Communities Cluster Community Frequency 1 GAMBARANA A 11 2 LIMAN FONG 11 3 TINSUGU 11 4 TAMBOKU A 11 5 GBANGU C 11 6 NANYERI 11 7 PORINGONE 11 8 NALERIGU-A2 11 9 NALERIGU-B2 11 10 NORLOBI/BUYA/BARINYA 11 11 KOLINVAI A 11 12 GBANGU 11 13 ZIIKAYA 2 11 14 LANGBENSI C 11 15 KASAPE 11 16 BUMBOAZIO 11 17 BURUGU 11 18 SAMINI B 11 19 WUNDUA A 11 20 BOAYINI 11 21 SAKOGU C 11 22 NAMEBOKU 11 23 DINDANI A 11 24 ZAMBULUGU 11 25 TINTARIGA 11 26 GUNGONG 11 27 JAGOO 11 28 GBINTIRI EAST 11 29 NAKURUGU 1012 30 NAMANGBAI 1013 TOTAL 328 12 Some pages could not be found in one questionnaire hence the interview was incomplete and was dropped out of the 11 sampled during data entry from NAKURUGU 13 One incomplete interview was also dropped during data entry from NAMANGBAI 32 Demographics The average age of the survey respondents is 28 years (SD6.3). Majority of the women interviewed in this survey (71%) had never been to school. Most of those who had been to school had basic level education, with an average of 6.6 years of schooling. Almost all the respondents (98.8%) were married at the time of the survey. In terms of religious practices, the respondents were largely Moslems (53.4%) and Christians 44.2%. Although over eighty percent (83.2%) of the respondents speak Mampruli, only 65.2% reported Mampruli as the language they felt most comfortable communicating in. Other languages that respondents felt comfortable communicating in include Likpakpa (20.4%), Moar (4.3%) and others (9.1%). The number of reported surviving births at the time of the survey ranged from 1 to 9, with an average of 3.2 (SD 1.9). About 79% of the women did not report any child death at the time of the survey. Slightly more than half (53.1%) of the births under 24 months reported in the survey were males. In majority of the cases (83%) the biological father of the index child lived in the same household as the child. About 90% of the households of the respondents were headed by males, with the husband/partner being the household head for 55% of the respondents, while male relatives headed 34.8% of households. Female headship is low, with only 6.5% of respondents’ households being headed by females. Overall, many of the demographic characteristics of the 2015 survey were comparable to those recorded at baseline. In both cases, majority of respondents have never attended school. Mampruli is the most common language, and male headship of households is predominant. In majority of the households the father of the index child was living in the same household with the child on the day of interview. Core Indicators In this section we present the core indictors for the EPPICS intervention. These indicators are categorized into two groups, the Rapid CATCH Indicators and non-Rapid CATCH Indicators for maternal and newborn health. 33 Rapid CATCH Indicators Table 2 Rapid Catch Indicators at Baseline and Endline Indicator Baseline indicators Endline indicators Indicator Nume rator Deno minat or % 95%CI Num erat or Deno minato r % 95%CI p-values Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child 200 313 63.9 % ±6 268 328 82% ±6 0.001 Percentage of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child 200 313 64% ±8 233 328 71% ±7 0,0519 Percentage of children age 0-23 months whose births were attended by skilled personnel 135 313 43% ±8 250 328 76% ±7 0.005 Percentage of children age 0-23 months who received a post￾natal visit from an appropriately trained health worker within two days after birth 95 313 30% ±7 273 328 83% ±6 <0.001 Percentage of mothers of children age 0-23 months who are using a modern contraceptive 69 313 22% ±6 115 328 35% ±7 <0.001 34 method Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours 49 105 47% ±13 72 103 70% ±12 0.001 Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 112 205 55% ±10 174 223 78% ±8 <0.001 Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 152 205 74% ±8 173 223 78% ±8 0.332 Percentage of mothers of children age 6-23 months who received a dose of Vitamin A in the first 2 months after delivery – reported 119 205 58% ±10 232 328 71% ±7 0.005 Percentage of children aged 12- 23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 107 113 95% ±6 107 120 89% ±8 0.093 Percentage of children aged 12- 23 months who received DTP1 109 113 96% ±5 114 120 95% ±6 0.713 35 according to the vaccination card or mother’s recall by the time of the survey Percentage of children aged 12 - 23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 107 113 95% ± 6 113 120 94% ± 6 0.738 Percentage of children age 0 -23 months with a febrile episode during the last two weeks who were treated with an effective anti -malarial drug within 24 hours 15 156 10% ± 7 27 156 17% ± 8 0.070 Percentage of children age 0 -23 months with diarrhea in the last two weeks who received oral rehydration solution and/or recommended home fluids 60 126 48% ±12 97 149 65% ±11 0,005 Percentage of children age 0 -23 months with chest -related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 35 73 48% ±16 40 64 63% ±17 0.078 Percentage of households of 12 313 4% ±3 1 3 33% ±75 0.013 36 children age 0-23 months that treat water effectively Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing 89 313 28% ±7 151 328 46% ±8 <0.001 Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 112 205 55% ±10 174 223 78% ±8 <0.001 Percentage of children age 0-23 months who are underweight (-2 SD for the median weight for age, according to WHO/NCHS reference population) 135 313 43% ±8 36 322 11% ±5 <0.001 Maternal and Newborn Care Indicators The provision of quality health care during pregnancy, delivery, and immediately after delivery is important for the survival and health of the mother and newborn. For instance, ANC visits to skilled provider, skilled assisted delivery, tetanus immunization, exclusive breastfeeding practices and post-natal visit by health workers to check on the health of mothers and newborns are critical interventions to improve maternal and newborn health outcomes. Accordingly, the antenatal period thus provides an opportunity to health workers to provide services that are vital to quality maternal and newborn health. In this section we present results on indicators related to maternal and newborn health (antenatal care, tetanus injection, skill birth attendance, exclusive breastfeeding, post-natal care and contraceptive use). The results of the Rapid Catch indicators (presented in Table 2 above) are important in assessing the impact of the EPPICS intervention to improve maternal and newborn health care services in the intervention district. Antenatal Care (ANC) Coverage The World Health Organization (WHO) recommends that pregnant women should have a minimum of four antenatal visits. In the EPPICS endline survey we obtained antenatal care information such as the timing and number of ANC visits, the services received during antenatal care (such as weight 37 measurement, blood pressure check, urine and blood test, iron and folic acid supplementation, etc.). Table 2 presents the percentage distribution of ANC services, skilled delivery and postnatal care indicators during the last pregnancy for mothers interviewed in the survey. Eighty-two percent (82%) of mothers of children 0-23 months received four or more ANC services when they were pregnant with their youngest child. This shows a two percent increase over the baseline prevalence of 80% (see Figure 2). First ANC in the first trimester of pregnancy Antenatal care especially in the first trimester of pregnancy is an important indicator for healthy gestation and for the health of the mother and the unborn child. About 74% of mothers attended their first ANC in the first trimester of their pregnancy. This is a marked improvement compared to a little over half of women attending their first ANC at baseline. The figure below describes the percentage and cumulative percentage distribution of the timing of the first ANC visits by mothers. Figure 1: First ANC Visit by Month of Pregnancy Mothers satisfaction and abuse during ANC About 90% of mothers said they were very satisfied and 8% said they were somewhat satisfied with the services they received from health staff during ANC visits. Just 1.5% said they were not satisfied. Despite the high level of level of satisfaction, some also said they were abused during ANC visits. Almost 6% of mothers said they felt abused during ANC visit. Among those who reported of being abused by health staff during ANC, about 26% reported health staff ignored them, 47% said they were yelled at, 26% said health staff insulted them and 21% reported of other form of abuse. 0 20 40 60 80 100 120 1 2 3 4 5 6 7 8 9 Percent First ANC visit % Cummulative 38 Perception of abuse during delivery About 7% (18) of the mothers who delivered at the health facility said they felt abused during delivery. Among those abused during delivery, 11% said health staff ignored them, 67% complained that they were yelled at, 11% indicated staff made fun of them, 17% reported that health staff insulted them and 17% said staff slapped or hit them. Tetanus Toxoid Immunization This indicator measures the proportion of women who received at least two doses of tetanus-toxoid (TT2+) vaccine in their last pregnancy. The findings showed an increased in the uptake of Tetanus injection for pregnant women in the area. For instance, the proportion of women who received at least two tetanus toxoid injections (TT2+) increased from 64% at baseline to 71% at the endline. Over 89% of the mothers interviewed reported receiving at least one tetanus injection compared to 82% at baseline. About 35% of the women reported receiving tetanus injection on two occasions during the pregnancy, but more than half of them had already received at least one dose of tetanus injection before becoming pregnant. At baseline 33% received tetanus injection on two occasions and almost 50% received it before becoming pregnant. This is an indication that majority of the pregnant women were immunized against tetanus and therefore protecting their children. Skilled Birth Attendance Most maternal and neonatal deaths occur during delivery and within 48 hours after delivery. Therefore, one essential safe motherhood intervention is to ensure that every pregnant woman is attended to by a competent health provider with midwifery skills (medical doctor, midwife or nurse) during birth, as well as ensuring the availability of transport to facilitate referral in case of obstetric emergency. The endline result shows that 76% of deliveries were supervised by skilled personnel compared to 43% at baseline. Skilled birth attendance in this survey includes births that were assisted by a medical doctor, a midwife or a nurse. The rest of the deliveries (24%) were performed by trained TBAs, untrained TBAs, community health volunteers, relatives and friends as reported by the respondents. Compared to the baseline (43%) there has been a substantial increase in the prevalence of skilled attendance at delivery during the intervention period. It is important to indicate that about 77% of the mothers delivered in a health facility. Majority delivered in a health center (42%), followed by hospital (32%) and health post (2.4%). Post-Natal Visit to Check on Newborn Health This indicator assesses the percent of infants aged 0-23 months who received a visit by a health care provider immediately after birth (critical period) to provide essential newborn care services. More babies die in the first week of life than at any other time in childhood, and the condition of those who become ill shortly after birth may deteriorate and they may die very rapidly if immediate care is not provided. As part of the EPPICs project trained health workers made home visits to check on the health of newborns and their mothers and to provide newborn care services such as check body temperature, thermal care, hygienic cord care and early and exclusive breastfeeding practices. The results indicate a significant improvement from 30% prevalence during the baseline survey to 83% at the end of project implementation in the proportion of newborns who received a home visit by a trained health care provider. In addition, the findings indicate that 96% of children were checked on by either a health care provider or a traditional birth attendant after delivery. This is a marked improvement over 79% 39 recorded at baseline. Similarly, 88% of the children were checked in less than one day, 11% in less than 1 week and 1% after one week. Post-Natal Visit to Check on Mother Health The proportion of mothers to children age 0-23 months who received a post-natal visit from an appropriate trained health worker within two days after birth of child increased from 32% at baseline to 82% at the endline. This increase is statistically significant at 95% confidence level (see Annex 7). Overall, 95% compared to 86% at baseline of mothers were checked by either a health care provider or a traditional birth attendant either at a health facility, home or any other location. About 88% of the mothers were checked in less than one day, 10% in less than 1 week and 0.7% after one week. About 87% of them were checked by trained health personnel with 39% being midwives, 34% nurses and 14% doctors. Breastfeeding and Infant and Young Child feeding Breastfeeding is an established evidence-based life-saving intervention for newborns and infants. Routine antenatal care, facility-deliveries and community-based home visits are opportunity to counsel expectant mothers on the importance of immediate and exclusive breastfeeding and to influence and change knowledge, attitudes, and behaviors towards exclusive breastfeeding. We assessed the proportion of children aged 0-5 months who were exclusively breastfed during the last 24 hours. The results show a significant improvement in the levels of exclusive breastfeeding after the EPPICS project intervention – from 47% at baseline to 70% at endline. Also infant and young child feeding practices among children aged 6-23 months has improved over the period. The proportion of children fed according to a minimum of appropriate feeding practices increased from 55% [95%CI (45%-65%)] at baseline to 78% [95%CI (70%-86%)] at the end of the project implementation, and this is statistically significant at 95% confidence level. Current Contraceptive Use among Mothers of Young Children The uptake of appropriate family planning services is important to the health of mothers as well as their children as this will prevent unwanted and unintended pregnancies. In Ghana use of family planning services has been increasing steadily since the 1990s. However, progress has been slow and uneven across regions particularly, in the northern region where fertility level remains relatively high (DHS 2008). Thus one of the non-Rapid CATCH Indicators of the EPPICS project was to increase update of contraceptive use by women of reproductive age and their partners. Therefore, the EPPICS survey asked mothers of children age 0-23 months if they and their partners were currently using a modern contraception method to delay or avoid getting pregnant. In Figure 2, it can be observed that contraceptive use is generally low. With regards to the current use of any method, about 65% of women of reproductive age (who were not currently pregnant) were not using any contraceptive methods. In other words, 35% of women were currently using a modern contraceptive method to delay or prevent pregnancy compared to 22% at baseline. Non-Rapid CATCH Indicators Maternal and Newborn Care Indicators Table 3 Non-Rapid CATCH Indicators for Maternal and Newborn Care 40 Indicator Baseline Endline Nu mer ator Den omi nato r % 95% CI Nu mer ator Deno minat or % 95% CI p￾value Quality Antenatal Care Percentage of mothers of children age 0-23 months who had four or more antenatal visits with a skilled provider and were adequately counseled when they were pregnant with the youngest child. 116 313 37% ±8 168 328 51% ±8 <0.0 01 IPT during Pregnancy Percentage of mothers of children age 0-23 months who received Intermittent Preventive Treatment (IPT) for malaria during the pregnancy with the youngest child 185 313 59% ±8 189 328 58% ±8 0.797 Iron Tablets for Pregnant Women Percentage of mothers of children age 0-23 months who took iron tablets before the birth of their youngest child. 254 313 81% ±6 239 328 73% ±7 0.016 Feeding Colostrum Percentage of children age 0-23 months, who were fed colostrum after birth. 300 313 96% ±3 321 328 98% ±2 0.013 6 Pre-lacteal Feeds Percentage of children age 0-23 months who did not receive pre￾lacteal feeds. 287 313 92% ±4 317 328 97% ±3 0.005 HIV Testing During Pregnancy Percentage of mothers of children 0-23 months who were counseled about HIV during the pregnancy, accepted an offer of testing, and received their test results when they were pregnant with their youngest child. 79 313 25% ±7 119 328 36% ±7 0.003 41 Immediate Drying Percent of children age 0-23 months who were dried immediately after birth. 302 313 96% ±3 317 328 97% ±3 1.000 Immediate Wrapping Percentage of children age 0 -23 months, who were wrapped with a cloth or blanket immediately after birth. 299 313 96% ±3 316 328 96% ±3 0.048 Thermal Care (Immediate drying and wrapping) Percentage of children age 0 -23 months who were dried and wrapped with a cloth or blanket immediately after birth 296 313 95% ±4 311 328 95% ±3 1.000 Clean Cord Care Percent children age 0 - 23 months that had clean cord care at the time of birth 68 313 22% ±6 240 328 73% ±7 <0.0 01 Clean Cord Cutting Percent children age 0 - 23 months that had clean cord cutting at the time of birth 251 313 80% ±6 269 328 82% ±6 0.519 Clean Birth Kit Percentage of women of children age 0 -23 months who used a clean delivery kit during the birth of their youngest child. 205 313 65% ±7 313 328 95% ±3 <0.0 01 Birth Preparedne ss Percentage of mothers of children 0 -23 months who made preparations before the birth of the their youngest child 49 313 16% ±6 133 328 41% ±8 <0.0 01 Trained Delivery Attendant Percent of children age 0-23 months whose births were attended by a trained provider including a trained TBA. 248 313 79% ±6 307 328 94% ±4 <0.0 01 Knowledge of MTCT of HIV Percentage of mothers of children age 0 -23 months who know that HIV can be transmitted from an HIV -positive mother to her unborn child during pregnancy, during delivery, and 189 313 60% ±8 175 328 53% ±8 <0.0 01 42 through breastfeeding. Knowledge of PMTCT of HIV Percentage mothers of children age 0-23 months who know that there are special medications that can be given to a pregnant woman infected with HIV to reduce the risk of mother-to-child transmission. 114 313 36% ±8 213 328 65% ±7 <0.0 01 Knowledge of Post￾partum Danger Signs Percentage of mothers of children age 0-23 months who knew at least two post-partum danger signs. 241 313 77% ±7 284 328 87% ±5 <0.0 01 Knowledge of Neonatal Danger Signs Percentage of mothers of children age 0-23 who know at least two neonatal danger signs. 225 313 72% ±7 263 328 80% ±6 0.018 Quality Antenatal Care for Pregnant Women The package of services provided to pregnant women determines the quality of ANC. To achieve the full benefits that ANC promises it is recommended that pregnant women make antennal visits to skilled providers at least four or more times to enable pregnant women receive the full essential ANC servicers. These essential services include the monitoring of vital signs to help in the early detection and management of complications, nutrient supplementation, tetanus immunization, malaria and anemia prevention and provision of education on danger signs during pregnancy, delivery and birth preparedness. Therefore, mothers were asked whether they received “quality ANC” service (defined as the proportion of mothers of children aged 0-23 months who had four or more ANC visit to a skilled provider and were adequately counseled when they were pregnant with the youngest child) during their last pregnancy. The results show a significant increase from 37% at baseline to about 51% after the EPPICS intervention. Intermittent Preventative Treatment of Malaria in Pregnancy (IPTp) In areas of high malaria transmission, IPTp with two to three doses of the recommended antimalarial medicine during pregnancy has been shown to significantly reduce the risk of severe maternal anemia, placental parasitemia and low birth weight. In Ghana, the recommended drug for IPTp is sulfadoxine– pyramithamine (SP) (also known as Fansidar®) and is delivered as a single dose under observation by a health worker. In the current survey we assessed IPTp coverage among mothers of children aged 0-23 months who received IPTp for malaria during the pregnancy with the youngest child. The IPTP uptake was 58% at the end of the intervention compared to 59% at baseline. 43 Iron Tablets for Pregnant Women The World Health Organization recommends a daily dose of 60 mg of essential iron along with 400 µg of folic acid for a period of six months during pregnancy and, in areas of high anemia (> 40% prevalence) for an additional three months’ post-partum supplementation after delivery. In the current survey we assessed the percent of mothers of children aged 0-23 months who took iron tablets before the birth of their youngest child. The results indicate a decreasing trend in the uptake of iron tablets among pregnant women from 81% at baseline to 73% at endline. Immediate Breastfeeding of Newborns, feeding colostrum and pre-lacteal feeds This indicator assesses the practice of placing the newborn at the mother’s breast within one hour after birth (immediately following birth). Immediately placing the infant at the mother’s breast have several beneficial effects. For instance, the colostrum that is produced in the first few days after birth is nutritious and helps to protect the infant against common infections. In this survey, women were asked to indicate how long after birth it took them to first put their last born babies to the breast. The results showed some remarkable improvement after the project intervention. At baseline, only half of the children sampled (50%) were reported to have been immediately breastfed. This has improved at the end of the intervention with about three quarters (75%) of children being put to the breast immediately after birth. Also the proportion of children who were fed colostrum after birth increased from 96% at baseline to 98% at end of project intervention. On pre-lacteal feeds, similar improvements were recorded in the proportion of children who did not receive pre-lacteal feeds from 92% baseline to 97% at endline Figure 2. Figure 2: Comparison of Endline and Baseline Non-Rapid CATCH Infant Breastfeeding Indicators HIV testing during pregnancy We assessed the percentage of mothers of children 0-23 months who were counseled about HIV during the pregnancy, accepted an offer to be tested, and received their test results when they were pregnant 50 96 92 75 98 97 0 20 40 60 80 100 120 Immediate breastfeeding Feeding colostrum No Pre-lacteal feeds Percent Indicator Figure 3: Comparison of Endline and Baseline Non-Rapid CATCH Infant Breastfeeding Indicators Baseline Endline 44 with their youngest child. The endline results shows a remarkable improvement of 36% of women counseled and tested for HIV compared to 25% before the EPICS project implementation. Thermal care (immediate drying and wrapping) All thermal care non-Rapid CATCH indicators had significant coverage at baseline, and therefore, did not show any improvement over the baseline indicators at the end of project implementation. For instance, the proportion of children aged 0-23 months who were dried immediately after birth increased marginally from 96% at baseline to 97% at the end of EPPICS intervention. Similarly, there was no improvement in the coverage of children who were wrapped immediately after birth (96% vs 96%) and those who were dried and wrapped immediately after birth (95% vs 95%) at end of EPPICS intervention (see Figure 3). Clean cord care and clean cord cutting The use of clean home delivery kits (new or sterile blade or instrument) for cutting the umbilical cord have been shown to reduce the incidence of simple cord infection against tetanus and sepsis. The results show some remarkable improvement after the project intervention. At baseline, only two out of ten children (22%) had clean cord care at the time of birth compared to seven out of ten (73%) at end of project implementation. The proportion of deliveries with clean cord cutting increased marginally from 80% at baseline to 82% after project implementation. Typically, in computing the proportion of mothers who used clean cord cutting, the use of new scissors is usually not considered as a clean cord cutting method. However, in this instance, mothers who delivered in a health facility and mentioned that a new scissor was used to cut the cord, this was considered as using a clean cord cutting method. On the clean cord cutting methods, about 31% of mothers said a new blade was used, 26.6% mentioned new scissors, 5.5% used new and boiled scissors, and 20.8% said a used and boiled scissors was used in cutting the cord. Birth preparedness and clean birth kit Birth preparedness by expectant mothers and the use of clean-delivery kit is a simple and effective approach to reducing risk of infections during birth. Mothers were asked about the use of clean delivery kits and birth preparedness. The results show some improvement in the proportion of mothers of children aged 0-23 months who use clean delivery kit during the birth of their youngest child. At baseline, only 65% of mothers reported using clean delivery kits. However, this improved significantly at the end of the EPPICS project intervention to 95%. On the other hand, the proportion of mothers who made preparations towards the birth of their youngest child increased from 16% at baseline to 41% at end of project intervention. This implies that over half of mothers are not making adequate preparations towards delivery. This might be due to several factors including lack of education during ANC services. There is the need for health care providers to intensify education during ANC visit on the importance of birth preparedness. Trained delivery attendants Trained delivery attendance at birth (defined as the proportion of children aged 0-23 months whose births were attended by a trained provider including a trained traditional birth attendant (TBA) was one of the non-Rapid CATCH interventions implemented by the EPPICS project to address the low levels of 45 skill attendance at birth and improve on maternal and newborn survival. The endline result clearly shows an improvement in the proportion of trained deliveries (94%) as compared to baseline results of 79%. Care during delivery Immediately after the placenta was out, about 80% of mothers had their uterus massaged to make them contract strongly and to prevent them from prolong and continuous bleeding. The proportion at baseline was also 80% indicating no change. Also the proportion of mothers who indicated that the health care provider or a Traditional Birth Attendant held their stomachs and pulled the cord to help the placenta come out declined to 74% compared to 82% at baseline. Care of child when mother is away On who usually takes care of a child when the mother is away from home, most of the mothers said older children (36%) and other relatives (36%) usually take of them. About 13% of the mothers of the children reported that their mothers take care and nearly 10% indicated their children are taken care of by the husband. Knowledge of MTCT of HIV and PMTCT of HIV UNAIDS, UNICEF, WHO and UNFPA have partnered with individual countries to continue rapid scale up of quality, comprehensive prevention of maternal-to-child transmission of HIV (PMTCT) services with the goal of eliminating mother-to-child transmission (MTCT) of HIV by 2015. In the EPPICS intervention, efforts were made to educate women about PMTCT and MTCT of HIV. The endline survey recorded improvement in the proportion of mothers who knew that there were special medications that can be given to HIV positive pregnant women to reduce the risk of MTCT of HIV (Table 3). However, there was a decline from 60% at baseline to 53% at endline in the proportion of mothers who knew that HIV can be transmitted from an HIV positive mother to her child during pregnancy, delivery and through breastfeeding. The knowledge that transmission from mother to child can be prevented is likely to shape women‘s care-seeking and breastfeeding behavior and needs further improvement. Knowledge of Post-Partum Danger Sings and Neonatal Danger Signs Mothers’ knowledge and awareness of the danger signs of post-partum and newborn complications are critical for seeking immediate care and improving newborn survival. The results indicated clear improvements in the proportion of mothers who knew at least two post-partum danger signs - from 77% before the intervention to about 87% after the project intervention. Similarly, the proportion of mothers who knew at least two neonatal danger signs increased from 72% to 80% (Figure 3). 46 Figure 3: Other Non-Rapid CATCH indicators on knowledge of mothers on MTCT HIV, Danger signs of pregnancy, delivery, post-partum and neonatal danger signs Prevention and control of major childhood diseases Malaria About 50% of children below 24 months were reported to have had fever in the last two weeks prior to the survey. Among those with fever 17% were treated for malaria. Although this is low it represents an increase over the baseline figure of 10%. More than two-thirds of the households reported ownership of ITN. Reported use of ITN is equally high among children less than 24 months as 71% of children 0-23 months slept under ITN the night before the survey. This represents a substantial increase over the baseline prevalence of 42%. Control of diarrhea Forty percent of children below 24 months had diarrhea two weeks before the survey. Among those who had diarrhea, 65% received proper preventive or curative rehydration therapy. This is an improvement over the baseline situation where less than half (48%) of children with diarrhea received proper preventive or curative rehydration therapy. Table 4: Indicators on prevention, control and Treatment of major childhood diseases, and good Hygiene practices Indicator Baseline prevalence (%) Endline prevalence (%) Percentage difference EPPICS RAPID CATCH INDICATORS Malaria ITN use RC 42 71 29 60 36 81 69 77 72 53 65 86 72 87 80 0 10 20 30 40 50 60 70 80 90 100 Knowledge of MTCT of HIV Knowledge of PMTCT of HIV Knowledge of danger sings during pregnancy Knowledge of danger sings during delivery Knowledge of post-partum danger sings Knowledge of neonatal danger signs Percent Indicator Baseline Endline 47 Treatment of fever in Malaria zones RC 10 17 7 Control of diarrhea ORT Use RC 48 65 17 Acute respiratory infections Appropriate Care Seeking for Pneumonia RC 48 63 15 Water and Sanitation Point of Use (POU) Water Treatment RC 4 33 29 Appropriate Hand Washing Practices RC 28 46 18 NON RAPID CATCH INDICATOR ITN Ownership NRC 45 71 26 Acute Respiratory Infections From the mothers’ reports, 68% of children less than 24 months who had symptoms of pneumonia in the two weeks prior to the survey received appropriate care. This represents an increase over the baseline situation where 48% of children with pneumonia reportedly received appropriate treatment. Water and Sanitation The survey obtained information on basic hygiene and sanitation practices that affect the health of infants. A third of the households of children below two years reported treating water effectively. Compared to the baseline situation there has been an improvement in the POU. However, the actual number of cases involved is small and should be viewed cautiously. Appropriate hand washing practices as reported by mothers also appears to have improved. In 2015 46% of respondents reported appropriate hand washing practices compared to 28% at baseline. Anthropometrics The height and weight of all the children were taken during the survey. Below are the weight-for-age, height-for-age and weight-for-height anthropometric indicators for both the baseline and end of intervention surveys. Table 5: Baseline and endline anthropometric indicators Indicator Baseline Endline Weight for age z-score Frequency % Frequency % Severely underweight 61 19 16 5 Moderately underweight 74 24 36 11 Mildly underweight 80 26 63 20 Normal 98 31 207 64 Total 313 100 322 100 48 Height for age z-score Frequency % Frequency % Severe stunting 52 17 10 3 Moderate stunting 39 12 24 8 Mild stunting 73 23 65 21 Normal 149 48 213 68 Total 313 100 312 100 Weight for height z-score Frequency % Frequency % Severe wasting 66 21 24 8 Moderate wasting 92 29 30 10 Mild wasting 81 26 75 24 Normal 74 24 184 59 Total 313 100 313 100 The results clearly show some remarkable improvement in the anthropometric indicators over the period of the intervention. At baseline, less than half of the children sampled were within “normal” measurements with a relatively high percentage of them being severely underweight. This has improved at the end of the intervention with 68% of children less than 2 years having normal weight for age z￾scores compared to 31% at baseline. The proportion of children who were severely underweight also dropped from 19% at baseline to 5% at the end of the intervention. Similar improvements in the anthropometric indicators for height for age and weight for height were also recorded (see table 5). Birth weight In all, 243 children had information on their birth weight recorded on their child health cards. The mean birth weight was approximately 2.9kg (s.d=0.6). The proportion of children with low birth weight (birth weight <2.5kg) was 21% (51/243). Vitamin A supplementation Table 7 shows the percentage distribution of the baseline and end of intervention indicators on immunization and Vitamin A supplementation to children at six months and mothers who received Vitamin A in the first two months after delivery. Vitamin A supplementation at six months was verified by card and by recall. The proportion of children at six months who received Vitamin A supplementation has improved marginally from 84% at endline from the baseline proportion of 74%. Vitamin A supplementation to mothers in the first two months after delivery also increased from a baseline percentage of 58% to 71% at the end of the intervention. Table 6: Immunization status and Vitamin A supplementation Indicator Baseline (%) Endline (%) Percentage difference Comment Vitamin A Supplementation 74 78 4 Positive Vitamin A supplementation Mother 58 71 13 Positive 49 Measles Vaccination 95 89 6 Negative DTP1 96 95 1 Not much change DTP3 95 94 1 Not much change Immunization All three Immunization Rapid CATCH indicators at the end of the intervention did not show any improvement over the indicators recorded at baseline. Measles vaccination coverage reduced from 95% at baseline to 89% at the end of the intervention (see figure 5). The coverage for DTP1 which is an indication of access to immunization and DTP3 which is a measure of the performance of health Systems regarding immunization services also showed some marginal decreases of 1% from the proportions recorded at baseline (figure 5). These indicators reflect the performance of child health prevention services in the intervention area and can be improved upon. Emphasizing or educating women on the importance of timely vaccination would help. 50 Figure 4: Comparison of Endline and Baseline indicators on Immunization status and Vitamin A supplementation Figure 5: General KPC EPPICS project Baseline and Endline Rapid CATCH indicators 74 58 95 96 95 78 71 89 95 94 0 20 40 60 80 100 120 Vitamin A Supplementation Vitamin A supplementation Mother Measles Vaccination DTP1 DTP3 Percent Indicator Baseline Endline 4 10 85 28 30 42 43 47 48 48 55 64 74 80 95 95 96 33 17 87 46 83 71 76 73 65 63 78 71 78 84 89 94 95 0 20 40 60 80 100 120 Percent Indicator Baseline Endline 51 Discussion Immunizations The results show that the three Immunization Rapid CATCH indicators at the end of the intervention did not show any improvement over the indicators recorded at baseline. Measles vaccination coverage reduced from 95% at baseline to 89% at the end of the intervention. The other indicators (penta1 and penta3) experienced marginal reductions in coverage. Recommendation on immunization: These indicators can be improved upon by emphasizing or educating women on the importance of timely vaccination. Maternal and newborn care: Antenatal Care (ANC) The study found a significant increase in the proportion of mothers of children 0-23 months received 4 or more ANC visits (82%) against baseline (BL) value (63.9%). Overall eight out of ten pregnant women had four or more ANC visits. The results showed significant improvement in the proportion of pregnant women who received Tetanus Toxoid during ANC visits. Therefore, efforts should be made to maintain and improve coverage to ensure that all pregnant women attending ANC are fully protected against infections. However, the results showed declining coverage on the proportion of pregnant women who received intermittent preventive treatment for malaria during pregnancy and Iron supplementation. Thus, there was a marginal decline by 1% of mothers who received IPT during pregnancy with their youngest child at the end of project intervention. Similarly, there was a reduction in the coverage of Iron supplementation (taking iron supplements for 90 days or more) which was 81% at baseline but declined to 73% at endline. Recommendations: GHS: The package of services provided for pregnant women during ANC determines the quality of ANC services. The increase in coverage of ANC attendance especially in the first trimester of pregnancy should provide opportunity to health care providers to improve on the package of ANC service provided to pregnant women in the district. There is also the need to encourage women to continue attending ANC in order to receive full ANC service and improve on their health and pregnancy outcome. EPPICS: The gain by the project is commendable. Any opportunity that will see additional support for GHS to continue to roll-out social behavior change communication activities to help sustain or improve the gains made is encouraged. First ANC in the First Trimester of Pregnancy Gestation especially in the first trimester is a very critical period in the life of the unborn child and mother. Accessing health care services within this period is very important in promoting the health of 52 the child and mother and an avenue for safe delivery in future. The endline data, therefore, showed remarkable improvement in ANC attendance at first trimester (74%) over baseline performance which was just a little over half of the women covered at baseline. Recommendation GHS: The community liaison with the CHV should be encouraged towards the identification of potential mothers during the early months of pregnancy and encouraging them to go for ANC services in the early months of the pregnancy. EPPICS: Performance in ANC attendance in the first trimester of pregnancy has been encouraging. Newborn Care Thermal care: Drying the newborn immediately after birth, wrapping the infant with a dry cloth or towel, clean cord care and cord cutting and prophylactic eye care are essential newborn care practices for keeping the newborn warm and healthy. These indicators are used to assess core components of recommended newborn care at delivery and to measure the quality and adherence to service protocols, performance of birth attendants, and adoption of newborn care messages at the community. Overall, these indicators have recorded very good coverage after the project intervention. About 97% of mothers reported immediate drying and wrapping of their youngest child after project implementation. Similarly, the results showed some level of improvement in the proportion of mothers with a clean birth kit which increased from 65% at baseline to 95%, clean cord care from 22% to 73% and clean cord cutting increased marginally from 80% to 82% after project implementation. There were major increases in skilled birth and trained delivery attendants. Recommendation GHS: Continue with the practice of supporting and guiding mothers and caregivers to immediately wrap, and dry the newborn, and to ensure that babies are not bath within 24 hours according to service protocols. Also, mothers should be encouraged to put their babies to breast immediately after birth. Providers should counsel and educate mothers during ANC, delivery and post-partum care visits about the importance of thermal care and early initiation of breast milk. EPPICS: Overall, there were improvements in essential newborn care practices at the end of project intervention. While systems and structures are in place to sustain the gains of EPPICS in East Mamprusi, CRS and other actors should continue to search for opportunities that will facilitate the scale-up of the EPPICS strategies to other districts in Ghana However, there is need for sustainability or scale-up of community mobilization programs to sustain and further improve on these gains. Skilled Birth Attendance Most maternal and neonatal deaths occur during delivery and within 48 hours after delivery. Therefore, one essential safe motherhood intervention is to ensure that every pregnant woman is attended to by a competent health provider with midwifery skills (medical doctor, midwife or nurse) during delivery. Interventions implemented by the EPPICS project to address the low levels of skill attendance at birth and improve on maternal and newborn survival were successful. The endline results showed that 76% of all deliveries were attended by skilled personnel compared to 43% at baseline. Similarly, there has also been a substantial increase in the prevalence of trained delivery attendants from 79% to 94% at the end 53 of project intervention. It is important to indicate that about 77% of the mothers delivered in a health facility. Majority delivered in a health center (42%), followed by hospital (32%) and health post (2.4%). Recommendation GHS: Skilled delivery indicators can further be improved by continued collaboration with community health volunteers and TBAs and all stakeholders. EPPICS: There have been appreciable levels of improvements in these indicators, an indication that intervention packages for these indicators were well executed Clean cord cutting Clean cord cutting is another important method of maternal and newborn care. The survey we therefore assessed the instruments used for cutting the cord after delivery. Typically, in computing the proportion of mothers who used clean cord cutting, the use of new scissors is usually not considered as a clean cord cutting method. However, in this instance, mothers who delivered in a health facility and mentioned that a new scissor was used to cut the cord were considered as using a clean cord cutting method. The proportion of deliveries with clean cord cutting, therefore, increased marginally from 80% at baseline to 82% after project implementation. About 31% of mothers said a new blade was used, 26.6% mentioned new scissors, 5.5% used new and boiled scissors, and 20.8% said a used and boiled scissors was used in cutting the cord. Recommendation GHS: Health workers should continue with the practice of clean cord cutting as it is an important method of preventing mother and child from infection and enhancing their health. EPPICS: Achievement has been very remarkable. GHS: These indicators can further be improved by continued collaboration with community health volunteers and TBAs and all stakeholders. EPPICS: There have been appreciable levels of improvements in these indicators - an indication that intervention packages for these indicators were well executed. Post-natal visit to check on newborn health: Baseline report showed that visits by trained health care providers to check on health of newborn child and mother were very rare in the intervention district as only 30% of newborns received post-natal visit from health providers. However, at the end of the project intervention, the results showed clear improvements in the proportion (76%) of newborns who were visited during the post-natal period. There is growing evidence that more babies die in the first week of life than at any other time in childhood, and post-natal visit of check on newborn health during those critical moments are important intervention for their survival and reduction in neonatal mortality. Recommendations: GHS: Though there was improvement in home visits, postpartum and postnatal visits by community health officers, this should be encouraged to further improve the health of newborns in the district. EPPICS: The improvements in post-natal care is another plus in the efforts of the EPPICS project towards improving maternal and child health in the East Mamprusi district. 54 Post-Natal Visit to Check on Mother On the other hand, the proportion of mothers to children age 0-23 months who received a post-natal visit from an appropriate trained health worker within two days after birth of child increased from 32% at baseline to 82% at the end of the project implementation. This increase is statistically significant at 95% confidence level. Overall, 95% of mothers were checked by either a health care provider or a traditional birth attendant either at a health facility, home or any other location compared to 86% at baseline. About 88% of the mothers were checked in less than one day, 10% in less than 1 week and 0.7% after one week. About 87% of them were checked on by trained health personnel: 39% being midwives, 34% nurses and 14% doctors. Recommendation: GHS: A good feat chalked and efforts by health workers has to be sustained EPPICS: Very remarkable achievement with the efforts of project staff Mothers satisfaction and abuse during ANC In recent times the attitude of health workers has been reported in several platforms to play in a major part in the deteriorating health care delivery especially in many deprived communities in developing countries. The KPC sought to assess whether or not mothers were satisfied with the treatment they received from health workers when they visited the facilities for ANC services. It was revealed that about 90% of mothers were very satisfied while 8% said they were somewhat satisfied with the services and just 1.5% reported that they were not satisfied. Despite the high level of level of satisfaction, some also said they were abused during ANC visits. Almost 6% of mothers said they felt abused during ANC visit. Among those who reported of being abused by health staff during ANC, about 26% reported health staff ignored them, 47% said they were yelled at, 26% said health staff insulted them and 21% reported of other form of abuse. Perception of abuse during delivery On perception of abuse during delivery it was found that about 7% (18) of the mothers who delivered at the health facility said they felt abused during delivery. This also means that 93% of mothers were not abused when they went to deliver at a health facility. Among those abused during delivery, 11% said health staff ignored them, 67% complained that they were yelled at, 11% indicated staff made fun of them, 17% reported that health staff insulted them and 17% said staff slapped or hit them. GHS: The majority of women did not complain of any abuses when they went to deliver at the health facility and this is a positive indicator on the health worker attitude towards clients. EPPICS: A very good feat chalked. 55 Recommendation: GHS: Even though there is a high level of satisfaction about the conduct of health staff, more still needs to be done since GHS seeks to maintain high levels of professional conduct and customer satisfaction remains key towards meeting this goal. EPPICS: Results in this indicator has been encouraging. Contraceptive use Demand for modern contraceptive services improved at the end of project intervention from 22% to 35%. Use of modern contraceptives enhances the health of mothers and children. However, current use of modern contraceptives in the intervention district remains relatively low, with only about a third of women in the survey district currently using a modern method of contraception at the end of project intervention. Culture, religion and cost of FP services which are currently not covered by the National Health Insurance Scheme may have contributed to the slow progress on project implementation. Recommendations: GHS: Enabling couples to demand for FP services, including proper spacing of their children and deciding when, and how often to have children is vital to achieving the safe motherhood program. There is the need to improve the supply of family planning service to women and their partners in the district. Health care providers should use ANC visit, delivery and postnatal care visits to provide information on family services and to encourage couples to take up FP. EPPICS: Good progress in increasing modern contraceptive use among women in the district. Nutrition Breastfeeding and Infant and Young Child feeding One of the life-saving interventions for newborns and infants is breastfeeding. Routine antenatal care, facility-deliveries and community-based home visits are opportunity to counsel expectant mothers on the importance of immediate and exclusive breastfeeding and to influence and change knowledge, attitudes, and behaviors towards exclusive breastfeeding. We assessed the proportion of children aged 0-5 months who were exclusively breastfed during the last 24 months. The results show a significant improvement in the levels of exclusive breastfeeding after the EPPICS project intervention – from 47% at baseline to 70% at endline. Infant and young child feeding practices among children age 6-23 months has improved over the period. The proportion of children fed according to a minimum of appropriate feeding practices increased from 55% [95%CI (45%-65%)] at baseline to 78% [95%CI (70%-86%)] at the end of the project implementation, and this is statistically significant at 95% confidence level. Recommendations: GHS: Even though a lot of progress has been made on exclusive breastfeeding and infant and young child feeding practices, more work needs to be done to further improve on the nutritional status of children in the district. Educating women on the importance of exclusive breastfeeding and proper child feeding practices during ANC, post-partum/post-natal care, immunization and growth monitoring outreach activities should continue. 56 EPPICS: Very good achievement for improving on exclusive breastfeeding and infant and young child feeding practices in the district. Micronutrients Iodine deficiency: Just 16% of households had iodized salt in their kitchens on the day of the survey. This is an improvement over the 4% recorded at baseline. This is very low and needs to be improved. Vitamin A: There was a 4% improvement in the proportion of children over 6 months who received Vitamin A supplementation at the endline survey (78%) compared to baseline (74%). The East Mamprusi District is performing reasonably well by assuring that children have access to vitamin A. A little more than two-thirds of the children less than 6 months were protected through supplementation of their mothers; a 13% increase over the baseline indicator. Records of Vitamin A supplementation are often not documented in the health cards. Recommendations: GHS: Document Vitamin A supplementation on health cards of children. The promotion of the use of iodine fortified salt or supplementation of iodine should continue. EPPICS: There was some improvement in the availability of iodized salt in households compared to baseline indicators. But any activity that can improve on this is welcomed. Malaria At the end of the EPPICS intervention, ownership of ITN and use of same for the prevention of malaria in households with children less than two years had increased markedly. Less than half (45%) of households with children (0-23 months) in the study district owned a treated mosquito net at baseline and more than two-thirds (71%) owned ITN at the end of the EPPICS interventions. The baseline ITN ownership of 45% was less than the national ITN ownership of 49% of as reported by the 2011 multiple indicator cluster survey (MICS) report. Similarly, there was a significant increase in reported use of ITN among children less than 24 months as 53% of children slept under ITN the night preceding survey compared to 42% at baseline. The baseline ITN use of 42% is slightly higher than the (40%) coverage for children under-five in all households who slept under LLIN the night prior to survey as reported by the 2011 multiple indicator survey report. Comparison of the end of intervention study indicators with national figures can adequately be made with the next MICS report. On febrile episodes among children below 24 months who had fever two weeks to the survey, the endline survey revealed about 50% of children had fever. Among those with fever, 17% were treated with an effective anti-malarial drug within 24 hours. Although this is low it represents an increase over the baseline figure of 10%. Though there was a significant improvement in ownership of ITN at the end of EPPICS intervention compared to the situation at baseline, only half of the children slept under the treated nets. However, only a small percentage of those who had fever were treated. Recommendation: GHS: There is the need to encourage community-directed intervention where CHV can be trained to distribute treated nets, monitor use of nets and administer medications to uncomplicated ailments. Also 57 mothers can be encouraged to take their children to the health facilities as soon as they detect that their children are not well including minor ailments. EPPICS: Recommend during dissemination of findings the need for communities to continue to support the community efforts to sustain the Giant scoreboard initiative which will keep community members informed about community performance on key health indicators including ITN use. Health Facilities The end of intervention survey results shows some level of improvement in sick child care needs over the baseline indicators, but these have to be improved. Almost 2 out of 3 children with diarrhea in the last two weeks to the survey received ORS or a home based fluid compared. This is an improvement over the 48% recorded at baseline. There was also some improvement in appropriate care seeking for pneumonia with over 60% of children with signs of pneumonia taken to an appropriate health care provider compared to less than half at baseline. Almost two in ten (17%) compared to one in 10 (10%) of children with fever were treated with an effective anti-malarial drug within 24 hours. GHS: Steps should be taken to improve the situation by educating mothers on good health seeking practices for their children. They should also ensure that facilities have the necessary drugs and trained staff. EPPICS: Some progress has been made but the indicators are still undesirable and need to improve. 58 Annex 1: KPC Endline Survey Questionnaire IDENTIFICATION CLUSTER NUMBER HOUSEHOLD NUMBER RECORD NUMBER Community Name of Mother 1 2 3 Final Visit Interview date ___/___/___ day/mnt/year ___/___/___ day/mnt/year ___/___/___ day/mnt/year For Supervisor Day Name of Interviewer Month Year Result Code* Result Code *Result Codes: 1. Completed 2. Respondent not at home 3. Postponed 4. Refused 5. Other (Specify) ______________________________________ Form checked by Supervisor: Signature Data Entered by 1. 2. Date: ___/___/____ Date: ___/___/____ INFORMED CONSENT Hello. My name is ______________________, and I am working with Ghana Health Services and CRS. We are conducting a survey and would appreciate your participation. I would like to ask you about your health and the health of your youngest child under the age of two. This information will help CRS and Ghana Health Services to plan health services and assess whether it is meeting its goals to improve children’s health. The survey usually takes 60 minutes to complete. Whatever information you provide will be kept strictly confidential. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. You can stop the survey at any time. However, we hope that you will participate in this survey since your views are important. Will you participate in this survey? YES NO At this time, do you want to ask me anything about the survey? SIGNATURE OF INTERVIEWER: _____________________________________ Date: ____/_____/_______ 59 RESPONDENT AGREES TO BE INTERVIEWED 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2  END 60 RESPONDENT BACKGROUND CHARACTERISTICS NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1 For how many years have you attended school?1 IF NEVER, RECORD ‘00'. Years In School 2 What is your level of formal education? Basic School…………………….......1 Senior High School………………...2 Tertiary (College/University…...3 Never been to school………….….4 Other (specify)……………………....5 3 What is your age in complete years? AGE…………. 4 What is your marital status Single………………………………...1 Married……………………………….2 Divorced……………………………..3 Widowed……………………………..4 5 What religion do you practice? Christianity………………….............1 Islam……………………………………….2 African Traditional Religion…….3 None……………………………………….4 Other (Specify):…………….. ………5 61 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 6 What languages do you speak? Mampruli………………….………A Moar……………………………. ….B Kusal…………………………………C Likpapka…………………………..D Others (Specify)………………..E 7 In what language do you feel most comfortable communicating? Mampruli………………….…1 Moar…………………….…….2 Kusal……………………………3 Likpapka………………………4 Others (Specify)……………5 8a What is the total number of births you have had that are still alive 8b What is the total number of all the births you have had that have died 9 What is the name, sex, date of birth of your youngest child that you gave birth to and that is still alive? YOUNGEST CHILD NAME ______________________________ SEX MALE..........................................................................1 FEMALE.....................................................................2 DATE OF BIRTH DAY (Use 15 for unknown days) MONTH (Multiple options allowed) 62 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP YEAR 10 What are the dates of birth of your two youngest children?” Youngest Older __ __ / __ __ / __ __ DD MM YY __ __ / __ __ / __ __ DD MM YY 11 Does (NAME’S) biological father live in this household? Yes .................................................................................1 No ..................................................................................2 Don’t Know.................................................................8 12 Who is the head of this household? Mother (Respondent) .............................................1 Husband/ Partner .....................................................2 Female Relative___________ ...........................3 (Specify) Male Relative_____________............................4 (Specify) Other ____________________ .......................7 (Specify) 63 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 13 Do you work outside of the home to earn money? IF NO, CIRCLE “A” (NO OUTSIDE WORK) IF YES, What kind of work do you do? No Outside Work .....................................................A Handicrafts .................................................................B Harvesting ...................................................................C Selling Foods..............................................................D Shop Keeper/Street Vendor...................................E Servant/Household Worker................................... F Salaried Worker........................................................G Farming………………………………………...H Other____________________........................X (Specify) 14 Who usually takes care of (NAME) when you are away from home? (Select only one response) Mother (Respondent) ..............................................A Husband/Partner.......................................................B Older Children............................................................C Other Relatives ___________ ...........................D (Specify) Neighbors/Friends.....................................................E Maid.............................................................................. F Nursery School...........................................................G Other………..___________________.........X (Specify) Child Immunizations 15 Do you have a card or child health booklet where (Name’s) vaccinations and Vitamin A (capsules) are written down? IF YES: May I see it please? YES ................................................................................1 NO.................................................................................2 DON’T KNOW..........................................................9  17  17 64 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 16 COPY VACCINATION DATES and VITAMIN A, FROM THE CARD OR BOOKLET. IF VACCINES ARE NOT RECORDED IN CHILD HEALTH CARD OR BOOKLET, FILL IN 99/99/9999. DAY MONTH YEAR A BCG BCG B POLIO 0 (GIVEN AT BIRTH - BEFORE 6 WkS) C POLIO 1 OPV1 D POLIO 2 OPV2 E POLIO 3 OPV3 F Diph/PERT/TET/HEP B/HAEMO INF B 1 G Diph/PERT/TET/HEP B/HAEMO INF B 2 H Diph/PERT/TET/HEP B/HAEMO INF B 3 I VITAMIN A (6 months) J MEASLES (9 months) K MEASLES 2 (18 months) L PNEUMONIA 1 M PNEUMONIA 2 N ROTARIX 1 O ROTARIX 2 P PNEUMONIA 3 Q YELLOW FEVER (9 months) 65 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 17 Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations given during immunization campaigns? YES ................................................................................1 NO.................................................................................2 DON’T KNOW..........................................................9  21  21 18 Has (NAME) received a DTP/PENTA vaccination, that is, an injection given in the left thigh, sometimes at the same time as polio drops? YES ................................................................................1 NO.................................................................................2 DON’T KNOW..........................................................9  21  21 19 How many times? NUMBER OF TIMES.................................... 20 Did (Name) ever receive an injection in the arm to prevent Measles? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9 Malaria - Treatment of Fever of Child 21 Has (Name) been ill with fever at any time in the last 2 weeks? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  26  26 22 Did you seek advice or treatment for the fever? YES.................................................................................... 1 NO..................................................................................... 2  26 23 How many days after the fever began did you first seek treatment for (Name)? SAME DAY ..................................................................... 0 NEXT DAY..................................................................... 1 TWO OR MORE DAYS.............................................. 2 24 At any time during the illness did (Name) take any drugs for the fever? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  26  26 66 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 25 What drugs did (Name) take? Any other drugs? RECORD ALL MENTIONED. ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN. IF TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT COUNTRY SPECIFIC BASED ON NATIONAL MALARIAL PROTOCOL. FOR EACH ANTIMALARIAL MEDICINE ASK: How long after the fever started did (NAME) start taking the medicine? CIRCLE THE APPROPRIATE CODES: SAME DAY = 0 NEXT DAY AFTER THE FEVER = 1 TWO OR MORE DAYS AFTER THE FEVER=2 DON’T KNOW = 9 ANTI-MALARIAL A SP/Fansidar............... 0 1 2 9 B Chloroquine .............. 0 1 2 9 C Amodiaquine............ 0 1 2 9 D Quinine...................... 0 1 2 9 E ACT ............................. 0 1 2 9 OTHER DRUGS F ASPRIN....................... 0 1 2 9 G PARACETAMOL...... 0 1 2 9 X. Other....................... 0 1 2 9 Control of Diarrhea 26 Has (Name) had diarrhea in the last two weeks? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  28  28 67 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 27 Was s/he given any of the following to drink at any time since s/he started having diarrhea: READ CHOICES ALOUD: a) A fluid made from a special packet called ORS or kpaazaa? b) A government-recommended homemade fluid? (rice water, coconut juice, mashed kenkey… SHOW LOCALLY AVAILABLE ORS PACKAGE OR PICTURE. YES NO DK A. FLUID FROM ORS PACKET….1 2 9 B. HOMEMADE FLUID………......1 2 9 ARI/Pneumonia 28 Has (Name) had an illness with a cough that comes from the chest at any time in the last two weeks? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  32  32 29 When (Name) had an illness with a cough, did he/she have trouble breathing or breathe faster than usual with short, fast breaths? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  32  32 30 Did you seek advice or treatment for the cough/fast breathing? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  32  32 31 Who gave you advice or treatment? Anyone else? RECORD ALL MENTIONED. DOCTOR..............................................................................A NURSE..................................................................................B AUXILIARY NURSE (ENROLE NURSE) ....................C TRAINED COMMUNITY HEALTH WORKER .......D OTHER ................................................................................X Water and Sanitation 68 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 32 Where do you usually get water for drinking purposes? (Select only 1 response) Borehole…………………………….1 Well……………………………………2 Dam……………………………………3 Rain harvest……………….........4 Others(Specify)…..................5  35  35 33 Do you treat your water in any way to make it safe for drinking? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  35  35 34 If yes, what do you usually do to the water to make it safer to drink? ONLY CHECK MORE THAN ONE RESPONSE IF SEVERAL METHODS ARE USUALLY USED TOGETHER, FOR EXAMPLE, CLOTH FILTRATION AND CHLORINE. LET IT STAND AND SETTLE/SEDIMENTATION................................. A STRAIN IT THROUGH CLOTH........................B BOIL........................................................................... C ADD BLEACH/CHLORINE ................................D WATER FILTER (CERAMIC, SAND, COMPOSITE) ......................................................... E SOLAR DISINFECTION ....................................... F OTHER ..................................................................... X DON’T KNOW......................................................Z 35 Can you show me where you usually wash your hands and what you use to wash hands? ASK TO SEE AND OBSERVE INSIDE/NEAR TOILET FACILITY.. ..........................…1 INSIDE/NEAR KITCHEN/COOKING PLACE ...........2 ELSEWHERE IN YARD...................................................3 OUTSIDE YARD.................................................................4 NO SPECIFIC PLACE........................................................5 NO PERMISSION TO SEE .............................................8  37  37 69 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 36 OBSERVATION ONLY: IS THERE SOAP OR DETERGENT OR LOCALLY USED CLEANSING AGENT? THIS ITEM SHOULD BE EITHER IN PLACE OR BROUGHT BY THE INTERVIEWEE WITHIN ONE MINUTE. IF THE ITEM IS NOT PRESENT WITHIN ONE MINUTE CHECK NONE, EVEN IF BROUGHT OUT LATER. SOAP................................................................................. 1 DETERGENT ................................................................. 2 ASH................................................................................... 3 MUD/SAND................................................................... 4 NONE .............................................................................. 5 OTHER .......................................................................... 6 Malaria – ITN use 37 Does your household have any mosquito nets that can be used while sleeping? YES.................................................................................... 1 NO..................................................................................... 2  42 38 Who slept under a bed net last night? If ANYONE OTHER THAN THE CHILD IS MENTIONED, RECORD OTHER. NO ONE .................................................…….....0 CHILD (NAME) .....................................……....1 OTHER ....................................................…….....2  42  42 39 Which brand of bed net did (Name) sleep under last night? SHOW PICTURES OF TYPICAL NET TYPES AND BRANDS. PERMANENT NET Permanet...........................................................……....1 Oliset...................................................................……....2 Long lasted treated net ................................……....3 OTHER NET OTHER NET ..................................................…….....5 DON’T KNOW...............................................……....9  42  42  42 40 Was the bed net that (Name) slept under last night ever soaked or dipped in a liquid treated to repel mosquitoes or bugs? YES.................................................................................... 1 NO..................................................................................... 2 DON’T KNOW...............................................……....9  42  42 70 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 41 How long ago was the net last soaked or dipped in a liquid treated to repel mosquitoes or bugs? IF LESS THAN 1 MONTH AGO, RECORD 00 MONTHS. IF LESS THAN 2 YEARS AGO, RECORD MONTHS AGO. IF 12 MONTHS AGO OR 1 YEAR AGO, PROBE FOR EXACT NUMBER OF MONTHS. MONTHS MORE THAN 2 YEARS AGO.............95 DON’T KNOW........................................98 Maternal Newborn Care 42 How long should you wait after the birth of your child before you try to become pregnant again? LESS THAN 2 YEARS ......................................................1 2 TO 5 YEARS....................................................................2 MORE THAN 5 YEARS...................................................3 DON’T KNOW ..................................................................9 43 What are the risks of getting pregnant too soon after the birth of a child? DO NOT READ RESPONSES. RECORD ALL THAT ARE MENTIONED. NO RISK …………………………………………A BABY BORN TOO SMALL………………..B BABY BORN TOO EARLY………………….C MOTHER CAN DIE…………………………..D MOTHER CAN HAVE MISCARRIAGE…E MOTHER CAN SUFFER ANEMIA………F DON’T KNOW…………………………………G OTHER ____________________.................X (SPECIFY) 44 Are you currently pregnant? YES……………………………….1 NO…………………………………2 45 Are you currently doing something or using any method to delay or avoid getting pregnant? YES ....................................................................................1 NO.....................................................................................2 DON’T KNOW .............................................................9  47  47 71 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 46 Which method are you (or your husband/ partner) using? DO NOT READ RESPONSES. CODE ONLY ONE RESPONSE. IF MORE THAN ONE METHOD IS MENTIONED, ASK, What is your MAIN method that you (or your husband/ partner) use to delay or avoid getting pregnant?” IF REPONDENT MENTIONS BOTH CONDOMS AND STANDARD DAYS METHOD, CODE “12” FOR STANDARD DAYS METHOD IF RESPONDENT MENTIONS ABSTINENCE OR ISOLATION, CODE “15” FOR OTHER AND RECORD RESPONSE IN SPACE PROVIDED. FEMALE STERILIZATION.............................................1 MALE STERILIZATION..................................................2 PILL.......................................................................................3 IUD.......................................................................................4 INJECTABLES....................................................................5 IMPLANTS .........................................................................6 CONDOM..........................................................................7 FEMALE CONDOM........................................................8 DIAPHRAGM…………………………………….9 FOAM/JELLY...................................................................10 LACTATIONAL AMEN. METHOD..........................11 (EXCLUSIVE BRESTFEEDING) STANDARD DAYS METHOD/ CYCLEBEADS.................................................................12 RHYTHM METHOD (OTHER THAN STANDARD DAYS) ....................................13 WITHDRAWAL.............................................................14 OTHER………_________________.................15 (SPECIFY) 47 Can the virus that causes AIDS be transmitted from a mother to a child: a. During pregnancy? b. During delivery? c. By breastfeeding? YES NO DK A. DURING PREG ...........1............ 2 ................9 B. DURING DELIVERY...1............ 2 ................9 C. BREASTFEEDING.......1............ 2 ................9 72 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 48 Are there special drugs that a doctor or a nurse can give a woman infected by the virus that causes AIDS to reduce the risk of transmission to her baby? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 49 During your pregnancy with (Name), did you see anyone for antenatal care? IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN. DOCTOR/MEDICAL ASSISTANT..................... A NURSE........................................................................ B MIDWIFE................................................................... C TRADITIONAL BIRTH ATTENDANT............. D OTHER ____________________...........................X (SPECIFY) NO ONE ................................................................... Y 59 50 During your pregnancy with (Name), where did you receive antenatal care? CIRCLE ALL MENTIONED. IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. _________________________________ (NAME OF PLACE) HOME YOUR HOME.......................................................... A MIDWIFE/TBA HOME...........................................B OTHER HOME ....................................................... C PUBLIC SECTOR HOSPITAL................................................................D HEALTH CENTER.................................................. E HEALTH POST........................................................ F OUTREACH........................................................... .G OTHER PUBLIC___________________.....H (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL ............................................... I PRIVATE CLINIC ..................................................... J OTHER PRIVATE___________________ .. K (SPECIFY) OTHER ____________________..........................X (SPECIFY) 73 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 51 During your pregnancy with (Name), how many months pregnant were you when you first received antenatal care? MONTHS……………………… DON’T KNOW………………….9 52 During your pregnancy with (Name), how many times did you receive antenatal care? TIMES… DON’T KNOW………99 53a As part of your antenatal care during this pregnancy, were any of the following done at least once? A. Was your height taken? B. Was your blood pressure measured? C. Did you give a urine sample? D. Did you give a blood sample? YES NO A. HEIGHT..........................1............................. 2 B. BP......................................1............................. 2 C. URINE.............................1............................. 2 D. BLOOD..........................1............................. 2 53b At any of your antenatal care visits during your pregnancy with (NAME), did you feel abused and mistreated by the health staff at the facility? YES………………………………………….... ....1 NO…………………………………………. ……..2 DON’T KNOW………………………………99  53d  53d 74 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 53c In what ways did the health staff abuse or mistreat you during these antenatal care visits for this pregnancy? DO NOT READ RESPONSES MULTIPLE RESPONSES APPLY STAFF IGNORED HER…………....A STAFF YELLED AT HER…………. B STAFF MADE FUN OF HER………C STAFF INSULTED HER…………….D STAFF TOUCHED HER INAPPROPRIATELY………………..E STAFF SLAPPED OR HIT HER………F OTHER (SPECIFY) …………………G _____________________________ 53d How satisfied were you with the service you received from the health staff during the antenatal care visits? VERY SATISFIED……………………………………. 1 SOMEWHAT SATISFIED……………………………………. .2 NOT SATISFIED……………………………………. .3 75 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 54 During (any of) your antenatal care visits, were you told about the signs of pregnancy complications? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  56  56 55 Were you told where to go if you had any of these complications? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 56 During any of the antenatal visits for your pregnancy with (Name), did anyone talk to you about getting tested for the virus that causes AIDS? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 57 I don’t want to know the results, but were you tested for the virus that causes AIDS as part of your antenatal care? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  59  59 58 As a reminder, I don’t want to know the results, but did you get the results of the test? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 76 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 59 During pregnancy, woman may encounter severe problems or illnesses and should go or be taken immediately to a health facility. What types of symptoms would cause you to seek immediate care at a health facility (right away)? ASK: Anything else? DO NOT READ RESPONSES. RECORD ALL THAT ARE MENTIONED. VAGINAL BLEEDING...............................................A FAST/DIFFICULT BREATHING.............................B FEVER ...........................................................................C SEVERE ABDOMINAL PAIN...................................D HEADACHE/BLURRED VISION............................E CONVULSIONS.........................................................F FOUL SMELLING DISCHARGE/FLUID FROM VAGINA..........................................................G BABY STOPS MOVING ...........................................H LEAKING BROWNISH/GREENISH FLUID FROM THE VAGINA................................................I OTHER……..____________________....................X (SPECIFY) 60 During your pregnancy with (Name) did you receive an injection in the arm to prevent the baby from getting tetanus that is convulsions after birth? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  62  62 61 While pregnant with (name), how many times did you receive such an injection? ONE............................................................................ 1 TWO .......................................................................... 2 THREE OR MORE .................................................. 3 DON’T KNOW ...................................................... 9 62 Did you receive any tetanus toxoid injection at any time before that pregnancy, including during a previous pregnancy or between pregnancies? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  64  64 63 Before the pregnancy with (Name), how many times did you receive a tetanus injection? ONE............................................................................ 1 TWO .......................................................................... 2 THREE OR MORE .................................................. 3 DON’T KNOW ...................................................... 9 77 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 64 During your pregnancy with (Name), were you given or did you buy any iron tablets/syrup? SHOW TABLETS YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 66  66 65 During the whole pregnancy, for how many days did you take the tablets/syrup? IF THE ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. DAYS…………… DON’T KNOW………..999 66 When you were pregnant with (NAME), did you take any drugs in order to prevent you from getting malaria? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  69  69 67 Which drugs did you take to prevent malaria? RECORD ALL METNIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT. SP/FANSIDAR ....................................................... A CHLOROQUINE ..................................................B OTHER___________________________ __.............................................................................. X DON’T KNOW Z  69  69  69 68 How many times did you take SP/Fansidar during this pregnancy? TIMES DON’T KNOW…..98 78 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 69 Who assisted with the delivery of (Name)? Anyone else? PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY. DOCTOR.....................................................................A NURSE...........................................................................B MIDWIFE......................................................................C AUXILIARY MIDWIFE (ENROLE NURSE).........D OTHER HEALTH STAFF WITH MIDWIFERY SKILLS. ................................................E TRAINED TRADITIONAL BIRTH ATTENDANT.............................................................F TRAINED COMMUNITY HEALTH NURSE ......G TRADITIONAL BIRTH ATTENDANT................H COMMUNITY HEALTH WORKER .....................I RELATIVE/FRIEND ....................................................J NO ONE ......................................................................Y 70a Where did you give birth to (Name)? IF BIRTH WAS IN A HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE PLACE AND CIRCLE ONLY ONE ________________________________ (NAME OF PLACE) HOME YOUR HOME.......................................................... A MIDWIFE/TBA HOME...........................................B OTHER HOME ....................................................... C PUBLIC SECTOR HOSPITAL................................................................D HEALTH CENTER.................................................. E HEALTH POST........................................................ F OTHER PUBLIC___________________.....H (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL ............................................... I PRIVATE CLINIC ..................................................... J OTHER PRIVATE___________________ .. K (SPECIFY) OTHER ____________________..........................X (SPECIFY)  71  71  71 79 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 70b During the delivery of (Name) did you feel abused and mistreated by the health staff? YES………………………………………….... ...1 NO…………………………………………… …..2 DON’T KNOW………………………………..9  70d  70d 70c In what ways did the health staff abuse or mistreat you during the delivery of (NAME)? DO NOT READ RESPONSES MULTIPLE RESPONSES APPLY STAFF IGNORED HER…………. A STAFF YELLED AT HER………… B STAFF MADE FUN OF HER…… C STAFF INSULTED HER …………….D STAFF TOUCHED HER INAPPROPRIATELY……….………….E STAFF SLAPPED OR HIT HER………………………………………….. F OTHER (SPECIFY) ……………………G _____________________________ 80 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 70d During the delivery of (Name) how satisfied were you with the service you received from the health staff? VERY SATISFIED……………………………………. 1 SOMEWHAT SATISFIED……………………………………. .2 NOT SATISFIED……………………………………. .3 71 Was a Clean Delivery Kit used during delivery? (SHOW DELIVERY KITS LOCALLY PROMOTED) YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 72 What instrument was used to cut the cord? NEW RAZOR BLADE ......................................................1 NEW AND BOILED RAZOR BLADE ..........................2 USED RAZOR BLADE......................................................3 USED AND BOILED RAZOR BLADE..........................4 NEW SCISSORS ................................................................5 NEW AND BOILED SCISSORS ....................................6 USED SCISSORS................................................................7 USED AND BOILED SCISSORS ...................................8 KNIFE....................................................................................9 REED.................................................................................. 10 OTHER ____________________........................ 97 (SPECIFY) DON’T KNOW ............................................................... 98 73 Was anything placed on the umbilical cord either before or after it was cut? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  75  75 81 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 74 What was placed on the cut cord? COW DUNG........................................................... 1 ANY TYPE OF OIL................................................. 2 ANTISEPTIC............................................................. 3 ASH............................................................................. 4 CHALK....................................................................... 5 CHARCOAL POWDER........................................ 6 OTHER _____________________________ ... .97 (SPECIFY) 75 Was (NAME) dried (wiped) immediately after birth before the placenta was delivered? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 76 Was (NAME) wrapped in a warm cloth or blanket immediately after birth before the placenta was delivered? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 77 Immediately after (NAME) was born, before the placenta was delivered, did you receive an injection to prevent you from bleeding too much? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 78 Did the care provider or a traditional birth attendant hold your stomach and pull on the cord to help the placenta come out? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 79 Immediately after the placenta was delivered, did someone massage your uterus to make it contract strongly and to prevent you from bleeding too much? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 82 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 80 When labor sets in, once contractions start, a woman may encounter severe problems or illnesses and should go or be taken immediately to a health facility. While having contractions during the time that labor sets in, what types of symptoms would cause you to seek immediate care at a health facility (right away)? ASK: Anything else? DO NOT READ RESPONSES. RECORD ALL THAT ARE MENTIONED. CONVULSIONS.........................................................A HIGH FEVER................................................................B HEAVY BLEEDING....................................................C FAST/DIFFICULT BREATHING.............................D RETAINED PLACENTA...........................................E HEADACHE/BLURRED VISION............................F PROLONGED LABOUR..........................................G OTHER.....................................................................................X ____________________ (SPECIFY) 81 In the first hour after delivery, was (NAME) given eye ointment or drops in his/her eyes? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 82a Was (NAME) weighed at birth? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  83  83 82b How much did (NAME) weigh? RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE. KG FROM CARD . KG FROM RECALL . DON'T KNOW 99.998 . The following questions refer to the mother after the delivery of her youngest child 83 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 83 Did a health care provider or a traditional birth attendant check on your health after the delivery of your youngest child, either at a health facility, home or other location? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  85a  85a 84 How long after the delivery did the first check take place? IF LESS THAN ONE DAY, CIRCLE 0 AND RECORD HOURS; IF LESS THAN ONE WEEK CIRCLE 1 AND RECORD DAYS; IF MORE THAN 6 DAYS CIRCLE 2 AND RECORD WEEKS. HOURS 0 LESS THAN 1 HOUR = 00 DAYS 1 WEEKS 2 DON’T KNOW……………..…99 85a Who checked your health at that time? Anyone else? PROBE FOR THE MOST QUALIFIED PERSON AND RECORD ONLY ONE DOCTOR.....................................................................A NURSE...........................................................................B MIDWIFE......................................................................C AUXILIARY MIDWIFE (ENROLE NURSE).........D OTHER HEALTH STAFF WITH MIDWIFERY SKILLS. ................................................E TRAINED TRADITIONAL BIRTH ATTENDANT.............................................................F TRAINED COMMUNITY HEALTH NURSE ......G TRADITIONAL BIRTH ATTENDANT................H COMMUNITY HEALTH WORKER .....................I RELATIVE/FRIEND ....................................................J NO ONE ......................................................................Y 85b Did you feel abused or mistreated by the health staff who checked on you after the birth of (NAME)? YES………………………………………….... 1 NO…………………………………………… ..2 DON’T KNOW………………………………..9 85d 85d 84 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 85c In what ways did the health staff abuse or mistreat when they checked on you after the birth of (NAME)? DO NOT READ RESPONSES MULTIPLE RESPONSES APPLY STAFF IGNORED HER……………. A STAFF YELLED AT HER………… B STAFF MADE FUN OF HER……… C STAFF INSULTED HER ……………..D STAFF TOUCHED HER INAPPROPRIATELY……………. E STAFF SLAPPED HER………………………………. F OTHER………………………………..G _____________________________ 85d How satisfied were you with the service you received from the health staff when they visited you after the birth of (NAME)? VERY SATISFIED……………………………………. 1 SOMEWHAT SATISFIED……………………………………. .2 NOT SATISFIED……………………………………. .3 85e In the first two months after delivery of (Name), did you receive a vitamin A dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS. YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 85 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 86 Sometimes mothers after delivery have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to go to a health facility right away? ASK: Anything else? DO NOT READ RESPONSES. RECORD ALL THAT ARE MENTIONED. EXCESSIVE VAGINAL BLEEDING .......................A FAST/DIFFICULT BREATHING ............................B HIGH FEVER................................................................C SEVERE ABDOMINAL PAIN...................................D SEVERE HEADACHE/BLURRED VISION............E CONVULSIONS/LOSS OF CONSCIOUSNESS ....................................................F FOUL-SMELLING DISCHARGE FROM THE VAGINA........................................................................G PAIN IN CALF ............................................................H VERBALIZATION/BEHAVIOR THAT INDICATES SHE MAY HURT HERSELF OR THE BABY....................................................................I OTHER _______________________ ............X (SPECIFY) The following questions refer to the youngest child shortly after birth 87 After (Name) was born, did any health care provider or traditional birth attendant check on (Name’s) health? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  90  90 88 How many hours, days or weeks after the birth of (Name) did the first check take place? IF LESS THAN ONE DAY, CIRCLE 0 AND RECORD HOURS; IF ONE TO SIX DAYS CIRCLE 1 AND RECORD DAYS; IF MORE THAN 6 DAYS CIRCLE 2 AND RECORD WEEKS. HOURS 0 DAYS 1 WEEKS 2 DON’T KNOW……………..…99 86 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 89 Who checked on (Name’s) health at that time? Anyone else? PROBE FOR THE MOST QUALIFIED PERSON AND RECORD ALL MENTIONED. DOCTOR.....................................................................A NURSE...........................................................................B MIDWIFE......................................................................C AUXILIARY MIDWIFE (ENROLE NURSE).........D OTHER HEALTH STAFF WITH MIDWIFERY SKILLS. ................................................E TRAINED TRADITIONAL BIRTH ATTENDANT.............................................................F TRAINED COMMUNITY HEALTH NURSE ......G TRADITIONAL BIRTH ATTENDANT................H COMMUNITY HEALTH WORKER .....................I RELATIVE/FRIEND ....................................................J NO ONE ......................................................................Y 90 Sometimes newborns, within the first month of life, have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your newborn to a health facility right away? ASK: Anything else? DO NOT READ RESPONSES. RECORD ALL THAT ARE MENTIONED. CONVULSIONS ........................................................A FEVER ...........................................................................B POOR SUCKLING OR FEEDING .......................C FAST/DIFFICULT BREATHING ............................D BABY FEELS COLD ..................................................E BABY TOO SMALL/TOO EARLY ........................F YELLOW PALMS/SOLES/EYES ..............................G SWOLLEN ABDOMEN ..........................................H UNCONSCIOUS ....................................................... I PUS OR REDNESS OF THE UMBILICAL STUMP, EYES OR SKIN .....................................................................J OTHER ____________________ ............................X (SPECIFY) 87 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 91 What kind of preparations did you make before the birth of (NAME)? Anything else? RECORD ALL MENTIONED SAVED MONEY .........................................................A BOUGHT CLEAN DELIVERY KIT........................B FOUND BLOOD DONOR ....................................C ARRANGED OF TRANSPORT .............................D CONTACTED HEALTH WORKER TO HELP WITH DELIVERY............................................E OTHER ____________________..............................X (SPECIFY) NO PREPARATION..................................................Y NUTRITION Breastfeeding/ Infant and Young Child Feeding 92 Did you ever breastfeed (NAME)? YES.......................................................................................1 NO........................................................................................2 DON’T KNOW................................................................9  99  99 93 How long after birth did you first put (NAME) to the breast? IF LESS THAN 1 HOUR, RECORD ‘00’ HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS. IMMEDIATE .........................................................00 HOURS……………………. DAYS……………………… DON’T REMEMBER ..........................................99 94 During the first three days after delivery, did you give (NAME) the liquid (Colostrum) that came from your breasts? YES ............................................................................1 NO ............................................................................2 DON’T KNOW ......................................................9 95 In the first three days after delivery, was (NAME) given anything to drink other than breast milk? YES ............................................................................1 NO ............................................................................2 DON’T KNOW ......................................................9  97  97 96 What was (NAME) given to drink? Anything else? DO NOT READ THE LIST RECORD ALL MENTIONED BY CIRCLING LETTER FOR EACH ONE MENTIONED MILK (OTHER THAN BREASTMILK) ............A PLAIN WATER .......................................................B SUGAR OR GLUCOSE WATER.........................C GRIPE WATER .......................................................D SUGAR-SALT-WATER SOLUTION ..................E FRUIT JUICE ...........................................................F INFANT FORUMULA ...........................................G TEA / INFUSIONS ................................................H HONEY ....................................................................I OTHER (SPECIFY) _____________ ...........X 88 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 97 Are you still breastfeeding (NAME)? YES.........................................................................................1 NO..........................................................................................2 DON’T KNOW..................................................................9  99 98 For how many months did you breastfeed (NAME)? IF LESS THAN ONE MONTH, RECORD “00” MONTHS. MONTHS 99 Did (NAME) drink anything from a bottle with a nipple yesterday or last night? YES.......................................................................................1 NO........................................................................................2 DON’T KNOW................................................................9 100 Now I would like to ask you about liquids or foods (NAME) had yesterday during the day or at night. Did (NAME) drink/eat: READ THE LIST OF LIQUIDS (A THROUGH E, STARTING WITH “BREAST MILK”). YES NO DK A. Breast milk? ………......…1 2 9 B. Plain water? ………......…1 2 9 C. Commercially produced infant formula? ………......…1 2 9 D. Any fortified, commercially available infant and young child food” [e.g. Cerelac]? ………......…1 2 9 E. Any (other) porridge or gruel? ………......…1 2 9 101 Now I would like to ask you about (other) liquids or foods that (NAME) may have had yesterday during the day or at night. I am interested in whether your child had the item even if it was combined with other foods. Did (NAME) drink/eat: PLEASE FILL OUT THE FOLLOWING TABLE WITH THE ANSWERS TO THE QUESTIONS BELOW: GROUP 1:DAIRY YES NO DK A. CHECK Q.100C – IF YES, CIRCLE YES HERE Commercially produced infant formula? ……………………1 2 9 B. Milk such as tinned, powdered, or fresh animal milk? ……………………1 2 9 C. Cheese, yogurt, or other milk products? ……………………1 2 9 89 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP GROUP 2: GRAIN YES NO DK D. CHECK Q.100D – IF YES, CIRCLE YES HERE Any fortified, commercially available infant and young Child food (e.g. Cerelac)? ……………………1 2 9 E. CHECK Q.100E – IF YES, CIRCLE YES HERE Any (other) porridge or gruel? ……………………1 2 9 F. Bread, rice, noodles, or other foods made from grains? ……………………1 2 9 G. White potatoes, white yams, manioc, cassava, or any other foods made from roots? ……………………1 2 9 GROUP 3: VITAMIN A RICH VEGETABLES YES NO DK H. Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside? ……………………1 2 9 I. Any dark green leafy vegetables? ……………………1 2 9 J. Ripe mangoes, papayas or (INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS)? ……………………1 2 9 K. Foods made with red palm oil, palm nut, palm nut pulp sauce? ……………………1 2 9 GROUP 4: OTHER FRUITS/VEGETABLES YES NO DK L. Any other fruits or vegetables like oranges, grapefruit or pineapple? ……………………1 2 9 GROUP 5: EGGS YES NO DK M. Eggs? ……………………1 2 9 GROUP 6: MEAT, POULTRY, FISH YES NO DK N. Liver, kidney, heart or other organ meats? ……………………1 2 9 O. Any meat, such as beef, pork, lamb, goat, chicken, or duck? ……………………1 2 9 P. Fresh or dried fish or shellfish? ……………………1 2 9 Q. Grubs, snails, insects, other small protein food? ……………………1 2 9 GROUP 7: LEGUMES/NUTS YES NO DK 90 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP R. Any foods made from beans, peas, lentils, or nuts? ……………………1 2 9 GROUP 8: OILS/FATS YES NO DK S. Any oils, fats, or butter, or foods made with any of these? ……………………1 2 9 T. CHECK 101A – 101S: HOW MANY FOOD GROUPS (GROUPS 1-8 IN ABOVE TABLE) HAVE AT LEAST 1 ‘YES’ CIRCLED? Number of Group GROUP 9: OTHER FOODS YES NO DK U. Tea or coffee? ……………………1 2 9 V. Any other liquids? ……………………1 2 9 W. Any sugary foods, such as chocolates, candy, sweets, pastries, cakes, or biscuits? ……………………1 2 9 X. Any other solid or soft food? ……………………1 2 9 102 How many times did (NAME) eat solid, semi-solid, or soft foods other than liquids yesterday during the day or at night? IF CAREGIVER ANSWERS SEVEN OR MORE TIMES, RECORD “7” WE WANT TO FIND OUT HOW MANY TIMES THE CHILD ATE ENOUGH TO BE FULL. SMALL SNACKS AND SMALL FEEDS SUCH AS ONE OR TWO BITES OF MOTHER’S OR SISTER’S FOOD SHOULD NOT BE COUNTED. LIQUIDS DO NOT COUNT FOR THIS QUESTION. DO NOT INCLUDE THIN SOUPS OR BROTH, WATERY GRUELS, OR ANY OTHER LIQUID. USE PROBING QUESTIONS TO HELP THE RESPONDENT REMEMBER ALL THE TIMES THE CHILD ATE YESTERDAY NUMBER OF TIMES DON’T KNOW………9 Vitamin A Supplementation 103 Has (Name) ever received a Vitamin A dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9  105  105 91 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 104 Did (Name) receive a Vitamin A dose within the last 6 months? YES .......................................................................................1 NO........................................................................................2 DON’T KNOW ................................................................9 105 We would like to check whether the salt used in your household is iodized. May I take a sample of the salt used to cook the main meal eaten by members of your household last night? ONCE YOU HAVE EXAMINED THE SALT, CIRCLE NUMBER THAT CORRESPONDS TO THE TEST OUTCOME NOT IODIZED (0 PPM)................................................1 LESS THAN 15 PPM......................................................2 15 PPM OR MORE.........................................................3 NO SALT IN HOME.......................................................4 SALT NOT TESTED........................................................5 Anthropometrics 106 Apart from (Name), how many children that are under the age of five years live in this household? NONE .................................................................................0 MORE THAN 0 WRITE DOWN NUMBER  108 107 How many of those children did you give birth to? NONE .................................................................................0 WRITE DOWN THE NUMBER  108 108 Now I would like to weigh and measure (Name) and your other children younger than five years old. May I weigh and measure (Name) and the other children? YES .......................................................................................1 NO........................................................................................2  END 92 BELOW, WRITE DOWN (NAME)’S NAME, SEX AND DATE OF BIRTH. THEN ASK FOR (AND WRITE DOWN) THE NAMES, AGE AND SEXS FOR ALL OF THE MOTHER’S OTHER BIOLOGICAL CHILDREN UNDER 5 YEARS OF AGE THAT LIVE WITH HER AND ARE PRESENT TODAY: ASK: Can you give me the name, sex and birth date of the child that was born just before (NAME)? WRITE DOWN BELOW AND ASK: Can you give me the name, sex and birth date of the child that was born just before this child? ASK THE SAME QUESTION TILL THE NEXT CHILD IS 5 YEARS OR OLDER FROM THE FIRST PAGE OF THE QUESTIONNAIRE COPY THE IDENTIFICATION INFORMATION TO THE FIELDS BELOW AND SEND THIS PAGE ONLY WITH THE MOTHER AND CHILDREN TO THE CENTRAL ANTROPOMETRY SITE. IDENTIFICATION CLUSTER NUMBER HOUSEHOLD NUMBER RECORD NUMBER 109 NAME SEX M/F Date of Birth DD/MM/YYYY WEIGHT IN KILOGRAMS HEIGHT (CM) ##.# How Measured 1 = Lying Down 2 = Standing Up 1 ___/___/_____ _ 2 ___/___/_____ _ 3 ___/___/_____ _ 4 ___/___/_____ _ 93 Annex 2: Rapid CATCH Indicators Maternal and Newborn Care 1. Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child 2. Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid before the birth of the youngest child 3. Percentage of children age 0-23 months whose births were attended by skilled personnel 4. Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after birth 5. Percentage of mothers of children age 0-23 months who are using a modern contraceptive method Breastfeeding and Infant and Young Child Feeding 6. Percentage of children age 0-5 months who were exclusively given breast milk the day prior to the interview 7. Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices Vitamin A Supplementation 8. Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall Immunization 9. Percent of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 10. Percent of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 11. Percent of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey Malaria 12. Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 13. Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night Control of Diarrhea 14. Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 94 Acute Respiratory Infections 15. Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Water and Sanitation 16. Percentage of households of children age 0-23 months that treat water effectively 17. Percentage of mothers of children age 0-23 months who live in a household with soap at the place for hand washing Anthropometrics 18. Percentage of children age 0-23 months who are underweight (-2SD for the median weight for age, according to WHO/NCHS reference population) 95 Annex 3: Complete Indicator list Maternal Newborn Care Antenatal Care (Rapid-CATCH indicator) Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child Tetanus Toxoid (Rapid-CATCH indicator) Percentage of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child Skilled Birth Attendant (Rapid-CATCH indicator) Percentage of children age 0-23 months whose births were attended by skilled personnel Post-Natal Visit to Check on the Newborn (Rapid-CATCH indicator) Percentage of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within two days after birth Current Contraceptive Use Among Mothers of Young Children (Rapid-CATCH indicator) Percentage of mothers of children age 0-23 months who are using a modern contraceptive method IPT during Pregnancy (MNC key indicator) Percentage of mothers of children age 0-23 months who received Intermittent Preventive Treatment (IPT) for malaria during the pregnancy with the youngest child Clean Cord Cutting (MNC key indicator) Percent children age 0-23 months that had clean cord cutting at the time of birth Active Management of the third stage of labor (AMTSL) (MNC key indicator) Percent of mothers of children age 0-23 months who received AMTSL after the birth of her youngest child Post-Partum visit for the mother (MNC key indicator) Percentage of mothers of children age 0-23 who received a post-partum visit from an appropriate trained health worker within two days after the birth of the youngest child Thermal Care (Immediate drying and wrapping) (MNC key indicator) Percentage of children age 0-23 months who were dried and wrapped with a cloth or blanket immediately after birth Immediate breastfeeding of newborns (MNC key indicator) Percentage of children age 0-23 months who were put to the breast within one hour of delivery Knowledge of Healthy Timing and Spacing of Pregnancies Percentage of mothers of children age 0-23 months who know that a woman should wait 24 months after the live birth of her child before trying to get pregnant again. Knowledge of Risk Associated with Birth to Pregnancy Intervals Less than 24 Months Percentage of mothers of children age 0-23 months who know at least two risks of having a birth to pregnancy interval of less than 24 months. Quality Antenatal Care Percentage of mothers of children age 0-23 months who had four or more antenatal visits with a skilled provider and were adequately counseled when they were pregnant with the youngest child. Iron Tablets for Pregnant Women Percentage of mothers of children age 0-23 months who took iron tablets before the birth of their youngest child. Knowledge of MTCT of HIV Percentage of mothers of children age 0-23 months who know that HIV can be transmitted from an HIV-positive mother to her unborn child during pregnancy, 96 during delivery, and through breastfeeding. Knowledge of PMTCT of HIV Percentage mothers of children age 0-23 months who know that there are special medications that can be given to a pregnant woman infected with HIV to reduce the risk of mother-to-child transmission. HIV Testing During Pregnancy Percentage of mothers of children 0-23 months who were counseled about HIV during the pregnancy, accepted an offer of testing, and received their test results when they were pregnant with their youngest child. Knowledge of Danger Signs during Pregnancy Percentage of mothers of children 0-23 months who knew at least two danger signs during pregnancy. Knowledge of Maternal Danger Signs During Delivery Percentage of mothers of children 0-23 months who know at least two danger signs during delivery. Knowledge of Post-partum Danger Signs Percentage of mothers of children age 0-23 months who knew at least two post￾partum danger signs. Knowledge of Neonatal Danger Signs Percentage of mothers of children age 0-23 who know at least two neonatal danger signs. Trained Delivery Attendant Percent of children age 0-23 months whose births were attended by a trained provider including a trained TBA. Clean Birth Kit Percentage of women of children age 0-23 months who used a clean delivery kit during the birth of their youngest child. Immediate Drying Percent of children age 0-23 months who were dried immediately after birth. Immediate Wrapping Percentage of children age 0-23 months, who were wrapped with a cloth or blanket immediately after birth. Essential Newborn Care Percentage of children age 0-23 who received all three elements of essential newborn care: thermal protection immediately after birth, clean cord care, and immediate and exclusive breastfeeding. Clean Cord Care Percent children age 0-23 months that had clean cord care at the time of birth. Feeding Colostrum Percentage of children age 0-23 months, who were fed colostrum after birth. Pre-lacteal Feeds Percentage of children age 0-23 months who did not receive pre-lacteal feeds. Prophylactic Eye Care Percentage of children age 0-23 months who received appropriate preventive eye care within the first hour after birth. Birth Preparedness Percentage of mothers of children 0-23 months who made preparations before the birth of the their youngest child Nutrition Underweight (Rapid-CATCH indicator) Percentage of children age 0-23 months who are underweight (-SD for the median weight for age, according to WHO/NCHS reference population) Exclusive Breastfeeding (Rapid-CATCH indicator) Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Infant and Young Child Feeding (Rapid-CATCH indicator) Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices Vitamin A Supplementation (Rapid-CATCH indicator) Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall Ever breastfed Percent of children aged 0-23 months ever breastfed Continued breastfeeding 6-11 months Percent of children aged 6-11 months who are still breastfeeding Continued breastfeeding 12-17 months Percent of children aged 12-17 months who are still breastfeeding 97 Continued breastfeeding 18-23 months Percent of children aged 18-23 months who are still breastfeeding Bottle use Percent of children aged 0-23 months who had anything by bottle in the 24 hours preceding survey Iodized Salt Percentage of households with Iodized salt (tested as 15 ppm or more) the day of the study Vitamin A Supplementation Mother Percentage of mothers of children age 6-23 months who received a dose of Vitamin A in the first 2 months after delivery - reported Vitamin A-rich food 6-23 months Percent of children aged 6-23 months who ate vitamin A-rich foods in 24 hours preceding survey Iron-rich food 6-23 months Percent of children aged 6-23 months who ate iron-rich foods in 24 hours preceding survey Fortified food 6-23 months Percent of children aged 6-23 months who ate fortified food in 24 hours preceding survey Animal source flesh food 6-23 months Percent of children aged 6-23 months who ate beef, game, poultry, fish, shellfish, or organ meat in 24 hours preceding survey Egg 6-23 months Percent of children aged 6-23 months who ate eggs in 24 hours preceding survey Dairy 6-23 months Percent of children aged 6-23 months who had dairy in 24 hours preceding survey Malaria ITN Use (Rapid-CATCH indicator) Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night Treatment of Fever in Malarious Zones (Rapid-CATCH indicator) Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours ITN Ownership (Malaria key indicator) Percentage of households of children age 0-23 months that own at least one insecticide-treated bed net IPT during pregnancy (Key indicator) Percentage of mothers of children age 0-23 months who received Intermittent Preventive Treatment (IPT) for malaria during the pregnancy with the youngest child 98 Annex 4: Indicator Tabulation Plan Rapid CATCH Tabulation Plan Indicator How to Calculate the Indicator Antenatal Care Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child Number of mothers of children age 0-23 months who had at least four antenatal visits while pregnant with their youngest child (Q49= A, B, or C) AND (Q52 ≥ 4 AND Q52 < 98 ) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen anc=1 if (q52>=4 & q52<98) & (q49a==1|q49b==1|q49c==1) replace anc=2 if mi(anc) lab val anc yesno lab var anc "Antenatal Care" ta anc Tetanus Toxoid Percentage of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child Number of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child (Q61 + Q63 >=2) AND (Q61<> 9 AND Q63 <> 9) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear replace q61=0 if q61==9 replace q61=0 if q61==. replace q63=0 if q63==9 replace q63=0 if q63==. gen tetanus=1 if (q61+q63)>=2 replace tetanus=2 if mi(tetanus) lab val tetanus yesno lab var tetanus "Tetanus injection" ta tetanus Skilled Birth Attendant Percentage of children age 0-23 months whose births were attended by skilled personnel Number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife or auxiliary midwife (Q69 = A, B , C or D,E) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen skillbir=1 if q69a==1 | q69b==1 | q69c==1 | q69d==1 | q69e==1 replace skillbir=2 if mi(skillbir) lab val skillbir yesno lab var skillbir "Skilled Birth Attendant" ta skillbir 99 Post-Natal Visit to Check on the Newborn Percentage of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within two days after birth Number of children age 0-23 months who received a post-natal visit (Q87=1) AND within two days after birth (Q88a = 0) or (Q88a= 1 and (Q88b <= 2)) AND by an appropriate health worker (Q89= A, B , C, D,E,F,G) ____________________________________________ Total number of children age 0-23 months in the survey U refers to the units of time (hours, days, weeks) and N refers to the corresponding number (Q80U=0 and Q80N=12 means 12 hours) x 100 use crsfinal, clear gen check24=1 if q88a==0 & q88b!=. replace check24=1 if q88a==1 & q88b<=2 gen postncheck=1 if q87==1 & check24==1 & (q89a==1 | q89b==1 | q89c==1 | q89d==1 | q89e==1 | q89f==1 | q89g==1) replace postncheck=2 if mi(postncheck) lab val postncheck yesno lab var postncheck "Post-Natal Visit to Check on the Newborn" ta postncheck Current Contraceptive Use Among Mothers of Young Children Percentage of mothers of children age 0-23 months who are using a modern contraceptive method Note: This indicator is not comparable to the DHS or Flex Fund’s contraceptive use indicator Number of mothers of children age 0-23 months who are using a modern method of contraception (Q45 = 1) AND (Q46 = 1 - 12) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen contraceptive=1 if q45==1 & q46>=1 & q46<=12 replace contraceptive=2 if mi(contraceptive) lab val contraceptive yesno lab var contraceptive "Current Contraceptive Use Among Mothers of Young Children" ta contraceptive 100 Exclusive Breastfeeding Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours NOTE: If any answers to Q14 or Q15 are coded as Don’t Know (9) or Missing (Blank) then the entire case should not be included in the numerator and denominator Number of children age 0-5 months who drank breast milk in the previous 24 hours (Q100A= 1) AND Did not drink any other liquids in the previous 24 hours (Q100B<> 2 and Q100C<> 2 and Q100D<>2, and Q100E<> 2) AND Was not given any other foods or liquids in the previous 24 hours (Q101T=0 AND Q101U=2 and Q101V=2 and Q101W=2 and Q101X=2) ____________________________________________ Total number of children age 0-5 months in the survey x 100 use crsfinal, clear gen agem=int((dint-q10young)/30) keep if agem<6 gen excbf=1 if q100milk==1 & q100wat==2 & q100form==2 & q100food==2 & q100por==2 & q101t==0 & q101u==2 & q101v==2 & q101w==2 & q101x==2 replace excbf=2 if mi(excbf) lab val excbf yesno lab var excbf "Exclusive breastfeeding" ta excbf Infant and Young Child Feeding Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices use crsfinal, clear keep if int((dint-q10young)/30)>5.99 & int((dint￾q10young)/30)<24 gen iycf=1 if q100milk==1 & (q100form==1 | q100food==1 | q100por==1 | q101w==1 | q101x==1) replace iycf=2 if mi(iycf) ta iycf Vitamin A Supplementation Percentage of children age 6 -23 months who receive a dose of vitamin A in the last 6 months: card verified or mother’s recall months who received a dose of Vitamin A in the last 6 months [(Q101=1) AND (Q104=1)] OR [(Q15=1) AND (Q11Vitamin A Month <> 99 AND Q11Vitamin A Year <> 9999) AND (Date of Interview - Date of VitaminA<=6 months)] ____________________________________________ Total number of children age 6-23 months in the survey x 100 use crsfinal, clear keep if int((dint-q10young)/30)>=6 & int((dint-q10young)/30)<24 gen vita=1 if (q103==1 & q104==1) | ((q15==1 & !mi(vitama)) & (dint-vitama)/30.4<=6) replace vita=2 if mi(vita) lab val vita yesno lab var vita "Vitamin A Supplementation" ta vita 101 Measles Vaccination Percentage of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey Number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card (Q15=1) AND (Q16MM <> 99 AND Q16MY <> 9999) OR recalled by the mother (Q15 = 1) ____________________________________________ Total number of children age 12-23 months in the survey x 100 use crsfinal, clear keep if int((dint-q10young)/30)>=12 & int((dint-q10young)/30)<24 gen mv=1 if (q15==1 & !mi(meas9)) replace mv=1 if q20==1 replace mv=2 if mi(mv) lab val mv yesno lab var mv "Measles Vaccination" ta mv Access to Immunization Services Percentage of children aged 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey Number of children who received DTP1 at the time of the survey according to the vaccination card/child health booklet [(Q15=1) AND (Q16DTP1M <> 99 AND Q16DTP1Y <> 9999)] OR mother’s recall [(Q18=1) AND (Q19>=1)] __________________________________________ Total number of children age 12-23 months in the survey x 100 use crsfinal, clear keep if int((dint-q10young)/30)>11.99 & int((dint-q10young)/30)<24 gen dpt1=1 if (q15==1 & !mi(penta1)) replace dpt1=1 if q18==1 & q19>=1 replace dpt1=2 if mi(dpt1) lab val dpt1 yesno lab var dpt1 "Access to Immunization Services" ta dpt1 Health Systems Performance Regarding Immunization Services Percentage of children aged 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey Number of children who received DTP3 at the time of the survey as verified by vaccination card or child health booklet (Q15=1) AND (Q16DTP3M <> 99 AND Q16DTP3Y <> 9999) OR Recalled by the mother [(Q18=1) AND (Q19>=3)] ____________________________________________ Total number of children age 12-23 months in the survey x 100 use crsfinal, clear keep if int((dint-q10young)/30)>11.99 & int((dint-q10young)/30)<24 gen dpt3=1 if (q15==1 & !mi(penta3)) replace dpt3=1 if q18==1 & q19>=3 replace dpt3=2 if mi(dpt3) lab val dpt3 yesno lab var dpt3 "Health Systems Performance Regarding Immunization Services" ta dpt3 102 Treatment of Fever in Malarious Zones Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began Number of children age 0-23 months with a febrile episode during the last two weeks (Q21 = 1) AND who sought treatment within 24 hours (Q22=1) AND (Q23 = 0 OR Q23=1) AND Was treated with an appropriate anti-malarial drug (Q24 = 1) AND ( (Q25A <= 1or Q25B <= 1 or Q25C <= 1 or Q25D <=1 or Q25E <=1)) ___________________________________________ Total number of children age 0-23 months with a febrile episode in the last two weeks (Q16 = 1) x 100 use crsfinal, clear gen fever=1 if q21==1 & q22==1 & (q23==0 | q23==1) & q24==1 & (q25a==1 | q25b==1 | q25c==1 | q25d==1 | q25e==1) replace fever=2 if mi(fever) & q21==1 lab val fever yesno lab var fever "Treatment of Fever in Malarious Zones" ta fever ORT Use Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution and/or recommended home fluids Number of children age 0-23 months with diarrhea in the last two weeks (Q26 = 1) AND who received oral rehydration solution (ORS) and/or recommended home fluids (Q27A = 1 or Q27B = 1 ____________________________________________ Total number of children age 0-23 months who had diarrhea in the last two weeks (Q26=1) x 100 use crsfinal, clear gen ort=1 if q26==1 & (q27a==1 | q27b==1) replace ort=2 if mi(ort) & q26==1 lab val ort yesno lab var ort "ORT Use" ta ort 103 Appropriate Care Seeking for Pneumonia Percentage of children age 0-23 months with chest￾related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Number of children age 0-23 months with chest-related cough and difficult breathing in the last two weeks (Q28=1) AND (Q30= 1) AND who were taken to an appropriate health provider (Q30=1) AND (Q31 = A,B,C, or D) ____________________________________________ Total number of children age 0-23 months with chest-related cough in the last two weeks (Q23=1) AND (Q24= 1) x 100 use crsfinal, clear gen pnemo=1 if q28==1 & q29==1 & q30==1 & (q31a==1 | q31b==1 | q31c==1 | q31d==1) replace pnemo=2 if mi(pnemo) & q28==1 & q29==1 lab val pnemo yesno lab var pnemo "Appropriate Care Seeking for Pneumonia" ta pnemo Point of Use Water Treatment Percentage of households of children age 0-23 months that treat water effectively Number of households of mothers of children age 0-23 months that treat water effectively (Q33=1) AND (Q34= C, D, E or F) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen treatwat=1 if q33==1 & q34=="C" replace treatwat=2 if mi(treatwat) & q33==1 lab val treatwat yesno lab var treatwat "Point of Use Water Treatment" ta treatwat Appropriate Hand Washing Practices Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Number of mothers of children age 0-23 months who live in households with soap at the place for hand washing (Q35 <=4) AND (Q36<=2)) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen handwash=1 if q35<=4 & q36<=2 replace handwash=2 if mi(handwash) lab val handwash yesno lab var handwash "Appropriate Hand Washing Practices" ta handwash 104 ITN Use Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night Number of children age 0-23 months who slept under an insecticide￾treated bed net the previous night ((Q37 =1) AND (Q38 =1)) AND (Q39 <= 3) OR ((Q39 > 3 and Q39 <> 9) AND (Q40=1) AND (Q31 <=6)) ___________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen netuse=1 if q37==1 & q38==1 & q39<=3 replace netuse=1 if q38==1 & q39==5 & q40==1 & q41<=6 replace netuse=2 if mi(netuse) lab val netuse yesno lab var netuse "ITN Use" ta netuse Underweight Percentage of children age 0-23 months who are underweight (-SD for the median weight for age, according to WHO/NCHS reference population) Number of children age 0-23 months with weight/age -2 SD for median weight for age, according to WHO/NCHS reference population (Q45= 1) AND (Kilograms ≤ -2 SD for median weight for age) ___________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen underw=1 if waz<-2 replace underw=2 if waz>=-2 & waz!=. lab val underw yesno lab var underw "Underweight" ta underw ITN Ownership: Percentage of households of children age 0-23 months that own at least one insecticide-treated bed net Number of households of children age 0-23 months that own at least one insecticide-treated bed net (Q37=>1) AND (Q38=1 or 2 or 3) OR (Q39=5 AND Q41<7) ___________________________________________ Number of households with children age 0-23 months in the survey X 100 use crsfinal, clear use crsfinal, clear gen itnown=1 if q37==1 & (q39<=3) replace itnown=1 if (q39==5 & q41<7) replace itnown=2 if mi(itnown) lab val itnown yesno lab var itnown "ITN Ownership" ta itnown 105 Maternal Newborn Care Tabulation Plan Indicator How to Calculate the Indicator Knowledge of Healthy Timing and Spacing of Pregnancies Percentage of mothers of children age 0- 23 months who know that a woman should wait 24 months after the live birth of her child before trying to get pregnant again. Number mothers of children age 0-23 months who know a woman should wait at least 2 years and less than 5 years before trying to become pregnant again (Q42=2) ____________________________________________ Number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen binterval=1 if q42==2 replace binterval=2 if mi(binterval) lab val binterval yesno lab var binterval "Knowledge of Healthy Timing and Spacing of Pregnancies" ta binterval Knowledge of Risk Associated with Birth to Pregnancy Intervals Less than 24 Months Percentage of mothers of children age 0- 23 months who know at least two risks of having a birth to pregnancy interval of less than 24 months. Number of mothers of children age 0-23 months who know at least two risks associated with having a birth to pregnancy interval of less than 24 months (Q43= any two responses A-E) _________________________________________ Number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear foreach var of varlist q43b q43c q43d q43d q43e q43f{ replace `var'=0 if `var'==2 } gen totalrisk=q43b+q43c+q43d+q43e+q43f gen intervalrisk=1 if totalrisk>=2 replace intervalrisk=2 if mi(intervalrisk) lab val intervalrisk yesno lab var intervalrisk "Knowledge of Risk Associated with Birth to Pregnancy Intervals Less than 24 Months" ta intervalrisk Current Contraceptive Use Among Mothers of Young Children Percentage of mothers of children age 0- 23 months who are using a modern contraceptive method This indicator is not comparable to the DHS or Flex Fund’s contraceptive use indicator Number of mothers of children age 0-23 months who are using a modern method of contraception (Q45 = 1) AND (Q46 = 1 - 12) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 106 use crsfinal, clear gen contraceptive=1 if q45==1 & q46>0 & q46<=12 replace contraceptive=2 if mi(contraceptive) lab val contraceptive yesno lab var contraceptive "Current Contraceptive Use Among Mothers of Young Children" ta contraceptive Knowledge of MTCT of HIV Percentage of mothers of children age 0- 23 months who know that HIV can be transmitted from an HIV-positive mother to her unborn child during pregnancy, during delivery, and through breastfeeding. Number of mothers of children age 0-23 months who know that HIV can be transmitted from an HIV-positive mother to her unborn child during pregnancy AND During delivery AND Through breastfeeding (Q47A = 1 AND Q47B =1 AND Q47C = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen mtct=1 if q47a==1 & q47b==1 & q47c==1 replace mtct=2 if mi(mtct) lab val mtct yesno lab var mtct "Knowledge of MTCT of HIV" ta mtct Knowledge of PMTCT of HIV Percentage mothers of children age 0-23 months who know that there are special medications that can be given to a pregnant woman infected with HIV to reduce the risk of mother-to-child transmission. Number of mothers of children age 0-23 months who know that there is a special medication that can be given to a pregnant women infected with HIV to reduce the risk of mother-to-child transmission (Q48 = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen pmct=1 if q48==1 replace pmct=2 if mi(pmct) lab val pmct yesno lab var pmct "Knowledge of PMTCT of HIV" ta pmct Antenatal Care Percentage of mothers of children age 0- 23 months who had four or more antenatal visits when they were pregnant with the youngest child. Number of mothers of children age 0-23 months who had at least four antenatal visits while pregnant with their youngest child (Q49= A, B, or C) AND (Q52 ≥ 4 AND Q52 < 98 ) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 See CATCH 107 Quality Antenatal Care Percentage of mothers of children age 0- 23 months who had four or more antenatal visits with a skilled provider and were adequately counseled when they were pregnant with the youngest child. Number of mothers of children age 0-23 months who had “quality “ ANC with a “skilled provider” AND at least four antenatal visits AND adequate counseling while pregnant with their youngest child (ANC1 = A, B or C) AND (ANC4 ≥ 4) AND (ANC5 = A1, B1, C1, AND D1) AND (ANC6 = 1) AND (ANC7 = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen anccatch=1 if (q49a==1 | q49b==1 | q49c==1) & (q52>=4 & q52<98) gen quality=1 if anccatch==1 & q53aa==1 & q53ab==1 & q53ac==1 & q53ad==1 & q54==1 & q55==1 replace quality=2 if mi(quality) lab val quality yesno lab var quality "Quality Antenatal Care" ta quality HIV Testing During Pregnancy Percentage of mothers of children 0-23 months who were counseled about HIV during the pregnancy, accepted an offer of testing, and received their test results when they were pregnant with their youngest child. Number of mothers of children age 0-23 months who were counseled about HIV during the pregnancy AND Were offered an HIV test AND Accepted the HIV test AND Received the results of their test during when they were pregnant with their youngest child (HIV1 = 1 AND HIV2 = 1 AND HIV3 = 1 AND HIV4 = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen tested=1 if q56==1 & q57==1 & q58==1 replace tested=2 if mi(tested) lab val tested yesno lab var tested "HIV Testing During Pregnancy" ta tested Knowledge of Danger Signs during Pregnancy Percentage of mothers of children 0-23 months who knew at least two danger signs during pregnancy. Number of mothers of children 0-23 months who know at least two danger signs during pregnancy (DSP1= any two responses A-I) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 108 use crsfinal, clear foreach var of varlist q59a q59b q59c q59d q59e q59f q59g q59h q59i { replace `var'=0 if `var'==2 } gen totsigns=q59a+q59b+q59c+q59d+q59e+q59f+q59g+q59h+q59i gen dangerpreg=1 if totsigns>=2 replace dangerpreg=2 if mi(dangerpreg) lab val dangerpreg yesno lab var dangerpreg "Knowledge of Danger Signs during Pregnancy" ta dangerpreg Tetanus Toxoid Percentage of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child. Number of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child (TT2 + TT4 ≥2) AND (TT2 ≠ 9 AND TT4 ≠ 9) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear replace q61=0 if q61==9 replace q61=0 if q61==. replace q63=0 if q63==9 replace q63=0 if q63==. gen tetanus=1 if (q61+q63)>=2 replace tetanus=2 if mi(tetanus) lab val tetanus yesno lab var tetanus "Tetanus injection" ta tetanus Iron Tablets for Pregnant Women Percentage of mothers of children age 0- 23 months who took iron tablets before the birth of their youngest child. Number of mothers of children age 0-23 months who received iron tablets and consumed them for at least 90 number of days (IT1 = 1 AND IT2 ≥ 90) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen irontab=1 if q64==1 & q65>89 & q65<999 replace irontab=2 if mi(irontab) lab val irontab yesno lab var irontab "Iron Tablets for Pregnant Women" ta irontab 109 IPT during Pregnancy Percentage of mothers of children age 0- 23 months who received Intermittent Preventive Treatment (IPT) for malaria during the pregnancy with the youngest child. NOTE: The term “effective antimalarial” should be based on national protocol, which includes two doses. Modify the tabulation according to national protocol. Number of mothers of children age 0-23 months who received 2 or more doses of an effective antimalarial drug treatment to prevent malaria during their pregnancy with their youngest child (IPT1 = 1 AND IPT2 = A AND IPT3 ≥ 2) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen iptp=1 if q66==1 & q67a==1 & q68>=2 replace iptp=2 if mi(iptp) lab val iptp yesno lab var iptp "IPT during Pregnancy" ta iptp Skilled Birth Attendant Percentage of children age 0-23 months whose births were attended by skilled personnel. Number of children age 0-23 month whose birth was attended by a doctor, nurse, midwife, auxiliary midwife or other health staff with midwifery skills (BA1 = A, B , C or D,E) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 CATCH Trained Delivery Attendant Percent of children age 0-23 months whose births were attended by a trained provider including a trained TBA. Number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, other health staff with midwifery skills, trained TBA or trained community health worker, (BA1 = A, B , C, D, E, F, or G) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen delattend=1 if q69a==1 | q69b==1 | q69c==1 | q69d==1 | q69e==1 | q69f==1 | q69g==1 replace delattend=2 if mi(delattend) lab val delattend yesno lab var delattend "Trained Delivery Attendant" ta delattend Clean Birth Kit Percentage of women of children age 0- 23 months who used a clean delivery kit during the birth of their youngest child. Number of mothers of children age 0-23 months who used a clean birth kit during the delivery of their youngest child (CD1 = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 110 use crsfinal, clear gen birthkit=1 if q71==1 replace birthkit=2 if mi(birthkit) lab val birthkit yesno lab var birthkit "Clean Birth Kit" ta birthkit Clean Cord Cutting Percent children age 0-23 months that had clean cord cutting at the time of birth. Number of children age 0-23 months who’s cord was cut with a clean birth instrument (CC1 = 1 or 2 or 4 or 6 or 8) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen cordcut=1 if q72==1 | q72==2 | q72==4 | q72==6 | q72==8 replace cordcut=2 if mi(cordcut) lab val cordcut yesno lab var cordcut "Clean Cord Cutting" ta cordcut Clean Cord Care Percent children age 0-23 months that had clean cord care at the time of birth. Number of children age 0-23 months who had nothing or only antiseptic put on the stump of the cord after birth (CC2 = 2) OR (CC2=1 AND CC3=3) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen cord=1 if q73==2 replace cord=1 if q73==1 & q74==3 replace cord=2 if mi(cord) lab val cord yesno lab var cord "Clean Cord Care" ta cord Thermal Care (Immediate drying and wrapping) Percentage of children age 0-23 months who were dried and wrapped with a warm cloth or blanket immediately after birth. Number of children age 0-23 months who were dried before the placenta was delivered AND wrapped in a warm cloth or blanket (TC1 = 1 AND TC2 = 1) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen thermal=1 if q75==1 & q76==1 replace thermal=2 if mi(thermal) lab val thermal yesno lab var thermal "Thermal Care (Immediate drying and wrapping)" ta thermal 111 Immediate Drying Percent of children age 0-23 months who were dried immediately after birth. Number of children age 0-23 months who were dried before the placenta was delivered (TC1 = 1) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen drying=1 if q75==1 replace drying=2 if mi(drying) lab val drying yesno lab var drying "Immediate Drying" ta drying Immediate Wrapping Percentage of children age 0-23 months, who were wrapped with a cloth or blanket immediately after birth. Number of children age 0-23 months who were wrapped in a cloth or blanket (TC2 = 1) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen wrap=1 if q76==1 replace wrap=2 if mi(wrap) lab val wrap yesno lab var wrap "Immediate Wrapping" ta wrap Active Management of the third stage of labor (AMTSL) Percent of mothers of children age 0-23 months who received AMTSL after the birth of her youngest child. Number of mothers of children age 0-23 months who immediately after the birth of their youngest child received an injection of uterotonic drug AND Controlled cord traction was performed AND Received uterine massage after the delivery of the placenta (MTS1 = 1 AND MTS2 = 1 AND MTS3 = 1) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear gen amtsl=1 if q77==1 & q78==1 & q79==1 replace amtsl=2 if mi(amtsl) lab val amtsl yesno lab var amtsl "Active Management of the third stage of labor (AMTSL)" ta amtsl Knowledge of Maternal Danger Signs During Delivery Percentage of mothers of children 0-23 months who know at least two danger signs during delivery. 112 use crsfinal, clear foreach var of varlist q80a q80b q80c q80d q80e q80f q80g { replace `var'=0 if `var'==2 } gen totdangers=q80a+q80b+q80c+q80d+q80e+q80f+q80g gen mdanger=1 if totdangers>=2 replace mdanger=2 if mi(mdanger) lab val mdanger yesno lab var mdanger "Knowledge of Maternal Danger Signs During Delivery" ta mdanger Immediate breastfeeding of newborns Percentage of children age 0-23 months who were put to the breast within one hour of delivery. Number of children age 0-23 months who were breastfed AND Put to the breast within 1 hour of delivery (BF1 = 1 AND BF2 = 00) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen bf=1 if q92==1 & q93hour==0 & mi(q93days) replace bf=1 if q92==1 & q93hour==0 & q93days==0 replace bf=1 if q92==1 & q93hour==. & q93days==0 replace bf=2 if mi(bf) lab val bf yesno lab var bf "Immediate breastfeeding of newborns" ta bf Feeding Colostrum Percentage of children age 0-23 months, who were fed colostrum after birth. Number of children age 0-23 months who were breastfeed AND Were fed colostrum (BF1 = 1 AND BF3 = 1) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen colostrum=1 if q92==1 & q94==1 replace colostrum=2 if mi(colostrum) lab val colostrum yesno lab var colostrum "Feeding Colostrum" ta colostrum Pre-lacteal Feeds Percentage of children age 0-23 months who did not receive pre-lacteal feeds. Number of children age 0-23 months who were breastfeed AND Did not receive any pre-lacteal feeds (BF1 = 1 AND BF4 = 2) ____________________________________________ Total number of children age 0-23 months in the survey x 100 113 use crsfinal, clear gen lacteal=1 if q92==1 & q95==2 replace lacteal=2 if mi(lacteal) lab val lacteal yesno lab var lacteal "Pre-lacteal Feeds" ta lacteal Essential Newborn Care Percentage of children age 0-23 who received all three elements of essential newborn care: thermal protection immediately after birth, clean cord care, and immediate and exclusive breastfeeding. Number of children age 0-23 months who had clean cord care at birth AND Were immediately dried and wrapped AND Were immediately breastfed (CC1 = 1 or 2 or 4 or 6 or 8) AND (TC1 = 1 and TC2 = 1) AND (BF1 = 1 AND BF2 = 00) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen enbcare=1 if (q73==2 | (q73==1 & q74==3)) & q75==1 & q76==1 & q92==1 & q93hour==0 replace enbcare=2 if mi(enbcare) lab val enbcare yesno lab var enbcare "Essential Newborn Care" ta enbcare Prophylactic Eye Care Percentage of children age 0-23 months who received appropriate preventive eye care within the first hour after birth. Number of children 0-23 months who received eye ointment or eye drops within the first hour after birth (EC1 = 1) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear gen eye=1 if q81==1 replace eye=2 if mi(eye) lab val eye yesno lab var eye "Prophylactic Eye Care" ta eye Post-Partum Visit for the Mother Percentage of mothers of children age 0- 23 who received a post-partum visit from an appropriate trained health worker within two days after the birth of the youngest child. Number of mothers of children age 0-23 months who received a post-partum visit AND within two days after birth AND by an appropriate health worker (PP1=1) AND [(PP2U = 0) or (PP2U= 1 and (PP2N ≤ 2))] AND (PP3= A, B , C, D,E,F,G) ____________________________________________ Total number of mothers of children age 0-23 months in the survey U refers to the units of time (hours, days, weeks) and N refers to the corresponding number (PP2U=0 and PP2N=12 means 12 hours) x 100 114 use crsfinal, clear gen povisit=1 if q83==1 & q84==0 & q84b<48 & q85aa>=1 & q85aa<=7 replace povisit=1 if q83==1 & q84==1 & q84b<=2 & q85aa>=1 & q85aa<=7 replace povisit=2 if mi(povisit) lab val povisit yesno lab var povisit "Post-Partum visit for the mother" ta povisit Knowledge of Post-partum Danger Signs Percentage of mothers of children age 0- 23 months who knew at least two post￾partum danger signs. Number of mothers of children 0-23 months who know at least two post-partum danger signs (DSM1= any two responses A-I) ____________________________________________ Total number of children age 0-23 months in the survey x 100 use crsfinal, clear foreach var of varlist q86a q86b q86c q86d q86e q86f q86g q86h q86i{ replace `var'=0 if `var'==2 } gen totposdan=q86a+q86b+q86c+q86d+q86e+q86f+q86g+q86h+q86h gen postdanger=1 if totposdan>=2 replace postdanger=2 if mi(postdanger) lab val postdanger yesno lab var postdanger "Knowledge of Post-partum Danger Signs" ta postdanger Post-Natal Visit to Check on the Newborn Percentage of children age 0-23 months who received a post-natal visit from an appropriate trained health worker within two days after birth. Number of children age 0-23 months who received a post-natal visit AND within two days after birth AND by an appropriate health worker (PC1=1) AND [(PC2U = 0) or (PC2U= 1 and (PC2N <= 2))] AND (PC3= A, B , C, D,E,F,G) ____________________________________________ Total number of children age 0-23 months in the survey U refers to the units of time (hours, days, weeks) and N refers to the corresponding number (PC2U=0 and PC2N=12 means 12 hours) x 100 use crsfinal, clear gen check24=1 if q88a==0 & q88b!=. replace check24=1 if q88a==1 & q88b<=2 gen postncheck=1 if q87==1 & check24==1 & (q89a==1 | q89b==1 | q89c==1 | q89d==1 | q89e==1 | q89f==1 | q89g==1) replace postncheck=2 if mi(postncheck) lab val postncheck yesno lab var postncheck "Post-Natal Visit to Check on the Newborn" ta postncheck 115 Knowledge of Neonatal Danger Signs Percentage of mothers of children age 0- 23 who know at least two neonatal danger signs. Number of mothers of children 0-23 months who know at least two neonatal danger signs (DSN1= any two responses A-J) ____________________________________________ Total number of mothers of children age 0-23 months in the survey x 100 use crsfinal, clear foreach var of varlist q90a q90b q90c q90d q90e q90f q90g q90h q90i q90j { replace `var'=0 if `var'==2 } gen totneosigns=q90a+q90b+q90c+q90d+q90e+q90f+q90g+q90h+q90i+q90j gen neodanger=1 if totneosigns>=2 replace neodanger=2 if mi(neodanger) lab val neodanger yesno lab var neodanger "Knowledge of Neonatal Danger Signs" ta neodanger 116 Annex 5: List of Communities GHANA HEALTH SERVICE EAST MAMPRUSI HEALTH DIRECTORATE SAKOGU SUB-DISTRICT GAMBAGA SUB-DISTRICT NO NAME OF COMMUNITIES ESTIMATED POPULATION NO. NAME OF COMMUNITIES ESTIMATED POPULATION 1 SAKOGU 4896 1 GAMBARAN -1 901 2 GBELINZERI 877 2 GAMBARAN -2 1040 3 LEBZINGA 888 3 YAPALA 787 4 WUNZUTINGA 481 4 NAKOSUGU 1017 5 KPATIRITINGA 592 5 GAAGBINNI 983 6 DABARE 399 6 NAKOSUGU 638 7 BOGNI 122 7 GBALLA 121 8 BANGU 322 8 LIMAN FONG 1121 9 BONBILA 223 9 SIBIA 946 10 NAMEBOKU 986 10 ZIMASA 137 11 SOANSOBGI 896 11 NYINGARI 425 12 BANAWA 233 12 DINTIGE 228 13 TAMBONA 109 13 ZAARI 863 14 YAPALA 512 14 LA-ATARI 609 15 BARILONG 624 15 ZIGUM 86 16 KONDI 219 16 NANORI 413 17 ZOGELGU 613 17 TINSUGU 465 18 DINDANI A 690 18 LA-ATARIGU 507 19 DINDANI B 997 19 DAGBIRIBO-ARI -1 879 21 SUMNIBOMA 974 20 DAGBIRIBO-ARI -2 2709 22 NAMASIM 864 21 TAMBOKU -1 910 23 KPIKPARIGBINI 516 22 TAMBOKU -2 412 24 ZARANTINGA 1114 23 GBANGU A 4129 25 BADURI 249 24 BANTAMBARE 300 26 ZAMBULUGU 710 25 BONGBINI-1 1201 27 YUNYOORANYIRI 87 26 BONGBINI-2 634 30 TICHIRIGITABA 1035 27 NAYORKU 221 31 JERIGITINGA 379 28 NAMIYALA 223 32 ZAMBULKURA 542 117 33 GADANTINGA 653 34 GAZERETINGA 202 35 TAKORATINGA 569 36 LAFORUM 415 37 TINTARIGA 389 38 YANKAZIA 124 39 NAKPANBON 587 40 TUUGBINI 225 41 GURUGU 454 42 NANYUNG 654 43 MAASUTINGA 456 44 MAAGIMBIENTINGA 642 45 SUMANIFONG 198 46 WAKURITINGA 333 47 BUMURITINGA 183 48 JASINFAFONG 228 118 NALERIGU SUB-DISTRICT NO NAME OF COMMUNITIES ESTIMATED POPULATION NO NAME OF COMMUNITIES ESTIMATED POPULATION 1 KULGONA-1 538 41 KPIKPARIBOGU 201 2 KULGONA-2 452 42 BARINYA 302 3 JABLAJO A 102 43 NAGBO-1 2053 4 JABLAJO B 423 44 NAGBO-2 1289 5 BANJAM 117 45 KOLINVAI A 630 6 BOLGATINGA 432 46 KOLINVAI B 750 7 NANYIRI 217 47 KOLINVAI C 152 8 MANYA 115 48 SUMNIBOMA 2A 126 9 GBANPAA/ GBANKPIK 565 49 SUMNIBOMA 2B 221 10 GBANDARI 171 50 BADURI 223 11 TINTARIGA-1 109 51 ZINIAYA 221 12 BRAIMAHTINGA 342 52 LANGBINA 288 13 ZIKAYA 1 297 53 ADARIBE 225 14 TANGBINI 423 54 BINDURI 147 15 TOAK 342 55 KWALIK 449 16 NACHIAN 296 56 LAAPLIT 117 19 ZORIZUGU 218 57 JIMBALI 247 20 KPASOKU 530 58 GBANKUKUA 171 21 NAKPAZONG A 225 59 GBANDABILA 214 22 NAKPAZONG B 181 60 TINDANTUA 215 23 MOZIO 314 61 GBANGU 320 24 PORINGONE 246 62 JAWANIM A 1059 25 NAKPANYARIGA 219 63 JAWANIM B 734 26 LUMU 295 64 TEANOBA A 224 27 NAANI 194 65 TEANOBA B 151 28 KANCHINA 222 66 DA-AZIO 254 29 KAMBONAATINGA 127 67 KPALIVAKA 194 30 BILALOGRI 160 68 ZANDUA A 340 31 NABOTARI 106 69 ZANDUA B 252 32 WAGAI 241 70 NANGUA 184 33 YANKAZIA 2 312 71 DUUNI 1 307 34 ALAFIAFONGU 112 72 DUUNI 2 276 35 NALERIGU-1 4038 73 TINTARIGA-2 197 36 NALERIGU-2 4780 74 DIMUGI/TIMONG 98 37 NORLOBI 139 75 ZIIKAYA 2 784 119 38 BUYA 342 76 TUNDI A 308 39 KUKUGBINI 323 77 TUNDI B 278 40 TUBZIA 225 78 KALBOYIRI 421 GBINTIRI SUB-DISTRICT LANGBINSI SUB-DISTRICT NO NAME OF COMMUNITIES ESTIMATED POPULATION NO NAME OF COMMUNITIES ESTIMATED POPULATION 1 KUFORI 648 1 LANGBENSI A 2888 2 WAGAI 241 2 LANGBENSI B 1648 3 JANGANDERI 180 3 YARO YIRI 351 4 GUNGONG 414 4 KASAPE 1741 5 NAWUNA 552 5 BUZULUNGU 642 6 KUTONG 224 6 TIMPELLA 734 7 DIBONI 513 7 SOMNIBOMA 423 8 MEIMBENA 386 8 BOWKU 1607 9 TUGBINI 144 9 BUMBOAZIO 1082 10 LAKPIRI 1 168 10 NAMANGO A 1221 11 LAKPIRI 2 822 15 NAMANGO B 1032 12 NAJONG 305 16 GBINGBIRIGA 765 13 KPALSOK 410 17 BURUGU 845 14 JAGOO 189 18 DIMEA 440 15 GBINTIRI WEST 2153 19 GUBIU 949 16 GBINTIRI SOUTH 873 20 SAMINI A 1818 17 GBINTIRI EAST 2616 21 SAMINI B 2042 18 KPATINGA 183 22 TANGBINI A 1338 19 WABURI 205 23 TANGBINI B 1019 20 KPALGU 300 24 WUNDUA A 1003 21 NAGBAI 1 423 25 WUNDUA B 2097 22 NAGBAI 2 264 26 CHIRIFOYIRI 404 23 NAKURUGU 327 27 POANAYIRI 235 24 SAKURUKPONG 237 28 BOAYINI 223 25 NAJIL 209 26 MANIA 220 120 27 KPAGNAL 203 28 KWALICK 436 29 BANJAM 381 30 NAKPAYILI 306 31 GBEDURI 419 32 DAMAKO 625 33 NAGANI 242 34 NAMANGBAI 332 35 NYARIGBINI 341 36 DOBIYANTO 361 37 MONTANA A 286 38 MONTANA B 305 39 BLAGAN 382 40 TATAIN 429 41 LANGBENBONG 357 42 TANDIUK 381 121 Annex 6: Percentage Distribution of Variables RESULTS FOR CRS EPPICS CHILD SURVIVAL ENDLINE STUDY FINAL TABLES Variables Frequency (N) Percentage (%) Consent Given Agreed 328 100 Not agreed 0 0 1. Years in school Number (mean) SD 96 (6.6) 3.7 2. What is your level of formal education Basic school 79 24.1 Senior high school 14 4.3 Tertiary (college/university 2 0.6 Never been to school 232 70.7 Other 1 0.3 3. What is your marital status Single 2 0.6 Married 323 98.8 Widowed 2 0.6 4. Age of respondents in years Number (mean) SD 328 (27.74) 6.26 122 5. What religion do you practice? Christianity 144 44.2 Islam 174 53.4 African traditional religion 4 1.2 None 4 1.2 6. Speak Mampruli? Yes 273 83.2 No 55 16.8 Speak Moar? Yes 23 7 No 305 93 Speak Kusal? Yes 18 5.5 No 310 94.5 Speak Likpapka? Yes 102 31.1 No 226 68.9 Speak other language Yes 118 36 No 210 64 7. In what language do you feel most comfortable communicating? Mampruli 214 65.2 Moar 14 4.3 Kusal 3 0.9 Likpapka 67 20.4 123 Others 30 9.1 8a. Total births alive 1 81 24.7 2 54 16.5 3 55 16.8 4 57 17.4 5 36 11.0 6 24 7.3 7 15 4.6 8 4 1.2 9 2 0.6 8b. Children dead 0 258 78.9 1 47 14.4 2 15 4.6 3 5 1.5 4 1 0.3 5 1 0.3 9. Sex Male 173 53.1 Female 153 46.9 11. Does (name's) biological father live in this household? Yes 272 82.9 No 56 17.1 12. Who is the head of this household? Mother 1 0.3 124 Husband/partner 180 54.9 Female relative 21 6.4 Male relative 114 34.8 Other 12 3.7 13. No outside work Yes 273 83.2 No 55 16.8 Handicrafts Yes 23 7 No 305 93 Harvesting Yes 18 5.5 No 310 94.5 Selling foods Yes 102 31.1 No 226 68.9 Shop keeper/street vendor Yes 118 36 No 210 64 Servant/household worker Yes 2 0.6 No 326 99.4 Salaried worker Yes 0 0 125 No 328 100 Farming Yes 0 0 No 328 100 Other Yes 1 0.3 No 327 99.7 14. Who usually takes care of (name) when you are away from home? Mother 42 12.8 Husband/partner 31 9.5 Older children 116 35.5 Other relatives 116 35.5 Neighbors/friends 1 0.3 Maid 3 0.9 Other 18 5.5 15. Do you have a card or child health booklet? Yes 314 96 No 13 4 17. Has (name) received any vaccinations that are not recorded on this card? Yes 57 17.4 No 261 79.6 Don't know 10 3 18. Has (name) received a DTP/Penta vaccination? Yes 283 86.3 126 No 45 13.7 19. How many times 0 45 13.7 1 24 7.3 2 21 6.4 3 238 72.6 20. Did (name) ever receive an injection in the arm to prevent measles? Yes 161 49.1 No 167 50.9 21. ill with fever at any time in the last 2 weeks? Yes 156 47.6 No 171 52.1 Don't know 1 0.3 22. Did you seek advice or treatment for the fever? Yes 140 89.7 No 16 10.3 23. First treatment? Same day 36 25.7 Next day 65 46.4 Two or more days 39 27.9 24. Took drugs for fever? Yes 137 97.9 No 3 2.1 127 25a. Sp/fansidar Same day 6 4.4 Next day 1 0.7 Two or more days 1 0.7 25b. Chloroquine Same day 1 0.7 Next day 1 0.7 25c. Amodiaquine Same day 7 2.1 Next day 1 0.7 Two or more days 1 0.7 25d. Quinine Same day 7 5.1 Next day 2 1.5 Don't know 1 0.7 25e. ACT Same day 6 4.4 Next day 24 17.5 Two or more days 16 11.7 25f. Asprin Same day 2 1.5 25g. Paracetamol Same day 43 31.4 Next day 56 40.9 128 Two or more days 24 17.5 Don't know 1 0.7 25x. Other Same day 2 1.5 Next day 11 8 Two or more days 6 4.4 26. Any diarrhea in the last two weeks? Yes 149 45.4 No 179 54.6 27a. Given fluid from ORS packet to drink Yes 86 57.7 No 54 36.2 27b. Homemade fluid Yes 15 10.1 No 95 63.8 28. llness with cough Yes 99 30.2 No 229 69.8 29. Trouble breathing? Yes 64 64.5 No 35 35.5 30. Seek advice /treatment for the cough/fast breathing? Yes 55 85.9 No 9 14.1 129 31a. Doctor/medical assistant gave advice Yes 6 10.9 No 49 89.1 31b. Nurse advice Yes 32 58.2 No 23 41.8 31c. Auxiliary nurse (enrolled nurse) advice Yes 0 0 No 55 100 31d. Trained community health worker advice Yes 4 7.3 No 51 92.7 32x. Other Yes 16 29.1 No 39 70.9 32. Where do you usually get water for drinking purposes? Borehole 189 57.6 Well 97 29.6 Dam 3 0.9 Rain harvest 1 0.3 Others 38 11.6 33. Do you treat your water in any way to make it safe for drinking? Yes 3 7.14 No 39 92.9 130 34. Water treatment Strain it through cloth 2 66.7 Boil 1 33.3 35. Washing hands Inside/near toilet facility 29 8.9 Inside/near kitchen/cooking place 25 7.7 Elsewhere in yard 152 46.6 Outside yard 17 5.2 No specific place 103 31.6 36. Cleaning agent? Soap 150 45.7 Detergent 3 0.9 Mud/sand 1 0.3 None 53 16.2 Not Applicable 121 36.9 37. Mosquito net Yes 246 75 No 82 25 38. Who slept under a bed net last night? No one 6 2.5 Child 233 95.1 Other 6 2.5 39. Brand of Bed net Permanent 59 24.0 Long lasted treated net 174 70.7 131 Other net 1 0.4 40. Was the bed net ever treated No records 42. Waiting period before getting pregnant again? Less than 2 years 3 0.9 2 to 5 years 286 87.5 More than 5 years 26 8 Don't know 12 3.7 43a. No risk Yes 20 6.1 No 308 93.9 43b. Baby born too small Yes 87 26.5 No 241 73.5 43c. Baby born too early Yes 50 15.2 No 278 84.8 43d. Mother can die Yes 83 25.3 No 245 74.7 44e. Mother can have miscarriage Yes 133 40.5 No 195 59.5 132 44f. Mother can suffer anemia Yes 123 37.5 No 205 62.5 44g. Don’t know Yes 22 6.7 No 306 93.3 44x. Other Yes 130 39.6 No 198 60.4 44. Are you currently pregnant? Yes 7 2.2 No 318 97.8 45. Method to delay or avoid getting pregnant? Yes 143 43.6 No 181 55.2 Don't know 1 0.3 3 0.9 46. Which method are you (or your husband/ partner) using? Female sterilization 2 0.6 Pill 11 3.4 Injectable 69 21 Implants 1 0.3 Lactational amen method/exclusive breast feeding 26 7.9 Standard days method/cycle beads 9 2.7 Other 26 7.9 Not Applicable 184 56.1 133 47a. Can HIV be transmitted during pregnancy Yes 212 64.6 No 53 16.2 Don't know 63 19.2 47b. Can HIV be transmitted during delivery Yes 208 63.4 No 53 16.2 Don't know 67 20.4 47c. Can HIV be transmitted during breastfeeding Yes 205 62.5 No 55 16.8 Don't know 68 20.7 48. Drugs to reduce HIV risk transmission from mother to child? Yes 213 64.9 No 31 9.5 Don't know 84 25.6 49a. Doctor/medical assistant for ANC Yes 17 5.2 No 311 94.8 49b. Nurse for ANC Yes 229 69.8 No 99 30.2 49c. Midwife for ANC Yes 168 51.2 134 No 160 48.8 49d. Traditional birth attendant for ANC Yes 20 6.1 No 308 93.9 49y. Other for ANC Yes 10 3 No 318 97 49y. ANC from No one No 328 100 Yes 0 0 50a. Your home No 325 99.1 Yes 3 0.9 50b. Midwife/TBA home No 319 97.3 Yes 9 2.7 50c. Other home No 328 100 Yes 0 0 50d. Hospital No 289 88.1 Yes 39 11.9 50e. Health Centre 135 No 128 39 Yes 200 61 50f. Health post No 294 89.6 Yes 34 10.4 50g. Outreach No 274 83.5 Yes 54 16.5 50h. Other public No 323 98.5 Yes 5 1.5 50i. Private hospital No 328 100 Yes 0 0 50j. Private clinic No 328 100 Yes 0 0 50k. Other private No 328 100 Yes 0 0 50x. Other No 328 100 51a. Months pregnant before first ANC care 136 Number (mean) SD 327 (2.82) 1.33 51b. Received first ANC in the first trimester of pregnancy Yes 241 73.5 No 87 26.5 52. ANC visits Number (mean) SD 328 (5.30) 1.75 53a. Was your height taken? Yes 289 88.1 No 38 11.6 1 0.3 Was your blood pressure measured? Yes 304 92.7 No 24 7.3 Did you give a urine sample? Yes 261 79.6 No 67 20.4 Did you give a blood sample? Yes 275 83.8 No 53 16.2 53b. During ANC visits, did you feel abused by the health staff? Yes 19 5.8 No 308 94.2 53c. Staff ignored her 137 Yes 5 1.5 No 14 4.3 Staff yelled at her Yes 9 2.7 No 10 3.1 Staff made fun of her Yes 0 0 No 19 5.8 Staff insulted her Yes 5 1.5 No 14 4.3 Staff touched her inappropriately Yes 0 0 No 19 5.8 Staff slapped or hit her Yes 0 0 No 19 5.8 Other Yes 4 1.2 No 15 4.6 53d. How satisfied were you with the service you received from the health staff? Very satisfied 296 90.2 Somewhat satisfied 27 8.2 138 Not satisfied 5 1.5 54. During ANC visits, were you told about the signs of pregnancy Yes 274 83.5 No 53 16.2 Don't know 1 0.3 55. Were you told where to go if you had any complications? Yes 266 81.1 No 6 1.8 Don't know 1 0.3 55 16.8 56. During ANC visits, did anyone talk to you about getting tested for HIV? Yes 212 64.6 No 106 32.3 Don't know 8 2.4 2 0.6 57. Tested for HIV during ANC? Yes 184 56.1 No 99 30.2 Don't know 45 13.7 58. Did you get the results of the test? Yes 124 67.4 No 55 29.9 Don't know 5 2.7 59a. Vaginal bleeding 139 Yes 149 45.4 No 179 54.6 59b. Fast/difficult breathing Yes 73 22.3 No 255 77.7 59c. Fever Yes 156 47.6 No 172 52.4 59d. Severe abdominal pain Yes 225 68.6 No 103 31.4 59e. Headache/blurred vision Yes 135 41.2 No 193 58.8 59f. Convulsions Yes 21 6.4 No 307 93.6 59g. Foul smelling discharge/fluid from vagina Yes 26 7.9 No 302 92.1 59h. Baby stops moving Yes 74 22.6 No 254 77.4 140 59i. Leaking brownish/greenish fluid from the vagina Yes 4 1.2 No 324 98.8 59x. Other Yes 68 20.7 No 260 79.3 60. Tetanus injection? Yes 292 89 No 34 10.4 Don't know 2 0.6 61. How many times did you receive such an injection? One 161 55.1 Two 101 34.6 Three or more 26 8.9 Don't know 4 1.4 62. Tetanus toxoid injection at any time before that pregnancy? Yes 192 58.5 No 109 33.2 Don't know 27 8.2 63. Before pregnancy how many times did you receive tetanus injection One 102 31.1 Two 52 15.9 Three or more 31 9.5 Don't know 7 2.1 Not Applicable 136 41.5 141 64. Were you given or did you buy any iron tablets/syrup? Yes 317 96.6 No 3 0.9 Missing 8 2.4 65. How many did you take tablets? 322 (137) 54.24 Number (mean) SD 66. Take drugs to prevent you from malaria? Yes 246 75 No 80 24.4 Don't know 2 0.6 67a. Sp/fansider Yes 250 76.2 Not Applicable 78 23.8 67b. Chloroquine No 245 74.7 Yes 1 0.3 Not Applicable 82 25 67c. Other No 245 74.7 Yes 1 0.3 Not Applicable 82 25 68. How many times did you take SP/Fansidar during this pregnancy? Number (mean) SD 249 (2.39) 1.03 69a. Doctor 142 Yes 16 4.9 No 312 95.1 69b. Nurse Yes 127 38.7 No 201 61.3 69c. Midwife Yes 208 63.4 No 120 36.6 69d. Auxiliary midwife Yes 12 3.7 No 316 96.3 69e. Other health staff with midwifery skills Yes 7 2.1 No 321 97.9 69f. Trained traditional birth attendant Yes 59 18 No 269 82 69g. Trained community health nurse Yes 7 2.1 No 321 97.9 69h. Traditional birth attendant Yes 13 4 No 315 96 143 69i. Community health worker Yes 1 0.3 No 327 99.7 69j. Relative/friend Yes 13 4 No 315 96 69y. No one Yes 2 0.6 No 326 99.4 70a. Where did you give birth to (name)? Your home 61 18.6 Midwife/tba home 8 2.4 Other home 4 1.2 Hospital 106 32.3 Health center 138 42.1 Health post 8 2.4 Other public 1 0.3 Other 2 0.6 70b. During delivery, did you feel abused by the health staff? Yes 18 7.1 No 238 92.9 70c. Staff ignored her Yes 3 1.2 No 16 6.3 Staff yelled at her 144 Yes 12 4.7 No 6 2.4 Staff made fun of her Yes 2 0.8 No 16 6.3 Staff insulted her Yes 3 1.2 No 15 5.9 Staff touched her inappropriately Yes 0 0 No 18 7.1 Staff slapped or hit her Yes 3 1.2 No 15 5.9 Other Yes 0 0 No 18 7.1 70d. During delivery, how satisfied were you with the service you received from health staff? Very satisfied 230 90.9 Somewhat satisfied 20 7.9 Not satisfied 3 1.2 71. Was a clean delivery kit used during delivery? Yes 313 96.6 145 No 9 2.8 Don't know 2 0.6 72. Instrument used to cut the cord? New razor blade 102 31.2 Used razor blade 1 0.3 New scissors 87 26.6 New and boiled scissors 18 5.5 Used and boiled scissors 68 20.8 Don't know 51 15.6 73. Anything placed on the umbilical cord before or after it was cut? Yes 212 65 No 71 21.8 Don't know 43 13.2 74. What was placed on the cut cord? Cow dung 1 0.3 Any type of oil 25 7.6 Antiseptic 170 51.8 Charcoal powder 4 1.2 Other 12 3.7 116 35.4 75. Was child dried immediately after birth Yes 317 96.6 No 8 2.4 Don't know 2 0.6 76. Was child wrapped in a warm cloth or blanket ? Yes 316 96.3 146 No 10 3 Don't know 1 0.3 Not Applicable 1 0.3 77. Received an injection to prevent you from bleeding too much? Yes 211 64.3 No 108 32.9 Don't know 8 2.4 1 0.3 78. Did the care provider or TBA hold your stomach to placenta out? Yes 241 73.5 No 63 19.2 Don't know 23 7 79. Did someone massage uterus to prevent too much bleeding? Yes 263 80.2 No 41 12.5 Don't know 23 7 80a. Convulsions Yes 52 15.9 No 276 84.1 80b. High fever Yes 76 23.2 No 252 76.8 80c. Heavy bleeding Yes 155 47.3 No 173 52.7 147 80d. Fast/difficult breathing Yes 97 29.6 No 231 70.4 80e. Retained placenta Yes 33 10.1 No 295 89.9 80f. Headache/blurred vision Yes 141 43 No 187 57 80g. Prolonged labor Yes 113 34.5 No 215 65.5 80x. Other Yes 63 19.2 No 265 80.8 81. In the first hour after delivery, was (name) given eye ointment or drops in the eye? Yes 83 25.4 No 200 61.2 Don't know 44 13.5 82a. Child weighed at birth? Yes 244 76.3 No 74 23.1 Don't know 2 0.6 148 82b1. Weight from card Number (mean) SD 243 (2.88) 0.55 82b2. Weight from recall Number (mean) SD 26 (3.78) 2.59 83. Where you checked by a health care provider or a TBA? Yes 311 94.8 No 14 4.3 Don't know 3 0.9 84. How long after delivery was mother first check take place? Hours 260 88.1 Days 30 10.2 Weeks 2 0.7 Don’t know 3 1 85a. Who checked your health at that time? Doctor 46 14 Nurse 110 33.5 Midwife 128 39 Trained traditional birth attendant 28 8.5 Trained community health nurse 6 1.8 Traditional birth attendant 4 1.2 Community health worker 2 0.6 Relative/friend 4 1.2 85b. Did you feel abused or mistreated by the health staff who checked on you? Yes 10 3.1 149 No 314 96.3 Don't know 2 0.6 85c. Staff ignored her Yes 2 20 No 8 80 Staff yelled at her Yes 4 40 No 6 60 Staff insulted her Yes 4 40 No 6 60 85d. How satisfied were you with the service you received from the health staff? Very satisfied 299 92 Somewhat satisfied 23 7.1 Not satisfied 3 0.9 85e. In the first two months after delivery of (name), did you receive a vitamin A dose? Yes 232 70.7 No 87 26.5 Don't know 9 2.7 86a. Excessive vaginal bleeding Yes 180 54.9 No 148 45.1 86b. Fast/difficult breathing 150 Yes 83 25.3 No 245 74.7 86c. High fever Yes 62 18.9 No 266 81.1 86d. Severe abdominal pain Yes 255 77.7 No 73 22.3 86e. Severe headache/blurred vision Yes 123 37.5 No 205 62.5 86f. Convulsions/loss of consciousness Yes 52 15.9 No 276 84.1 86g. Foul-smelling discharge from the vagina Yes 34 10.4 No 294 89.6 86h. Pain in calf Yes 35 10.7 No 293 89.3 86i. Verbalization/behavior that indicates she may hurt herself or the baby Yes 5 1.5 No 323 98.5 151 86x. Other Yes 39 11.9 No 289 88.1 87. After (name) was born, did any health care provider or TBA check on health? Yes 314 95.7 No 10 3 Don't know 4 1.2 88. How many hours, days or weeks after the birth of (name) did the first check take place? Hours 260 87.8 Days 33 11.1 Weeks 3 1 89a. Doctor Yes 45 13.7 No 283 86.3 89b. Nurse Yes 138 42.1 No 190 57.9 89c. Midwife Yes 180 54.9 No 148 45.1 89d. Auxiliary midwife Yes 9 2.7 No 319 97.3 152 89e. Other health staff with midwifery skills Yes 3 0.9 No 325 99.1 89f. Trained traditional birth attendant Yes 28 8.5 No 300 91.5 89g. Trained community health nurse Yes 6 1.8 No 322 98.2 89h. Traditional birth attendant Yes 4 1.2 No 324 98.8 89i. Community health worker Yes 3 0.9 No 325 99.1 89j. Relative/friend Yes 1 0.3 No 327 99.7 89y. No one Yes 0 0 No 328 100 90a. Convulsions Yes 82 25 153 No 246 75 90b. Fever Yes 248 75.6 No 80 24.4 90c. Poor suckling or feeding Yes 156 47.6 No 172 52.4 90d. Fast/difficult breathing Yes 99 30.2 No 229 69.8 90e. Baby feels cold Yes 57 17.4 No 271 82.6 90f. Baby too small/too early Yes 17 5.2 No 311 94.8 90g. Yellow palms/soles/eyes Yes 18 5.5 No 310 94.5 90h. Swollen abdomen Yes 52 15.9 No 276 84.1 90i. Unconscious 154 Yes 40 12.2 No 288 87.8 90j. Pus or redness of the umbilical stump, eyes or skin Yes 17 5.2 No 311 94.8 90x. Other Yes 76 23.2 No 252 76.8 91a. Saved money Yes 107 32.6 No 221 67.4 91b. Bought clean delivery kit Yes 310 94.5 No 18 5.5 91c. Found blood donor Yes 1 0.3 No 327 99.7 91d. Arranged of transport Yes 22 6.7 No 306 93.3 91e. Contacted health worker to help with delivery Yes 20 6.1 No 308 93.9 155 91x. Other Yes 82 25 No 246 75 91y. No preparation Yes 8 2.4 No 320 97.6 92. Did you ever breastfeed (name)? Yes 328 100 93. How long (in hours) did you first put child to the breast after birth? Immediately 245 87.2 1 15 5.3 2 9 3.2 3 2 0.7 4 1 0.4 5 1 0.4 6 1 0.4 10 2 0.7 13 2 0.7 20 1 0.4 Don’t remember 2 0.7 94. During the first three days after delivery, did you give (name) the liquid Yes 321 97.9 No 6 1.8 Don't know 1 0.3 95. First three days after delivery, was child given anything to drink 156 Yes 10 3.1 No 317 96.6 Don't know 1 0.3 96. What was child given to drink? Milk (other than breast milk) 2 25 Plain water 3 37.5 Gripe water 2 25 Other 1 12.5 97. Are you still breastfeeding (name)? Yes 318 96.9 No 10 3.1 98. For how many months did you breastfeed (name)? 3 1 9.1 12 1 9.1 15 1 9.1 16 1 9.1 19 2 18.2 20 2 18.2 21 1 9.1 22 1 9.1 23 1 9.1 99. Did child drink anything from a bottle yesterday or last night? Yes 57 17.5 No 268 82.5 100a. Breast milk? Yes 318 97 157 No 10 3 100b.Plain water? Yes 229 69.8 No 98 29.9 Don't know 1 0.3 100c. Commercially produced infant formula? Yes 42 12.8 No 285 87.2 100d. Any fortified, commercially available infant and young child food Yes 28 8.5 No 300 91.5 100e. Any (other) porridge or gruel? Yes 155 47.3 No 173 52.7 101a. Commercially produced infant formula? Yes 43 13.1 No 285 86.9 101b. Milk such as tinned, powdered, or fresh animal milk? Yes 51 15.5 No 277 84.5 101c. Cheese, yogurt, or other milk products? Yes 13 4 No 315 96 158 101d. Any fortified, commercially available infant food Yes 32 9.8 No 296 90.2 101e. Any (other) porridge or gruel? Yes 173 52.7 No 155 47.3 101f. Bread, rice, noodles, or other foods made from grains? Yes 154 47 No 174 53 101g. White potatoes, yam, cassava etc. Yes 32 9.8 No 289 90.2 101h. Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside? Yes 38 11.6 No 289 88.4 101i. Any dark green leafy vegetables? Yes 124 37.9 No 203 62.1 101j. Ripe mangoes, papayas etc Yes 55 16.9 No 271 83.1 101k. Foods made with red palm oil, palm nut, palm nut pulp sauce? Yes 56 17.2 159 No 270 82.8 101l. Any other fruits or vegetables like oranges, grapefruit or pineapple? Yes 63 19.3 No 264 80.7 101m. Eggs? Yes 60 18.4 No 266 81.6 101n. Liver, kidney, heart or other organ meat Yes 39 11.9 No 288 88.1 101o. Any meat, such as beef, pork, lamb, goat, chicken, or duck? Yes 61 18.7 No 265 81.3 101p Fresh or dried fish or shellfish? Yes 65 19.9 No 262 80.1 101q. Grubs, snails, insects, other small protein food Yes 7 2.2 No 318 97.8 101r. Any foods made from beans, peas, lentils, or nuts? Yes 116 35.5 No 211 64.5 160 101s. Any oils, fats, or butter Yes 87 26.6 No 240 73.4 101t. Number of groups ticked 0 110 33.8 1 34 10.5 2 47 14.5 3 20 6.2 4 28 8.6 5 25 7.7 6 20 6.2 7 22 6.8 8 19 5.8 101u. Tea or coffee? Yes 61 18.8 No 264 81.2 101v. Any other liquids? Yes 102 31.4 No 223 68.6 101w. Any sugary foods, such as chocolates, candy, sweets, pastries, cakes, Yes 59 18.3 No 264 81.7 101x. Any other solid or soft food? Yes 115 37.1 No 194 62.6 161 Don't know 1 0.3 102. How many times did (name) eat solid, semi-solid, or soft foods other than liquids yesterday? 0 121 36.9 1 13 4 2 23 7 3 70 21.3 4 28 8.5 5 17 5.2 6 6 1.8 7 13 4 Don’t know 37 11.3 103. Has (name) ever received a Vitamin A dose? Yes 228 69.5 No 96 29.3 Don't know 4 1.2 104. Did (name) receive a vitamin a dose within the last 6 months? Yes 178 77.4 No 50 21.7 Don't know 2 0.9 105. Is salt in household iodized? Not iodized (0 ppm) 193 59.8 Less than 15 ppm 68 21.1 15 ppm or more 54 16.7 No salt in home 8 2.5 106. Children under five apart from name 162 Number (mean) SD 325 (2.04) 1.98 107. Number given birth to Number (mean) SD 322 (1.01) 0.96 108. May I weigh and measure (name) and the other children? Yes 319 99.1 No 3 0.9 109. Sex of child Female 158 48.5 Male 168 51.5 Weight in kg Number (mean) SD 325 (7.84) 2.19 Height in cm Number (mean) SD 321 (70.0) 11.97 How measured Lying down 310 98.1 Standing up 6 1.9 163 Annex 7: Summary of Baseline and Endline Indicators Baseline indicators Endline indicators Indicator Num Deno % ±(95 %CI) Num Deno % ±(95 %CI) P-value Antenatal Care Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child 249 313 80% 6 268 328 82% 6 0.001 Tetanus injection Percentage of mothers with children age 0-23 months who received at least 2 tetanus toxoid vaccinations before the birth of their youngest child 200 313 64% 8 233 328 71% 7 0.519 Skilled Birth Attendant Percentage of children age 0-23 months whose births were attended by skilled personnel 135 313 43% 8 250 328 76% 7 0.058 Post-Natal Visit to Check on the Newborn Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after birth 95 313 30% 7 273 328 83% 6 <0.001 Current Contraceptive Use Among Mothers of Young Children Percentage of mothers of children age 0-23 months who are using a modern contraceptive method 69 313 22% 6 115 328 35% 7 <0.001 Ever breastfed Percent of children aged 0-23 months ever breastfed 313 313 100% 0 328 328 100% 0 - Exclusive breastfeeding Percentage of children age 0-5 months who 49 105 47% 72 103 70% 12 164 were exclusively breastfed during the last 24 hours 13 0.001 Bottle use Percent of children aged 0-23 months who had anything by bottle in the 24 hours preceding survey 47 313 15% 6 57 328 17% 6 0.490 Contnued Breastfeeding 6- 11 months Percent of children aged 6-11 months who are still breastfeedin 88 92 96% 6 123 124 99% 2 0.144 Contnued Breastfeeding 12-17 months Percent of children aged 12-17 months who are still breastfeeding 65 67 97% 6 89 90 99% 3 0.358 Contnued Breastfeeding 18-23 months Percent of children aged 18-23 months who are still breastfeeding 38 46 83% 15 58 65 89% 11 0.362 Vitamin A Supplementation Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 152 205 74% 8 173 223 78% 8 0.332 Vitamin A supplementation Mother Percentage of mothers of children age 6-23 months who received a dose of Vitamin A in the first 2 months after delivery – reported 119 205 58% 10 159 223 71% 7 0.005 Measles Vaccination Percentage of children aged 12-23 months who received measles vaccine according to the vaccination card or mother’s recall by the time of the survey 107 113 95% 6 107 120 89% 8 0.093 Access to Immunization Percentage of children aged 12-23 months 109 113 96% 114 120 95% 6 165 Services who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 5 0.713 Health Systems Performance Regarding Immunization Services Percentage of children aged 12 -23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 107 113 95% 6 113 120 94% 6 0.738 Treatment of Fever in Malarious Zones Percentage of children age 0 -23 months with a febrile episode during the last two weeks who were treated with an effective anti -malarial drug within 24 hours 15 156 10% 7 27 156 17% 8 0.070 ORT Use Percentage of children age 0 -23 months with diarrhea in the last two weeks who received oral rehydration solution and/or recommended home fluids 60 126 48% 12 97 149 65% 11 0.005 Appropriate Care Seeking for Pneumonia Percentage of children age 0 -23 months with chest -related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 35 73 48% 16 40 64 63% 17 0.078 Point of Use Water Treatment Percentage of households of children age 0 -23 months that treat water effectively 12 313 4% 3 1 3 33% 75 0.013 Appropriate Hand Washing Practices Percentage of mothers of children age 0 -23 months who live in households with soap at the place for hand 89 313 28 151 328 46% 8 166 washing 7 <0.001 Infant and Young Child Feeding Percent of children age 6-23 months fed according to a minimum of appropriate feeding practices 112 205 55% 10 174 223 78% 8 <0.001 ITN Ownership ITN Ownership: Percentage of households of children age 0-23 months that own at least one insecticide-treated bed net 141 313 45% 8 233 328 71% 7 <0.001 ITN Use Percentage of children age 0-23 months who slept under an insecticide-treated bed net the previous night 132 313 42% 8 232 328 71% 7 <0.001 Underweight Percentage of children age 0-23 months who are underweight (-2 SD for the median weight for age, according to WHO/NCHS reference population) 135 313 43% 8 52 322 16% 6 <0.001 Iodized Salt Percentage of households with Iodized salt (tested as 15 ppm or more) the day of the study 13 313 4% 3 54 328 16% 6 <0.001 IPT during Pregnancy Percentage of mothers of children age 0-23 months who received Intermittent Preventive Treatment (IPT) for malaria during the pregnancy with the youngest child 185 313 59% 8% 189 328 58% 8% 0.797 Clean Cord Care Percent children age 0- 23 months that had clean cord care at the time of birth 68 313 22% 6% 240 328 73% 7% <0.001 Clean Cord Cutting Percent children age 0- 23 months that had clean cord cutting at 251 313 80% 6% 269 328 82% 6% 167 the time of birth 0.519 Active Management of the third stage of labor (AMTSL) Percent of mothers of children age 0 -23 months who received AMTSL after the birth of her youngest child 103 313 33% 7% 164 328 50% 8% <0.001 Post -Partum visit for the mother Percentage of mothers of children age 0 -23 who received a post - partum visit from an appropriate trained health worker within two days after the birth of the youngest child 101 313 32% 7% 269 328 82% 6% <0.001 Immediate Drying Percent of children age 0-23 months who were dried immediately after birth. 302 313 96% 3% 317 328 97% 3% 0.490 Immediate Wrapping Percentage of children age 0 -23 months, who were wrapped with a cloth or blanket immediately after birth. 299 313 96% 3% 316 328 96% 3% 1.000 Thermal Care (Immediate drying and wrapping) Percentage of children age 0 -23 months who were dried and wrapped with a cloth or blanket immediately after birth 296 313 95% 4% 311 328 95% 3% 1.000 Immediate breastfeeding of newborns Percentage of children age 0 -23 months who were put to the breast within one hour of delivery 155 313 50% 8% 247 328 75% 7% <0.001 Birth Preparedness Percentage of mothers of children 0 -23 months who made preparations before the birth of the their youngest child 49 313 16% 6% 133 328 41% 8% <0.001 Knowledge of Healthy Timing and Spacing of Percentage of mothers of children age 0 -23 months who know that 267 313 85% 286 328 87% 5% 168 Pregnancies a woman should wait 24 months after the live birth of her child before trying to get pregnant again. 6 0.465 Knowledge of Risk Associated with Birth to Pregnancy Intervals Less than 24 Mont Percentage of mothers of children age 0 -23 months who know at least two risks of having a birth to pregnancy interval of less than 24 months. 110 313 35% 7 177 328 54% 8 <0.001 Knowledge of MTCT of HIV Percentage of mothers of children age 0 -23 months who know that HIV can be transmitted from an HIV -positive mother to her unborn child during pregnancy, during delivery, and through breastfeeding. 189 313 60% 8 175 328 53% 8 0.074 Knowledge of PMTCT of HIV Percentage mothers of children age 0 -23 months who know that there are special medications that can be given to a pregnant woman infected with HIV to reduce the risk of mother -to -child transmission. 114 313 36% 8 213 328 65% 7 <0.001 Quality Antenatal Care Percentage of mothers of children age 0 -23 months who had four or more antenatal visits with a skilled provider and were adequately counseled when they were pregnant with the youngest child. 116 313 37% 8 168 328 51% 8 <0.001 HIV Testing During Pregnancy Percentage of mothers of children 0 -23 months who were counseled about HIV during the pregnancy, 79 313 25% 119 328 36% 7 169 accepted an offer of testing, and received their test results when they were pregnant with their youngest child. 7 0.003 Knowledge of Danger Signs during Pregnancy Percentage of mothers of children 0-23 months who knew at least two danger signs during pregnancy. 254 313 81% 6 283 328 86% 5 0.088 Iron Tablets for Pregnant Women Percentage of mothers of children age 0-23 months who took iron tablets before the birth of their youngest child. 254 313 81% 6 239 328 73% 7 0.016 Trained Delivery Attendant Percent of children age 0-23 months whose births were attended by a trained provider including a trained TBA. 248 313 79% 6 307 328 94% 4 <0.001 Clean Birth Kit Percentage of women of children age 0-23 months who used a clean delivery kit during the birth of their youngest child. 205 313 65% 7 313 328 95% 3 <0.001 Knowledge of Maternal Danger Signs During Delivery Percentage of mothers of children 0-23 months who know at least two danger signs during delivery. 215 313 69% 7 236 328 72% 7 0.405 Feeding Colostrum Percentage of children age 0-23 months, who were fed colostrum after birth. 300 313 96% 3 321 328 98% 2 0.136 Pre-lacteal Feeds Percentage of children age 0-23 months who did not receive pre￾lacteal feeds. 287 313 92% 4 317 328 97% 3 0.005 Essential Newborn Care Percentage of children age 0-23 who received all three elements of 36 313 12% 171 328 52% 8 170 essential newborn care: thermal protection immediately after birth, clean cord care, and immediate and exclusive breastfeeding. 5 <0.001 Prophylactic Eye Care Percentage of children age 0-23 months who received appropriate preventive eye care within the first hour after birth. 58 313 19% 6 83 328 25% 7 0.067 Knowledge of Post-partum Danger Signs Percentage of mothers of children age 0-23 months who knew at least two post-partum danger signs. 241 313 77% 7 284 328 87% 5 0.001 Knowledge of Neonatal Danger Signs Percentage of mothers of children age 0-23 who know at least two neonatal danger signs. 225 313 72% 7 263 328 80% 6 0.018 Vitamin A-rich food 6-23 months Percent of children aged 6-23 months who ate vitamin A-rich foods in 24 hours preceding survey 155 205 76% 8 161 223 72% 8 0.346 Iron-rich food 6- 23 months Percent of children aged 6-23 months who ate iron-rich foods in 24 hours preceding survey 152 205 74% 8 173 223 78% 8 0.332 Fortified food 6- 23 months Percent of children aged 6-23 months who ate fortified food in 24 hours preceding survey 18 205 9% 5 30 223 13% 6 0.188 Animal source flesh food 6-23 months Percent of children aged 6-23 months who ate beef, game, poultry, fish, shellfish, or organ meat in 24 hours preceding 148 205 72% 9 120 223 54% 9 <0.001 171 survey Egg 6-23 months Percent of children aged 6-23 months who ate eggs in 24 hours preceding survey 44 205 21% 8 58 223 26% 8 Dairy 6-23 months Percent of children aged 6-23 months who had dairy in 24 hours preceding survey 21 205 11% 6 74 223 33% 9 <0.001 172 ANNEX VI. COMMUNITY HEALTH WORKER TRAINING MATRIX Project Area (Name of District Or Community) Type of CHW Official Government CHW or Grantee￾Developed Cadre Paid or Voluntee r Number Trained Over Life of Project Focus of Training Male Femal e East Mamprusi Community Health Officers and Community Health Nurses Official Government CHW Paid 15 20 - Emergency Obstetric Care - Essential Newborn Care East Mamprusi Healthy Mothers and Newborn Care Grantee Developed Cadre Volunteer 960 720 - Community Mobilization for MNC - Operations and Management of Walls of Good Health East Mamprusi Community Health Officers and Community Health Nurses Official Government CHW Paid 15 20 - Malaria in Pregnancy - Strategies - Essential Nutrition Action - Lactation Management and Infant and Young Child Counselling Skills East Mamprusi Traditional birth attendants/Traditional Medical Practitioners Government Volunteer 512 352 - Dangers in pregnancy - Importance of skill assisted deliveries - Danger signs in newborns - Referrals and its importance - Home visiting Techniques - Essential Newborn Care Sakogu Sub District Council of Champions Grantee Developed Cadre Volunteer 112 88 - MNC and related PRABs - Home Visiting Techniques - Communication Techniques - Roles and Responsibilities East Mamprusi Positive Deviant Mothers Grantee Developed Cadre Volunteer 0 480 - Delivery of SBCC messages on MNC - Nutrition Behaviour Change Communication - Maternal and Child Nutrition East Mamprusi/Zonal Community Health Volunteers Government Volunteer 300 284 - Community-based MNC data collection and reporting - Mobilization and sensitization of EPPICS Strategies - Malaria Prevention Strategies 173 ANNEX VII. EVALUATION SCOPE OF WORK Terms of Reference for Final Evaluator External Consultant for the Encouraging Positive Practices for Improving Child Survival Project in East Mamprusi District of Northern Ghana Revised December 2015 I. Introduction Catholic Relief Services – USCCB Ghana Program will hire an independent consultant to complete the final performance evaluation (FE) report for the “Encouraging Positive Practices for Improving Child Survival” (EPPICS) project funded by USAID’s Child Survival and Health Grants Program (CSHGP) AID￾OAA-A-11-00042, October 1, 2011 – September 29, 2015. The initial report has already been provided by the consultant who was hired previously, however a decision was made to cancel that contract and identify a new consultant who would be able to finalize the evaluation report in line with guidance provided by CSHGP and on time. As part of this consultancy contract, the materials created thus far (draft evaluation report, project data etc.) will be made available to the successful candidate with the view of finalizing the draft evaluation report under this consultancy. Headquarters Contact: Field Office Contact: Elena McEwan Kris H. Ozar Catholic Relief Services - U.S.C.C.B Catholic Relief Services - U.S.C.C.B Senior Technical Advisor for Health Country Representative - Ghana Program Quality and Support Department P.O Box 6333 Accra-North 228 West Lexington Street Accra, Ghana Baltimore, MD 212012 kris.ozar@crs.org elena.mcewan@crs.org In East Mamprusi District of the Northern Region of Ghana, USAID’s CSHGP supports community￾oriented projects implemented by U.S. private voluntary organizations (PVOs) and nongovernmental organizations (NGOs) and their local partners. The purpose of this program is to contribute to sustained improvements in child survival and health outcomes by supporting the innovations of PVOs/NGOs and their in-country partners in reaching vulnerable populations. This document describes the Final Evaluator’s Scope of Work (SOW) for the EPPICS Final Evaluation. In spite of national strides to strengthen health services to meet MDGs 4 and 5 in Ghana, maternal and infant mortality and morbidity remain much higher in the Northern Region (NR) than in the rest of the country. Ghana Health Services (GHS) and their partners are implementing the high-impact, evidence￾based interventions to improve the situation. Most of their efforts have focused on health services only at the facility level. Gaps remain at the community/household levels, both in improving service delivery and in overcoming harmful cultural practices which pose barriers to seeking skilled health care for Maternal, Newborn and Child Health and Nutrition services. The EPPICS project was therefore designed to couple facility based health services with innovative community strategies to close those gaps. The goal and strategic objectives of the EPPICS project: 174 EPPICS targets an estimated 27,000 women of reproductive age and 24,000 children (< 5 years) and has the following goal and strategic objectives: To contribute to sustainable maternal/newborn morbidity/mortality reduction in East Mamprusi District of Northern Region of Ghana by 2015: • SO1: East Mamprusi District has improved maternal and neonatal health outcomes • SO2: Families have increased access to quality maternal and neonatal services The key project strategy will be to scale up community-led strategies that enhance positive Maternal, Newborn and Child Health/Nutritional practices and service utilization. Technical interventions include: Maternal and Newborn Care (60%), Nutrition (30%) and Malaria in Pregnancy (10%). CRS and GHS will scale-up a motivational community mobilization strategy using Healthy Mother and Newborn Committees (HMNC), Positive Deviant Inquiry and, as part of the community information system (CIS), the Giant Community Scoreboards for communities to track progress on process indicators and provide feedback to community members. At the Health Facility, CRS and GHS will improve health staff counseling skills to improve quality in health worker-client communication in response to identified gaps. II. Background Ghana ranks 138 on the UN Human Development Index and is considered to be a medium development country15. The three northern regions of Ghana have significantly poorer MNCH/N Indicators than the rest of the country.16 (See Table 1) East Mamprusi (EM) District is one of the poorest districts in the Northern Region (NR).17 It is divided into 5 sub districts with 240 settlements of about 200-500 inhabitants each.18 Average family size is 7 and 48% of married women are in polygamous unions.19 A high percentage of men and women migrate to other regions looking for work, sometimes leaving young children behind in the care of relatives.20 Mamprusi are the dominant ethnic group (84%); the population is 70% Muslim and 30% Christian or traditional African religions. 78% of women are illiterate, and 1 in 6 pregnancies occurs in girls 15-19 years old.21 14http://hdr.undp.org/en/statistics/. 15 http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/GHA.pdf 16 Ghana Demographic and Health Survey (GDHS) (2010) 17 EM GHS Annual Report 2010. 18 EM District Assembly Website and EM GHS Annual Report 2010 19EM District Website. 20 EM District Assembly Annual Report, 2010 21 Ghana Statistical Service et al, Districts MICS Report, 2009 Table 1: Mortality and Fertility Statistics, Northern Region and Ghana (National)14 Indicator NR National U5 Mortality Rate 137 80 IMR 70 50 NNMR 35 30 MMR n/a 187 TFR 6.8 4.0 175 Over 60% of IMR in Ghana is in the newborn period.22 Ghana’s MMR (2007) was estimated at 451, but it is considered to be much higher in NR.23 Causes of maternal death listed were anemia, obstructed labor, sepsis, and hemorrhage. Neonatal deaths in EM are attributed to asphyxia, low birth weight/prematurity and infections; reported stillbirths are increasing.24 Poor uptake of Malaria in Pregnancy (MIP) services such as LLIN utilization and Intermittent Presumptive Therapy (IPT) for Malaria completion also impacts on maternal anemia, low birthweight and perinatal mortality, including stillbirths. Additional factors contributing to poor maternal and newborn outcomes include delays in recognition of danger signs (in both mother and newborn) and low institutional deliveries as illustrated in Table 2. Malaria and anemia are the leading causes of Out Patient Department visits and hospital admissions. Over 95% of pregnant women have at least one ANC visit, but only 46% complete 4 or more visits. The majority (70%) do not report for their first ANC visit until the third trimester.25 Pregnant women, especially first-time mothers, do not have the power to make decisions themselves whether or not to use skilled health services.26 A UNICEF study found that 68% of mothers trusted skilled health professionals, but only 21% of first time mothers would use them. The study also identified Key Decision Makers (KDM) in the use of MCH services as mothers-in-law/fathers-in-law, especially at the time of delivery and complications. They also found that health workers’ negative attitudes contributed to choosing TBA-assisted delivery instead of skilled services.27 Only 15% of women with home births receive a post-natal check-up during the first week after delivery and early initiation of breastfeeding rates (within the first hour) were closely tied to skilled delivery rates.28 CRS investigated several factors related to access and use of MCH services in an NR district and found that even when geographic and financial access were adequate, socio-cultural and traditional practices were still significant barriers to receiving key evidence-based MNCH/N services.29 Because this is such an important factor influencing key maternal behaviors nation-wide, CRS and GHS focused the project Innovation in this area. Child under-nutrition contributes to 53% of U5 deaths in Ghana30 and 34% of U5 children are stunted in EM, much higher than the national average of 14%.31 Only 6.3% of newborns in the district are weighed 22 Ghana Demographic and Health Survey, 2008 23 Ghana Statistical Service et al (2009). Ghana Maternal Health Survey Report for 2007 24EM GHS Annual Report 2010. 25EM GHS Annual Report 2010 26 EM DHMT stakeholder’s meeting March 2011. 27 UNICEF C4D Five Key Health and Hygiene Final Report, 2010 28 UNICEF HIRD Report, 2007 29 CRS CIMACS Formative Research Report, 2008 30 GHS Policy document on malnutrition, 2008, HIRD report 2007 Table 2: MNCH/N Indicators EM, NR and National Indicator EM12 NR8 Ghana8 Supervised delivery 48 35.5 48.2 Antenatal visits (1st trimester) 30 49 55 Antenatal visits(4+) 46 58 78 IPT2+ 51 33 44 ITN use (pregnant women) 36 45 H/A -2 SD 39 31 28 W/A -2 SD 30 29 14 WRA (any anemia) 59 59 176 at birth, so it is difficult to estimate birth weight figures. The High Impact Rapid Delivery (HIRD) project found that factors in child under-nutrition include: anemia during pregnancy (often related to malaria); late initiation and low exclusive breastfeeding (16.1%); early introduction of sub-optimal complementary foods; micro-nutrient deficiency (especially vitamin A and iron); and the high prevalence of diarrhea.32 GHS promotes EBF for the first six months and continued breastfeeding for at least two years, with introduction of complementary foods starting at 6 months. In 2006, AED/GSCP conducted research to investigate the influence of cultural/traditional beliefs and perceptions on Infant and Young Child Feeding Practice in the EM area that uncovered myths about feeding colostrum to newborns. Many women believe that colostrum is dirty and “not healthy’’ for newborns and it is therefore commonly discarded. In NR, including EM, 34% of pregnant women were undernourished (BMI <18.5), almost double the national average of 17%. Health workers familiar with EM cultural practices said that pregnant women are given no additional or special foods during the pregnancy and energy expenditure is high from heavy workloads. After delivery, however, she is given abundant high quality food while she is lactating (for a strong baby). EM DHMT midwives said that when they try to counsel women about what foods to eat during pregnancy, women respond that the midwife “wants them to steal.” Only 35% ANC attendees are screened for Hb. 2010 facility-based data in EM on anemia showed that 19% and 10% of pregnant women were anemic at registration and at 36 weeks respectively33 but this underestimates the true situation. Data specific to EM on the uptake of Iron/Folic tablets in pregnancy is not available, but health workers report high levels of non-compliance with taking Iron/Folic tablets due to side effects and beliefs that they will lead to a large baby and difficult labor.34 Although GHS policy requires deworming pregnant women as an anemia control strategy, compliance by health facilities is low: only 26% of women who attend ANC receive an anti-parasitic drug.35 Iodized salt is not widely available, only 21% of pregnant women in the district and 28% at the regional level consumed iodized salt when it was last measured by HIRD in 2006.36 UNICEF confirms periodic reports of goiter in WRA and some cases of mental retardation related to iodine deficiency have been found in some infants in rural areas. UNICEF and partners are advocating at the national level for enforcement of the existing national salt iodization laws.37 EM GHS tracks maternal deaths that occur in facilities only.38 GHS and the Christian Health Association of Ghana (CHAG) administer formal health services in 7 health facilities, 6 with 24/7 capacity for deliveries and 4 that have vehicles for transport, but there are still many times when transport is not available.39 Regional GHS also reports that attempts to address emergency transport problems have “been a miserable failure.” CHAG facilities include the Baptist Medical Center (BMC), a referral hospital and the only facility with capacity for EmOC and ability to care for sick or premature newborns. HS intended constructing a fully-equipped hospital in the district capital since 2011.40 District health staff shortages, particularly staff capable of performing skilled deliveries, are severe; each facility averages only 31 GDHS,2008 32 HIRD MICS, 2007 33 EM GHS Annual Report 2010 34 Proposal Development Workshop in EM, March 2011 35GDHS, 2008. 36 UNICEF HIRD/MICS Report, 2007 37 Personal conversation with UNICEF MCH consultant March 2011 38 EM and MR Annual Reports 2009, 2010 39 EM DHMT Stakeholder’s meeting 40 GDHS 2008 and Personal Communication, RDHS NR, March 2011 177 50% of staff they need according to GHS standards. Many doctors assigned to work in the NR never report for duty and there are only two doctors currently working in the entire district. NR GHS has begun the training of Community Health Nurses (CHNs) to become midwives but these efforts have been slow. Community Health Volunteers (CHVs), usually two per community, serve as the outreach and surveillance arm of GHS, linked to the Sub district level. Many have been in place for decades and they are respected members of the community. GHS, supported by UNICEF, has extended their role to include Community Case Management (CCM) of Childhood Illness that was recently expanded from Home Base Management of Malaria to include zinc for diarrhea and antibiotics for pneumonia in children over 6 months of age. CHV will soon also provide Community Management of Acute Malnutrition (CMAM) with support of UNICEF. Improved MNCH services, including achieving progress in MDGs 4 and 5, are priorities of the MOH and GHS. GHS, with assistance from UNICEF, UNFPA and the Gates-Foundation supported Fives Alive! (5A) Project, has been working to improve quality of maternal and newborn care at the facility level, and increase coverage to IMCI at the facility and community level, including home-based management of childhood illnesses and CCM of childhood illness; improving Essential Obstetrical Care (EOC) and access to Emergency Obstetric and Newborn Care (EmOC), promoting birth plans and preparing for transport in case of complication in the mother or baby. World Food Program (WFP) provides supplementary food to pregnant women and children through GHS ANC services. United States Government (USG) health programs in Northern Region of Ghana include the President’s Malaria Initiative (PMI). PMI partners in NR include Research Triangle Institute (RTI) for IRS and ProMPT Ghana (University Research Corporation) for promoting ITNs, clinical case management, MIP and surveillance. PMI partners said that MIP is a particular challenge for them because increasing MIP indicators are linked with ANC and very dependent on demand-creation at household and community level. PMI sponsored a massive “hanging LLIN exercise” in May 2010 in NR and RTI began supporting Indoor Residual Spraying (IRS) in 2010. EM was included in USAID’s LINKAGES maternal and child nutrition and LAM project from 1997-2004 and Ghana was the country where impact evaluations were undertaken; CRS was an implementing partner in EM. USAID supports the CMAM strategy and EM is one of the beneficiary districts in NR. PEPFAR support for HIV/AIDS programs is present in Ghana, but EM and NR are low prevalence areas and therefore not priority areas for PEPFAR programs. Ghana is now both a Global Health Initiative (GHI) and Feed the Future (FtF) focus country. CRS MNCH programs in the northern regions included the promising Community-led Initiative for Maternal and Child Survival (CIMACS) pilot project funded by CRS in two districts in the adjoining Upper East Region. Lessons learned and best practices from CIMACS are the basis for the proposed CRS CSP strategy. CIMACS has had success in increasing early ANC registration, skilled delivery and Exclusive Breastfeeding (EBF), all challenges identified by GHS and international organizations. CIMACS approach has been enthusiastically received by communities, local government, UNICEF, and GHS and CRS has received requests from other districts to introduce the program. Although the LINKAGES and Title II-supported Food Assisted Child Survival (FACS) have both ended, there is evidence that both had a sustainable, positive effect on community-level MNCH/N activities in partnership with GHS. The CRS CSP interventions complemented several targeted activities implemented by other actors without duplication of effort, as described further in the Project Strategy and Innovation sections. 178 East Mamprusi District was selected as the project site from five potential districts recommended by the Northern Region Director of GHS after choosing the Northern Region based on discussions at the national level. The final choice was based on high rates of maternal, newborn and infant mortality, chronic malnutrition, and low utilization of MNC services. Other factors included a previous positive partnership experience between GHS and CRS in the same district (with different MCH/N activities); a supportive DHMT with corresponding MNCH/N goals and objectives and suitability of the district as a setting to effectively implement and test the project Innovation. The project design, including RF was developed jointly with EM DHMT with input from GHS and their health partners, including UNICEF and PMI implementing organizations at the Regional Level. MIP was specifically mentioned as a “gap” by GHS and PMI partners that must be addressed using community level interventions. This is based on low IPT3 uptake and maternal LLIN utilization. III. Project Population Beneficiaries* Total Total Population 139,606 Total Neonates 5,584 Infants aged 0–11 Months 5,584 Children aged <5 Years 27,921 Women of Reproductive Age (15–49 years) 30,713 Total Beneficiaries 58,634 Expected Pregnancies 5,584 Community Health Workers or Volunteers (CHWs), Disaggregated by Sex Males=255 Females=255 Health Facilities (Hospital to Sub Health Post) 12 Community-Based Structures (e.g., Village Development Committees [VDCs]) 175 *Source: District Health Information System II, Ghana IV. Partners Project activities are designed to contribute to Ghana MOH and GHS MNCH/N policies, USAID’s Health Program, Global Health Initiative (GHI) and NMCP/PMI objectives, all focus on contributing progress toward progress in MDGs 4 and 5. Within the District, project implementation is done by GHS, with TA and support from CRS at every level: DHMT, Sub district, Health Center CHPS and outreach points. All activities are jointly planned, implemented, supervised and evaluated in partnership with GHS. The HMNC will advocate for change through civil society structures, primarily with the 41 EM GHS Annual Report, 2010 calculated to 2012 with 3% Annual Growth Rate (per EM District Assembly) Table 3: Estimated Beneficiary Population (WRA+U5 Children)41 Percent Number WRA 15-49 22 26,881 Children 0-59 months 20 24,437 Beneficiaries (WRA + children 0-59 months) 42 51,318 Total EM District Population 100 123,626 179 District Assembly whose representatives in the community sit on the HMNCs. The District Community Development Officer (CDO), a local expert on overall community mobilization is included in planning activities and District and Sub district Activity Planning and Supervision. V. Key Activities Technical interventions for the project is integrated based on the Minimum Activities for Mothers and Newborns (MAMAN)42 Framework for Maternal and Newborn Care43 technical intervention activities at all levels of the project. The project provides several specific preventative and health services interventions in all communities in the project area including those specifically identified to test the project Innovation. The nutrition component works through ongoing improvement of the quality of prenatal care, focusing on improvement in the capacities of health care personnel to provide counseling to pregnant women regarding diet and counseling mothers in breastfeeding and complementary feeding during ANC and postnatal care. At the community level TBAs and CHWs counsel mothers regarding quantity and quality of food during pregnancy, lactation, BF and complementary feeding as well. MIP component is included in both MNC and Nutrition. The social and BCC strategy at the household and community level is essential in achieving SO1 and its IRs. Community organization and mobilization supports the achievement of SO2 and its IRs. Activities at the District Level include information sharing and advocacy with the District Assemblies. The MNC component have an impact on the three delays that contribute to maternal and neonatal morbidity and mortality, the delays of 1) recognizing harmful practices and danger signs, 2) decision making in seeking appropriate care, and 3) diagnosing and providing timely care. The first and second delays are addressed through the behavioral changes strategy and by improving community response to maternal and neonatal complications via the Innovation’s Community-led responses to Maternal and Newborn Care. The third delay is addressed by strengthening GHS capacities and quality of care. THE FOLLOWING ARE SOCIAL AND BCC ACTIVITIES THAT WILL CONTRIBUTE TO SO1: At the Community and Household Levels, EPPICS combines tested methodologies developed in earlier projects including the recent CIMACS project to link communities with GHS by providing networks of support and encouragement to use existing and improved MNCH/N health services. Key components of the EPPICS strategy include a package of technical interventions and strategies at multiple levels (individual/household and community). 1. Creation of Healthy Mothers and Newborn Committees (HMNCs). The HMNCs comprises of influential members of the community, both men and women, who are able to influence the male and female household decision-makers with regard to mothers and newborns. HMNCs include one or two grandmothers, two CHVs; one active TBA; one or two religious leaders, compound heads (male head of a large extended family all living in one compound), traditional healers, and the community’s District Assembly Representative. Members of the HMNC will each have different roles and responsibilities. The 3 or 4 most influential people will not be in the HMNC but instead will be in the Council of Champions (CoC) described in the Innovation section below. The HMNC implement a standardized SBCC and capacity building approach using “action messages” to mobilize communities to 42 USAID Global Health Bureau, Child Survival and Grants Program, 2007 43 Thermal care, cord, care, and immediate and exclusive breastfeeding; and sick newborn care including identification and treatment of neonatal infection and complications, resuscitation, and special care of preterm and low birth weight infants. 180 1) develop community birth plans, especially providing for transport and expenses that currently pose barriers; 2) engage newborns’ fathers and fathers-in-law to support household birth plans and promote and encourage pregnant women and new mothers to practice preventive and curative MNC and nutrition behaviors; and 3) organize and influence women through community women leaders. Specific MNCH/N messages for religious leaders,44 both Muslim and Christian that were developed by IMA as partners in USAID’s former ACCESS project, will be adapted for use by religious leader members of the HMNCs, depending on the community’s religious orientation(s). 2. PD Inquiry as an approach applied to HMNC.45 This strategy is based on an approach that has been successfully applied to increase key MNCH/N indicators in the CIMACS project to identify women in the community who were able to overcome factors that have led to low MNCH/N utilization. PD mothers are selected because they 1) registered early for ANC, 2) used skilled delivery and 3) employ newborn care practices that are known to prevent mother and baby deaths. The PD mothers penetrate (false) beliefs and cultural barriers in spite of facing the same obstacles as other women in the same community.46 Well-trained CHVs identify the PD mothers and study what they have done and the project uses that information as the basis for the SBCC strategy in that particular community. It also contributes to developing and targeting effective BCC face-to-face messages. This approach also raises the perception of women’s capabilities to contribute to the household and their communities. Experience shows these mothers have good access to households to conduct visits and are very effective face-to-face peer counselors.47 3. Community Pregnancy and Newborn Surveillance and Education Sessions with Home Visits: PD leader mothers trained and assisted by CHVs, TBAs and GHS focal points (with Capacity Building from CRS) implement the SBCC strategies during bi-weekly group meetings. PD group mothers follow up these meetings with face-to-face counseling home visits. The ratio of PD mothers to pregnant/lactating women are 1:10-15 depending on the configuration of the community. Growth monitoring and mother-to-mother BF support group volunteers are invited to become involved with these groups as appropriate. These groups have specific SBCC activities promoting maternal nutrition and preparation for early initiation of breastfeeding. They collect data for the project and GHS HIS. 4. Mother-to-Mother Breastfeeding Support Groups revitalized: The groups support early initiation and exclusive breastfeeding and introduces complementary feeding at 6 months. Baseline assessments determine groups’ knowledge and activities related to maternal nutrition, Complementary Feeding and the Lactational Amenorrhea Method for birth spacing, and integrate them into the Community Pregnancy and Newborn Surveillance and Education Sessions based on their capacity. 5. Using CBIS for Community Motivation and Feedback with “Community Giant Scoreboard” (CGS): HMNCs use data to display publicly the numbers of home or facility-based deliveries and other project indicators. This allowed for spirited discussion at the local level where the information would normally only be reported in one direction, to the national GHS Health Information System. Experience in CSPs implemented by other PVOs such as World Relief, Plan International, Salvation Army World Service Organization, Medical Teams International and Food for the Hungry showed that collecting data through Community Based Information Systems allows for analysis at the 44 IMA and JHPIEGO, ACCESS Project. 45 This is an approach for pregnant/lactating women and not PD/Hearth for rehabilitating malnourished children. 46This is complementary to, but not synonymous with, Doer-Nondoer SBCC formative research. 47Capps, J. et al World Relief Rwanda FE 2006, Plan International Kenya 2009, Medical Teams International Liberia, 2010 CSHGP Evaluation Reports. 181 level where it is collected.35 Community Giant Scoreboards,48 developed by CRS, is an easily implemented and understood method of feedback that demonstrates to the whole community to what degree their contributions have been successful. They have been shown to generate enthusiasm and motivate communities in their role as advocates for mothers and babies. The high visibility keeps the MNCH/N efforts in the forefront of the communities’ attention and becomes a form of visible, friendly competition among communities. UNICEF representatives that have seen CGS in communities have recommended scale up to all NR communities and CRS has received several requests to start them in other districts. Maternal and Newborn Care: The project focuses on minimum activities for mothers and newborns using the Community Birth Plans (CBP) strategy. GHS staff members received an orientation to the CBP strategy. The limiting factors in complete roll-out were lack of time and lack of skills in community organizations. The project works alongside GHS staff to implement the strategy in all communities, transferring the skills and attitudes needed for community organization through modeling and discussion. Key components of CBP include organizing community emergency transport systems and emergency medical funds, and training CHVs and TBAs to enable them to transmit messages. Part of CBP is training TBAs, CHVs, and staff who provide pre-natal care to assist families in filling out a format which guides them through planning for the birth of their child and any eventual emergency. Key messages include; ANC check up in the first trimester, at least four ANC check-ups from health facilities, advantages to an institutional deliver, IPT intake, use of LLIN, danger signs, immediate medical care at the first sign of complication, postpartum check-up within 24-48 hours after delivery and the importance of a family birth plan to be ready for delivery and any complications. CBP includes a Community Information System (CIS) to track pregnant women, births, and deaths. This data is reported to the Health Facilities. CRS and GHS work with CHVs to interpret the data. It is lack of understanding how to derive meaning from the data that most often impedes utilization of data for planning and evaluation. The innovation in this project contributes to the success of CBP. In addition, TBAs are trained in essential newborn care: cord care, thermal care, immediate and exclusive breastfeeding, infection recognition and referral to health facilities. A limitation to TBAs promoting institutional births is that, in doing so, they are losing the remunerations they receive for attending births. On the other hand, the GHS health workers do not have the capacity (time nor transport) to visit every new mother to provide post-partum and neonatal check-ups. The project discussed with the GHS and community members the feasibility and potential of families being willing to pay TBAs for post-partum and newborn care visits when the woman delivers at the health center and returns home in less than 24 hours. Nutrition Interventions are integrated into the majority of the MNCH activities and delivery mechanisms of the overall project. Essential Nutrition Actions is the package of activities and services the project uses for capacity building in health facilities and SBCC at the household/community level. Specific behaviors target initiation of BF in the first hour and feeding colostrum, nutrition during pregnancy and lactation, anemia prevention and treatment and Lactation Management for maternal/infant health and Birth Spacing. ENA is an essential ingredient for the other technical interventions to meet their objectives. This includes health facility QI.49 Essential Nutrition Actions are also intentionally 48 Community-led M&E tool designed using available and affordable material with pictorial illustrations. The scores are kept with two sets of ten score sticks, either Green (desirable outcome) or Red (undesirable outcome). On the billboard and beneath the picture illustrations is a frame with 10 score holes for each of the 10 sticks that go into holes based on desirable or undesirable outcomes. 49UNICEF, C4D Report 2010. 182 integrated within the MNCH technical interventions to improve birth outcomes and decrease low birthweight, one of the major contributing factors to the district’s high chronic malnutrition rates in children. It also gives intentional increased emphasis on maternal nutrition which can have a profound impact on outcomes of both mother and baby. EPPICS addresses the “medical” side of maternal nutrition – deworming pregnant women, routine ANC blood tests, Iron/Folate, Vitamin A and access to iodized salt -- that are already included in GHS policies and protocols. The local nutrition situation is being assessed, including Household Food Consumption and Seasonal Patterns using Nutrition Program Design Assistant Tool for Program Planners50 and formative research using PRA/PLA, PDI or other appropriate tools/approaches. CRS provides ENA refreshers to health workers and ENA included in training for all community groups. CRS nutrition specialist’s reviews ANC maternal nutrition counseling content and job aids to determine if they correspond with ENA and assist GHS with any revisions. Joint analysis and problem solving with DHMT Nutrition and Safe Motherhood and Child Health Focal Persons will be used to adapt materials to meet the needs of EM MNCH/N clientele. MI and GHS specifically recommend that CRS develop MIP interventions to address gaps in nutrition and MIP at the household level. The project addresses two specific maternal household behaviors: 1) use of available LLINs and IPT3. While all pregnant women are targeted, reaching first time mothers receive extra emphasis because of the epidemiologic evidence that they are most likely to experience poor birth outcomes due to MIP. As part of this strategy, ‘DOTS’ approach is used to ensure uptake of IPT at the facility level. Also PD mothers during their home visits inspect/facilitate hanging of LLINs and encourage pregnant women and lactating mothers to sleep under these nets with their newborns. COMMUNITY ORGANIZING/MOBILIZING ACTIVITIES WILL CONTRIBUTE TO SO2 AS FOLLOWS: 1. Re-positioning TBAs as Link Providers as partners in skilled care: To encourage early and frequent ANC, maternal nutrition, skilled delivery and discourage home deliveries, ToT to GHS Focal Persons, midwives, CHOs and CHVs, are carried out who will in turn train TBAs in their new roles as Link Providers to Skilled HWs such as accompanying pregnant/postpartum women to facilities and assist with the HF delivery. This is already part of the EM DHMT plan, but they need support to roll it out in all communities. TBAs will become providers and teachers of ENC when babies are born at home. (This is not a traditional role for TBAs; the HMNC members negotiates these new roles for them within the community) TBAs also promote skilled post-partum and newborn care and accompany mothers and babies to a facility within 24 hours after a home birth for postnatal and newborn checkups. 2. Health Service Quality Improvement at the CHPS and Health facility level: EPPICS do not ignore the significant health manpower, health staff attitudes, and supply chain management challenges the NR and EMD face; these are being addressed by GHS with support of other partners.51 EPPICS filled the gaps in a comprehensive approach to link the formal health sector to communities and improve the skills of CHVs and TBAs, building a wider base of sustainable volunteer support to regularly reach every household with a pregnant/lactating mother. 50 CORE Group, Nutrition Working Group, 2010. 51UNICEF is supporting GHS to implement CIMCI, including CCM malaria CM, DD with zinc and antibiotics for children over 6 months; b) PMI partners addressing ITNs, IRS, CM and said IPTp supply chain c) Five Alive QI 183 EPPICS provides training in health worker interpersonal communication and counseling skills to address wide-spread reports of health worker disrespectful attitudes toward women52 and complaints about mixed messages that clients receive from health personnel.53 Several facilities MNC QI issues, including neonatal resuscitation training and EmOC are already targeted for TA by 5A and UNFPA. There is consensus between 5A, GHS and CRS that need still include: birth plans, maternal and newborn nutrition, IPT3 and Skilled Delivery, early postpartum/newborn checkups, and emphasis on early and exclusive BF. CRS also included maternal LLIN use. HW interpersonal and counseling skills was assessed at the baseline RHFA and use existing strategies that PVOs54 have successfully applied to improving health worker quality of care in other child survival programs. Partnership Defined Quality (PDQ) methodology is also used to gain insight into client perceptions of the quality of services, both from mothers who use services from those who do not. INNOVATION: Community-led responses to maternal and newborn care The problem: High maternal and neonatal deaths in East Mamprusi (EM) district have been attributed to two main factors: a) household beliefs and rituals that jeopardize the health of pregnant women and their unborn child and delays seeking ANC and b) recognition and danger signs (in both mother and newborn) to make timely decisions to seek care at health facilities. 70%55 of pregnant women sought ANC first during the third trimester of pregnancy, and only 48% used skilled birth attendants at deliveries. During the proposal design, health staff from EM reported that women were coming late to ANC meant they could not benefit from life-saving services available at the health facilities, such as HIV/AIDS and syphilis and anemia testing and treatment, and IPT. Also, low utilization of skilled staff during child birth increases risk of obstetric complications, such as rupture of uterus, hemorrhage or sepsis frequently seen at the referral hospital in EM. Low institutional deliveries also has a negative impact on early initiation of breastfeeding, subsequently exclusive breastfeeding practices and cord care.45 While speedy interventions are essential in the management of obstetric and neonatal emergencies, the ability of the health system to provide rapid interventions is mediated by challenging socio-cultural practices of mothers/fathers-in-law. Chiefs, Magazias, and Religious Leaders are the custodians of these practices and also dominate the obstetric and gynecologic scene in much of the rural districts of Ghana56. GHS and partners under the HIRD approach are increasing coverage and improving the quality of maternal and newborn care in 7 health facilities. These approaches, however, fall short of addressing the socio-cultural and traditional practices within communities and households which influence attitudes and behaviors that impacts negatively on the utilization of the MCH services.57,58,59 The innovation is 52 NR GHS Annual Report 2009 and EM GHS Annual Report 2010, and interview with Director Health Services, NR 2011 53 EM GHS Annual Report, 2010 and UNICEF C4D report 2010. 54World Relief, Salvation Army World Service Organization (SAWSO), Food for the Hungry, ARC, and Medical Teams International. 55 GHS statistic 56MoH (2008). National consultative meeting on the Reduction of maternal mortality in Ghana: Partnership for action. A synthesis report 57Poku-Boansi (2010) Combating maternal mortality in the Gushiegu district of Ghana: the role of rural transportation. Journal of Sustainable Development in Africa, Vol 12, No 5. 58Vaah E (2010) Reducing maternal and neonatal mortality in Ghana: the need for community focus approaches. Health Platform Forum. 59Senah K (2003).Maternal Mortality in Ghana: The Other Side. Research Review NS 19,1 (2003) 47-55 184 community-led and targets challenging socio-cultural practices. It is timely as Ghana repositions itself to roll-out HIRD approaches to enhance its chances of achieving health related MDG targets. Results of this intervention will contribute to influencing national and global approaches to address harmful practices, reinforcing new ones and the low use of MCH services. Operational research has been conducted throughout the project period to advance learning on social cultural barriers to improved maternal and child health. The results of this research will be available to the final evaluation consultant. VI. Purpose of the Final Evaluation The purpose of USAID’s CSHGP is to contribute to advancing the health system strengthening goals of Ministries of Health toward achieving sustained improvements in child survival and health outcomes, particularly among vulnerable populations, by supporting the innovative, integrated community-oriented programming of PVOs/NGOs and their in-country partners. CSHGP cooperative agreements offer unique opportunities to demonstrate the links between specific delivery strategies implemented within the CHPS zone and Health Centers as well as measured outcomes. The FE is intended as a performance evaluation but should be broadly accessible to various audiences including Ministries of Health (MOHs), and findings will contribute evidence relevant to global initiatives such as the Global Health Initiative and Feed the Future.60 It is important that the final evaluator consider the audiences listed below, when conducting the evaluation and writing the report. The FE provides an opportunity for all project stakeholders to take stock of accomplishments to date and to listen to the beneficiaries at all levels (Health Centers, CHPS compounds etc), including mothers and caregivers, other community members and opinion leaders, health workers, health system administrators, local partners, other organizations, and donors. The FE Report will be used by the following audiences as a source of evidence to help inform decisions about future program designs and policies:  In-country partners at national, regional, and local levels (e.g., MOH and other relevant ministries, district health team, local organizations, communities in project areas).  USAID (CSHGP, Global Health Bureau, USAID Missions), and other CSHGP grantees.  The international global health community. The FE report will be posted for public use at http://www.mchipngo.net and the USAID Development Experience Clearinghouse at https://dec.usaid.gov. VII. Methodology The evaluation methodology consists of a mixed-methods approach using both quantitative and qualitative data. The approach comprises both a desk review of secondary data sources as well as the draft evaluation report provided by the previous consultant, which would need to be finalized. At present, due to short timeframe to complete the report, collection of additional qualitative data from stakeholders to complement existing data is not envisaged but the consultant will rely on data that has been collected. Catholic Relief Services – USCCB Ghana Program will facilitate this sharing and feedback. 60 For more information on these two initiatives, visit http://www.usaid.gov and http://www.feedthefuture.gov. 185 Secondary Data: The final evaluator will review project reports (e.g. Detailed Implementation Plan; annual reports; Knowledge, practice, and coverage, Health Facility Assessment report, Operations Research final report and baseline; and final survey and any monitoring reports) to make assessments of project results in relation to the project design and targets set. The final evaluator should also review key U.S. Government/USAID strategic documents at the global and national levels relevant to the content of project. All relevant policy and strategy documents at the national level (e.g., MOH policies and strategies) are also crucial and should be used and referenced. Qualitative Data: Due to short time period available for completion of the draft evaluation report, no field visits are envisaged for this consultancy. Data collected by the previous consultant may be provided (if and as available) by CRS, or any other data that is available at CRS/Ghana level that may contribute to this consultancy. Limitations: The evaluation report must include a discussion of the methodological limitations of the evaluation. Additional guidance on reporting format is provided in the CSHGP Guidelines for Final Evaluations, specifically in the Final Evaluation Report Template included therein. VIII. Evaluation Questions The final evaluator and the evaluation team will use existing data collected or compiled during the life of the project, as well as additional data reviewed during the evaluation to answer the following questions: 1. To what extent did the project accomplish and/or contribute to the strategic objectives and Intermediate Results stated in the DIP?  Describe the extent to which the project was implemented as planned, any changes to the planned implementation, and why those changes were made.  How were results achieved? If the project improved coverage of high-impact interventions simultaneously, what types of integration enabled this? Specifically, refer to community based strategies and approaches and construct a logic model describing inputs, process/activities, outputs, and outcomes.  Document high impact interventions and its potential for scalability 2. What were the key strategies and factors, including management and partnership issues that contributed to what worked or did not work:  What were the contextual factors such as socioeconomic factors, gender, demographic factors, environmental characteristics, baseline health conditions, health services characteristics,61 and so forth that affected implementation and outcomes?  What capacities were built, and how? 61See Table 1 in the document here: http://heapol.oxfordjournals.org/content/20/suppl_1/i18.long 186  Were gender considerations incorporated into the project at the design phase or midway through the project? If so, how? Are there any specific gender-related outcomes? Are there any unintended consequences (positive and negative) related to gender? 3. Which elements of the project have been or are likely to be sustained or expanded? e.g., through institutionalization or policies  Analyze the elements of scaling-up and types of scaling-up that have occurred or could likely occur (dissemination and advocacy, organizational process, costs and/resource mobilization, monitoring and evaluation using the Expand Net resource for reference).62  Analyze the costs and resources associated with implementation relevant for replication or expansion, as well as estimated cost per beneficiary (using Marginal Budgeting for Bottlenecks, Lives Saved Tool, and Cost Benefit Analysis: A Primer for Community Health Workers, 63 or other tools). 4. What are stakeholder perspectives on the OR implementation, and how did the OR study affect capacity, practices, and policy? IX. Final Evaluator Characteristics and Expected Timeline The consultant will serve as the evaluation team. The consultant will coordinate closely with the Catholic Relief Services – USCCB Ghana Program team regarding tool finalization, evaluation methodology, timeline, and report finalization. Requirements: The consultant must be approved by USAID CSHGP and should meet the following minimum requirements:  Proven expertise and leadership in integrated community-oriented reproductive, maternal, newborn, and child health projects  conduct of evaluations (baseline, endline) using mixed methods  Experience with design, collection, and analysis using applied research methods in a program implementation context  Familiarity with public health system in Ghana  Demonstrated ability to communicate with and lead a team of stakeholders, staff, and national experts in participatory evaluation  Familiarity with USAID programming  Skill or familiarity with cost analysis methods for program assessments  Excellent analytical and writing skills (English)  Signed statement explaining any conflict of interest64 62http://expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Step%20Guide%20published.pdf 63https://apps.publichealth.arizona.edu/CHWToolkit/PDFs/Framewor/costbene.pdf 64 CSHGP grantees are required to hire an external evaluator for the final evaluation. That fiduciary relationship creates a conflict of interest that is minimized by the CSHGP requirement of submission of a draft evaluation report directly to the CSHGP. 187 Key Tasks of the Evaluator:  Review project documents and resources to better understand the project  Review and Refine the evaluation objectives and key questions based on the CSHGP guidelines in coordination with Catholic Relief Services – USCCB Ghana Program team and its partners  Interpret both quantitative and qualitative results and draw conclusions, lessons learned, and recommendations regarding project outcomes  Prepare draft report in line with the CSHGP guidelines and submit to Catholic Relief Services – USCCB Ghana Program on or before December 18, 2015  Prepare and submit the final report using CSHGP guidance, which is due at the USAID CSHGP GH/HIDN/NUT office on or before 90 days after the close out of the project X. Final Evaluation Report The FE report should follow the outline in USAID CSHGP’s Guidelines for Final Evaluations. A draft and final report, written by the final evaluator, must be submitted directly to CRS; CRS will submit the final report to CSHGP and copy the final evaluator. Draft and final reports should be submitted according to the submission instructions as indicated in the guidelines. Kris Ozar Catholic Relief Services - U.S.C.C.B Country Representative - Ghana P.O Box 6333 Accra-North Accra, Ghana kris.ozar@crs.org XI. Budget Include the allocated level of effort and budget, including what expenses will be covered (such as local travel). If expressions of interest are solicited, they should include a detailed budget listing the consultant’s daily rate and any foreseen expenses that may be incurred during this evaluation. International and local travel and lodging should not be included. XII. Deliverables At the conclusion of the consultancy period, the consultant is expected to complete the following deliverables:  Prepare a draft report in line with the CSHGP guidelines and submit to Catholic Relief Services – USCCB Ghana Program on or before December 18, 2015. Note that dates may be updated upon finalization of consultant contract.  Finalize and submit a project brief using compelling results from project strategies  Prepare and submit the final report by December 25, 2015 Note that dates may be updated upon finalization of consultant contract. 188 ANNEX VIII. EVALUATION METHODS AND LIMITATIONS Methods used by the evaluation team (and limitations) are described in the Final Evaluation report. The table included here provides further details. Method Number and duration Location Group discussion with mothers Two (around 15 mothers in each group); 2 hours per discussion Communities; One in an area where project has done well (Jawani); the second where the project has not done well (Tamboku) Group discussion with mothers (three sub￾groups of mothers in each session: those with children less than 1 year old, those with children around 5 years old, and those with children around 20 years old) Two (around 9 mothers in each group); 2 hours per discussion Communities; One in an area near a major health facility (Nalerigu); the second far from a major health facility (Yunyoranyiri) Interviews with health facility staff Five; around 30 minutes per interview Sakogu and Nalerigu Discussions with project staff Several; varying duration East Mamprusi and Tamale Discussions with project volunteers and other community members, representatives from project partners, and with coordinators of the household survey, operations research studies, and facility surveys Several; varying duration East Mamprusi and Tamale Discussion with Catholic Relief Services￾Accra staff One hour-long discussion Accra 189 ANNEX IX: DATA COLLECTION INSTRUMENTS Guide for Discussion with Mothers  Source, timing, and frequency of antenatal care  Participatory diagramming (before discussion of delivery)  Place where deliveries occur (and transportation used to reach the place)  Birth attendant  Breast feeding and introduction of other foods  Use of bed nets  Opinion about project activities Guide for Interview with Head of Health Facility (facility that provides obstetric services)  Schedule of services  Types of services (especially types of obstetric services)  Staff (number, qualifications, and responsibilities) [especially staff handling obstetric, anesthesia, and surgical services]  Equipment (especially equipment for obstetric and neonatal services)  Medicines (especially medicines used in obstetric services)  Cost of consultation, procedures, and treatment (especially for obstetric services)  Use of services (number of patients, waiting periods)  Thoughts about improving services Guide for Interview with Pharmacist at Health Facility (facility that provides obstetric services)  Qualifications  Responsibilities  Stock-outs of medicines (especially those used in obstetric services)  Thoughts about improving services Guide for Interview with Health Worker at Sub-district Health Facility  Qualifications  Years of experience  Responsibilities  Problems faced in providing services  Thoughts about improving services  Opinion about project activities 190 ANNEX X. INFORMATION SOURCES Documents and Reports reviewed 1. Detailed implementation plan 2. Reports on baseline and final knowledge, practice, and coverage surveys 3. Reports on baseline and final operations research studies 4. Annual reports Places visited 1. Accra, Gambaga, Jawani, Nalerigu, Sakogu, Tamale, Tamboku, Tinsungu, and Yunyoranyiri People contacted: To protect the privacy of the people contacted by the evaluation team, names are not provided here. They include:  48 mothers  3 traditional birth attendants  2 members of a family (contacted during investigation of maternal death)  2 Community Health Volunteers  2 drivers of three-wheeled motorcycle ambulance  1 leader of women  1 village chief  1 assemblyman  2 patients at health facilities  7 project staff members  1 sub-district public health official  2 district government health officials  1 regional government health official  2 university faculty members  2 health researchers  5 health facility staff members  7 Catholic Relief Services-Accra staff members 191 ANNEX XI. DISCLOSURE OF ANY CONFLICTS OF INTEREST 192 193 194 ANNEX XII. STATEMENT OF DIFFERENCES Grantee’s Comments Evaluation Team’s Response Reformat report to conform with the guidelines for final evaluation reports Reformatted Reformat executive summary to conform with the guidelines Reformatted Present [Summary Table of Inputs, Activities, and Outputs That Contributed to Key Outcomes] Included Present [Table of Recommendations] Included Conceptual frameworks [not included in guidelines] Guidelines suggest information should be "presented visually in easy-to-read charts, tables, graphs, and maps" [Recent] literature should be employed Literature from 1990s summarized in section that explains how some maternal care strategies have long been considered ineffective in reducing maternal mortality. Studies from 2013 also summarized. Annexes [should be included] Included Quality of diagrams should be improved Improved 195 ANNEX XIII. EVALUATION TEAM MEMBERS, ROLES, AND THEIR TITLES  Karunesh Tuli and Sandra Wilcox- Final Evaluation Independent Consultants (Team Leader)  Mohammed Ali, Catholic Relief Services (Team Member)  Elena McEwan, , Catholic Relief Services (Remote support)  Paul Armah Aryee, University for Development Studies (Team Member)  Paulina Bayiwasi, District Director of Health Services (Team Member) 196 ANNEX XIV. OPERATIONS RESEARCH FINAL REPORT 197 ENGAGING COMMUNITY LEADERS AS ‘’COUNCIL OF CHAMPIONS’’ TO IMPROVE UPTAKE OF MATERNAL AND NEWBORN CARE SERVICES IN EAST MAMPRUSI DISTRICT OF NORTHERN GHANA OPERATIONS RESEARCH REPORT REPORT PREPARED BY OPERATIONAL RESEARCH TEAM: Dr. Mahama Saaka, (PhD), University for Development Studies, Tamale- Ghana Dr. Paul Armah Aryee (PhD), University for Development Studies, Tamale- Ghana Mohammed Ali, MPH, RD, Catholic Relief Services, Ghana Program Dr.Robert Kuganab-Lem, (PhD), University for Development Studies, Tamale- Ghana August, 2015 The Encouraging Positive Practices for Improving Child Survival (EPPICS) in East Mamprusi District, Ghana is supported by the American people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The EPPICS Project is managed by Catholic Relief Services – Ghana Program under Cooperative Agreement No. AID-OAA-A-11-00042 The views expressed in this material do not necessarily reflect the views of USAID or the United States Government. 198 TABLE OF CONTENTS TABLE OF CONTENTS .......................................................................................................................................... 198 ACRONYMS ........................................................................................................................................................ 199 1.0 INTRODUCTION ............................................................................................................................................ 204 1.1 GLOBAL PROBLEM................................................................................................................................................204 1.2 THE SPECIFIC PROBLEM AND RESEARCH SETTING .........................................................................................................204 1.3 RESEARCH JUSTIFICATION ......................................................................................................................................205 1.4 RESEARCH QUESTIONS/HYPOTHESIS ........................................................................................................................206 2.0 METHODS .................................................................................................................................................... 206 2.1 STUDY DESIGN.....................................................................................................................................................206 2.2 PARTICIPANTS .....................................................................................................................................................207 2.3 IRB APPROVAL AND INFORMED CONSENT.................................................................................................................207 2.4 STUDY DURATION ................................................................................................................................................207 2.5 INTERVENTION DESCRIPTION ..................................................................................................................................207 2.6 INTERVENTION MONITORING ................................................................................................................................. 210 2.7 OUTCOME (DEPENDENT) VARIABLE .........................................................................................................................210 2.8 DATA COLLECTION METHODS................................................................................................................................. 210 3.0 RESULTS ....................................................................................................................................................... 213 3.1 INTERVENTION MONITORING RESULTS ...........................................................................ERROR! BOOKMARK NOT DEFINED. 3.2 COMPARISON OF SOCIO-DEMOGRAPHIC CHARACTERISTICS AT BASELINE SURVEY......................ERROR! BOOKMARK NOT DEFINED. 3.2 EXPOSURE OF RESPONDENTS TO COMMUNITY LEADERS INFLUENCE................................................................................214 3.3 DIFFERENCE-IN-DIFFERENCE ANALYSIS (DID) .............................................................................................................215 3.4 FACTORS THAT INFLUENCE EARLY INITIATION OF PRENATAL CARE ..................................................................................217 3.5 FACTORS THAT INFLUENCE INSTITUTIONAL DELIVERY...................................................................................................218 3.6 FACTORS THAT INFLUENCE POSTNATAL CARE SERVICES IN THE FIRST WEEK OF DELIVERY ......................................................220 3.7 PREVALENCE OF MNCH RELATED PRABS.................................................................................................................222 3.8 MATERNAL KNOWLEDGE ON DANGER SIGNS AND SYMPTOMS DURING PREGNANCY ...........................................................222 4.0 DISCUSSION AND RECOMMENDATIONS ...................................................................................................... 224 SUMMARY OF MAIN FINDINGS AND EVIDENCE..................................................................................................................224 REFERENCES CITED ............................................................................................................................................. 228 199 ACRONYMS ANC Antenatal Care AR Annual Report BF/EBF Breastfeeding/Exclusive Breastfeeding BMC Baptist Medical Center CBA Community-Based Agent CBIS Community-Based Information System CETS Community Emergency Transport System CDO Community Development Officer CHPS Community-Based Health Planning and Services CHC Community Health Committee CHV Community Health Volunteer CHO Community Health Officer CIS Community Information System CoC Council of Champions C-PreS Community Pregnancy Surveillance CRS Catholic Relief Services DA District Assembly DDHS Director District Health Services DHMT District Health Management Team DIMS District Information Management System DOTS Directly Observed Treatment Short course EMD East Mamprusi District EmOC Emergency Obstetrical Care ENA Essential Nutrition Actions ENC Essential Newborn Care EPPICS Encouraging Positive Practice for Improving Child Survival FP Focal Person FGD Focus Group Discussion FtF Feed the Future GDHS Ghana Demographic and Health Survey (2008) GHI Global Health Initiative GHS Ghana Health Services HHs Households Hb Hemoglobin HDM Household Decision Makers HF Health Facility HIS/HMIS Health Information System/Management Information System HMNCCs Healthy Mothers and Newborn Care Committee IFA Iron Folic Acid 200 IMR Infant Mortality Rate IPTp Intermittent preventive therapy (Pregnancy) IPT3 Intermittent preventive therapy (3 doses of SP) KPC Knowledge Practice and Coverage Survey LAM Lactation Amenorrhea Method LAQS Lot Quality Assurance Sampling LOE Level of Effort MAMAN Minimum Package for Mothers and Newborns MD/MW Medical Doctor/Midwife M&E Monitoring and Evaluation MDG Millennium Development Goals MMR Maternal Mortality Ratio MMT Modified Motor Tricycle MNC Maternal and Newborn Care MN/N Maternal, Newborn and Nutrition MOH Ministry of Health NNMR Neonatal Mortality Rate NR Northern Region OR Operations Research PRABs Practices, Rituals, Attitudes and Beliefs PD/PDI Positive Deviance/Positive Deviance Inquiry PDQ Partnership Defined Quality P/L M Pregnant/Lactating Mothers PP Post-Partum Care RF Results Framework RHFA Rapid Health Facility Assessment RTI Research Triangle Institute SBCC Social Behavior Change Communication SD Sub-district SO Strategic Objective TA Technical Assistance TBA/TTBA Traditional Birth Attendant/Trained TBA TMP Traditional Medical Practitioner TT Tetanus Toxoid (Immunization) UDS University for Development Studies UNICEF United Nations Children’s Fund USAID United States Agency for International Development WFP United Nations World Food Program WRA Women of Reproductive Age 201 Background and Setting Encouraging Positive Practices for Improving Child Survival (EPPICS) was designed to improve maternal and newborn health in East Mamprusi district of northern Ghana. It included three interventions with varied level of efforts: maternal and newborn care (60%), Nutrition (30%), and Malaria in Pregnancy (10%). The project started in 2011, with a target of 51,000 direct beneficiaries (women of reproductive age and children 0-59 months). EPPICS combined facility and community based strategies and addressed barriers that prevented people from using available services: it improved georgrahic access to health services through provision of modified motortricycles as ambulances and worked to reposition Traditional Birth Attedants as link providers for skilled assisted childbirth. In addition to the main project activities, Catholic Relief Services (CRS) in collaboration with the University for Development Studies (UDS) and Ghana Health Services (GHS), developed, tested, and documented an innovative approach that modified practices, rituals and beliefs (PRABs) which had been delaying prompt care-seeking among the target beneficiaries. In Sakogu sub-district, EPPICS constituted councils of champions (CoC) in each community (comprising the chief, and women and religious leaders). The sub-district of Langbensi served as the control area. Problem and Solution High maternal and neonatal deaths in East Mamprusi District (EMD) have been attributed to a number of factors including community and household practices, rituals, attitudes and beliefs (PRABs) that delay care seeking during pregnancy labor, delivery and newborn emergencies. Previous strategies to reach households have focused on providing “action” messages without an in-depth analysis of household dynamics to understand factors perpetuating those PRABs. It is against this realization that CRS and UDS developed, tested and documented the Council of Champions strategy as an approach to addressing the problem of PRABs that reduce health seeking behavior. Council of Champions at Soabigi community - Photo CRS Key Findings:  Innovative Council of Champions strategy effectively addresses practices, rituals, attitudes and beliefs (PRABs) that act as barriers to uptake of maternal and newborn care services  The prevalence of MNCH related PRABs in the intervention was significantly lower than in the comparison communities (33.9 % versus 50.0 %) (Chi = 27.1, p < 0.001).  The CoC strategy significantly improved essential newborn care practices (safe cord care, optimal thermal care and good neonatal feeding) EPPICS Operations Research Executive Summary This operations research was funded by the U.S. Agency for International Development through the Child Survival and Health Grants Program from October 01, 2011 to September 29, 2015 202 Interventions In most part of rural Ghana, the ability of the formal health system to provide rapid MNC interventions is mediated by challenging practices, rituals, attitudes and beliefs (PRABs) of key household decision makers: husbands, mothers- and fathers-in-law. Chiefs, Magazias, Traditional Birth Attendants/Medical Practitioners and Religious Leaders are the custodians of these PRABs and also dominate the obstetric and gynecologic scene in much of the rural districts of Ghana. CRS and partners regrouped a total of 200 (5 – 7 per community) most influential people to serve on the community Council of Champions. The intervention was therefore to develop, test and evaluate the effect of CoCs on addressing PRABs as barriers to the uptake of maternal and newborn care services in EM District, as a complement to a comprehensive package of maternal and newborn health services. A total of 200 (5 – 7 per community) most influential people to serve on the community Council of Champions to address/promote PRABs related barriers/enforcers to health seeking behavior. The CoCs were selected and given 36 hours training on key knowledge areas such as an introduction to methods for reducing maternal neonatal and child (MNCH) morbidity and mortality using the triple A concept – assessing the problem, analyzing the causes and taking appropriate and timely action to address￾including engaging of Household Decision Makers, identification and prioritization of PRABs to be modified and or eliminated, organizing CoCs meetings, team building strategies, home visits, interpersonal communication as well as their roles and responsibilities Methods Two sub-districts (Sakogu and Langbinsi) within the East Mamprusi District were purposefully selected as the intervention and comparison study areas respectively. The sub-districts were selected because preliminary data indicated that they had similar socio-economic, demographic and health-seeking behaviors. The main outcome of this study is to increase the proportion of institutional deliveries. This outcome indicator was used to calculate a sample size of 1,020 (510 per study arm). The sample was set to detect a 15% difference in the comparison (43%) and intervention areas (58%). Given the sampling method, a design effect of 2.0 was selected. Power (1-β) and statistical significance (α) were set at 90 % and 0.05 respectively. A non-response of 10% was also considered in the sample size calculation. Thirty communities were selected in both the intervention and comparison areas. In each selected community, field supervisors met with community leaders and obtained permission to conduct the interviews. Next, a complete list of all households was compiled, and systematic random sampling was used to select households. Households with at least one woman who had delivered in the past 24 months were eligible for selection. Only one woman was selected from each household. If a household had more than one eligible mother, the names were listed and one woman was selected randomly for interview. The Institutional Review Board (IRB) of the School of Medicine and Health Sciences, University for Development Studies reviewed and approved the study protocol (Reference no SMHSER0001). Verbal informed consent was sought from all study participants (mainly women of reproductive age) before the commencement of any interviews or study activity. Study participants were free to refuse or withdraw from the study at any time without any penalty. 203 Findings The study established significant differences in the uptake of maternal, newborn care health services between the study groups. Coverage of timely initiation of first ANC attendance, frequency and adequacy of ANC attendance and uptake of post-natal care uptake was significantly higher in the intervention communities than in the comparison communities. However, there was a slight decline of early initiation of ANC and facility deliveries with time due to the absence of skilled health professionals at the only health facility in the intervention area. Additionally, the intervention significantly improved essential newborn care practices (safe cord care, optimal thermal care and good neonatal feeding). Also, the prevalence of at least one MNCH related PRABs in the intervention was significantly lower than in the comparison communities (33.9 % versus 50.0 %) (Chi = 27.1, p < 0.001). Conclusions This report tested and confirmed the hypothesis that repositioning and engaging key custodians of household and community-based practices, rituals, attitudes and beliefs (PRABs) as Council of Champions (CoCs) for maternal and child health has assisted in either modifying the challenging/harmful PRABs as well as reinforce positive PRABs. The CoC strategy supported the earlier assertion that engaging the custodians at the community-household level (demand side) and providing quality and adequate healthcare services at the facilities (supply side), barriers to the uptake and use of maternal and child health services is addressed. Recommendations In the light of the outcome of the study, the following suggestions/recommendations apply: 1. Social and behavior change communication should form part of the strategy to address household and community related PRABs as part of improving maternal and newborn health in Northern Ghana and in similar contexts. 2. Innovative education strategies are needed to increase knowledge of women of reproductive age and household decision makers on the importance and uptake of attending PNC after 2 days of delivery especially among women who deliver at home. 3. In view of the low maternal knowledge of danger signs, the national reproductive strategy on maternal and newborn health should empower families and communities to recognize pregnancy related risks, and to take responsibility for developing and implementing appropriate response to them Use of Evidence Based on the findings of this study, CRS and GHS should advocate with the Ministry of Health to adopt the Council of Champion strategy as part the strategies in the maternal and child health policies. 204 1.0 INTRODUCTION 1.1 Global Problem Globally supply and demand-side barriers exist to the uptake of essential maternal and newborn health services (Montagu et al., 2011). Though several high impact interventions are being implemented, progress towards attainment of significant improvement in maternal and newborn health still remains a big challenge to most developing countries, including Ghana. In sub-Saharan Africa, the region with the highest maternal mortality ratio (500 deaths per 100,000 live births) and perinatal mortality rate (56 per 1,000 births) and coverage of facility deliveries are particularly low (WHO, 2012). A recent estimate indicated that in sub-Saharan countries, less than half of the births take place in a health facility (Moyer and Mustafa, 2013). Additionally, suboptimal newborn care practices still persist and neonatal mortality rates seemed resistant to change, contributing to about 40 % of all under-five deaths world-wide (Lawn et al., 2005). Therefore, a continuum of care approach that includes prenatal, intrapartum, immediate newborn and postpartum care for mother and newborn is therefore considered essential for promotion of mother-infant health (Kerber et al., 2007). 1.2 The specific problem and research setting The East Mamprusi (EM) district in the Northern Region (NR) of Ghana is burdened with a higher maternal mortality ratio (MMR) and infant mortality compared to the regional averages. In 2010, institutional MMR was estimated at 217/100,000 in EM compared to the regional average of 201/100,000 while infant deaths were slightly lower (34/1000) compared to 35/1000 for NR. Estimated neonatal deaths constitute 60% of all infant deaths in Ghana. High maternal and neonatal deaths in EM have been attributed to late registration (3rd trimester) for antenatal care (30%), low utilization of skilled care at birth (48.0%), high prevalence of low birth weight (9.8%), low rate of exclusive breastfeeding (16.1%), unhygienic and unsafe delivery practices and cord care, and delays in recognition of danger signs (in both mother and newborn) and making timely decisions at the household level to seek care at health facilities. The high maternal and neonatal (MN) deaths in EM District have been largely attributed to low utilization of MNC services at crucial stages of pregnancy, delivery, post-partum and post-natal periods (EM –GHS, 2011). To address the challenges enumerated above, the Ghana Health Service (GHS) and its partners have put in place interventions and policies aimed at increasing coverage and improving the quality of maternal and newborn care (MNC). These efforts include introduction of national health insurance and free antenatal and delivery policies to improve financial access to health services, the scale-up of the Community-Based Health Planning and Services (CHPS) to improve geographic access, and improvement of human resource for health and supply chain management to enhance quality of health service delivery (MOH, 2011). Despite these policies and strategies in the health sector, MNC service quality, coverage and utilization remained major challenges, particularly in the EM district of Northern Ghana (Ghana Statistical Service 205 (GSS) et al., 2009).Apart from poor quality of health services, socio-cultural factors in the form of practices, rituals, attitudes and beliefs (PRABs) have been identified as key contributors to the poor health seeking behaviors and has engaged the attention of Ghana’s Ministry of Health (MoH) over the past years (Ghana Statistical Service (GSS) et al., 2009, MOH, 2010, MOH, 2007). The negative contribution of challenging PRABs to poor maternal and neonatal health outcomes calls for innovative community based strategies to help address their effects (MOH, 2010, MOH, 2011, MOH, 2007, UNICEF, 2010). Existing traditional PRABs such as ‘peligibu65’, Kalogutiim66, waligu67, tidugukoom68 and ‘Nangbantuom69’ are among the key barriers to the up-take of maternal and newborn health services (GCSP, 2006, Wuni, 2009, Yunus et al., 2007). 1.3 Research Justification High maternal and neonatal deaths in EM district have been attributed to a number of factors including: a) community and household practices, rituals, attitudes and beliefs (PRABs) that delay care seeking during labor and delivery, and b) lack or inadequate recognition of danger signs (in both mother and newborn) by the mother and health worker to make timely decisions to seek care at health facilities during obstetric and newborn emergencies. Strategies or approaches to effectively reach households have focused on providing “action” messages without an in-depth analysis of the households’ dynamics to understand factors perpetuating those behaviors. PRABs are guided by key community leaders (KCLs) namely: Chiefs, Magazias (“Queen Mothers”, the senior females in communities), traditional healers, Religious leaders/shrine owners. These KCLs are also the custodians of the norms and values of their people and exert significant influence on various Household Decision Makers (HDMs) whose actions influence the health of women and children within their communities (CRS Ghana, 2011, Senah, 2003). Yet no known community-based intervention existed in the EM District to adequately leverage the powers and influence of these respected community leaders in addressing obstacles that stand against improvements in the use of health facility￾led MNC services at the household and community levels. It is against this realization that Catholic Relief Services (CRS) and its partners implemented a community-based intervention titled “Encouraging Positive Practices for Improving Child Survival” (EPPICS) project from October 2011 through September 2015 in the East Mamprusi District. As part of the EPPICS Project design and in acknowledging the influence of HDMs on mothers and caregivers, CRS in collaboration with University for Development Studies nested this operations research (OR) to assess the effectiveness of the CoCs innovation in the context of the EPPICS project to improve uptake of essential MNCH services. 66 A local herbal preparation of an oxytocin derivative for pregnant women with obstructed labor. Kalogutiim enhances contractions without dilating the cervix and has also been responsible for many cases of ruptured uterus. 67 A form of prelacteals select verses of the Quran are written on a piece of wood usually by Imams and given to newborn babies to drink in order to protect the newborns from the evil eye and to make them strong. 68 Special Herbs usually contained in pots place in front of compounds given to the newborn baby as a welcome to the family. 69 Special herbal preparation believed to offer spiritual protection to the newborn baby against evil eyes. 206 The research is expected to provide evidence-based outcomes that will contribute to influencing national and global policies and approaches regarding innovative community-led strategies in addressing harmful practices, reinforcing positive practices and improving the low uptake of maternal and newborn health services. 1.4 Research Questions/Hypothesis The objective of the research study was to develop, test and evaluate the effect of CoCs on addressing PRABs as barriers to the uptake of maternal and newborn care services in EM District, as a complement to a comprehensive package of maternal and newborn health services. The specific objectives were to: i. Compare changes in the early initiation of ANC (within the first trimester) between intervention and comparison areas ii. Compare changes in facility deliveries between intervention and comparison areas iii. Compare the changes in uptake of post-natal care services between the intervention and comparison areas. iv. Describe changes in attitudes towards traditional PRABS related to care seeking during pregnancy, intra-partum and postpartum stages between the intervention area and the comparison area. v. Compare essential newborn care practices (safe cord care and optimal thermal care) and early recognition of danger signs during pregnancy, birth, postpartum and the neonatal periods between intervention and comparison areas. vi. Compare infant and young child feeding practices (early initiation of breastfeeding, exclusive breastfeeding, neonatal feeding) in intervention and comparison areas. Primary Hypothesis: The addition of the Council of Champions (CoCs) to a comprehensive package of maternal and newborn health services will improve uptake of institutional delivery. 2.0 METHODS 2.1 Study Design The effectiveness of the intervention was evaluated through a “pretest-posttest non-equivalent groups design”. Two cross-sectional surveys at baseline and end point were carried out in both the intervention and comparison areas. The baseline survey was carried out in February 2013 and the end line survey was conducted in July 2015. Two sub-districts (Sakogu and Langbinsi) within the East Mamprusi District were purposefully selected as the intervention and comparison study areas. The sub-districts were selected because preliminary data indicated that they had similar socio-economic, demographic and health-seeking behaviors. The 207 main outcome of this study is to increase the proportion of institutional deliveries. This outcome indicator was used to calculate a sample size of 1,020 (510 per study arm). The sample was set to detect a 15% difference in the comparison (43%) and intervention areas (58%). Given the sampling method, a design effect of 2.0 was selected. Power (1-β) and statistical significance (α) were set at 90 % and 0.05 respectively. A non-response of 10% was also considered in the sample size calculation. 2.2 Participants The primary respondents comprised women of reproductive age who delivered within the previous two years. A two-stage cluster sampling design, probability proportional to size (PPS) was used given the lack of a comprehensive sampling frame and the geographic distribution of the population. The sample was stratified by intervention and comparison areas. Communities within each sub-district served as primary sampling units (PSU). The sampling frame of the communities was constructed using population data projected by the Ghana Health Service (GHS) from the 2010 population census. Thirty communities, or clusters, were selected in both the intervention and comparison areas. In each selected cluster, field supervisors met with community leaders and obtained permission to conduct the interviews. Next, a complete list of all households was compiled, and systematic random sampling was used to select households. Households with at least one woman who had delivered in the past 24 months were eligible for selection. Only one woman was selected from each household. If a household had more than one eligible mother, the names were listed and one woman was selected randomly for interview. 2.3 IRB Approval and Informed Consent The Institutional Review Board (IRB) of the School of Medicine and Health Sciences, University for Development Studies reviewed and approved the study protocol (Reference no SMHSER0001). Verbal informed consent was sought from all study participants before the commencement of any interviews or study activity. Study participants were free to refuse or withdraw from the study at any time without any penalty. The study’s purpose and objectives were explained to each participant prior to interview. No biological sample was obtained as a part of the data collection. Data were kept strictly confidential and no personal identifiers were captured. 2.4 Study Duration The baseline survey was conducted in February 2013 and was immediately followed by the implementation of the intervention which lasted 28 months (March 2013 to June 2015). The endline survey was conducted during the month of July 2015. 2.5 Intervention Description Council of Champions (CoC): In most part of rural Ghana, the ability of the formal health system to provide rapid MNC interventions is mediated by challenging practices, rituals, attitudes and beliefs (PRABs) of key household decision makers: husbands, mothers- and fathers-in-law. Chiefs, Magazias, Traditional Birth Attendants/Medical Practitioners and Religious Leaders are the custodians of these PRABs and also dominate the obstetric and gynecologic scene in much of the rural districts of Ghana. Thus, EPPICS regrouped a total of 200 (5 – 7 per community) most influential people to serve on the 208 community Council of Champions to address/promote PRABs related barriers/enforcers to health seeking behavior. Below points provide details in terms of:  Who was recruited and how were they recruited: The CoCs were selected with the support of community members. Each CoC member needed to fulfill the following criteria prior to being recruited: (i) Permanent resident and commands respect and authority; (ii) Plays leadership role and is not involved in communal disputes; (iii) has interest in working as a CoC and committed in achieving the CoC objective. Once the CoCs were identified, they were met by the OR Coordinator and the EPPICS team to ascertain whether they satisfied the recruitment criteria.  What was the target number of recruits: Our target was to train 210 CoCs in all the 42 communities. However, only 200 CoCs were trained due to the varied sizes of the communities and the distribution of active TBAs and TMPs in the target communities  Why they were trained:They were trained so that they were familiar with maternal and newborn health issues and also positioned to be able to engage other Household Decision Makers on modifying challenging PRABs while enforcing the positive PRABs  What subjects were covered in the training and training duration : The 36 hour training Orientation included an introduction to methods for reducing maternal neonatal and child (MNCH) morbidity and mortality using the triple A concept – assessing the problem, analyzing the causes and taking appropriate and timely action to address- including engaging of Household Decision Makers, identification and prioritization of PRABs to be modified and or eliminated, organizing CoCs meetings, team building strategies, home visits, interpersonal communication as well as their roles and responsibilities After the training, the CoCs were supported by GHS Staff and CRS Field Officer to perform the under listed functions: i. Engage influential family/household members through monthly community-wide meetings to discuss and agree on ways that community members especially HDMs could support pregnant women and nursing mothers to patronize MNC services (early and continuous antenatal care visits, delivery with a skilled midwife, etc.). ii. Institute periodic meetings with health staff and heads of health facilities. These meetings will serve as channels not only to relay concerns that women and their families regards the quality of care at health facilities but will provide constructive feedback on the performance of health service providers thus helping to address the issues such as abuse and disrespect and their causes. iii. Monitor and evaluate community performance/achievements, using the Community Giant Scoreboard (CGS)/ Wall of Health to track process in MNCH indicators of interest, and then score performance on the MNC indicators (monthly) and publicly displaying these on the CGS. iv. Engage with the larger community members in establishing by-laws that will modify challenging PRABs while enforcing positive ones with the aim of contributing towards improved MNC outcomes. 209 v. Established and enforce MNC related bye-laws in their communities vi. Work hand –in-hand with their respective local government representatives (assemblymen) and members of parliament to advocate of provision/ improvement in health infrastructure The intervention area received Council of Champion innovation in addition to the other EPPICS program components. The comparison area received only the EPPICS components listed in Table 2.1 below. The CoC is defined as members of the community who have authority (be it traditional, spiritual or religious) and are custodians of PRABS. They play mediatory and community welfare roles which could be leveraged to improved community-health staff relationship to enhance uptake of MNC services. Table 2.1 shows components of the intervention that were implemented in study intervention and comparison areas Table 2.1: Project components implemented in study intervention and comparison areas Project Component Intervention Area Comparison Area CoC innovation Yes No Healthy Mothers and Newborn Care Committees (HMNCCs) Yes Yes Community Giant Scoreboard (CGS)/Walls of Health Yes Yes Positive Deviant Mothers as facilitators of Community Pregnancy and Newborn Surveillance and Education Sessions (C-PrES) with Home Visits Yes Yes Repositioning TBAs as Link Providers Yes Yes Healthy Mothers and Newborn Care Committees (HMNCCs): There was formation of Healthy Mothers and Newborn Care Committees (HMNCCS) which comprised influential members of the community, both men and women, who are able to influence the male and female household decision￾makers with regard to mothers and newborns. The members of the HMNCCs were trained and they implemented a standardized Social and behavior change communication (SBCC) and capacity building approach using “action messages” to mobilize communities to 1) develop community birth plans; 2) engage newborns’ fathers and fathers-in-law to support household birth plans and promote and encourage pregnant women and new mothers to practice preventive and curative MNC and nutrition behaviors; and 3) organize and influence women through community women leaders. Community Giant Scoreboard (CGS): HMNCCs members used community-level data that they collected to display publicly and track the numbers of home or facility-based deliveries or other project indicators. The high visibility of the CGS kept the MNCH/N efforts in the forefront of the communities’ attention, generated enthusiasm, and became a form of visible, friendly competition among communities. Positive Deviant Inquiry and Positive Deviant (PD) Mothers: This strategy identified 240 women in the community who were able to overcome factors that have led to low MNCH/N utilization. PD mothers are selected because they 1) registered early for ANC, 2) used skilled delivery and 3) 210 employed newborn care practices that are known to prevent mother and baby deaths. The PD mothers facilitated Community Pregnancy and Newborn Surveillance and Education Sessions (C-PrES) and home visits. These educational sessions brought together pregnant women on bi-weekly basis and lactating women on a monthly basis to discuss MNCH as well as nutrition related issues in the community. PD mothers follow up these meetings with face-to-face counseling and home visits. 2.6 Intervention Monitoring The CoCs in each of the 42 intervention communities were directly supported by Field Officers to generate monthly reports to help the project team monitor some of the key targets outlined for the intervention. Table 3.1 presents the monitoring data collected in the course of the intervention monitoring. Also, during the implementation period, a total number of 13,632 Household Decision Makers (HDM) were engaged by the CoCs. Additionally, a total of 15,152 mothers/caregivers were visited by the CoCs within the period of implementation. On an average, 20 CoCs groups received monthly monitoring and facilitative support visits. The monitoring visits were conducted by the CRS field officer with support from GHS. The monitoring visits were guided by an OR customized checklist. A joint UDS/GHS/CRS team conducted quarterly monitoring visits to the OR intervention site. Cluster based reflection meetings were held semi-annually with CoCs committees to review performance, trouble shoot challenges and brainstorm on how to get these addressed. On monthly basis, the CoCs submit summary reports of their activities to the field officer to inform progress of the groups. 2.7 Outcome (Dependent) Variable The primary outcome measures were:  Proportion of mothers of CU2 who attended received antenatal care services from a trained health worker in the first trimester of the pregnancy of their youngest child.  Proportion of mothers of children under two years (CU2) who delivered at a health facility (institutional delivery)  Proportion of mothers of CU2 who sought a post-partum visit from an appropriate trained health worker within 7 days of delivery of the birth of the youngest child The secondary outcome measures included:  Proportion of mothers of CU2 who sought four or more antenatal visits when they were pregnant with the youngest child  Percentage of CU2 that were put to the breast within one hour of delivery.  Proportion of mothers of CU2 who know at least two risks of having a birth with pregnancy interval of less than 24 months 2.8 Data Collection Methods A mixed-methods approach was used to meet the study goal and objectives. Data collection methods included structured questionnaires (applied pre and post intervention) and semi-structured interviews. 211 Data were collected on socio-economic conditions of household, nutritional status, maternal and newborn care practices, and health services utilization. Additionally, two separate Focus Group Discussions (FGD’s) were held with household decision makers and mothers with children under 24 months. In-depth interviews (IDIs) were also conducted with key community members who influence decision making at household and community levels (that is, chiefs, magazia, imams and pastors etc.) in each sub-district. A full report on the qualitative component is presented elsewhere and attached as an optional annex. Table 2.2 Summary of Data Collection Methods Data Collection Method When Administered Respondents Sample Size Household Survey Baseline (Feb 2013) Mothers of CU2 1020 Household Survey Endline (June 2015) Mothers of CU2 1020 Focus Groups Discussions Baseline & Endline Household Decision Makers and Mothers of CU2 8 FGDs (2 FGDs in 4 clusters; In-depth interviews (IDIs) Baseline & Endline Community Members including chiefs, mother-in-law, Magazia, imams and pastors A minimum of 2 members in each of 4 clusters. Training of Data Collectors and testing of tools: In order to ensure reliability and validity of data collected, all field assistants with a minimum qualification of Senior High School were given training for three days. The content of the training included objectives and methodology, standard measurement procedures, data recording, recruitment, administration of questionnaires and supervision. The final stage in the training of data collectors was used to field-test the data collection tools. The main aim here was to refine the tools and to ensure the competence of the data collectors. Data Processing and Analysis: The quantitative data collected were checked for completeness, appropriateness and inconsistencies in the field before data entry. Data cleaning and range and consistency checks were also done before the analyses were carried out using the Statistical Package for Social Sciences (SPSS) version21.Appropriate statistical techniques were used to compare changes within and between intervention and comparison communities. These included multivariable analyses and difference-in-difference (DID) analysis. Since the methods of data collection were identical in the baseline as the follow-up studies, the initial baseline results were taken into account in the impact analyses and the simplest approach to calculate the difference overtime is by simple subtraction, and this is usually satisfactory (Habicht et al., 2009). The difference over time in the comparison group is usually subtracted from the difference over time in the intervention group to obtain an estimated impact. This second difference is referred to as “the difference of the differences”. Key outcome variables were compared between intervention and comparison arms of the study. Categorical variables were compared in descriptive statistics using chi-square test to measure the significance of difference between proportions. For quantitative outcome variables, analysis of variance (ANOVA) was used to compare differences. Statistical significance of difference was considered at 5% significance level (p-value <0.05). Independent variables found to be significant at the 0.1 level based 212 upon the results of the bivariate tests, were entered as potential variables to be included in multivariable logistic regression analyses. In order to derive a correct overall estimate, sample weights were applied to each stratum to account for differences in population size. 213 3.0 RESULTS 3.1 Comparison of socio-demographic characteristics at baseline survey At baseline, a total of 1003 respondents were interviewed; 510 from Sakogu District (Intervention District) and 493 from Langbinsi (Comparison District). There were significant differences between the two areas with respect to mean distance of health facility to home, the age distribution of the children and ethnicity of the mothers (Table 3.1). Table 3.1: Comparison of socio-demographic characteristics of mothers having children less than 24 months in comparison versus intervention communities at baseline survey Characteristic Intervention (n=510) Comparison (n=493) p-value n (%) n (%) Age of mother (years) 17- 24 156 (30.6) 138 (28.0) 0.07 25-35 267 (52.4) 291 (59.0) 35+ 87 (17.0) 64 (13.0) Age of child (months) 0-5 104 (20.4) 130 (26.4) 0.02 6-11 124 (24.3) 133 (27.0) 12-23 282 (55.3) 230 (46.7) Educational level None 411 (80.6) 386 (78.3) 0.63 Basic (Primary or JHS) 91 (17.8) 97 (19.7) Senior high school or higher 8 (1.6) 10 (2.0) Ethnicity Mampruli 244 (47.8) 276 (56.) < 0.001 Moar 96 (18.8) 51 (10.3) Kusal 30 (5.9) 1 (0.2) Likpakpa 89 (17.5) 2 (0.4) Other 51 (10.0) 163 (33.1) Parity Primiparous 84 (16.5) 92 (18.7) 0.06 Secundipara 92 (18.0) 113 (22.9) Multiparous 334 (65.5) 288 (58.4) Total No. Health Facilities 1 4 NA 214 3.2 Intervention Monitoring Results As part of the intervention monitoring results, a number of key indicators were monitored and include: # of COCs formed, # of COCs trained, % of COCs receiving monthly supervision visits, # of and the Average number times that the COCs met each month. The details of the monitoring results are presented in Table 3.1 below Table 3.2 Monitoring data collected during the intervention implementation period S/N INDICATORS TARGET ACHIEVED 1 Number of Council of Champions (CoCs) formed 42 42 2 Number of CoC members trained 210 200 3 % of CoCs visited and provided support 100 100 4 Average number of monthly community meetings held by CoCs per community 36 30 3.3 Exposure of respondents to Community Leaders Influence At endline, women of CU2 were asked about their exposure to key community leaders (chiefs, religious leaders70, Magazia71 and traditional medical practitioners) who promoted select MNCH behaviors. Significantly more Magazia in the intervention area promoted early ANC, facility delivery and PNC in the intervention area (92%, 92% and 90% respectively) versus the comparison area (76%, 78% and 75% respectively) (Table 3.3 below). There was no significant difference in the exposure to the promotion of essential MNCH behaviors by the other community leaders. 70 These are Imams for the Muslim communities and Pastors for the Christian communities 71 Magazia is a term for women leaders including queen mothers in northern communities of Ghana Mean Distance of Health Facility to Home (Km) 5.6±5.7 4.6±4.6 0.004 215 Table 3.3: Percentage of mothers having children less than 24 months exposed to the promotion of MNCH behaviors by community leaders in comparison vs. intervention communities at endline (2015) Exposure Intervention (n=510) Comparison (n=510) % 95% CI % 95% CI Chief Early ANC (≤ 3 months) 86.5 76.2 – 92.7 69.6 59.0 – 78.5 Facility delivery 85.9 75.7 – 92.2 69.6 59.0 – 78.5 Post-natal care uptake 84.5 74.5 – 91.1 69.2 58.9 – 77.9 Religious Leader Early ANC (≤ 3 months) 85.7 74.7 -92.4 76.3 67.6 – 83.2 Facility delivery 86.9 75.9 - 93.3 76.7 67.8 – 83.7 Post-natal care uptake 84.1 73.6 – 91.0 75.3 67.0 – 82.1 Magazia Early ANC (≤ 3 months)* 91.8 86.0 -95.3 76.3 66.9 – 83.7 Facility delivery* 91.6 86.0 – 95.1 77.5 67.7 – 84.9 Post-natal care uptake* 89.8 84.3 – 93.5 75.1 66.2 – 82.3 Traditional Medical Practitioners Early ANC (≤ 3 months) 56.5 45.2 – 67.1 44.3 32.7 – 56.6 Facility delivery 57.8 46.7- 68.2 45.7 33.5 – 58.4 Post-natal care uptake 55.1 43.8 – 65.9 40.4 29.4 – 52.4 *p<0.05 3.4 Difference-in-difference analysis (DID) Difference-in-difference analysis allows determination of whether the intervention households did better than comparison households while taking into account any initial differences between the groups at baseline. By doing so it controls for any changes that took place in the project area that are not related to project interventions or that are only indirectly related to them through spillover effects. The difference-in-difference (DID) analysis comparing the changes over time for eligible intervention households and the comparison households indicates a significant improvement in respect of all the outcomes measures except facility delivery (Table 3.4). 216 Table 3.4: Difference-in-difference analysis: Changes in key project outcome measures from baseline to end-line Intervention Communities Comparison Communities Outcome Baseline (2013) Endline (2015) Difference Baseline (2013) Endline (2015) Difference DID Timely initiation of ANC (≤ 3 months) 97.5 [CI:95.4 – 98.6] 85.3 [CI:80.9 – 88.8] -39.2* 99.4 [CI:98.1 – 99.8] 38.8 [CI:29.4 – 49.1] -60.6* 21.4 Frequency of ANC (≥ 4) 79.9 [CI:74.7 – 84.3] 93.7 [CI:91.5 – 95.4] 13.8* 76.2 [CI:68.0 – 82.8] 31.0 [CI:17.6 – 48.5] -45.2* 59.0 Adequacy of ANC 82.9 [CI:77.6 – 87.1] 82.5 [CI:77.7 – 86.5] -0.4 80.0 [CI:74.3 – 84.7] 22.4 [CI:12.8 – 36.1] -57.6* 57.2 Facility delivery 54.1 [CI:43.4 – 64.5] 79.6 [CI:73.3 – 84.7] 25.5* 54.0 [CI:44.2 – 63.4] 93.4 [86.9 – 96.8] 39.4* -13.9 Timely initiation of breastfeeding 38.2 [CI:27.3 – 50.6] 91.8 [CI:87.2 – 94.9] 53.6* 74.0 [CI:63.6 – 82.3] 91.5 [CI:87.2 – 94.4] 17.5* 36.1 Good neonatal feeding 33.7 [CI:23.7 – 45.5] 77.6 [CI:68.4 – 84.8] 43.9* 64.9 [CI:55.2 – 73.5] 31.0 [CI:18.1 – 47.6] -33.9* 77.8 Optimal thermal care 72.7 [CI:62.3 – 81.1] 96.9 [CI:95.0 – 98.1] 24.2* 81.1 [CI:71.4 – 88.1] 98.6 [CI:96.3 – 99.5] 17.5* 6.7 Safe cord care 12.9 [CI:9.1 – 18.1] 44.1 [CI:33.3 – 55.5] 31.2* 9.0 [CI:6.1 – 13.1] 5.9 [CI:2.4 – 13.5] -3.1 34.3 217 Maternal knowledge in at least 3 danger signs during pregnancy 15.3 [CI:12.2 – 19.1] 60.0 [CI:49.1 – 70.0] 44.7* 21.9 [CI:18.1 – 26.3] 42.2 [CI:30.3 – 54.9] 20.3* 24.4 * Represents statistical significance of the difference at p < 5%.CI: 95 % confidence interval 3.5 Factors that Influence Early Initiation of Prenatal Care Results of the logistic regression analysis are presented in Table 3.5, which gives the adjusted odds ratios for the impact of intervention group on early initiation of ANC. Women from the intervention communities were 2.9 times more likely of having initiated first visit early in pregnancy (AOR = 2.95 (CI: 2.01 to 4.34). Women who attended ANC at least 4 times were 7.9 times more likely of having initiated first visit early in pregnancy [AOR = 7.88 (CI: 5.35 to 11.58)]. Factors including maternal education, age, parity, and occupation were tested but found not associated with early initiation of ANC. Surprisingly, compared to women staying more than 10 km from a health facility, women closer to health facilities were less likely of initiating ANC early (that is protective against early attendance). Compared to women staying more than 10 km away from health facility, women who were 0-5 km away were 70 % less likely to attend ANC early (AOR = 0.30 CI: 0.17 to 0.53), and 62.0 % less likely if they were 6-10 km away (AOR = 0.38, CI: 0.19 to 0.74). Factors including maternal education, age, parity, and occupation were tested but found to be not associated with early initiation of ANC. Table 3.5: Logistic regressions predicting odds of Early ANC among women with children less than 24 months old in Sakogu and Langbinsi Subdistricts of East Mamprusi District, Ghana Unadjusted Odds Ratio Adjusted Odds Ratio 95% CI Variable OR 95% CI OR 95% CI Treatment Arm Intervention 9.04 6.65 – 12.30*** 2.95 2.01 – 4.34*** Comparison Ref Ref Ref Ref Mother’s age (years) Under 25 Ref Ref Ref Ref 25-34 0.86 0.64 - 1.18 35+ 0.93 0.63 – 1.39 Ethnicity 218 Mampruli Ref Ref Ref Ref Moar 3.30 1.73 – 6.27*** Kusal 1.63 0.67 – 3.95 Likpakpa 4.52 2.35 – 8.72*** Others 0.63 0.44 – 0.89** Household Head Employed No Ref Ref Ref Ref Yes 1.21 0.80 – 1.84 Material used in Sleeping Room Construction Mud Ref Ref Ref Ref Cement 0.54 0.28 – 1.07 Distance to health facility >10 Km Ref Ref Ref Ref 6-10 0.76 0.44 – 1.30 0.38 0.19 – 0.74** 0-5 0.42 0.27 – 0.67*** 0.30 0.17 – 0.53*** Frequency of ANC attendance < 4 visits Ref Ref Ref Ref ≥ 4 visits 13.65 9.92 – 18.76*** 7.88 5.35- 11.58*** Knowledge on newborn danger signs < 3 signs Ref Ref Ref Ref ≥ 3 signs 1.60 1.21- 2.10** *p<0.05; **p<0.01; ***p<0.001 The set of variables accounted for 42.5 % of the variance in early initiation of ANC (Nagelkerke R Square = 0.425). 3.6 Factors that Influence Institutional Delivery The most consistent determinants of health facility delivery were residents in the comparison communities, frequency of ANC attendance, content of ANC services received and ethnicity (Table 3.6). Women from the intervention communities were 50 % less likely (AOR = 0.50 CI: 0.26 to 0.95) to deliver in a health facility, compared to their counterparts from the comparison communities. Though 219 women who attended ANC at least four times were most likely to attend ANC early, they were 68 % less likely to deliver in a health facility. Compared to the Mampruli ethnic group, the Mossi were 8.6 times more likely to deliver in the health facility (AOR = 8.66, CI: 1.15 to 64.99) whereas the Likpakpa ethnic group were 54 % less likely to deliver in a health facility. In terms of ANC content, women who received more ANC services (≥ 7) were more likely to deliver in a health facility, compared with women who received less than the seven ANC services rendered. At endline survey, factors such as maternal educational level, occupation of household head, distance from health facility, age of the mother and parity were not important determinants of health facility delivery in this study population. Table 3.6: Logistic regressions predicting odds of health Facility Delivery among women with children less than 24 months old in Sakogu and Langbinsi Subdistricts of East Mamprusi District, Ghana Unadjusted Odds Ratio Adjusted Odds Ratio 95% CI Variable OR 95% CI OR 95% CI Treatment Arm Intervention 0.27 0.18 – 0.41*** 0.50 0.26 – 0.95* Comparison Ref Ref Ref Ref Mother’s age (years) Under 25 Ref Ref Ref Ref 25-34 0.89 0.57 – 1.36 35+ 0.94 0.54 – 1.64 Ethnicity Mampruli Ref Ref Ref Ref Moar 0.58 0.31 – 1.08 0.86 0.45 - 1.63 Kusal 1.58 0.36 – 6.88 2.31 0.52- 10.20 Likpakpa 0.28 0.17 – 0.47*** 0.46 0.27 - 0.78* Mossi 10.45 1.43 – 76.55* 8.66 1.15 - 64.99* Tampulima 0.86 0.40 – 1.82 0.43 0.17 - 1.04 Others 1.13 0.66 – 1.91 0.79 0.44 - 1.40 Household Head Employed No Ref Ref Ref Ref Yes 0.35 1.30 – 0.75 2.266 Material used in Sleeping Room Construction 220 Mud Ref Ref Ref Ref Cement 1.75 0.53 – 5.79 ANC content Low Ref Ref Ref Ref High 0.72 0.50 – 1.03 1.57 1.02 – 2.41* Frequency of ANC attendance < 4 visits Ref Ref Ref Ref ≥ 4 visits 0.25 0.15 - 0.42 0.32 0.16 – 0.64** Knowledge on newborn danger signs < 3 signs Ref Ref Ref Ref ≥ 3 signs 0.69 0.48 - 0.99* *p<0.05; **p<0.01; ***p<0.001 The set of variables accounted for 13.7 % of the variance in health facility delivery (Nagelkerke R Square = 0.137). 3.7 Factors that Influence postnatal care services in the first week of delivery In multivariable logistic regression analysis, only intervention communities and content of ANC services received were the only determinants of postnatal care services in the first week of delivery. Women from the intervention communities were 1.7 times more likely to utilize postnatal care services at least two times in the first week of delivery compared with women from the comparison communities (AOR = 1.74, CI: 1.28 to 2.37). Women who received more ANC services (≥ 7) were 1.9 times more likely AOR = 1.97 (CI: 1.44 to 2.70) to seek postnatal services in the first week of delivery, compared with women who received less than the seven ANC services rendered (Table 3.7). Table 3.7: Logistic regressions predicting odds of post-natal care uptake in the first week of delivery among women with children less than 24 months old in Sakogu and Langbinsi Subdistricts of East Mamprusi District, Ghana Unadjusted Odds Ratio Adjusted Odds Ratio 95% CI Variable OR 95% CI OR 95% CI Treatment Arm Intervention 2.34 1.77 – 3.09*** 1.74 1.28 - 2.37*** 221 Comparison Ref Ref Ref Ref Mother’s age (years) Under 25 Ref Ref Ref Ref 25-34 0.99 0.723 – 1.36 35+ 0.71 0.464 – 1.08 Ethnicity Mampruli Ref Ref Ref Ref Moar 1.38 0.82 – 2.31 Kusal 2.02 0.91 – 4.46 Likpakpa 1.06 0.66 – 1.71 Mossi 0.62 0.35 – 1.08 Tampulima 0.51 0.26 – 0.98* Others 0.72 0.49 – 1.06 Household Head Employed 1.43 0.89 – 2.30 No Ref Ref Ref Ref Yes Material used in Sleeping Room Construction Mud Ref Ref Ref Ref Cement 0.78 0.36 – 1.69 ANC content Low Ref Ref Ref Ref High 2.52 1.90 – 3.34*** 1.97 1.44 - 2.70*** Early initiation of ANC >3 months Ref Ref Ref Ref ≤ 3 months 1.97 1.46 – 2.66*** Frequency of ANC < 4 visits Ref Ref Ref Ref ≥ 4 visits 1.95 1.43 – 2.64*** *p<0.05; **p<0.01; ***p<0.001 222 3.8 Prevalence of MNCH related PRABs The prevalence of at least one MNCH challenging PRABs in the intervention was significantly lower than in the comparison communities (33.9 % versus 50.0 %) (Chi = 27.1, p < 0.001). Similarly, the mean score for MNCH challenging PRABs in the comparison communities was significantly higher than that of the intervention communities (0.90 versus 0.46), F (1, 1019) = 49.66, p < 0.001 3.9 Maternal Knowledge on danger signs and symptoms during pregnancy The mothers were asked about risks associated with frequent pregnancies, signs and symptoms during pregnancy, delivery, postpartum and newborn danger signs which demanded seeking immediate care from the health facility or health workers. Generally, most of the respondents in the intervention communities were familiar with these signs. However, the proportion of respondents in comparison communities who had knowledge of dangers of frequent pregnancies was higher than in the intervention communities (Table 3.9). Table 3.8: Maternal Knowledge on risks and danger signs associated with pregnancy, delivery and newborn Danger Sign N Intervention Sub￾district (%) Comparison Sub-district (%) Test statistic Knowledge of at least three dangers of frequent pregnancies Yes 252 22.0 27.5 Chi-square (χ 2 ) = 4.1 , p = 0.04 No 768 78.0 72.5 Knowledge of at least three danger signs of during pregnancy Yes 521 60.0 42.2 Chi-square (χ 2 ) = 32.5 , p < 0.001 No 499 40.0 57.8 Knowledge of at least three danger signs of during postpartum Yes 353 53.3 15.9 Chi-square (χ 2 ) = 158.0 , p < 0.001 No 667 46.7 84.1 223 Knowledge of at least three newborn danger signs Yes 383 47.1 28.0 (χ 2 ) = 39.3 , No 637 52.9 72.0 p < 0.001 224 4.0 DISCUSSION AND RECOMMENDATIONS Main conclusion: This community-based intervention study tested and confirmed the hypothesis that repositioning and engaging key custodians of household and community-based practices, rituals, attitudes and beliefs (PRABs) as Council of Champions (CoCs) for maternal and child health has assisted in either modifying the challenging/harmful PRABs as well as reinforce positive PRABs. The CoC strategy supported the earlier assertion that engaging the custodians at the community-household level (demand side) and providing quality and adequate healthcare services at the facilities (supply side), barriers to the uptake and use of maternal and child health services is addressed. Summary of main findings and evidence i. Comparing the changes over time, significantly more pregnant women in the intervention communities received adequate prenatal care (defined as having initiated ANC in the first trimester and made at least four visits) than the comparison communities. ii. The difference-in-difference (DID) analysis comparing the changes over time for eligible intervention households and the comparison households indicates a significant improvement in respect of all the outcomes measures except health facility delivery. iii. The find study established significant differences in the uptake of maternal, newborn care health services between the study groups. Coverage of timely initiation of first ANC attendance, frequency and adequacy of ANC attendance and uptake of post-natal care uptake was significantly higher in the intervention communities than in the comparison communities. However, there was a decline of early initiation of ANC and facility delivery with time due to the absence of skilled health professionals at the only health facility in the intervention area iv. Among the community leaders, the magazia was the most influential with regards to encouraging mothers to patronize early ANC, post-natal services and health facility delivery. v. Women from the intervention communities were 2.9 times more likely to initiate first visit early in pregnancy [AOR = 2.95 (CI: 2.01 to 4.34)]. Women who attended ANC at least 4 times were 7.9 times more likely to initiate first visit early in pregnancy [AOR = 7.88 (CI: 5.35 to 11.58)] but were less likely to deliver at the health facilities. [AOR = 0.50 (CI: 0.26 to 0.95)] to deliver in a health facility, compared to their counterparts from the comparison communities. vi. Women from the intervention communities were 1.7 times more likely to utilize postnatal care services at least two times in the first week of delivery compared with women from the comparison communities (AOR = 1.74, CI: 1.28 to 2.37). Women who received more ANC services (≥ 7) were 1.9 times more likely AOR = 1.97 (CI: 1.44 to 2.70) to seek postnatal services in the first week of delivery, compared with women who received less than the seven ANC services rendered. 225 vii. The intervention significantly improved essential newborn care practices (safe cord care, optimal thermal care and good neonatal feeding). viii. The prevalence of at least one MNCH related PRABs in the intervention was significantly lower than in the comparison communities (33.9 % versus 50.0 %) (Chi = 27.1, p < 0.001). ix. The mothers were asked about risks associated with frequent pregnancies, signs and symptoms during pregnancy, delivery, postpartum and newborn danger signs which demanded seeking immediate care from the health facility or health workers. Generally, respondents in the intervention communities were more knowledgeable with danger signs during pregnancy, delivery, postpartum and neonatal periods The Limitation of the study – The key limitation of the study was the difficulty in controlling extraneous factors that seemed to have a direct or indirect impact on the outcome indicators of interest. For instance, there was a serious ethnic conflict in the intervention area about 6 -8 months towards the endline. This affected the availability of health staff in the intervention area to provide MNC services. Also, the intervention area had only one health facility while there were four health facilities in the comparism area. In spite of these limitations, we conclude that the CoC strategy does have an impact on uptake of MNC services which could influence morbidity and mortality rates positively Comparison with similar research efforts: Similar to studies conducted in other contexts, we found that direct engagement with community leaders were successful in improving uptake of essential MNCH services. Details of these are discussed below: Factors predicting the initiation of prenatal care: The frequency and early initiation of ANC (≤ 3 months) were higher amongst women in the intervention than in the comparison communities. A similar finding was reported in an earlier study (Midhet and Becker, 2010). According to this finding the decision to access prenatal care during the first trimester depends on personal, cultural, and societal beliefs. Mothers from the intervention communities, compared to the comparison communities were 2.9 times more likely to initiate first visit early in pregnancy. Women who attended ANC at least 4 times were also more likely to initiate first visit early in pregnancy. Unexpectedly, compared to women staying more than 10 km from a health facility, women closer to health facilities were less likely to initiate ANC early (that is protective against early initiation). On average women in the intervention communities were further away from health facilities, compared to women staying in the comparison communities. The SBCC activities in the intervention communities could have influenced women to seek early ANC services in spite of the distance they had to travel. Factors including maternal education, age, parity, and occupation were tested but found to be not associated with early initiation of ANC. In the literature various factors that influence early initiation and frequency of antenatal care visits have been reported. These include age of the mother (Braun, 1995, Moyer and Mustafa, 2013), maternal education (Braun, 1995, Grosse, 1998, Kerber et al., 2007), occupation (WHO, 2012) and distance to health facilities (Montagu et al., 2011). These were not however evident in this study Utilization of Health Facilities for Delivery: Institutional deliveries increased overall but less in the intervention area towards the endline. The proportion of women who initiated ANC early (≤ 3 months) 226 decreased, with most of the decline amongst women in the comparison arm. Frequency of ANC visits was also reduced in the comparison communities. The 2015 mid-year routine monitoring data at the institutional level by the Ghana Health Service show similar figures for early ANC attendance of 41.0 % for the intervention area and 32.0 % in the control area. The study found that frequent antenatal check￾ups of at least four times during pregnancy seem to be associated with several targeted behaviors, including institutional delivery, neonatal feeding and postnatal care within 7 days of delivery. Therefore, strategies that support early and subsequent ANC attendance should be promoted. Factors that Influence postnatal care services in the first week of delivery: Exposure to intervention activities and content of ANC services received were the only determinants of postnatal care services in the first week of delivery. Women who initiated PNC at an early stage were more likely to live in an intervention community. Uptake for post-natal care services refers to the proportion of mothers of infants 0-5 months who seek postnatal care (PNC) within 2 days of delivery. Generally, uptake for post-natal care services of at least two visits in the first week after delivery was low in both the intervention and comparison communities (40.4% versus 22.4 %). It appears women are not aware of the importance of postnatal check-ups for the mother and newborn within 7 days of delivery and they also had poor knowledge of postnatal danger signs that signal the need for medical care among mothers and newborns. This finding is consistent with other studies (Sigman et al., 1991). More education is needed to increase the importance and uptake of attending PNC after 2 days of delivery especially among women who deliver at home. Essential newborn care behaviors (neonatal feeding, thermal and cord care): Over the four years of implementation, the project achieved significant improvements in essential newborn care practices, including breastfeeding, hygienic cord care, and thermal protection practices associated with reduced neonatal mortality. All these recorded increases between baseline and end-line. These findings demonstrate the power of community leaders as council of champions and their ability to effect change in behaviors around maternal and newborn care, and are similar to those reported elsewhere (Kirkwood et al., 2013, Prost et al., 2013, Waiswa et al., 2015). Women in intervention communities reported following better thermal care practices, safe cord care than their counterparts in comparison areas. Similarly, good neonatal feeding practices were commonly reported in the intervention than in the comparison areas. Maternal Knowledge on risks and danger signs associated with pregnancy, delivery and newborn: Maternal knowledge of the danger signs of obstetric complications is the essential first step in seeking and accepting timely referral to obstetric and newborn care. The mothers were asked about risks associated with frequent pregnancies, signs and symptoms during pregnancy, delivery, postpartum and newborn danger signs which demanded seeking immediate care from the health facility or health workers. In this study a woman was considered knowledgeable when she mention at least three recognized danger signs for each of the critical periods of pregnancy, delivery, postpartum and neonate. These results showed a general low level of knowledge of obstetric and newborn danger signs during pregnancy, child birth and postpartum period among women in the district. This indicates a significant number of pregnant women who do not have the knowledge are likely to delay in deciding to seek care. Every woman should be made aware of the likelihood of complications during pregnancy, childbirth/labor, the postpartum and neonatal periods. 227 The proportion of mothers who could mention at least three danger signs associated with frequent pregnancies, delivery, postpartum and newborn was higher in the intervention than in the comparison arm. This is corroborated by previous studies. For example, a community based cross-sectional study conducted in Tanzania showed that about half of the study subjects knew at least one obstetric danger sign (Pembe et al., 2009) and in Kenya, only 27.9 % of women attending ANC were not informed about danger signs in pregnancy (Mutiso et al., 2008). This finding is also consistent with the study conducted in Ethiopia in which 30.9% of respondents mentioned at least two danger signs of pregnancy (Hailu et al., 2010). The most common danger signs during pregnancy include severe vaginal bleeding, swollen hands/face and blurred vision. Key danger signs during labor and childbirth include severe vaginal bleeding, pro￾longed labor, convulsions, and retained placenta. Danger signs during the postpartum period include severe bleeding following childbirth, loss of consciousness after childbirth, and fever. Raising awareness of pregnant women on the danger signs would improve early detection of problems and reduces the delay in deciding to seek obstetric care (JHPIEGO, 2004, Thaddeus and Maine, 1994). Recognizing these danger signs for pregnancy related complications and what to do if they arise would therefore significantly increase the capacities of women and newborns to remain healthy, to take appropriate steps to ensure a safe birth and to seek timely skilled care in emergencies in low income countries (HPIEGO, 2004, WHO, 2006) . 228 REFERENCES CITED Braun, J., 1995. Agricultural commercialization: Impacts on income and nutrition and implication for policy Food Policy 20(3), 187–202. CRS Ghana, 2011. Encouraging Positive Practices for Improving Child Survival (EPPICS) Knowledge, Practice and Coverage (KPC) survey, Unpublished Report. Catholic Relief Services, Tamale, Ghana. GCSP, 2006. Report of a formative research on maternal and child nutrition and health in districts of northern Ghana. Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF Macro, 2009. Ghana Demographic and Health Survey (GDHS) 2008. GSS, GHS, and ICF Macro., Accra, Ghana. Grosse, S.D., 1998. Farm animals, consumption of animal products, and children’s nutritional status in developing countries. In: Symposium on Human Nutrition and Livestock. Heifer Project International, Little Rock, Arkansas, USA. Habicht, J., Pelto, G.H., Lapp, J., 2009. Methodologies to Evaluate the Impact of Large Scale Nutrition Programs In: Doing Impact Evaluation Series. World Bank, Washington, D C. Hailu, M., Gebremariam, A., Alemseged, F., 2010. Knowledge about obstetric danger signs among pregnant women in Aleta Wondo district, Sidama Zone, Southern Ethiopia. Ethiop J Health Sci. 20(1), 25–32. JHPIEGO, 2004. Maternal and Neonatal Health Pro-gram. Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibilities. JHPIEGO,, Maryland, USA. Kerber, J.K., de Graft-Johnson, E.J., Z, B.A., Okong, P., Starrs, A., Lawn, J., 2007. Continuum of care for maternal, neonatal, and child health: from slogan to service delivery. Lancet 370, 1358. Kirkwood, B.R., Manu, A., ten Asbroek, A.H., Soremekun, S., Weobong, B., Gyan, T., et al., 2013. Effect of the newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. Lancet 381:218492. Lawn, J.E., Cousens, S., Zupan, J., 2005. 4 million neonatal deaths: when? Where?Why? Lancet 365(9462), 891-900. Midhet, F., Becker, S., 2010. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan Reprod Health. 7: 30. MOH, 2010. The Health Sector Medium-term development plan, 2010 (HSMTDP, 2010-2013. Ghana Ministry of Health, Accra, Ghana. MOH, 2011. MDG Accelerated Framework, Ghana Country Action Plan, Maternal Health. Ministry of Health Accra. MOH, 2007. National Health Policy: Creating Wealth through Health. Ministry of Health, Accra, Ghana. Montagu, D., Yamey, G., Visconti, A., Harding, A., Yoong, J., 2011. Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLoS ONE 6(2), e17155. 229 Moyer, A.C., Mustafa, A., 2013. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reproductive Health 10, 40. Mutiso, S.M., Qureshi, Z., Kinuthia, J., 2008. Birth preparedness among antenatal clients. East Afr Med J. 85(6), 275–283. Pembe , A.B., Urassa, D.P., Carlstedt, A., Lindmark, G., Nyström, L., Darj, E., 2009. Rural Tanzanian women’s awareness of danger signs of obstetriccomplications. BMC Pregnancy Childbirth 9(12). Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy, A., Copas, A., et al., 2013. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 381: 173646. Senah, K., 2003. Maternal mortality in Ghana: the other side. Research Review NS 19 (1), 47-55. Sigman, M., McDonald, M.A., Neumann, C.G., Bwibo, N., 1991. . Prediction of cognitive competence in Kenyan children from toddler nutrition, family characteristics and abilities Journal of Child Psychology and Psychiatry 32, 307–320. Thaddeus, S., Maine, D., 1994. Too far to walk: Maternal mortality in context. Social Science and Medicine 38(8) 1090- 1110. UNICEF, 2010. A study on five key health and sanitation indicators in four regions of Ghana. Report for the C4D Program. UNICEF, Accra, Ghana. Waiswa, P., Pariyo, G., Kallander, K., Akuze, J., Namazzi, G., Ekirapa-Kiracho, E., Kerber, K., Sengendo, H., Aliganyira, P., Lawn, J.E., Peterson, S., 2015. Effect of the Uganda Newborn Study on care-seeking and care practices: a cluster￾randomised controlled trial. Glob Health Action 8:24584. WHO, 2006. Standards for Maternal and Neonatal Care: Birth and emergency preparedness in antenatal care: Department of Making Pregnancy Safer (MPS). World Health Organization,, Geneva. WHO, 2012. Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank estimates. World Health Organization, Geneva. Wuni, A., 2009. Determinants of use of MCH services among women of reproductive age in West and East Mamprusi. Unpublished dissertation. Yunus, M., Bomfe, K.A., Sulemana, P.Y., 2007. Kalogutiim the cause of many rupture uterus among women in northern of Ghana. Northern Health Monitor. 230 ANNEX XV. STAKEHOLDER DEBRIEF POWERPOINT PRESENTATION 231 232 233 234 235 236 237 238 239 240 ANNEX XVI. PROJECT DATA FORM Child Survival and Health Grants Program Project Summary Oct-29-2015 General Project Information Cooperative Agreement Number: AID-OAA-A-11-00042 CRS Headquarters Technical Backstop: Elena McEwan CRS Headquarters Technical Backstop Backup: Elena McEwan Field Program Manager: Ane Adondiwo Midterm Evaluator: Final Evaluator: Headquarter Financial Contact: Tia Simmons Project Dates: 10/1/2011 - 9/30/2015 (FY2011) Project Type: Innovation USAID Mission Contact: Juliana Pwamang Project Web Site: Field Program Manager Name: Ane Adondiwo (Project Manager) Address: Ghana Phone: +233247031458 Fax: E-mail: ane.adondiwo@crs.org Skype Name: Ane Adondiwo Alternate Field Contact Name: Melissa Kreek (Head of Programming) Address: 16 Labone Crecent Accra Ghana Phone: (233)-21-776188 Fax: E-mail: melissa.kreek@crs.org Skype Name: Grant Funding Information USAID Funding: $1,750,000 PVO Match: $438,649 241 General Project Description Catholic Relief Services (CRS), a 2011 Innovation category grantee, is implementing the Encouraging Positive Practice for Improving Child Survival Project (EPPICS) in East Mamprusi District, Northern Region, Ghana. The project goal is to contribute to sustainable reduction of maternal and newborn morbidity and mortality. At the community level, the project will scale up a motivational community mobilization strategy using Healthy Mother and Newborn Committees, Positive Deviant Inquiry, and community scorecards for communities to track progress and provide feedback to their members. At the health facility level, the project will improve health staff counseling skills in response to gaps identified in another CRS in nearby districts. Project Location Latitude: 7.95 Longitude: -2.02 Project Location Types: Rural Levels of Intervention: Health Center Health Post Level Home Community Province(s): Northern Region District(s): East Mamprusi District Sub-District(s): -- Operations Research Information OR Project Title: ENGAGING COMMUNITY LEADERS AS ‘’COUNCIL OF CHAMPIONS’’ TO IMPROVE UPTAKE OF MATERNAL AND NEWBORN CARE SERVICES IN EAST MAMPRUSI, A RURAL DISTRICT OF NORTHERN GHANA Cost of OR Activities: -- Research Partner(s): University for Development Studies, OR Project Description: CRS, in collaboration with the University for Development Studies, a Ghanaian research institute, is conducting operations reserach that will address sociocultural and traditional practices at the household level. Committees of Champions for mothers and babies, composed of chiefs, "queen mothers," and imams/pastors, will be formed and trained . These committees will attempt to overcome barriers and change practices by directly influencing the most influential members of a family at critical times during pregnancy and the neonatal period. Partners Ghana Health Services (Collaborating Partner) $0 THE UNIVERSITY FOR DEVELOPMENT STUDIES (SUBGRANTEE) $0 Strategies Social and Behavioral Change Strategies: Community Mobilization Group interventions Interpersonal Communication Health Services Access Strategies: Emergency Transport Planning/Financing Addressing social barriers (i.e. gender, socio-cultural, etc) Implementation in a geographic area that the government has identified as poor and underserved Health Systems Strengthening: Quality Assurance Conducting capacity assessment of local partners Supportive Supervision Developing/Helping to develop job aids Providing feedback on health worker performance Monitoring CHW adherence with evidence-based guidelines Referral-counterreferral system development for CHWs Community role in supervision of CHWs Community role in recruitment of CHWs Coordinating existing HMIS with community level data Community input on quality improvement Strategies for Enabling Environment: Advocacy for revisions to national guidelines/protocols Stakeholder engagement and policy dialogue (local/state or national) Tools/Methodologies: BEHAVE Framework Rapid Health Facility Assessment Community-based Monitoring of Vital Events 242 Mobile Devices for Data Collection MAMAN Framework Capacity Building Local Partners: Dist. Health System Health Facility Staff Non-government sanctioned CHWs TBAs Faith-Based Organizations (FBOs) Interventions & Components Infant & Young Child Feeding (30%) - ENA - Comp. Feed. from 6 mos. - Cont. BF up to 24 mos. - Maternal Nutrition - Peer support - Promote Excl. BF to 6 Months - Intro. or promotion of LAM CHW Training HF Training Malaria (10%) - IPT CHW Training HF Training Maternal & Newborn Care (60%) - Emergency Obstetric Care - Neonatal Tetanus - Recognition of Danger signs - Newborn Care - Post partum Care - Child Spacing - Integation. with Iron & Folic Acid - Normal Delivery Care - Home Based LSS - Control of post-partum bleeding - Emergency Transport - AMTSL 243 OPERATIONAL PLAN INDICATORS 244 Locations & Sub-Areas Total Population: 122,187 Target Beneficiaries Ghana - CRS - FY2011 Children 0-59 months 24,431 Women 15-49 years 26,881 BENEFICIARIES TOTAL 51,312 RAPID CATCH INDICATORS: DIP SUBMISSION 245 ANNEX XVII. LEARNING BRIEF 246 Alaafia Goomni (the Wall of Good Health) An innovative tool for rallying communities to demand and use data on Maternal and Newborn Care At the community level, there is often limited or no feedback on maternal and newborn care (MNC) indicators to community members by health care providers. This impacts negatively on the motivation of community members to participate and contribute resources (human and financial) in assisting to improve MNC. Additionally, there is limited responsiveness of the part of the healthcare providers since there is no demand for MNC related data and feedback by community members. To address this challenge, Catholic Relief Services (CRS) through its USAID funded maternal and child survival project titled Encouraging Positive Practices for improving Child Survival (EPPICS) Project developed an innovative community-led monitoring tool to rally communities to demand and use MNC data. Alaafia Goomni (Walls of Good Health) are Community Giant scoreboards to help improve data demand and use of MNC data by community members as well as improve the responsiveness of healthcare providers in 240 communities in the East Mamprusi District of Ghana. Methodology During the design of the Wall of Good Health, the following M&E questions used to inform the design of the project:  How will EPPICS assist community members to use data collected monthly to monitor the performance of their MNC indicators?  How will communities measure their contributions in improving MNC indicators?  How will the project provide feedback on data collected from communities?  How can communities visibly display their performance in a way that can be understood by all? Alaafia Goomni is a giant wall that has pictorial illustrations of desirable and undesirable MNC outcomes—with a maximum of two outcomes—one on each side of the wall. For example, one face/front of the wall could display the photograph of an infantbeing Photograph of the Alaafia Goomni, the Wall of Good Health Photo/CRS Key Findings on the Wall of Good Health: - It’s a tool for community engagement - Complements the delivery of targeted BCC messages - Enhances feedback and decision making process using MNC data 247 breastfed and the other, an infant being fed on other foods. The second face/back displays a woman at the point of childbirth with assistance from skilled personnel in a health facility and the other, a woman at child birth at home with the assistance of a Traditional Birth Attendant/Mother-in-law. On the top side of each side are the Scoreboard with10 slots, each representing 10%. Two sets of ten colored sticks are used for scoring indicators: achieved or desirable indicators =green and not achieved or undesirable =red to illustrate outcomes. The sticks displayed on the frame indicates the progress for that specific indicator, the goal being for 100% (=10 green sticks to be achieved). Data for scoring is generated from community and clinic registers for all indicators; indicators are scored and updated monthly. In each community, the CGS committee updates the scores, share the findings and engage the larger community in assessing, analyzing and agreeing on key actions to take based on the outcomes. There are a number of steps required to operationalize the Wall of Good Health (WGH) in the community setting and these include: 1. Community visits – first visit for mobilization and sensitization process for community leadership, second first- community-wide meeting to provide detailed information to community members and guide them to elect the management committee of the WGH. 2. Construction of Walls: The management committee with the support of 10 other members is trained to lead the construction and day to day management of the wall. 3. Baseline data collection: To set the stage for updating the WGH. The management committee with support the project staff collects baseline data to determine in the first instance the portion of categories of score sticks to use (# of red or # green sticks). Right after the installation of the baseline scores, the management committee leads the community to assess the levels, analyze why such levels and take appropriate actions to improve Findings Through the implementation of EPPICS, Ghana Health Service reached more than 52,000 direct beneficiaries using the WGH IN 240 communities. The contribution of the WGH has led to improvement of MNC indicators: Early registration at antenatal increased from 51% to 82%. Exclusive breastfeeding improved from 47% to 70%, skilled assisted deliveries increased from 43% to 70% and uptake of postnatal care increased from 30% to 83% Also, community members were able to visibly see the progress they made toward achieving positive MNC outcomes, and this fostered an enabling environment for communities to actively improve their health status. This tool also brought about friendly competition among communities and reinforced positive behaviors and practices regarding seeking timely healthcare services Conclusions and Lessons Learned Based on the use of the WGH over the years, the following conclusions and lessons are reached: - Tool for community empowerment: The WGH presents as rallying tool for the community members to meet and access, analyze and take prompt and proactive actions that improve their health and well-being. - Complements delivery of targeted health messages: The WGH is directly used as an advocacy tool to promote adoption of some key behavior change communication messages including working to reduce or eliminate child undernutrition, exclusive breastfeeding, consumption of iodized salt, use of health facilities by 248 pregnant women for childbirth and related services - Feedback and Decision-making processes enhanced: The WGH is a great tool in assisting to provide feedback on health and nutrition indicators and to communicate the outcomes of key efforts and interventions on the health and overall wellbeing of community members. Using the assessment, analysis and action as key process in the periodic WGH meetings with the entire community, exchanges and suggestions are made to enhance the community-based decision making processes tracked on demand for Recommendations The Wall of Good Health has proven to be a great tool that visibly assists communities to appreciate how their contributions has assisted in improving their MNC indicators. Its recommended that this tool be used in health facilities to track the quality of health service delivery as a way of improving service uptake among users The Encouraging Positive Practices for Improving Child Survival (EPPICS) Project in East Mamprusi District of Ghana is supported by the American people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The EPPICS Project is managed by the Catholic Relief Services- Ghana Program under Cooperative Agreement No. AID￾OAA-A-11-00042. The views expressed in this material do not necessarily reflect the views of USAID or the United States Government