CATHOLIC RELIEF SERVICES Catholic Relief Services - USCCB Child Survival and Health Grant Project Implemented by: CRS-Nicaragua, Caritas Matagalpa Diocese and the Ministry of Health-Nicaragua Cooperative Agreement Number: GHN-A-00-08-00007-00 Grant Period: October 1, 2008 to September 30, 2012 Project Location: Municipalities of Matiguas and Rio Blanco in the Province of Matagalpa; Municipality ofWaslala in the North Atlantic Autonomous Region and Municipality of Bocana de Paiwas in the South Atlantic Autonomous Region Mid Term Evaluation December 2010 Principal Author: Renee Charleston, Consultant Table of Contents Acronyms A. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 B. Overview oftlle Project ...................................................................................... 4 C. Data Quality: Strengths and Limitations ............................................................. 8 D. Assessment of progress toward tlle achievement of project results .................... 11 E. Discussion of tlle Progress toward Achieving Results ........................................ 14 F. Discussion of Potential for Sustained Outcomes, Contribution to Scale, Global uarn.ing, and EQ.uicy I I I I I I I I I I I I I I I I I I II I I I I I II I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I II I I I I I I I I 1 29 G. Conclusions and Recommendations ................................................................ 32 H. Action Plan for Responding to Evaluator Recommendations ........................... 36 ANNEXES Annex 1: Results Highlight Annex 2: Publications and Presentations Related to the Project Annex 3: Project Management Evaluation Annex 4: Workplan Table Annex 5: Rapid CATCH Table No Mid-Term KPC survey performed Annex 6: Mid-Term KPC Report No Mid-Term KPC survey performed Annex 7: CHW Training Matrix Annex 8: Evaluation Team Members Annex 9: Evaluation Assessment Methodology Annex 10: Persons Interviewed and Contacted during the MTE Annex 11: Project Data Form Annex 12: Reports on Project Innovation Annex 13: Recommended Modifications to Indicators ACRONYMS AINMA AMTSL ANC BCA BCC BF BFHI BL Caritas CHA CHW CIES CSP CRS DIP EBF EOC ETB FGD HCI HF HFA HIS HQ KPC LQAS M&E MIN SA MNC MOH MTE MWH N-IMCI NCO NICASALUD OR PAHO SICO SILAIS TBA UNAN UNICEF US AID WHO IntegTal Care for Women, Children and Adolescents Active Management of the Third Stage of Labor Antenatal Care Behavior Change Agent (Promotor de Cambio de Comportamiento) Behavior Change Communication Breast Feeding Baby Friendly Health Initiative Baseline Social Services Arm of the Catholic Church Community Health Agent (Salubrista) Community Health Worker (Brigadista) Center for Health Research and Studies Child Survival Project Catholic Relief Services Detailed Implementation Plan Exclusive Breastfeeding Emergency Obstetric Care Emergency Transport Brigade (BTEO) Focus Group Discussion Health Care Improvement Project Health Facility (Center and Post) Health Facility Assessment Health Information System Headquarters (of CRS in Baltimore, Mm·yland) Knowledge, Practice and Coverage Lot Quality Assurance Sampling Monitoring and Evaluation Ministry of Health of Nicaragua Maternal - Neonatal Cm·e Ministry of Health Mid Term Evaluation Maternity Waiting Home (Casa Materna) Neonatal Integrated Management of Childhood Illnesses Non-Governmental Organization Nicaragum1 NCO Health Network Operational Resem·ch Pan-American Health Organization Community Information System (MINSA & Project) Depmtmentallevel of MIN SA Traditional Birth Attendant (Partera) Autonomous University of Nicm·agua United Nations Children's Fund United States Agency for International Development World Health Organization A. Executive Summary Catholic Relief Services (CRS) received funding from USAID for the implementation of a four year Child Survival Prqject in Nicaragua (October 2008-September 2012). Goal: Contribute to the reduction of maternal and neonatal morbidity and mortality in the municipalities of Matiguas, Rio Blanco, Paiwas and Waslala of the Matag-alpa SILAIS by 2012. There are 125 target communities and 13 Ministry of Health (MIN SA) facilities. The prqject is being implemented by three principal partners; CRS is leading efforts in institutional strengthening for MINSA facilities under Objective 2: Increased families' access to quality maternal and neonatal services and Caritas Matagalpa Diocese is implementing community activities in coordination with MIN SA under Objective 1: Improved knowledge and behaviors for maternal and neonatal health among families and communities. The overall prqject plan is to implement with MINSA a complete "package" of household, community and health facility (HF) activities to strengthen maternal neonatal care. These include: Neonatal IMCI at both clinical and community levels, Birth Planning, Live Saving Skills, Nutrition During Pregnancy, Breastfeeding, Institutional Strengthening for MINSA (Training, equipment, Quality Improvement). The main implementation strategy for working at community level is the formation, training and support to a network of volunteers in activities specific to improving maternal newborn care (70% level of effort-) and nutrition (30% level of effort). At the community level volunteers counsel families, provide gToup education, and monitor and refer women for required services. The CSP includes two innovations: Innovation N 1: Engagii1gN/en to Improve Guc:-Seelungin 20 communities where 60 Behavior Change volunteers have been h·ained. Qualitative research was conducted to understand the situation and opinions of men, to identify barriers and facilitators, and negotiate new behaviors. This methodology is being implemented by NICASALUD, and Center for Health Research and Studies is measuring impact tlu·ough a series of surveys. Innovation N 2 hnprov1i1g Community Response to Maternal and Neonatal Complications to increase access to emergency health services in 25 isolated rural communities by use of a higher level volunteer trained in lifesaving skills, emergency care, neonatal IMCI. They have been equipped with essential supplies and materials for emergencies and are monitored monthly by the Caritas staff. There is no operations research planned for this innovation. Project implementation is on track to achieve planned results. The majority of planned activities have been completed, the project suffered h·om a slow start up and some activities are slightly behind schedule. Positive aspects evident during the MTE include: o Respondents cited perceived impact; increased use of health services, Maternity Waiting Homes, institutional births, and y lor monitming 2.2.16. Establish a referral and counter-relerral system. Completed 2.2.17. Training of technical and MOH personnel in EMNC Technical staff and MIN SA trained in EMNC and clinical ""think would appro1-e if you make joint decisions with your wife? The Formative Research will usc group and in-depth interviews with men to give usn better understanding of men feelings, beliefs, gender lens, social and cultural behaviors towards their families and relationship with their wives during pregnancy. It will also help us to better understand the barriers and enablers that innuence !hose behaviors (why they behave the way lhey do) and identify feasible enablers for the desired new behaviors. Using in-depth interviews will help us find answers to pending questions about the situation and to better understand the results from the baseline described above regarding how decisions are made at the household level. This methodology aims to identify key factors that innucncc current behaviors, and to understand the benefits lhey pcn:eive from lhe current bebavior11 and lhe barriers they face to practice the proposed new behavior11. Simullnneously, this methodology will help us ascertain their willingness to adopt new behaviors, how liable they are to pmdice them. Refer to fonn I-IV to record the infonnalion. Ph ate 2: To develop an approach to Implement and monitor the DCC lntenentlons to promote beha\·lors and develop draft BCC materlols. The phase two involves the development of droll DCC materials, including assessment reaction to draft BCC materials. In this phase the CSP will select male oommunily memben who will be<:ome DCC counselors. These volunteers would have worked on health, community committee5 or any other activity and have gained respect from their communities. Once the promoters are selected by their communities, they will be 1rained in counseling skills and the content of specific behaviors. The BCC counselors will receive materials and supplies to implement the activities. This phase will be conducted until all the promoters are trained. will negotiate with community members regarding the feasibility of the proposed strategies to be implemented, to define channels of conununication, to perfonn a training needs assessment, and to develop processes and monitoring and evaluation tools. In order to monitor and evaluate the BCC activities a M&E system based ot the community level will be developed by odopting the guidelines developed by NicaSolud. This system includes matrix and checklists to record the data, as well as the process to compile and analyze the infonnation. The infonnation will be used to field test the innovation and evaluate its effectiveness in changing behavio"'; the results will be used to adjust the strategy and improve it. Refer to the fonns V- VIII to record the infonnation Phase 3: To carry out a small·scale pilot testing of the lnten·entlon, Including assenment reaction to draft DCC muterlals The CSP will work with the men in negotiating ond probing specific behavio"'. This methodology helps to identify enablers for and barriers against the desired behavior. While men are nt home, they will be asked to record situations when they could or could not practice the desired behavior and how they felt. During home visits, CRS staffnnd Caritas Technicians will review whether men have practiced the desired behavior and in subsequent visits they will discuss their experience in probing the new behavior. The following questions will be used to record the acceptability, feasibility, affordability of the behavioral n:commendotions and their self-efficacy in practicing the new behavior: I. Could you pmctice the behavior? 2. Are you willing to continue practicing the new behavior? 3. Why do you think you could continue practicing the new behavior? (See fonns V-VIII to record the information) Phase II: Summath·e Research: The CSP, in partnmhip with CIES, proposes the following methodology to develop a Summative Research (SR) in 20 selected communities of the municipality of Matigull!, Rio Blanco ond Paiwas. This SR will be aimed at meaJuring if behavior change activities with men may contribute to decreasing the first barrier in recognizing and deciding to access timely obstetric and neonatal emergency care and secondly to better understand men's attitudes about their perceived role, their perception of authority and of family well-being. On the providers' side, rhe CSP will strengthen the services by providing MoH staff new skills to diagnose and tn:at obstetric ond newborn emergencies, by re·structuring the health services to become mon: culturally sensitive, and by including new indicators in the MoH health's infonnation system to record the number of pregnant women seeking care with their partners and the number of men who asked questions regarding their wives' health during care. The CSP will also improve the coordination between health units and community structures to improve timely referrals. Objecrh·es and hypolh.,ls: I. Ultimate objective: Contribute to the reduction of motcmal and neonotal morbidity and mortality in 20 targeted isolated ruml communities in the municipalities of Matiguas, Rio Blrutco and Paiwas by decreasing fundamental barriers in recognizing danger signs and encouraging pregnant women and their partners to make joint decisions vis a vis seeking prompt maternal and new born care. 2. Immediate objecllvu : a) To assess men's knowledge in recognizing danger signs during pregnancy, labor and delivery, post partum and new born periods. b) To detennine if participating men change their behaviors concerning health care seeking decisions and taking care of their family's health. c) To document the innovation process; and d) To measure health outcomes in increasing maternal and newborn care. 3. Hypothesis Increasing awareness among men in regards to recognizing danger signs during pregnancy and new born periods, and by motivating them to make joint decisions with their wives will result in boosting seeking care during obstetric and newborn emergencies in a timely manner and an increase in ANC, institutional deliveries; therefore improving maternal and newborn heahh. 4. Expected outcome: Healthier pregnancies and healthier newborns by increased timely demand to maternal and neonatal heath care. It is expected to increase the percentage of ANC, institutional deliveries, postpartum and new born care. 5. Variables affecting outcome This innovation will fonn part of a comprehensive project which will also include other community BCC activities, birth planning, supporting CH\Vs in promoting care-seeking, exclusive breast feeding (EBF), adequate maternal nutrition, community emergency transport plans and medical emergency funds and health system strengthening by improving the quality of ANC, institutional deliveries and newborn care. o Intervention description I. Intervention sltet. The intervention sites will be chosen in 20 communities in the municipalities of Matigut\s, Rio Blanco and Paiwas. 2. Activities: Strategy Larmcllillg aud lmp/e;rulltatiotr : Trnined BCC counselor and lay rutd religious leaders will implement this phase in twenty targeted communities in the three municipalities from April2010 to April 2012. o Study methodology The CSP carried out two types of surveys as part of the baseline: KPC and qualitative surveys. This information was used to prioritize seeking care indicators the project wants to increase (see Quantitative Analysis Mattix). age two). o Study population: Rural men and their partners (pregnant, postpartum or with children under o Inclusion criteria: Rural men whose wives are pregnant, postpartum or have children under two years old and their wives. o Sampling methodology: For monitoring purpose the CSP will include all men and their partners that fits the criteria described above participating in the BCC activities Alouitorlug of tire BCC activities: A community information system will also be put in place to monitor process indicators. The community infom1ation system (SICO) developed by the MoH will be adapted to include the process indicato"' to monitor the BCC activities. It includes matrix and checklists to record the data, as well as the process to compile and analyze the infonnation. The information will be used to document the implementation and evaluate its effectiveness in changing behaviors; the results will be used to adjust the strategy and improve it. The counselors and religious leaders will be monitored by the MoH Municipal Educators and Caritas technicians. At the end of April201l the annual evaluation and documentation of the process will commence. Depending on results of the annual evaluation the CSP and MoH will detennine if it will be feasible to start tmnsfening some of the BCC activities to neighboring communities in Matigulis, Rio Blanco and Paiwas Municipalities. The final evaluation will take place at the end of the second year. Due to time constraints the CSP will not be able to roll out the innovation to all the project communities, but will document and share the innovation with the MoH and other partners at district and national level for them to adapt and scale. The methodology for the quantitative assessment that will be used for the annual and final evaluation will be defined with CSTS. Qualltutlve assessment: To complement the quantitative survey, the CSP will also carry out a qualitative study documentationusing focus group discussions and in-depth interview techniques. In both, targeted communities and control group communities the CSP will conduct five FGD with men whose wives are pregnant, postpartum or who have children under two yean of age, and five FGD with pregnnnt women, postpartum or women who have children under two years old, and five in-depth interviews in each group. o Use or not of control group: Men from 20 neighboring communities whose wives are pregnant, post partum of have children under two. These communities will be participating in all the CSP activitie-S but the ones referring to the BCC described in the innovation men to improl'e care- seeking. Limitation or the study: a) Two years is nn insuffi!;ient amount of time to sustain these behaviorol changes as they involve profound cultural behavio"' that could be difficult to adjust. b) The qualitative emphasis of the intervention methodologies focuses the results on the intervention site, rather than the whole project area. c) The health care environment does not include men's participation as a standard to evaluate quality of maternal and child care at the health posts and cente"'. Partners Carltas Matagalpa (Subgrantee) SILAIS Matagalpa (MOH) (Collaborating Partner) Internal Review Board (IRB) compliance CIES will give formallRB approval. Description of mechanisms to share evidence and utilize lessom with key stnkcholdcrs to infonn replication and scale up of innovation To show the potential for scaling up, the CSP will first implement and refine the strategy in the municipality of MatiguAs. The project will share the experience and methodology with the MoH, specifically through the community organization specialists of the SILAIS, Iending them technical support to implement the same strntegy thmugh health facility staff in the municipalities ofPaiwas and Rio Blanco. CRS, Caritas Matagalpa and the SILAJS staff will monitor the MoH efforts, including challenges and succe!:ses in order to jointly document a process for a concrtte approach for reaching men to scale up in other provinces. CRS and Caritos will look for opportunities to promote the concept and approach for male involvement in health through their work in other sectors and other municipalities and parishes. in the beliefth $317,779 $0 Strategies Social and Behavioral Change Strategies: Health Services Access Strategies: Health Systems Strengthening: Strategies for Enabling Environment: Tools/Methodologies: Capacity Building Local Partners: Interventions & Components Childhood Injury Control of Diarrheal Olseases HIV/AIDS Immunizations Infant & Young Child Feeding - Maternal Nutrition - l'eer support - Promote Excl. BF to 6 Months - lntro. or promotion of LAM - Support baby friendly hospital Malaria Maternal & Newborn Care (60%) - Emergency Obstetric Care - Neonatal Tetanus - Recognition of Danger signs - Newborn Care - l'ost partum Care - Nom1al Delivery Care -Birth l'lans - Home Based LSS - Control of post-partum bleeding - Emergency Transport Pneumonia Case Management Tuberculosis Group interventions interpersonal Communication Mass media and small media Emergency Transport Planning/Financing Addressing social barriers (i.e. gender, socio-cultural, etc) Implementation with a sub-population that the government has identified as poor and underserved Implementation in a geographic area that the government has identified as poor and underserved Quality Assurance Conducting capacity assessment of local partners Supportive Supervision Task Shifting Developing/Helping to develop clinical protocols, procedures, case management guidelines Developing/Helping to develop job aids Monitoring health facility worker adherence with evidence-based guidelines Providing feedback on health worker perfornmnce Monitoring CHW adherence with evidence-based guidelines Referral-counterreferral system development for CHWs Community role in supervision ofCHWs Review of clinical records (for quality assessment/feedback) Coordinating existing HMIS with community level data Community input on quality improvement Create/Update national guidelines/protocols Advocacy for revisions to national guidelines/protocols Building capacity of communities/CBOs to advocate to leaders for health BEHAVE Framework Rapid Health Facility Assessment Community-based Monitoring of Vital Events LQAS MAMAN Framework Local Non-Government Organization (NGO) Dist. Health System Health Facility Staff Other National Ministry TBAs Faith-Based Organizations (FBOs) IMCIIntegration IMCIIntegration IMCI Integration IMCIIntcgration IMCIIntegration IMCIIntegration IMCIIntegmtion IMCIIntegmtion CHW Training HF Training CHW Training HF Training CHW Training HFTraining CHW Training HF Training CHW Trnining HF Training CHW Training HF Training CHW Training HFTraining CHW Training HF Training CHW Training HF Training Vitamin A and Mlcronutrlents IMCIIntegration CHW Training HF Training Operational Plan Indicators Number of People Trained in MaternaVNewborn Health Gender Year Target Female 2010 186 Female 2010 Male 2010 Male 2010 517 Female 2011 320 Male 2011 450 Female 2012 300 Male 2012 450 Number of People Trained In Child Health & Nutrition Gender Year Target Female 2010 263 Female 2010 Male 2010 Male 2010 246 Female 2011 369 Male 2011 220 Female 2012 320 Male 2012 IJO Number of People Trained in Malalia Treatment or Prevention Gender Female Female Male Male Female Male Female Male Locations & Sub-Areas Matlguas Paiwas y Rio Blanco Total Population: Target Beneficiaries Children 0-59 months Women 15-49 years Beneficiaries Total Year 2010 2010 2010 2010 2011 2011 2012 2012 Matlguas 5,958 11,124 17,082 Target 0 0 0 l o 0 0 Actual 383 720 Actual 308 270 Actual 0 0 Pahvns y Rio Blanco 10,391 16,646 27,037 Total 16,349 27,770 44,119 __j 44,971 68,589 113,560 Rapid Catch Indicators: DIP Submission Sample Type: 30 Cluster Antenatal Care Description - Percentage of mothers of children age 0-23 months who had four or more antenatal visits when they were pregnant with the youngest child Numerator: Enter the number of mothers with children age 0-23 months who had at least four antenatal vbits while pregnant with their youngest child Denominator: Enter the total number of mothers of children nge 0-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas 124 302 41.1% 9.1 Paiwas y Rio Blanco 159 298 53.4% 10.0 Maternal Tf Vaccination Description - Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number ofmnthers with children age 0-23 months who received ot least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total numller of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas 167 302 55.3% 10.1 Pnlwns y Rio Blanco 130 298 43.6% 9.4 I Skilled Birth Attendant Description - Percentage of clll!Giren age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth wos attended by a doctor,nurse, midwife, auxiUary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguns 217 302 71.9% 10.8 Palwas y Rio Blanco 243 298 81.5% 11.2 I Current Contraceptive Use Among Mothers of Young Children Description - PercentugP. of mGthre rs Gf children age 0-23 months who are using a modern contraceptive method Numerator: Enter the number of motln rs with children age 0-23 months who are using a modern contraceptive method Denominator: Enter the IolBI numbu of met hers of children age 0-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas 194 302 64.2% 10.5 Palwas y Rio Blanco. 85 298 62.1% 10.5 Post-Natal Visit to Check on Nev1born Witbin tbe First 2 Days After Birth Description -- Percentage of €luils•·ern sge 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after bkth Numerator: F.nter the number of children •ce 0-23 month• who received a post-natal vloit within two day3 after birth by on appropriate health worker Denominator: Enter the total number of cllildren age 0-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas 152 302 50.3% 9.8 Palwas y Rio Dia ~to 133 298 44.6% 9.5 ·-':: ''-' .' - ~~c._..,:-·,· -~~.: . ...!"-:~ . :\-· ,. - fr:· ;,_ Exdusln Breastfeedlng Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the 11umber of children age 0-S months who drank breast milk In the previous 24 hours AND did not drink any other liquids In the previous 24 hours AND Wl>ll not given any other foods or liquids In the previous 24 hours Denon1lnator: Enter the total number of children age 0-S months In the su1-vey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas 29 84 34.5% 16.2 Pahvas y Rio Blanco 25 94 26.6% 13.7 I Infant and Young Child Feeding Description - Percentage of Infants and young children age 6-23 months fed according to a mlnimLim of appropriate feeding practices Numerator: Enter the number Infants ond young children age 6-23 months fed according loa minimum of appropriate feeding practices Denominator: Enter the total number of ~hlldren age 6-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas 92 218 42.2% 10.3 Palwas y Rio Blanco 76 204 37.3% 10.7 I Vitamin A Supplementation in the Last 6 Months Description - 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 Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A In the last6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits M atiguas 55 218 25.2% 8.8 Paiwas y Rio Blanco 61 204 29.9% 9.8 I l\leasles Vaccination Description - Percentage of children age 12-23 months who receiveCl a measles vac m Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the Shoe of! he Interview as seen on the card or recalled by the mother Denominator: Enter the total number of childN" age 12-23 months In the survey Sub Area Name Numerator Denominator Percenl(clllculale) Confidence Limits Matiguas 76 125 60.3% 16.1 Paiwas y Rio Blanco 8§ 127 66.9% 16.4 I Access to Immunization Services Description - Percentage of child;en age 12-23 months wl:io r eceived TPI accordir.Jg io the vaccina tion urd or mother's recall by the time of the survey Numerator: F.nler the ur.~IJ.er 11f chlldrelll age months who i\!celved m O.TPI allhe thn2 of the acrordlng 111 the vncclna.,lon card/child health booklet or mother's recall Denominator: Enter the total m1mber of cltlla ren age 12-23 months in the survey Sub Area Name Numerator Denominator Percenl(calcu!ale) Confidence Limits Matiguas 95 125 76.0% 17.0 Pahvas y Rio Blanco 127 7<$.0% 16.8 I Health System Performance Regarding lmmunlzllltlon Services Description - Percen age of chilc:lven age 12-23 months who received DT P3 according to the vacc!11at:on card oT mother's recall by the time of the survey Numerator: Enter the number of chlldr age 12-23 months who received DTPJ &t lite time oflbe survey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the total number oq hlldren age 12-23 numlhs In the survey Sub Area Name NJiil 84 125 6'1.2% 16.6 Paiwas y Rio Blanco 75 127 59.1% 15.9 Treatment of Fever in Malarious Zones Description - Percentagl! of children age 0-23 months a febrile episode during the la3t two weeks who were treated wNh an effective anti-malarial drug within 24 hours after the fever began Numerator: Enter the number of chlldrtdlan weight for ag~, according to the WHO/NCHS reference jX)pulation) Numerator: Enter the number oi children 0-23 months »Ill• weight/age -2 SD forth~ median weight for age, according to the WHO/NCHS reference population Denominator: Enter the totel number of children zge 0-23 months In the survey Sub Area Nam~ Numen:tor Dennmlnator Percent( calculate) Confidence Limits Matlguas 22 302 7.3% 4.2 Palwns y Rio Blanco 21 298 7.0% 4.2 Rapid Catch Indicators: Mid-term Sample Type: Antenatal Care Description - Percentage of mothers of children age 0-23 months who had four or more antenatal visits whe11 they were pregnant with the youngest child Numerator: Enter the number of mothers wilh children age 0-23 months who hod at least four nntenalal vislls while pt·egnant with their youngest child Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name NumerRtor Denominator Pereent(ulcu!ate) Confidence Llmlls Matiguas % Paiwas y Rio Blanco % I Maternal TI Vaccination Description -- Percer;tage of mothers with children age 0-23 moiltils who recelvi!d nt least two Tetanus toxoicl before the birth of their child Numerator: Enter the number of mo!hers w!lh ch!ldrel!l age 0-23 manth3 who recelvell at least two tetanns toxoid vaccinations the birth of tileir youngest child Denominator: Enter t!ie total of mothers of children age 0-23 lhc survey Sub Area Name Denominator Percent(cal not drink any other liquids In the previous 24 hours AND was not given any other foods or In the previous 24 hours Denominator: Enter the total number of children age ll-5 months In the survey Sub Area Name Numerator Denominator Pereent(ca!cuhcte) Confidence Llmlls Matigu&s % Paiwas y Rio Blanco % I Infant and Young Child Feeding Description -- Pel'centage of infants nnd youog children age 6-23 months fed according to a minimum of approp.riate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed accordiii!J to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 rnontlis in the survey Sub Area Nome Numerator Denominator Percent( late) Confidence Limits Matiguas % Paiwas y Rio Blanco % I Vitamin A Supplementation in tbe Last 6 Months Description - 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 Numerator: Enter the number of children age 6-23 months who received a dose of VItamin A In the last 6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months In the sun•ey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Paiwas y Rio Blanco % I l\leasles Vaccination Description -Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the lime of the Interview as seen on the card or recalled by the mother Denominator: Enter the total number of chl!dren age 12-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Paiwas y Rio Blanco % I Acces• to Immunization Services Description -Percentage of children age 12-23 months who receivoo DTPl according to the vaccination card m· mother's recall by the time of the survey Numerator: F.nter the number of children age 12-23 mont~s who received a lb1'PI at the lime of the •urvey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the tolal number of children age 12-23 months In the survey Sub Area Name Numeratot· Denom!nator Percenl(calculate) Confidence Limits Matiguas % Paiwas y Rio Blanco % Health System Performance Regarding Immunization Services Description - Percentage of children age 12-23 mon~hs who received DTP3 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the \'Rcdnatlon card/child health booklet or mother's recall Denominator: Enter the total number oU children age 12-23 month! l!:tthe survey Sub Area Name Numerztor Denominator Percent(calcuiE>le) Confidence Llml15 Matiguas % Paiwas y Rio Blanco % Treatment of Fever In Mal rio us Zones Description - Percentage of child~en 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 Numerator: Enter the number of children age !l-23 months with a febrile episode In the last two weeks AND wh{IS~ mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of childrer< nge 0-23 month! with a febrile episode In the last two weel!s Sub Area Name Numernnor Denominator Percent( calculate) Confidence Limits Matiguas o/o Pahvas y Rio Blanco o/o I ORTUsc Description - Percenta~ge of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with dlarrhe21 in the last two week! AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea In the last two weeks Sub Area Name Numerator Denominator Percent(calcul•te) Confidence Limits Matiguas •;. Paiwas y Rio Blanco % I Appropriate Care Seeking for Pneumonia Description - 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 Numerator: Enter the number 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 Denominator: Enter the total number of children with chest-related cough and fast and /or difficult breathing in the lasltwo week! Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Pahvas y Rio Blanco o/o I Point of Use (POU) Description - Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Paiwas y Rio Blanco % Appropriate Hand Washing Practice• Description -- Percentage of mothers of children age 0-23 months who live in households with soap tbe place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live In households with •oap at the for hand washing Denominator: Enter the total number of mothers of children age 0-23 moelhs In the survey Sub Area Name Numerator DeJJominator Percent( calculate) Confidence Llmits Matiguas 0/o Paiwas y Rio Blanco % I Child Sleeps Under an lnsecllcide-Treated Bt>dnet Description - Percentage chil(lren age 0-23 months whu slept undtr liD insecticide-treated bellnet (In malaria risk a1reas, where bednet use is effective) the previous nlght Numerator: Enter the number of children nge 0-23 months who !l!ept under an insectlclde-treaied IJcdnet the prevlolis night Denominator: Enter the total number of children age 0-23 months in the Sub Area Name Numerator Dznomlnntur Percent(calculnte) Confidence Limits Matiguas 0/o Paiwas y Rio Blanco % I Undenveigbt Description -- Percentag2 of children 11-23 months who are underweight (-2 SD for the median weight for age, actordlng to WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SD for toe median welgbt for age, acccrdio.g to the WHO/NCHS reference Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denomillator Percent( calculate) Confidence Limits Matiguas 0/o Paiwas y Rio Blanco 0/o I Rapid Catch Indicators: Final Evaluation Sample Type: Antenatal Care Description - Percentage of mothers of children age 0-23 months who had four or more antenatal viglts when they were pregnant with the youngest child Numerator: Enter the number of mothers with children age 0-23 months who had at least four antenatal visits while pregnant with their youngest child Denominator: Enter the total number of mothers of children age 0-23 months In the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguag % Palwas y Rio Blanco % J Maternal TT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanl!ls toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received aliens! l : Limits Matlguas % Palwas y Rio Blanco % I Skilled Birth Attendant Description - Percentage of children age 0-23 months wimse births were attended by skllled persoi'lnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxll!ary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months In the survey Sub Area Name Numerator Denominator l'ercekll(calculnte) Confidence Limits Matlguas 0/o Palwas y Rio Blan.:o 0/o .· Current Contraceptive Use Among Mothers of Youl!g Children Description --Percentage of mothen of children age 0-23 months who are using a modern contraceptive method Numerator: Enter the number o! mothers with children age 0-23 months who are using a modern contraceptive method Denominator: Enter I he total number of mol hers of children age 0-23 months In the survey Sub Area Name Numerator Denominator Confidence Limits Matlguas % Pahvas y Rio Blanco % Post-Natal Visillo Check on Newborn Wltbln the First 2 Days After Blrlb Description - Percentage of children age 0-23 months who recelvttd a post-natal visit from am appropriately trained health wor:ker within two days after birth Numerator: Enter I he number of c1lildren 11ge 0-23 montbs who received a post-natal visit wlthln two days after birth by an ajJproprlale health worker Denominator: Enter the total numbfr of chlldren age 0-23 months In the survey Sub Area Name Numerator Denomlnalur Percenl(calcul9le) Confidence Limits Matlguas % Palwas y Rio Blanco % I Exclusive Breastfeedlng Description - Percentage of children age 0-5 months who were excJuglvely breastfed during the last 24 hours Numerator: Enter I he number of children age 0-S months who drank bre11st milk luthe previous 24 hours AND did nul drink any other liquids in I he previous 24 hours AND was not given arJy other foods or liquids In the previous 24 hours Denominator: Enter the total number 01f children age 0-S months In the survey Sub Area Name Numerator Deoomlnator Percent( calculate) Confidence Limits Matigu11s % Palwas y Rio Blanco 0/o Infant and Young Child Feeding Description --Percentage of Infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Euler the number Infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the lolal number of children age 6-23 months in the survey Sub Area Name Numerator Denomlnalar Perceol(calculate) Cm1fidence Limits Matlguas % Palwas y Rio Blanco % Vitamin A Supplementation in the La•t 6 Month• Description -- 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 Numerator: Enter the number of children age 6-23 months who received a dose of VItamin A in the last 6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months in the sun•ey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas % Paiwas y Rio Blanco % J l\leasles Vaccination Description - Percentage of children age 12-23 months who received a measles vaccina tion Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Palwas y Rio Blanco 0/o Access to Immunization Services Description -Percentage of children age 12-23 months who received DTPI according to the vaccination card or mother's recall by the time of the survey Numerator: F.nter the number of children age 12-23 month• who received a llTPI at the time of the •urvey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas % Palwas y Rio Blanco % - ' -· • Health System Performance Regarding Immunization Sen•lceJ Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of lhe survey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the total number of children age 12-23 months In the survey Sub Area Name Numeratoi!" Denominator Pcrcent(calcull\te) Confidence Limits Matlguas 0/o Pahvas y Rio Blanco % I Treatment of Fever in 1\lalarlou• Z<~oe• Description - 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 lilfter the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode In the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate antl·nt9larlal drug Denominator: Enter the total number of children age 0-23 months with a febrile episode In the last two weeks Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas % Pahvas y Rio Blanco % ORTUsc Description ·- Percentage of children age 0-23 months with diarrhea In the last two weeks who r eceived or1:1l rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age ()..23 months with diarrhea In the last two weeks AND who received oral rehydration solution (ORS) and/or recommended borne fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas 0/o Palwas y Rio Blanco % Appropriate Care Seeking for Pneumonia Description - Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing In last two weeks who were taken to an appropriate health provider Numerator: Enter the number 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 Denominator: Enter the total number of children with chest-related cough and fast and /or difficult breathing in the last two week! Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matlguas % Pahvas y Rio Blanco % I Point of U5e (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguas % Pahvas y Rio Blanco •;. Appropriate Hand Washing Practices Description --Percentage of mothers of childt·en age 0-23 months who live In households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households wlth ~oap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limit! Matlguas % Paiwas y Rio Blanco % Child Sl~p• Under an lnsecUclde-Treated Bednet Description -Percentage of children age 0-23 months who slept underr all insecticide-treated bednet (in malaria risk areas, where bed net use is effective) the previous night Numerator: Enter the number or children age 0-23 month! wi'Jo slelJt under an tlch tre ted bed net the previous nlgbt Denominator: Enter the total number of children age 0-23 months In the survey Sub Area Name Numerator Dcnorniuatur Pcrceut(calculale) Confidence Limit~ Matiguas % Paiwas y Rio Blanco % Undenvelgbt Description --Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number ar children O-l3 months with welghl/age -2 SD for the median weight for age, according to the WHO/NCHS reference population Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent( calculate) Confidence Limits Matiguzs 0/o Pahvas y Rio Blanco 0/o Rapid Catch Indicator Comments Birth spacing not collected during KPC. Malaria indicators N/ A Annex 12: Results from the Innovation (NICASALUD & CIES) tiiiiCWCitlol& ln. wod wltl& m.~~ foe tlw.rc 1.n.volnmen.t ln. t!. luuJtla -~ of tlw.rc parctn.eti • .., ~· illrctl& an.tl tM. fH'fjtpG'Cflun. pa'CI«L Cd wJI. Cd fA. Hb of tJ.. l&eWIJorcn. EXECUTIVE SUMMARY In the framework of the Child Survival Project and the United Families for Health Project (FarniSalud), both financed by the United States Agency for International Development (USAID), innovations for changes in the behavior of men have been developed to involve them in the care of their partners during pregnancy, birth and the postpartum period, as well as in the care of the newborn. This innovation is being implemented by Catholic Relief Services (CRS), Caritas and the Ministry of Health (MOH) in 20 communities in the municipalities of Matiguas, Rio Blanco and Paiwas, through a collaboration agreement between CRS and the NicaSalud Network Federation. This initiative endeavors to generate a community intervention strategy that captures the interest, commitment and responsibility of the men, actively involving them in seeking timely care of their partners during pregnancy, birth and the postpartum period and of their newborns. The initiative has been guided by the application of two research protocols: the protocol for formative research that NicaSalud undertakes and the protocol for sumrnative research applied by the Center for Health Research and Studies (CIES) of the National Autonomous University of Nicaragua (UNAN) to evaluate and certify the results generated by the innovation. The formative research protocol developed by NicaSalud involves the application of the methodology on behavioral changes containing six phases of implementation; however, for the preparation of the innovation, the protocol grouped the activities from these six phases of the methodology into three application phases as follows: • Phase 1: To identify key factors, perceived benefits, barriers that influence men's behaviors regarding joint decision-making to seek care and their involvement in their wives' and children's health, and to ascertain their willingness to adopt new behaviors and the likelihood that they will practice them. • Phase 2: To develop an approach to implement and monitor the Behavioral Change Communication (BCC) interventions to promote behaviors and develop draft BCC materials. • Phase 3: To carry out a small-scale pilot test of the intervention, including assessment of the reaction to the draft BCC materials. This report addresses the application of the phases of the methodology and the results of the process implemented according to the three phases of the formative research protocol. In Phase 1, a qualitative formative research process was developed with the participation of 80 husbands of pregnant women, 36 fathers of children older than 40 days of age and less than two years of age, 16 husbands of postpartum women and 16 postpartum women (couples) in the 42-day period following birth. This process was applied through discussion groups and in-depth interviews with participation by a technical team from the project and from the Ministry of Health in the field work. The information obtained made it possible to identify a list of current behaviors, barriers and resistance or obstacles to the proposed change in behavior. That process brought the men, women and communities closer to learn about their experiences and to understand their perceptions regarding their socially practiced and culturally accepted family role for decision-making with their partners, seeking timely care and being involved during pregnancy, birth and the postpartum period of their wives and in the care of the newborn. Phase 2 reexamined the information researched with the men to decide upon the type of strategy to promote and the communications materials to use and to select and train the volunteer promoters from the community to foster the behavioral changes. To define and decide what to do and how to do it, a consultation process was conducted at the community level (eight workshops) and at the municipal level (four working sessions) to reach consensus regarding the community strategies, training and communications that included the development of materials that were validated. During this same phase, 61 community promoters were selected and trained and the intervention methodology was developed along with the monitoring and follow-up instruments to be used during the implementation of the community strategies. Phase 3 involves the implementation of a trial intervention, including the evaluation reaction to the communication materials. Lastly, this phase includes the launch of the innovation and the beginning of implementation of the community activities with the men. This report summarizes the important aspects of the results from the phases applied to prepare this innovation, including current behaviors, barriers, resistance and motivations for change. Furthermore, it presents the results of the small scale trial that tested 10 behaviors with men in the intervention communities. The community promoter training results are also summarized, as are the community launches and the beginning of community strategy implementation. COMMENTS AND REFLECTIONS The comments below are not intended to be final conclusions regarding this common effort that has been developed over the past year. For the moment, it is a sharing of the results attained with the possibility of becoming measurable achievements of this intervention in the short and long term. The launching of this joint initiative among CRS, Ciritas and the Ministry of Health to promote behavioral changes among men adds to the experience of these organizations and has facilitated sharing among them and particularly with the people in the community that signed up to be promoters. The efforts to undertake such an important initiative require recognition of those who have, with great dedication, made available their skills, knowledge and, especially, a mentality directed at change. Developing ideas to jointly build and weave, in a participatoty fashion, an initiative to generate and produce changes in behavior was a challenge and the road taken has had many indications and signs that will need to be reexamined together in the implementation of this initiative. In general, the results obtained in each phase reveal that it is possible to put the intervention methodology and strategies that have been generated into practice efficaciously in the modeling of behavioral changes. To achieve the intended results of this initiative, personal and institutional commitment will be vital, among both the organizations and institutions that support the initiative as well as the community leaders and promoters. With the completion of the training and planning phases, the foundation is laid for the start-up and harmonization of efforts. Nevertheless, it is necessaty to continue to refine the strategies and methodologies, and to strengthen the organizational and community management capacities. NicaSalud will continue to provide technical assistance in following up on this initiative to further strengthen these local capacities and to document and systematize the experience. One of the aspects of the phases that is still being finalized is the monitoring and evaluation system for the initiative, specifically related to the follow-up mechanisms, information flow and the use of the information by the community, the MOHand the project. Although the forms are available, they must be harmonized with the project information system and the Ministry of Health System. The arenas for coordination and mechanisms for the optimization of resources and common efforts are key elements for more efficiently and efficaciously developing the processes that will continue for the implementation of this initiative. The enthusiasm and commitment shown by the community should continue to sustainably contribute to the attainment of the expected results of this investment and effort. MINISTRY OF HEALTH OF NICARAGUA LOCAL INTEGRATED HEALTH CARE SYSTEM (SILAIS) MATAGALPA CATHOLIC RELIEF SERVICES (CRS) I CARITAS OF MATAGALPA "BASELINE STUDY AND EVALUATION SYSTEM FOR THE INITIATIVE: BEHAVIORAL CHANGES IN MEN TO IMPROVE SEEKING OF HEALTH CARE FOR WOMEN AND CHILDREN IN THE COMMUNITIES OF THE MUNICIPALITIES OF MATIGUAS, RIO BLANCO AND PAIWAS, PROVINCE OF MATAGALPA. NICARAGUA" FINAL REPORT (PHASE 1) Document Prepared by: Center for Health Research and Studies (CIES - UNAN Managua) Managua, September 30, 2010 Executive Summary The Ministry of Health, with the support of international assistance, develops and implements actions to comprehensively address maternal mortality and maternal disability, seeking to reduce damage through the detection of problems, their causes and possible solutions. These actions are based on the causal chain that links maternal deaths with program activities. For this purpose, the model of the three delays has been implemented, based on the premise that any delay that prevents a pregnant woman from receiving treatment can cost her her life. In the strategic framework mentioned, Catholic Relief Services (CRS) and Caritas Matagalpa, in coordination with the Ministry of Health and the Local Integrated Health Care System (SILAIS) in Matagalpa, conducted an initial investigation as a point of departure for the design and implementation of an evaluation methodology to facilitate the progress and results of the initiative for Behavioral Changes in Men to Improve Seeking of Health Care to contribute to a: i. Decrease in the first delay through recognition and the decision to seek and access emergency obstetric and neonatal care in a timely fashion. ii. Better understanding of the attitudes of men regarding their perceived role, their perception of authority and the well-being of their families. iii. Documentation of the degree of participation recorded by community agents and health care personnel regarding the incorporation of men into the initiative. The objectives of the baseline study were: 1. Evaluate the knowledge of the men and their wives in recognizing the danger signs during pregnancy, birth, the postpartum period and for newborns. 2. Determine whether men participating in the innovation change their behavior regarding decisions for seeking health care and regarding the health care of their families. 3. Measure health results in the increase in maternal and neonatal care through the implementation of evaluation processes. The baseline study for the initiative on Behavioral Changes in Men to Improve Seeking of Health Care for Women and Children was conducted between July 1 and September 13, 2010, with the participation of the Ministry of Health (MOH), CRS, Caritas Matagalpa and the CIES - UNAN Managua. It was a transversal study in which quantitative techniques were applied in three municipalities of the Matagalpa SILAIS. The geographic areas of the study were the municipalities of Matiguas, Rfo Blanco and Bocana de Paiwas that are administratively under the political divisions of the province of Matagalpa and the South Atlantic Autonomous Region (RAAS) located in the Central and Caribbean sub-regions of the country. There was broad participation in the study by the meta-benefited groups, community leaders and the Ministry of Health. Procedures were applied to learn information about people based on previously identified determinant variables and using official data from the MOH. The universe for the study was: • 388 men and their wives or partners that live in rural areas and who are pregnant, in the postpartum period or who have children younger than 12 months of age. • 40 community stakeholders (counselors, midwives, community health volunteers/brigadistas or others) that support health actions and the incorporation of men into the activities of the pregnant women and mothers of children under 12 months of age. • Three MOH first level health care units located in the municipal seats that provide services and record information on prenatal, birthing, postpartum and newborn care in the communities where the innovation activities will be developed. The quantitative data collected is captured and processed through Epi-lnfo 3.5.1 software. The tabulation and analysis of the data will be performed in Microsoft Office (Word- Excel). Results Encountered Some 8.7% of all women in Nicaragua of childbearing age (15 to 49 years of age) are concentrated in Matagalpa. The municipality of Matiguas has 8.8% (41,127) of the total beneficiary population while Rfo Blanco has 6.6% (30,785); and 31,762 people live in the municipality of Paiwas in the RAAS. The maternal child health indicators reveal that these municipalities present low coverage of institutional birth and postpartum care, given the rural conditions of the areas. The municipalities also present nutritional deficiency in children under 5 years of age. The data was collected through surveys of men and women that investigated general information related to age, civil status, academic level and occupation. It was found that most of the women and men were under 29 years of age (71.4% and 53.0% respectively), living in a common law marriage (62.4% women- 57.2% men), who had not finished primary school or who had had no schooling (48.5%- 20.1% for women I 49.5%- 31.4% men). The women work in the care of the home (97.4%) and the men work in agriculture (66.5%). Some 90.2% of the women report that prenatal care was provided to them during their last pregnancy - including those that are currently in the gestational period - of these, 46.3% received more than four prenatal care sessions, 17.1% had four sessions and 36.6% had between one and three prenatal sessions. The concentration of prenatal care is important as more frequent care makes it possible to assess progress and detect problems in a timely fashion. The low concentration in certain areas is generally related to difficulties in accessing health services and a greater risk of complications and maternal and perinatal death. The men were asked if they had helped their partners in daily activities during their last pregnancy; 89.7% responded that they had, while 81.9% of the women stated that they had received help during that time. Most of the couples make joint decisions about how to use money for the diet of the pregnant woman (78.4% women- 86.1% men). Some 77.3% of the women and 86.1% of the men stated that they save to face the costs of the birth, hospitalization, and the needs and care of the newborn. Most of the women felt appreciated by their partner during their last pregnancy, mainly manifested through affectionate words and finding her attractive. These responses are related to the low frequency of physical or verbal abuse of her and children. In the baseline study, the women and men were asked about making joint decisions regarding seeking timely care during and after pregnancy. In this case, 91.8% of the women and 94.8% of the men responded that they do make these decisions as a couple. Similar results were obtained regarding the decision on medical care for the birth, during the postpartum period, care of the newborn or in emergency situations. Some 45.4% of the women responded that they decided together with their partner to go to the nearest Casa Materna (maternity house) two weeks prior to the birth in order to have health services available in case of emergency; a higher number of men (56.2%) stated likewise. Some 61.3% of the women and 73.7% of the men responded that they decided together how many children to have; furthermore, 59.3% of the women and 75.3% of the men state that they agreed upon when to have children. Some 67.5% of the women and 76.3% of the men considered the significance of the risk when the interval between pregnancies is very short. Approximately one of every three men accompanied his partner during her last birth, according to the men and the women. Likewise, 37.6% of the women reported that their husbands were present at their last birth whether at home or in a health facility, although only 18.0% participated in the birthing process. The results clearly express traditional cultural attitudes and practices regarding couple relationships in seeking care, where the defined mother-infant priority and the availability of health services contribute to the promotion of models that "exclude" the participation of men. Regarding the knowledge of men and women about danger signs during birth that encourage them to seek medical assistance, both mentioned hemorrhaging with the greatest frequency (46.4% men￾52.0% women), followed by headache and fever. The total percentage of those surveyed (43.3% men -34.5% women) that reported no knowledge about this issue is significant given the repercussions of this. All community volunteers have received training and record the births that they attend (82.5%) as part of their regular activities, with 51.5% using the Community Information System (SICO), although they also use their own notebooks or the card that the Ministry of Health provides to them. Some 90.8% have recorded between two and ten pregnant women and 97.0% of these have developed a birth plan; 72.7% of these plans include the participation of the husbands or partners of the pregnant women. Some 72.5% of the volunteers stated that their activities include referral of pregnant women to health care facilities. 4.6 Evaluation Indicators Table 19: Baseline Indicators by Municipality 2010 - 2012 Variabla Delinnion Indicator Del in~ ion of Indicator Matiauas Rio Blanco Paiwas Total Number ol mothers with children < 12 1.1 Percentage of mothers with children< t2 months of age and pregnant !hal had ar least four prenatal care sessions during months that had four or more prenatal care !he pregnancy with !heir youngest child. 66.1% 47.2% 45.0% 58.1% sessions during !he pregnancy with !heir X tOO youngest child. Number of women with children < 12 months of aae in !he survey Number of mothers with children< 12 1.2 Percentage of mothers with children < 12 months of age !hat received a postpartum visn from an appropriate trained hea«h months of age !hat received a postpartum v~n worl