TAHSEEN Project
CATALYST Consortium


  	


 	

	
Project funded by the
United States Agency for
International Development
		

The CATALYST Consortium is a global reproductive health activity initiated in September 2000 by the
Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International
Development (USAID). The Consortium is a partnership of five organizations: the Academy for Educational
Development (AED), Centre for Development and Population Activities (CEDPA), Meridian Group International,
Inc., Pathfinder International and PROFAMILIA/Colombia.
This publication was made possible through support provided by the Office of Population and Health,
United States Agency for International Development, under the terms of contract No. HRN-A-00-00-
00003-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the
United States Agency for International Development.
40th Day Congratulations Card Campaign
i


BACKGROUND..........................................................................................................1
OBJECTIVES .............................................................................................................3
METHODS..................................................................................................................5
INTERVIEWING KEY PERSONS .....................................................................................5
REVIEWING AVAILABLE INFORMATION .......................................................................6
RAPID SURVEY...........................................................................................................6
RESULTS ....................................................................................................................9
INTERVIEWING KEY PERSONS .....................................................................................9
REVIEWING AVAILABLE INFORMATION .....................................................................11
RAPID SURVEY.........................................................................................................12
CONCLUSION..........................................................................................................23
RECOMMENDATIONS ..........................................................................................25

40th Day Congratulations Card Campaign
1

A campaign called the Congratulations Card Campaign was launched in Fayoum
governorate as part of the 40th Day Initiative. The idea for the campaign was that every
new mother would be visited by a community outreach worker to congratulate her upon
the arrival of her new baby. The outreach worker would bring a printed congratulations
card with her and invite the mother to visit the health facility on her 40th day
postpartum, or earlier if possible. The time and date of this appointment would be
marked on the congratulations card. During the visit to the health facility, the new
mother would be examined by a doctor and, most importantly, would begin use of an
appropriate contraceptive method.
This campaign approached women at a time when they are most likely to accept a
family planning method. Furthermore, early use of contraceptives after delivery not
only contributes to the global objective of increasing contraceptive prevalence rates in
the community, but also has the added value of preventing a common problem: early
unwanted postpartum pregnancy.

40th Day Congratulations Card Campaign
3

This report seeks to evaluate the effectiveness of the 40th Day Initiative’s
Congratulations Card Campaign in promoting the utilization of the 40th day services at
the health facility and family planning use in the postpartum period.

40th Day Congratulations Card Campaign
5

A pilot visit to the Mansheit Sanarous Model Unit was carried out in order to collect
background information about the Congratulations Card Campaign, as part of the 40th
Day Initiative, and to conduct an exploratory meeting with the community outreach
worker team. Consequently, an evaluation was planned. This evaluation was based on
rapid assessment procedure methodology and was carried out in three selected health
units, each one from a different district of Fayoum Governorate. The evaluation used
three main techniques:
1. Interviewing key persons in each unit
2. Reviewing available relevant information at each unit
3. Conducting a rapid survey in the unit's catchment area
The selected sites were:
• Mansheit Sanarous in the Sanarous district
• Zawyet El Karadsa in the Fayoum district
• Sanrou El Keblia in the Ibshway district
 !"#
A meeting was held in each unit with the head of the unit and the community outreach
worker team responsible for planning and carrying out campaign activities. The aim of
the interview was to obtain the following data:
• To determine whether the unit adopted the Congratulations Card Campaign (40
th
Day Initiative)
• To ascertain available resources for executing the initiative, including:

 The size of the team conducting the campaign's visits (i.e. number of
community outreach workers)

 Cards or printed material used during the initiative visits. Community
outreach worker teams were asked about the value of the printed card in
improving the outcome of the visit. The investigator recorded the frequency
of each response during the meeting. The question was standardized and
had three responses:
1. Printed card improves the outcome of the visit
2. Printed card has no effect on the outcome of the visit
3. I'm not sure/Do not know

 A recording system for the initiative's activities and regularly generated
monitoring report forms
40th Day Congratulations Card Campaign
6
$ %


From April 1 to June 30, 2004 the following information was reviewed: baseline vital
indices, especially the number of deliveries recorded; and when available, particular
records for the Congratulations Card Campaign as part of the 40
th Day Initiative
activities.
&

The reviewed information was used to calculate the following indicators to help in the
evaluation process.

 	
	
  
	  

This is the number of visits each community outreach worker is supposed to conduct
during a given period of time (usually per quarter). It is obtained by dividing the
number of deliveries occurring during that period of time (quarter) by the number of
community outreach workers in the unit.

 	 
	

 	
	
This is the percentage of new mothers who received a congratulations visit within a
given period of time. It is obtained by dividing the number of new mothers who were
visited during that period of time (quarter) by the number of all new mothers who
delivered during that period of time.



  	 
 	
 
This is the percentage of visited new mothers who actually went to the health facility
and used a contraceptive method on or before the 40
th
day postpartum. This percentage
is obtained by dividing the number of visited new mothers who used a contraceptive
method on or before the 40th day postpartum during a given period of time by the
number of all new mothers visited during that period of time.
$' ("
A survey was conducted in each selected unit.
('

The sample was taken from women who delivered within the catchment area of the unit
during the quarter from April 1 until June 30, 2004.
For this purpose, a list of deliveries during the selected period served as a sampling
frame. The list was obtained from the records of the health office of each unit and was
arranged in chronological order. The first delivery recorded in the first unit, the second
birth recorded in the second unit and the third in the third unit were the index at which
the sample selection started in the corresponding unit. Every third subsequent delivery
after the index birth on the list was then included in the sample until a total of thirty
40th Day Congratulations Card Campaign
7
births from the catchment area of each unit was obtained. Dropouts or non-responses
were replaced by the next delivery in the original list of the health office.




A specifically designed questionnaire was prepared for the collection of the survey data.
The questionnaire was designed to be:
1. Very concise not taking more than ten minutes for each woman, to allow thirty
respondents to be interviewed in one day
2. In the Arabic language, for standardization, allowing application by different
interviewers
3. Administered orally during an interview with the respondents due to the
expected high level of illiteracy among rural women
The draft questionnaire was modified and finalized in the light of information obtained
during the pilot visit to the Mansheit Sanarous Unit before the implementation of the
survey.
#')
 *
Pilot visits revealed that in order to coordinate work at each unit, community outreach
workers divided the catchment area geographically into sectors equal to their number.
One sector was assigned to each community outreach worker, who was consequently
responsible for conducting visits to all new mothers living in that sector.
These sectors served as the basis for planning the field work of the survey. The list of
sampled women was subdivided on the basis of residence, so that women living within
the geographical sector of each worker were grouped together into a common sub-list.
The questionnaire was read, explained and discussed with health educators to clarify
any ambiguity and make sure that they properly understood each and every question.



Each community outreach worker visited target women in her geographical sector with
the investigator. The worker was responsible for briefly introducing the survey to the
visited women, obtaining their oral consent to participate in the study and for asking the
interview questions in the presence of the investigator. The investigator was responsible
for recording the answers to the questions and correcting any deviations from the
intended course of the interview or improperly asked questions.

The data has been coded to fit a statistical analysis program. The data was processed
and analyzed using the program (SPSS) Statistical Package for Social Sciences, version
11 using Windows XP.

40th Day Congratulations Card Campaign
9
$

 !"#
%'
	"
In each of the three visited units, the respective head of the health team reported that the
40
th Day Initiative had already been adopted in the unit and was a routine activity by the
time s/he had taken charge of the unit.
%
The initiative in the three units was carried out through the same set of activities: new
mothers were visited by a community outreach worker to congratulate them upon the
arrival of the new baby and to give them a health education session on family planning.
They would also encourage them to visit the unit by the 40
th
day postpartum, or even
before, to be examined by a physician and, most importantly, to start using a
contraceptive method.
$



The personnel responsible for conducting the congratulations visits were all community
outreach workers. Table 1 shows the number of workers in each of the visited units.
Table 1: Number of community outreach workers in the studied units
+ ,-"
*
Mansheit Sanarous 4
Sanrou El Keblia 8
Zawyet El Karadsa 10
 	!

The pilot visit revealed that, ideally, a printed congratulations card should be presented
to the mother by the community outreach worker during the visit, preferably with an
indication of the time/date at which the mother should come to the health unit for her
checkup and family planning counseling. Currently, however, all three visited units had
no printed material to offer to the mother during the visit, obviously due to a lack of
financial resources.
One of the three units (Mansheit Sanarous), however, had had an initiative by the
former head of the unit to personally design and print a congratulations card using a
computer and printer that were available in the women's club affiliated to the unit. This
40th Day Congratulations Card Campaign
10
initiative did not last long as they ran out of resources to finance the purchase of paper
and toner cartridges for the printer. In the other two units, the community outreach
workers stated that they had never used printed material during the congratulations
visits.
The following table summarizes community outreach workers’ responses to a question
concerning the value of the printed card in improving the outcome of the visit.
Table 2: Opinion of community outreach workers on printed congratulations
cards
' 
(
(&

!

. "&

!


'


Count
%
2
50.0%
4
50.0%
6
60.0%
12
54.5%



Count
%
2
50.0%
1
12.5%
1
10.0%
4
18.2%
,/
 
Count
%
0
0.0%
3
37.5%
3
30.0%
6
27.3%

 Count
%
4
100.0%
8
100.0%
10
100.0%
22
100.0%
It was evident that more than half of the interviewed community outreach workers
thought that a printed congratulations card might improve the outcome of the visits to
new mothers. They supported their opinion by stating that the being given the card
might make the client feel privileged, that it could serve as a form of referral document
or a written commitment that she will be received at the unit on or before the 40
th
day
postpartum and be given quality service.
The small proportion of interviewed workers who thought the card would not affect the
outcome of the visit were aware of the high level of illiteracy among women they work
with, making them unable to understand and appreciate written material. They
perceived the health education messages given during the visit as the cornerstone of
visit success.

!

It was determined that no standard printed recording system for the 40
th Day Initiative's
activities was in use. However, two out of the three units had an individually designed
record, consisting primarily of a notebook where the births and their locations were
recorded (obtained through coordination with the health office). Those mothers who had
been visited were marked and the date of the visit recorded. A follow up visit was
conducted at the end of the puerperium to find out the outcome of the congratulations
visit and determine whether the mother actually used a contraceptive method.
40th Day Congratulations Card Campaign
11
In the third unit (Zawyet El Karadsa) such a record was adopted by only some of the
community outreach workers as a tool for planning and monitoring personal activities.
Globally, no cyclical report forms were generated concerning the activities of the 40
th
Day Initiative in any of the studied units.
$ %


The following table summarizes relevant data collected from the three studied units.
Table 3: Relevant data collected from the studied units

(
(&

!

. "
&

!
 104 97 108


'
80 90 NA*
0   
' 

	"''
68 46 NA*
* Data not available at the unit
The collected data was then used to calculate indicators for the purpose of evaluation.
These indicators have been extensively described in the section on methods. The
following table summarizes the indicators calculated for each studied unit.
Table 4: Evaluation indicators calculated for the studied units

(
(
&
!

. "
&

!
/"
 
26 12.12 10.8

 76.92% 92.8% NA
$' 85% 47.42% NA
As shown in Table 4, the number of target visits per community outreach worker was
highest at Mansheit Sanarous. The highest congratulations visit coverage (92.8%) was
achieved by Sanrou El Keblia, but the response rate achieved by the latter was only
approximately half that achieved by Mansheit Sanarous. The low coverage achieved at
Mansheit Sanarous was justified by the presence of an inaccessible cluster of houses
unreachable by public transportation.
40th Day Congratulations Card Campaign
12
$' ("
 ( ('

Table 5: Mean age, standard deviation and 95% confidence interval of the
respondents
123 



%
(

Lower Upper

(
25.46 4.68 23.71 27.21
(&
!
 26.90 5.68 24.77 29.02
. "&

!
25.03 3.82 23.60 26.46

 25.80 4.80 24.79 26.80
The mean age of the respondents was 25.8 years old with a standard deviation of 4.8,
the 95% confidence limit for the age ranged from 24.79 to 26.80. There was no
significant difference between the mean ages of the respondents from the three selected
units. None of the mothers included in the sample was younger than 19 years old or
over 42 years of age.
40th Day Congratulations Card Campaign
13
Table 6: Distribution of the studied mothers according to the level of education
4
 
(
(
&
!

. "
&

!




 Count
%
12
40.0%
22
73.3%
22
73.3%
56
62.2%
$  
/

Count
%
7
23.3%
0
0.0%
1
3.3%
8
8.9%
("



Count
%
11
36.7%
8
26.7%
7
23.3%
26
28.9%

 Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
The majority of the studied mothers were either illiterate (62.2%) or had obtained a
secondary level education (28.9%). A minority (8.9%) had a basic education and could
only read and write.
Table 7: Distribution of studied mothers according to work status
5  
(
(&

!

. "
&

!


6 Count
%
4
13.3%
5
16.7%
1
3.3%
10
11.1%
, Count
%
23
76.7%
25
83.3%
29
96.7%
77
85.6%
(
7
8
Count
%
3
10.0%
0
0.0%
0
0.0%
3
3.3%

 Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
Only 11.1% of the studied females worked on a regular basis, and 88.9% either did not
work at all or did so only on a seasonal basis.
40th Day Congratulations Card Campaign
14
Table 8: Distribution of studied mothers according to the level of education of
the husband
95 
(
(&

!

. "
&

!





Count
%
15
50.0%
22
73.3%
13
43.3%
50
55.6%
$  /

Count
%
11
36.7%
1
3.3%
0
0.0%
12
13.3%
("



Count
%
2
6.7%
7
23.3%
14
46.7%
23
25.6%
+"

Count
%
2
6.7%
0
0.0%
3
10.0%
5
5.6%


Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
The majority of respondents had illiterate husbands, nearly one quarter of the sample
had husbands who had secondary level education and only five mothers (representing
5.6% of the total sample) had husbands with a university education or higher.

"( ('

Table 9: Sex distribution of the neonates of studied mothers
(: 
(
(&

!

. "&

!




Count
%
17
56.7%
17
56.7%
10
33.3%
44
48.9%
)

Count
%
13
43.3%
13
43.3%
20
66.7%
46
51.1%


Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
Slightly more than half of the delivered babies were females.
40th Day Congratulations Card Campaign
15
Figure 1: Distribution of studied females according to the type of delivery
The majority of the deliveries encountered among the study sample were normal vaginal
deliveries with Cesarean section representing only 11.1% of all deliveries.
Figure 2: Distribution of the studied mothers according to place of delivery
It was evident that the majority of deliveries (43.3%) took place at home; a lesser
proportion took place in the hospital, followed by private clinics. Only 10% of the
deliveries took place at the primary health care unit facility.
Hospital
31.1%
Health Unit
10.0%
Home
43.3%
Private Clinic
15.6%
88.9%
11.1%
Normal Vaginal Delivery Cesarean Section
40th Day Congratulations Card Campaign
16
Table 10: Distribution of studied mothers according to birth attendant
% 
(
(
&
!

. "&

!



Count
%
16
53.3%
12
40.0%
25
83.3%
53
58.9%
,/
 
Count
%
0
0.0%
5
16.7%
0
0.0%
5
5.6%
"
Count
%
14
46.7%
13
43.3%
5
16.7%
32
35.6%


Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
Doctors attended more than half of the studied deliveries (58.9%) and dayas attended
slightly more than one third of the studied births (35.6%). Only a minority of deliveries
(5.6%) were attended by a nurse or midwife.
40th Day Congratulations Card Campaign
17
 
0
Figure 3: Percentage of studied females covered by congratulations visit
Table 11: Proportion of females covered by a congratulations visit




(
(
&
!

. "
&

!


6
Count
%
21
70.0%
30
100.0%
28
93.3%
79
87.8%
,
Count
%
9
30.0%
0
0.0%
2
6.7%
11
12.2%


Count
%
30
100.0%
30
100.0%
90
100.0%
The congratulations visit coverage in Sanrou El Keblia was 100%, while only 70% of
the mothers in Mansheit Sanarous were covered. For Zawyet El Karadsa, the coverage
was favorable at 93.3%.
Yes
87.8%
No
12.2%
40th Day Congratulations Card Campaign
18
! 

	"'
Figure 4: Percentage of studied mothers with knowledge about 40
th
day
contraception
Out of the 90 mothers interviewed during the current study, 93.3% knew that they could
and should use a method of contraception on or before the 40
th
day postpartum.
Table 12: Distribution of mothers according to knowledge about 40
th day
contraception
It was obvious that all the interviewed mothers at the Sanrou El Keblia unit knew about
40
th
day contraception use. Two mothers interviewed from Zawyet El Karadsa (6.7% of
the local sample) and four mothers interviewed from Mansheit Sanarous reported that
they did not know that they could/should use a method of contraception on or before the
40
th
day postpartum.
! 

'

(
(&

!

. "
&

!


6
Count
%
26
86.7%
30
100.0%
28
93.3%
84
93.3%
,
Count
%
4
13.3%
0
0.0%
2
6.7%
6
6.7%


Count
%
30
100.0%
30
100.0%
30
100.0%
90
100.0%
Yes
93.3%
No
6.7%
Yes No
40th Day Congratulations Card Campaign
19
Table 13: Distribution of mothers who were aware of 40
th day contraception
according to source of knowledge
( 
 
(
(
&
!

. "
&

!


"

 
Count
%
19
73.1%
21
70.0%
18
64.3%
58
69.0%

/
%,
'
Count
%
3
11.5%
5
16.7%
5
17.9%
13
15.5%
0/
Count
%
4
15.4%
2
6.7%
5
17.9%
11
13.1%
)/


Count
%
0
0.0%
2
6.7%
0
0.0%
2
2.4%

 Count
%
26
100.0%
30
100.0%
28
100.0%
84
100.0%
Figure 5: Frequency distribution of mothers who were aware of 40
th
day
contraception according to the source of knowledge
It was evident that the major source of knowledge for mothers who knew about 40
th
day
contraception was the community outreach worker, followed by the birth attendant
19
3
4
0
21
5
2 2
18
5 5
0
0
5
10
15
20
25
Frequency
Mansheit Sanarous Sanrou El Keblia Zawyet El Karadsa
CO Worker Birth Attendant /ANC Provider TV/Radio Friend/ Relative
40th Day Congratulations Card Campaign
20
and/or ANC provider and TV/radio. Peers constituted the least common source of
information.
#
	"'
Figure 6: Percentage of different types of contraceptives among 40
th day users
It was observed that slightly more than half the studied females (48 women) actually
used a contraceptive method on or before the 40
th
day postpartum. The IUD was the
most commonly used, followed by the injectables, with pills and sub-dermal implants
being the least commonly used methods.
Table 14: Distribution of 40
th day contraception users according to service
provider
(' 
(
(&

!

. "
&

!


9

Count
%
17
89.5%
12
70.6%
8
66.7%
37
77.1%
#
'"
Count
%
2
10.5%
5
29.4%
4
33.3%
11
22.9%


Count
%
19
100.0%
17
100.0%
12
100.0%
48
100.0%
Non Use
46.7%
IUD
36.7%
Injectables
12.2%
Pills
2.2%
Subdermal
Implants
2.2%
Users
53.3%
Non Use IUD Injectables Pills Subdermal Implants
40th Day Congratulations Card Campaign
21
It was observed that the health unit was the service provider for the vast majority of
users in all three units.
Table 15: Causes of non-use of contraceptive methods on or before the 40th day
postpartum given by study sample non-users
; 
(
(&

!

. "
&

!


9

Count
%
2
18.2%
1
7.7%
8
44.4%
11
26.2%
&:

"

Count
%
2
18.2%
3
23.1%
3
16.7%
8
19.0%
9  " Count
%
2
18.2%
3
23.1%
1
5.6%
6
14.3%
*
'
Count
%
0
0.0%
4
30.8%
1
5.6%
5
11.9%

"

'
Count
%
4
36.4%
0
0.0%
1
5.6%
5
11.9%
 Count
%
1
9.1%
2
15.4%
4
22.2%
7
16.7%

 Count
%
11
100.0%
13
100.0%
18
100.0%
42
100.0%
It was observed that the most common reason given by non-users for non-use of 40
th
day contraception was husband refusal, this was followed by the practice of exclusive
breastfeeding, which from their point of view and past experience they consider a
reliable contraceptive method. The next most common reason was that the husband was
working abroad. Five women frankly declared that they wanted to get pregnant and an
equal number reported difficulty in reaching the provider of FP methods either due to
geographical inaccessibility or lack of free time.
Seven women gave miscellaneous reasons, four had previously experienced difficulty in
conception, two women experienced death of the neonate and one gave no particular
reason.
40th Day Congratulations Card Campaign
22

0
Table 16: Knowledge about 40th day contraception among mothers who received
a congratulations visit compared to those who received none
! 

	"'






6 ,
6
Count
%
79
100.0%
5
45.5%
84
93.3%
,
Count
%
0
0.0%
6
54.5%
6
6.7%


Count
%
79
100.0%
11
100.0%
90
100.0%
It was determined that 100% of mothers who received a congratulations visit by the
community outreach worker knew about 40
th
day contraception compared to only
45.5% of those who were not visited by a community outreach worker. This difference
was statistically significant at the 0.05 level when tested using the Fisher's Exact test
(one cell has an expected value of less than 5) (p< 0.001).
Table 17: Actual use of 40
th
day contraception among mothers who received a
congratulations visit compared to those who received none

	"' 
 

6 ,
6
Count
%
45
57.0%
3
27.3%
48
53.3%
,
Count
%
34
43.0%
8
72.7%
42
46.7%


Count
%
79
100.0%
11
100.0%
90
100.0%
It was observed that while slightly less than 60% of those who received a
congratulations visit after delivery actually used a contraceptive method on or before the
40
th
day postpartum, only 27.3% of those who did not receive such visits used
contraceptives on or before the 40
th
day postpartum. The observed difference however
was not statistically significant at the 0.05 level (Chi Square 3.42, p= 0.062), or for 40
th
day contraception use among visited and non-visited =3.529, with a 95% CL extending
from 0.871-14.307.
40th Day Congratulations Card Campaign
23


The Congratulations Card Campaign contributed to the 40th Day. It has been adopted at
the district and unit levels. A strong association between the campaign visits and
increased knowledge and actual practice of contraception use on or before the 40th day
postpartum has also been established.

40th Day Congratulations Card Campaign
25
$
• Community outreach workers who conduct the initiative's visits should be
provided with a printed form (card) which serves simultaneously as:

 A congratulations card to congratulate the new mother for the arrival of her
baby (it should be specifically designed to appeal to an illiterate mother).

 A referral letter to guarantee that the woman will be welcomed at the health
unit on or before the 40
th
day postpartum and offered quality services.

 A reminder for the mother to visit the unit at the appropriate time by
providing the date of the anticipated visit clearly marked on the card.
• Standard recording procedures should be developed for the different activities of
the initiative. These should include:

 Regular timely filling out of printed record forms at the health unit level.
These records should also be the basis for derivation of regular periodic
reports.

 Regular periodic reports relying on the calculation of evaluation indicators,
which have been suggested in this report. These reports can provide a basis
for monitoring and evaluation of performance at the unit level, and act as a
considerable source of feedback to support decision makers at the central
level in making future plans.
• Further training of community outreach workers should be conducted in order to
help them gain more skills, especially in handling objections. Involving women
who pose objections to the use of 40
th
day contraception (such as those who
justify non-use by exclusive breastfeeding, a completely unreliable method of
contraception) could improve the outcome of visits.
• More coordination should be established between the initiative team and the
other teams working in the health unit to improve the outcome.

 The situation at the Mansheit Sanarous Unit in which a sector of the unit's
catchment area was inaccessible by public means of transportation and
consequently a large number of mothers could not be covered by
congratulations visits, was a good example of how coordinating teams may
improve the outcome. The workers suggested a solution for the problem
involving coordinating with the mobile clinics team to accompany them
during their visit to that area. This coordination also provides the first steps
in building sustainability of the initiative.
• Antenatal care providers and birth attendants should be involved in order to gain
their support for the initiative, given the role they played in the current study as
an important source of information about the use of contraception on or before
the 40
th
day postpartum.