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HBLSS: Improving on InnovationAmerican College of Nurse MidwivesSafe Motherhood and Reproductive Health Working Group ShowcaseCORE Group Spring Meeting, April 29, 2010
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HBLSS: Improving on Innovation
HBLSS Elevator Speech• Family-focused community mobilization program• Series of facilitated community meetings to
discuss and form action plans around individual topics to promote self care & effective referral– Women problems: Too much bleeding, birth delay
sickness with pain and fever, swelling and fits, too many children
– Baby problems: Trouble breathing at birth, baby too small, baby is sick
– Preventing problems: self-care, family planning (LAM), PMTCT
– Referral
Step 1: Review the previous meeting
Step 2: Ask what participants know and do when they see particular problems
Step 3: Share what trained health workers know and do when they see those problems
Step 4: Come to agree on what to do: negotiation
Step 5: Practice the (agreed) actions
Step 6: Discuss how to know if the actions are helpful
Step 7: Decide how to prevent the problem
Interactive Community MeetingsCore Methodology
Problem Side Action Side
Key Tool: Take Action Cards
HBLSS Strengths
• Low-tech and sustainable• Skills-based, participatory• Designed for non- or low-literate participants• Uses a step-wise process that works towards
safe, acceptable practices while recognizing & respecting traditional practices
• Can be used for any community issue (e.g., water & sanitation, TB, malaria)
• Transformative
Evidence to date
• Community members are able to retain information following the training– Enhancing problem recognition
• Community members who are exposed to HBLSS are more likely to take action to:– Provide first aid to respond to a complication– Refer women to a facility
• Community is supportive and actively engaged in MNH issues
Skills Demonstration of Community Facilitators
0%
20%
40%
60%
80%
100%
Too Much Bleeding, Ethiopia
Too much Bleeding, L
iberia
1st Actio
ns, Ethiopia
1st Actio
ns, Liberia
Birth Delay, B
angledesh
Birth Asphyxia, B
angladesh
Womn Referral, L
iberia
Baby referra
l, Liberia
Pre-training
Post-training
1-yr. post-training
Ability to Respond to Identified Complications
0%
20%
40%
60%
80%
100%Unexposed
Exposed
Other Positive Results• Creates a sustainable community resource• Improves problem recognition• Initiates earlier referral of complications • Increases team work and better working relations
between community-based providers/TBAs & clinic/hospital staff
• Puts systems in place to track maternal & infant morbidity and mortality
• Generates support of community leaders and members• Promotes change in peoples’ attitudes related to
reproductive health and the value of individual life• Leads to inclusion of men in the birth process
-1
1
3
5
7
9
11
13
15
1998-1999 2000-2001 2002-2003 2004-2005 2006-2007 2008-2009
Nu
mb
er
of
Co
un
trie
s
Year of Introduction
India
Ethiopia(Liben)
Ethiopia (Harag)Afghanistan
TibetGhana
HaitiLiberia
Bangladesh
KenyaZambiaGuatemalaIndiaPakistan
Ethiopia (Somali)
Tanzania
Niger, Peru, and Cameroon In planning stage
Expansion of HBLSS Programs
Perceived weaknesses
• Rigid, cumbersome, expensive & un-scalable
• Limited pool of master trainers
• Promotes obstetrical first aid & home birth over skilled attendance at birth
• Inconsistent feel of materials; expense & accessibility of materials
• Methodology not readily apparent
• Concerns r/t evidence based practices
Combating Perceptions & Reality
• Rigidity– Promote the adaptability of HBLSS as a
strength – recently adapted in Zimbabwe to address land restoration. Elegance is in the method, content can be changed!
– Communities can choose priorities– Modular formatting aids ability to mix and
match
Combating Perceptions & Reality
Two key endeavors: • Collaborative 2nd edition Revision
• ACNM/CORE joint HBLSS initiative
2nd Edition Key Objectives & Methods
• Seek expanded input from those with HBLSS implementation experience
• Follow collaborative model of revision– Asked for broad stroke recommendations
from wide field of users– A core group discussed & made changes– Edited version went back to wide field for
review & comments– Comments discussed & incorporated by core
group
2nd Edition Key Objectives & Methods
• Clarify methodology at the outset, make it more accessible– New ‘process explanation’ and introduction
• Produce consistent look and feel of materials– Hired professional editor– Chose standard format to use with all
meetings
2nd Edition Key Objectives & Methods
• Update technical information – Reviewed evidence base & updated references
• Add new proven interventions– Misoprostal
• Make materials more accessible– Previously laminated large picture cards will be
printed in bound book– All materials will be available free of charge in
pdf format on website; possibly sold via Hesperian in the future
Perceived weaknesses
• Rigid, cumbersome, expensive & un-scalable
• Limited pool of master trainers
• Promotes obstetrical first aid & home birth over skilled attendance at birth
• Inconsistent feel of materials; expense & accessibility of materials
• Methodology not readily apparent
• Concerns r/t evidence based practices
ACNM/CORE Joint Initiative: Basic Premise
A model to create a household-to-hospital continuum of care capable of reducing maternal & neonatal morbidity and mortality is not widely available in a field friendly program package
HBLSS IS POISED TO BE THAT PACKAGE
ACNM/CORE Joint Initiative: 5 yr Overview
• Year 1: Repackaging of HBLSS materials• Years 2-4: 4 implementation sub-grants
awarded; implementation and outcomes research carried out
• Year 5: Wrap-up and Dissemination
ACNM/CORE Joint Initiative: Yr1: Repackage & Rebrand HBLSS
• Steering committee will leverage collective experience and expertise of– ACNM– CORE Community Health Network
– SMRH working group– Social and behavior change working group– M&E working group
ACNM/CORE Joint Initiative: Yr1: Repackage & Rebrand HBLSS
• Renewed focus on – Streamlined design of materials, training
cascade, & M&E tools– Practical program guidance– Adaptability, Scalability
• Evaluate need for name change• Co-brand all materials with ACNM/CORE logos
• 1 staff from ACNM & CORE will be dedicated ½ time to this project
ACNM/CORE Joint Initiative: Yr 2: Implementation and Outcomes
Research
Goal: • Yield credibly field tested product that can
perform in diverse settings & foster ownership among wide array of stakeholders
Plan: • Put out call for applications to all CORE
members to compete for 4, 3 year implementation sub-grants
ACNM/CORE Joint Initiative: Yr 2: Implementation and Outcomes
Research• Grantees will conduct research on process &
outcomes of repackaged model using incorporated M&E tools
• M&E experts will assist to ensure effectiveness of research protocols & data collection tools/methods
• ACNM/CORE staff will visit implementation sites
ACNM/CORE Joint Initiative: Dissemination
• Partners will analyze data, synthesize lessons, and refine model and tools as needed.
• Dissemination will target a range of global health channels and networks & use a variety of media.
Perceived weaknesses
• Rigid, cumbersome, expensive & un-scalable
• Limited pool of master trainers
• Promotes obstetrical first aid & home birth over skilled attendance at birth
• Inconsistent feel of materials; expense & accessibility of materials
• Methodology not readily apparent
• Concerns r/t evidence based practices
Work to ensure that all births are accompanied by skilled attendants must continue, but the needs of women and their infants who deliver in the absence of a skilled attendant must not be ignored as a result. This proposed package can be put into action immediately, contributing to reducing maternal & neonatal mortality, empowering communities, and fostering a stronger continuum of care
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