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December 2009

Photos by Nicolas Axelrod, CARE

Piloting an Integrated Postpartum Care Program for Midwives in Cambodia

December 2009



Table of Contents Acknowledgments....................................................................................................................v

Abbreviations ..........................................................................................................................vi

Executive Summary ................................................................................................................ 1

Introduction ............................................................................................................................. 4

Development of the Integrated Postpartum Care Training Package ...................................... 5

Core Features of the IPPC Training Package......................................................................... 6

Piloting the Integrated Postpartum Care Program .................................................................. 8

Results .................................................................................................................................. 10

Conclusion ............................................................................................................................ 18

Successes, Challenges, and Key Recommendations .......................................................... 20

Appendix 1. Participant Registration Form ........................................................................... 22

Appendix 2. Assessment Summary (Pre- and Post- Scores) for Integrated Postpartum Care Training.................................................................................... 23

Appendix 3. Observation Checklist ....................................................................................... 24

Appendix 4. Performance Standards for Health Centers Postpartum Care of the Mother and Newborn ........................................................................................................................ 26

Appendix 5. Short Supervisory Checklist (from PHD/OD to the Health Center) ................... 34

Appendix 6: Exit Interview with Women Following a Post Partum Visit at a Health Facility.................................................................................... 37


List of Tables Table 1. Summary Results for Integrated Postpartum Care Pilot: postpartum women and newborn visits and interventions at baseline and endline Table 2. IPPC Training Program: three recommended postpartum/postnatal care contacts and services Table 3. IPPC Pilot Operational Districts and Public Facility Coverage Table 4. Number of Deliveries Reported per pilot facilities during baseline and intervention period (source: HIS 2008-2009), Data on Reported Deliveries Table 5a. Postpartum Women Visited: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Overall Results Table 5b. Postpartum Women Visited: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Results by Operational District Table 6a. Newborn Visits: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Overall Results Table 6b. Newborn Visits: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Results by Operational District Table 7a. Interventions for Postpartum Women: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Overall Results Table 7b. Interventions for Postpartum Women: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Results by Operational District Table 8a. Interventions for Newborns: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Overall Results Table 8b. Interventions for Newborns: Baseline and Endline Results from Pilot Health Facilities; Number and Percent of Reported Deliveries – Results by Operational District Table 9. Number of Referrals to Health Facilities for Postpartum Women and Newborns – Results by Operational District

Piloting an Integrated Postpartum Care Program for Midwives in Cambodia v

Acknowledgments The Integrated Postpartum Care Pilot (IPPC) program was made possible through the collaboration of several partners under the leadership of the Cambodian National Reproductive Health Program (NRHP), supported by ACCESS Cambodia and UNICEF. The IPPC implementing partners provided direct support to government-funded health facilities, assisted in refining the IPPC training package, trained midwives in their respective provinces, and provided on-site technical assistance. The IPPC partners are: ACCESS, CARE, GTZ, Reproductive and Child Health Alliance (RACHA), Reproductive Health Association of Cambodia (RHAC), Save the Children, UNICEF, and World Vision, Inc. This report was made possible through support provided by the U.S. Agency for International Development (USAID), under the terms of Associate Cooperative Agreement No: 442-A-00-07-00002-00. The opinions expressed herein do not necessarily reflect the views of USAID. Suggested Citation This report may be reproduced if credit is given to NRHP and ACCESS Cambodia. Please use the following citation: NRHP and ACCESS Cambodia. Piloting an Integrated Postpartum Care Program for Midwives in Cambodia (2009). Phnom Penh, Cambodia.

vi Piloting an Integrated Postpartum Care Program for Midwives in Cambodia

Abbreviations ACCESS Access to clinical and community maternal, neonatal and women’s

health services

GTZ Gesellschaft für Technische Zusammenarbeit

HC Health center

HIS Health information system

IPPC Integrated Postpartum Care

M&E Monitoring and evaluation

MCH Maternal and child health

MOH Ministry of Health

NMCHC National Maternal and Child Health Center

NRHP National Reproductive Health Program

OD Operational district

PHD Provincial health department

PNC Postnatal care

RACHA Reproductive and Child Health Alliance

RHAC Reproductive Health Association of Cambodia

TA Technical assistance

TBA Traditional birth attendant

TOT Training-of-trainers

USAID United States Agency for International Development

WHO World Health Organization

Piloting an Integrated Postpartum Care Program for Midwives in Cambodia 1

Executive Summary In recognition of the need for better care for newborns, the National Safe Motherhood Technical Sub-Committee formed a sub working group to examine the issues and work toward improving newborn health in Cambodia. The Neonatal Health Sub Working Group identified care of the newborn in the immediate postpartum period as a priority, as well as the need to ensure that maternal care during this time period was integrated into any approach. The components of postpartum care have been extensively examined globally. To avoid duplicating such documents and program approaches, the Ministry of Health’s (MOH’s) National Reproductive Health Program endorsed the use of the World Health Organization (WHO) manual Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice as the basis for the new strategy’s technical content and the related training package because they are evidence-based. The Neonatal Sub Working Group revised each element of the WHO package and adapted it to the existing Government of Cambodia policies and to the local context. In collaboration with the NRHP, this working group developed the Integrated Postpartum Care Package, which was supported by several partners already working in maternal and newborn care. ACCESS Cambodia and UNICEF, along with seven other maternal and child health care partners, developed the package components and funded the associated training courses and material development. The program aims to define and provide a package of services to the mother and the newborn, delivered during three recommended contacts between the family and the trained provider. The competency-based approach includes a training package for midwives that has a significant clinical component and several tools, including: a Trainer’s Guide and a Participant’s Handbook, pre- and post-tests, supervision tools, checklists, and WHO reference materials. All materials are available in both English and Khmer. In addition, monitoring tools were developed that could be incorporated into the existing health information system, and a revised PNC register was also developed and field-tested. The IPPC Package was successfully piloted by the Cambodian health workers, supported by the seven partners—UNICEF, Reproductive and Child Health Alliance (RACHA), Reproductive Health Association of Cambodia (RHAC), World Vision, Inc., CARE, Save the Children, and GTZ—with ACCESS providing technical assistance (TA). Following an initial training of trainers conducted by ACCESS, and two field-test courses, the partners completed cascade trainings in 12 operational districts in seven provinces. The trainings targeted midwives in public funded health facilities. Eighty health facilities participated in the pilot program and 335 midwives completed the IPPC training. ACCESS provided ongoing TA to the partners, who in turn provided TA to the operational districts. All of the partners intend to continue using the IPPC training package and all have plans to expand the program to additional health centers. Across the major areas of the IPPC pilot program—postpartum women visited, newborns visited, postpartum women interventions, and newborn interventions—partners reported improvements between baseline and endline results, as seen in the general trend of positive percentage changes (see Table 1).

2 Piloting an Integrated Postpartum Care Program for Midwives in Cambodia

Table 1. Summary Results for Integrated Postpartum Care Pilot: Postpartum Women and Newborn Visits and Interventions at Baseline and Endline

BASELINE (5,271 DELIVERIES)*

ENDLINE (11,389 DELIVERIES)*

Postpartum women

Postpartum women visited within 24 hrs. after delivery

1,288 (24%) 6,158 (54%)

Postpartum women visited on the 2nd or 3rd day after delivery

850 (16%) 2,799 (25%)

Postpartum women visited within 6 weeks after delivery

387 (7%) 1,298 (11%)

Newborns

Newborn visited within 24 hrs. after delivery

1,350 (26%) 6,113 (54%)

Newborn visited on the 2nd or 3rd day after delivery 779 (15%) 2,807 (25%)

Newborn visited within 6 weeks after delivery

167 (3%) 1,461 (13%)

Postpartum interventions

Vitamin A within 6 wks 3,047 (58%) 8,743 (77%)

42 tablets iron folate 3,006 (57%) 8,502 (75%)

Mebendazole 1,949 (37%) 7,876 (69%)

Birth space counseling 1,626 (31%) 4,753 (42%)

Newborn interventions

Hep B immunization 2,017 (38%) 6,730 (59%)

BCG immunization 2,461 (47%) 8,545 (75%)

Skin-to-skin 1,708 (32%) 4,730 (42%)

Breastfeeding within 1 hour 2,086 (40%) 4,770 (42%)

*In general, the baseline reporting period per operational district was shorter than the intervention period, resulting in fewer overall reported deliveries during the baseline period in comparison to the intervention period. Among postpartum women visited, the largest observed percentage change occurred in the proportion of women visited within 24 hours of delivery (24% to 54%) (see Table 5a). The current health information system register does not specify when PNC visits occur, in terms of the number of days after delivery, which is critical to maternal mortality reduction. The current health information system register currently does not include indicators specific to newborn follow-up. The IPPC pilot register tracked newborn visits at three time periods: within 24 hours, within 2 or 3 days after delivery, and within 6 weeks after delivery. The largest percentage change in newborn visits, similar to postpartum women, occurred in the proportion of infants visited within 24 hours of delivery (26% to 54%) (see Table 6a). Among interventions for postpartum women, the largest percentage change occurred in the proportion of women receiving vitamin A (58% to 77%) and iron folate (57% to 75%). A smaller change was observed in birth space counseling (31% to 42%) (see Table 7a).


Among newborn interventions, the largest percentage change occurred in the proportion of infants being immunized: Hepatitis B, 38% to 59% and BCG, 58% to 77% (see Table 8a). At baseline, less than half of newborns were reported to have been breastfed within 1 hour of delivery. This number did not improve during the pilot period (40% to 42%), which is understandable, as the behavior has already taken place at the time of delivery, and therefore counseling during the PNC visit could not change this indicator, (see Table 8a). For improvements in this area, better antenatal counseling and care at delivery are recommended. Strengths of the IPPC Competency-based Training Package

• The IPPC package standardizes PNC technical content, competencies, and indicators for all partners who wish to work on improving PNC care and can ensure that the MOH standards are followed.

• The midwifery training module can serve as the foundation of PNC training in both the pre-service and in-service midwifery curricula.

• The IPPC Register tracks newborn outcomes and provides a greater level of detail for PNC-related indicators, resulting in improved methods for monitoring PNC progress.

• Given its positive reception, the IPPC package can form the foundation for the MOH’s updated PNC approach that reflects a commitment to integrated care for the mother and newborn.


Introduction The 2005 Cambodian Demographic and Health Survey found neonatal mortality, or the probability of a child dying within the first month of life, to be 28 deaths per 1,000 live births. The probability of a child dying between the first month and first birthday, or postneonatal mortality, was even higher, at 37 deaths per 1,000 live births among children who survived the first month of life. Maternal mortality is also an area of concern for Cambodia, with a woman’s lifetime risk of dying from maternal causes 1 in 50 (i.e., the maternal mortality ratio is currently 472 deaths per 100,000 live births). In 2007 the Neonatal Health sub workgroup was formed by the National Safe Motherhood Technical Sub Working Group to identify methods to improve neonatal health in the Cambodian health system. The working group identified a need for better care for newborns in the immediate post-delivery and postnatal periods. It was also recognized that care given to mothers during this time period was limited and could be improved, and it was essential that care for both mothers and newborns be integrated. The resulting strategy was therefore defined as integrated maternal and newborn care.


Development of the Integrated Postpartum Care Training Package The Neonatal Health Working Group consisted of representatives from the National Reproductive Health Program (NRHP), the National Maternal and Child Health Center (NMCHC), donors, and other partners working in maternal and child health (MCH). An overall package of integrated postpartum care (IPPC) materials and tools was developed by this working group, and seven agencies with field programs, which were able to support the Ministry of Health (MOH) local staff in field-testing this package, offered to take part in the field-testing. The partners were: UNICEF, Reproductive and Child Health Alliance (RACHA), Reproductive Health Association of Cambodia (RHAC), World Vision, Inc., CARE, Save the Children, and GTZ. Each of these implementing partners provides maternal and child health support to government-funded health facilities in seven of Cambodia’s 23 provinces. NRHP supported the idea of using the World Health Organization’s (WHO) Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice, which is consistent with the 2008 Safe Motherhood Clinical Management Protocols, as the basis for the integrated training package, since it is evidence-based. The Neonatal Health Working Group reviewed each element of the WHO package and adapted it to the existing Government of Cambodia policies and to the local context. To accompany the revised technical content, a new postnatal care (PNC) register layout was designed. The register was developed by expanding on indicators in the existing health information system (HIS) register. The existing HIS register has a limited number of indicators specific to PNC and did not include any indicators specific to the newborn. Additionally, the existing PNC indicators were considered too general to track the necessary components of PNC. The revised integrated care register includes indicators with sufficient specificity to track the three recommended postnatal contacts, when the contact takes place, and related services, and incorporated indicators specific to the newborn. Based on the Neonatal Health Working Group’s updated technical content, ACCESS Cambodia, in collaboration with the partners, developed a 5-day, competency-based IPPC training course for primary and secondary midwives working at public health facilities, with an emphasis on clinical skills.


Core Features of the IPPC Training Package The IPPC training package consists of a Trainer’s Guide and a Participant’s Handbook, pre- and post-tests, supervision tools, monitoring tools, and translated WHO reference materials. The course is available in both English and Khmer. The training package uses a range of learning methods and includes skills checklists and other support materials in addition to the pre- and post-test questions. Two observation checklists were used to monitor quality of care during the pilot phase, one assessing clinical competence, the second assessing the operational quality of a health facility (see Appendices 3 and 4). The content of the visits was designed to ensure that women received all of the interventions they required, even if the interventions did not fit exactly into the visit schedule. The visits were designed in this way because under the previous system, PNC 1, PNC 2 and PNC 3, if a woman missed the first visit (PNC 1), she might not receive some of the components specified for that visit. In response to this limitation, the IPPC pilot was designed to be a simpler and more responsive system to allow a woman to receive necessary care, regardless of when she attends during the postpartum period. The IPPC training package aims to provide a package of health-related services (see Table 2) to the mother and the newborn, delivered during three recommended contacts between the family and the trained provider.


Table 2. IPPC Training Program: Three Recommended Postpartum/Postnatal Care Contacts and Services

CONTACTS Minimum Package of Services Provided by Midwife (at Health Facility or Community Level)

Minimum Package of Services Provided by Trained Village

Health Support Group Volunteer or Traditional Birth Attendant

Once Only, at the First Postnatal Contact (Unless Otherwise Specified)

MOTHER Iron folate for 42 days Vitamin A single dose 200 000 IU Mebendazole single dose 500 mg TT immunization, if necessary NEWBORN Eye prophylaxis with tetracycline ointment 1% (within 1 hour of delivery) Hep B birth doze (Hep B 0) – as soon as possible after birth, preferably within first 24 hours (possible up to 1 week) BCG immunization – as soon as possible after birth Measure and record birth weight, or assess the baby size Measure and record weight at 6 weeks Advise when next contact/visit due

MOTHER Iron folate for 42 days Vitamin A single dose 200 000 IU Mebendazole single dose 500 mg NEWBORN Measure and record birth weight, or assess the baby’s size Measure and record weight at 6 weeks Advise when next contact/visit due

At Every Contact MOTHER Check for danger signs and manage/refer for complications; Observe and support exclusive breastfeeding; Counsel on danger signs for herself and the baby; Counsel on special care for small babies, if required Advise on home care, including hygiene, diet, sleeping under bed net (for malaria-endemic areas); Advise on family planning options Refer for PMTCT, if relevant [HIV+ mother] NEWBORN Assess for danger signs and manage/refer for complications; Ensure warmth; Support optimal feeding practices; Counsel on cord, skin, and eye care; Counsel on danger signs; Advise on birth registration Advise when next contact/visit due

MOTHER Check for danger signs and refer for complications; Advise on danger signs for the mother; Check for danger signs and refer for complications; Advise on exclusive breastfeeding; Advise on home care, including hygiene, diet, sleeping under bed net (for malaria-endemic areas); NEWBORN Check for danger signs and refer for complications; Advise on danger signs; Advise on exclusive breastfeeding; Advise on cord, skin, and eye care; Advise on birth registration Advise when next contact/visit due

At contact 6 weeks after the birth

NEWBORN - DPT, OPV-1, HB-2


Piloting the Integrated Postpartum Care Program The implementing partners of the IPPC pilot provide MCH support to public facilities in seven provinces. Within these provinces, 80 pilot facilities (75 health centers and five referral hospitals) were identified in 12 operational districts. The 80 pilot sites represent 45% of all public facilities in these operational districts (see Table 3). Two initial pilot training courses were held in Kampong Thom and Koh Kong provinces, with 37 participants, primarily midwives, from the NRHP, the provincial and operational district MOH, and the partner agencies. The IPPC training materials and methodology were subsequently refined and adjusted following these test courses. In April 2008 the pilot program began with a 5-day training-of-trainers (TOT) in Phnom Penh. The 23 TOT participants included two trainers from NMCHC, representatives from the IPPC partner agencies, and maternal and child health staff from the seven participating pilot provincial health departments (PHDs) and operational districts (ODs). Following the TOT, the participants returned to their respective provinces and conducted trainings for midwives and others at the PHD and OD level to orient them to the IPPC program and how to monitor maternal and newborn care activities.

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Results The IPPC pilot training program continued until July 2009. By this time, 335 midwives providing services at the 80 health facilities had completed the IPPC training (see Table 3). In August 2009, ACCESS convened a stakeholders’ meeting in Phnom Penh for PHDs/ODs and partner agencies to share their experiences with the pilot program. During the 2-day meeting, PHDs/ODs presented their initial results from the pilot, identified successful elements of the program, discussed challenges, offered suggestions for improving the IPPC training program, and discussed follow-on activities. Across the major areas of the IPPC pilot program—postpartum women visited, newborns visited, postpartum women interventions, and newborn interventions—partners reported improvements between baseline and endline results, as seen in the trend of overall positive percentage changes (see Tables 5a–8a). While the overall trend in percentage change was positive across indicators tracked by the IPPC pilot register, differences in performance are evident in Tables 5b–8b, which present results by operational district. Data Source for Number of Deliveries To determine the number of deliveries per pilot area, monthly reports from the Cambodia HIS for each of the pilot sites were used to determine the number of deliveries recorded for a given facility during the baseline and intervention periods (see Table 4). The total number of deliveries recorded per pilot facility included the number of deliveries at the given facility, the number of home deliveries by health staff that were reported to the health center/hospital, and the number of deliveries performed by traditional birth attendants (TBAs). The number of deliveries reported in the HIS does not include deliveries occurring in private facilities. Additionally, the HIS underestimates the number of home deliveries assisted by health staff as well as those assisted by a TBA. In general, the baseline reporting period was shorter per OD than the intervention period, resulting in fewer overall reported deliveries during the baseline period in comparison to the intervention period. We could not reliably account for maternal and/or newborn deaths or multiple births across all of the pilot facilities. As a result, the number of reported deliveries per the HIS was used as the denominator to calculate percentages for the postpartum and newborn indicators presented in Tables 5–8.


Table 4. Number of Deliveries Reported per Pilot Facilities during Baseline and Intervention Period (source: HIS 2008-2009 )*

PROVINCE (#OD)

OPERATIONAL

DISTRICT

BASELINE PERIOD

INTERVENTION PERIOD

BASELINE PERIOD:

NUMBER OF DELIVERIES

REPORTED IN PILOT SITES

INTERVENTION PERIOD:

NUMBER OF DELIVERIES

REPORTED IN PILOT SITES

Kampong Thom

Stong Kampong

Thom

Baray and Santuk

June–Aug '08 Oct '08–June '09

553 1,999

Stung Treng Stung Treng May–Sept '08 Oct '08–July '09

989 2,123

Smach Mean Chey Koh Kong

Srae Ambel

June–Aug '08 Sept '08–July '09

963 1,979

Somlot district (OD

Battambang) Aug –Sept '08 Oct '08–July

'09 90 602

Battambang

Sangkae July–'08 Jan–July '09 241 1,817

Memut Kampong Cham Ponhea Krek

Jan–July '08 Jan–July '09 1,116 1,279

Kompot Kompot July–Sept '08 March–May '09 827 665

Pursat Sampov Meas

Jan–Feb '09 April–July 2009 492 925

Total 5,271 11,389

* Number of deliveries includes deliveries at public health centers, deliveries at home by health staff, and deliveries by traditional birth attendants as reported in facility HIS registers.

Among postpartum visits, the largest observed percentage change occurred in the proportion of women visited within 24 hours of delivery (24% to 54%) (see Table 5a). Given the increased risk for both neonatal and maternal mortality during the first 24 hours following delivery, strong emphasis was placed on this early visit during implementation of the pilot program. Anecdotally, this increased emphasis may have led to greater attention being paid to the first PNC visit compared to the subsequent PNC visits.


Table 5a. Postpartum Women Visited: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Overall Results

POSTPARTUM WOMEN VISITED WITHIN 24 HRS.

AFTER DELIVERY

POSTPARTUM WOMEN VISITED ON THE 2ND OR

3RD DAY AFTER DELIVERY

POSTPARTUM WOMEN VVISITED WITHIN 6 WEEKS AFTER DELIVERY

Baseline (%) (n=5,271)

Endline (%) (n=11,389)

Baseline (%)(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Overall 1,288 (24%) 6,158 (54%) 850 (16%) 2,799 (25%)

387 (7%) 1,298 (11%)

Table 5b. Postpartum Women Visited: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Results by Operational District

POSTPARTUM WOMEN VISITED WITHIN 24 HRS.

AFTER DELIVERY

POSTPARTUM WOMEN VISITED ON THE 2ND OR 3RD DAY AFTER DELIVERY

POSTPARTUM WOMEN VISITED WITHIN 6 WEEKS AFTER DELIVERY

PROVINCE ODS WITH PILOT

HEALTH FACILITIES

Baseline Endline Baseline Endline Baseline Endline

Kampong Thom

Stong Kampong

Thom Baray and

Santuk

231 (42%) 800 (40%) 149 (27%) 483

(24%) 73 (13%) 273 (14%)

Stung Treng Stung Treng 274 (28%) 762 (36%) 90 (9%) 359

(17%) 257 (26%) 193 (9%)

Smach Mean Chey

Koh Kong

Srae Ambel

247 (26%) 1,222 (62%) 146 (15%) 723

(37%) 43 (4%) 91 (5%)

Battambang Somlot

district (OD Battambang)

51 (57%) 336 (56%)

39 (43%) 147 (24%)

0 40 (7%)

Battambang Sangkae 77 (32%) 1,174 (65%)

24 (10%) 163 (9%) 11 (5%) 28 (2%)

Memut Kampong

Cham Ponchear Krek

*^ 760 (59%)

*^ 369 (29%)

* 663 (52%)

Kompot Kompot 181 (22%) 548 (82%) 261 (32%) 376

(57%) 3 (0%) 6 (1%)

Pursat Sampove Meas 227 (46%) 556

(60%) 141 (29%) 179 (19%) 0 4 (0%)

*Data not available Note: Percentages are not additive. Each denominator was calculated for each cell, given the reported number of deliveries per pilot facility during the data collection period (see Table 4 for denominators). *^The IPPC pilot register was not used during the baseline data collection period for this site, so data are not available for postpartum visits within 24 hrs, 2 to 3 days, and within 6 weeks.


The current HIS register does not include indicators specific to newborn follow-up. The IPPC pilot register tracked newborn visits at three time periods: within 24 hours, within 2 or 3 days after delivery, and within 6 weeks after delivery. The largest percentage change in newborn visits, similar to that for postpartum women, occurred in the proportion of infants visited within 24 hours of delivery (26% to 54%) (see Table 6a). Table 6a. Newborn Visits: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Overall Results

NEWBORN VISITED WITHIN 24 HRS. AFTER DELIVERY

NEWBORN VISITED ON THE 2ND OR 3RD DAY AFTER DELIVERY

NEWBORN VISITED WITHIN 6 WEEKS AFTER DELIVERY

Baseline

(%) (n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Overall 1,350 (26%) 6,113 (54%) 779 (15%) 2,807 (25%)

167 (3%) 1,461 (13%)

Table 6b. Newborn Visits: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Results by Operational District

NEWBORN VISITED WITHIN 24 HRS.

AFTER DELIVERY

NEWBORN VISITED ON THE 2ND OR 3RD

DAY AFTER DELIVERY

NEWBORN VISITED WITHIN 6 WEEKS AFTER DELIVERY


HEALTH FACILITIES

Baseline (%)

Endline (%)

Baseline (%)

Endline (%)

Baseline (%)

Endline (%)

Kampong Thom

Stong Kampong

Thom

Baray and Santuk

124 (22%) 764 (38%)

52 (9%) 501 (25%)

5 (1%) 331 (17%)

Stung Treng Stung Treng 274 (28%) 762 (36%) 90 (9%) 359

(17%) 98 (10%) 193 (9%)

Smach Mean Chey

Koh Kong

Srae Ambel

247 (26%) 1,222 (62%) 146 (15%) 723

(37%) 43 (4%) 91 (5%)

Battambang Somlot


51 (57%) 336 (56%)

39 (43%) 147 (24%)

0 40 (7%)

Battambang Sangkae 86 (36%) 1,174 (65%)

38 (16%) 163 (9%) 11 (5%) 45 (2%)

Memut Kampong

Cham Ponchear Krek

*^ 759 (59%)

*^ 356 (28%)

*^ 751 (59%)

Kompot Kompot 324 (39%) 541 (81%)

273 (33%) 379 (57%)

10 (1%) 6 (1%)

Pursat Sampove Meas

244 (50%) 555 (60%)

141 (29%) 179 (19%)

0 4 (0%)

*Data not available


Note: Percentages are not additive. Each denominator was calculated for each cell, given the reported number of deliveries per pilot facility during the data collection period (see Table 4 for denominators).

*^The IPPC pilot register was not used during baseline data collection at this site, so newborn-specific visit data are not available. Among interventions for postpartum women, the largest percentage change occurred in the proportion of women receiving vitamin A (58% to 77%) and iron folate (57% to 75%). A smaller change was observed in birth space counseling (31% to 42%) (see Table 7a). Table 7a. Interventions for Postpartum Women: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Overall Results

VITAMIN A WITHIN 6 WKS

42 TABLETS IRON FOLATE MEBENDAZOLE

BIRTH SPACE COUNSELING

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Overall 3,047 (58%)

8,743 (77%)

3,006 (57%)

8,502 (75%)

1,949 (37%)

7,876 (69%)

1,626 (31%)

4,753 (42%)

Table 7b. Interventions for Postpartum Women: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Results by Operational District

VITAMIN A WITHIN 6 WKS

42 TABLETS IRON FOLATE MEBENDAZOLE BIRTH SPACE

COUNSELING PROVINCE

ODS WITH PILOT

HEALTH FACILITIES Base-

line (%) Endline

(%) Base-

line (%) Endline

(%) Base-

line (%) End-

line (%) Base-

line (%) Endline

(%)

Kampong Thom

Stong Kampong

Thom Baray and

Santuk

237 (43%)

954 (48%)

237 (43%)

972 (49%)

237 (43%)

972 (49%)

* *

Stung Treng Stung Treng

549 (56%)

1,889 (89%)

549 (56%)

1906 (90%)

549 (56%)

1,730 (81%)

533 (25%) *


Srae Ambel

280 (29%)

1,208 (61%)

287 (30%)

1,214 (61%)

260 (27%)

1,141 (58%)

295 (31%)

1,177 (59%)

Battambang

Somlot district (OD

Battam-bang)

56 (62%)

351 (58%)

56 (62%)

351 (58%)

56 (62%)

351 (58%)

* *

Battambang Sangkae 108 (45%)

1,353 (74%)

109 (45%)

1,353 (74%)

108 (45%)

1,353 (74%)

81 (34%)

1,353 (74%)

Memut Kampong

Cham Ponchear Krek

1,045 (94%)

1,211 (95%)

1,029 (92%)

1,125 (88%) * 768

(60%) * 752 (59%)

Kompot Kompot 454 (55%)

872 (131%)

^

421 (51%)

676 (102%)

^

421 (51%)

656 (99%)

411 (50%)

566 (85%)

Pursat Sampove

Meas 318

(65%) 905

(98%) 318

(65%) 905

(98%) 318

(65%) 905

(98%) 306

(62%) 905

(98%)

*Data not available


Note: Percentages are not additive. Each denominator was calculated for each cell, given the reported number of deliveries per pilot facility during the data collection period (see Table 4 for denominators). ^Vitamin A and iron folate provision exceeded the number of reported deliveries in this pilot area. Possible reasons for this discrepancy include: 1. A spike in the number of out-of-catchment area clients visiting the operational district for ANC/PNC visits; 2. A vitamin A campaign initiated in May may have boosted intervention numbers; 3. Includes postpartum women who did not deliver at the facility, thereby not captured in the HIS register for the denominator. Among newborn interventions, the largest percentage change occurred in the proportion of infants being immunized: Hepatitis B, 38% to 59% and BCG, 58% to 77% (see Table 8a). Less than half of newborns were reported to have been breastfed within 1 hour of delivery. This number did not improve during the pilot period (40% to 42%) primarily because the visit occurred “after the event” (i.e., post-delivery). For improvements in this area, better antenatal counseling and care at delivery are recommended. Table 8a. Interventions for Newborns: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Overall Results

HEP B IMMUNIZATION

BCG IMMUNIZATION

SKIN-TO-SKIN BREASTFEEDING WITHIN 1 HOUR

Base-line (%)

(n=5,271)

Endline (%) (n=11,389)

Baseline (%)

(n=5,271)

Endline (%)

(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)(n=11,389)

Baseline (%)

(n=5,271)

Endline (%)(n=11,389)

Overall 2,017 (38%)

6,730 (59%)

2,461 (47%)

8,545 (75%)

1,708 (32%)

4,730 (42%)

2,086 (40%)

4,770 (42%)

Table 8b. Interventions for Newborns: Baseline and Endline Results from Pilot Health Facilities; Number and Percentage of Reported Deliveries – Results by Operational District

HEP B IMMUNIZATION

BCG IMMUNIZATION

SKIN-TO-SKIN BREASTFEED-ING WITHIN 1

HOUR


HEALTH FACILITIES

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Kampong Thom

Stong Kampong

Thom Baray and

Santuk

202 (37%)

879 (44%)

192 (35%)

902 (45%)

* * * *

Stung Treng

Stung Treng

153 (15%)

976 (46%)

314 (32%)

2,408 (113%)

^

153 (15%) * 459

(46%) *


Srae Ambel

252 (26%)

869 (44%)

251 (26%)

1,049 (53%)

267 (28%)

1,182 (60%)

263 (27%)

1,218 (62%)

Battambang Somlot


58 (64%)

304 (50%)

62 (69%)

326 (54%) * 126

(21%) * 126 (21%)

Battambang Sangkae 119 (49%)

1,185 (65%)

101 (42%)

1,265 (70%)

* 1,174 (65%)

* 1,174 (65%)


HEP B IMMUNIZATION

BCG IMMUNIZATION

SKIN-TO-SKIN BREASTFEED-ING WITHIN 1

HOUR


HEALTH FACILITIES

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Base-line (%)

Endline (%)

Memut Kampong

Cham Ponchear Krek

789 (71%)

1,045 (82%)

1,069 (96%)

1,156 (90%)

745 (67%)

992 (78%)

745 (67%)

992 (78%)

Kompot Kompot 180 (22%)

567 (85%)

201 (24%)

534 (80%)

310 (37%)

556 (84%)

313 (38%)

560 (84%)

Pursat Sampove

Meas 264

(54%) 905

(98%) 271

(55%) 905

(98%) 233

(47%) 700

(76%) 305

(62%) 700

(76%)

*Data not available Note: Percentages are not additive. Each denominator was calculated for each cell, given the reported number of deliveries per pilot facility during the data collection period (see Table 4 for denominators). ^The number of BCG immunizations exceeded the number of reported deliveries in this pilot area. Possible reasons for this discrepancy include: 1. The BCG vaccine is provided to all children under 1 year, which might include some children born before the IPPC baseline reporting period; 2. There is a community of migrant workers in the area. For this population, many of the deliveries may not be captured in the facility HIS, but children may subsequently be vaccinated. The modified HIS register used for the IPPC pilot included indicators to track the referral of both postpartum women and newborns to health facilities. Table 9 presents baseline and endline data for these indicators, but the data were very sparse. Anecdotally, some partners reported that referral data were often not noted in the HIS register, even though columns were created to capture this information. Table 9. Number of Referrals to Health Facilities for Postpartum Women and Newborns – Results by Operational District*

NUMBER OF POSTPARTUM

WOMEN REFERRED TO HEALTH FACILITIES

NUMBER OF NEWBORNS

REFERRED TO HEALTH FACILITIES

PROVINCE ODS WITH PILOT HEALTH FACILITIES

Baseline Endline Baseline Endline

Kampong Thom

Stong Kampong Thom

Baray and Santuk

0 8 0 0

Stung Treng Stung Treng 2 13 1 10


Srae Ambel 5 0 3 0

Battambang Somlot district (OD Battambang)

5 25 1 2

Battambang Sangkae 0 11 0 0

Memut Kampong Cham

Ponchear Krek 0 0 0 1

Kompot Kompot 0 0 0 0


NUMBER OF POSTPARTUM

WOMEN REFERRED TO HEALTH FACILITIES

NUMBER OF NEWBORNS

REFERRED TO HEALTH FACILITIES

PROVINCE ODS WITH PILOT HEALTH FACILITIES

Baseline Endline Baseline Endline

Pursat Sampove Meas 0 0 0 0

Total 12 57 5 13

*Referral data for both postpartum women and newborns were very limited. Partners reported that these field in the HIS register were often not completed.


Conclusion The Integrated Postpartum Care Package defined and provided a package of services for the mother and the newborn that was delivered during three recommended contacts between the family and the trained provider. Across the major areas of the IPPC pilot program—postpartum women visited, newborns visited, postpartum women interventions, and newborn interventions—partners reported improvements between baseline and endline results as seen in the general trend of positive percentage changes. The primary aim of increasing health care coverage for this population and improving the quality and content of PNC visits was achieved. While some activities showed marked improvement in comparisons of endline to baseline performance, for example, PNC visits occurring 24 hours following delivery, other areas such as breastfeeding within 1 hour of delivery showed limited improvement. Implementing one single package and ensuring complete consistency among partners and MOH staff were significant challenges. There is always room for local interpretation, and there was limited technical assistance available for such a large pilot effort over so many geographic locations. While it was understood that the implementation was a field-test, despite instructions to the contrary, some areas insisted on filling in both the old PNC register and the new one. This understandably made it difficult to implement, caused a heavier workload than was necessary, and resulted in some confusion. However, most staff were able to fill in the new register, and if the pilot is scaled up and taken as a national standard, this duplication should be resolved. There was positive feedback on the definition of the PNC components, with midwives saying they were much clearer now on the contents of PNC visits. The training course was well received and participants commented on both the technical updates and evidence-based information they found useful, as well as their improved training ability following the TOT. The fact that all of the materials are in Khmer was also well received, because much midwifery information and technical material are not translated. The largest challenge was in the monitoring of the project. Numerous coordination meetings were held and a standard monitoring and evaluation (M&E) package and indicators were developed, but still the partners were not always consistent in their application of some elements (e.g., the referral information is sparse). This of course needs much more continuing support and is not specific to this pilot but is a very common thread throughout the Cambodian HIS. The denominator data also presented a challenge, since birth records are inconsistent at best. The Jhpiego M&E advisor did a thorough job meeting with all partners concerned, ascertaining what methods and data they had used, and drawing the most practical and sensible conclusions and interpretations. Please see methods section above for the details of this effort. While this pilot faced many challenges, it did prove that it is possible to improve access to and quality of PNC care for both mothers and babies, and that it is perfectly possible in the future both to expand the approach nationally and to continue to improve the quality of that care. One year is an extremely short time period in which to demonstrate change, and the results do


indicate success and the possibility of continued improvement if the efforts are sustained and expanded. In addition, this course can benefit the new midwifery pre-service training currently being developed, and form the basis of any in-service midwifery package that may be introduced on a regular basis.


Successes, Challenges, and Key Recommendations Successes

• The IPPC package standardizes PNC technical content, competencies, and indicators for all partners who wish to work on improving PNC care and can ensure that the MOH standards are followed.

• Several partners reported a perceived increase in the quality of PNC services after the initiation of the IPPC program. Partners felt that the IPPC training, combined with the job aids and modified register, provided needed guidance for midwives and PHD/OD staff regarding the specific components of PNC.

• The IPPC pilot program register was valued. All seven of the partners believed that the revised register should be adopted by the MOH, given the inclusion of newborn-specific indicators and a greater level of detail for PNC-related indicators, resulting in an improved ability to monitor PNC progress.

• Several PHDs/ODs and implementing partners intend to continue and in some cases expand the IPPC training program.

• In Stung Treng Province, which has one OD, UNICEF piloted the program in eight of the 10 health centers and in the one referral hospital. UNICEF has plans to expand the IPPC program to the remaining two health centers in the province and to conduct two additional IPPC training courses, with the aim of training 40 additional health center midwives.

Challenges

• Implementing the two observation checklists was a challenge for all partners, given the time required to complete them. The partners did acknowledge that the checklists were very useful in their content; however, they believed they were not practical given the limited human resources. The midwife checklist in particular was considered too long and detailed to complete. Partners reported the PHDs/ODs were already required to conduct supportive supervisory visits to health facilities and used checklists. They advised that the IPPC program integrate its checklists into the existing reports used by PHD/OD staff to minimize the paperwork and time required. As a result of this feedback, the two checklists were modified.

• There were parallel reporting systems in some instances. In situations where facility staff were reluctant to stop using the existing HIS register, they completed both registers, which was not the intent of the field-testing.

• The pilot program model was resource-intensive with regard to technical assistance. For future scale-up, a more decentralized approach for ongoing technical assistance is recommended. The package can serve as a module for regular in-service midwifery training.

• Calculating the number of deliveries per pilot area was a challenge for many partners. It was suggested that for future scale-up efforts, implementing partners/facilities focus on numerator data while standardized denominator data are provided centrally.


Key Recommendation: Beyond the IPPC Pilot Training Program • The community module of the IPPC, under UNICEF’s coordination, has finished its

pilot phase and has been incorporated and ratified under the Community Integrated Management of Childhood Illness curriculum. Some provinces are planning roll-out of this module.

• The IPPC midwife training module can serve as the foundation of PNC training in both the pre-service and in-service midwifery curricula.

• Given its positive reception, the IPPC package can form the foundation for the MOH’s updated PNC approach, which reflects a commitment to integrated care for the mother and newborn.


Appendix 1. Participant Registration Form


Appendix 2. Assessment Summary (Pre- and Post- Scores) for Integrated Postpartum Care training Course Start Date: Course End Date:

Province:

Name of Trainer(s):

Number of Participants:

PARTICIPANT NO. (ANONYMOUS)

SCORE (PRE) SCORE (POST) COMMENTS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Average score

Please return completed Participant Registration and Assessment Summary forms promptly to:

- National Reproductive Health Programme (Dr.Rathavy, manager) with copy to - UNICEF for training organized in UNICEF-supported provinces, Kampong Thom and Stung Treng - CARE (Paula Gleeson, chief of party) and ACCESS (Judith Moore, resident adviser maternal and

newborn health) for Koh Kong - Other NGO that supports the cost of training activity


Appendix 3. Observation Checklist (TO BE COMPLETE EVERY MONTH BY OD/PHD) PROVINCE: DISTRICT: FACILITY TYPE: Hospital Health Center FACILITY NAME: OBSERVER: DATE: NO. RECOMMENDED STANDARD YES,

NO OR N/A

COMMENT

General information

1. Availability of a midwife trained in Postnatal Care at the HC

If midwife is not available, explain why: Went for outreach Left for training Sick Retired or transferred Other

_____________

Supplies and Drug: Check availability, storing conditions and expiration dates.

2. Essential drugs in stock: Hepatitis B vaccine Vitamin A, 200,000 IU Iron Folate

Only if all three drugs are available mark “Yes”

If “no”, please comment

3. Record family planning methods available: 1._______ 2._______ 3._______ 4._______ => Record “Yes” if at least 3 family planning methods available

Supervision

4. At least 1 supervision visit by PHD/OD supervisor conducted to HC in the past month

Outreach

5. At least one outreach visit per village/ per month is conducted by the Health Center midwife in the catchment’s area

Service provision

6. Record postnatal contacts for postpartum women within last months: Number of postpartum women visited in the first 3 days after delivery:___(A) Number of delivery___________(B) (A)÷(B)x100%=________(C) => 80% postpartum women visited by the 3rd day of delivery


NO. RECOMMENDED STANDARD YES, NO OR

N/A

COMMENT

7. Record postnatal contacts for newborns within last months: Number of newborns visited in the first 3 days after delivery:___(A) Number of live births:___________(B) (A)÷(B)x100%=________(C) => 80% newborns visited by the 3rd day of delivery

Record Maintenance: Check availability and accuracy of the PNC logbooks

8. PNC logbooks well maintained and up-to-date

Quality of service provided/ Performance: Observe at least one provider giving care to one postpartum woman and her newborn(s) (or any place one day after childbirth). If there is not patient ask the midwife to describe step-by-step her actions during the postnatal care visit.

9. Use standard questionnaire for mothers/caregivers who just received PNC at health facility [exit poll interview – Appendix 6

Note: Health facility is considered to provide good quality of PNC if at least 80% of standards are being met.

Total number of standards 9 Total standards met Percent achievement %

26

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her

and

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as th

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27

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as th

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Ver

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at th

e m

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and

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s w

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dual

to

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easu

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d pr

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re

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tem

pera

ture

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reas

ts a

nd n

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rus

for

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ness

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uts

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s pr

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to v

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m

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oks

at th

e vu

lva

and

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for

tear

s, s

wel

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n

4.

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mid

wife

per

form

s a

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ph

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28

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teg

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NA

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ME

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for

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r

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es g

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d pl

aces

them

in 0

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chl

orin

e so

lutio

n

Ver

ify th

at th

e m

idw

ife:

• P

uts

on a

noth

er p

air

of g

love

s if

baby

has

not

yet

bee

n ba

thed

• A

sses

ses

baby

’s b

reat

hing

• A

sses

ses

baby

’s m

ovem

ents

• Lo

oks

at p

rese

ntin

g pa

rt fo

r sw

ellin

g or

bru

isin

g

• Lo

oks

at b

aby’

s sk

in to

det

erm

ine

if it’

s ye

llow

• Lo

oks

at th

e ba

by’s

eye

s

• Lo

oks

at th

e um

bilic

us

• Lo

oks

at th

e ab

dom

en fo

r pa

llor

• Lo

oks

for

mal

form

atio

ns (

birt

h de

fect

s)

• F

eels

the

baby

’s m

uscl

e to

ne

• F

eels

the

baby

for

war

mth

. M

easu

res

tem

pera

ture

if b

aby

feel

s co

ld

• W

eigh

s th

e ba

by

• R

emov

es g

love

s an

d pl

aces

them

in 0

.5%

chl

orin

e so

lutio

n

5.

The

mid

wife

per

form

s a

thor

ough

ph

ysic

al e

xam

inat

ion

for

the

baby

.

• W

ashe

s ha

nds

and

drie

s w

ith in

divi

dual

tow

el o

r ai

r dr

ies

Ver

ify th

at th

e m

idw

ife a

sks:

• H

as h

er b

aby

fed

in th

e pr

evio

us h

our?

• Is

she

hav

ing

diffi

culti

es w

ith fe

edin

g?

• Is

the

baby

sat

isfie

d af

ter

feed

ing?

• H

as s

he g

iven

the

baby

any

oth

er fo

ods

or d

rinks

?

• H

ow d

o he

r br

east

s fe

el?

6.

The

mid

wife

doe

s a

thor

ough

as

sess

men

t of b

reas

tfeed

ing.

• D

oes

she

have

any

con

cern

s ab

out f

eedi

ng th

e ba

by?

29

Pilo

tin

g a

n In

teg

rate

d P

ost

par

tum

Car

e P

rog

ram

fo

r M

idw

ives

in C

amb

od

ia

PE

RF

OR

MA

NC

E S

TA

ND

AR

DS

D

EF

INIT

ION

(V

ER

IFIC

AT

ION

CR

ITE

RIA

) Y

/N

NA

C

OM

ME

NT

S

Ver

ify th

at th

e m

idw

ife:

• E

xpla

ins

the

impo

rtan

ce o

f exc

lusi

ve b

reas

tfeed

ing.

• E

ncou

rage

s th

e m

othe

r to

bre

astfe

edin

g on

dem

and

• O

bser

ves

the

baby

bre

astfe

edin

g fo

r co

rrec

t pos

ition

, atta

chm

ent,

and

suck

ling

7.

The

mid

wife

pro

vide

s ap

prop

riate

co

unse

ling

and

guid

ance

abo

ut

brea

stfe

edin

g

• T

each

es th

e m

othe

r ab

out c

orre

ct p

ositi

onin

g an

d at

tach

men

t

Ver

ify th

at th

e m

idw

ife a

dvis

es th

e m

othe

r to

go

to h

ealth

cen

ter

imm

edia

tely

if s

he o

r th

e ba

by h

as:

• B

leed

ing

in m

othe

r in

crea

ses

rath

er th

an d

ecre

ases

afte

r de

liver

y

• S

ever

e ab

dom

inal

pai

n in

mot

her

• S

wol

len

hand

s or

face

in m

othe

r

• C

onvu

lsio

ns in

mot

her

and

baby

• F

ast o

r di

fficu

lt br

eath

ing

in m

othe

r or

bab

y

• F

ever

or

cold

in m

othe

r or

bab

y

• D

iarr

hoea

in b

aby

8.

The

mid

wife

adv

ises

on

dang

er s

igns

fo

r m

othe

r an

d ba

by th

at r

equi

re

imm

edia

te a

ttent

ion

• B

aby

not f

eedi

ng a

t all

or d

iffic

ulty

feed

ing

Ver

ify th

at th

e m

idw

ife a

dvis

es th

e w

oman

to g

o to

hea

lth c

ente

r as

soo

n as

pos

sibl

e if

she

or th

e ba

by h

as:

• F

ever

• A

bdom

inal

pai

n

• F

eels

ill

• B

reas

ts s

wol

len,

red

, ten

der,

or

nipp

les

sore

• U

rine

drib

blin

g or

pai

n on

pas

sing

urin

e

• In

crea

sed

pain

in p

erin

eum

or

drai

ning

pus

• E

xces

sive

tire

dnes

s or

bre

athl

essn

ess

9.

The

mid

wife

adv

ises

on

dang

er s

igns

th

at r

equi

re a

ttent

ion

• F

oul-s

mel

ling

loch

ia

30

Pilo

tin

g a

n In

teg

rate

d P

ost

par

tum

Car

e P

rog

ram

fo

r M

idw

ives

in C

amb

od

ia

PE

RF

OR

MA

NC

E S

TA

ND

AR

DS

D

EF

INIT

ION

(V

ER

IFIC

AT

ION

CR

ITE

RIA

) Y

/N

NA

C

OM

ME

NT

S

• P

us fr

om b

aby’

s ey

es

• P

ustu

les

on b

aby’

s sk

in

• Y

ello

w s

kin

on b

aby

• C

ord

stum

p re

d or

dra

inin

g pu

s

• B

aby

feed

ing

few

er th

an 5

tim

es in

24

hour

s

Ver

ify th

at th

e m

idw

ife a

dvis

es th

e w

oman

:

• H

ave

som

eone

with

her

con

stan

tly fo

r 24

hou

rs a

fter

birt

h

• W

here

do

go if

dan

ger

sign

s ar

e pr

esen

t

• H

ow to

get

to th

e he

alth

faci

lity

• H

ow m

uch

mon

ey s

he s

houl

d pr

epar

e

10.

The

mid

wife

adv

ises

the

wom

an o

n ho

w to

pre

pare

for

an e

mer

genc

y.

• S

he s

houl

d br

ing

her

mat

erna

l rec

ord

with

her

Ver

ify th

at th

e m

idw

ife:

• T

ells

the

wom

an n

ot to

inse

rt a

nyth

ing

into

her

vag

ina

• A

dvis

es h

er to

hav

e en

ough

sle

ep

• A

dvis

es h

er a

bout

was

hing

her

self

and

baby

to p

reve

nt in

fect

ion

11.

The

mid

wife

adv

ises

the

wom

an o

n se

lf ca

re a

nd h

ygie

ne

• A

dvis

es h

er to

avo

id s

exua

l int

erco

urse

unt

il an

y pe

rinea

l wou

nd is

he

aled

Ver

ify th

at th

e m

idw

ife:

• A

dvis

es th

e w

oman

to e

at a

var

iety

of h

ealth

y iro

n ric

h fo

ods

• R

eass

ures

the

wom

an th

at s

he c

an e

at a

ny n

orm

al fo

ods

12.

The

mid

wife

cou

nsel

s th

e w

oman

on

nutr

ition

• A

dvis

es th

e w

oman

aga

inst

food

tabo

os

Ver

ify th

at th

e m

idw

ife:

13.

The

mid

wife

cou

nsel

s on

birt

h sp

acin

g an

d fa

mily

pla

nnin

g •

Exp

lain

s if

the

wom

an h

as s

ex a

nd is

not

exc

lusi

vely

bre

astfe

edin

g,

she

can

beco

me

preg

nant

with

in 4

wee

ks

31

Pilo

tin

g a

n In

teg

rate

d P

ost

par

tum

Car

e P

rog

ram

fo

r M

idw

ives

in C

amb

od

ia

PE

RF

OR

MA

NC

E S

TA

ND

AR

DS

D

EF

INIT

ION

(V

ER

IFIC

AT

ION

CR

ITE

RIA

) Y

/N

NA

C

OM

ME

NT

S

• A

sks

the

wom

an a

bout

pla

ns fo

r ha

ving

mor

e ch

ildre

n an

d ad

vise

s he

r to

wai

t 2-3

yea

rs b

efor

e ha

ving

ano

ther

bab

y •

Adv

ises

the

wom

an a

bout

LA

M

• T

ells

the

wom

an th

at s

he c

an c

hoos

e ot

her

fam

ily p

lann

ing

met

hod,

ei

ther

to u

se a

lone

or

toge

ther

with

LA

M

• P

rovi

des

info

rmat

ion

on m

etho

d ch

oice

s or

mak

es a

rran

gem

ents

for

the

wom

an to

see

a fa

mily

pla

nnin

g co

unse

lor

if sh

e w

ants

to u

se

anot

her

met

hod

• A

dvis

es th

e w

oman

on

safe

r se

x in

clud

ing

the

use

of c

ondo

ms

• V

erify

that

the

mid

wife

:

• E

xpla

ins

to th

e w

oman

the

impo

rtan

ce o

f kee

ping

the

baby

war

m

• E

xpla

ins

that

the

baby

sho

uld

be d

ress

ed in

one

laye

r m

ore

than

ot

her

child

ren

or a

dults

14.

The

mid

wife

cou

nsel

s th

e w

oman

on

ensu

ring

that

the

baby

is w

arm

• E

xpla

ins

that

if th

e ba

by is

sm

all,

the

wom

an s

houl

d pr

ovid

e sk

in-t

o-sk

in c

onta

ct (

kang

aroo

car

e) to

the

new

born

)

Ver

ify th

at th

e m

idw

ife a

dvis

es th

e m

othe

r:

• T

o pu

t not

hing

on

the

cord

. A

void

trad

ition

al p

ract

ices

of p

uttin

g as

h or

was

p ne

st o

n th

e co

rd.

• T

o ke

ep th

e co

rd c

lean

and

dry

15.

The

mid

wife

pro

vide

s co

unse

ling

on

prop

er c

ord

care

• T

o co

ver

the

cord

stu

mp

with

cle

an c

loth

es

• If

the

cord

get

s so

iled

was

h it

with

cle

an w

ater

and

soa

p an

d dr

y w

ith

clea

n cl

oth

Alw

ays

was

h ha

nds

with

cle

an w

ater

and

soa

p be

fore

to

uchi

ng th

e co

rd

32

Pilo

tin

g a

n In

teg

rate

d P

ost

par

tum

Car

e P

rog

ram

fo

r M

idw

ives

in C

amb

od

ia

PE

RF

OR

MA

NC

E S

TA

ND

AR

DS

D

EF

INIT

ION

(V

ER

IFIC

AT

ION

CR

ITE

RIA

) Y

/N

NA

C

OM

ME

NT

S

16.

The

mid

wife

pro

mot

es th

e us

e of

be

dnet

s V

erify

that

the

mid

wife

exp

lain

s th

e im

port

ance

of u

sing

impr

egna

ted

bedn

ets

to p

rote

ct h

erse

lf an

d ba

by fr

om m

osqu

ito b

ites

17.

The

mid

wiv

es a

dvis

es o

n B

irth

Reg

istr

atio

n V

erify

that

the

mid

wife

exp

lain

s th

e im

port

ance

of B

irth

Reg

istr

atio

n fo

r th

e ch

ild:

• E

xpla

ins

that

the

birt

h sh

ould

be

regi

ster

ed a

t the

Com

mun

e C

ounc

il’s

offic

e •

Exp

lain

s th

at th

e bi

rth

regi

stra

tion

in th

e fir

st 3

0 da

ys a

fter

deliv

ery

is

free

of c

harg

e an

d th

at th

at la

te r

egis

trat

ion

is s

ubje

ct to

fee

(4,0

00

Rie

ls)

Ver

ify th

at th

e m

idw

ife:

• G

ives

the

wom

an 4

2 ta

blet

s (1

tabl

et=

60 m

g iro

n an

d 40

0 m

icro

gram

s of

folic

aci

d

18.

The

mid

wife

dis

pens

es ir

on

supp

lem

enta

tion

• A

dvis

es h

er a

bout

how

to ta

ke ir

on fo

late

Ver

ify th

at th

e m

idw

ife:

• G

ives

BC

G a

nd H

epat

itis

B v

acci

ne in

firs

t wee

k of

life

• G

ives

BC

G o

nly

if th

e ba

by is

bet

wee

n 1-

4 w

eeks

of a

ge a

nd is

un-

imm

uniz

ed.

Adv

ises

the

wom

an to

ret

urn

whe

n ba

by 6

wee

ks o

ld fo

r fir

st H

epat

itis

B v

acci

ne

19.

The

mid

wife

imm

uniz

es th

e ba

by

• R

ecor

ds th

e im

mun

izat

ion

in th

e ba

by’s

rec

ord

Ver

ify th

at th

e m

idw

ife:

• A

sks

the

wom

an a

bout

TT

imm

uniz

atio

n

• G

ives

app

ropr

iate

dos

e of

TT

, if d

ue

20.

The

mid

wife

pro

vide

s te

tanu

s to

xoid

im

mun

izat

ion

to th

e w

oman

• G

ives

TT

1 is

imm

uniz

atio

n st

atus

unk

now

n an

d re

cord

s in

the

pink

ca

rd

Ver

ify th

at th

e m

idw

ife:

• E

xpla

ins

the

bene

fits

of V

itam

in A

for

the

mot

her

and

her

baby

21.

The

mid

wife

giv

es v

itam

in A

to th

e w

oman

• G

ives

1 c

apsu

le o

f vita

min

A (

200,

000

IU)

and

asks

her

to s

wal

low

th

e ca

psul

e in

fron

t of t

he m

idw

ife

33

Pilo

tin

g a

n In

teg

rate

d P

ost

par

tum

Car

e P

rog

ram

fo

r M

idw

ives

in C

amb

od

ia

PE

RF

OR

MA

NC

E S

TA

ND

AR

DS

D

EF

INIT

ION

(V

ER

IFIC

AT

ION

CR

ITE

RIA

) Y

/N

NA

C

OM

ME

NT

S

Ver

ify th

at th

e m

idw

ife

22.

The

mid

wife

giv

es m

eben

dazo

le to

the

wom

an

• G

ives

the

wom

an 5

00 m

g m

eben

dazo

le if

she

has

not

had

any

in la

st

6 m

onth

s an

d as

ks h

er to

sw

allo

w th

e ca

psul

e in

fron

t of t

he m

idw

ife

23.

The

mid

wife

doe

s no

t pro

vide

any

un

nece

ssar

y po

stpa

rtum

inte

rven

tions

V

erify

that

the

mid

wife

doe

s no

t: •

Inje

ct c

alci

um

• In

ject

vita

min

s •

Inje

ct a

ntib

iotic

s w

ithou

t hav

ing

iden

tifie

d th

e ne

ed fo

r th

is

Ver

ify th

at th

e m

idw

ife

• R

ecor

ds n

eces

sary

info

rmat

ion

on th

e m

othe

r’s r

ecor

d

• A

dvis

es th

e w

oman

whe

n to

ret

urn

for

the

next

vis

it

24.

The

mid

wife

con

clud

es th

e vi

sit

appr

opria

tely

.

• T

hank

s th

e w

oman

for

the

visi

t.

To

tal n

um

ber

of

stan

dar

ds

24

To

tal s

tan

dar

ds

met

Per

cent

ach

ieve

men

t %


Appendix 5. Short Supervisory Checklist (from PHD/OD to the Health Center) NOTE: TO BE USED AT LEAST EVERY MONTH BY PHD/OD DURING VISITS TO THE HCS. CAN BE COMBINED

WITH THE USE OF POSTPARTUM CARE PERFORMANCE STANDARDS FOR GETTING MORE DETAILS (APPENDIX 4)

Part 1. Delivery and Immediate Postnatal Care

1. Routine activities during delivery (ask the midwife’s to describe actions taken during a normal delivery and check the right answer):

RECOMMENDED ACTION DURING AND IMMEDIATELY DELIVERY

YES NO COMMENTS

Use of sterile equipment/supplies for delivery (i.e. scissors or blade for cord cutting, suture, etc.) – please ask and check the sterilization procedures

Hand-washing practices before the delivery and care of the newborn

Use of partograph (if mentioned, ask to check for correct use)

Thoroughly drying the baby immediately after delivery

Assessing baby’s breathing while drying

Delayed clamping of cord (few minutes after delivery, after the cord stops pulsating)

Placing the baby on mother’s chest immediately after drying (skin-to-skin contact) and covering the baby and the mother with a blanket (thermal control)

Active Management of the Third Stage of Labour:

- give 10 IU Oxytocin IM to the mother after the baby is delivered

Encouraging early initiation of breastfeeding, in the first hour after delivery

Appropriate cord care:

- puts nothing on the cord after legating it with sterile (or clean) strings

- no bandage is put on the cord!

Eye prophylaxis for the newborn (with Tetracycline ointment 1% in the first hours after delivery)

Continuous assessment of the mother and the baby for danger signs and keeping them under close surveillance for few hours after delivery

Weighing the baby and recording the newborn’s weight If some of the above practices are not being done or is done incorrectly, explain what, when and how needs to be done.


2. Equipment, supplies and drug in stock – ask and check availability, storing conditions and expiry date for drugs; ask to see and check the status of equipment

Description Yes No Comments

Parthographs are available

Oxytocin is available

Tetracycline ointment 1% is available

Equipment for newborn resuscitation is available

Equipment for newborn resuscitation is ready for use in delivery room (easily accessible and clean)

Gas for sterilization if available

Battery/source of electricity for the light (for night deliveries) If some of the supplies/drugs are not available or stored inappropriately, find out the causes and develop solutions for addressing those. Discuss those with the health center staff

Part 2. Postnatal Care (before discharge)

3. Routine activities during postpartum/’postnatal period (ask the midwife’s to describe actions taken before discharging the mother and the newborn delivered at the Health Center and check the right answer):

RECOMMENDED ACTIONS BEFORE DISCHARGE YES NO COMMENTS

Assess the mother and the baby for danger signs

Advises the mother on possible danger signs for the mother and the newborn and the need to seek care immediately should those arise

Advises the mother on exclusive breastfeeding (importance, number of feeds – 8 and >)

Advises the mother on hygiene and appropriate cord care (hand-washing, nothing on the cord, clean clothes, bathing of the mother and the baby)

Advises the mother on family planning options

Advises on birth registration (why, where, when and how to do)

Provides to the mother:

- single dose of Vitamin A, 200 000 IU

- 42 tablets of Iron Folate

- Single dose of Mebendazole, 500 mg

- TT vaccine, if necessary.

Ensures the newborn gets:

- Hepatitis B (birth dose) vaccine

- BCG vaccine

Advises on the next postnatal care visit:

- by the end of the 1st week after delivery (preferably in the first 2-3 days), and

- at 6 weeks after delivery


If some of the above practices are not being done or is done incorrectly, explain what, when and how needs to be done.

4. Equipment, supplies and drug in stock – ask and check availability, storing conditions and expiry date for drugs and vaccines; ask to see and check the status of equipment

Description Yes No Comments

Hepatitis B vaccine

BCG vaccine

TT vaccine

Vitamin A, 200,000 IU

Iron Folate

Mebendazole, 500 mg

Family Planning commodities (contraceptives): pills condoms IUD insertion pack injectable contraceptives

If some of the supplies/drugs are not available or stored inappropriately, find out the causes and develop solutions for addressing those. Discuss those with the health center staff.


Appendix 6: Exit Interview with women following a post partum visit at a health facility Note: this form will be used by OD/PHD during quarterly visit to Health Center. NO. QUESTIONS ANSWER

1. Did you have the visit/contact with a midwife after having delivered the baby?

Yes; No; Don’t know

2. When did you have the visit/contact with the midwife after the delivery

In the first 6 hours after delivery In the first 24 hours after delivery On day 2 or 3 after delivery After day 3 but before the end of the first

week after delivery?

3. Did you have your blood pressure taken? Yes; No; Don’t know

4. Did you have your temperature taken? Yes; No; Don’t know

5. Did you receive Vitamin A capsule? Yes; No; Don’t know

6. Did you receive Iron Folate tablets? Yes; No; Don’t know

7. Were you asked/had your health card checked for Tetanus Toxoid injection?


8. Did the M/W ask you if you had problems or questions


9. Did the M/W examine the baby? Yes; No; Don’t know

10. Did the M/W ask you questions about the baby?


11. Did the M/W talk to you about keeping the baby warm


12. Did the M/W discuss breastfeeding with you and give you advice and answer your questions?


13. Did the M/W talk to you about care of the baby’s cord


14. Did the M/W talk to you about general cleanliness for the baby


15. Did the M/W tell you about danger signs for you when you should go to the H/C or hospital for assistance?


16. Did the M/W tell you about danger signs for your baby and when you should go to the H/C or hospital for assistance?


17. Did the M/W tell you where and when to bring your baby for immunizations?


18. Did the M/W tell you why immunization is important?


19. Did the M/W tell you about the birth registration (where and when you need to do it)?


20. Did the M/W tell you why birth registration is important?


21. Did the M/W talk to you about keeping the baby under a bed net (malarious areas)



NO. QUESTIONS ANSWER

22. Did the M/W discuss birth spacing methods with you


23. If Y did she discuss LAM or another modern method

LAM; Other (record) _______________________

24. Did she tell where to go or who to go to obtain this method of birth spacing?

Yes; No

25. Was the M/W pleasant and friendly? Yes; No

26. Did you understand everything she discussed with you?

Yes; No

27. If ‘no’, what you did not understand?

28. Did the M/W refer you? Yes; No

29. Did the M/W refer your baby? Yes; No

30. If yes, where Another clinic or hospital Another midwive A doctor Other (specify) _______________________

31. Was there anything you were not satisfied with (check the box for the services with which the mother was NOT satisfied)?

Services provided? Medicines available? Attitude or way provider treated you? Clinic hours? Waiting time? Other ?

Documents

Piloting an Integrated Postpartum Care Program for ...reprolineplus.org/system/files/resources/cambodia_pncreport.pdf · Piloting an Integrated Postpartum Care Program for Midwives