roving auxiliary nurse midwives (ranms): addressing family...
TRANSCRIPT
Roving Auxiliary Nurse Midwives (RANMs): Addressing Family Planning Concerns Through Home-based Services in Nepal
OUTLINE OF PRESENTATION
1. Background – Why RANMs?
2. The RANM Model & Package of Services
3. Implementation Elements for success
4. Results – Who received what services?
5. Results – Change in access and behavior
6. Lessons learned and future implications
BACKGROUND
Need for Family Planning in Nepal▪ 27% of married women have an unmet need for family planning
▪ Unmet need is highest among women age 15-19 at 42%
▪ Modern contraceptive prevalence rate has stagnated (43%)
(Nepal DHS 2011)
of women received postnatal care for
their last birth within the critical first 2 days
following delivery
45% 35%of births occur in a health facility
Why Roving Auxiliary Nurse Midwives?
• Need to deliver services to marginalized populations or the
“Hard-to-reach”, especially those who have social barriers
to accessing services in Nepal
• Community-based providers can enhance community level
health care to improve access and quality.
RANM INTERVENTION SERVICE DELIVERY APPROACH
AND PACKAGE OF SERVICES
The RANM Model
RANM Package of ServicesEngaging spouses and extended family, particularly around antenatal, postnatal & newborn care, and FP discussions
Expanded package of
individual-level integrated
services and referrals for:
• Family planning
• Antenatal Care
• Postnatal & newborn care
• Nutrition Counseling
• First Aid / Illness consultation
Engaging husbands through picture cards
When engaging husbands in discussions around MNCH with their
wives, RANMs used picture cards to enhance couples counseling and
engage family members in reflections on existing social norms to
encourage the adoption of supportive health behaviors
WHAT DID WE ACHIEVE? RANM INDIVIDUAL & GROUP ACTIVITIES
618777 735
999774
155
290 480
735
499446
10461070
1172
856
175
111
Q2 (Jan-March 2017) Q3 (April-June 2017) Q4 (July-Sept 2017) Q5 (Oct-Dec 2017) Q6 (Jan-March 2018)
Number of counseling visits, by person-contact type
Individual Married Couple In-Laws Others
Total: 11,053 counseling visits made by RANMs
1251
21552326
3081
2240
RANMs provided counseling to individuals (often repeated visits to the same woman) and sometimes
included the spouse or in-laws, when appropriate.
*Tools an RANM services were expanded in June 2017, hence data for ANC, PNC, MNCH, and U5 child health services is only presented here from July 2017 – mid-March **The data in this chart do not reflect total clients, as one client could receive more than one service or counseling discussion during a visit.
RANM Individual Client Visits:
Types of visits, counseling and services provided
• In total, 18% of RANM individual visits were clients for new problem visits, and 82% of
visits were follow-up visits*
• RANM’s provided both clinical services and counseling to individual clients, as detailed
below.
• RANM’s also referred 2,559 clients to health facilities for a variety of services (including FP, MNCH, ANC, delivery, PNC, Child Health, and First Aid)
1079431 216 444793 390
5796
2078
6551358
49
First Aid ANC PNC and
Newborn Care
Family Planning Fertility
Awareness
MNCH U5 Child Health Other types of
health topics
Services Client Counseling
Service-only Service & Counseling Counseling-only
“I really enjoy working as an RANM. My self confidence has also increased because I move from home to home and teach them well….Doing this has given importance to my life.” RANM
ENDLINE EVALUATION FINDINGS
Study Design & Sampling Goal: Assess the acceptability and reach of RANMs in Rupandehi, Nepal
Study Participants: Men and women between ages 15-25 years old
Study Methods & Sampling:
• Focus groups and in-depth interviews
• Quantitative household survey
• Representative sample of 212 women & 131 men from Rupandehi at
Endline
Note: RANM clusters were a subset of the area in which the data was
collected. Some women may not have had exposure to RANMs.
9
Reasons for
RANM Visits
9%5%
37%
83%
9%15%
0%
55%
40%
5%
ANC PNC/Newborn
Care
Fertility
Education
Family Planning Immunization
Women (n=66) Men (n=20)
“She teaches us to take good care of the baby, to bathe the baby, to use soap….I feel nice when she comes to visit me.” - Client
RANMs & Spousal Engagement
• Over one-third of participants
discussed FP with the RANM and
their spouse
• Among those that discussed FP, FP
methods were the most frequent
topic.
• Over ¾ of women reported they
were very comfortable discussing
FP with their husband & the RANM
68%16%
19%
FP MethodsChild-spacingSide Effects
Current FP Use
FP use increased from 19% at baseline to 27% at endlineamong women residing in RANM-communities
0% 0%
22%
11%
56% 56%
0%3%7%
30%
7%
20%27%
10%
Female
Sterilization
IUD Injectable Implant OC Pill Condom MalaChakra
Baseline (n=9) Endline (n=30)
FP Use & Intention to Use
When compared with women in non-RANM communities in
Rupandehi, women in the RANM sites were:
• 2.4 times [CI: 1.2-4.8] more likely to be currently using FP
• 3.4 times [CI: 1.6-7.0] more likely to intend to use an FP method
in 3 months
• 2.0 times [CI: 1.0-3.7] more likely to intend to use an FP method
in 6 months
*Controlling for pregnancy intention, spousal migration, ethnicity,
literacy, and age; p<0.05.
LESSONS LEARNED
Lessons Learned• Expanding services & role of RANMs provides more comfortable
entry points to addressing FP concerns and providing FP services
• In-home trust and appreciation of RANMs makes it easier to
influence social norms around FP methods and their use
• Caseload management and prioritization of client needs is an
important part of managing workload
• Urban strategy adjustments are needed as the behaviors and
context of HTR groups in urban areas require different
approaches
RANM RESOURCES
Result BriefImplementation Manual
RANM FILM
youtube.com/user/IRHgeorgetown
THANK YOU! irh.org/roving-auxiliary-nurse-midwives