“ Matri Surakchya Chakki (MSC)” for the prevention of bleeding ( postpartum hemorrhage) at home births

1. “Matri Surakchya Chakki (MSC)” for the prevention of bleeding (postpartum hemorrhage) at home births Family Health Division, Department of Health Services, Ministry of Health and Population Nepal CRS Company Nepal Fertility Care Center Venture Strategies for Health and Development (USA)

2. Focus Areas of Presentation • Maternal Mortality, Post-Partum Hemorrhage (PPH), and Millennium Development Goals • Matri Surakchya Chakki - MSC for Post-Partum Hemorrhage in Nepal • Introduction of Matri Surakchya Chakki through private sector – pilot initiative in Bardiya

3. Focus Areas of Presentation • Maternal Mortality, Post-Partum Hemorrhage (PPH), and Millennium Development Goals

4. Global Maternal Mortality and Post-partum Hemorrhage • Over 500,000 women die of pregnancy related causes every year (WHO, 2001) • Among those, about 128,000 maternal deaths per year are due to post-partum hemorrhage (PPH) • PPH is the most important cause of death in developing countries Once a mother dies, her newborn Is ten times more likely to die 4

5. Causes of Maternal Deaths Worldwide Source: Bixby Program UC Berkeley School of Public Health

6. Maternal Mortality and PPH in Nepal • MMR is 281/100,000 live births, with PPH accounting for nearly half Source: NDHS, 2006; Study of Maternal Diseases and Death 1998

7. Place of Delivery in Nepal • 77% of deliveries in Nepal occur at home Source: Annual Report 2007/08

8. Millennium Development Goal (MDG) Reduce MMR to 231/100,000 live births by the year 2015.

9. Focus Areas of Presentation • Matri Surakchya Chakki - MSC for Post-Partum Hemorrhage in Nepal

10. Community Based Postpartum Hemorrhage in BankeResearch Findings Research findings • Among the 11,658 women reached with Misoprostol over the first 18 months of the program there were only 16 deaths, i.e. fewer than half expected number (33) Research conclusions • Community volunteers given suitable training and supervision, performed adequately, providing PPH prevention counseling and then safely distributing Misoprostol to pregnant women unlikely to be reached by skilled providers. • Neonatal mortality significantly declined as there is suggestive evidence of maternal mortality impact. • Strong partnership resulted in sense of ownership among a wide range of partners, which facilitated more rapid expansion. Source: Findings of household surveys in Banke June 2007 -NFHP

11. Brief Description on MSC Product Description • MSC pack is composed of three tablets of Isovent with 200 mcg of Misoprostol each • Brand name: Matri Surakchya Chakki Pricing • The MRP of each consumer pack is Rs 33 which is set with the objective to provide user with subsidized rate Consumer Pack

12. Focus Areas of Presentation • Introduction of Matri Surakchya Chakki through private sector – pilot initiative in Bardiya

13. Objectives • Primary: Reduce maternal mortality due to PPH in Bardiya district through increased use of Matri Surakchya Chakki for PPH • Secondary: • Launch Matri Surakchya Chakki through Sangini social franchising network for the management of PPH in Bardiya district • Provide Matri Surakchya Chakki to at least 10,000 potential women (out of 16,000 total pregnancies per annum) in Bardiya district

14. Pilot Introduction of Matri Surakchya Chakki • To broaden availability of Matri Surakchya Chakki, CRS will pilot distribution through its Sangini Social Franchising Network • This Network is a network of paramedics that makes available of condoms, oral contraceptives, Sangini (Injectable), ORS , CDK and Emergency Contraceptive Pills through the pharmacies. • Private sector introduction will start in Bardiya through 40 Sangini franchising outlets in the first phase, later it will be extended in Banke, Rupendehi, Nawalparasi and Chitwan

15. Key Strategies for Pilot Initiative in Bardiya • Utilize Sangini social franchising network of pharmacy providers for product distribution and counseling of potential users • Enroll Sangini Didi Chhar Chhimek Program for IEC and monitoring • Conduct routine monitoring, evaluation and follow-up of program activities and outcomes

16. Sangini Social Franchising Network • Tier One: A network of medical shops that stock and sell condoms, oral contraceptives , Clean Delivery Kit (CDK) ,Oral rehydration salt (ORS) and Emergency Contraceptive Pills (ECP). • Tier two: Sangini (women’s friend) centers – franchisee network of paramedical providers that makes available of condoms, oral contraceptives, Sangini (Injectable), ORS,CDK and ECP • Tier Three: Sewa clinics – a franchisee network of qualified female providers to make available of condoms, oral contraceptives, Sangini (Injectable), ORS , CDK , ECP and IUD • Tier Four: PSSN (private doctors) clinics – a franchisee network of qualified doctors to make available clinical family planning services

19. Why Bardiya? • Strong Network of community groups in all 31 VDC • Unique partnership with WWF, National Trust for nature conservation and Park community health • Reach of Sangini Social Franchising outlets in all VDCs

20. Sangini Didi Chhar Chhimek Program • Community based program comprised of women’s groups of Bardiya • Women meet regularly to discuss family planning and reproductive health issues with an Inter Personal Communicator (IPC) • Offers a platform for discussion at the community level

21. Sangini Didi Chhar Chhimek Program • One “Sangini Didi Chhar Chhimek (Neighborhood) Program” has 10-12 group members • Active members of “Sangini Didi Chhar Chhimek (Neighborhood ) Program” will act as “community change agents” for spreading the message on Matri Surakchya Chakki and its use for the prevention of PPH • Each community change agent will conduct at least 35-40 sessions of meeting with the married women of reproductive age (MWRA) at the ward level of all VDC of Bardiya.

22. Client-centered Approach Disseminate message on MSC Client QoC Monitoring Interpersonal Communicator (IPC) Sangini Pharmacy Provider Client Dispense Product Nepal Fertility Care Center Overall QoC Monitoring

23. Framework for Pilot Initiative NFCC-Monitoring/ Supervision NFCC-Monitoring/ Supervision Pregnant Woman Inter Personal Communicator (IPC) Community Groups Sangini Outlets Stock MSC/CDK Sangini Outlets Stock MSC/CDK Sangini Outlets Stock MSC/CDK 8 months Pregnant Purchases MSC/CDK from Sangini Pharmacies YES Uses MSC Uses MSC Uses MSC Uses MSC Uses MSC NO Follow up Monitoring In case of complications, advised to visit health institution QOC monitoring by NFCC IPC- Early post natal home visit IPC collects the Product and reimburses IPC collects the Product and reimburses IPC collects the Product and reimburses IPC collects the Product and reimburses

24. CRS Oversees Overall Project Management and Product Activities Procurement of Misoprostol Re-package Misoprostol under Matri Surakchya Chakki CRS Program management and product promotion Introduce Misoprostol through Sangini Franchising Network

25. NFCC Oversees Training, Monitoring, and Quality Assurance Development of Trainers Guide & Reference Manual NFCC Conduct basic Training to Sangini Service Providers Quality Assurance and Monitoring Evaluation and Feedback

26. InterPersonal Communicators are Central to the Initiative Antenatal counseling to pregnant women and household decision makers Counsel pregnant women or decision makers to buy Misoprostol and CDK IPC Early post natal home visit (within first two days of birth) Monitoring & Supervision

27. The campaign includes • Product distribution and promotion through Sangini service centre • Community change agents to disseminate the message • Interpersonal communicator (IPC) for implementation, supervision & monitoring Promotional Campaign Approach Campaign Objective: Inform & educate potential target group on product usage and its benefit

28. Promotional Campaign Strategy Snapshot Key Audience Role Message Channel Married women Users of product Be safe and secure after giving birth SDNP,IPC, FM radio, Peer counseling, POP Mother-in-law and female family members Prime influencers Safe delivery ensures safe mother, resulting in healthy family SDNP, FM radio Father-in-law & male family members Decision-makers & purchasers SDNP, FM radio, outdoor media, POP

29. IEC Materials to disseminate product message

30. Print Communication Materials Consumer Brochure Flyer Poster

31. Outdoor Promotional Materials Outdoor Boards (Size: 8ft X5ft) Dangler On-Shop Board

32. Training Materials Reference Manualfor Providers Trainer’s Guide

33. Materials for Sangini Providers Flipchart Certificate Notepad

34. Giveaway Items to Create Awareness

35. Monitoring tools

36. Monitoring Checklists of IPC

37. Monitoring Checklists for Service Provider

38. Clients’ Record Book

39. THANK YOU