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