Final evaluation of the breastfeeding and maternal and neonatal health sub-project

The project has been implemented by John Snow, Inc. MotherCare's first phase has been marked by significant achievements in project design, health research, health policy, and dissemination of health care information. In part, this success can be attributed to a highly skilled and committed project staff; well-planned, high-quality activities; and effective collaboration with central, bilateral, and regional projects, ministries of health, NGOs/PVOs, professional associations, universities, other donors and organizations, and the private sector. In general, the project has enhanced A.I.D.'s reputation as a global leader in maternal and neonatal health care. The project's state-of-the-art methods for project design and implementation have included (1) an integrated, 4-component demonstration and research approach that has addressed issues of improved service delivery and facilities, IEC, and health policy; (2) development of a typology for classifying geographic areas by availability of health services; (3) use of health planning tools and indicators, including situational analysis (a key to the success of MotherCare's complex demonstration projects), community auto-diagnosis, maternal and perinatal deaths case reviews, verbal autopsy, and an assessment of the maternal care system; (4) activities addressing the needs of expectant mothers from the home, to the medical center, to the hospital; (5) sustainable, community-based, development activities in isolated conditions with limited resources; (6) a comprehensive approach to training traditional birth attendants; (7) capacity building activities for local universities and research agencies; and (8) promotion of local ownership through involvement of key stakeholders in project planning, design, and implementation. Major research activities have included: (1) the Kangaroo Mother Method study in Ecuador, which proved that babies that remained longer in hospitals became less seriously ill and were less likely to return to the hospital after being discharged; (2) community-based distribution of iron-folate tablets in Indramayu, Indonesia, which increased the treatment's acceptance; (3) a study in Probolinggo, Indonesia, which proved that slow-release iron capsules can raise hemoglobin levels in anemic pregnant women; and (4) an IEC enhanced syphilis treatment campaign in Nairobi, Kenya, which raised the treatment level of seropositive women from 9% to 85%, and to 52% in their partners. The project's long-term demonstration projects have lain midway on the continuum between advocacy and policy formulation, the most advanced of these being the Uganda Life-Saving Skills activity, which has led the Ministry of Health to allocate funds for upgrading midwives' skills, using a MotherCare training model. Indonesia, Guatemala, Bolivia, and Bangladesh also plan to adopt MotherCare training models. Finally, MotherCare core and field staff have written extensively; publications include a working paper series, journal articles, a newsletter, training manuals, guides, and conference proceedings. Where the project's performance has been less successful than expected, blame could be placed on limitations in staff size, financial resources, interest by host countries and A.I.D. Missions, and time. In some instances, other A.I.D. centrally funded projects were already addressing maternal and neonatal care. It is recommended that during Phase II, the project: "scale up" (e.g., geographically or in terms of target populations) successful Phase I activities; focus on maternal nutrition and neonatal health and nutrition; emphasize research on barriers to health care, including transportation, costs, and relationships with health care providers; and maintain its integrated, 4-component approach. The following were among the lessons learned. (1) Development of a warm respectful environment in birth centers can be achieved by sensitizing health care providers to the needs and concerns of center users. This, in turn, can increase center use. For example, in a health clinic in Cochabamba, Bolivia, women were provided with a private room to discuss family planning; as a result, the local contraceptive prevalence rates were raised. (2) While the project has used various approaches to health service delivery based on local needs, its basic tenets have remained the same and are appropriate for maternity care around the world. (3) Because few women in the Third World use child delivery facilities, interventions should focus on educating women about labor and delivery danger signs and how to seek appropriate medical treatment. (4) Good referral systems include not only treatment protocols but also community workers who can assess danger signs, clearly established lines of referral for each danger sign, 2-way radios that can speed referral between health centers and hospitals, and reliable, emergency transportation. (5) Medical worker supervision and follow-up are paramount. (6) It is important to balance market and with epidemiological research to ensure a comprehensive picture of a community's needs. (7) The project's Technical Advisory Group (TAG) meetings, attended by principal investigators and counterparts from field projects, can be useful model for other centrally funded projects. The project also taught lessons regarding administration and contracting: communication between A.I.D. and the contractor is critical; the number of contractually required documents should be carefully reviewed and all reporting simplified; there are no financial savings in an administratively understaffed report; while buy-ins have facilitated some of MotherCare's work, they are in general cumbersome.