Reducing iron deficiency and anaemia in women of reproductive age, Thyolo District, Malawi : Sept. 1995 to August 1998 [-- final report]

The project, a joint effort of Project HOPE, the London School of Hygiene and Tropical Medicine, and MotherCare, worked predominantly on two tea and coffee estate companies and the surrounding areas in Thyolo district, comprising a total target population of about 106,000. Initial activities included: (1) research, including a baseline study, qualitative formative research, a productivity study, and a final survey; (2) the training of health care providers, traditional birth attendants (TBAs), and the local drama group; and (3) the development and pre-testing of research-based IEC materials such as posters, counseling charts, reminders-to-take posters, and pill bags. The primary research-based intervention was the distribution of iron folic acid (IFA) tablets to the two hospitals in the district, all health centers, and all TBAs within the impact area. The tablets were supplied to all pregnant women who attended prenatal clinics and all women who recently delivered at government, Christian Hospital Association of Malawi (CHAM), and private estate health facilities and at TBAs within the impact area. The number of IFA tablets distributed significantly increased over the intervention period both during pregnancy and after delivery. IEC interventions involved drama performances on anemia themes, as well as health education talks by health providers at the health clinic, by health surveillance assistants (HSAs) in the community, and by TBAs at their clinic. The health care providers and TBAs were supervised quarterly by the Project HOPE coordinator, accompanied at times by the District Health office TBA coordinator. The project significantly influenced one of the two estate companies, the Central African Company, to start prenatal clinic services for pregnant women living on the estates. It also increased the TBAs" awareness of the anemia problem, the importance of treatment, identification of side effects, and ways to manage side effects. Finally, hemoglobin levels significantly increased in recently delivered women, while the prevalence of anemia decreased in both pregnant and recently delivered women. Lessons were learned regarding both program strategy and program management and implementation. Lessons on strategy included the following: (1) Formative research does determine a package of maximally effective interventions, but these prove to be expensive, especially the research is conducted by external rather than local consultants. (2) Involving TBAs in iron distribution is an effective strategy for improving access to iron at community level. (3) Multiple IEC methodologies improve program effectiveness and the profile for anemia. (4) The use of existing community dissemination structures promotes project success. (5) Including men as a target for IEC might have a positive impact on the program. (6) Separating maternal anemia from other types of anemia and using a comprehensive approach to maternal anemia reduction increases impact. (7) Collaboration between Project HOPE and the tea estates has led to significant changes in health services on the estates and serves as a good model for public/private sector collaboration. Lessons regarding project management and implementation are as follows: (1) Failure to plan for sustainability or incorporate lessons learned endangers the potential improvement and continuity of the services. (2) Although the program worked within existing policies, some providers were still unaware of some policies. (3) Iron procurement needed a contingency plan due to the dependence of project results on consistent iron supply. (4) Limited staffing for a program creates dependency on single individuals and problems in fulfillment of program activities.