Strengthening the capacity of communities to increase utilization of postnatal care services in Nyaruguru district, Rwanda

In Rwanda, the postnatal period is a time when newborns are most vulnerable to illness and death, and PNC visits represent an opportunity for providers to facilitate healthy breastfeeding practices, screen for postpartum depression, monitor the newborn's growth and overall health status, treat childbirth-related complications, counsel women about their family planning options, and refer the mother and baby for specialized care if necessary. Rwanda has achieved a 76% reduction in maternal mortality since 1990, but there has been a smaller decrease in neonatal mortality, with a rate of 20 per 1,000 live births in 2014-2015. While the proportion of women who received a postnatal checkup has increased significantly since 2010, in 2015 only 45% of women received a postnatal checkup. The Rwandan Ministry of Health's Community Health Strategic Plan aims to increase the percentage of newborns receiving at least one postnatal visit within the first two days of birth from an average of 18% to an average of 70% by 2018. To address this challenge, the Maternal and Child Survival Program (MCSP) worked with the Rwandan Ministry of Health and the Rwanda Biomedical Centre to accelerate the reduction of preventable child, neonatal, and maternal mortality in 10 districts in Rwanda from April 2015 to September 2018. MCSP emphasized integration of newborn care with maternal care while strengthening health services through the household-to-hospital continuum of care. The program focused on facility births and pre-discharge PNC followed by PNC provided by community health workers, known as animatrice de santé maternelles (ASM). MCSP's efforts to strengthen PNC in Rwanda included a range of interventions, including review and development of clinical policy, protocol, and frameworks, as well as simple provider tools and job aids to be used nationally. In the 10 RMNCH districts, MCSP trained 455 health facility service providers on how to deliver an integrated package of high-impact PNC interventions for mothers and newborns and how to provide supportive supervision and mentoring to ASMs. At the community level in the 10 districts, 3,873 ASMs were trained on community-based maternal and newborn health care, communication, and how to use job aids and reporting tools. The Community Mobilization Framework, developed by MCSP in collaboration with the Rwanda Health Communication Center (RHCC) Division of RBC, is a national framework for mobilizing communities for social and behavior change. The framework is guided by a number of objectives aimed at creating demand for, and improving access to, equitable health services, in alignment with two objectives of the national Community Health Strategic Plan. MCSP supported the implementation of this framework specifically through implementation of the Community Action Cycle (CAC) approach in Nyaruguru district. The CAC approach is a proven community mobilization approach that fosters individual and collective action to address key health program goals and improve health outcomes. In Rwanda, the CAC process, as described in the Community Mobilization Framework, was used to reinforce the capacity of communities to resolve their own health-related challenges, particularly around use of quality health services and healthy behaviors at the household and community levels. The CAC process is comprised of seven phases: Prepare to Mobilize, Organize Communities for Action, Explore and Set Priorities, Plan Together, Act Together, Evaluate Together, and Prepare to Scale-up.