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In 1998,
Anemia was a severe public health concern
Women suffering from Anaemia
80 60 40 20 0 Pregnant women
percent (%)
75
67
Non-pregnant women
Three out four pregnant women were anaemic Worm infection extremely high-Hookworm infection as high as 80% in some areas Only 23% were taking any IFA tablets
Source: NMSS-1998 and NDHS-2001
> 90 days 3%
60-89 days 6%
( NDHS 2001)
Government policy on Pregnancy Iron Supplementation is to provide one iron/folic acid tablet daily from second trimester till 45 days after delivery
Main Problems
Lack of awareness about need for iron supplementation during pregnancy and lactation Iron tablets not accessible to most women
Based on effectiveness of the intensified model, the program expanded to other districts gradually in later years
2. 3. 4. 5.
Increase coverage and compliance of iron supplementation during antenatal and postpartum period Increase coverage of deworming among pregnant women Increase use of antenatal health services at the local health facilities Increase coverage of high dose Vitamin A capsule supplementation during the postpartum period Promote dietary diversification for increasing consumption of micronutrient rich foods including adequately iodized salt among pregnant and postpartum women
FCHV
9
3 4 2
Mothers group
Settlement
Nepal
75 districts
Each ward has 80-100 households and there is a Female Community Health Volunteer (FCHV) who provides maternal and child care services in the community. In each ward there is also a mother group coordinated by FCHV for community mobilization
12
13
Mobilization of FCHVs
After receiving training, FCHVs conducting a mothers group meeting to inform the community about the importance of iron supplementation and related interventions
Key messages for the Community: Eight of ten pregnant women suffer from lack of blood
Low intake Iron Inadequate blood. Deprives of oxygen and nutrients to mother and fetus Maternal complication and poor mental development of the baby
14
Intensive Monitoring
Pregnant Women are registered by FCHVs in the Micronutrient Register Each pregnant woman received 30 tablets iron
Each pregnant woman was provided a compliance card to filled by someone in the family
15
16
Program Scale Up Milestones: Program implemented in 74 districts out of total 75 by May 2012
2003: First phase program introduction in 5 districts 2004: Expansion to 3 districts 2005: Expansion to 12 districts 2006: Expansion to 12 districts 2007: Expansion to 11 districts 2008: Expansion to 9 districts 2009: Expansion to 10 districts 2010: Expansion to 6 districts 2011: Expansion to 2 districts 2012: Expansion to 4 districts
Intensification of IFA
Kathmandu
RASUWA
Tibet / China
India
JHAPA
Modality of Scale Up
Conduction of one-time initial training at district and community level for all health workers and FCHVs with funding support from external development partners
MI (64 districts), UNICEF (8 districts), WHO (1 district), and Plan (1 district)
Procurement of entire quantity of IFA tablets by government Recording and reporting of IFA among pregnant and postpartum women through routine Health Management Information System (HMIS) Monitoring under routine integrated monitoring supervision system of health facilities
52
50
55
40
Percent
30
20
10
2
0
DHS-2001
DHS-2006
DHS-2011
75
42
48
Challenges
Identifying hard to reach groups and increasing coverage and compliance of IFA among them Identifying pregnant women at an early stage so that they could start taking IFA tablets from commencement of second trimester to improve compliance Increasing coverage and compliance of IFA among postpartum women Prevalence of Anemia slightly increased in 2011 compared to 2006 (Nepal Demographic and Health Surveys) Maintain and sustain IFA distribution and deworming
Conclusions
The reduction has been possible due integrated approach including: - Community based distribution of iron supplements - Constant monitoring of pregnant women - Community based awareness creation activities - Improved logistic supply (including packaging) - Promotion of complementary measures such as deworming to pregnant women after 2nd trimester Nearly covered all 75 districts as aimed by Government Government ownership of total IFA procurement and supply through well established existing logistic management system
Next Steps
Refresher training to health workers and FCHVs for enhancing skills and sustaining motivation Strengthening recording/reporting of IFA supplementation under HMIS, supply chain management and monitoring/supervision Study on etiology of anemia among pregnant women and other target groups in Nepal
Acknowledgements
Female Community Health Volunteers in Nepal- the key factor to the success !!
Government of Nepal received support from MI, UNICEF (USAID & CIDA), WHO and Plan