Cómo Será, Pues: The NGO Contribution to Neonatal Health in Bolivia

"...more than 44 percent of births in Bolivia still occur at home. The figure is far higher in rural areas and poor urban neighborhoods....Many women are unable to access skilled delivery services or postnatal care due to transportation costs, geographic isolation, and significant health system limitations. Though some have heard the basic newborn messages in radio spots, health fairs, or community meetings and can even recite them by heart, they continue to use a piece of ceramic to cut the umbilical cord. They bathe their babies immediately, delay initial breastfeeding, and ignore other critical recommendations. Why?"

This 26-page field story examines the development and implementation of low-cost, community-based mobilisation and surveillance strategies to improve newborn care in Bolivia (2003-2005). These communication-centred strategies were motivated by the context highlighted above, as well as by the observation that poor client-provider relations are a key cause of low service utilisation in rural Bolivia. The idea is that, by treating patients with respect, communicating with them in their own language (through a nurse interpreter if necessary), and informing them clearly about their illness and treatment, health providers can facilitate dialogue toward better care and reduced neonatal mortality.

Specifically, 4 non-governmental organisations (NGOs) worked together under the Saving Newborn Lives (SNL) initiative to introduce an essential newborn care (ENC) package in Bolivia's at-risk communities, which covers care during pregnancy, care during childbirth, immediate care for the infant, and continued and routine visits with a trained health care provider. Project partners included the Ministry of Health and a national NGO network known as the Integrated Health Coordination Program (PROCOSI). As part of this consortium, the 4 NGOs (the Research, Education and Services Center (CIES) and CARE, Project Concern International (PCI), Center for Rural Livestock Promotion (CEPAC), and Save the Children/USA) started a dialogue between rural and economically poor communities and the health care facilities serving them through a methodology called Calidad y Calidez, adapted from Save the Children's partnership-defined quality model. A key component of this methodology is a 3-day workshop which brings community members and health service personnel together in an effort to break down communication barriers (such as those that led one indigenous woman quoted here to comment, "The doctors don't speak our language, they don't respect our customs, and they don't explain anything"), setting a foundation for core programme activities. NGOs developed different methodologies to identify pregnant women and newborns, to engage the community in acknowledging reasons why mothers and babies get sick or die, and to prepare action plans involving community health workers and municipal authorities. Examples include:

• Training community health workers and untrained traditional birth attendants (parteras) - A key strategy here involved fostering women's participation in training activities: NGOs applied the ORPA methodology (includes observation, group discussion, learning from experience, negotiation and commitment to change) with community health volunteers, and included women as community peer trainers.
• Educating women's groups, men's groups, and local and district officials about neonatal health - strategies included use of health centre personnel to lead educational groups and work with pregnant women and new mothers, which "helped build confidence in the health system and will allow for greater potential sustainability." A complementary behaviour change communication strategy included educational vehicles such as public fairs and dramas to promote basic ENC messages.
• Developing community surveillance and data gathering systems - community mapping was used to identify families at high risk of a neonatal death. Another instrument, called "Verbal Autopsy", enables community volunteers to identify probable cause of death,
  particularly in home deliveries, in order to develop solutions to prevent future neonatal deaths. Participatory approaches feature prominently in these and other activities; for example, PCI worked to organise community health surveillance committees
  called Comités de Análisis de Información which are meant to be participatory meetings in which community members and health workers analyse local health problems and identify plans of action.
• Developing community support plans - facilitators drew a map of the community, and participants identified local resources such as telephones, transportation, babysitters, and financial resources. One instrument for birth preparedness helped families to identify local transport facilities, purchase or make appropriate clothing for infants, and prepare materials for home deliveries.

These strategies were found to be exceptionally effective. For instance, in the areas served by SNL Bolivia and its partners, the number of mothers whose birth was attended by a trained provider (nurse, nurse midwife or doctor) increased 34% over the 2-year period of the project. The number of mothers who breastfed their infant within one hour of birth increased by 23%. The number of mothers whose infants received newborn care within one week after delivery increased by 30%. Nearly 70% more mothers now know at least two newborn danger signs.

Lessons learned include:

• "An integrated strategy, taking into account the health of women during pregnancy, delivery, and postpartum, creates a coherent way to speak to communities about danger signs, prevention, and the importance of trained health care, and to introduce
  the mother-newborn continuum of care concept.
• Collaboration with communal or grassroots organizations, pre-existing social structures, and people in indigenously accepted roles can be more effective and more sustainable than creating such new roles and entities such as the 'volunteer health worker.'...
• In cases where there are wide cultural gaps between health providers and the communities being served, the partnership-defined quality (PDQ) methodology can uncover misperceptions and miscommunications that pose a threat to newborn health programs. The resulting dialogue can lay a strong foundation for introducing new services that span the home-community-facility continuum.
• Communication and mobilization strategies were key to marshaling support for an ENC package in the community. Time spent negotiating consensus among community members on what constitutes 'best practices' for newborns was a vital determinant of program impact."