BackgroundNearly half of births in low-income countries occur without a skilled attendant, and even fewer mothers and babies have postnatal contact with providers who can deliver preventive or curative services that save lives. Community-based maternal and newborn care programs with postnatal home visits have been tested in Bangladesh, Malawi, and Nepal. This paper examines coverage and content of home visits in pilot areas and factors associated with receipt of postnatal visits.MethodsUsing data from cross-sectional surveys of women with live births (Bangladesh 398, Malawi: 900, Nepal: 615), generalized linear models were used to assess the strength of association between three factors - receipt of home visits during pregnancy, birth place, birth notification - and receipt of home visits within three days after birth. Meta-analytic techniques were used to generate pooled relative risks for each factor adjusting for other independent variables, maternal age, and education.FindingsThe proportion of mothers and newborns receiving home visits within three days after birth was 57% in Bangladesh, 11% in Malawi, and 50% in Nepal. Mothers and newborns were more likely to receive a postnatal home visit within three days if the mother received at least one home visit during pregnancy (OR2.18, CI1.46–3.25), the birth occurred outside a facility (OR1.48, CI1.28–1.73), and the mother reported a CHW was notified of the birth (OR2.66, CI1.40–5.08). Checking the cord was the most frequently reported action; most mothers reported at least one action for newborns.ConclusionsReaching mothers and babies with home visits during pregnancy and within three days after birth is achievable using existing community health systems if workers are available; linked to communities; and receive training, supplies, and supervision. In all settings, programs must evaluate what community delivery systems can handle and how to best utilize them to improve postnatal care access.

Peer mobilization is a potential approach for improving health- and nutrition-related knowledge and behaviours among women in hard-to-reach communities of Nepal.

The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal’s 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII’s 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2–5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6–24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2–5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2–5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.

When comparing the sensitivity and specificity of mid-upper arm circumference (MUAC) versus weight-for-height z-scores (WHZ) to identify wasting in children aged 6–59 months in Nepal, our findings suggest that only using MUAC compared to WHZ to screen may exclude a large number of children who could be at risk of severe or moderate acute malnutrition.

Objectives Despite being implemented for decades, Nepal's Integrated Management of Acute Malnutrition program has experienced several implementation challenges such as low coverage, stock outs of ready-to-use therapeutic food supplies, poor reporting, loss to follow up and sub-optimal counselling. To address these and build a culture of continuous service delivery improvement, the Suaahara-II program adopted and assessed a quality improvement (QI) approach. Methods Change ideas, including increasing case identification through various platforms, developing QA standards to measure service quality, and providing incentives for female community health volunteers, were implemented as part of the QI initiative in four pilot municipalities. To assess changes in outcomes such as cure rate and number of cases identified and lost to follow-up, baseline information was collected over six months pre-implementation and performance was monitored throughout the QI implementation cycle of 17 months (February 2019—June 2021). We also analyzed secondary data from the government health management information system and established a monitoring mechanism to ensure data quality for outcome measures. For the outcome measure of service quality score, we developed a quality assurance (QA) checklist to score services while treating children with severe acute malnutrition (SAM). Results Our findings suggest that the QI effort was effective. The SAM cure rate increased from 67.4% pre-implementation to 80% post-implementation and the loss-to-follow-up rate declined from 26% to 8%. The number of new SAM cases fluctuated between 0–20 cases per month likely due to restrictions to mobility caused by the COVID-19 pandemic. Although there is no comparison to facilities that did not participate in the QI pilot, those that did had an average quality assurance score of 82.4%–above the 80% benchmark. Conclusions We found that the QI approach helped improve SAM cure rate, limited loss-to-follow-up and improved quality of case management for children with SAM. To successfully and sustainably implement QI to improve service delivery, leadership and local government accountability, regular coaching support and collaborative team efforts are key. Funding Sources United States Agency for International Development (USAID).