MaNHEP used a three pronged intervention strategy to achieve its objectives. Ultimately to influence both the supply of and demand for CMNH care. This strategy was comprised of a CMNH training program, a collaborative quality improvement initiative, and behavior change communications. These prongs were designed to be mutually reinforcing. Let's take a look at the main elements of each of the prongs. First, the CMNH training program, aimed at achieving objectives one and two. This training program worked with Florida health officials and community stakeholders to teach the CMNH care package. The training program was adapted from the American College of Nurse-Midwives' Home Based Life Saving Skills program. It had two components. In a facility-based component, the health extension workers were given refresher clinical training in safe, clean birth and postnatal at a healthcare facility with a high volume of births. This was done to develop their competence and confidence in providing CMNH care. In a community based component, health extension workers and the other frontline health workers shared their knowledge and expertise in week long training sessions, acquiring new knowledge and skills to provide better CMNH care. All were volunteers selected by their communities. The newly trained frontline health workers worked in pairs called guide teams to then transfer their CNMH knowledge and skills to women in their second and third trimester of pregnancy along with those family caregivers who would be present at the woman's birth. These caregivers included mothers-in-laws, husbands and other relatives, as well as birth attendants. The health extension workers supervised the guide teams. The training of the pregnant women and family caregivers took place during a series of four CMNH family meetings. The guide teams facilitated the CMNH family meetings using a unique stepwise process adapted for adult learning. This process encouraged full participation through experience sharing, discussion, demonstration, negotiation, roleplay, and practice. The idea was to create a space for real dialogue between the guide teams and participants and skills building so that the women and their caregivers could actually use what they learned when needed. In the first of the four CNMH family meetings, each of which lasts about two hours, the participants were introduced to a two part story told using pictures. The story, called Road to Death & Road to Life is about two women who develop bleeding during late pregnancy. It contrasts the responses and decisions of each of the women and their families to a continuum of events. In the end, one of the women dies and the other survives. Participants then discussed the story and drew lessons from it. In the second CMNH meeting, the guide teams and participants discussed the kinds of life threatening problems that mothers and babies may encounter. The participants shared their own experiences with these problems, for example postpartum bleeding or a baby who has trouble breathing at birth. In subsequent meetings the guide team used the participatory learning process to identify ways to address one of the problems. For example, in this process the participants first shared what they know or heard to do for the particular problem. Next, the guide team shared what a trained health worker does for the problem. Then together they compare what has been shared so far about solutions to the problem, and they then negotiate towards safer practices. Finally, the participants practice the skills needed to prevent the problem or overcome, or improve the outcome. The CMNH family meetings and materials were tailored to persons who may not be literate. The materials incorporated local knowledge and cultural practices and were available in [INAUDIBLE] the dominant language in the projects two region. These materials included a trainer's manual and record book, a demonstration kit with props such as the ones you see here, and a take action card booklet, which contains pictorial skills checklist. In the CMNH family meetings guide teams used the kit and take action cards to roll play action steps for birth preparation and complication readiness, clean birth and immediate care of the mother and baby, prevention of postpartum hemorrhage, newborn resuscitation, and safe transport of women and baby to a health facility. The take action cards were given to women and their family caregivers during the meetings where they practiced until they were able to demonstrate that they had mastered the action steps. The women then took the take action cards home for reference during their own birth. Here is an example of the take action card for too much bleeding after birth. On the front side of the card is a picture of the problem. Bleeding. On the other side of the card, the steps to slow or stop the bleeding are shown pictorially. Beginning in the upper left corner, the steps are call for help, pass urine, use nipple stimulation, rub the womb, use a pressure bandage, drink plenty of fluids, and go to a trained health worker at a health facility. This is not rocket science, it's basic, basic care. Here we see a CMNH family meeting demonstration and role play about immediate care of the newborn baby. It is both instructive and a lot of fun. The guide teams and participants jointly decided when and where the CMNH family meetings would take place. In the beginning, the guide teams conducted meetings at the pregnant woman's home. In which case, her caregivers, for example, her mother-in-law, another relative, or even her husband were present. Later in the program, the health extension workers and guide teams conducted the CMNH family meetings with groups of pregnant women at the health post on antenatal care days. This approach was more efficient but it meant that the husbands were not always able to participate.
