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The Manoshi Project 2014 INNOVATIVE METHODS INNOVATIVE The Manoshi Project Bringing quality maternity care to poor women in urban Bangladesh The Manoshi project was implemented in 2007 to bring skilled care into the informal settlements of six major cities in Bangladesh, with a particular focus on women and children.1,2 The objective of the project, developed by BRAC, is to: Decrease illnesses and death in mothers, newborns, and children in urban slums in Bangladesh through the development and delivery of an integrated, community- based package of “essential health services”.3 AUTHORS PETRA TEN HOOPe-Bender, ICS Integrare ANNIE KEARNS, Women and Health Initiative & Maternal Health Task Force JACQUELYN CAGLIA, Women and Health Initiative & Maternal Health Task Force ANA LANGER, Women and Health Initiative & Maternal Health Task Force oveRVIEW OF BANGLADESH care compared with 74% of pregnant women in other urban areas.1 Newborn and child health care coverage is also low; Bangladesh is a country of 151 million people of which almost a immunisation coverage is just 63%, much lower than national third live below the poverty line. Nearly a quarter live in urban and urban averages of 73%. Basic hygiene can be difficult, with 4 areas and a third of the urban population lives in slums. Urban less than five percent of slum dwellers accessing water-sealed areas are growing fast, mainly due to the influx of poor rural latrines. In short, people living in urban informal settlements families. With infrastructure and public services unable to keep face much greater challenges to improving their health than up with growth, urban poverty is worsening and inequality in people from other parts of the country.1 urban areas such as Dhaka is higher than the national average. Several key socioeconomic and demographic indicators are BRAC summarised in Table 1. BRAC was founded in 1972 with the goal of both alleviating Table 1: Socioeconomic and poverty and empowering the poor. It is one of the largest non- demographic indicators governmental organisations in the world, employing over 100,000 people, and has led the charge in promoting sustain- able human development in Bangladesh and around the world. IndicatoR DHAKA BANGLADESH BRAC’s programmes in education, economic development, and health touch around 100 million people in Bangladesh and 5,6 1 Population (millions) 15.39 150.49 many more in other low income countries. 7 Urban population (%) n/a 29.4 The Manoshi Project Poverty, below national Adapting the BRAC Essential Health Care (EHC) programme, 30.5 31.5 poverty line (%)8 which offers a package of basic health services through community health workers (CHWs), the Manoshi project Human Development focuses primarily on empowering communities, particularly 9 – 0.515 Index (HDI) women, in order to develop a system for the delivery of an essential package of interventions for mothers and babies Gini coefficient9 40.6 32.1 throughout the continuum of care. Access to improved Manoshi works to provide services to eight million people – 83 drinking water (%)5 living in urban informal settlements and help improve uptake of health services among mothers, neonates and under- five children. Manoshi was originally developed at the Health in Bangladesh community level, close to women and families, in order to Although Bangladesh has witnessed remarkable progress in utilise effective community action and solution-oriented health status over the last few decades, the maternal mortality initiatives to maximise behaviour change at the household ratio (MMR) remains high at 170 per 100,000 live births.10 and community levels. BRAC projects that, if universal health While the neonatal mortality rate has declined from 65 per 1,000 coverage continues in Bangladesh, Manoshi will realise a 40% live births in 1990 to 31 in 2010,11 stillbirths remain common, to 50% reduction in neonatal mortality, 50% decrease in under- with a reported rate of 36.4 per 1,000 births in 2009.12 Nearly five mortality, and a substantial drop in maternal mortality in two-thirds of these (21 per 1,000 births) occur at delivery, urban informal settlements across six cities in the country.1 illustrating the potential to reduce the rate of stillbirths by Manoshi focuses on several different aspects of community expanding access to skilled healthcare personnel during the development, including: providing basic health care for intrapartum period. Table 2 gives an overview of the health pregnant and lactating women, newborns and under-five situation in Bangladesh and Dhaka, the country’s capital. children; building a referral system to connect women with Access to health care and health status is quite poor in quality health facilities when complications arise; creating informal urban settlements across Bangladesh and often worse women’s groups to drive community empowerment; skills than in other urban areas. While the distance between women development and capacity building for CHWs and birth and skilled care is not long, nearly 80 percent of the deliveries attendants; and linking community organisations with both in urban slums are attended by neighbours or relatives at governmental and non-governmental organisations to further home.17 Just 55% of women in urban slums receive antenatal their goals.1 innovative METHODS 2014 2 Table 2: Health and epidemiologic indicators IndicatoR DHAKA BANGLADESH Average life expectancy at birth (total/female/male)5 70 / 69 / 70 Physicians (per 10,000 population)13 10.8 5.4 Nurses and midwives (per 10,000 population)13 2.8 2.1 HIV prevalence (per 100,000)5 – 5.1 Anti-retroviral therapy coverage for advanced HIV (%)5 – 31 Total fertility rate (live births per woman)14 2.2 2.3 Maternal mortality ratio (per 100,000 live births)15,16 158 170 Under-five mortality rate (per 1,000 live births)14 54 53 Neonatal mortality rate (per 1,000 live births)14 36 32 Married women using any contraceptive method (%)14 61.0 61.2 Birth interval, months since preceding birth (median)14 47.3 47.4 Antenatal care coverage, at least 4 visits (%)5 44.7a 26 Births attended by skilled provider (%)14 31.5 31.7 Births delivered in a health facility (%)14 29.9 28.8 Birth weight < 2500g (%)14 16.5 17.7 Births by Caesarean section (%)14 20.2 17.1 Postnatal care visit within 2 day of birth (%)14 29.0 27.2 a: All urban women b: Includes births in all facilities, regardless of quality • Monitoring all birth records, offering essential newborn care, and managing or referring newborns with complications The Manoshi project provides several specific services along • Arranging immunisation, ensuring adequate Vitamin A intake, the continuum of care, from pregnancy through the postnatal and performing quarterly growth monitoring of children under period, which include: five years of age • Identifying all pregnant women and offering high-quality • Educating and motivating mothers to take up and continue antenatal, delivery, postnatal (for the mother and the baby), exclusive breastfeeding and, at later ages, complimentary and child health care feeding, and referring severely underweight children to hospitals • Tracking all eligible couples and offering the most appropriate for treatment family planning methods • Forming committees with local stakeholders to strengthen • Encouraging pregnant women to give birth at ‘delivery centres’ community health actions, monitor activities, provide super- or ‘maternity centres’ that have been established by BRAC vision and safety-net operations, assist in referral mechanisms, inside the informal settlements conduct verbal autopsies, and assist with a range of community activities • Offering Emergency Obstetric Care (EmOC) in pre-selected referral facilities innovative METHODS 2014 3 CHWs are selected from the community and the local vicinity. One of the key features of the Manoshi project is the pre- There are several cadres, including first-line workers, midwives, selection of referral facilities. This was established at the outset paramedics, and ‘Urban Birth Attendants’ (UBAs), which are of the project in collaboration with local community networks. drawn from the local pool of Traditional Birth Attendants. Several public hospitals, including the Dhaka Medical College, Birthing centres, locally known as ‘BRAC delivery centres’, as well as some private hospitals were selected and partner- have been set up to serve about 2,000 households each (10,000 ships built with hospital managers to assure ready access people). Women come to deliver with UBAs or midwives. These to quality care for emergency obstetric and newborn complica- are basic, clean facilities that maintain privacy and dignity, tions. Memoranda of Understanding were developed to deliver provide the necessary supplies and expertise for normal births, emergency services at fixed low prices. Local transport drivers and have direct referral mechanisms to pre-selected facilities were identified to provide transport in case of emergencies, and if complications arise. Mothers are given misoprostol BRAC referral staff were stationed at all selected hospitals to tablets (400 micrograms) during the third stage of labour after navigate any referred patients through the admission process to the delivery of the baby and before the delivery of the placenta subsequent care. to reduce postpartum blood loss. They are taught to keep the All women access services free of charge at the community baby warm, to breastfeed, and to identify and report any danger level. Financial support is provided to those patients unable to signs during the neonatal
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