Mhuri/ Imuli Project Cooperative Agreement Number: 72061318-CA-00008

Baseline report

September 2018

Table of Contents Abbreviations ...... 4 Executive Summary ...... 5 1.Introduction ...... 8 Background ...... 8 Rationale ...... 9 2. Methods ...... 10 Design ...... 10 Study setting ...... 11 Data management ...... 12 Data Collection and tools ...... 12 Data analysis ...... 12 Ethical Review ...... 12 3.Results ...... 13 3.1 Percentage of Institutional deliveries ...... 14 3.2 Proportion of pregnant women booked for 1st ANC before 16 weeks ...... 14 3.3 Percent of pregnant women attending at least 4 ANC visits ...... 15 3.4 Number and percentage of pregnant women attending ANC who receive Intermittent preventive treatment for malaria ...... 15 3.5 Women giving birth who received uterotonics through USG support ...... 16 3.6 Percentage of newborns not breathing at birth who were resuscitated ...... 16 3.7 Percentage of Low Birth Weight babies initiated on KMC ...... 16 3.7 Proportion of infants who were breastfed within an hour of birth ...... 17 3.8 Child Mortality ...... 18 3.9 Neonatal and perinatal mortality ...... 18 3.10 Increased number of PHC facilities meeting BEmONC standards and referrals for CEmONC ...... 18 3.11 Number of cases of child diarrhea treated in facilities and/or by community health workers in USG assisted program areas ...... 19 3.12 Contraceptive Prevalence Rate (mCPR) ...... 19 3.13 Proportion of facilities providing post abortion Care (PAC) ...... 20 3.14 Proportion of children with fever screened for malaria with RDT at community level ...... 21 3.15 Summary of baseline indicator values ...... 21

4. Discussion ...... 26 Limitations ...... 28 5. Conclusion and Recommendations ...... 30 Programmatic recommendations ...... 30 Research and Data recommendations ...... 31 References ...... 32 Appendix 1: Data Collection Tool ...... 33

Abbreviations ANC Antenatal Care e ARK Absolute Return for Kids BEmONC Basic emergency obstetric and newborn care CEmONC Comprehensive emergency obstetric and newborn care FP Family planning ICDS Inter-censal demographic survey IMNCI Integrated management of childhood illnesses. IPTp Intermittent preventive treatment of malaria in Pregnancy IUCDs Intra-Uterine contraceptive devices KMC Kangaroo mother care LARCs Long-acting reversible contraceptives MCHIP Maternal Child Health Integrated Program MNCH-FP Maternal newborn child health-family planning mCPR Modern contraceptive prevalence rate (mCPR) MoHCC Ministry of Health and Child Care MVA Manual vacuum aspiration PAC Post Abortion Care PIH Pregnancy induced hypertension PPH Postpartum hemorrhage USAID United States Agency for International Development USG United States Government VMAHS Vital Medicines Availability and Health Survey WHO World Health Organization ZNFPC Zimbabwe National Family Planning Council

This report is made possible by the support of the U.S. Government and American people through the United States Agency for International Development (USAID). The contents of this report are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.

Executive Summary

Introduction The Mhuri/Imuli project is a five-year USAID-funded activity (2018 – 2023) aimed at improving maternal, new-born, child health and family planning (MNCH-FP) in Zimbabwe’s Manicaland Province, working in collaboration with the Ministry of Health and Child Care (MOHCC), and the Zimbabwe National Family Planning Council (ZNFPC) for countrywide FP service provision.

In Zimbabwe, the maternal mortality ratio of 651 maternal deaths per 100,000 live births is way above global averages and is not on track to meet the Government of Zimbabwe (GOZ) target of 300 maternal deaths per 100,000 live births by 2020. Despite progress made in improving Zimbabwe’s MNCH and FP status, challenges persist. While the use of facility-based services has increased they are not easily accessed by some populations, and cultural and religious beliefs – specifically the apostolic sects- inhibit women from seeking services for themselves and their children. As part of the roll-out of the Mhuri/Imuli project and to facilitate evidence-informed planning, the project conducted a desk review of existing MNCH interventions in Manicaland province and FP activities nationally as a baseline.

Methods We developed a data extraction tool to collect information from various sources including national surveys, the national District Health Information System (DHIS2), national strategies, annual MOHCC reports and reports from the Maternal, Newborn and Child Health Integrated Project (MCHIP) which was the predecessor project to Mhuri/Imuli. Data was extracted for maternal, new born, child health and family planning (MNCH-FP) for Manicaland and only for FP in the other provinces.

Data for Manicaland MNCH-FP indicators were disaggregated by district wherever possible while FP, impact and outcome level indicators were disaggregated by province where data was available. Data were summarized using frequencies, proportions and presented in graphs and tables generated in Microsoft Excel. There was no ethical clearance required for this desk review as it involved secondary data obtained from published reports. All data sources were acknowledged in the report.

Results Manicaland province’s performance is lower than national averages for most MNCH-FP indicators. Manicaland province has the lowest modern contraceptive prevalence rate (mCPR) at 57%. At 37%, the provincial proportion of first ANC visits below 16 weeks is below the national target of 40%. There are seven districts in Manicaland. District comparisons show that among women who seeking antenatal care only 24% register before 16 weeks in Mutare District, which is the lowest in the province (compared to Buhera district in which 58% seek care before they are sixteen weeks pregnant. Only 60% of women in Manicaland attended all four ANC visits and only 53% received the recommend three doses of IPTp, way less than the national average of 81%.

Manicaland province has the third highest under five-mortality rate, the second-highest neonatal mortality and the highest peri-natal mortality in Zimbabwe. BEmONC coverage (six signal functions) in the province ranges from 0-6%. There is no data on facilities that provide 5 signal BEmONC functions. Twenty percent of primary health facilities in Manicaland offer post abortion care, with only 6% reported offering manual vacuum aspiration (MVA).

Conclusion and Recommendations The assessment shows that performance of most MNCH-FP indicators in Manicaland are below the national averages and targets. Nevertheless, results suggest that improvements are possible, as exemplified by progress seen at 36 health facilities Supported by USAID’s MCHIP from 2014-2017.

The assessment provides baselines for Mhuri/Imuli from which targets will be set, and highlights gaps with data for key community-level services, and for service-quality indicators. Further, the assessment highlights a critical need for health promotion activities in communities in support of improved health seeking behaviors. Early attendance of ANC, IPTp and utilization of a broader range of contraceptive methods are areas that would benefit from health promotion to adolescents, and members of religious objector communities.

A programmatic recommendation is to build on MCHIP interventions which yielded improvements and build in sustainability mechanisms. At community level, suggestions for improvement include health promotion to improve ANC, IPTp utilization and institutional delivery. In all health promotion efforts, a deliberate effort to engage men will be important for empowering women and girls to seek health services. Where possible, leveraging feed-the-future programs in the province to integrate critical service utilization indicators into food distribution and community savings schemes should be encouraged. Further, strengthening VHW skills to enhance household – facility linkages, particularly in under-served communities as will targeted approaches for religious objectors to adjust social norms and behaviors in support of improved health seeking.

We recommend that the MoHCC use monthly tally sheets (T5) to accurately document the utilization of uterotonics a key intervention that should be used to prevent postpartum hemorrhage. Another indicator without available data is the utilization of MVA for removal of retained products of conception, which should also be included on the T5. Further, assessment of BEmONC availability should be based on 6 signal functions in line with MOHCC policy, and the method for removal of retained products of conception should be noted, to enable stratification of BEmONC availability by MVA. This change will enable targeted interventions aimed at improvements in MVA availability.

At the community level, a data recommendation for Mhuri/Imuli is to facilitate the use of routine data collection tools including the deployment, testing and expansion of electronic C-series forms, whose entry into DHIS-2 can be achieved in real time. In addition to enhancing routine data collection, establishing a systematic process for generating data on utilization of community-based MNCH and FP services and information, as well as tracking MNCH/FP behaviors at household level using Lot Quality Assurance Sampling (LQAS) is recommended. Application of LQAS surveys would enable Mhuri/Imuli to attain insight into investments into health promotion and behavioral outcomes. Finally, Mhuri/Imuli should support the utilization of a training database such as TrainSmart, an open-source, web-based training data collection system which allows users to accurately track training programs, trainers, and trainees.

1.Introduction

The Mhuri/Imuli project is a five-year USAID-funded activity (2018 – 2023) aimed at improving maternal, new-born, child health and family planning (MNCH-FP) in Zimbabwe’s Manicaland Province, working in close collaboration with the Ministry of Health and Child Care (MOHCC), and the Zimbabwe National Family Planning Council (ZNFPC) for countrywide FP service provision. FHI 360 is the lead partner working in collaboration with Absolute Return for Kids Zimbabwe (Ark) and VIAMO1.

The project objectives are: • To improve the availability of quality MNCH-FP services in the seven districts of Manicaland Province; and to increase access to a broad range of FP services nationwide through outreach services; • To increase use of MNCH-FP services, targeting hard-to-reach populations; • To strengthen community systems and linkages to integrated MNCH-FP services and; • To improve policy implementation within the Ministry of Health and Child Care (MOHCC) and Zimbabwe National Family Planning Council (ZNFPC).

Background In Zimbabwe, the maternal mortality ratio of 651 maternal deaths per 100,000 live births (ZDHS 2015) is not on track to meet the Government of Zimbabwe (GOZ) target of 300 maternal deaths per 100,000 live births by 2020 (MoHCC 2016). Long distance to health facilities, lack of supplies, staff shortages and high social costs of accessing health services are major barriers to maternal health services uptake (MCHIP IPTp Study Report,2017). The major causes of maternal mortality in Zimbabwe are postpartum hemorrhage, pregnancy-related hypertension, sepsis and malaria (Munjanja, Nystrom, Nyandoro, & Magwali, 2007).The timely utilization of high quality EmONC services provided at facilities address many of these causes of death, yet only 69.9% deliveries occur in facilities, lower than the national average of 78% (ZIMSTAT, 2016).

Several approaches including national-level trainings in BEmONC, life-saving skills and implementation of maternity waiting homes have been implemented and have resulted in some progress in reducing Zimbabwe’s maternal, new-born and child mortality, However, this progress fell short of the GOZ’s 2015 Millennium Development Goals targets.

Substantial investments have been made to strengthen Zimbabwe’s health system, resulting in improvement in rates of facility-based births. Nevertheless, the high maternal mortality suggests that delivering in facilities is not a panacea for maternal mortality. It also indicates that facilities and health care workers (HCWs) are not sufficiently able to manage the direct causes of maternal death. Similarly, high rates of neonatal deaths due to complications of prematurity, birth asphyxia and sepsis, suggest high-impact practices such as integrated management of neonatal and childhood illness (IMNCI) and kangaroo mother care are not delivered systematically (UNICEF, 2008).

1 Viamo is a social enterprise that connects individuals and organizations using digital technology to make better decisions

Progress has been made in improving Zimbabwe’s MNCH and FP status. For example, the use of modern FP methods among currently married women increased from 50% in 1999 to 66% in 2015 and Zimbabwe has achieved its FP2020 target for contraceptive prevalence rate (67%). Further decreases have been observed in maternal mortality ratio and neonatal mortality rate (MoHCC 2016). Whereas malaria in pregnancy contributed to10% of maternal deaths in Manicaland province (Manicaland PMD Report, 2017), malaria-related maternal mortality has declined in the province since 2013.

Despite the progress made, challenges persist. For example, teenage pregnancy for the country is 22%, which according to MoHCC (2012) is a major driver of unmet need for FP. One in ten women has an unmet need for FP, behind the global FP 2020 target of 6.5% for unmet need For FP. Child mortality remains high, as does neonatal mortality, driven by conditions surrounding labour and the immediate post-partum period. The major drawbacks are caused by hard to reach populations and confinement of service provision to health facilities which limit accessibility by the non-health seeking population, especially teenagers; as well as shortages of material and human resources (McCoy et al., 2014).

Other studies have shown that unmet need for FP and maternal deaths are higher in adolescents and older women with no education in low income communities. This context mirrors Manicaland’s socio economic status, in which most of the population being poor. Higher rates of adolescent pregnancy and maternal deaths among the apostolic faith (41,7% of Manicaland population) reported at 34 percent of all maternal deaths in Manicaland, requires tailored and inclusive approaches for these groups (Maguranyanga, 2011).

Rationale As part of the roll-out of the five-year Mhuri/Imuli project, FHI 360 and its implementing partners need to develop project indicator benchmarks, targets and identify implementation gaps to improve maternal, new born and child health and survival in beneficiary communities and populations. To facilitate evidence-informed planning, the project conducted a review of existing records and reports of MNCH in Manicaland province and FP activities nationally. The aim of the assessment was to determine the baseline status of key project MNCH-FP indicators and produce evidence to inform decision making.

2. Methods

Design A review of existing data using a data extraction tool was conducted by the Mhuri/Imuli Monitoring, Evaluation and Research (MER) team in Manicaland. The design enabled collection of selected indicator data from national surveys, national District Health Information System (DHIS2), national strategies, annual MOHCC reports and MCHIP project documents. Contextual qualitative information extracted from existing reports gave meaning to the indicator data.

The following documents and reports were reviewed as part of the desk-review:

• Zimbabwe Demographic Health Survey (ZDHS) 2015 • Multiple Indicator Cluster Survey (MICS) 2014 • Zimbabwe Intercensal Demographic survey report 2017 • Vital Health Services and Medicines Availability Survey (VHMAS) Reports for 2017 and Q1 20182 • Annual DHIS2 reports from MoHCC for Manicaland province and Family Health • Annual Manicaland province and Family Health Reports, 2017 • IPTp Study and Cross Border Study 2017 • MCHIP program reports

The data sources listed below were used:

Table 1: Desktop review data sources Source of data Frequency of Next collection collection date ZDHS 5 years 2020 Census 10 years 2022 DHIS2 Continuous/live Continuous/live VHMAS Every Quarter End of quarter

Data was extracted for the indicators in the project’s PMELP, listed below by Intermediate Results (IR):

Intermediate Result 1: Improved quality of MNCH-FP services • Percentage of institutional deliveries • Percentage of nurses, midwives, clinicians and doctors in Manicaland (MNCH-FP section) who undergo integrated competence based on job training. • Proportion of primary health facilities who meet 6 BEmONC standards

2 The VMAHS dataset is a database on vital medicines availability and health services survey which is conducted every quarter at a sample of health facilities in every district in the country to monitor the health development fund initiative (HDF). The data is managed by UNICEF and is shared with partners upon request. The Mhuri/Imuli requested the dataset for Q1 2018 from UNICEF through USAID to enable calculation of district level estimates of indicators on BEmONC signal functions and provision of MVA. The dataset was in an excel format and had been cleaned already.

• Proportion of USG-supported facilities that conduct maternal, perinatal, and child deaths reviews/ audits. • Proportion of children with fever screened for malaria with RDT at community level. • Percentage of low birth weight (LBW) (<2.5kg babies initiated on KMC • Proportion of facilities offering post abortion (lifesaving) care (MVA) • Percentage of women giving birth who received Uterotonics in the third stage of labour (or immediately after birth) through USG-Funded MNCH-FP project. • Percentage of new-borns delivered in health facilities not breathing at birth who were resuscitated. • Number and percentage of pregnant women attending ANC who receive intermittent preventive treatment for malaria. • Number of cases of child diarrhoea treated in facilities and/or by community health workers in USG assisted program areas.

Intermediate Result 2: Increased use of MNCH-FP services and targeting of hard-to-reach populations

• Proportion of pregnant women booked for 1st ANC visit before 16 weeks. • Percent of pregnant women attending ANC who receive at least 4 visits for pregnancy-related reasons.

Study setting The baseline assessment focused on the geographic scope of the Mhuri/Imuli project, i.e. Manicaland province for MNCH services and nationwide for FP services.

Manicaland province has a population of 1,752,698, accounting for 13.4% of Zimbabwe’s population (ZIMSTAT, 2012). The province is one of the largest rural provinces by land size and population with seven districts namely, Buhera, Chimanimani, Chipinge, Makoni, Mutasa, Nyanga and Mutare. Evidence of higher maternal and child mortality among ultra-conservative apostolic sects in Manicaland province exists (ZDHS 2005/6). Two major apostolic sects, the Johanne Marange and Johanne Masowe were founded in Manicaland province in the 1930’s in Mutare and Makoni Districts respectively (Maguranyanga,2011). Poor maternal and child health outcomes among the apostolic sects in Manicaland are attributed to religious beliefs opposed to the use of modern medicine (UNDP,2011).

The crude birth rate for the province was 33.4 per 1,000 and the crude death rate was 10.3 per 1,000 with a 2.3% per annum natural population increase, the highest provincial growth rate in Zimbabwe. In 2018, Manicaland province had 285 health facilities, whose distribution is presented in table 2.

Table 2: List of health facilities by ownership and District in Manicaland

Chimanimani

Mutare City Mutare

Ownership

Chipinge

Province

Nyanga

Makoni

Mutasa

Mutare

Buhera

Government 8 8 8 22 16 5 8 0 75 26.3 Rural District Council 20 8 26 28 26 23 13 0 144 50.5 Town Council 0 0 2 0 0 0 0 8 10 3.5 Mission 2 3 4 5 3 7 4 0 28 9.8 Mines 1 0 0 0 0 1 0 0 2 0.7 Industry/Commercial 0 4 11 1 1 7 2 0 26 9.1 Total 31 23 51 56 46 43 27 8 285 100

Data management

Data Collection and tools Two members of the project team conducted the desk review in August 2018 using a data extraction tool developed in Microsoft excel (2016 version) to organise and consolidate data (appendix 1). The data collection template contained indicators approved in the Mhuri/Imuli project Monitoring, Evaluation and Learning Plan (PMELP), organized by data source and year

Data for Manicaland MNCH-FP indicators were disaggregated by district wherever possible while FP, impact and outcome level indicators were disaggregated by province were data was available.

The extracted data was presented in graphs and tables generated in Microsoft Excel and checked for quality by the Mhuri / Imuli M&E and technical staff in Manicaland, while the FHI 360 M&E Director also reviewed data for quality and provided input into the narrative report.

Data analysis Data were summarized using frequencies, proportions, graphs and tables in Microsoft Excel. Data was sorted by each district for MNCH indicators and by province for the FP indicators. Where disaggregated data was available for each indicator data was also presented in the disaggregated format. Excel was deemed appropriate for handling the secondary data which had already undergone rigorous statistical tests. National targets and averages were used as benchmarks to identify poorly performing districts where provincial benchmarks were not available.

Ethical Review There was no ethical clearance required for desk review exercise as it used reports which are already in the public domain and the review did not involve research with human subjects.

3.Results

Table 3 shows the performance of MNCH indicators in Manicaland and its comparison with other provinces and the Zimbabwe national average. Results show that Manicaland province has the lowest modern contraceptive prevalence rate (mCPR) and proportion of infants exclusively breast-fed within an hour of birth. It also has the worst peri-natal mortality rate of 43 per 100 live births. Table 4 shows the Manicaland district performance dashboard on selected MNCH indicators, Mutare district is the worst performing on all but one of the seven indicators while Chipinge is the best-performing.

Table 3: Selected MNCH indicators, Manicaland Province Vs All provinces

Indicators

aland

ingo

lands

National Man Central Mash MashEast MashWest MatNorth MatSouth Mid Masv Bulawayo Harare Perinatal Mortality Rate (PMR) (per 1000LB) 34 43 42 42 32 32 17 24 33 30 29

Under-5 Mortality Rate (per 1000 72 60 75 116 77 36 95 65 69 50 43 LB) Modern Contraceptive 66 57 65 69 71 66 60 67 61 71 70 Prevalence Rate (mCPR) (%) Proportion of infants born in the year preceding a survey who were exclusively breastfed from 58 43 60 56 57 76 95 95 59 52 53 within an hour of birth during neonatal period

Table 4: District Performance dashboard on selected indicators

District % ANC <16 % ANC 4th % Institutional IPTp 3 % RHC providing 6 % RHC % CEmoNC weeks Visit deliveries Coverage BEmONC functions providing MVA facilities Buhera 58 70 76 55 0 0 100 Chimanimani 32 82 66 58 0 0 50 Chipinge 33 64 102 62 21 21 100 Makoni 34 38 66 43 2 2 100 Mutasa 51 112 88 61 7 7 67 Mutare 24 41 45 47 7 7 100 Nyanga 44 60 87 55 0 0 33

Key Variance from national target +/-5% 100 - 6% - 10 % 67 > -10% 33

3.1 Percentage of Institutional deliveries In Manicaland province, 76% of deliveries take place in a health facility, lower than the national average (83%) and below the national target (80%) (ZDHS,2015). At 45% Mutare district is the least performing district in Manicaland province while Chipinge district had the highest proportion of institutional deliveries at 102%(DHIS2,2017). Other districts performing above national average are Nyanga and Mutasa while Chimanimani and Makoni performed below the provincial average (Figure 1)

Figure 1: Proportion of institutional deliveries by district, DHIS 2,2017

Proportion of institutional deliveries by district,2017 120% 102% 100% 88% 83% 87% 80% Target 76% 76% 80% 66% 66% 60% 45% 40%

20%

0% Mutare Chimanimani Makoni Manicaland Buhera Zimbabwe Nyanga Mutasa Chipinge

3.2 Proportion of pregnant women booked for 1st ANC before 16 weeks At 37%, the provincial proportion of first ANC visits below 16 weeks is below the national target of 40%(DHIS2,2017). The national average is 30%, (Family Health Department Report,2017). District comparisons show that Mutare District has the least proportion of pregnant women registering for ANC before 16 weeks (24%) while Buhera district (58%) has more than double the proportion of women in Mutare district and well above the national and provincial average (DHIS2,2017). Other districts performing above the national target are Nyanga and Mutasa. Chipinge, Makoni, and Chimanimani performed above the national average but below provincial levels of 37% (Figure 2)

Figure 2: First ANC Bookings before 16 weeks, DHIS2,2017

Proportion of pregnant women booked for 1st ANC visit before 16

weeks

58% 51%

44% Target 40%

37%

34%

33%

32%

30%

24% proportion of ANC of ANC proportion bookings

BUHERA MUTASA NYANGA MANICALAND MAKONI CHIPINGE CHIMANIMANI ZIMBABWE MUTARE

3.3 Percent of pregnant women attending at least 4 ANC visits Sixty percent of pregnant women in Manicaland province attend all 4 recommended ANC visits. Makoni district (38%) and Mutare district (41%) are the least performing districts while Chimanimani (82%) and Mutasa (112%) are the best performing districts. The province performed below the national average of 81%, as shown in Figure 3.

Figure 3: Women attending 4 or more ANC Visits, DHIS2,2017

Proportion of women attending 4 or more ANC Visits 120% 112%

100% 82% 81% Target 75% 80% 70% 64% 60% 60% 60% 41% 38% 40%

20% % of women of % women attending4thANC 0% Mutasa Chimanimani Zimbabwe Buhera Chipinge Manicaland Nyanga Mutare Makoni

3.4 Number and percentage of pregnant women attending ANC who receive Intermittent preventive treatment for malaria The provincial average for women who receive three doses of preventive malaria treatment during pregnancy (IPTp3) is 53%, above the national average of 37and below the national target of 85% (NMCP 2017). Districts above the provincial average are Chipinge (62%), Mutasa (61%) and Chimanimani (58%) while Makoni (43%) and Mutare (47%) are performing below the average.

Figure 4: IPTp3 Coverage, DHIS2,2017

IPTp3 Coverage by District,DHIS 2017

100% 90% 80% 70% 62% 61% 58% 60% 55% 55% 53% 47% 50% 43% 40% 30%

20% receivingIPTp3 10%

0% proportion of of proportion pregnantwomen

3.5 Women giving birth who received uterotonics in the third stage of labor (or immediately after birth) through USG-funded MNCH-FP project

At 36 USG supported health facilities under the MCHIP project, the proportion of women receiving uterotonics steadily increased from 94% to 97% between 2014 and 2016, (MCHIP EOP report, 2017). The figure however declined from 97% to 87% in 2017 (Figure 4).

3.6 Percentage of newborns not breathing at birth who were resuscitated Based on data from 36 USG MCHIP supported facilities, the proportion of newborn babies not breathing at birth who were successfully resuscitated declined between 2014 and 2017, (Figure 4)

3.7 Percentage of Low Birth Weight <2.5kgs babies initiated on Kangaroo Mother Care. A total of 4,918 low birth weight babies were identified and initiated on Kangaroo Mother Care (KMC) at 36 USG supported facilities between 2014 and September 2017. The annual proportion of low birth weight children under 2500g initiated on KMC increased from 28% to 56% between 2014 and 2017(Figure 4).

Figure 5: Proportion of Women who received uterotonics in 3rdstage of labor, babies resuscitated and initiated on KMC ,2014-2017

Percent of women receiving uteretonics in third stage of labour, babies resuscitated and babies initiated on Kangaroo Mother Care 2014-2017 100% 94% 95% 97% 87% 89% 85% 80% 83% 82%

60% 53% 56% 46% 40% 28% 20%

0% 2014 2015 2016 2017 Percentage of babies resuscitated Percentage of Babies initiated on KMC Percent of women receiving uteretonics in third stage of labour

3.7 Proportion of infants born in the year preceding a survey who were breastfed from within an hour of birth during neonatal period At 43%, Manicaland province is the worst performing province on this indicator. Results also show that children born at health facilities have the highest chance (61%) of being breastfed within one hour of birth than those delivered at home (44%).

Figure 6: Infants breastfed within an hour, ZDHS,2015

100% 90% 81% 80% 76% 70% 67% 59% 60% 60% 56% 57% 52% 53% 50% 43% 40% 30%

20% Proportion infants of breastfedProportion 10% 0%

3.8 Child Mortality At 83 under five deaths per 1000 live births, Manicaland province has the third highest under five mortality, which is above the national average of 72/1000, (ICDS,2017). Data disaggregated by district is not available on this indicator. The ZDHS 2016 estimates the under-five mortality rate at 112 per 1000 live births for Manicaland province.

3.9 Neonatal and perinatal mortality Manicaland province has the second-highest neonatal mortality (35 per 1,000 LB) and the highest peri-natal mortality (43 per 1,000 LB) in Zimbabwe (ICDS,2017). The national average for peri-natal mortality is 34/1000 live births as shown in Figure 6. According to the ZDHS 2016, the Manicaland perinatal mortality rate is at 43 per 1000 live births.

Figure 7: Perinatal mortality rates by province, ICDS,2017

Perinatal Mortality Rates by Province,2017 50 45 42 42 43 40 34 35 32 32 33 29 30 30 24 25 20 17 15 10

Deaths per 1000 Live births per Deaths Live 1000 5 0 Mat South Midlands Harare Bulawayo Mash West Mat North Masvingo Zimbabwe Mash Mash East Manicaland Central

3.10 Increased number of primary health care facilities meeting standards of BEmONC services and referrals for CEmONC Nationally, only 7.6% of primary level facilities in Zimbabwe provide the six BEmONC signal functions and 89.3% of facilities are classified as BEmONC-1 sites, i.e. they provide six signal functions (excluding assisted delivery). Thirteen percent of facilities have trained personnel while 56.9% have sufficient equipment.

An extended analysis of the VMAHS dataset indicated that 6% of the rural health centers in Manicaland provide the standard six signal functions3 for BEmONC. Only Chipinge district (21%) is performing above the national average on this indicator while in other districts like Nyanga, Buhera and Chimanimani there were no facilities which were offering the six BEmONC signal functions.

3Manual removal of placenta, Manual removal of retained products of conception, Parental antibiotics, parental anti-convulsants, parental uterotonics, neonatal resuscitation.

Figure 8: Proportion of primary health care facilities in Manicaland providing six BEmONC signal functions by district, Q1 2018

Chipinge 21 Zimbabwe 8 Mutare 7

Mutasa 7 Manicaland 6 Makoni 2 Nyanga 0 Buhera 0 Chimanimani 0 0 5 10 15 20 25 Proportion

3.11 Number of cases of child diarrhea treated in facilities and/or by community health workers in USG assisted program areas In Manicaland province. 25% of children with diarrhea receive zinc with oral rehydration solution (ORS), below the national average of 28.7%(ZDHS,2015). Against a target of 54,409 children under the USG supported MCHIP project, a total of 48,823 (90%) children with diarrhea were treated with iron and zinc at the 35 USG supported facilities in Manicaland province between 2014 and December 2017. (MCHIP EOP Report,2017)

3.12 Contraceptive Prevalence Rate (mCPR) Manicaland province has the lowest mCPR (57%) against a national average of 66% (ZDHS,2015). Nationally, the most popularly used modern method is the pill with 41% of married women preferring this method. The uptake and use of Injectables and implants are at 10% for each method while 1% of all women use IUCDs and sterilizations as methods of family planning (ZDHS2015:110).

Figure 9: Modern method contraceptive prevalence rates by province, ZDHS,2015

100% 90% 80% 71% 71% 66% 66% 67% 69% 70% 70% 65% 57% 60% 61% 60% 50% 40%

Rate 30% 20% 10%

0% Modern Contraceptive Prevelance Contraceptive Modern

3.13 Proportion of facilities providing post abortion Care (PAC) The Q1 2018 Q1VMAHS data showed that 20% of primary health facilities in Manicaland were offering PAC (removal of retained products of conception) and 6% reported offering manual vacuum aspiration (MVA). Chipinge district (21%) has the highest proportion of facilities offering MVA while in Chimanimani there is no primary health facility offering MVA despite having the highest proportion (60%) of facilities offering removal of retained products of conception. The most common post abortion method used in the province by secondary level hospitals is Dilatation and Curettage (D&C). Only 3 of all the district hospitals in the province (Chipinge, Hauna and Mutasa) were providing both D&C and MVA.

Figure 10: Provision of removal of retained products of conception at primary health care facilities by district, VMAHS Q1 2018 extended analysis.

70 60 60 50 40 35 30 26 21 20 20 20 18 6 7 6 10 7 8 7 2 0 0 0 0

0 Proportion of facilities of Proportion

remove retained products Provision of MVA

3.14 Proportion of children with fever screened for malaria with RDT at community level There is no province-wide data on this indicator. Documented screening of children for malaria at community level occurred in Chimanimani district only with support from the MCHIP program in Manicaland province.

3.15 Summary of baseline indicator values The summary of baseline indicator values by location are indicated in Table 4, 5 and 6 below. The sources of data for each indicator was also recorded. Table 4 and 5 shows indicators for which data is collected routinely and Table 6 shows indicators which are collected through surveys.

Table 5: Summary of routine indicator values by location

Indicator Data Source Year District/Location

Manicaland Buhera Chimanimani Chipinge Makoni Mutare Mutasa Nyanga Zimbabwe

1.1. Percentage of institutional deliveries (%) [2.4.1 -3_STANDARD] PMD Reports, 2017 76 76 66 102 66 45 88 87 83 Family Heath Report 1.2 Case fatality Rate (PPH, PIH, sepsis & malaria) No ------data 1.3 % of nurses, midwives, clinicians and doctors in Manicaland (MNCH -FP No ------section) who undergo integrated competence based on job training data

1.4 Number of CEmONC facilities VMAS Q1 12 2 1 3 1 2 2 1 85 2018

1.5 Proportion of primary health facilities who meet 6 BEmONC standards VHMAS Q1 6% 0% 0% 21% 2% 7% 7% 0% 7.60% 2018

1.6 Proportion of USG-supported facilities that conduct maternal, No ------perinatal, and child deaths reviews/ audits [2.4.1 -1_CUSTOM] data

1.7 Proportion of children with fever screened for malaria with RDT at No ------community level (Survey Indicators) data

1.8 Percentage of low birth weight (LBW) (<2.5kg babies initiated on KMC MCHIP EOP 2017 56% ------Report

1.9 Proportion of facilities offering post abortion (lifesaving) care (MVA) VHMAS Q1 6% 0% 0% 21% 2% 7% 7% 0% 7.6% 2018

2.1 Proportion of pregnant women booked for 1st ANC visit before 16 DHIS2, Family 2017 10% 14% 8% 8% 9% 6% 14% 11% 30% weeks Heath Report

2.2 Percent of pregnant women attending ANC who receive at least 4 visits DHIS2, Family 2017 63% 70% 83% 65% 38% 39% 113 60% 81% for pregnancy-related reasons [2.4.2-1_CUSTOM] Heath Report %

2.3 Percent of women giving birth who received Uterotonics in the third MCHIP EOP 2017 87% ------stage of labor (or immediately after birth) through USG -Funded MNCH-FP Report project [HL.6.2.1_STANDARD] 2.4 Percentage of new-borns delivered in health facilities not breathing at MCHIP EOP 2017 82% ------birth who were resuscitated [HL6.3.1_STANDARD] Report 2.5 Number and percentage of pregnant women attending ANC who DHIS2 2017 53% 55% 58% 62% 43% 47% 61% 55% receive intermittent preventive treatment for malaria

2.6 Number of cases of child diarrhea treated in facilities and/or by MCHIP EOP 2017 48823 ------community health workers in USG assisted program areas Report [HL.6.6.1_STANDARD] 2.8 Number of clients who receive FP/RH counseling and took up an FP No ------method as a result of USG support data

3.1 Proportional of functional HCC No ------data

3.2. Number of referrals to health facility by VHWs for MNCH -FP services MCHIP EOP 2017 5354 ------for further management (under 5 yrs) Report

- No data

Table 6: CYPs by province, DHIS 2017

Indicator 1.10 Couple Years Protection in USG -supported programs (CYPs by method) [HL.7.1.1_STANDARD] Disaggregat Location: Province/District ion

Manicaland Buhera Chimanimani Chipinge Makoni Mutare Mutasa Nyanga Zimbabwe Central Mash East Mash West Mash North Mat South Mat Midlands Masvingo Bulawayo Harare

Total 153733 26166 9982 22665 25193 33852 24410 11464 95091 10781 98750 12628 56205 54349 138925 181983 11254 21616 5 2 8

LAPM/Sterili 2380 0 10 200 60 1950 60 100 14220 1600 680 1030 1330 1010 1030 720 4350 90 zation

Implants 40796 4967 1748 6737 4514 9283 10575 2972 28080 24518 30974 39942 14413 19885 40265 59223 3260 7524 1

IUCDs 4444 64 175 308 598 2650 166 483 29642 1661 5902 4462 2029 1513 4002 3445 409 1776

Injectables 37474 6482 3062 4678 7998 6340 5796 3119 23530 28003 24427 25051 21195 19963 36372 37781 1706 3329 1

Orals 68638 14653 4987 10741 12023 13629 7814 4791 39095 52031 36767 55804 17238 11977 57257 80813 1528 8897 1

Table 7: Summary of baseline values for survey indicators

Indicator Disaggre Data Year Province/Location gation Source

Zimbabwe Manicaland Central Mash East Mash West Mash North Mat South Mat Midlands Masvingo Bulawayo Harare

3.2. Number of referrals to health facility by VHWs Total No for MNCH-FP services for further management dat a

< 5 yrs MCHIP 2017 5354 EOP Report Maternal Mortality ratio (MMR) [2.4_STANDARD] Total ICDS 2017 525 No (per 1000 000 LB) dat a

Perinatal Mortality Rate (PMR) [2.4.2_CUSTOM] Total ZDHS 2015 34 43 42 42 32 32 17 24 33 30 29 (per 1000LB)

Under-5 Mortality Rate [2.4_STANDARD] (per Total ICDS 2017 72 83 75 116 77 36 95 65 69 50 43 1000 LB)

Infant mortality Rate (IMR) [2.4_STANDARD] (per Total ICDS 2017 52 60 59 57 61 32 80 48 54 35 33 1000 LB)

0 - 6 days No dat a

0 -28 days ZDHS 2015 29 35 28 34 46 25 16 32 22 26 23 (NMR)

29 days - 1 ZDHS 2015 22 43 36 35 25 21 29 28 22 14 20 yr. (PNMR) Modern Contraceptive Prevalence Rate (mCPR) (%) Total ZDHS 2015 66% 57% 65 69% 71% 66% 60% 67% 61% 71% 70% %

Proportion of health care facilities consistently Total No delivering MNCH-FP services that are youth friendly dat a at or above agreed minimum standards Proportion of men and women who say they do not Total No want more children who are using long acting dat a reversible or permanent contraceptive methods Number of persons from religious objector Total No communities using MNCH/FP services in the dat a community and at facilities

Percent of audience who recall hearing or seeing a Total No specific USG-supported Family Planning dat a /Reproductive Health (FP/RH) message [HL.7.2.1_STANDARD] Number of children (under 5) who have died in the Total No year prior to a survey in religious objector dat a communities Proportion of infants born in the year preceding a Total ZDHS 2015 43% 60 56% 57% 76% 95% 95% 59% 52% 53% survey who were breastfed from within an hour of % birth during neonatal period Proportion of individuals (female and males, adult Total No and youth) reporting views that gender-based data violence and/or forced sex are wrong

4. Discussion

Manicaland province has the highest perinatal and second-highest neonatal mortality rates, while under-five mortality is the third-highest nationally. This is despite a relatively high level of institutional deliveries of 76%, which though below the national average, is higher than the sub-Saharan Africa average of 52%(UN, 2014). As suggested by Costello et al., (2006), higher levels of institutional deliveries are expected to result in better maternal and newborn outcomes. In Zimbabwe and Manicaland in particular, however, this relationship is not observed. The apparent paradox suggests that quality standards for basic and comprehensive obstetric care are not optimally implemented in the province. Indeed, this assessment found that within the province, only 12 sites are currently providing full CEmONC packages. Non-availability of nurse anesthetists, medical doctors or key medical theatre equipment and or infrastructures has resulted in potential CEmONC sites failing to provide critical services in districts like Nyanga and Chimanimani. Providing the necessary medical theatre equipment and or staff required at sites like Regina Coeli and Elim Mission in Nyanga district and Rusitu in Chimanimani will go a long way in improving access to comprehensive MNCH services currently inaccessible to many women in these districts.

The assessment found that rural health centers in Manicaland province currently do not provide all six signal BEmONC functions for which they are designated. Additionally, there is no reliable data on MVA use, constraining an accurate assessment of BEmONC service availability. Chipinge is the only district in Manicaland which received H4+ support, including BEmONC and MVA trainings, explaining its relatively better BEmONC performance. Although a high proportion of rural health centers indicated they provide removal of retained products a very low proportion indicated they provide MVA when probed on methods used. Stratifying BEmONC facilities by MVA availability would also help easily identify facilities that require support to strengthen BEmONC services. Institutional deliveries in Manicaland are below the national average. Considering that border districts like Chipinge have institutional deliveries rates over 100% and that 44% of Mozambicans along the Zimbabwe/Mozambique border utilize health services from the Zimbabwean side (Malaria Cross Border study,2017), the rate of institutional deliveries among Zimbabwean women in Manicaland is likely to be lower. Statistics excluding Mozambican women could present a true picture of institutional deliveries in all border districts.

Thirty seven percent of pregnant women in the province attend their first ANC before 16 weeks, above the national average of 30% but below the national target of 40%. Lack of information on the importance of seeking ANC services early during pregnancy may be a factor in the low ANC coverage in Manicaland Province. This observation is consistent with a study in Zambia which shows that women well informed about the importance of ANC visits are more likely to book early and follow the maternal calendar (Isaac Banda, Charles Michelo, Alice Hazemba,2012). Low proportion of women attending ANC at 16 weeks is attributed to low importance associated with pregnancy testing to confirm pregnancy at early stages. Lack of knowledge about the importance of early ANC booking is exacerbated by myths and misconceptions in some communities in

Manicaland were people still believe that early notification of a pregnancy invites bad luck and leads to miscarriage.

The study by Banda et al., (2012) also confirms that young women seeking ANC services sometimes seek advice from elderly women before they seek professional help at the clinic. This is consistent with practices in districts such as Chipinge in which young mothers whose husbands are based in South Africa seek approval from their mothers in law to seek ANC services (MCHIP Project, 2017). This practice contributes to late ANC booking. Other studies also show that unplanned pregnancies are also linked to late ANC bookings since the women will be ashamed of revealing the pregnancy early (Gebremeskel et al., 2015). This applies to teenage pregnancies in districts like Chipinge and Mutare. Stigma associated with teenage and adolescent pregnancy could also be responsible for late booking among this age group. Further researches could be done to establish the effects of stigma around teenage pregnancy in relation to late booking for first ANC.

Attendance of four ANC visits, just like the first ANC visits remains lower than expected and the same factors associated with long distances to health centers and high consultation and maternity service fee costs might also contribute to the low coverage. Although ANC services are considered free by the government of Zimbabwe (GOZ), evidence indicates that Council and mission-led health institutions continue to charge fees to access these services (IPTp Study Report,2017). Additionally, older women and women of high parity consider themselves experienced to handle minor maternal problems by themselves, hence wait until the last trimester to visit the health center (Banda et al, 2012). Health promotion activities with specific messages on the importance of each ANC visit are essential, especially considering the MOHCC’s planned move to eight ANC contacts. There is also need for the GOZ to enforce the free maternity service policy at all facilities without exception, including local authority and mission hospitals. Decentralization of all ANC services to local clinics will also limit unnecessary referral of pregnant women to distant health facilities.

IPTp coverage in Manicaland province is among the low performing indicators with a provincial coverage of 53%. (Manicaland PMD Report,2017) This is related to the low ANC attendance, linked to high consultation fee costs to access maternity services at health facilities and long distances travelled to access health services at the nearest health Centers, (MCHIP IPTp Study Report,2017). Districts with above provincial IPTp coverage average (Chipinge 62%, Mutasa 61% and Chimanimani 58%) can attribute their performance to border locations, with attendance from women across the Mozambican border (Malaria cross-border study, 2017). Districts below average (Makoni, 43% and Mutare 47%) are indicative of the high concentration of apostolic communities opposed to use of modern health services in the district.

We found that at 57%, Manicaland province currently has the lowest modern contraceptive prevalence rate. This can be explained by the existence of large communities of religious sects opposed to modern medicine and family planning in Mutare, Mutasa, Buhera, Makoni and parts of Chipinge districts. This however does not explain the reliance on short term methods; 41% of users choose short term methods such as the oral contraceptive pill (OCP), even when they plan to have a child five years later. This method mix is in sharp contrast to most countries in the region for whom use of OCPs

27 is low, and declining (Darroch and Singh, 2013). The dominance of user-dependent methods like OCPs in Zimbabwe’s method mix suggests that the relatively high CPR is delicate and emphasizes the need to expand contraceptive choice, including access to a variety of long-term reversible methods. Social and behavior change strategies aimed at mobilizing women and men to consider more appropriate methods of contraception could go a long way in addressing this gap. The implementation of known effective strategies such as family planning outreaches will also help to address barriers associated with distances travelled by women to clinics seeking family planning advice and services thereby reaching out to the “hard to reach” women.

This assessment found that post abortion care (PAC) in the province appears to rely on sharp curettage, although reports indicate that most women consider it invasive and uncomfortable. Additionally, despite misoprostol being a widely accepted treatment option for incomplete abortion among women (MOHCC, 2013), the method is not widely provided. The non-utilization of misoprostol could be attributed to its unavailability at rural health centers which are closer to the community compared to district and mission hospitals. Providing MVA at rural hospital level could improve uptake of this service. Availability of misoprostol and sensitization of health care workers on this method could increase its uptake in the province (MOHCC, 2013).

Limitations Some project indicators did not have a data source. For example, Chimanimani is the only district with information available about children under five with fever screened for malaria with RDT at community level by VHWs. Current MOHCC reporting tools do not disaggregate data reported by VHWs, who report on malaria through the Rapid Disease Notification System (RDNS) in which the data is reported as an aggregated health facility report. There is need to consider disaggregating data by VHW and facility in the District Health Information System (DHIS2) reports to establish the community contribution to the health system and the necessary feedback to support the community health delivery and reporting system. The Mhuri/Imuli project will promote the utilization of mobile based technologies in delivering health education and reporting by VHWs at community level. The data will eventually be reported in the DHIS2 with clear disaggregation by facility and by VHW contribution.

Additionally, no data is available on health care workers trained using on-the-job competency-based approaches, as this is a technique that will be initiated by the Mhuri/Imuli project. On the job approaches are considered effective in terms of learning outcomes, skill delivery and cost compared to workshop based (Bluestone et al., 2013). The Mhuri/Imuli project will administer a database of all health staff trained on the job and continuous support will be provided to ensure quality and accessible MNCH services reach the intended populations.

Further, no standard data collection tools exist to ensure systematic reporting of women receiving uterotonics in the third stage of labor. Regular reporting this indicator would help assessment of the quality of intrapartum services, especially the management of post-partum hemorrhage. We recommend that MoHCC standard data collection tools such as the Tally 5(T5) include this key indicator in its monthly reports.

Finally, no data was available in any official document for case fatality rates for postpartum Hemorrhage (PPH), Pregnancy Induced Hypertension (PIH), sepsis and malaria related pregnancy complications. The Mhuri/Imuli project will support the MoHCC to regularly report on this indicator during MPMA meetings. This will help health care workers identify major causes of maternal deaths and design OJTs that addresses them.

5. Conclusion and Recommendations

This assessment set out to determine the status of key Mhuri/Imuli project indicators to inform project implementation. The assessment shows that most MNCH and FP indicators in Manicaland province are behind national performance or targets. The results of the assessment suggest that improvements are possible, as exemplified by progress seen at 36 health facilities under MCHIP during the period 2013 – 2017. However, these improvements need to have mechanisms in built to sustain the gains.

The assessment shows that whereas most indicators have reliable data sources, gaps exist with data for key community-level services, as well as with service-quality indicators. Considering that maternal and perinatal outcomes remain poor in the province despite reasonably high levels on institutional delivery, filling gaps in service quality data is critical for improving facility-based intrapartum care. Systematic collection of community-level data would support a complete picture of service utilization in the province both at community and facility levels.

Further, the assessment highlights a critical need for health promotion activities in communities in support of improved health seeking behaviors. Early attendance of ANC, IPTp and utilization of a broader range of contraceptive methods are areas that would benefit from SBCC. Adolescents, who exhibit high teenage pregnancy and poor MNCH outcomes, as well as members of religious objector communities are suggested targets for health promotion.

Programmatic recommendations A programmatic recommendation from the assessment is to build on MCHIP interventions which yielded improvements, and inbuild sustainability mechanisms. Suggestions for enhancing sustainability include introducing OJT, which is low-cost, and user driven. OJT coupled with cQI with monitoring and incentives at the system level will help to drive HCW-led demand for skills and data improvements. In addition to skills enhancement in the clinics, continuation of maternal and perinatal death audits with a focus on learning and following up recommendations is suggested as a management strategy.

At community level, suggestions for improvement include SBCC to improve ANC and IPTp utilization, as well as institutional delivery. Messages that embrace and support health seeking behaviors among pregnant teenagers will go a long way to encourage early ANC service uptake by expectant teen mothers. Additionally, messages aimed at discouraging stigmatization of pregnant teens could help change community perspectives towards adolescent pregnancies and increase uptake of early ANC services by this critical age group. In all SBCC efforts, a deliberate effort to engage men will be important for empowering women and girls to seek health services.

Where possible, leveraging feed-the-future programs in the province to integrate critical service utilization indicators into food distribution and community savings schemes should be encouraged. Further, strengthening VHW skills to enhance household – facility linkages, particularly in under-served communities will go a long way in enhancing trust in MNCH and FP services. Since the province has a large proportion of apostolic

30 communities, targeted approaches for religious objectors to adjust social norms and behaviors in support of improved health seeking are critical

Research and Data recommendations This section presents suggestions for improving the availability and quality of MNCH and FP data in Manicaland province. To increase the availability of data on utilization of uterotonics, the project recommends that the MoHCC Tally (T5) include this key indicator. This will enable monthly reporting on this key indicator.

Another key indicator whose data availability requires improvement is the availability of MVA for removal of retained products of conception, which is one of the six BEmONC signal functions. Currently, BEmONC facilities offer 5 signal functions (excluding assisted vaginal delivery, in line with MOHCC policy for rural hospitals and health centers). As such, assessment of BEmONC availability should be based on 5 signal functions. In addition, the method for removal of retained products of conception should be noted for each facility which provide this service and an exhaustive list of options provided, to enable stratification of BEmONC availability by MVA. This change will enable targeted improvements in MVA availability.

At the community level, a recommendation is to facilitate the deployment of routine data collection tools to enable continuous collection and reporting of community-level data by VHWs. Currently, the C-series forms are intended for use by VHWs to collect information that is DHIS-2 compatible. However, the use of these forms is dependent on availability of the paper formats, and reporting is dependent on timely submission of the paper forms and their transcription into DHIS 2. We recommend the deployment, testing and expansion of the use of electronic C-series forms, whose entry into DHIS-2 can be achieved in real time. Electronic tools would ease the burden on VHWs and facilitate data quality audits at the community level.

In addition to enhancing routine data collection, we recommend establishing a systematic process for generating data on utilization of community-based MNCH and FP services and information, as well as tracking MNCH/FP behaviors at household level. Lot Quality Assurance Sampling (LQAS) is a practical, rapid, cost-effective but robust methodology which can be used to measure spatial change in health behaviors when applied at intervals (Robertson & Valadez, 2006). Application of LQAS surveys would enable Mhuri/Imuli to attain insight into investments into health promotion and behavioral outcomes.

Finally, OJT is a new method that Mhuri / Imuli will apply for strengthening HCW skills, as a departure from traditional workshop-style training. Because there is no systematic method to track OJT, Mhuri/Imuli should support the utilization of a training database such as TrainSmart, an open-source, web-based training data collection system which allows users to accurately track training programs, trainers, and trainees.

References

Banda I, Michelo C, Hazemba A, (2012) Factors Associated with late Antenatal Care Attendance in Selected Rural and Urban Communities of the Copperbelt Province of Zambia, Medical Journal of Zambia, Vol. 39, No. 3 (2012) Campbell, O. M., Graham, W. J., & group, L. M. S. S. s. (2006). Strategies for reducing maternal mortality: getting on with what works. The Lancet, 368(9543), 1284-1299. Christopher Pell, Arantza Men˜ aca , Florence Were , Nana A. Afrah , Samuel Chatio , Lucinda MandaTaylor Mary J. Hamel , Abraham Hodgson, Harry Tagbor, Linda Kalilani , Peter Ouma, Robert Pool, (2013, vol 8 issue 1) Factors Affecting Antenatal Care Attendance: Results from Qualitative Studies in Ghana, Kenya and Malawi Houweling, T. A., & Kunst, A. E. (2009). Socio-economic inequalities in childhood mortality in low-and middle-income countries: a review of the international evidence. British medical bulletin, 93(1), 7-26. Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R., . . . Dicker, D. (2014). Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384(9947), 980-1004. R Loewenson, S Laver , A Kadungure, S Shamu, W Mushayi (2012). Assessment of facilitators and barriers to maternal and child health services in four rural and urban districts of Zimbabwe. Maguranyanga, B. (2011). Apostolic religion, health, and utilization of maternal and child health services in Zimbabwe: UNICEF. Maternowska, Catherine ,Alexio Mashu, Precious Moyo,Mellissa Withers, Tsungai Chipato (2015). Perceptions of misoprostol among providers and women seeking post-abortion care in Zimbabwe Makuei Gabriel , Mali Abdollahian and Kaye Marion,(2018). Optimal profile limits for maternal mortality rate (MMR) in South Sudan McCoy, S. I., Buzdugan, R., Ralph, L. J., Mushavi, A., Mahomva, A., Hakobyan, A., . . . Padian, N. S. (2014). Unmet need for family planning, contraceptive failure, and unintended pregnancy among HIV-infected and HIV-uninfected women in Zimbabwe. PloS one, 9(8), e105320. MCHIP, (2017)Assessment of drivers and barriers for achieving target IPTp coverage in Chipinge and Mutare districts, Manicaland province, Zimbabwe MCHIP,(2017) End of Project Report MCHIP,2016, Assessment of drivers and barriers for achieving target IPTp coverage in Chipinge and Mutare districts, Manicaland province, Zimbabwe Munjanja, S. P., Nystrom, L., Nyandoro, M., & Magwali, T. (2007). Maternal and perinatal mortality study, 2007: Ministry of Health and Child Welfare. Malaria Indicator Survey 2016 Prata, N., Passano, P., Sreenivas, A., & Gerdts, C. E. (2010). Maternal mortality in developing countries: challenges in scaling-up priority interventions. Women’s Health, 6(2), 311-327. UNDP. 2011. "Keeping the Promises: United to Achieve the Millennium Development Goals. Fast Facts, Millennium Development Goals." Pp. 8-10. Harare: The Saturday Herald, 12 March 2011 UNICEF. (2008). The state of the world's children 2009: maternal and newborn health (Vol. 9): Unicef. VSI.(2013). Expanding!Access!to!Postabortion!Care!in!Zimbabwe!through! Integration!of!Misoprostol Van Lerberghe, W., Matthews, Z., Achadi, E., Ancona, C., Campbell, J., Channon, A., . . . Fogstad, H. (2014). Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. The Lancet, 384(9949), 1215-1225. Zimbabwe Statistical Office,2017, Inter-cencal Demographic Survey,Harare Zimbabwe Statistical Office,2005/6, Zimbabwe Demographic and Health Survey,Harare Zimbabwe Statistical Office,2015 Zimbabwe Demographic and Health Survey,Harare

Appendix 1: Data Collection Tool Baseline Data Collection (desk review) Tool for Mhuri/Imuli Project Indicators:

Baseline data

Value Data Indicator Manicaland Buhera Chimanimani Chipinge Makoni Mutare Mutasa Nyanga Zimbabwe Central Mash East Mash West Mash North Mat South Mat Midlands Masvingo Bulawayo Harare Disaggreg Source Year ation

Intermediate Result (IR) 1: Improved quality of MNCH -FP services

Sub-IR 1:1: Strengthened health worker knowledge, skills and attitudes to deliver high quality, integrated MNCH -FP services at facilities

1.1. Percentage PMD of institutional Reports 10 8 deliveries (%) Total , Family 2017 76 76 66 66 45 88 83 2 7 [2.4.1- Heath 3_STANDARD] Report

(PPH, PIH, No sepsis & data malaria)

1.2 Case fatality PPH Rate (PPH, PIH, sepsis & malaria) PIH

Sepsis

Malaria

No Total 1.3 % of nurses, data midwives, clinicians and Male doctors in Manicaland Female (MNCH-FP section) who 19 -24 yrs undergo integrated 25 - 49 yrs competence based on job training 50+

Baseline data

Sub IR 1.2: Increased of primary health care facilities to meet standards of BEmONC services & referrals for CEmONC

1.4 Number of Q1 CEmONC Total VMAS 12 2 1 3 1 2 2 1 85 2018 facilities

1.5 Proportion of primary health Q1 No 7.6 facilities who Total VHMAS 2018 data % meet 6 BEmONC standards

1.6 Proportion of USG-supported facilities that conduct maternal, No Total perinatal, and data child deaths reviews/ audits [2.4.1- 1_CUSTOM]

No Total data 1.7 Proportion of children with Male fever screened for malaria with Female RDT at community level < 12

(Survey months Indicators) 12 - 59

months

1.8 Percentage of MCHIP low birth weight Total EOP 2017 56% (LBW) (<2.5kg Report babies initiated on KMC Male

Baseline data

Female

Sub IR 1.3: Increased # of facilities equipped to offer post -abortion (life-saving) care

1.9 Proportion of facilities offering Q1 No 7.6 post abortion Total VHMAS 2018 data % (lifesaving) care (MVA)

Sub IR 1.4: Increased access to a broader range of family planning methods through outreach services

Total DHIS2 2017

733 915 812 288 925 983

, , , , , ,

166 665 193 852 410 464 750 205 349 254 616

, , , , , , , , , , ,

982

153 26 9 22 25 33 24 11 950 107 98 126 56 54 138 181 11 21

LAPM/Ste

DHIS2 2017

220

rilization ,

380 950 600 030 330 010 030 350

, , , , , , , ,

2 0 10 200 60 1 60 100 14 1 680 1 1 1 1 720 4 90

1.10 Couple

Years Protection Implants DHIS2 2017

801

575 518 974 942 413 885 265 223

in USG- 796.8

, , , , , , , , ,

967 748 737 514 283 972 260 524

, , , , , , ,

supported ,

40 4 1 6 4 9 10 2 280 24 30 39 14 19 40 59 3 7 programs (CYPs

by method)

[HL.7.1.1_STAND IUCDs DHIS2 2017

642

650 661 902 462 029 513 002 445 776

ARD] 444

, , , , , , , , , ,

4 64 175 308 598 2 166 483 29 1 5 4 2 1 4 3 409 1

Injectable

DHIS2 2017 301

003 427 051 195 963 372 781

s 474

, , , , , , , ,

482 062 678 998 340 796 119 706 329

, , , , , , , , ,

37 6 3 4 7 6 5 3 235 28 24 25 21 19 36 37 1 3

Orals DHIS2 2017

951

638 653 741 023 629 031 767 804 238 977 257 813

, , , , , , , , , , , ,

814 791 528 897

, , , ,

68 14 4987 10 12 13 7 4 390 52 36 55 17 11 57 80 1 8

Baseline data

Intermediate Result 2: Increased use of MNCH -FP services and targeting of hard -to-reach population s

Sub IR2.3: Reduced misinformation, attitudes, and practices harmful to MNCH -FP

DHIS2Fa 1 mily 14 Total 2017 10% 8% 8% 9% 6% 14% 1 30% Heath % % Report 2.1 Proportion of 14 yrs & pregnant women booked for 1st below ANC visit before 16 weeks 15 -19 yrs

20 -24 yrs

25 - 49 yrs

DHIS2 6 Family 70 83 65 38 39 113 Total 2017 63% 0 81% Heath % % % % % % 2.2 Percent of % pregnant women Report attending ANC 14 yrs & who receive at least 4 visits for below pregnancy- related reasons 15 -19 yrs [2.4.2- 1_CUSTOM] 20 -24 yrs

25 - 49 yrs

MCHIP Total EOP 2017 87% Report

2.3 Percent of 14 yrs &

women giving below birth who received 15 -19 yrs Uterotonics in

Baseline data

the third stage of 20 -24 yrs labor (or immediately after birth) through USG- Funded MNCH-FP 25 - 49 yrs project [HL.6.2.1_STAND ARD]

2.4 Percentage of MCHIP new-borns Total EOP 2017 82% delivered in Report health facilities not breathing at Male birth who were resuscitated [HL6.3.1_STAND Female ARD]

5 55 58 62 43 47 Total DHIS2 2017 53% 61% 5 % % % % % 2.5 Number and % percentage of pregnant women 14 yrs &

attending ANC below who receive intermittent 15 -19 yrs preventive treatment for malaria 20 -24 yrs

25 - 49 yrs

MCHIP 2.6 Number of 4882 Total EOP 2017 cases of child 3 diarrhea treated Report in facilities and/or by Male community health workers in Female USG assisted

Baseline data

program areas < 12

[HL.6.6.1_STAND months ARD] 12 - 59

months

No Total data 2.8 Number of 14 yrs & clients who receive FP/RH below counseling and took up an FP 15 -19 yrs method as a result of USG support 20 -24 yrs

25 - 49 yrs

2.9 Average Q1 No 2.4 Implants VHMAS stockout rate of 2018 data % contraceptive commodities at Q1 7.70 IUCDs VHMAS Family Planning 2018 % service delivery points (%) Injectable Q1 4.50 [HL.7.1.3_STAND VHMAS ARD] s 2018 %

Intermediate Result 3: Strengthened community systems and linkages to integrated MNCH -FP services.

Sub IR3.1 Improved functio ning of Health Centre Committees

3.1 Proportional Total of functional HCC

Sub IR3.3: Strengthened VHW knowledge and skills to promote appropriate MNCH -FP health seeking behaviors

Baseline data

Total

Male

Female

3.2. Number of MCHIP referrals to < 5 yrs EOP 2017 5354 health facility by Report VHWs for MNCH- FP services for 5 - 9 yrs further management 10 -14 yrs

15 -19 yrs

20 -24 yrs

25 -49 yrs

Intermediate Result 4: Incre ased use of MNCH-FP services, targeting hard-to-reach populations

Sub IR4.1: Increased capacity for policy implementation including advocacy to reduce other barriers to quality integrated MNC H- FP services by health providers

4.1 Number of Ministry of Health and Child Care (MOHCC) actions related to national Total policy implementation undertaken annually [2.4.4- 1_CUSTOM]

Maternal Mortality ratio (MMR) Total ICDS 2017 525 [2.4_STANDARD] (per 1000 000 LB)

Baseline data

Perinatal Mortality Rate (PMR) Total ZDHS 2015 43 34 42 42 32 32 17 24 33 30 29 [2.4.2_CUSTOM] (per 1000LB)

Under-5 Mortality Rate Total ICDS 2017 83 72 75 116 77 36 95 65 69 50 43 [2.4_STANDARD] (per 1000 LB)

Total ICDS 2017 60 52 59 57 61 32 80 48 54 35 33

Infant mortality 0 - 6 days Rate (IMR) [2.4_STANDARD] 0 -28 days (per 1000 LB) (NMR) ZDHS 2015 35 29 28 34 46 25 16 32 22 26 23

29 days - 1 yr. (PNMR) ZDHS 2015 43 22 36 35 25 21 29 28 22 14 20

Modern Contraceptive Total ZDHS 2015 57% 66% 65% 69% 71% 66% 60% 67% 61% 71% 70% Prevalence Rate (mCPR) (%)

Proportion of health care facilities consistently delivering MNCH-FP Total services that are youth friendly at or above agreed minimum standards

Baseline data

No Total data Proportion of men and women Male who say they do not want more children who are Female using long acting reversible or permanent 15 -19 yrs contraceptive methods 20 - 24 yrs

25 -49 yrs

No Total data

Male Number of persons from Female religious objector < 5 yrs communities using MNCH/FP services in the 5 - 9 yrs community and at facilities 10 -14 yrs

15 -19 yrs

20 -24 yrs

No Percent of Total audience who data recall hearing or seeing a specific Male USG-supported Family Planning Female /Reproductive Health (FP/RH) 15 -19 yrs message

Baseline data

[HL.7.2.1_STAND ARD] 20 -24 yrs

No Total data Number of children (under 5) who have died Male in the year prior to a survey in Female religious objector < 1 yr. communities 1 -5 yrs

Proportion of infants born in Total ZDHS 2015 43% 60% 56% 57% 76% 95% 95% 59% 52% 53% the year preceding a survey who were Male exclusively breastfed from within an hour of birth during Female neonatal period

No Total Proportion of data individuals (female and Male males, adult and youth) reporting Female views that gender-based 15 -19 yrs violence and/or forced sex are 20 - 24 yrs wrong 25 -49 yrs

Key of Source Documents and Systems

DHIS District Health Information Systems EOP End of Project Report ICDS Inter Censal Demographic Survey PMD Provincial Medical Director VMAHS Vital Medicines Availability and Health Services Survey ZDHS Zimbabwe Demographic Health Survey