A Community Based Surveillance System for Maternal and Early Neonatal Complications:

The Intibucá Case Study

Rosales A. Catholic Relief Services, Program Quality and Support Departments,

Baltimore, Maryland USA

Galindo J. Catholic Relief Services/Honduras

Flores A.

Secretary of Health, Honduras

2

Abstract:

One determinant for the prevailing health inequalities in the developing world is

the inappropriate or lack of health information, especially in rural areas. New and

innovative methods for collection of information in developing countries have

recently been developed and implemented by countries such as China,

Tanzania, and India. Notwithstanding these efforts, maternal generated data

remains one of the most neglected areas. This paper describes the development

of a population-based health information system designed and implemented by

CRS in the rural areas of Intibucá, Honduras. The main objectives of this system

were: first, to estimate the magnitude of maternal and early neonatal health

problems in the population of pregnant women and newborn children; second, to

document its distribution and spread at a population level; and third, to evaluate

the impact on maternal and neonatal mortality of an intervention utilizing

traditional birth attendants for risk assessment, first aids in obstetric

emergencies, and management of an emergency transport system. The

collection, analysis, and dissemination of health data and information were

designed to support the decision making at the community level and the entire

system was sustained by community structures. Additionally, the paper describes

the various steps taken by the program in the design phase of the system; its

training methodology, its implementation and information flow within the system,

and it provides an in-depth description of the supervision methodology and used

approach, as well as an innovative approach to promote the utilization of

information at all levels of the system. The case study, also presents an example

of maternal-related indicators with potential use in the management of the

program at local and national levels. The authors of the paper concluded that

maternal information to prioritize, plan, implement, and sustain effective

intervention strategies can be produced and sustained by community structures

at a low cost, that this information is useful for health planning and policy

development at district and national level, and that the information produced

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complies with WHO standards. The implementation of information systems at

population level could be a factor in decreasing health inequalities in developing

countries.

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A Community Based Surveillance System for Maternal and Early Neonatal Complications: The Intibucá Case Study. Introduction: In developing countries inequalities in health are overwhelmingly prevalent.

Health care between rich and poor, urban and rural, adults and children, female

and male, is just not the same. It is better for some, and worse for others.

Determinants for these differences are many, but one of them, especially in rural

areas, is without a doubt: lack of information. One important limitation in

addressing global and developing country health status is the limitation of

available measures of global-country health status. In this 21st century, less than

90 countries contributed age and sex death statistics and cause specific death

statistics to the latest WHO data bank.1 Less than one third of the world’s

population is adequately covered by national vital registration systems and there

is a wide regional variation ranging from 80% population coverage in the

European region to less than 5% population coverage in the Eastern

Mediterranean and African regions of WHO. Hence, many public health experts

have questioned the process by which countries and international agencies are

producing relevant and responsive health policies at national and global level.

Given this picture, some developing countries are resorting to new and

innovative methods to collect this type of data. Since 1992, Tanzania initiated a

demographic surveillance system2 to monitor health and poverty status at

national level. This “sentinel” system generates a wide range of indicators from a

sample of 500,000 persons, with a cost of only US $ 0.20 per person. In China,

provincial authorities have provided death data on a routine basis for the past

decade from a nationally representative system of 145 disease surveillance

centers covering 1% of the total Chinese population.3 Similar attempts have

1 World Health Report 2003: Making the future. WHO: Geneva 2003 2 Mswia R et al. and the AMMP Team. Dar es Saalam demographic surveillance system . In: The INDEPTH Network. Population and Health in Developing countries. Vol. 1: Population, Health and Survival at INDEPTH sites. Ottawa, International Development Research Centre, 2002:143-150 3 Lopez AD. Counting the death in China: measuring tobaccos impact in the developing world. BMJ 1998; 317: 1399-400

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been made in India where, through multiple channels (Sample Registration

System and retrospective half-yearly population surveys), a high coverage of all

deaths (estimated at 95%) has been achieved.

Honduras, where this case study took place, according to reports in the last

decade is estimated to have at least a 40% under-reporting of mortality data. The

under reporting is especially severe for maternal-related deaths and acutely tilted

towards rural areas. It has been very well documented through many reports the

acute inequalities in health that takes place in the American continent. Health

inequalities between urban and rural communities in Honduras are abysmal. In

an effort to bring this inequality to a halt, Catholic Relief Services (CRS) started

implementing during 1999, in conjunction with a local agency (COCEPRADII), a

child survival program funded by the United States Agency for International

Development (USAID) in the rural areas of Intibucá, Honduras.

The four-year program spends 35% percent of program effort on “safe

motherhood and newborn care” interventions, the objectives of this component

were to improve the ability of women, families and traditional birth attendants

(TBAs) to recognize/prevent, and respond to obstetric complications; and to

improve the ability of women, families, and TBAs to access first-level referral

facilities in the event of obstetric complication. In this area of Honduras, where

UNICEF estimated a maternal mortality rate of 534 per 100,000 live births, and

where 83.5% of deliveries occur in the home, a community based health

information system (CB-HIS) was the first step in the process of improving

access to, and adequate maternal care.

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Purpose of the Health Information System:

The main objectives of the health information system were to estimate the

magnitude of maternal and early neonatal health problems in the population of

pregnant women and newborn children, to document its distribution and spread

at a population level, and to evaluate the impact on maternal and neonatal

mortality of an intervention utilizing traditional birth attendants for risk

assessment, first aids in obstetric emergencies, and management of an

emergency transport system. The program considered this model a community-

based HIS since the collection, analysis, and dissemination of health data and

information were designed to support the decision making at the community

level.

Development of the System:

Design: the surveillance system was designed by CRS health technical officer at

headquarters in collaboration with the Honduras field office. Health staff from the

Ministry of Health and community resources started to take part in the system

design after the second step was finalized.

First step: The first step taken was to define

specific information needs; specifically, what

do we want to know? One principle applied in

this step was to carefully include information

that would have implicit action, information

with a purpose. Thus, the system does not

become overwhelmingly filled with “nice” but

useless information that eventually causes

the entire system to become unmanageable.

Steps in the Design Phase • Establish objectives • Develop indicators • Develop or adapt data-

collection instruments • Field-test instruments • Develop dissemination

mechanisms • Assure use of analysis

and interpretation

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Second step: Once information needs, based on the objectives of the system,

were defined, the program’s team worked on developing health indicators that

would comply with program information needs. Numerators and denominators

were also defined, and their collection feasibility assured. In this case in

particular, many of maternal indicators were already being defined during the

program development phase, but even these were subject to revision given local

reality and program needs.

Third step: once indicators were defined, the field team started gathering

information regarding locally designed data collection tools. The program was

basically looking for a tool with two characteristics, simplicity and sustainability.

After considering various models, the program adopted a data collection tool

developed by University Research Corporation/Quality Assurance Program for

the Hondurans’ Ministry of Health. The tool had been designed to collect

maternal information at the community level, and to be used by individuals with

limited educational skills. Thus, the tool was of simple use and integrated into the

ministry of health information system. After its selection, the tool then went under

a process of adaptation, in which program staff and stakeholders from the

communities revised the tool to satisfy program requirements. The tool (Listado

Comunitario de la Salud Materna) collects 16 pregnancy-related variables and it

has drawings incorporated to aid those community resources with limited literacy

skills.

Fourth step: The team proceeded to probe the effectiveness of the tool in

supplying the information needed by the program and its user- friendliness, thus

a small group of TBAs was trained to use the tool on a small scale and report

back to the team. The tool was adapted based upon recommendations from

users during the probing period.

Fifth step: During the next phase, program staff with support from an adult

educator expert proceeded to design the training content and methodology for

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trainers of trainers and community resources. Likewise, during this period the

staff determined the flow of information within the system. During an evaluation

after one year of implementation, it was noted that information collected was not

been used by all levels in the system for program management purposes,

therefore a sixth step in the system design was added.

Sixth step: Assure use of analysis and interpretation. With support from the

health STA at headquarters, the program identified criteria for decision-making at

each operational level, from the household to headquarters level for

interpretation and use of information. The process utilized in this step is

discussed in the section “programmatic use of information”.

Training methodology: The training on the HIS for this program was done in two

phases. During the first phase, all program personnel (field supervisors and

health educators) received a 4-day training. The training used an adult education

approach, based on experiential reflection and group discussions. The content of

the training included a general concept of a health information system,

programmatic needs of information, information utilization in program

management, strengths and weaknesses of a health information system, and

differences between monitoring and evaluation. In the first topic concepts related

to goals and objectives, indicators, and monitoring and evaluation were reviewed

and discussed. During the programmatic needs of information, participants

discussed the need of information for management purposes, assessment of

program activities and readjustment in response to program information. Also in

this section other topics for discussion were program benefit distribution, financial

assessment, and program limitation and responsiveness to local needs. An

exercise to analyze potential users of program information was done, followed by

a presentation on the qualities of an information system in terms of credibility,

precision and opportunity, result attribution, relevancy, and representativeness.

Technical and operational limitations of an information system were also

examined with the participants. The last part of the training content dealt with

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monitoring and evaluation information needs vis-à-vis the various phases in

program implementation.

A second part of the training included working groups to determine specific

program information needs based upon program indicators, and identification of

local information sources at community and health facility level. Based on this

process, the last day of the training the group adapted HIS tools and standard

format reports.

During the second phase, program staff (health educators) trained the TBAs on

the utilization of HIS tools. During an initial stage a 3-day training was

implemented for the TBAs; followed by weekly home-visits to review use of data-

collection forms and limitations in its utilization by TBAs.

The training was focused on proper utilization of the data collection tool and

information for decision-making. A very important part of the training

methodology was the field visits to localities where the TBAs were collecting data

and accompaniment on this process. This accompaniment was intense during

the first month after the training, once the appropriate use of the data collection

instrument was assured program personnel relaxed individual accompaniment of

TBAs. In those cases in which serious limitations in the use of the instrument

were identified, a peer-to-peer approach was utilized, in which more experienced

TBAs visited less experienced ones until capacities were improved. There were

few cases in which due to serious literacy limitations the TBAs were found to

have serious limitations in the use of the instrument. In these cases, program

staff identified and selected a literacy-able person in the community to assist the

TBA in data collection activities (in many occasions the TBA would select this

person, which in many cases ended up being a relative of the TBA with literacy

skills).

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Each Month, health officials and program personnel with the TBA held a meeting

in the health facility during which the information collected was reviewed. The

meetings emphasized a process of analysis and reflection on real situations

experienced by the TBAS during that period of time, how situations were

addressed, what limitations were encountered, and possible solutions were

discussed.

How the system works: The system is initiated by the identification of a pregnant woman. The local

traditional birth attendant does this identification. Once the woman is identified,

the data collection tool is applied. This tool collects the number of pregnant

women in the village; status of prenatal care; age of the pregnant woman,

presence of complication, its period of occurrence (prenatal, delivery, post-

partum), and type of complication; referral and its causes; place of delivery and

by whom; outcome of pregnancy (dead or alive) for both mother and newborn, as

well as cause of death (see annex 1). The tool collects enough data to produce 6

out the 17 indicators for monitoring progress in achieving reproductive health

goals4 recommended by the World Health Organization, UNICEF and UNFPA.

See box 1.

Box 1. Indicators for monitoring maternal health collected by the Intibucá maternal surveillance system

1. Maternal Mortality ratio 2. Percentage of women attended, at least once during pregnancy, by

skilled health personnel for reasons related to pregnancy 3. Percentage of births attended by skilled health personnel 4. Number of facilities with functioning basic essential obstetric care per

500,000 population 5. Number of facilities with comprehensive obstetric care per 500,000

population 6. Early Perinatal Mortality rate

4 July 2000 inter-agency revision added two new indicators to the list of 15 defined during the 1996 inter-agency consultation, involving WHO, UNICEF, and UNFPA.

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Information system flow: the second step in the development of the system was

to determine how the information would flow between the different levels as well

as how this information would be utilized at these various levels. As observed in

figure one, the traditional birth attendant collects the information from a pregnant

woman in the community. On a monthly basis, the TBA reports this information to

the next level, the health educator. At this level the information from various

TBAs is tabulated using a formatted report. The report is subsequently delivered

to the next level, the field supervisor, and a copy is shared with the local health

facility. The supervisor tabulates information from various health educators to

produce a report of his/her area of supervision. The program manager then

collects this report, and shares a copy with the health region officer from the

ministry of health.

The CRS’ program manager aggregates monthly data to produce a quarterly

report, which is submitted to CRS’ program quality and support department in

headquarters (Baltimore). The health officer in headquarters uses these quarterly

reports to develop an annual report, which examines variables associations and

trends.

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Figure 1. Community reproductive health information system flow, Intibucá, Honduras.

Case report source

Traditional Birth attendant

Program Health Educator

Program Field Supervisor

CRS-Program Manager

First level HF-MoH

Health District-MoH

CRS-Headquarters

Supervision: the supervisory approach in the program was conceived and

applied as a support activity. Every effort was taken in the program to avoid

police-approach supervision. The system supervision had various levels, with

each level having a clear set of supervisory activities and responsibilities. At all

levels the supervisory methods applied were observation with checklists, field

visits, work plans reviews, and report analysis. Supervisory activities counted at

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each level with skill specific-checklists to aid in the implementation of supervisory

activities.

In the first level of supervision, the health educator supervised the local level of

data collection (TBA). This supervision was done on a monthly basis, and it had

three main objectives: a) To review the information system b) To analyze

maternal health status in the locality based upon the information collected, and c)

To provide skill-related continued education to the TBA. The health educator

reviewed each data collection form submitted by the TBA and corroborated that

the form had been adequately filled. When a form was identified with errors, the

health educator contacted the responsible TBA and supported him/her in

correcting the mistake. Also, during each supervisory visit the health educator

applied a skill-specific checklist to assess through observation how the TBA was

implementing an obstetric-specific skill. Those TBAs identified with major

technical or administrative needs during supervision were visited more

frequently. Each health educator had 6 or 7 TBAS under their supervision. Based

on information collected during supervisory visits a technical support agenda was

developed to be implemented on a monthly basis at the health facility monthly

meetings. Each month, a meeting with community health resources (TBAs) was

held at the health facility. During these meetings, the TBAs would use their health

registry (listado comunitario) collected during that month and submit it as a report

to the local health facility. Health facility personnel would use this registry to

update their official health information system. Also during these meetings a

maternal mortality cause analysis was done in those communities in which a

maternal death had occurred during the previous month. Communities with

identified maternal deaths would receive a joined CRS-MoH field visit, which

would provide information on how to prevent maternal deaths in the community.

In the second level of supervision, the field coordinator accompanied the health

educator in field visits. Each field coordinator supervised 5 or 6 health educators.

During this visits the field coordinator reviewed a sample of data collection forms

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from each health educator to assure data quality. Also a supervisory checklist

was applied in each visit with individual support supplied. Common challenges

identified during these visits were addressed during monthly group meetings.

In the third level of supervision, the health coordinator in collaboration with the

program manager supervised three field coordinators utilizing the same

methodology, but mostly focused on improving supervisory skills. On a monthly

basis, meetings with technical personnel were done for activity planning and

performance analysis.

Data analysis and Interpretation: the main purpose of a MIS is to have

information for the management of a program5. Analysis of collected data is an

intrinsic piece, and the first step in information usage; it is an essential

prerequisite for programmatic management decisions. In the case of Intibucá, the

information system systematically collected, analyzed, and interpreted ongoing

information about maternal and neonatal health status at the population level for

use in the planning, implementation, and evaluation of community maternal

interventions.

In its more simplistic way, data analysis refers to the aggregation of information

collected, whereas interpretation conveys the action of assessing the emergence

of patterns in the information collected. The aggregation phase of data collected

took place at field level (health educator/field coordinator/program manager).

Data interpretation in the system took place progressively from simple to complex

interpretation at program manager and headquarters level. The Intibucá

information system was descriptive in its nature, providing the What, Who, When,

and Where of maternal health related events in the rural communities of Intibucá.

Data was organized and summarized according to time, place and person.

5 Guide for Program Managers in Developing Simple, Participatory Systems to Enhance Use of Data for Decision Making. Catholic Relief Services 1999

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The Intibucá program managers (CRS/COCEPRADII) carried out on a monthly

and quarterly basis a descriptive analysis of data collected at the community

level. Additionally, an assessment of achievement of field personnel monthly

objectives was done. The Intibucá health team in collaboration with CRS

headquarters created a database on EPI-INFO 2000 and Microsoft Excel with

information collected on the maternal-neonatal component. Using this database

CRS Honduras produced and submitted a quarterly report to CRS headquarters.

This report included the computation of frequencies and percentages on

variables such as prenatal care, pregnancy by age group, deliveries by locus,

maternal and neonatal death rates etc. CRS headquarters used these quarterly

data to further its analysis in finding trends and associations amongst variables.

Based on these analyses a two- years report was produced and used in an

impact evaluation of the program6.

At the local level, program managers held a monthly meeting with program staff

to present descriptive analysis and monthly objectives achievement per

municipality. Likewise, every four months, a community meeting was held to

present data on maternal and neonatal status in the respective communities.

This meting was held during a weekend and attended by the entire community,

municipal leaders, local ministry of health staff and health program personnel

(CRS-COCEPRADII). The information was communicated verbally and with

support from visual aids to encourage participation from illiterate community

members. During these community meetings, participants were expected to

participate in problem-analysis and discuss and propose feasible solutions to the

problems analyzed.

Programmatic Use of Information: one of the main objectives of CRS health

programs worldwide is to empower communities to manage their health as part

of the development process. As such, building capacity at community level to use

6 Anderson et al. Final Evaluation Report Community Based Child Survival Program CRS Intibucá Honduras. December 2003.

16

relevant health information to make decisions is a fundamental aspect in the

empowerment process. A review of the Intibucá CB-HIS highlighted the fact that

the system was operational and producing the expected information,

nonetheless, use of this information by the various programmatic levels involved

in the program was limited 7. The recommendation by this review was to identify

the criteria for decision-making at each operational level: TBAS followed by

health educators, field supervisors, and finally, CRS managers. During that time

it was stipulated that community members and staff from the ministry of health

would be involved in this process of setting criteria for decision-making as well as

in the regular assessment of decision-making that would follow. Hence, criteria

for decision-making and related information needs were defined for each level of

the system, starting with decisions at household, followed by decisions at the

TBA level, health educator, field supervisors and managers. See figure 2.

The program followed the traditional steps in the decision making process8:

• Define the problem or decision to be made: at each level, starting with the

household, the program staff defined in accordance with information collected

vis-à-vis program objectives, what type of decisions were expected to be

taken at each level.

• Determine who will use the data/information gathered: from the beginning of

system design the different levels of information use were determined. Use of

information even at the client level (pregnant woman) was incorporated into

the design.

7 Rosales A, Report on Intibucá HIS evaluation. CRS June 2001 8 Debay M et al. On the Design of Community-Based Health Information Systems. CSTS February 2003

17

• Define the information needed and gathered the relevant data: this step was

done during the design of the information system in this particular case. It is

important to note that the process can occur in

any order, and is iterative. As mentioned

before, the definition of information needs in

this program was done in several moments of

program implementation, starting at the

proposal design phase.

• Define the criteria to select the best solution:

based on information gathered and local

feasibility of action, a criterion for its selection

was established. The most important fact in

this selection was the feasibility for action given

local conditions and community consensus.

• Generate solutions and select the best alternative: the best solutions to

potential problems were identified at each level.

• Compare solutions and select the best alternative: this step was implemented

simultaneously with the previous one, and executed in a participatory way to

assure commitment from the decision maker.

• Implement and monitor the best alternative: monitoring of decision-making

implementation was done through monthly staff meetings and quarterly

community meetings.

Steps in the Decision-making Process • Define the problem or decision to

be made • Determine who will use the

information • Define the information needs • Establish criteria • Generate alternative solutions • Predict the consequences of

alternative solutions • Compare solutions and select the

best alternative • Implement and monitor the best

alternative

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Figure 2: Criteria for Decision-Making defined in the Intibucá program by oprational level

Community/Household/pregnant woman Decisions: adopting key behaviors, seeking outside care,emergency transport

Traditional Birth Attendant/Community Decisions: case management, referral, follow-up with support;supportive actions

Program Health Educator Decisions: collective education-information, quality of TBAData, technical assistance for TBA, inter-sectoral coordination

Program Field Supervisor Decisions: program management, operational supervision

Program Manager Decisions: program management, technical supervision, needsassessments

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Household and pregnant woman: in the community and household members as

well as the pregnant woman decisions were related to which key behaviors to

adopt, and when and where to seek care outside the home. The program

emphasized information on danger signs related to pregnancy as well as

exclusive breastfeeding for neonatal health. The program improved substantially

referral of pregnant women with complications to health centers with essential

obstetric care through decisions at the household level to seek care outside and

through decisions at the community to support evacuation of complicated cases

via a community emergency transportation system. Community and household

members receive feedback information from collected data during community

meetings held every four months. During these meetings program and ministry of

health staff reported back to the community on status of its maternal and

newborn population. Emphasis was done on information about key behaviors

and emergency transport activities.

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Example of desicions taken by communities during quaterly Community

meetings

Community Problem addressed Community analysis Decision take/commitment

El Gabriel - Colomoncagua

During August-November period FY 02, CHWs attrition increased, 10% of children weighted with inadequate weight-gain tendency.

Economic situation in the area is promoting external migration, especially to El Salvador. In the community there is only one CHW in place. Some members of health committees have also emigrated.

•

•

•

Continue with weight monitoring of children in the community One more CHW is assigned and began training New community members for the health committee are incorporated.

Callejón - Colomoncagua

During August-November period FY 02, 32% of children weighted with inadequate tendency, and 7% of these have done so in two consecutive periods.

Children in communities experienced an increased in diarrheal and ARI diseases.

•

•

•

Chlorination of water for adult consumption and boiled water for children. Referral of children with danger signs to health facility Training of 5 more community resources on nutrition.

• Referral of children with nutritional deficits to nutritional center.

Las Aradas, Ojos de agua, La montaña – Santa Lucía

Lack of access to Obstetric emergencies in the 3 communities

There are no community plans for evacuation during emergencies.

Emphasis on: * Surveillance to pregnant women, prenatal care promotion, continuation of TBAs health promotion on danger signs during pregnancy, delivery and puerperium. *TBAs will identify those women with danger signs, and the transportation committee will provide the means to evacuate those cases with obstetric emergencies.

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Traditional Birth Attendants: at the TBA operational level decisions were taken on

daily organization of work activities, prioritization of home-visits, selection of

education activities, as well as detection and referral of complicated cases,

investigation of maternal and neonatal deaths. TBAs received from program staff

and secretary of health staff specific guidelines on information utilization during

supervisory visits and during their monthly meetings.

Health Educators: at this operational level, information was utilized to identify

training needs of TBAs, prioritization of geographical sectors for technical

support, and monitoring of work activities. Programmatic and management

decisions were taken systematically during monthly meetings.

Field Supervisors and program managers: at this level most of the information

was used to make programmatic decisions. Also maternal and neonatal health

priorities were identified through data analysis, as well as development of action

plans to address these priorities. Also information was used to assess staff

performance on a monthly basis.

Links with SOH health information system: the Intibucá HIS was linked to the

official (MOH) health information system through monthly reports shared at two

levels of the system (see figure 1). The first link was established through the

systematic submission of the health educator’s report to the local health facility;

also the program’s manager report was shared systematically with the regional or

district level. These linkages in addition to provide valuable information for

program planning at the local and district level, it also galvanized a sense of

program ownership as well in the government sector.

Overall results of the HIS: some of the results documented by the information

system were the following: postpartum visits within a 48 hours period were

increased in 75 percent points, 100% of maternal complications were referred to

a health center with resolution capacity, 100% of these referrals were

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accompanied by a TBA, 98% of communities produced an emergency plan for

evacuation of maternal complications, exclusive breastfeeding increased in 31

percent points, the population of women in reproductive age showed an

increased of 70 percent points in knowledge of danger signs associated with

pregnancy, likewise this population improve their knowledge on the lacto

amenorrheic method by 78 percent points.

In the following section, we present an example of descriptive and analytical

epidemiological data produced by the system during two years of

implementation.

The system identified a total of 2123 pregnancies for the period of September

2001 through September 2003 in 95 villages. The estimated total population of

women of reproductive age (12-49 years) in this location is 11,310. It was

estimated based on fertility rates an annual number of pregnancies of

approximately 600 live births per year for this locality (810 LB FY02). Therefore

we can infer that the HIS is probably detecting 100% of pregnancies in the area.

96% of these pregnancies are receiving prenatal care.

N um ber and P ro po rtion o f P regna nc ies in P re n a ta l C a re . In tibuca , H o nd ura s . S ep tem be r 01 - S ep te m ber 03

P ro p o rtio nN u m b erV a ria b le

4 %9 3W ith o u t P C

9 6 %2 0 3 0P ren a ta l ca re

1 0 0 %2 1 2 3# to ta l o fp regn an c ies

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Additionally, the system allows to identified number and proportion of

pregnancies by age group.

N u m b e r a n d p r o p o r t io n o f p r e g n a n c ie s b y a g e -g r o u p . In t ib u c a , H o n d u r a s . S e p t 0 1 - 0 3

1 3 %2 7 5> 3 5

7 5 %1 5 9 41 9 - 3 5

1 2 %2 5 41 2 - 1 8

p r o p o r t io n# p r e g n a n c ie sA g e G r o u p

In relationship with pregnancy-related health problems, the system showed an

overall complication rate in the area of 14%. The majority of these complications

occurred during the prenatal period. The main causes of prenatal complications

were headache, abnormal presentations, edema, hemorrhage, and fever. During

delivery and postpartum hemorrhage was the main complication identified.

C om p lica tion ra te d u ring p re g n a nc y, d e live ry, an d p u e rp e rium . In tibuca , H o nd u ras . S e p t-

01 /S e p t.0 3

7 %2 1P o st-p a rtum

3 1%9 4D e live ry

6 2%1 8 5P ren a ta l

1 4%3 0 0T o ta l

p ro p o rtio nN u m b erC o m p lic a tio n s

Health outcomes in the system were defined as referral, status of mother: dead or alive; and status of the newborn: dead or alive

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The HIS identified maternal deaths. The cases in this indicator (Maternal

Mortality Ratio [MMR]) are defined according to the definition of pregnancy-

related death proposed in ICD-10. In the computation of this indicator, two types

of aggregates can be used as denominators: the number of live births or the

number of total births. WHO recommends the second one. This indicator

provides the program and health area with information about the magnitude of

the problem.9

M a te rn a l M o rta lity R a tio b y m u n ic ip a lity a n d to ta l c o v e re d a re a .In tib u c a , H o n d u ra s . S e p t 0 1 - 0 3

3 9 43 8 32 6 1 /2 5 31S a n ta L u c ia

4 5 24 4 82 2 3 /2 2 11C a m a s c a

1 6 5 91 6 2 02 4 7 /2 4 14T o ta l

8 1 37 8 92 5 3 /2 4 62C o lo m o n c a g u a

T o ta l b ir th s

# o fliv e -b ir th s

M M R/1 0 0 ,0 0 0 lb

N u m b e rm a te rn a l

d e a th s

P la c e

Proportion of women attended at least once during pregnancy by skilled health

personnel for reasons related to pregnancy: This indicator is aimed at maternal

health (not maternal mortality). This is a process indicator that provides

information on the level of utilization of care by pregnant women for reasons

related to pregnancy. “Skilled health personnel” is defined as doctors (specialist

or non-specialist) and/or persons with midwifery skills who can diagnose and

manage obstetric complications as well as normal deliveries. The term excludes

TBAs trained or not trained (WHO definition). The most common used

9 In terms of measuring impact at the moment, given the short period of data collection (24 months), trends are not advisable to examine, we are proposing to analyze these trends at a 3-5 year period. Nonetheless, during 1,999 UNICEF reported a MMR for the area of 534/100,000, which if correct, the current MMR reported for the

area of influence would represent a magnitude 47.2% less in maternal mortality.

25

denominator for this indicator is the number of live births, which acts as a proxy

for the number of pregnant women. This however underestimates the total

number of pregnancies. In our program we use the actual number of pregnant

women as denominator to have a more accurate indicator. The proportion

reported in the baseline (89%) was collected through a cross-

sectional/retrospective study using a cluster sampling methodology (30-cluster).

The proportion reported by the project area is a product of a prospective type of

study and not a sample. Therefore, we do not think these two proportions can be

comparable, and we even infer that if comparable there would not be a statistical

significant.

P r o p o r t io n o f w o m e n a t t e n d e d a t le a s t o n c e d u r in g p r e g n a n c y b y s k i l l e d h e a l t h p e r s o n n e l f o r r e a s o n s r e l a t e d t o t h e p r e g n a n c y . I n t ib u c a , H o n d u r a s . S e p t 0 3

8 9 %2 6 8B a s e l i n e

9 3 %5 1 04 7 4S . L u c ia

9 7 %5 5 15 3 4C a m a s c a

9 6 %1 0 6 21 0 1 6C o lo m o n c a g u a

9 6 %2 1 2 32 0 3 0P r o je c t a r e a

p r o p o r t i o n# p r e g n a n t w o m e n

# w o m e n a t t e n d e d

P la c e

Proportion of births attended by skilled health personnel: This indicator is aimed

both at maternal health and, to a limited extent, at maternal mortality. A skilled

health personnel is defined as doctors (specialist or non-specialist) and/or

persons with midwifery skills who can diagnose and treat obstetric complications

as well as normal deliveries. The term excludes TBAs. The numerator includes

the number of deliveries at clinic/hospital; and the denominator the total number

of deliveries reported at the communities. If our figures are correct since the start

of implementing activities there has been in 20 months an increment of 11

percent points in institutional deliveries; from 14% to 25%. The municipality of

26

Camasca has experienced the highest increment at 38% of total deliveries being

attended at clinic or hospital.

P ro p o r t io n o f b i r th s a t te n d e d b y s k i l le d h e a lth p e rs o n n e l. In t ib u c a , H o n d u ra s S e p t . 0 3

1 4 %4 33 0 0B a s e lin e

2 3 %9 03 8 3S . L u c ia

3 8 %1 7 04 4 8C a m a s c a

1 9 %1 4 87 8 9C o lo m o n c a g u a

2 5 %4 1 01 6 2 0P r o je c t a re a

p r o p o r t io n# d e l iv e r ie s c l in ic /h o s p ita l

# to ta l b i r th s

P la c e

Comparison of proportion of births attended by skilled health personnel at

baseline and final survey: the present graph, just to evidence the impact on

institutional deliveries in two years of program implementation in the area.

P ro p o rtio n o f b irth s a tte n d e d b y sk ille d h e a lth p e rso n n e l a t b a s e lin e a n d fin a l s u rv e y.

In tib u ca , H o n d u ra s , S e p t. 2 0 0 3

0 %

5 %

1 0 %

1 5 %

2 0 %

2 5 %

3 0 %

B a se lin e

F in a l

Early perinatal mortality rate (EPMR): Perinatal mortality (number of stillbirths

and deaths within one week of birth by the total number of births) is suggested

for utilization as a proxy indicator for maternal mortality and maternal health

27

outcomes. In addition it provides useful insight on the quality of intrapartum care.

One of its major advantages is that there are approximately 15 times more

perinatal deaths than maternal deaths. Its ability to register changes is therefore

probably superior to the maternal mortality ratio. Early perinatal mortality

(stillbirths plus one day deaths) is even a stronger indicator for maternal mortality

according to WHO (World Health Organization). In this table we observe that

early perinatal mortality in the program area is 30 per 1000. The national rate of

perinatal mortality for Honduras reported by ENESF (Encuesta Nacional de

Epidemiologia y Salud Familiar) in 2001 was of 29 per 1000. Since EPMR

indicator only includes those children dead after 24 hours and ENESF includes

those children dead after one week, we can infer that health status for pregnant

women and neonates in the program area is worst than at the national level.

Additionally, when we compare early perinatal mortality rate by municipality we

found that there is a statistical significant difference among them, additionally we

found that children born in Colomoncagua are 4 times more likely to die than

children born in Camasca, likewise children born in Santa Lucia are three times

more likely to die that children born in Camasca.

E arly perina ta l m orta lity ra te (s tillb irths p lus one -day o f age deaths) by loca lity . In tibuca , H onduras. M ayo 03

29x1000(O R =2.5 ; P =0.07)

38311S . Luc ia

11x1000 (O R =1)

4485C am asca

41x1000(O R =3.6 ; P =0.004)

78932C olom oncagua

30x1000162048P ro jec t area

E P M R x 1000# to ta l b irth s

# p erin ata l d eath s

P lace

But the most interesting finding is what we found in the association among MMR/Obstetric access and EPMR

28

Association between maternal health monitoring indicators at community: in this

graph, the association between increased access for prenatal care/institutional

delivery and decreased MMR and EPMR is evident. Likewise, the relative

advantage of institutional delivery over prenatal care in affecting EPMR is

obvious. Another interesting fact deduced from this graph is the higher sensitivity

to identify change of EPMR over MMR.

Association between m aternal health m onitoring indicators at the com m unity level. Intibuca, Honduras.

M ayo 2003

0

50

100

150

200

250

300

350

M M R %prenatal %deliver E P M R

All m unicipalitiesC olom oncaguaC am ascaS. Lucia

Percentage of population within 1-hour travel time to health center offering

essential obstetric care: this newly proposed indicator is aimed at measuring

progress towards the reduction of maternal mortality. This indicator measures the

extent of the availability of emergency obstetric facilities. It answers issues of

proximity rather than accessibility. This indicator measures the “delay” from the

moment a care-seeking decision is being made to actual arrival to health care

location where essential obstetric care (EOC [parenteral antibiotics/parenteral

sedatives/parenteral oxitocics/manual extraction of placenta/D&C]) can be

provided. In our covered area there is only one institution that provides EOC; and

only 3% of pregnant women in Camasca reach that center within one hour.

29

P e rc e n ta g e o f p o p u la tio n w ith in 1 h o u r tra ve l t im e to h e a lth c e n te r o ffe r in g e s s e n tia l o b s te tr ic c a re .

In t ib u c a , H o n d u ra s . M a y o 2 0 0 3

0 % (0 /5 1 0 )

3 % (1 4 /5 5 1 )

0 % (0 /1 0 6 2 )

0 .7 % (1 4 /2 1 2 3 )

P ro p o rtio n w ith in th e h o u r-E O C

5 7 % (2 9 0 /5 1 0 )5 1 0S . L u c ia

6 6 % (3 6 5 /5 5 1 )5 5 1C a m a s c a

4 7 % (4 9 8 /1 0 6 2 )1 0 6 2C o lo m o n c a g u a

5 6 % (1 1 9 8 /2 1 2 3 )2 1 2 3P ro je c t a re a

P ro p o rtio nw ith in th e h o u r-H F

# to ta lp re g n a n c ie s

P la c e

The association that exist between access to EOC and institutional delivery with

maternal health is demonstrated in this graph, where the municipality with the

lowest EPMR is the one with the highest percentage of institutional delivery and

the only one with access to EOC.

A ss o c ia tio n b e tw e e n in d ic a to rs o f a c ce s s to m a te rn a l c a re a t th e c o m m u n ity le ve l a n d e a r ly p e r in a ta l m o rta lity

ra te . In tib u c a , H o n d u ra s . M a yo 2 0 0 3

05

1 01 52 02 53 03 54 04 5

% Id e liv E P M A cces s

A ll m u n ic ip a lit ie sC o lo m o n c a g u aC a m a sc aS . L u c ia

30

Lessons Learned:

In developing a community based HIS, CRS Honduras identified several

important lessons:

1. The development process of a CB-HIS must take into account the

availability of local and simple tools for collecting information. Two

important characteristics that should never be relegated are local

idiosyncrasy and educational level of personnel using the system.

2. Information collected must be specific for project management purposes.

Information needs to be related to action, thus avoiding overburdening the

system with useless information.

3. Feasible and useful flow of information, and use at different management

level. The design of the system needs to take into account efficiency in the

information flow and information use specific for each level in the system.

4. Training methodology simple and acceptable. Adult training methods and

supervision ideology are important issues in the development of a useful

and efficient information system.

5. Supervisory approach must be oriented to a culture that values

information-based decision-making. In developing countries, and

especially at community levels one known barrier to using information is a

lack of interpretation skills. Thus, supervision activities need to include this

factor into the equation.

31

Conclusions:

In conclusion, information to fulfill the core functions of public health can be

collected effectively and efficiently at community level, using community

structures. This fact we think has been overlooked by international and national

initiatives.

The quality of information produced at population level, as demonstrated by this

case-study, fulfills international standards, is real information and not estimates,

and represents more accurately what is actually happening in poor and neglected

settings. Thus, this type of information better guides political and technical

decisions.

Maternal information to prioritize, plan, implement, and sustain effective

intervention strategies can be produced and sustained by “community-based”

structures. The information produced by a CB-HIS complies with WHO’s

standards, and it is useful for health planning and policy development at district

and national level.

Current literature and health policy discourages the inclusion of community

resources, such as TBAs, as part of the solution for the maternal health problems

as evidenced by the Colombo’s resolution. Our experience is showing that this is

not a matter of “either-or”; the participation of community resources such as

TBAs is a necessary complement to government initiatives in the solution of

maternal health problems. Impact and sustainability of the impact depends upon

this alliance.

The cost of these types of initiatives is extremely low when applied to a

population level.