Mobilizing men in rural Nepal to support safer mother hood and reproductive health services.

Research Report.

Executive Summary: There has been increased focus on the importance of men' s constructive role in reproductive health (RH) since the last decade. EngenderHealth's Men as Partners (MAP) program has been playing a key role in increasing men's access to family planning and their role in reproductive health. With the success of a MAP program in many countries, especially in Pakistan, a two-year MAP pilot project was initiated in the four Village Development Committees (VDCs) of Nawalparasi district of western Nepal in November 2002. The goal of the Nepal MAP project is to demonstrate the utility and effectiveness of male involvement in improving the reproductive health of both men and women. The project is a joint collaboration between the Ministry of Health, Family Health Division, and USAID supported Nepal Family Health Program (NFHP), of which EngenderHealth is a partner. The project included several interventions: MAP orientations for health facility staff, Health Facility Management Committee (HFMC) members and Female Community Health Volunteers (FCHVs), and a MAP Peer Educators' training. These preparatory interventions were carried out over a seven-month period (December 2002-May 2003) before the initiation of the Peer Educator outreach activities. Peer Educators who are the volunteers, have been active in their communities since June 2003. Peer educators' roles in the communities are to provide outreach information to men and women in their communities with key reproductive health messages about family planning, STI/HIV, safe motherhood, and men's constructive involvement in RH and to distribute condoms. Peer educators are followed up and monitored every two months by the MAP Program officer. The objective of this mid-term evaluation was to assess if the MAP project has contributed to improved reproductive health outcomes in the four intervention areas, and to assess the attitude and perception of key stakeholders in the community (i.e., women and men, service providers, health management committee members) toward the MAP project. The evaluation was carried out using both qualitative and quantitative methods, which included analysis of service statistics, interviews with service providers, FCHVs, peer educators and community people, and focus group discussions with HFMC members. Seven indicators for the mid-term evaluation were identified from the service statistics: number of condoms distributed, number of men accepting vasectomy, number of women accepting pill and Depo-Provera, number of women coming for antenatal check-up (ANC) visits, number of women delivering at health facilities or at home by a skilled attendant, and the number of male STI clients seeking services from the health facility. We collected information on these 7 indicators for the period January to December 2002 to serve as baseline data. Based on the service statistics information and the interviews with key stakeholders, the findings are quite encouraging. An increase has been noted for all the seven indicators between 2002 and 2003 from service statistic records. The most notable increase was in the number of condoms distributed, which increased from 20,620 pieces in 2002 to 56,477 pieces in 2003. The evaluation also indicated that after the MAP project began, more husbands are accompanying their wives to seek health services. Health facility data indicate that the number of men coming with their wives for (ANC) services has increased significantly in all the VDCs where the program has been implemented. For example, in the first quarter of 2003, 60 men visited a clinic with their wives in Jaganathpur health facility. During the fourth quarter of the same year, this number increased to more than 150. Increased male participation in ANC services was also reported during the inte rviews with various groups of respondents In addition to accompanying wives for ANC services, husbands are providing care and support in other aspects of safe motherhood after the MAP project. Women are encouraged by their husbands to have nutritious food during pregnancy, take rest and have ANC checkups, and are offering increased support in household activities etc. Respondents reported that there has been increase in the knowledge of reproductive health issues, including STI/AIDS among the community people. This has brought some changes in their health status and health seeking behavior. Community people feel that the quality of health services has improved at the health facilities-staff are more polite, responsive and encouraging men to visit the clinic with their wives. After the MAP training, health facility staff and FCHVs have realized why men's role in reproductive health is important. They feel that their work is supported by the Peer Educators (MAP project) and feel that the project should be continued, strengthened and expanded. There are some improvements to be made in the project as well. There is need for more collaborative work between the FCHVs and the male peer educators since they are serving the same communities. Although services in many reproductive health issues have increased after the MAP project, men and women are not seeking STIs services at local health facilities. Based on this mid-term evaluation findings the following recommendations have been developed: · Strengthen the linkages between Peer Educators and FCHVs, · Conduct orientation and refresher trainings to Peer Educators and health facility staff on STI prevention, and emphasize the use of condoms for dual protection, · Conduct interpersonal communication training for the peer educators, · Strengthen couple counseling during ANC check ups, in order to address issues such as increasing women's awareness in about danger signs during pregnancy and child birth, and precautions to be taken, · Expand the program in other areas in a cost-effective way, and · Continue monitoring the project.