Table 2

Challenges and measures taken during training, monitoring and supervision and mothers’ class and community awareness

Implementation stage	Challenges	Measures
Training	Many healthcare providers faced challenges in manual calculation of expected delivery date (EDD) and gestational age.	Pregnancy wheel was developed and introduced to determine EDD and gestational age more accurately and faster.
	There was a big discrepancy in basic knowledge and understanding between healthcare providers in urban area and rural area.	Pretest and post-test were added to the programme to evaluate participants’ understanding.
	Healthcare providers had difficulties in recording the MCH Handbook accurately.	More exercises and role-plays were included in the training programme.
	Training was not standardised but it depended more on individual ability of supervisors. Healthcare providers had to ask supervisors when there were queries. Distributed training materials were often left at home or misplaced.	Through e-learning platform, training was more standardised. Healthcare providers were able to review the e-learning training anytime they need. All materials and forms were downloadable from the e-learning system.
Monitoring and supervision	Many healthcare providers had difficulties in conducting in-facility training and found more challenges at their first consultation with the new tool.	First M&S was scheduled right after the training so that supervisors were able to support in-facility training and actual consultations using the new tool.
	Both healthcare providers and supervisors did not have clear goals to improve challenges at each health facility.	Based on the advice from supervisors, healthcare providers come up with short-term goals, written up and posted on the wall so that it is clear for everyone what should be achieved by the time supervisors visit health facility in 3 months.
	Many municipal health officials had challenges in reporting the results of M&S to their municipal health directors or provincial health officers.	Summary format was created so that municipal health officials were reminded about what to report and it was easier to capture the trend within each municipality.
	Allocating budget for vehicle and fuel for M&S was challenging for the municipal health offices.	Telephone M&S was conducted at some municipalities. It was suggested to combine M&S with other health programmes.
Mothers’ class and community awareness	There was no standardised educational material for mothers’ class at health facility and in the community.	Flipchart based on MCH Handbook content was developed.
	Mothers’ class was not systematically operated. Mothers received the same information at every class. Some mothers did not receive any class. It was unknown if mothers’ class were held	A monthly class plan form showing which two topics healthcare providers were expected to cover every month was developed and displayed at the facility where it could be viewed by multiple healthcare providers. They could also record their name and date against topics they conducted in each mother’s class.
	Healthcare providers did not have time to conduct awareness raising activities in the community.	As healthcare providers were too busy to do outreach activities in the community, a collaboration with existing Community and Health Development Agent was piloted.

MCH, maternal and child health; M&S, monitoring and supervision.