The Role of Community Based Providers in Improving Maternal and Newborn Health

1. The Role of Community Based Providers in Improving Maternal and Newborn Health Mary Sibande Kumwanje Community based RH Project-CRH-College of medicine, Malawi Technical Consultation meeting 30TH -31st May, 2012 Royal Tropical institute, Amsterdam, The Netherlands

2. Presentation lay out • Introduction • First broader • Community based RH Project • TBA initiative • How the initiative was implemented • Identifying the problem • Planning the intervention • Implementation • Evaluation • Best practices

3. Malawi &Cord aid project Community based RH Project (Safe mother hood &HIV prevention) • Malawi is a landlocked country in south-eastern Africa • Administratively divided into 3 regions, Has 28 districts, 13- Southern; 6-Northern • Population of 13,187,632 (National Statistical Office, 2007), 45% below the age of 15 • 20% of men have never been to school as compared to 30% of the women (MDHS, 2004). • About 83% percent of the population lives in the rural areas (MDHS, 2004).

4. Maternal Health Services- Malawi The Healthcare system: • Primary, secondary, and tertiary • Primary level- Healthcare needs of 85% of Malawians living rural areas. • Policy support • The National Health Policy • RH in SWAp Malawi 2008- “improved sexual and RH for all people in Malawi. especially the vulnerable and the underserved” • Health Sector Wide Approach (SWAp) with a common Program of Work (POW) • Decentralization of health services to District Assemblies • Expanding access to health services –Service Level Agreements *for maternal health with select Christian Health Association of Malawi (CHAM) institutions* • 2007- A Roadmap for Accelerating the Reduction of M & Neonatal Mortality / Morbidity

5. The Malawi SRHRR policy & LINKS SRHR policy linked to the Malawi Gender Policy. • Service focuses on Male involvement in the development, promotion and delivery of SRHRR services • Gender policy - women empowerment and gender mainstreaming in all developmental programmes 4.2.6 Ministry of Local Government and Rural Development (LG Act of 1998) • Support the promotion of community initiatives for SRHR at village level • Support empowerment of men and women –(make informed decisions on SRHR issues) • Assist communities dispel misconceptions and eliminate harmful practices that could prevent use of SRHR services • Mobilize community leaders to participate in birth preparedness including organizing & supporting community transport for referral of women with obstetric complications • Support empowerment of community leaders to promote SRHR

6. Community Based Health Providers Primary level; • TBAs, referral & education / Safe motherhood Field ass. • HSA, Village Health Committees; peer educators , CBDAs • Medical assistants ,midwives and community health workers From all three departments (clinical, maternal and public health • Majority under public health MOH :country wide • NGOs (UNFPA; UNCEF, Save the children) • College of medicine

7. Roles of CHWAs • Promoters of health education • Growth monitoring • Vaccinations • Community data collection • Treatment of minor ailments and reporting on all out breaks • Delivery services(midwives and medical assistants) • Reporting on maternal health outcomes • Sanitation and disease surveillance • Under five clinic services • IEC and delivery of Community MNH package • Community based distribution agents of FP • Out patient services • Assisting in referring patients

8. Practices/Nice policies • Persisting shortage of skilled health care professionals. • Up 50% vacant establishment posts in MOH & CHAM , (MoH Report 2003). • Inequitable deployment of health personnel, which favours urban areas, • Communication and transport systems remain inadequately developed. • Shortage of resources in the rural facilities • Too expensive for the rural poor • Poor access /availability of EmOC services • TBA burn to provide services • Geographical barriers • Low illiteracy levels/risky cultural practices • Too much resp. for CHWAs, few trained • Not many bottom up approaches

9. As a result/Challenges MMR Still High • Coverage and quality of health services being adversely affected • Delayed referrals to health facilities • 97%-Antenatal coverage, only about 54% of women deliver in a health • institution, • Other women deliver at home , on the way or at (TBA). • use of postnatal services is low. • Only 33% within the 6 weeks of delivery and 18% within 48 hours of delivery (MICS, 2006). • Increased infections for both neonates and mothers (postnatal period) • 2011 -42 MD deaths recorded , ¾ occurred in H/facilities

10. Motivating factors • Up grading , locum, transport and housing for staff in rural areas • Community based maternal &neonatal health package in some districts • Training and refresher courses, recognition by public sectors, supplies • Meetings, supervision • College of medicine • Award system, training, exchange visits-learning by living approach • Community empowerment and participation , • Applicable resources like bicycle ambulance • Community feedback meetings • Valuing their inputs

11. COM integrated INITIATIVES • TRADITIONAL BIRTH ATTENDANTS (TBA ) INITIATIVE • Bicycle ambulance initiativeImproving referral system from villages to health their nearest facilities • Increased male involvement, community ownership

12. Community based maternal death audits- Action-oriented approach to preventing future maternal deaths in Mangochi-Malawi Getting better insight in the causes and underlying contributing factors of maternal deaths regardless of the place of occurrence. Community participation –empowerment tool Com-community -based sm initiative

13. Community empowerment Building on available resources -local leaders, IEC groups

14. Compatibility, and adaptability • The project has been implemented in line with the Malawi SRH Policy 3 & 4 3.9.2.3 SRHRR services shall be participatory to ensure that such services meet the needs of men, women &young people as well as being culturally acceptable. 4.1.3 Community Participation Community participation contributes to the achievement of the goal of the programme, communities will be empowered with skills to take the lead in problem identification and solutions. 4.2.6 Support the promotion of community initiatives for SRHR at village level, Support empowerment of men and women to make informed decisions on SRHR issues Mobilize community leaders to participate in birth preparedness including organizing and supporting community transport for referral of women with obstetric complications

15. APPROACHES • Community based (Bottom up) • Building on what is available/ applicable • Community empowerment • Male involvement • Participatory approaches in all project steps

16. How was the program implemented Problem Identification 1. Health workers indicated: • Nearly half of all deliveries still occur outside medical facilities DHS results 2004. • TBAs delay to refer mother because, some of them overconfident even with cases they can not handle • Some TBAs take their service provision as their business • Their environment are not infection free, most referrals from TBAs come with or end up with infections • TBAs have no skills to identify and handle complications when they arise Com-community -based sm initiative

17. Community members indicated: Health facilities are far from most villages, A TBAs have passion for our mothers because they are her relatives. Some mothers ran away from the health facilities because of the attitude of the nurses CHAM facilities charge costs for all maternal health facilities and affordable for the rural poor During the rainy season, mothers are not willing to go to the hospitals, because they want to be in their garden Long distances and poor road networks Transport not readily available and not conducive No qualified health workers in some facilities Several factors to consider before going to a facility

18. Factors affecting Phases of delay utilization and outcome Phase 1 Social, economic, cultural factors Deciding to seek care Phase 2 Accessibility of facilities Identifiying and Reaching medical facility Phase 3 Quality of care Receiving Adquate and Appropriate treatment POINT Of Departure Thaddeus and Maine (1994)

19. Community Factors contributing to delays to accessing to health services Decision making processes Steps taken Determinants of transport to use -Type of illness – able to sit or not Step one Deciding means of transport to use • Factor affecting starting off for facility services • Finding means of carrying the patient • How & where to find these means • Identifying people to carry the patient • Preparing for the travel • Authority to go from the uncle Step two Getting organized and actual starting off • Factors affecting time of travel to facility • Condition of illness • Means of transport used • Number of people involved • Road net work • Distance to facility Step three Travelling to the facility

20. TBA initiative Improving access to maternal health care in Mangochi district, Malawi Sign posts for maternal health services Both trained and untrained (fact) well known and respected as maternal health services providers in the communities especially in the underserved rural areas

21. METHODOLOGY • Participatory Action research • Conduct research with people not on people • Data collection- FGDS • Women who were delivered by a TBA • ADC members • Husbands of women who were once assisted by a TBA • Influential local leaders • Data analysis qualitative soft ware –Atlas ti

22. Planning the initiative • Selection of TBA and training for a specific • limited scope of services • Ensure linkages and networking •  Clear definition- is a non paying post, the project will only meet the cost of the training and will work as volunteers • After the training, only trained TBAs would be • allowed to provide the services • Untrained would stop immediately by chiefs (bylaw) • Establishing safe motherhood village funds • Supporting/integrated initiatives

23. Implementation • 45 traditional Birth Attendants have been trained in the zone between 2006-2007 • 1 Re-positioning of the TBA in the village • Reintegration in the community – changed scope of TBA service provision) • Introductory village meeting, role of village leaders; HSAs , safe motherhood field assistants and facility health workers • 2 Record keeping • The chief said • “When the TTBA starts working she will be giving reports on every work she has done. At time you will see me at her place, but don’t associate me with other dirty things like kufuna chukumbuyo (looking for the after birth), In the current approach I will be checking on how she is working so that we do not pay the goats, During emergencies if you refuse to go to hospital, I will be coming there to help her, if the TBAs says go to hospital, just accept it is for your own good. Mukumva azimayinu “(Do you hear you women), he asked

24. Cheeking TBA records during supervision Wall messages

25. Community participation in implementation “As task force members we visit our TTBAs and see how they are working. If problems , we tell the ADC. But some village leaders are not serious, very lazy to work on this development A woman said We like TTBAs because they give letters to go to hospital, when you delay to go, a TBA follows on us and reports to the village headman” A woman said “In order to make our referrals, the project will give us a bicycle ambulance, This is our property, we will be maintaining it ourselves with the safe motherhood funds, (Chikole). The bicycle ambulance is given to us because we have a trained TBA who will know when to refer as she is being trained in the One A VHC members said “The SMFAs work hand in hand with HSAs and leaders to promote safe motherhood in our villages, They check TBA records and maternal health outcomes and report deliveries and MDs, even newborn deaths at the ADC and health facility“

26. Evaluation of the intervention • Increased referrals -from villages (TBAS) to health facilities • Community empowerment - ownership of the initiative - male involvement • Increased deliveries at health facilities • Increased number of pregnant women delivering at health facilities (Skilled) • Increased number of timely referrals • Reduced maternal deaths

27. INCREASED REFERRALS TO HEALTH FACILITIES

28. INCREASED INSTITUTIONAL DELIVERIES

29. Decline maternal death • 19 • 10 • 10 • 6 • 6 Trend *new trend No death occurred at TBAs, few in rural facilities most in the referral facility, non due to first delays *

30. As Perceived by community members An ADC member –(a chief0 said “ It is difficult to completely do away with TBA because the distances are still the same, we have no alternatives” One mother said “I went to the hospital , but they sent me back that there was no space, she gave me two weeks to come back when labour started. I went to the TBA , she welcomed me and took me back to the hospital” The husband said “I went to the TBA with my wife , but she politely told me, my wife needed to deliver at the hospital. There was still good time to go to hospital . Asked me to cycle my wife on a bicycle ambulance”.

31. More quotes Reduced delay in getting organized to start off for facility services: An ADC member “Nowadays We check on what is happening at TBAs, if untrained TBA s assists mothers we charged a goat. We work together to help mothers. A woman said “TBA s are sending us to hospital in good time, maternal deaths have reduced in our areas. May be to those not taking things serious . Also men are now supporting us, I went to antenatal with my husband we both had a health talk by the nurse”

32. Timely referrals by TBA Mothers are sent to hospitals on time verified by supervisors, as explained by SM field assistants

33. TTBA and Bicycle ambulances solves delays in decision making and travelling to facilities Steps taken Decision making processes Step one Bicycle ambulance -readily available for all conditions -No delays in making decision- Lay down Determinants of transport to use Type of illness – able to sit or not • No delays in getting organized to start off for facility services • . It has a mattress ,is comfortable • Just cycling • Bicycle ambulance driver/ partner willingness • Is fast and fits road net works • No old protocols time of saving lives • Improved ones have got canopies . • Trained TBA Step two Bicycle ambulance -Start off immediately Step three Bicycle ambulance -is faster -Shorter travelling time • Improved factors affecting time of travel to facility • It is comfortable • It promotes male involvement • One person cycles it • It is applicable to road networks • TBA sign post for health services

34. Positive Results • Successfully implemented a community based RH project declared as a learning site in the country • Empowered communities in promoting access to M/H services. • Community request for youth friendly health services, FP. • Request for care and support of MD orphans. • Community request improvement of the bike ambulances • Community request for up-scale of the initiatives • Successful community action oriented MD audit initiative

35. BEST PRACTICES (WORKSHOP) Referral to health services Focus TBA: 2-4th, no complications Training Delivery huts / waiting rooms Kits Messages on delivery huts Awards to best TBAs Learning by living approach Community participation Selection of TBA Reintegration TTBA Bye-law: untrained TBA Networking/linking Community ownership Support of TBA Safe Motherhood Fund Delivery huts building Community empowerment Knowing reasons (not witchcraft) Saving women’s lives Pride to deliver Awards best TTBA Cultural values Respect and care, attitude

36. Gaps/research • Only in one district- need to scale up • Research on more supporting initiatives • Document the process and develop a standard model for such rural areas • Scale up to other areas

37. Next step Needs of such initiatives in a developing country is very high! Over 200 MD orphans registered • What are your ideas? Indeed Thank !!