M. Bailor Barrie, M.B.Ch.B., 1 J. Daniel Kelly, M.D. 1,2

1. A community-based maternity care program improves utilization of antenatal care and referral obstetric services in Kono District, Sierra Leone: 12-month outcomes M. Bailor Barrie, M.B.Ch.B.,1 J. Daniel Kelly, M.D.1,2 1WellbodyAlliance, Koidu Town, Sierra Leone 2 Baylor College of Medicine, Houston, TX, USA

2. Background • Why maternal deaths? • Utilization of services • Emergent obstetric services • Drop-offs in ANC visits • Home-based deliveries • Lack of referral system

3. Program Goal • Implement a community-based program designed to increase utilization of maternal health services. • Support PHUs • Strengthen the referral system • Support Koidu Government Hospital • Prior experience in community-based program implementation • Adapted our model to maternal health • In KonoDistrict, we work in partnership with the Ministry of Health and Sanitation

4. Methods • In August 2011, WA trained 45 former traditional birth attendants and traditional health care providers to serve as community health workers. • WA launched its maternal mortality reduction program in September 2011 at three peripheral health clinics in Kono District, Sierra Leone. • They received monthly incentives for accompanying pregnant women to the clinic for their antenatal (ANC) care, delivery, and postnatal care, tracing those who missed appointments, referring women with pregnancy-related complications to the clinic, and educating them about the value of facility-based care.

5. Methods • Clinic staff performed deliveries and decided when to refer women with pregnancy-related complications from the clinic to the district hospital. • We analyzed data routinely collected from ANC and delivery registers to compare service utilization 12-months before and 12-months after implementation of the program.

6. Results • The average number of first and fourth ANC visits increased from 48.3 to 56.9 per month and from 22.5 to 30.7 per month, respectively. *statistically significant

7. Conclusion Our program demonstrated higher rates of women being initiated and retained in antenatal care.

8. Results • During the first year of the program, 83 women with complications were successfully referred to the district hospital compared to 27 in the preceding year. • Emergent caesarean sections decreased from 11 to 8. • No maternal deaths occurred among the women served by the program.

9. Conclusion Referral rates to the hospital dramatically improved.

10. Results • Facility-based deliveries increased on average from 27.4 to 31.5 per month. *statistically significant

11. Conclusion Home-based deliveries remain a common practice, and further studies need to develop an intervention that de-incentivizes them.

12. Limitations • Quality of facility-based care • Strength of overall health system and referral services • Cultural barriers of home-based deliveries • Supervisor system of community-based program • Variable performance of facilities

13. Story of Edna

14. Why was Koeyer successful? Further investigations need to be conducted to fully understand the reasons for Koeyer’s success

15. Way forward • Strengthening of facility-based care • Essential to the development of a community-based program • Accompaniment of family members to initial ANC visit to discuss value of facility-based delivery • Incentive packages for mother and child if facility-based delivery occurs • Expansion of emergent obstetric referral services • Restructuring of supervision system • Integration of community health work