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Assessing the capacity of community midwives to provide maternal and newborn health services

Alice Natecho, MPH, MAS Director Fountain Africa Trust (anatecho@fountainafrica.org)Dr. Pamela Godia PhD, Intervention Manager PSP4HDr. Robert Wekesa, MBChB; MMed, Director Health Services Fountain Africa Trust

Presented during the AMREF Health Africa International Conference at Safari Park Hotel Nairobi, Kenya24 November 2014

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Outline • Introduction

• Methodology

• Findings

• Conclusion and proposed interventions

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Introduction-1• Maternal and infant mortality remains one of the

greatest challenges in Kenya where the maternal mortality ratio is 488/100,000 live births (KDHS 2008/9).

• Over half of pregnant women in Kenya deliver at home with unskilled assistance

• Low use of postnatal care services• Contraceptive Prevalence Rate-low (46%) KDHS

2008/9

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Introduction - 2

Pop Council, 2013

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Introduction-3: Village Midwives Case Studies

Country Evaluation Period/ years

MMR Reduction

Sir Lanka 1940-1950 1967 - 577

Malaysia 1949-1961 520 - 200

Trends in MMRate Rural –Urban in Indonesia

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Introduction- 4: Justification

• Given the poor MNH indictors, and experiences from the three countries in Asia, Fountain Africa with PSP4H chose to strengthen the community midwifery model, which was launched by government in 2006.

• The model uses community midwifes who provide health services at community level.

• The current model has had challenges of sustainability – It heavily relies on supplies from gov’t facilities. See graph

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Intro- 5: Erratic supply of Long Acting FP-Methods

CM training update on LARC provision (2011)

Population Council &DRH /MOH(2012): Strengthening the Delivery of Comprehensive Reproductive Health Services through the Community Midwifery Model in Kenya. APHIA II OR Project in Kenya. Population Council: Nairobi, Kenya.

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Objectives of the study

Overall Objective

To assess the feasibility and effect of nesting a private sector model within a community midwifery programme on maternal and new-born health services

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Specific Objectives• Assess the capacity of community midwives to provide

MNH services

• Explore community members perception of the community midwifery model

• Determine the influence of social networks among community midwives on increasing access to skilled maternal health services

• Increase the knowledge and skills of CMs in MNH services and in entrepreneurship

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Study Design and Methodology • A quasi- experimental design • Sites

• Bungoma County and Butere Mumias Sub County in Kenya

• Phases• Baseline• Intervention• Evaluation

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Data Collection• Quantitative data: 4 structured questionnaires • CMs’ screening tool• CMs’ Knowledge and service provision tool• List of essential equipment and supplies tool • Workload data collection tool (previous 12 months)• Qualitative data: • KII, In-depth interviews, and FGDs

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Findings

Demographic information on Community Midwives 72 CMs identified (Bungoma – 43 (59.7%), Butere- Mumias (Kakamega) – 29 (40.3%)Sex (Females- 86%, Males-14%)Mean Age- 61.4 YrsQualification (Enrolled nurse/midwives (85%) and formerly MoH employees- (88%) Experience (Average years as CMs -11 yrs

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MNH Services and average No. of clients seen by CM per month

Bungoma B-Mumias CMs Total Clients

FP 22 20 72 1,512ANC 12 8 72 720Delivery 4 3 72 216Postnatal care 5 5 72 360Treatment of STIs 6 6 72 432Immunization 42 11 72 1,440

Growth monitoring for babies 24 16 72 1,440Cervical cancer screening 6 13 72 720Post rape care 1 0.5 72 72General OP - child 36 24 72 2,232General OP – Adults 47 52 72 3,528Total 12,672

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Cost of CM’s services Median price per visit – Kshs.

Bungoma BM Total US$Family planning - Long term 200.00 200.00 200.00 2.3Family planning – Short-term 50.00 50.00 50.00 0.6ANC 1st Visit 50.00 50.00 50.00 0.6ANC - Revisit 30.00 20.00 25.00 0.3Delivery 725.00 650.00 687.00 8.0Postnatal care 50.00 0.00 25.00 0.3Treatment of STIs 350.00 500.00 425.00 4.9Immunization 20.00 20.00 20.00 0.2Growth monitoring for babies 0.00 10.00 5.00 0.1Cervical cancer screening 50.00 100.00 75.00 0.9Post rape care 50.00 100.00 75.00 0.9General outpatient - Adults 300.00 425.00 365.00 4.2General outpatient - Children 250.00 250.00 250.00 2.9

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Client’s ability to pay for services offered by CMs (%)

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CM willingness to Join a Network

Yes, ….because I will access training, to help me get the license and get a better place for delivery-IDI 10, Bgm

Reasons cited•Networking with other CM•Learning•Improving supplies•Financial assistance•Market their services

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Management of CMs finances

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Provider Knowledge on ANC

Awareness on least no. of ANC visit is high but less than a half know the timing precisely

Least number of visits women should make during their entire pregnancy

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Providers’ Knowledge on Labour and Delivery

What to Be Done after Delivery (sig. diff. btwn counties on PPFP, Perineal care, Nutrition)

28.8% P= 0.01; p=0.03;

Danger Signs of APH (sign. diff btwn BGM & BM) 24.7% P=0.01Danger Signs Post-Partum Haemorrhage (PPH) 32.6%

Action on retained Placenta (sign. diff btwn Counties)

22.5% p< 0.05

Action on obstructed Labour (sign. diff btwn Counties)

17.7% P<0.05

Puerperal Sepsis during Prep (sign. diff btwn Counties)

30.% P<0.05

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Knowledge of CMs on Danger signs in Postnatal Period

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Providers’ Knowledge on FPHow the contraceptives work to prevent pregnancyProportions Butere Bungoma Total P-value

% % %Suppressing or preventing ovulation 58.6 72.1 66.7 0.234

Thickening the cervical plug/mucus to prevent sperm penetration

37.9 32.6 34.7 0.639

Inhibiting egg transportation 34.5 23.3 27.8 0.297

Changing the endometrial lining prevent implantation / thinning of uterine walls

13.8 25.6 20.8 0.227

Don’t know 0.0 14.0 8.3 0.036*

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Perception of the CMs services by the community

• Very essential• Community members (irrespective of their age and

gender) support the work of community midwives

‘It is very essential ….. when it is at night and a pregnant woman is in labour; not all pregnancies go to their due dates there are others which come early so there would be no preparedness. So if you are within this area the first people to be contacted are the domiciliary midwives around………….. FGD-MEN, COMMUNITY LEADER

R4…we normally call them sister, people in the community are able to differentiate them from the TBAs

R6….we appreciate them because they assist us in case of an emergency.

FGD-WOMEN 18-25

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Conclusion & Proposed Interventions• The recent baseline survey demonstrated that:

CMs have great potential in improving access to MNH services

there are many gaps in health service delivery and financial management that need to be addressed

• Preliminary results already shared with CMs & SHs

• The CMs have already registered a Network

• Planned training activities to focus on the gaps identified especially in EMoC/LAFP Methods and Business skills

• The County MOH very supportive of the initiative at all levels

Funded by

1. Community Midwives in Bungoma County and Butere Mumias sub County

2. The County Departments of Health in Bungoma and Kakamega

3. The Private Sector Innovation Programme for Health

4. Cardno Emerging Markets

5. UKaid

Acknowledgement