A solution to reducing maternal mortality? The role of community midwives

Author(s) Monika Christofori-Khadka1
Affiliation(s) 1International Cooperation, Swiss Red Cross, Bern, Switzerland.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Workforce
Summary Over the last 12 years, many countries have tried to reduce the high rates of maternal mortality by 75 % as outlined in the MDGs. However, not all countries have been successful so far. One of the major bottlenecks to reach the goal is the lack of skilled birth attendants. The Swiss Red Cross has been supporting different countries in their endeavour to increase their workforce. The approaches range from scaling up the quantity and quality of the skilled birth attendants in rural areas to providing on-the job training and facilitating community integration. These measures have resulted in increased antenatal care and institutional deliveries and helped to reduce access barriers.
What challenges does your project address and why is it of importance? UNFPA's report (2011) states that 350,000 skilled midwives are needed to fully meet the needs of women around the world. In the light of meeting the MDGs, some countries have been investing in the training of skilled birth attendants (SBA) by scaling up their number and by scaling up the quality of their service. However, the SBAs often lack practical experience when it comes to deliveries and complicated cases. They rarely have the chance to be teamed up with an experienced midwife and are left alone to take important decisions and conduct deliveries under difficult circumstances. Other countries do not even foresee midwifery in their health system and doctors exclusively carry out deliveries. SBA's prefer to work in urban and semi-urban health facilities therefore there is a lack of SBA's in rural areas. At the community level, cultural restrictions may hamper the access of a pregnant woman to a health centre. Lack of resources, transport possibilities, decision-making power and a functional referral system are causes which contribute to life-threatening delays during pregnancy and childbirth.The SRC projects attempt to address these challenges in different countries of the world by using tailor-made approaches to strengthen community midwifery, their role and uptake.
How have you addressed these challenges? Do you see a solution? The SRC project in Laos aims to better prepare already trained community midwives for their assignments in rural health centres. The project focuses on the hands-on training and exposure to sufficient practical skills with on-the job trainings. A functioning mentoring system and continuous on the job supervision are important features to successfully introduce the SBA to their role and to the community. Qualified and confident staff will earn the trust of the community and thus increase the number of safe deliveries in the country. Alongside the human resources, the local health authorities are trained to collect health data regularly and accurately as well as use the analysis to feed back achievements of the community midwife model. In rural Pakistan, the SRC project scaled up the number of skilled birth attendants in rural health centers. Their role is to do regular home visits and be available 24 hours on-call for deliveries. They accompany a pregnant woman to the nearest hospital in case of complications and emergency. The on-call transport system with an ambulance and driver enables quick and safe transport. A midwife is based at the referral hospital and specially designated to receive referred cases from the rural areas in order to facilitate quick administration, treatment and procedures.In Honduras only doctors are allowed to conduct deliveries and the profession of midwife does not exist in the formal Honduran health system. While most health centers in the rural areas are not staffed with a doctor, SRC tries to enhance service delivery by providing special trainings to traditional birth attendants and selected women from community committees. The courses are endorsed by the Government and complete with an official examination. The focus of the course is on antenatal and postnatal care and on preparedness of the pregnant woman and her family for an institutional delivery. The birth attendants act as a bridge between the pregnant women in remote areas and the health system, but are also prepared for safe delivery if transport not possible.
How do you know whether you have made a difference? Before project commences, all SRC projects conduct a needs assessment and integrate a baseline survey in the initiation phase. Inbuilt into the project design is regular monitoring through health system management information systems (HMIS), reviewing of secondary health data as well as carrying out regular ‘Knowledge, Attitude and Practise’ surveys with the beneficiary community. Analysis of the data depicts the changes the projects have contributed. Individual interviews and case stories show the impact the project makes in a person's life. While the project in Laos is only at its initiation stage (we hope to have more data by April 2014), the Community Midwife project in Pakistan has already illustrated an increased uptake of antenatal care services by 50 % in basic health units and 33 % in the district hospital within only 6 months of project start. In two out of five basic health units the Institutional deliveries have increased three fold and in the district hospital by 61 %. Similar data has been received from Honduras, where 92% of pregnant women attend four antenatal care visits and institutional deliveries have increased about 30% in the intervention area.
Have you or the project mobilized others and if so, who, why and how? Since SRC projects usually work together with local Community Based Organisations or the local Red Cross Partner, volunteers play an important role. The volunteers assist to promote the health services and deliveries with skilled birth attendants. They also disseminate the rights of the patients and ensure that particularly the poor are aware of incentive programmes for institutionalised deliveries, e.g. the Health Equity Fund in Laos or the safe delivery package in Pakistan. In order to bridge the gap between health provider and community, SRC projects establish community committees, who regularly meet with the health providers and monitor their presence, discuss problems and develop solutions. The main aim is to build good rapport and accountability, which will enhance trust, increase provider performance and result in a higher utilisation rate of the health centre and its staff. In the communities, the community committee disseminates information about the services and encourages families to use skilled birth attendants. Special focus is given to mobilise male decision-makers and heads of households to increase their understanding and consent as to why deliveries with a skilled birth attendant are important. The families are encouraged to start with precautions in the early stages of pregnancy, i.e. start saving for delivery costs, arrange transport etc. Well accepted and interested female community members receive basic training to become an important link to the health services in the rural areas. In Honduras more than 80 female and two male members have participated in the trainings.Traditional birth attendants are another important group targeted by all SRC projects. They are included in the service delivery and serves as important links with the community. They accompany pregnant women to the health centres, call the midwives for home services and are important assistants during deliveries. In Honduras, due to the absence of midwifes, they play an important service role in family preparedness, antenatal care, detecting danger signs and facilitating the referral to the next SBA.
When your donor funding runs out how will your idea continue to live? All SRC projects are designed to obtain sustainability by the end of the project period. Sustainability is tackled from both ends: the community and the service provider. Anchoring the projects in the community aims at decreasing access barriers and creating sustainable structures which tackle the four delays in delivery. Similarly, a positive experience of a pregnant woman and her family in the health centre will have a long term impact upon her health seeking behaviour and that of her immediate neighbours and family. Promoting the right to health and facilitating social accountability structures empowers local communities to demand public service provision. At the service provider level, all projects work with the existing health system providing interventions which enhance quality and quantity of service provision. Advocacy from the community level to policy level are geared towards positive change. However, levels of sustainability vary. In countries where community approach is supported by respective Government policies for the health system and where providers are motivated and encouraged by the public service system sustainability is reached in a shorter time frame and with less effort than in countries where the Government and public staff are not motivated for change.The projects are embedded within the pre-existing health system structures of the governments. Except in Pakistan, all skilled birth attendants are employed by the government and thus will continue working in the future. However, in some countries the management of the community midwives is not yet clear as to the importance of their role. The community midwifes are transferred to replace nurses or other health staff and may end up in health centers without equipment or appreciation of their skills. The SRC projects are sensitizing the Ministries of Health and governmental line managers in the careful management of their community midwives.In Pakistan, the project is a pilot intervention which will be used to lobby the local government to redistribute their existing workforce to rural areas, introduce regular outreach and ensure a functional transport system through ambulances etc. Rigorous research, which accompanies the pilot, shall demonstrate the effectiveness of the project and lead to policy change as well as increased strict performance and attendance supervision.

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