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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.

Effective elderly home care in Belarus.

Author(s) Christine Rutschmann 1, Irina Moroz 2, Tatyana Kalinina 3, Tatyana Svetlovic 4, Viktor Kalbanov 5, Svetlana Anatsko 6, Monika Christofori-Khadka 7,
Affiliation(s) Department of International Cooperation, Swiss Red Cross, Bern, Switzerland, Public health and Health care Faculty, Belarusian Medical Academy of postgraduate education, Minsk, Belarus, Public health and Health care Faculty, Belarusian Medical Academy of postgraduate education, Minsk, Belarus, Medical and Social Department, Belarus Red Cross Society, Minsk, Belarus, Belarus Red Cross Society, Belarus Red Cross Society, Minsk, Belarus, Medical Social Department, Belarus Red Cross, Minsk, Belarus, Department of International Cooperation, Swiss Red Cross, Bern, Switzerland,
Country - ies of focus Belarus
Relevant to the conference tracks Health Workforce
Summary In order to effectively lobby for home care services of the elderly and disabled, a study was conducted among different medical and social service providers in the public and non-profit sector to elicit the medical, social and cost-effectiveness of the different services. Integrated home care services through providers which do medical and social tasks has proved to be highly effective and more cost-effective than services provided by different professional groups. A high level of beneficiary satisfaction and less ambulance calls, less hospitalisation as well as better mental well-being call for a scale up of integrated home care services with one service provider.
Background Worldwide there is an increase of the proportion of older people in need of constant medical and social care. According to experts, about 20% of elderly people have different functional disorders and require medical and social care in their daily life. At present, about 20% of the population of the Republic of Belarus are people aged 60 and over. Many of them have different functional impairments and are in need of long-term medical and social care.
Medical and social care is mainly provided by public health institutions and social protection structures either in institutions or through home care. The Belarusian Red Cross (BRC) is the only non-governmental organization providing integrated medical and social home care comprising of medical assistance, individual care, social and household services united in one service provider, the Visiting Nurses (VNS). The VNS professional nurses and volunteers primarily visit lonely elderly people and the disabled who live alone. Depending on their health status, they are classified in disability levels I-III, with level I being the most severe. The services delivered by the VNS are appreciated by beneficiaries and receive a positive assessment from the state.
Objectives Despite various previous commitments, the Government has not yet been able to scale up the number of VNS. In order to lobby for a scale up, the effectiveness and cost-effectiveness of the VNS services was assessed. The objective of the study was to compare medical, social and economic effectiveness (cost-effectiveness) of integrated home care delivered by the VNS with different state-owned medical care and social care providers in providing care for the elderly (all persons above 60 year of age). The study was carried out in 2 districts of Grodno region (Lida and Oshmyany) and 2 districts of Vitebsk region (Lepel and Polotsk). The study aimed to show that medical and social services united in one service provider are of higher quality, serve the needs of the elderly better and are more effective. Additionally, the research assumed that VNS services are more cost-effective as a duplication of services can be avoided when the medical and social services are integrated. Likewise, the study wanted to test the present trend of elderly care in the Belarusian context and assess whether caring for the elderly at home results in a higher self-perception of quality of life than when being cared for in a public setting.
This was first research to canvas the effectiveness and cost-effectiveness of different health and social care providers in the country and compare the performance of the public sector versus the NGO sector.
Methodology This study was conducted in two stages between 2011 and 2012.
To assess the effectiveness of medical and social home care, a desk review was done of the various medical records and financial statements of the different health institutions and social protection structures of the Government, as well as those of the BRC VNS services in 2011. More than 30 official documents were analyzed. They included: reports of health institutions, social protection structures and the BRC VNS on the amount of care provision and financial expenses for 2010, the official statistical compilations of the Ministry of Health of the Republic of Belarus for 2002 – 2010, 12 specially designed statistical maps to assess the effectiveness of the provision of medical and social home care by health institutions and social protection structures and the VNS and 123 individual patient cards assessing the effectiveness of medical and social home care provision to the VNS beneficiaries. All data were analyzed in terms of medical effectiveness (analyzing length of stay in health institutions, frequency of VNS visits, workload per VNC, frequency of calls for emergency services and hospitalization) and social effectiveness (restoration of lost functions of the patient, patient satisfaction).
To assess the quality of life of lonely and living alone elderly people (60 years and older) under various conditions of medical and social care provision, individual interviews with 780 randomly selected lonely and living alone elderly were conducted in February 2012. A team of researchers applied the SF 36 (Health Status Survey Short Form, the Russian version). 150 respondents were randomly selected from inpatient departments of the various medical and social providers, 561 outpatients and 89 clients of VNS were randomly selected and included in the study. Data processing was carried out using «Statistics 6."
Results The study showed that VNS care for patients who are not well covered by the state structures. More than 41 % of their patients are classified ‘disability level 1’ (highest level of disability and mostly severe chronic diseases and bed ridden patients), as well as HIV positive or suffering form tuberculosis. Even though the frequency of home visits of the VNS is the same as the ones of social workers, the VNS care for 30 % more patients than the social workers. Patients taken care of by VNS are hospitalised far less often than patients taken care of by state structures. Among the 780 respondents, 52 persons were hospitalized in 2011, out of them 8% of patients from VNS. Despite being generally sicker than the patients of social workers, the VNS patients also call an ambulance less often. More than 98 % of patients were satisfied with the VNS services and more than 62% of patients registered improvement in their self-care and mobility over the past year.
The analysis of quality of life of the elderly in different medical and social care provision settings showed that the VNS services are more cost-effective in achieving the psychological dimensions of health of the elderly - 40.9 points (95% CI, 38,5 – 43,2), and the disabled of group I - 40.3 points (95% CI 31,4-49,3) compared to the same categories of the population served by the public health institutions and social protection structures. The indicators of the physical health component of the elderly receiving the VNS medical and social care were not cost-effective in comparison to other service providers, but they remain more constant and show almost no decrease with increasing age of the elderly and the disabled respondents. Since the VNS medical nurses provide medical and social care to the most severe ill patients (people with disabilities of group I and II) this, in general, explains the lower values of the physical health features.
The work of the VNS BRC medical nurses is supported by volunteers whose activity contributes not only to the provision of medical and social care, but also reduced the cost of its provision. Moreover, it is considered that the provision of medical and social home care increases the economic productivity of those who are caring for elderly relatives.
Conclusion The study showed that the BRC VNS is an important resource to meet the needs of the population in medical and social home care and is characterized by medical, social and economic effectiveness. The study also showed that to meet the needs of the elderly in the medical and social care it is necessary to develop different medical and social care provision forms to canvass the difference between medical and social care at home and in hospital settings.
An integrated approach to the provision of medical and social home care to elderly patients, especially when combined with the involvement of volunteers, can be an effective model of service delivery, which expands capacity by removing the burden of medical and social care provision of the state.
An in-depth study on the living conditions and quality of services for older people should be carried out to better understand the dependence of the quality of life of older people on the quality and type of medical and social care service-providing organizations. In addition, the study should be repeated in 1-2 years, which will not only allow a comparison of the effectiveness of medical and social care providers, but also enable a comparison of changes in the subjective health status of patients and to evaluate the effectiveness of the provision of medical and social care of the same service provider over time.