Combined Facility- and Community-based Interventions

 

Global strategies to address maternal and newborn mortality emphasize the need for multiple service-delivery sites within a continuum of care for maternal and newborn health. Much of this emphasis is underscored by a return to primary health care principles, with a clear focus on comprehensive and community-based services. Integration of facility- and community-based care and ensuring they complement each other in a positively synergistic way is a core function of primary health services. The strategy of using a more flexible multiple service-delivery approach aims to address the flaws noted in the previous facility-focused policy on skilled attendants, as well as difficulties with improving the safety of childbirth with traditional birth attendants.

Two examples from Bangladesh and Malawi have shown that skilled attendance alone is neither necessary nor sufficient for reducing maternal mortality. In Bangladesh in 2001, only 13% of deliveries were attended by a skilled attendant, and 9% in a health facility, but a steady fall in the maternal mortality ratio since 1990 will place the country within reach of the fifth Millennium Development Goal by 2015. In Malawi, on the contrary, the rates of institutional delivery are around 57% and have been so since the 1992 demographic health survey, but the maternal mortality ratio is high, around 800 nationally. The maternal mortality ratio has risen since 1990 when it was about 600 (reaching a peak of 1120 in the later 1990s from which it is now declining). The rise in the 1990s was partly, but not wholly, attributed to HIV.

The need for research to define an appropriate balance between facility- and community-based health care was highlighted by one of the working groups of the High Level Taskforce on Innovative Finance for Health Systems which revealed a lack of agreement between two models used to cost the scale-up of essential services. One model, promoted by WHO, advocated the simultaneous scaling-up of facility and community-based services; a second model promoted by the World Bank and UNICEF, was less ambitious and advocated scaling-up low-cost, community-based services before undertaking any strengthening or expansion of facility-based services. Current opinion and research trends support the expansion of community-based services in the form of home visits by trained community health workers shortly after childbirth. However, there remains uncertainty about whether this focus on community-based health care and the services they deliver can be adequately integrated with services provided at clinics, health centres and hospitals.

 

 

Facility-based postpartum care

 

Strengthening existing facility-based postpartum care involves an initial assessment of current service provision and uptake to inform the planning and design of interventions to improve the quality of these services as well as their coverage. Presently, scheduled postpartum visits for women in three of the study sites (Burkina Faso, Kenya and Malawi) entail care shortly after childbirth, and at 6 days and 6 weeks after childbirth. In the fourth site (Mozambique), only two postpartum visits are scheduled: shortly after childbirth and between 7 and 10 days after childbirth. Utilization of these services in each site is apparently low.

Child health services in each site presently focus narrowly on child health, giving scant, if any, attention to women's needs. This is clearly a lost opportunity for facilitating continuity of maternal and reproductive care. Introducing interventions for mothers into the package of services provided at immunization and child health clinics would not only have inherent benefits for immediate maternal health and wellbeing, but would also address factors that place women at risk of maternal mortality in subsequent pregnancies.

Integration of services at health facility level would also improve access to family planning. Fertility reduction with increased birth spacing has made a major contribution to lowering maternal mortality in many countries. Family planning is clearly a critical service in the postpartum period. Studies have shown that promotion of family planning in countries with high birth rates has the potential to avert 32% of all maternal deaths and prevent nearly 10% of all childhood deaths, in addition to being a major component of strategies to prevent mother-to-child transmission of HIV.

Finally, visits of mothers to child health clinics create an additional and vital opportunity for identifying HIV infection; providing interventions to reduce mother-to-child transmission of HIV; and securing entry of women to HIV care and treatment. HIV testing during the postpartum period complements antenatal testing and could potentially make a large contribution to improving overall coverage and effectiveness of mother-to-child transmission programmes. HIV testing in child health clinics is important not only for women who were not offered HIV testing during pregnancy, but also for those who had previously declined testing and have reconsidered their decision or developed better rapport with the health worker who offers testing. Repeating HIV testing at six to nine months postpartum for women who tested HIV negative in pregnancy has many advantages, especially where women breastfeed for two or more years (as in the study settings). Provision of interventions to prevent sexual transmission of HIV in the postpartum is also critical, given that several studies (but not all) indicate women have an increased risk of HIV acquisition during this time.

 

 

Community-based maternal and newborn care

 

Community-based prevention and treatment of maternal and newborn illness is a way to further complement and enhance the impact of services provided within health facilities.


Newborn care

In 2009, WHO and UNICEF issued a statement that home visits for the newborn should be a key strategy to improve survival. Studies in Bangladesh, India and Pakistan have shown that home visits can reduce newborn deaths in high mortality settings by 30-61%. The visits improve coverage of key newborn care practices such as early initiation of breastfeeding, exclusive breastfeeding, skin-to-skin contact, delayed bathing and attention to hygiene, such as hand washing with soap and water, and clean umbilical cord care. A visit by a community health worker in the early postnatal period can also improve newborn survival by impacting on the three most common causes of neonatal mortality, namely, infections, birth asphyxia and complications of preterm birth. Despite initial concerns, some studies have shown that community health workers can be trained to effectively identify preterm or low birth weight infants and to treat sepsis and pneumonia in infants. This evidence complements the experience from developed countries which shows that postnatal home visits are effective in improving breastfeeding rates and parenting skills. However surprisingly, there is little evidence of their feasibility and effectiveness in sub-Saharan Africa.

But the timing of these visits is crucial. A study in Bangladesh showed that home visits by trained community health workers in the first two days of life reduce newborn mortality, more so than visits on the third day or later. Specifically, receiving a visit on the day of birth reduced the risk of newborn mortality by two thirds compared with those who never received a postnatal visit (and reduced it by half for those visited on the second day after birth). The community health workers in this study underwent six weeks of training in skills for communicating behaviour change, providing essential newborn care, and assessing and managing sick neonates.


Maternal care

The role for community health workers to avert maternal deaths has been recognized for some time. Most maternal deaths occur in women presenting with a final common pathway of shock, secondary to haemorrhage or infection, or shock-related syndromes such as systemic inflammatory reaction syndrome or multiple organ dysfunction syndrome. There are classically three levels of delays before women reach the stage of shock; community actions can address two of these delays: firstly, delays in recognition by women and families of the need to seek prompt care, and secondly, the physical, cultural, or financial barriers leading to delays in accessing care. The third delay, stemming from ineffective interventions at facility level and breakages in the referral chain between facilities, is best addressed through facility-level interventions.

A recent modelling paper suggests that community-based provision of misoprostol - a relatively inexpensive drug that is stable at room temperature - and antibiotics, together with strengthening of oxytocin provision at facilities could reduce maternal deaths caused by postpartum haemorrhage (34% of maternal deaths in Africa) and sepsis (10% of maternal deaths in Africa) in sub-Saharan Africa by 32%.

The feasibility and effectiveness of such interventions provided at community level among postpartum women and newborns, however, requires additional study in sub-Saharan Africa. Enthusiasm for the role of community health workers in postpartum care draws on experiences in other fields, where over the past few decades community health worker programmes have been widely implemented in sub-Saharan Africa and beyond, using community health workers trained to deal with a wide range of ailments as well as those with a more specialist focus. Evaluations of these programmes have shown that community health workers can make a valuable contribution to community development by acting as a bridge between the community and formal health services. A recent WHO review on community health worker programmes concluded that for their contribution to be effective, they must be carefully selected, appropriately trained, and adequately supported through formalized supervision and management, and stipends.

There remain substantial uncertainties about the role of community health workers, however. With regard to community health workers' performance, some recent studies in Kenya have tried to measure this by assessing their adherence to clinical guidelines on the management of childhood illness. They found that while some deficiencies in community health worker performance could be attributed to varying complexities in the guidelines used, the broader determinants of community health worker performance remained poorly understood. And while there appears to be consensus in the literature on criteria for successful implementation of community health worker programmes, what remains uncertain is whether they apply equally to programmes implemented at scale. The MOMI study will provide answers to this question while also generating comparative data, across 4 country settings, on: common barriers to the successful implementation of specialist community health worker interventions to improve maternal and newborn health; and which strategies (supervision, training, guideline simplification, etc.) are most effective in maximizing community health worker performance and improving the quality of care they provide to postpartum women and newborns.