An integrated community health facility project to improve maternal and child health.
Pregnancy is such a dangerous time in a Malawian woman’s life that it is considered unlucky to tell people about it.
The majority of women in Malawi live in scattered villages and find it hard to reach health facilities. They lack the information needed to make informed health decisions and facilities struggle to provide the quality services needed to save mothers’ and babies’ lives.
Women and Children First (UK) has supported maternal, newborn and child health (MNCH) projects in Ntcheu District since 2005. This integrated community/facility project, implemented by the Malawi Ministry of Health’s Perinatal Care Project between 2010 and 2014, strengthened both the demand and supply sides of the health system to address maternal, newborn and under-fives’ health issues.
Overall, the project was very successful in enhancing the coverage of essential maternal, newborn and child health interventions in the target communities and health facilities.
The final evaluation showed 94% of women were delivering in health facilities, the percentage of newborns getting postnatal care within 2 weeks of birth had increased from 35% to 95% and the percentage of women attending ante-natal care in the first three months of pregnancy doubled. Women’s knowledge of good childcare practices increased from 12% to 96%.
Community women’s groups played a central role in the project. Through these groups. women identified their most pressing maternal and newborn health problems and devised strategies to address them, mobilising locally available resources to do so. Common strategies were: improving sanitation and village hygiene; village savings and loans associations; kitchen gardens to improve nutrition; drama groups to share MNCH information; and bylaws to discourage early marriages. Led by specially trained local facilitators, the women’s groups raised awareness of the value of antenatal (ANC) and postnatal care (PNC) and delivering with a skilled birth attendant.
“I’m 18, married and have four daughters. There weren’t any problems with the births. Now I use a contraceptive injection. In the group …. we learnt that when you are pregnant there may be problems, such as swelling of the feet, anaemia and nausea, and also that some women may still bleed during pregnancy. We have also been taught about some of the dangers of childbirth, for example eclampsia, blood loss and problems in removing the placenta. I share what I have learnt with other women, and encourage them to join the group.” Regina Ntebe, Daudi Village
Involving the wider community was important and the sensitisation of Village Chiefs, the training and deployment of growth-monitoring volunteers who promoted immunisation and improved nutrition, and encouraged men to accompany their wives to ANC and PNC contributed to the successful outcomes.
“We encourage all the women to join the groups. The … project has really helped us to ensure that almost all women now have their babies in health centres.” Group Village Headman Chipusile
Key interventions for improving the health services for pregnant women and newborns included training healthcare staff on care of women in labour, care of the newborn and emergency obstetric newborn care and the provision of medical equipment. Lack of consistent supervision for frontline staff was identified as an issue during the mid-term review and additional coaching and mentoring was provided to midwives and nurses during the final phase of the project.
The project findings provide a picture of “healthy communities” in Ntcheu, with population coverage indicators recording systematically higher rates than the country-level available estimates. The only indicators showing relatively unsatisfactory achievements were for male involvement in the postpartum period.
The women’s groups were highly regarded by all sectors of the community as key interventions contributing to improvements in maternal and newborn knowledge and care-seeking practices. Many of the community interventions have became embedded within the community infrastructure.
Whilst the demand for services increased, quality of care at the health facility level was often compromised due to staff shortages, inadequate emergency transport systems and poor facility infrastructure and resourcing. The supportive supervision and mentorship programme was rated very highly by health facility staff.
There was a positive improvement in women’s satisfaction with care received at facilities, resulting from education and empowerment of women in regards to their healthcare rights through the women’s groups, respectful care training for healthcare providers and the combined community/healthcare facility interface meetings.
“Nowadays women are supposed to report any bad treatment they receive at a health facility to the village leaders.” Village headman
However, maintaining high levels of satisfaction will be a challenge if health services cannot reliably provide the expected level of care.