Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique

Background: Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. Method: The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. Results: Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. Conclusions: This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

The findings hereby reported are part of a broader multicentre study on “The Feasibility of Community-Level Interventions for the prevention and treatment of Pre-eclampsia and Eclampsia in selected rural communities of southern Mozambique (CLIP Feasibility)” [23]. The feasibility study was implemented in advance of the CLIP trial ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT01911494″,”term_id”:”NCT01911494″}}NCT01911494), which aimed to assess a community-level intervention for the management of PE/E. The CLIP trial intervention consisted of community engagement, early identification of danger signs of PE/E, administration of oral methyldopa and intramuscular MgSO4 when needed and referral to the nearest health facility. To detect the signs of PE/E, CHWs were equipped with a mHealth application for guided risk stratification. The proposed CLIP Trial intervention that this study aimed to inform was planned to cover two delays, namely seeking care and prompt referral [24, 25]. The formative research study used a mixed methods (qualitative and quantitative). The qualitative approach was based on focus group discussions with health care providers (maternal and child health nurses, midwives, matrons, and TBAs) and other community members (pregnant women, partners and husbands, mothers and mothers-in-law), in-depth interviews with CHW supervisors, the chief medical officers and gynaecologists and obstetricians’ experts. The quantitative data was captured through health facility assessment and community health worker self-administered questionnaires. Data was complemented by a national-level document review of CHWs training curricula, job descriptions, and practice guidelines for the management of pre-eclampsia. Data collections guides were developed centrally by the study coordination team and adapted from those used in the other countries involved in the study (Nigeria, India and Pakistan). A detailed description of these methods is presented elsewhere [23]. Mozambique is a low-income country in southern Africa, covering 799,380 Km2, with a population of 27,909,798 in 2017 [5]. The GDP is 646 USD per capita, with around 60% of the population living under the poverty line [4]. The country is divided into 11 provinces, which are the basis of the health services administration. The National Health Service (NHS) is based on primary health care, with a 50–60% population coverage rate. The uncovered population live in remote areas with limited access; many of these regions do not have primary health care (PHC). In regions with PHCs, they often do not have adequate human resources, equipment or medicines [26]. In 2019, the total number of medical doctors in the NHS was 2556 (8.7 medical doctors per 100,000 inhabitants), and there were over 6000 maternal and child health nurses (52.6 nurses per 100,000 inhabitants) [27]. To overcome the shortage of medical doctors in the country, nurses and clinical officers have been trained to take on additional duties [28]. In 1978 the country introduced CHWs, designated as Agentes Polivalentes Elementares (APEs). CHW are considered volunteers supported by the Ministry of Health (MoH) although they receive a monthly subsidy equivalent to 20 US dollars (1200 meticais) per month as compensation for their work [29, 30]. These workers are chosen by the community and must have basic literacy and arithmetic skills. They complete intensive four-month training. Their responsibilities focus on health promotion and prevention, but in 2010 the MoH revitalized the programme to include some curative activities. Therefore, CHW tasks are continuously being reviewed and adapted [31]. The curative activities focus on the most prevalent childhood illnesses, including malaria, diarrhoea, acute respiratory tract infection, severe acute malnutrition, and home visits for new-borns. In addition, they may promote attendance for antenatal care, identify danger signs in pregnancy and refer pregnant women as needed. However, there is no specific guideline regarding the diagnosis or management of PE/E. Although in Mozambique, APEs are the leading cadre of CHWs, others also provide obstetric care at the community level, namely the matrons and traditional birth attendants (TBA). Matrons and TBAs are knowledgeable elders in their community with vast experience in maternity care. In Mozambique, the shortage of skilled birth attendants and limited coverage of births in facilities resulted in government support of TBAs and matrons in the late 1980s. However, more recently, the Ministry of Health has discouraged deliveries by TBAs as they were seen to challenge facility-based delivery. There were also concerns regarding the risk of HIV infection due to TBAs poor work conditions [32]. This study was conducted in the two southern-most provinces of Mozambique, namely Maputo and Gaza. In Maputo Province, two districts were involved Manhiça and Magude, while in Gaza, four districts were included Chokwé, Xai-Xai, Chibuto and Macia (Fig. 1). The study area has urban and rural areas. Most residents of this region belong to the Changana ethnic group. The predominant occupation is subsistence farming, especially among women. In southern Mozambique, most men migrate to South Africa, Swaziland and other cities in Mozambique for work [4]. Literacy rates vary between the two provinces, with a 22% literacy rate in Maputo and 38% in Gaza; in both cases, literacy is lowest among women [4]. More details on the study site were described elsewhere [33]. This analysis was complemented by a national-level document review of CHWs curricula, job descriptions, and national practice guidelines for the management of pre-eclampsia [34]. Map of the study area with representation of the health facilities participating in the study This analysis is the triangulation of five sources: a document review, CHW self-administered questionnaires, health facility assessments, in-depth interviews, and focus group discussions. Data collection was conducted between September 2013 and May 2014. This process was conducted by a Mozambican team comprising a junior social scientist (HB), clinicians (AV, AN) and trained interviewers (RP, AM, AT, LM), all employed by the Manhiça Health Research Centre (CISM). The team was supervised by a senior social scientist (KM) and the study principal investigator (ES). Interviewers were selected due to their familiarity with the communities and their research experience. Data collection teams included men and women, fluent in Portuguese and Changana (the predominant local language), and had no prior relationship with participants. The health facility questionnaire collected information about the level of care, available medication and commodities, diagnostic capacity, human resource capacity, obstetric statistics, including patient volume, mode of delivery, morbidity and mortality rates. All (56) health facilities in the study area, based on the list of facilities obtained from the Provincial Directorate for Health, were included in this assessment. The health facility questionnaire was completed by the chief nurse in the maternal and child health care. In primary health centres, only one nurse responded, but at other centres, the chief nurse and the midwife responsible for the maternity ward completed the questionnaire. The health facility clinical chief supported the study team in obtaining access to the necessary individuals for interview. The interviews took 30–45 min and were completed when the nurse’s workload was small. The questionnaire comprised of closed-ended questions which were mediated by a trained clinician. Items related to equipment and medications were verified through spot-check observations; only equipment that was physically seen by the study team was considered available. The CHW questionnaire assessed CHW preparedness, knowledge and skills to perform home-based treatment for PE/E and the capacity to give intramuscular injections to pregnant women [35]. Most questions used a Likert-scale and one open-ended question. All CHWs from the study area were included and were reached through the health facility to which they report according to a list provided by the district CHW program focal person. Data collection was conducted either in the health facility where each CHW was registered or at their home. Depending on the number of CHWs, individual or collective briefing sessions by a study team member were given to explain the questionnaire. Because CHWs had limited literacy, a study team member was present at the interview for clarification. The questionnaire took 30–45 min. The interviews focused on the experience of CHW program coordinators regarding CHW requirements, roles and responsibilities, including in the management of pregnant complications. The Mozambican Gynaecologists and Obstetricians Association (AMOG) identified individuals for interview based on their experience and contribution to relevant maternal health policies. At the district level, the chief medical officers and the CHW supervisors were interviewed. The interviews were conducted by trained social scientists. Each interview lasted 30–45 min, was audio-recorded, and notes were taken; they were conducted one-on-one in the house or workplace of participants, depending on their preference. The focus group discussion (FGD) guide touched upon the following topics: views on pregnancy complications, pregnancy management, preventive and treatment practices and the health workers’ role in managing pregnancy complications. Focus groups were chosen to best capture views of maternal and child health nurses, midwives, matrons and traditional birth attendants, and other community members (pregnant women, partners and husbands, mothers and mothers-in-law). FGDs with nurses and midwives were conducted at health facilities, as these groups could easily be convened and were scheduled at times when health care providers were less busy. For matrons and traditional birth attendants, the FDGs were in Changana (local language) and took place at the community, either at the círculos (the usual community gathering location) or at the community leaders’ house, according to the groups´ convenience. The FGDs were conducted by trained social scientists. Each FGD lasted between 30 and 80 min, was audio-recorded and notes were also taken. Panel discussions were also held at the Ministry of Health (with the Deputy Director of Public Health and his team), Maputo Provincial Directorate (with Provincial Medical Chief and his team) and in Manhiça (with members of Community Advisor Committee and with members of CISM Institutional Ethics Review Board). This exercise obtained views regarding task-sharing and was used to understand the policies and the processes related to CHWs. Information obtained through the desk review was summarized to extract relevant information regarding the history, role and challenges facing CHWs providing maternal and child health care. The data captured were sent to CISM Data Centre for double data entry and management using REDCap [36]. Prior to sending data to the CISM Data Centre, the study team reviewed each questionnaire in the field. The failures to validation rules and double data entry discrepancies were cross-checked with paper forms for confirmation. Frequency and cross tables were employed for data consistency checks. Outliers and missing values were also reviewed. Data were exported to Stata 13 (Stata Corp., College Station, Texas, USA) for analysis. Frequencies, means, medians, SD and IQR, were used to describe the data. Focus group discussions and in-depth interviews were digitally recorded using Olympus AS-2400 PC® recorders. In addition, FGDs, IDIs and the open-ended question from the CHW questionnaire were transcribed verbatim by the same team members who completed data collection. In-depth interviews and the CHW questionnaire were collected and transcribed in Portuguese, while focus group discussions were translated to Portuguese from the local language as needed while being transcribed. Quality control of transcripts was ensured by listening to 25% of the audio recordings and comparing them against the transcripts for accuracy and completeness. The qualitative data were analysed using NVivo version 10.0 (QSR International Pty. Ltd. 2012). A thematic analysis approach was taken (see Fig. 2). The coding structure (based on free nodes, branched nodes, attributes and some pre-determined queries) was developed in advance based on study objectives through a collaborative discussion between researchers at CISM and the University of British Columbia (UBC). Themes were subsequently adjusted, and new themes added as they emerged from the data. As the analysis was performed by two teams (CISM and UBC), the coding structured was in English. The two Mozambican social scientists coded all transcriptions in Portuguese by reading the text in Portuguese and labelling the concepts using the codes in English. Three IDI and two FGD transcripts were translated from Portuguese to English and coded by a social scientist based at UBC for three purposes: first, to support the discussions on the development of the coding structure; second, for the UBC collaborator to be familiar with the raw data, to assist interpretation; and finally, for quality control. To allow the two teams to work independently, the data was split into two NVivo projects, but the same coding structure was used for both teams. Regular coding consensus meetings to discuss data analysis strategy and findings were held via Skype™. The coding agreement between the coders was very high. When the coding was completed, the analysed data were merged into a single project managed by the Mozambican team, from which the final queries, interpretation and data reduction were conducted. Analysis scheme To define our study constructs, we used the 2007 WHO task-sharing global recommendation and guidelines. In this document, we found five essential recommendations to guide task-sharing: adoption as a public health initiative, enabling regulatory environment, ensuring the quality of care, ensuring organization of the clinical care service and ensuring the sustainability [37]. This study received approval from the CISM Institutional Review Board (CIBS_CISM/08/2013) and the University of British Columbia in Canada (H12-00132). All participants in the study provided informed consent after receiving a written study information sheet and a detailed verbal explanation. For the illiterate participants, a literate witness was asked to read and explain to the participant the contents of the participant information sheet. The consent form was signed by the witness, and the researcher assistant after the participant’s fingerprint was taken. All identifiable data of participants were anonymised through attribution of unique identification numbers or pseudonyms to guarantee anonymity. Before the field activities, the first contact was made with the Ministry of Health, the Provincial and District Health Directorate to obtain permission for data collection.

N/A

• Dima Health