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Background: Although it is now widely recognized that reductions in maternal mortality and improvements in women’s health cannot be achieved through simple, vertical strategies, few programs have provided successful models for how to integrate services into a comprehensive program for maternal health. We report our experience in rural Lesotho, where Partners In Health (PIH) in partnership with the Ministry of Health and Social Welfare implemented a program that provides comprehensive care of pregnant women from the community to the clinic level. Methods: Between May and July 2009, PIH trained 100 women, many of whom were former traditional birth attendants, to serve as clinic-affiliated maternal health workers. They received performance-based incentives for accompanying pregnant women during antenatal care (ANC) visits and facility-based delivery. A nurse-midwife provided ANC and delivery care and supervised the maternal health workers. To overcome geographic barriers to delivering at the clinic, women who lived far from the clinic stayed at a maternal lying-in house prior to their expected delivery dates. We analyzed data routinely collected from delivery and ANC registers to compare service utilization before and after implementation of the program. Results: After the establishment of the program, the average number first ANC visits increased from 20 to 31 per month. The clinic recorded 178 deliveries in the first year of the program and 216 in the second year, compared to 46 in the year preceding the program. During the first two years of the program, 49 women with complications were successfully transported to the district hospital, and no maternal deaths occurred among the women served by the program. Conclusions: Our results demonstrate that it is possible to achieve dramatic improvements in the utilization of maternal health services and facility-based delivery by strengthening human resource capacity, implementing active follow-up in the community, and de-incentivizing home births. © 2012 Satti et al.
In 2009, Elton John AIDS Foundation UK granted PIH Lesotho funding to implement and evaluate a program to improve access to HIV care and reproductive health services for women in rural Lesotho. The goal of the program was to increase utilization of antenatal services, facility-based delivery, and HIV case detection and treatment of pregnant women in the mountains of Lesotho. The program was first piloted in May 2009 in the catchment area of Bobete health center, a MOHSW clinic located in the mountains in Thaba-Tseka district that PIH has supported since 2007. Bobete health center serves 71 villages, with an estimated total catchment area of 25,000 people, including approximately 7,000 women of reproductive age. Results from the 2009 Demographic and Health Survey show that access to skilled birth attendants is lower in Thaba-Tseka district compared to nationwide: 57% women deliver at home (vs. 40% nationwide), and 43% are assisted by skilled birth attendants (vs. 61%) [6]. To implement the program both in the community and at the health center level, human resources were augmented and an incentive system was piloted to encourage ANC and facility-based delivery. At the community level, PIH trained 100 maternal health workers, between May and July 2009, to identify pregnant women and accompany them to the health center for ANC, delivery, and postpartum services (Figure 1). They also provide education about the program during community gatherings, emphasizing the importance of facility-based care for pregnant women and newborns. The maternal health workers were selected in consultation with the village chiefs to ensure community acceptability, and selection criteria included basic literacy and the ability to walk long distances. Many of the women selected were formerly traditional birth attendants. Historically, the Lesotho MOHSW hired women to serve as traditional birth attendants, training them in safe delivery practices and providing them with some basic supplies to conduct home deliveries. The MOHSW has since abandoned this policy. In some communities, traditional birth attendants have acquired their skills through apprenticeship, generally from older women in their families, and have not received any previous formal training. The new maternal health workers received a seven-day training, covering specific topics of maternal health (Figure 2) in addition to the standard PIH community health worker curriculum, which has been extensively field tested in Haiti, Rwanda, Malawi, and Lesotho [9], [10]. The maternal health workers received exercise books for recording their activities, and the training included practice filling out these records. They continue to return to Bobete health center monthly for refresher training. In addition, in their role as clinic-affiliated maternal health workers (as opposed to traditional birth attendants), the maternal health workers received performance-based incentives to promote the longitudinal accompaniment of women—i.e. attendance at antenatal clinic, facility-based delivery, and a postpartum follow-up visit. All maternal health workers are required to maintain a monthly record of their activities, including the number of patients counseled about attending the health center for ANC and delivery and the number of patients physically accompanied to the health center for these services. The supervising nurse-midwife also maintains records of the dates that the maternal health workers accompanied women to the health center, which are used to verify the maternal health workers’ records. The maternal health workers receive a performance-based salary on a monthly basis: 100 rand (US$12) for attending monthly trainings and submitting monthly reports, 100 rand (US$12) for accompanying women for a first ANC visit, 50 rand (US$6) for accompanying women for a subsequent ANC visit, and 200 rand (US$24) for accompanying women to the health center for delivery. The payment is comparable to the monthly salaries paid to community health workers employed by the Lesotho MOHSW (300 rand). As an additional incentive, mothers who attend all ANC visits, are tested for HIV, and deliver at the clinic receive “new baby starter packs” – a package of clothing and hygiene items to help care for the newborn. At Bobete health center, previously, a nursing assistant was responsible for ANC, and few deliveries took place at the clinic each month. As part of the maternal mortality reduction program, a nurse-midwife was hired to provide ANC and delivery care at Bobete health center and to train and supervise the new maternal health workers. The ANC provided at Bobete is comprehensive, integrating risk screening, health education, tetanus immunization, family planning counseling, pap smears, and testing and treatment for TB, HIV, and other sexually transmitted infections delivered as a “one-stop shop” (Figure 3). The health center staff was trained in clear protocols for referring women with maternal complications and obstetric emergencies to the district hospital. To overcome the geographic barriers to delivering at the clinic, PIH established a maternal waiting house (lying-in center) on the grounds of the clinic, which accommodates twelve women at a time. Women who live more than a two-hour walk from the clinic or face other geographic difficulties traveling to the clinic are invited to stay in the house in the two weeks prior to their expected delivery dates. The maternal health workers accompany women for admission to the waiting house, visit them regularly during their stay, and accompany them back to their villages after delivery. An on-site cook prepares three meals per day for the women staying in the house. A checklist of medications, supplies, and equipment for ANC, the delivery room, and maternal waiting houses ensures that the health center is adequately equipped to provide these services and ensure safe deliveries. All women who test positive for HIV are offered antiretroviral therapy (ART) or antiretroviral prophylaxis and counseled on their infant feeding options, in accordance with Lesotho MOHSW guidelines [11]. Women who choose replacement feeding are provided with formula, a gel stove, fuel, bottles, thermos, soap, and cleaning brush to ensure sanitary formula feeding practices. The maternal health workers are trained in safe formula feeding and exclusive breastfeeding and work with mothers to ensure they know how to use these techniques. All infants born to HIV-positive mothers who are formula-fed are tested by DNA polymerase chain reaction (PCR) at six weeks and nine months after birth. Infants who are exclusively breastfed are also tested at six weeks after the end of breastfeeding. Maternal health workers are also responsible for ensuring adequate postpartum care after delivery, which includes pap smears and family planning counseling and services. Women who deliver at the health center remain there for a 48-hour observation period. Women who are unable to get to the clinic in time and deliver at home are accompanied by the maternal health worker to the health center within 72 hours of delivery. HIV-exposed infants are accompanied to the health center for evaluation one week after delivery, and all women are accompanied for a postpartum visit six weeks after delivery. A strong monitoring and evaluation component has been integral to the program since its inception. Before the program was established, community health workers carried out a village survey in order to collect baseline household data on women of reproductive age. As part of their duties, the maternal health workers now conduct active monthly surveillance in the village to which they are assigned. Every month they visit each household in the village, identifying women who may be pregnant and encouraging them to visit the health center for evaluation. The program is now capturing data on home deliveries and maternal deaths in the community, which previously went unrecorded. The program is being implemented as part of a broader continuum of health services. Community health workers will continue to follow the mother and child for five years after the delivery, ensuring access to family planning and child health services, including childhood vaccines, monthly monitoring for malnutrition, and treatment of malnutrition. We analyzed data routinely collected from delivery and ANC registers for monitoring and evaluation purposes to compare service utilization before and after implementation of the program. This study was approved by the Partners HealthCare Human Research Committee. In the approved protocol, the requirement for informed consent was waived, since this was a retrospective study of information previously collected in the course of routine clinical care.
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