Home visits by community health workers for pregnant mothers and newborns: Coverage plateau in Malawi

  • Journal of Global Health, Volume 9, No. 1, Year 2019

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Study Justification:
The study aimed to evaluate the feasibility and coverage of home visits by community health workers (CHWs) for pregnant mothers and newborns in Ntcheu district, Malawi. This was important because home visits during pregnancy and after delivery are recommended to improve newborn survival. However, concerns were raised about the capacity of community health systems to deliver high effective coverage of these visits as the roles of CHWs expand.
Highlights:
1. Less than one third of pregnant women received a home visit during pregnancy, and only 20.7% received the recommended two visits.
2. Coverage of postnatal visits was even lower, with only 11.4% of mothers and newborns receiving a visit within three days of delivery.
3. Reaching newborns soon after delivery requires timely notification of the health surveillance assistant (HSA), but only 42.9% of mothers reported informing the HSA of the delivery.
4. Coverage of postnatal home visits was significantly higher among those who informed the HSA compared to those who did not (46.7% vs. 1.3%).
5. Most HSAs had the necessary equipment and supplies and were active in community-based maternal and newborn care (CBMNC).
Recommendations:
1. Re-align the CBMNC package with the existing platform’s capacity to deliver home visits. This means adjusting the visitation schedule to ensure feasibility and better coverage.
2. Identify strategies to better support HSAs in implementing home visits for those who would benefit most.
Key Role Players:
1. Ministry of Health: Responsible for overseeing and coordinating the implementation of home visits by CHWs.
2. Community Health Workers (CHWs): Conduct home visits and provide maternal and newborn care services.
3. Health Surveillance Assistants (HSAs): Provide community-based services and conduct home visits.
4. Mothers and Families: Participate in notifying the HSA of the delivery and engaging in home visits.
Cost Items for Planning Recommendations:
1. Training and Capacity Building: Budget for training CHWs and HSAs on conducting home visits and providing maternal and newborn care.
2. Equipment and Supplies: Allocate funds for necessary equipment and supplies needed for home visits, such as weighing scales, blood pressure monitors, and educational materials.
3. Monitoring and Evaluation: Set aside resources for monitoring and evaluating the implementation and coverage of home visits.
4. Supportive Supervision: Budget for regular supportive supervision visits to ensure quality and adherence to guidelines.
5. Communication and Outreach: Allocate funds for communication and outreach activities to raise awareness among mothers and families about the importance of home visits.
Note: The actual cost will depend on the specific context and resources available in Malawi.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides specific data on the coverage of home visits during pregnancy and postnatal period in Ntcheu district, Malawi. The study conducted a population-based survey of 150 households and included information on the number of visits received by pregnant women and newborns. However, the abstract does not provide information on the methodology used to collect the data or the statistical analysis performed. To improve the evidence, the authors could include more details on the survey methodology and statistical analysis, as well as provide information on the sample size calculation and any potential limitations of the study.

Background Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO’s Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. Methods A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. Results Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA-yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months. Conclusions We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health technology: Implementing mobile health technology, such as SMS reminders or mobile apps, to notify community health workers (CHWs) about upcoming deliveries and schedule home visits. This could improve communication and ensure timely visits.

2. Community engagement: Developing community engagement strategies to encourage families to notify CHWs about deliveries and the need for postnatal home visits. This could involve community education campaigns, involving community leaders, and leveraging existing social networks.

3. Task shifting: Exploring the possibility of task shifting, where certain responsibilities traditionally carried out by CHWs are delegated to other healthcare providers, such as nurses or midwives. This could help alleviate the workload on CHWs and allow them to focus on home visits.

4. Training and capacity building: Providing comprehensive training and ongoing capacity building for CHWs to ensure they have the necessary skills and knowledge to conduct effective home visits. This could include training on newborn care, breastfeeding support, and identification of danger signs.

5. Strengthening supply chains: Ensuring a reliable supply chain of essential equipment and supplies needed for home visits, such as clean delivery kits, medications, and educational materials. This could involve improving procurement processes, stock management, and distribution systems.

6. Monitoring and evaluation: Implementing robust monitoring and evaluation systems to track the coverage and quality of home visits. This could involve regular data collection, analysis, and feedback mechanisms to identify gaps and areas for improvement.

These innovations aim to address the challenges identified in the study and improve the coverage and effectiveness of home visits by CHWs for pregnant mothers and newborns.
AI Innovations Description
Based on the study conducted in Malawi, the recommendation to improve access to maternal health is to re-align the Community-Based Maternal and Newborn Care (CBMNC) package with the existing platform’s capacity and to provide better support to Health Surveillance Assistants (HSAs) in implementing home visits.

The study found that the coverage of home visits during pregnancy and postnatal period was low, with less than one third of pregnant women receiving a home visit during pregnancy and only 11.4% receiving a postnatal visit within three days of delivery. The study also highlighted the importance of timely notification to HSAs about deliveries, as it significantly increased the coverage of postnatal home visits.

To address these issues and improve access to maternal health, the CBMNC package needs to be adjusted to match the capacity of the community health system. This may involve revising the visitation schedule and focusing on delivering high-quality care during the available visits. Additionally, strategies should be developed to better support HSAs in implementing home visits, such as providing them with necessary training, resources, and supervision.

By re-aligning the CBMNC package and providing better support to HSAs, it is expected that the coverage of home visits during pregnancy and postnatal period will increase, leading to improved maternal and newborn health outcomes.
AI Innovations Methodology
Recommendation: Implement a mobile health (mHealth) application to improve access to maternal health services.

Description: One potential innovation to improve access to maternal health is the implementation of a mobile health (mHealth) application. This application can be designed to provide pregnant women and new mothers with important information, reminders, and support throughout their pregnancy and postnatal period. The mHealth application can be accessed through smartphones or other mobile devices, making it easily accessible to a wide range of users.

Methodology to simulate the impact of this recommendation:

1. Define the target population: Identify the specific group of pregnant women and new mothers who would benefit from the mHealth application. This could include women in a specific geographic area or those who are part of a particular healthcare program.

2. Collect baseline data: Gather information on the current access to maternal health services in the target population. This can include data on the percentage of women receiving home visits, the timing of postnatal visits, and the level of communication between healthcare providers and mothers.

3. Design the mHealth application: Work with healthcare professionals, technology experts, and potential users to develop an mHealth application that meets the needs of the target population. The application should include features such as educational content, appointment reminders, and a communication platform for users to ask questions or seek support.

4. Conduct a pilot study: Implement the mHealth application in a smaller scale to test its feasibility and effectiveness. Select a sample of pregnant women and new mothers from the target population to use the application and collect data on their usage, satisfaction, and health outcomes.

5. Analyze data: Evaluate the impact of the mHealth application by comparing the data collected during the pilot study to the baseline data. Look for improvements in access to maternal health services, such as an increase in the percentage of women receiving home visits or a decrease in the time between delivery and postnatal visits.

6. Scale-up and implementation: If the pilot study shows positive results, consider scaling up the implementation of the mHealth application to reach a larger population. This may involve collaborating with healthcare providers, policymakers, and technology partners to ensure widespread access and usage of the application.

7. Continuous monitoring and evaluation: Regularly monitor and evaluate the impact of the mHealth application as it is implemented on a larger scale. Collect feedback from users, track usage data, and assess health outcomes to identify areas for improvement and ensure the continued effectiveness of the intervention.

By following this methodology, it is possible to simulate the impact of implementing an mHealth application on improving access to maternal health services. This approach allows for data-driven decision-making and the identification of strategies to better support healthcare providers in delivering home visits and other essential maternal health services.


Statistics:
Citations: 11
Identifiers:
DOI: 10.7189/JOGH.09.010808
ISSN: 20472978
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Malawi
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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