“I cannot say no when a pregnant woman needs my support to get to the health centre”: Involvement of community health workers in Rwanda’s maternal health

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Study Justification:
The study titled “I cannot say no when a pregnant woman needs my support to get to the health centre”: Involvement of community health workers in Rwanda’s maternal health” aims to explore the perceptions and experiences of maternal community health workers (M-CHWs) in Rwanda regarding access and provision of maternal health services. This study is important because M-CHWs play a crucial role in promoting the use of health facilities for prenatal care and delivery, and understanding their experiences can help identify challenges and improve service provision.
Highlights:
1. The study highlights the significant role of M-CHWs in promoting the use of health facilities for maternal health services in Rwanda.
2. It identifies the challenges faced by M-CHWs in delivering adequate maternal health services, including limited resources and lack of formal training.
3. The study emphasizes the importance of addressing these challenges to improve the quality and quantity of maternal health services provided by M-CHWs.
4. It highlights the need to involve M-CHWs and the communities they serve in exploring context-specific areas to make the M-CHW program sustainable and achieve equitable access to maternal health services.
Recommendations:
1. Provide formal training for M-CHWs in maternal health to enhance their knowledge and skills.
2. Increase the allocation of resources to support M-CHWs in delivering maternal health services effectively.
3. Strengthen collaboration between M-CHWs and trained health professionals, such as nurses, to improve service provision.
4. Conduct regular assessments and evaluations to monitor the quality and impact of maternal health services provided by M-CHWs.
5. Involve M-CHWs and community members in decision-making processes to ensure their voices are heard and their needs are addressed.
Key Role Players:
1. Ministry of Health: Responsible for developing policies and guidelines for M-CHWs and allocating resources.
2. District Health Offices: Provide support and supervision to M-CHWs at the district level.
3. Health Center Coordinators: Oversee M-CHWs’ activities in different communities and provide guidance and support.
4. Trained Health Professionals (e.g., nurses, midwives): Collaborate with M-CHWs to deliver maternal health services.
5. Community Leaders: Engage with M-CHWs and advocate for the importance of maternal health services in their communities.
Cost Items:
1. Training Programs: Budget for developing and implementing formal training programs for M-CHWs in maternal health.
2. Resources and Supplies: Allocate funds for providing necessary resources and supplies to M-CHWs, such as educational materials and medical equipment.
3. Supervision and Support: Budget for regular supervision and support visits to M-CHWs by district health offices and health center coordinators.
4. Monitoring and Evaluation: Allocate funds for conducting regular assessments and evaluations to monitor the quality and impact of maternal health services provided by M-CHWs.
5. Community Engagement: Budget for community engagement activities, such as meetings and workshops, to involve M-CHWs and community members in decision-making processes.
Please note that the cost items provided are for planning purposes and do not reflect actual costs.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a case study methodology and qualitative research approach, which provides valuable insights into the perceptions and experiences of M-CHWs. However, the sample size is relatively small with only sixteen participants, which may limit the generalizability of the findings. To improve the strength of the evidence, future research could consider increasing the sample size and using a mixed-methods approach to provide a more comprehensive understanding of M-CHWs’ roles in maternal health services.

Background: In Rwanda, maternal community health workers (M-CHWs) are involved in the country’s overall health system. In maternal health, their role includes the provision of preventive and promotional health services at the community level. They provide services such as health education on maternal health wellbeing, advice and information on access and timely utilization of health facilities for prenatal, delivery and postpartum care. The contribution of M-CHWs in the health sector combined with other government initiatives led the country to achieving the fifth Millennium Development Goal (MDG) – target 5A- that aimed to improve maternal health through the reduction of maternal mortality ratio by 75% between 1990 and 2015). The objective of this study was to explore M-CHWs’ perceptions and experiences on access and provision of maternal health services. Methods: We used a case study methodology, a qualitative research approach to explore M-CHWs’ experiences and perceptions on access and provision of maternal health services at the community level in Rwanda. For the period of June–August 2014, in-depth interviews were conducted with sixteen M-CHWs who had been providing maternal health services in the Eastern Province of Rwanda. Participants shared their experiences and perceptions on access and provision of maternal health service in their communities. Results: The results of this research highlight the role of M-CHWs in promoting the use of health facilities for prenatal care and delivery and the ways they use to reach out to women. Several challenges prohibit M-CHWs to deliver adequate maternal health services and these are related to the poor resources settings in which they operate. Conclusion: The results of this study highlight the experiences and perceptions of M-CHWs on the provision and access to maternal health services in their communities. The fact that M-CHWs are volunteers operating in limited resources settings with no formal training in maternal health and with considerable workloads translates into challenges regarding the quality and quantity of services they provide in their communities. Such challenges create an impact on M-CHWs service provision, satisfaction and retention. The voices of M-CHWs and the communities they serve are needed to explore areas that are specific to each community context that would contribute to making the M-CHW program sustainable to achieve equitable access to maternal health services.

We used a case study research design to explore M-CHWs’ perceptions and experiences on access and provision of maternal health services. The case study approach was deemed appropriate for this research in order to explore the complex aspects of M-CHWs’ roles in the context of providing maternal health services [17, 18] . Through this approach, we conducted in-depth interviews with M-CHWs where they provided a deeper understanding of their experiences on access and provision of maternal health at the community level. We used a semi-structured interview guide that included open ended questions to elicit views from M-CHWs about: 1) their understanding of maternal health; 2) the types of maternal health services provided at the community level by M-CHWs; 3) the factors that contribute to the use of maternal health services; 4) gaps and barriers in the provision of maternal health services in the community; and 5) suggestions to improve service provision. All the sampled participants accepted to fully participate in the study. Body languages and non-verbal communication were observed, and field notes were taken. These were used during the analysis to better interpret the interviews. The current study reports on data collected as part of a master’s research conducted in the Eastern and Western provinces of Rwanda [19]. For this study, we used data from semi-structured interviews with M-CHWs [19] in the Eastern Province, where the MNCH project operated. The project interventions included in-service training of health professionals (nurses, midwives and physicians) on maternal, newborn and child health care. The trained health professionals, especially nurses, work closely with M-CHWs. The lead author (GT) conducted interviews in Kinyarwanda, the official language in Rwanda, which is also her mother tongue. GT is familiar with the Rwandan culture as well as the Rwandan health system, which helped her to navigate the communities where the study was conducted. The Eastern Province is the largest and most populated province with the lowest population density in the country [20]. Data were collected in eight district hospitals across the province: Nyamata, Rwamagana, Kibungo, Kirehe, Gahini, Kiziguro, Ngarama and Nyagatare. Each of these hospitals serves as a second level of health care for about 11–20 health centers. Health centers provide primary health services, and they oversee M-CHWs activities in different communities. For every health center, there are about 20–38 M-CHWs, each one of them operating in their own village of approximately 100 households and all together serving the population in the catchment area of a health center. All the M-CHWs included in this study operate in equally remote settings from the health centers. The sample size was determined by the qualitative nature of this study. In total, sixteen semi-structured interviews were conducted with M-CHWs on their perceptions and experiences on access and provision of maternal health services in their communities. There was at least one interview per hospital selected for this particular analysis. Eligible participants were identified and were given written and verbal information about the study by the coordinators of M-CHWs’ activities at the health center and district hospital levels. The letter of information stated the objective of the study and that there was no impact whatsoever on M-CHW following their (non) participation in the study. Those who were interested in participating in the study contacted the researcher, who in return, scheduled a meeting with each of them to further explain the study, answer questions, and schedule interviews. Following participants’ choice, most interviews took place at the health center (n = 12), very few took place at the M-CHW’s home (n = 4). The semi-structured interviews were about 30–45 min and proceeded in an open dialogue form and were audio recorded with participants’ permission. All the interviews were conducted in the Kinyarwanda language and were audio-recorded with participants’ permission. The audio recordings were transcribed verbatim, translated from Kinyarwanda into English prior to analysis. Three members of the research team (GT, CH & SR) are fluent in both English and Kinyarwanda which helped for translation validity. The transcripts were stored and organized with NVIVO™ software, a qualitative data management program. Selected transcripts that corresponded to research objectives were independently reviewed by each team member. Initially, inductive coding was done by GT using NVivo and simultaneously, by each research team member manually. A first analysis team meeting involved the discussion on codes and categorizing them into emerging themes [21]. Team members separately went back through the transcripts prior to a second meeting that was aimed to discuss on additional inductive and deductive codes for the application of thematic analysis. Thematic analysis was conducted involving the grouping of themes that emerged from the interviews in comparison to existing literature on CHWs’ involvement in promoting maternal health [4, 22–25] . Through thematic analysis, we developed different concepts and categories from the data: promoting access to maternal health services in communities, reaching out to women, and empowering M-CHWs. In order to verify the accuracy of our analysis, we returned the findings to study participants to gain their feedback and ensure that the final result and clustering were faithful and true to the data. This process helped to validate the data while offering gratitude and paying respect to acknowledge participants’ contributions. Prior to commencement of the study, ethical approvals to conduct this study were granted by Western University’s Research Ethics Board (File No: 103945) and Ministry of Education of Rwanda (MINEDUC/ S&T/251/2014). Before conducting interviews, letters of information were given to participants and written informed consent were obtained from them. Participants were assured of voluntary participation, confidentiality, anonymity and freedom to withdraw from the study at any time. Participants were given a token of appreciation for their time and contribution to the study. The token consisted of a food item (a bag of rice or sugar) as per the cultural protocols and participants’ socio-economic positions.

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

1. Mobile Health (mHealth) Applications: Develop and implement mobile health applications that provide pregnant women with access to information and resources related to maternal health. These applications can provide educational materials, appointment reminders, and access to telemedicine services.

2. Telemedicine Services: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals and receive prenatal care remotely. This can help overcome geographical barriers and improve access to timely healthcare services.

3. Community Health Worker Training: Provide formal training programs for community health workers (CHWs) focused on maternal health. This can enhance their knowledge and skills in providing quality maternal health services, leading to improved access and outcomes.

4. Transportation Support: Develop transportation support programs to ensure pregnant women have access to reliable and affordable transportation to healthcare facilities. This can include partnerships with local transportation providers or the use of innovative transportation solutions such as community-based ride-sharing services.

5. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve access to maternal health services. This can involve leveraging private sector resources and expertise to enhance healthcare infrastructure and service delivery in underserved areas.

6. Maternal Health Vouchers: Implement voucher programs that provide pregnant women with financial assistance to access maternal health services. These vouchers can cover the cost of prenatal care, delivery, and postpartum care, ensuring that financial barriers do not hinder access to essential healthcare.

7. Community Awareness Campaigns: Conduct community awareness campaigns to educate pregnant women and their families about the importance of maternal health and the available services. These campaigns can address cultural and social barriers that may prevent women from seeking timely care.

8. Telehealth Consultations: Introduce telehealth consultations for pregnant women, allowing them to connect with healthcare professionals remotely for non-emergency consultations. This can reduce the need for in-person visits and increase access to healthcare expertise.

9. Maternal Health Hotlines: Establish dedicated hotlines staffed by trained healthcare professionals to provide information, support, and guidance to pregnant women. These hotlines can be accessible 24/7 and offer multilingual services to cater to diverse populations.

10. Maternal Health Clinics in Remote Areas: Set up maternal health clinics in remote areas to bring essential healthcare services closer to pregnant women. These clinics can be staffed by trained healthcare professionals and equipped to provide prenatal care, delivery services, and postpartum support.

It is important to note that the implementation of these innovations should be context-specific and tailored to the unique needs and challenges of the target population.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the described study is to strengthen the training and support provided to maternal community health workers (M-CHWs) in Rwanda.

The study highlights the challenges faced by M-CHWs in delivering adequate maternal health services, including limited resources, lack of formal training in maternal health, and heavy workloads. To address these challenges and improve access to maternal health, the following recommendations can be considered:

1. Training and Capacity Building: Provide comprehensive and ongoing training to M-CHWs on maternal health, including topics such as prenatal care, delivery, postpartum care, and health education. This training should be tailored to the specific needs and context of the communities they serve.

2. Supervision and Support: Establish a system of regular supervision and support for M-CHWs, including mentorship and guidance from trained health professionals. This can help ensure that M-CHWs have the necessary knowledge and skills to provide quality maternal health services.

3. Resources and Infrastructure: Allocate sufficient resources and improve infrastructure in the communities where M-CHWs operate. This can include providing essential medical supplies, equipment, and transportation to enable M-CHWs to effectively deliver maternal health services.

4. Collaboration and Coordination: Strengthen collaboration and coordination between M-CHWs, health centers, and district hospitals. This can help improve the referral system and ensure that pregnant women receive timely and appropriate care throughout the continuum of maternal health services.

5. Community Engagement: Engage the community in the planning, implementation, and monitoring of maternal health programs. This can help raise awareness, address cultural barriers, and promote community ownership of maternal health initiatives.

By implementing these recommendations, the role of M-CHWs in promoting access to maternal health services can be enhanced, leading to improved maternal health outcomes in Rwanda.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening the training and capacity building of M-CHWs: Providing formal training and continuous education to M-CHWs on maternal health topics can enhance their knowledge and skills in providing adequate services. This can include training on prenatal care, safe delivery practices, postpartum care, and identifying high-risk pregnancies.

2. Improving the availability and accessibility of resources: Ensuring that M-CHWs have access to necessary resources such as medical supplies, transportation, and communication tools can enhance their ability to provide quality maternal health services. This can involve establishing supply chains, providing vehicles or bicycles for transportation, and equipping M-CHWs with mobile phones for communication.

3. Strengthening collaboration and coordination between M-CHWs and health facilities: Establishing effective communication channels and referral systems between M-CHWs and health facilities can improve access to timely and appropriate maternal health care. This can involve regular meetings and trainings to enhance collaboration and ensure smooth referrals.

4. Engaging the community and raising awareness: Conducting community outreach programs and health education campaigns can raise awareness about the importance of maternal health and encourage women to seek care. This can involve organizing community meetings, distributing informational materials, and engaging community leaders and influencers.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the number of women receiving prenatal care, the percentage of deliveries attended by skilled birth attendants, or the distance traveled to reach a health facility.

2. Collect baseline data: Gather data on the current status of the indicators before implementing the recommendations. This can involve surveys, interviews, or data from health facilities and M-CHWs.

3. Implement the recommendations: Put the recommendations into action, ensuring that the necessary resources and support are provided.

4. Monitor and evaluate: Continuously monitor the progress and impact of the recommendations. Collect data on the indicators at regular intervals to assess any changes or improvements.

5. Analyze the data: Use statistical analysis or other evaluation methods to analyze the collected data and determine the impact of the recommendations on improving access to maternal health.

6. Draw conclusions and make recommendations: Based on the analysis, draw conclusions about the effectiveness of the recommendations and identify any areas that may require further improvement. Use the findings to make recommendations for future interventions or policy changes.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions for further interventions.

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