Menu
Menu
Menu
Menu
Introduction: Delays due to long distances to health facilities, poor road infrastructure, and lack of affordable transport options contribute to the burden of maternal deaths in Mozambique. This study aimed to assess the implementation and uptake of an innovative community-based transport program to improve access to emergency obstetric care in southern Mozambique. Methods: From April 2016 to February 2017, a community transport strategy was implemented as part of the Community Level Interventions for Pre-eclampsia Trial. The study aimed to reduce maternal and perinatal mortality and morbidity by 20% in intervention clusters in Maputo and Gaza Provinces, Mozambique, by involving community health workers in the identification and referral of pregnant and puerperal women at risk. Based on a community-based participatory needs assessment, the transport program was implemented with the trial. Demographics, conditions requiring transportation, means of transport used, route, and outcomes were collected during implementation. Data were entered into a REDCap database. Results: Fifty-seven neighborhoods contributed to the needs assessment; of those, 13 (23%) implemented the transport program. Neighborhoods were selected based on their expression of interest and ability to contribute financially to the program (US$0.33 per family per month). In each selected neighborhood, a community management committee was created, training in small-scale financial management was conducted, and monitoring tools were provided. Twenty people from 9 neighborhoods benefited from the transport program, 70% were pregnant and postpartum women. Conclusion: These results demonstrate that it was feasible to implement a community-based transport program with no external input of vehicles, fuel, personnel, and maintenance. However, high cost and a lack of acceptable transport options in some communities continue to impede access to obstetric health care services and the ability for timely follow-up. When strengthening capacities of community health workers to promptly assist and refer emergency cases, it is crucial to encourage local transport programs and transportation infrastructure among minimally resourced communities to support access and engagement with health systems.
The community transport program was embedded within the larger Community-Level Interventions for Pre-eclampsia (CLIP) in Mozambique Trial (National Clinical Trials #01911494), which aimed to reduce maternal and perinatal mortality and morbidity by strengthening CHWs’ capacity to identify high-risk pregnancies and refer them to the health facility when needed.14 The CHWs in the CLIP Trial, known as agentes polivalentes elementares in Mozambique, belonged to the existing CHW program and received extra training as part of the trial. In turn, the trial was aligned with the existing referral system between the community and health facilities, whereby CHWs transfer patients that require higher levels of assistance by using referral slips that record the date, person’s name, age, residence, referral facility, reported signs and symptoms, and first aid or care provided, and CHW name. Formative research preceding the CLIP Trial, which used an ethnographic approach to investigate the problem of access to care, revealed that the lack of transport was a major contributor to poor referrals and hence low access to health care.5 In the same study, accounts from women of reproductive age, pregnant women, household decision makers, and health care providers in these communities revealed that even where transport was available in the form of minibuses or agricultural tractors, it was restricted to main roads or prohibitively expensive to arrange privately on a case-by-case basis for most women.5 Consequently, many residents had to walk long distances to access transport—a challenge during obstetric emergencies—or simply did not travel to the health facilities. Although ambulances were available to support referrals between facilities, there was no formal structured system providing transport from the community to health centers, mainly because of the physical distance between the communities and the health facilities. The transport program was designed to help facilitate the timely referral of pregnant women with obstetric emergencies to the nearest primary health facilities. The transport program was designed to help facilitate the timely referral of pregnant women with obstetric emergencies to the nearest primary health facility. The study area included Malehice, Chaimite, Chissano, Messano, Três de Fevereiro, Ilha Josina, and Calanga administrative posts from Maputo and Gaza Provinces in southern Mozambique (Figure 1), which were also part of the CLIP Trial. The study area is largely rural with agriculture, fishing, cattle breeding, and informal trade as the main resident income sources. During the rainy season from approximately November to March, some areas are severely affected by road blocks due to floods, particularly Ilha Josina and Calanga.15 Map Showing Study Areas Where Community Transport Program to Improve Access to Emergency Obstetric Case Was Implemented, Southern Mozambique A community-based participatory needs assessment was conducted to inform the community transport plan and to support the creation of a community fund to cover transport costs. While community financing programs to support transport for emergency referral have been used in other areas in sub-Saharan Africa,16 this concept was novel to this region. There were existing microfinance programs for non-health purposes in the communities, so members were familiar with the practice. As part of the rapport-building stage, contacts were first made with the community chief in each administrative post to obtain permission for the proposed activities. Subsequently, neighborhood chiefs (known as secretários dos bairros) were contacted to support scheduling of the activities with community members. The first activity consisted of 3 rounds of meetings: initial meetings to assess needs and raise awareness about the community transport program, mobilization meetings with interested communities to prepare for implementation, and follow-up meetings with communities who implemented the program. Community meetings, as part of community engagement activities for the CLIP Trial, included pregnant women, women of reproductive age, partners and husbands, mothers and mothers-in-law, and the community in general and were conducted at the círculos (the usual community gathering location). These meetings included discussions regarding launching the program; encouraging community contributions to the fund; sharing the list of transporters and management committee members; and presenting updates on uses, finances, and savings within the transport program. These community meetings occurred throughout the project and most meetings were conducted in Changana, the predominant local language. During the phase-out stage of the CLIP trial, a final round of community meetings was held to reflect upon the program achievements, and involved CHWs, selected community members, PHC facility staff, owners of the transport program vehicles and community leaders. Assessment of the transport program implementation utilized a mixed-methods approach. Both quantitative and qualitative data were collected using structured forms (referred to as logs). Quantitative data included demographic characteristics of meeting attendees and information associated with the management of funds and qualitative data included information on all medical complaints that required transport, transport methods used, transport users’ and stakeholders’ testimonials. Meeting details, including location, number of participants, and their backgrounds and messages discussed were also captured, including facilitator reflections and community feedback. Data collection was conducted by a team comprising a social scientist, a community liaison officer, 3 mobilizers, and 4 health activists employed by the CLIP Trial, separate from CHWs in the neighborhoods. All data collectors were fluent in both Portuguese and Changana. All data were sent to the Manhiça Health Research Center for data entry to a REDCap database (Nashville, TN, USA).17 Before data entry, all logs were checked for quality by study team members who conducted data collection. Missing data, outliers, and discrepancies were queried to maximize data integrity. Data analyses were performed using RStudio software version 3.4.1 (RStudio Inc, Boston, MA, USA) to generate frequency distributions of categorical variables. The analysis separated general community meetings and meetings where transport issues were discussed, the latter of which is the focus of this article. Demographic characteristics of the participants and the study variables of interest are presented using descriptive statistics. Qualitative data was also entered on a REDCap database and underwent content analysis using NVivo 12 (QSR International, Melbourne, Australia). Content analysis is a widely used method of qualitative analysis that includes organizing information based on emergent themes from the text and sorting themes into categories to further understand how issues are related.18 Approval for the CLIP Trial was obtained from the Institutional Bioethics Review Boards of Centro de Investigação em Saúde da Manhiça (CISM, CIBS-CISM/038/14), the Mozambique National Bioethics for Health Committee (219/CNBS/14) and the University of British Columbia (UBC, H12-03497). Written informed consent was obtained from households participating in the CLIP Trial.
N/A
