The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study

Background: Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers’ strikes in rural Kenya. Methods: The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods. Results: The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3. Conclusions: The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings. Busia County has seven sub-counties and is predominantly a rural setting. The proportion of births in the county attended to by skilled health personnel is 59% (lower than the national average of 62%) [31]. In addition, the county has traditional birth attendants who provided home antenatal and delivery services. During the project, these were reoriented to become birth companions (BCs) and primarily provided support in health education and referral of pregnant women to the health facilities for skilled antenatal, birth and postnatal care. The project supported four rural hard-to-reach sub-counties with poor maternal and newborn health indicators: Teso North, Teso South, Nambale and Samia. In this study, ‘hard-to-reach’ refers to populations who have limited regular contact with skilled pregnancy and childbirth services including people living in areas ‘too far’ from health services. ‘Too far’ not only refers to the physical distance but also limited logistics and human resource capacity [32]. The Community Midwifery Model (CMM) in Kenya uses skilled out of work or retired licensed healthcare professionals who are resident within a given community and seeks to contribute towards the achievement of SDG 3 [28] by addressing the three delays that commonly contribute to maternal and perinatal mortality [33]. The three delays are (1) delay in deciding to seek appropriate care, (2) delay in reaching an appropriate health care facility and (3) delay in receiving adequate emergency care at the facility [34]. The primary role of community midwives is provision of a continuum of care during normal pregnancy, childbirth, postpartum period, and in counselling for and providing family planning services as well as newborn care and referral. To achieve this, they link with community health volunteers (CHVs), BCs, community health extension workers (CHEWs), local committees, facility staff and county teams to promote safe motherhood in the community. All the community midwives included in this study met the requirements for providing services as stipulated in the national guidelines: were retired health professionals (nurse/midwives) with midwifery skills and registered with the national regulator Nursing Council of Kenya; had valid practicing licenses (evidence of retention on a professional register with the Nursing Council of Kenya) and were residents in the communities they served [28]. Their activities were supervised by the respective sub-county health management teams. Save the Children, in collaboration with the Busia County Department of Health, facilitated the work of the community midwives by supporting their training in emergency obstetrics and newborn care (EmONC) to enhance their skills in management of basic EmONC signal functions as well as providing the necessary logistics to enable them provide services (Table 1). The seven basic EmONC signal functions are: (1) administration of parenteral antibiotics, (2) administration of uterotonic drugs, (3) administration of parenteral anticonvulsants for pre-eclampsia and eclampsia (magnesium sulphate), (4) manual removal of retained placenta, (5) removal of retained products of conception (e.g., manual vacuum aspiration), (6) assisted vaginal delivery (vacuum extraction) and (7) neonatal resuscitation (with bag and mask) [35]. The health facilities to which the community midwives were linked provided them with pharmaceuticals (Oxytocin for prevention of postpartum hemorrhage) and non-pharmaceuticals supplies – gloves, syringes and needles, cotton wool and gauze. The project team and the respective sub-county health management teams (sub-county nursing officer, sub-county reproductive health coordinator and sub-county community strategy focal person) provided structured monthly and/or appropriate support supervision and mentorship on quality service delivery. Support package provided to community midwives aWhere sterilizing equipment were not available, link health facilities supported this function as appropriate The community midwives provided a range of antenatal, delivery and postnatal care services as recommended by the national guidelines in provision of community midwifery [28] and health services [36] (see Table 2). Importantly, all the childbirth services were conducted at the community midwife’s clinic and in exceptional cases, for instance, insecurity (especially at night), long distances and requests from clients, some were conducted at the community midwives’ homes, which was consistent with findings from an evaluation of the model in the country [37]. Services offered by the community midwives aHIV counselling available but testing not available in all the clinics bEmONC signal functions provided include administration of parenteral oxytocics, administration of parenteral antibiotics, administration of parenteral anticonvulsants, manual removal of placenta and newborn resuscitation Community midwives admitted clients for childbirth services. The period of stay at the CM varied from 1 to 3 days depending on the condition of the mother. Cases that required further review and care were referred to the nearby private facility to prevent obstetric complications. There was a minimal user fee for services provided by the CMs. However, the CMs did not deny women services for lack of payment in line with the universal health coverage policies. Non-monetary items and/or gifts in kind were also a form of payment that was acknowledged by the CMs for the services rendered to the community. In a few occasions however, the services were provided for free depending on the client’s socio – economic status. The project supported a reimbursement of KSh. 100 ($1) for BCs for every appropriate referral for a pregnancy, childbirth or postpartum condition with danger signs to the CMs. The danger signs for referral included maternal – vaginal bleeding, reduced or lack of movements of the unborn baby, convulsions, pale, fever, severe headache and severe abdominal pain; neonatal – refusal or poor breastfeeding, infection/fever, convulsions and difficulty breathing. The study used a quasi-experimental (one-group pre- and post-test) design. The aim was to determine the effect of the intervention (an enhanced community midwifery model) on maternal and newborn health service utilization and outcomes among hard-to-reach communities against the backdrop of the protracted healthcare workers’ strikes. The intervention was implemented over a period of 11 months from December 2016 to October 2017. In the first 6-month period, midwifery services were less affected in the public health sector health facilities (during a doctors’ strike in the first 3 months followed by a 3-month return to normalcy) compared to the last 5-month period (when the enhanced community midwifery model was strengthened due to nurses/midwives’ industrial action – see separate section describing intervention in detail below). To determine the effect of the enhanced community midwifery model, we aggregated periods 1 and 2 (first 6 months) into pre-intervention and considered period 3 (last 5 months) as post-intervention period. The study involved community midwives linked to six health facilities in Busia County. The health facilities were two comprehensive EmONC (Teso North sub-county hospital and Alupe sub-county hospital) and four basic EmONC (Sio Port sub-county hospital, Nambale sub-county hospital, Amukura health centre and Moding health centre) (Fig. 1). Map showing health facilities to which community midwives are linked in Busia County. *(Authors’ own; generated using QGIS software) The project introduced the community midwifery model in December 2016. During its implementation, there were two periods of industrial action by healthcare workers in the public sector over disagreements regarding terms of service: 3-month doctors’ strike between December 2016 – February 2017 followed by a 3-month period of return to normal services between March – May 2017 before the second 5-month nurses/midwives’ strike between June – October 2017. The project implemented an enhanced community midwifery model in the four sub-counties to improve skilled attendance during pregnancy and childbirth during the nurses/midwives’ strike. A total of 10 community midwives were purposively identified across the four sub-counties included in the project and enrolled in the interventions. They were then linked to the nearby health facilities with high volumes of clients in their respective sub-counties. The community midwives were distributed as follows: one in Samia sub-county – linked to Sio Port Sub-county Hospital; three in Nambale sub-county – all linked to Nambale Sub-county Hospital; three in Teso North sub-county – two linked to Teso North Sub-county Hospital and one linked to Moding Health Centre; and three in Teso South sub-county – two linked to Amukura Health Centre and one linked to Alupe Sub-county Hospital. During the doctors’ strike, maternal and newborn care service delivery (ANC, childbirth and postnatal care) were less affected in health facilities. During the nurses/midwives’ strike, maternal and newborn care services were severely affected across the country. During this time, the project supported a constellation of activities to create awareness and demand for community midwifery services. The activities included community sensitization by community health volunteers (CHVs) on danger signs in pregnancy and importance of seeking skilled antenatal, childbirth and postnatal care; linkage of the CMs with the CHVs; reorientation of traditional birth attendants (TBAs) to BCs – initiated during the strike by doctors; and linkage of the CMs and the CHVs with the reoriented BCs. Community midwives worked closely with CHEWs and CHVs in the provision of various health services at the community level; collection and reporting of monthly service utilization data as well as participation in the sub-county quarterly maternal and perinatal deaths surveillance and response (MPDSR) review meetings. In addition, the project team and the sub-county reproductive health and community health teams conducted support supervision and mentorship of CMs on emergency obstetrics and newborn care skills. The CHVs and BCs encouraged and referred pregnant women in their catchment areas to the nearby CM for antenatal, childbirth and postnatal care (Fig. 2). Chronology of intervention activities The project used the Kenya Ministry of Health (MOH) reporting tools that health facilities, community midwives and community health volunteers use to capture information on service utilization. Data on the numbers of pregnant women seeking antenatal and birth services from facilities and community midwives were collected using the monthly MOH 711 summary report (Integrated Summary Report: Reproductive & Child Health, Medical and Rehabilitative Services). This is a secondary reporting tool with all the ANC and maternity service utilization data summarized from the primary daily activity reporting registers and is open – access and publicly available on the DHIS2 – the national MOH reporting system for use by health facilities, sub-counties and counties. The sub-county reproductive health and the records and information management teams verified the data in the primary MOH tools: ANC register (MOH 405), maternity register (MOH 333) and postpartum care register (MOH 406). First and fourth ANC visits were used to determine access and utilization of focused ANC services respectively as recommended [38]. The maternity register captured data on skilled births while the postnatal register captured information on utilization of postnatal care services for the mothers who had either received delivery services at the CMs and/or had unskilled home births and sought skilled post-delivery care or immunization. Services provided by CHVs (referrals for ANC and skilled birth) were captured on MOH 514 form (Community Health Service Delivery Logbook) while CHEWs used MOH 515 form (Community Health Extension Worker Summary) to summarize information from MOH 514 forms. Community health extension workers and facility-based health care providers verified data from MOH 514 during routine monthly review meetings with CHVs before being uploaded on to MOH 515 in DHIS2. Data capture for the reporting month in the DHIS2 is completed by the 15th day of the subsequent month. Final data for this study were accessed from the DHIS2 on 6th April 2020. We analysed service utilization data for first and fourth ANC, birth and postpartum care provided by facilities and CMs for the periods of interest. A skilled birth was defined as a birth attended to by skilled health personnel - including a doctor, nurse or midwife - who is educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborn babies [10, 39]. Postnatal care was defined as care to a woman 2–3 days post-delivery by a skilled health personnel – either in the health facility or by a community midwife. First author extracted raw data from the DHIS2, entered in Microsoft Office Excel 2013, cleaned and exported to STATA version 12 for analysis. The first author extracted the data from DHIS 2 in Excel format, cleaned and exported it to STATA version 12 for analysis. Service utilization data were classified into three periods or groups. The three periods of analysis included the three-month strike by doctors between December 2016 and February 2017 (Period 1), the three-month period of normalcy following the end of the doctors’ strike (Period 2 occurring between March and May 2017), and the five-month strike by nurses/midwives between June and October 2017 (Period 3). We computed the performance mean scores of outcomes of interest (1st ANC attendance, 4th ANC attendance, skilled births and postnatal care) for the three periods. We conducted one-way analysis of variance (ANOVA) to test for significant differences in the mean scores of outcomes of interest between time periods [40]. We also conducted Kruskal-Wallis test for distributions with small numbers [41]. We further conducted Tukey post hoc tests to determine which time periods were significantly different from each other in terms of maternal and newborn health service utilization and outcomes. The results are reported as effect sizes with 95% confidence intervals. To determine the effect of the community midwifery model, we aggregated periods 1 and 2 into pre-intervention and considered period 3 as post-intervention period. We calculated indicators of performance by community midwives by comparing the number of antenatal care clients and deliveries conducted by this cadre as a fraction of the total number of antenatal care clients and deliveries conducted by health facilities and community midwives. We conducted two-groups test of proportions. Estimates with p-values less than 0.05 (p < 0.05) were considered statistically significant.