Setting
Busia County has seven sub counties and is predominantly a rural setting. The county’s skilled delivery is 59% (lower than the national average of 62%) meaning that two out of every five women deliver both at home and without a skilled attendance (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 support in health education and referral of pregnant women to the health facilities for skilled antenatal, birth and postnatal care. The four rural hard-to-reach sub counties with poor maternal and newborn health indicators supported were: Teso North, Teso South, Nambale and Samia. In this review, ‘hard-to-reach’ refer to populations who have little regular contact with skilled pregnancy and childbirth services including people living in areas ‘too far’ from the health services. ‘Too far’ not only refers to the physical distance but also logistics and human resource capacity as used in the ‘reaching every district’ strategy in immunization (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) and helping to address the three delays that commonly contribute to maternal and perinatal mortality (33, 34). Their primary role is the 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 as prescribed in the implementation guidelines. In this study, all community midwives had the essential prerequisites for community midwifery services as required in the implementation guidelines for community midwifery services in Kenya (28): retired health professionals (nurse/midwives) with midwifery skills 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 lastly, they all had residency within the community they were serving. Their areas/clinics for service provision were verified and supervised by the respective subcounty health management team.
To facilitate their work, Save the Children in collaboration with the Busia County Department of Health supported their training in emergency obstetrics and newborn care (EmONC) to reinforce their essential skills as SHP able to provide nearly all EmONC signal functions, and were provided with necessary logistics (Table 1). Pharmaceuticals (Oxytocin for prevention of postpartum hemorrhage) and non-pharmaceuticals supplies – gloves, syringes and needles, cotton wool and gauze were supplemented and replenished by the link health facilities. Structured monthly and/or appropriate support supervision and mentorship was provided by the project team and the respective subcounty health management team (subcounty nursing officer, subcounty reproductive health coordinator and subcounty community strategy focal person) on quality service delivery.
Table 1
Support package provided to community midwives
5-days training in emergency obstetrics and newborn care (EmONC) using national EmONC training curriculum |
Antenatal care equipment: weighing scale – adult and infant; fetal scopes |
Intrapartum care equipment: vaginal examination kits; delivery kits, partographs |
Newborn resuscitation equipment – bag and mask/ambubag for ventilation (size 0 and 1) and penguin suction devices; baby outfits (sweater, cap/hat and socks) |
Infection prevention & control decontamination and waste segregation buckets* |
Antepartum, intrapartum and postpartum care job aids/protocols |
Service delivery registers - mother and child health booklets, antenatal care registers, delivery registers; postnatal care registers |
Referral forms and registers and referral telephone numbers |
* Where sterilizing equipment were not available, link health facilities supported this function as appropriate. |
Scope Of Community Midwifery Services
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) & health services (35) (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, as also reported in recent evaluations in the country (36).
Table 2
Services offered by the community midwives
Period | Services offered |
Antenatal | dissemination of key messages on danger signs in pregnancy, birth planning and emergency preparedness to support safe pregnancy and delivery of a healthy newborn and early childhood care; monitoring and assessment of pregnancy through focused antenatal care (FANC) model; intermittent preventive treatment for malaria in pregnant women (IPT); tetanus toxoid vaccination; referral for antenatal profile; counseling and testing for HIV among the pregnant womena |
Childbirth | Childbirth care in uncomplicated labour and delivery (Essential Obstetric Care); provision of EmONC signal functionsb; stabilizing women and/or their newborns who have complications prior to referral; |
Newborn | Provision of essential newborn care – warmth, resuscitation, early initiation of breast feeding, nutritional counselling & hygiene |
Postnatal | Targeted health education/information on danger signs, early detection and treatment of problems, care of breasts, advise on caring for the newborn; immunizations as per the Kenya Expanded Program on Immunization schedule, counseling and testing for HIV among the pregnant and postnatal mothers and provision of family planning counselling and services |
Family planning | Provision of family planning counselling and methods – pills, injectables, implants and intra-uterine contraceptive devices |
a HIV 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 1–3 days depending on the condition of the mother. Cases that required further review and care were referred to the link private facility to prevent obstetric complications. It is important to note that there was a minimal user fee for services provided by the CMs. However, no emergency services or delivery services were denied for lack of these fees charged – 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 capacity. The project supported a reimbursement of KSh. 100 ($1) for BCs for every appropriate referral made with a pregnancy, childbirth or postpartum danger signs. The referral danger signs were: maternal – vaginal bleeding, reduced or no 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.
Design
A quasi-experimental (one-group pretest-posttest) was designed. This design was utilized to determine the effect of a treatment or intervention (an enhanced community midwifery model) on a given sample (hard-to-reach communities/health facilities) against the background of the protracted healthcare workers' strikes. Besides, the design is characterized by use of a single group of participants (10 community midwives and their link facilities in this study) where all participants are given the same treatments and assessments, therefore, all are in the experimental condition. Secondly, there is a linear ordering that requires the assessment of a dependent variable before and after a treatment is implemented (skilled birth attendance access and utilization for this study) (37). There was no comparison group of facilities that would have selected for a control as community midwives were only established/developed in the project sites making the choice of this one-group pretest-posttest design the best in the case to achieve the intervention effect. The 6-month pretest period used was between Dec 2016 – May 2017 where midwifery services were less disrupted (despite a 3-month doctors’ strike in the first half – December 2016 – Feb 2017 – of this period). Healthcare services resumed in the second half of this period (March – May 2017) in health facilities following the initial 3-month doctor’s strike. The 5-month posttest period used was June – October 2017 after rolling out the enhanced community midwifery model. During the posttest period, all healthcare services were severely disrupted in all health facilities across the country.
The six health facilities in this study were: two comprehensive EmONC (Teso North subcounty hospital and Alupe subcounty hospital) and four basic EmONC (Sio Port subcounty hospital, Nambale subcounty hospital, Amukura health centre and Moding health centre) (Fig. 1).
Intervention
A total of 10 available community midwives were enrolled, supported and linked to six high volume health facilities in each of the subcounty. Their distribution was as follows: Samia (1) – linked to Sio Port Subcounty Hospital; Nambale (3) – all linked to Nambale Subcounty Hospital; Teso North (3) – two linked to Teso North Subcounty Hospital and one linked to Moding Health Centre; and Teso South (3) – two linked to Amukura Health Centre and one linked to Alupe Subcounty 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 the nurses/midwives’ strike, a constellation of community midwifery model activities were supported and enhanced to create awareness and demand for community midwifery services: community sensitization by the 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 strike period 1; linkage of the CMs and the CHVs with the reoriented BCs. Besides, CMs worked closely with CHEWs and CHVs and recognizing the role of each in the provision of various health services at the community level; data collection and monthly reporting and participation in the subcounty quarterly maternal and perinatal deaths surveillance and response (MPDSR) review meetings. In addition, the project team and the subcounty reproductive health and community health teams conducted support supervision & mentorship of CMs on emergency obstetrics and newborn care skills and community linkage. 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).
Data Collection
MOH reporting tools were utilized for all the health facility, community midwifery and community health reporting for all the indicators of interest as prescribed by the Ministry of Health.
Data on the numbers of pregnant women seeking antenatal and birth services for both 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 delivery data summarized from the primary daily activity reporting registers and is open – access and publicly available on the DHIS2 with login credentials required. This data was verified in the primary MOH tools: ANC register (MOH 405), maternity register (MOH 333) and postpartum care register (MOH 406) by the subcounty reproductive health and the records and information management teams. During the ANC, first and fourth ANC visits were targeted to show the access and utilization of focused ANC services as recommended (38). The maternity register collected data on the skilled births conducted and the postnatal care register collected data on the utilization of postnatal care services for the mothers who had either received delivery services at the CMs and/or had unskilled home births and visited for skilled check – up and/or immunization.
Community health services data – referrals by CHVs for ANC and skilled birth were collected in the prescribed MOH 514 – Community Health Service Delivery Log Book – reporting for all the service delivery data by the CHVs; MOH 515 – Community Health Extension Worker Summary, summarised by the Community Health Extension Worker all the data reported in MOH 514. The data reported in the MOH 514 was verified by the Community Health Extension Worker and the health facility care provider during the CHVs routine monthly data review meetings before eventual transfer into the revised publicly available and open – access MOH 515 summary tool available on DHIS2.
Variables And Measurements
Service attendance data for first and fourth ANC, birth and postpartum care by the facilities and CMs for the periods of interest were reviewed. A skilled birth was defined as a birth supported by a skilled health personnel, formerly known as a skilled birth attendant (doctor, midwife, community midwife), defined as an accredited health professional-such as a midwife, doctor or nurse-who has been 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.
Data analysis
Raw data was extracted from the DHIS2, entered in Microsoft Office Excel 2013, cleaned and exported to STATA version 12 for analysis. Facilities and community midwives were classified into three periods or groups. The three periods of analysis were coded as “1” for the 3-month strike period 1 (doctors’ strike – between December 2016 and February 2017), “2” for the normality 3-month period 2 between March and May 2017 and “3” for the 5-month strike period 3 (nurses/midwives’ strike) between June and October 2017. Performance mean scores of variables of interest (1st ANC attendance, 4th ANC attendance, skilled births and postnatal care) for the three periods were computed. To test the differences between the three periods/groups’ mean scores of variables of interest, a parametric test – one-way analysis (ANOVA) of variance was performed because of their more statistical power than their non-parametric equivalents and therefore more likely to detect significant differences when they truly exist (40). Kruskal-Wallis test, a non-parametric version of one-way-analysis of variance based on ranks which can deal better with small numbers was applied in some cells (41). To determine which periods were different from each other, Tukey post hoc tests were performed for significant (p-value ≤ 0.05) variables at ANOVA. Effect size, P-values and 95% confidence intervals were reported.
To determine the pre and post effect of the community midwifery model, period 1 and period 2 were aggregated to form the pre-community midwifery model intervention period (after the double pretest conducted using ANOVA above) (42). Period 3 represented the post – intervention period after the double pretest period to support the effect of the intervention on MNH attendance and outcomes. Proportions of performance were calculated by comparing the community midwives’ performance to the overall sum of the health facility and community midwives’ skilled birth attendance. Two-groups test of proportions were computed. A p-value of 0.05 and less was considered to indicate significant statistical difference. The level of confidence interval was 95%.