Characteristics of the studied population.
Of the 72 CHWs trained, 65 completed the activities to the end of the project. The majority of them lived in rural areas (84.6%) with a low level of education (66.2%) and used to accompany women to health facilities for childbirth prior to the installation of the MOMI project (61.5%). The average age was 47 (± 10) years. Length of service ranged from 3 to 32 years with an average of 11 (± 8) years.
A total of 49 participants were interviewed during the case study, including 13 CHWs, 13 postpartum women, 16 health workers, 04 policymakers, and 03 project team members in Burkina Faso. The health workers included four head nurses, three maternity officers, four Expanded Program on Immunization (EPI) officers, and five other staff. Among the rural participants were six postpartum women, five CHWs, and six health workers.
2. Contribution analysis (CA)
Applying Step 1–3 of contribution analysis
The application of Steps 1 to 3 helped to define the causal issue, develop the theory of change, and gather evidence to support the hypotheses made. The evidence collected at this step is the activities carried out by the CHWs and the use of postpartum services by women.
Intervention activities carried out by the CHW
The proportion of women giving birth who were visited by CHWs or accompanied to a health facility varied according to time period and setting (> 50% in rural areas). Thus, 56.8% (6633/11675) of women received the first visit, 34.3% (3999/11675) the second visit and 9% (1067/11675) the third visit. Figure 3 shows the evolution of home visits by month from September 2013 to December 2015. During the same period, respectively, 57.3% (3803/6633), 51.4% (2056/3999) and 32.5% (342/1067) of women were accompanied to health facilities. A total of 5681 awareness-raising activities were carried out.
Women’s attendance at health services
The sixth day’s consultation rates increased from under 40% at the beginning of the intervention to 80% after, and the sixth week’s consultation (42nd day) rates increased from under 20% to over 50% for all the health facilities. All of the participants interviewed in this case study acknowledged that the number of women who came to postpartum care, including those who gave birth at home, had increased considerably since the implementation of the project activities. The observations during supervision and the data collected during monitoring confirmed this assertion. In addition, health workers who were interviewed reported that the number of women who received postpartum consultations was higher on the sixth day than in the 42nd day (Fig. 4).
Applying The Relevant Explanation Finder (step 4–5)
These steps were used to understand the influencing factors and alternative explanations
Among the facilitating factors, we noted the participatory approach adopted by the project for the selection of CHWs and their activities, CHWs commitment, the involvement of community leaders, the health workers collaboration, the non-financial motivation system, the influence of the other women and regular supervision of the activities.
The majority of CHWs (90.3%) conducted the activities until the end of the project. Their main motivation was the moral duty towards the community that had chosen them because they felt valued by this community. They had the conviction that their work had a positive impact on maternal and child health because they thought they were influencing women in the use of health services.
During the interviews, some of them expressed themselves as follows:
“I agreed to do this work because when the members of your community meet and choose you to entrust you with a responsibility, you have the duty to do it otherwise it will seem like you are not concerned about people’s health.” (CHW from a rural HF)
“It's for our well-being because health is priceless. And also, it is our village, and we have the duty to contribute to its development. If we are concerned about the development of our village, we must wholeheartedly support the well-being of the population. This is the reason for our involvement in contributing to the improvement of health.” (CHW2, Rural HF)
However, 9.7% of CHWs left the project because of the non-financial incentive. During supervision and interviews, a CHW from the urban area who left the project expressed herself:
“I warned you from the beginning that your volunteering story was not going to go far. Anyway, I am not visiting women anymore because we earn nothing in your project. I manage with my small business to feed my children and you want me to stop this and go visiting women with nothing in exchange?” (CHW, urban HF)
The baseline study showed that women's acceptance of the CHW would depend on her reputation within the community and her collaboration with health workers. Via this relationship, the CHWs conducted home visits and outreach sessions. Data from the various interviews confirmed this assumption.
“Our CHW helps us a lot. Even at night, when a woman is in labour, she accompanies her to the HF without any hesitation. Sometimes she gets on her bike to follow (the woman) to the HF.” (Postpartum woman, rural HF)
The messages they conveyed were welcomed by women. The women interviewed described them as a benchmark for maternal health in the village and advocates for women in interactions with their husbands and health workers. Their presence broke down barriers such as fear and mistrust that some women might feel in the presence of a health worker.
The following statements collected during the interviews confirmed these facts:
“There are women who want to go to the HF, but they are afraid of health workers. But they say that if the CHW working with the health workers accompanies them, they will no longer be afraid and will express themselves freely because the CHW is there.”(ICP, urban HF)
The involvement of community leaders and male CHWs facilitated the work of the CHWs in the field. Several CHWs interviewed reported that the community members consented to participate in their activities since the community leaders themselves were involved in the project. Thus, they had access to households for outreach sessions, and women were receptive.
“They [women] simply believed that it is for their benefit because an activity that village leaders and authorities are involved in can only be beneficial to the community. So, they consent as well.” (CHW6, urban FS)
However, other factors have limited women's access to these services, such as geographical and financial accessibility (especially during the rainy season), and the weak decision-making power of women, especially in rural areas. Women, health workers and the CHWs interviewed confirmed these obstacles.
“Here in the city there is no problem because women are autonomous. But in the villages, men decide where, when and how their wives can go. They decide whether their wives must go to the HF or not. Sometimes women or children can fall sick for more than a week, but they are waiting because their husbands did not give permission to go to consultation.” (Health worker, urban HF)
During the monitored supervision sessions, the CHWs reported that some women did not come to postpartum consultations because of the cost of consumables.
“You know, madam, I will tell you the truth. Our women do not come on the 42nd day because your health workers asked them to pay for gloves, speculum, etc. So, if you do not have money and your husband also refuses to give you some, you have to stay home.” (Rural CHW)
The health services component of the MOMI project, the performance-based funding (PBF) and the Save the Children NGO’s project called “Victoire sur la Malnutrition” (VIM) implemented in 2014, were alternative explanations.
Indeed, the health services component of MOMI advocated the integration of maternal and infant health care so that some health workers would include postpartum visits with mothers and their infants during immunization visits or healthy infant consultations. For example, in some health facilities, appointments for postpartum visits on the sixth day were scheduled at the same time as the child's BCG vaccination, and the sixth-week appointments were scheduled at the same time as the child’s PENTA1 vaccination or healthy infant consultation appointment. In addition, within all the health facilities, the health worker keeps the mother's health record after delivery. The records were delivered only on the sixth postpartum day. An urban health worker said the following during supervision:
“Since we are keeping the health records, women come back, if only for their health records, and we seize this opportunity to treat them. But sometimes we are obliged to hand over the notebook before the consultation when the woman is not from the same location”. (Supervision Report)
The performance-based financing (PBF) was funding some maternal health indicators, such as postpartum consultation rates. This led some health workers to become more involved in postpartum services. Their collaboration with the CHWs in the search for women who were absent at the various appointments was intensified.
The VIM project distributed food to pregnant and breastfeeding mothers in rural areas. This distribution was based on the mothers’ adherence to prenatal consultations and the immunization schedule for children. Another influence of the VIM project may lie in the fact that some CHWs who worked in the MOMI project were also working on the VIM project. These CHWs took advantage of the food distribution incentive to sensitize women. These facts were corroborated by supervisory data and interviews.
“We also take advantage of the distribution of VIM to raise awareness on FP (family planning), the importance of meeting (health consultations) appointments, and signs of danger (for mother and child’s health). We generally finish our sensitization before we start to share food; otherwise, women may leave.” (Supervision Report)
Assembling the performance story of contribution (Step 6)
This is an iterative process of identifying elements of the intervention that contributed to increasing the attendance of health services by postpartum women. Among the causal links established in the theory of change, we believe that the participatory approach adopted by the MOMI project for the identification of the activities and the selection of the CHWs enabled the appropriation of the intervention by the different actors. The involvement of the community through male CHWs and community leaders helped boost female CHWs in their actions in the sense that they felt valued and considered. Regular training and supervision boosted the CHWs’ self-esteem and confidence.
This perception of the importance of their role motivated them to carry out the project activities among women. These activities enabled women to become aware of the dangers that could arise after delivery and the importance of postpartum care at the health centre, which explained their agreement to attending postpartum health services.
However, of all the activities carried out, we believe that home visits and outreach sessions, as well as a good collaboration between health workers and CHWs, contributed more to the attendance of health services by women.
On the other hand, the accompaniment of women to the HFs seemed to have a smaller contribution because this activity was not carried out by all the CHWs because of the lack of adapted means of transport: while the CHWs were riding a bicycle or were walking, the postpartum woman would ride a motorcycle or a bicycle.