OBJECTIVE: To examine the remains of the Community-Based Reproductive Health Project (CBRHP) implemented by CARE-Tanzania to address high maternal mortality in two rural districts.
METHODS: In early 2007, data were collected from 29 villages and used to assess sustainability of emergency transport systems, retention of village health workers (VHWs), and their potential impact on maternal health. Surveillance data from the Ministry of Health were reviewed to assess changes in prenatal and service use indicators.
RESULTS: From 2001 through 2006, the CBRHP-trained VHWs have continued to provide education and referrals to women in their communities including prenatal and emergency obstetric care; six villages with emergency transport systems have continued for more than 5 years providing free or low-cost transport to health facilities. Selected maternal and infant health indicators, such as early prenatal care, identification of pregnancy-related danger signs, and data on maternal and infant outcomes, improved in the two targeted districts over time.
CONCLUSIONS: The two components of CBRHP, work of VHWs and community-financing for emergency transport systems in six villages, have continued. Both of these promote maternal health and linkages with the health delivery systems. Surveillance data show changes in maternal health indicators that were targeted by the district-wide CBRHP interventions. Programs such as CBRHP, with focus on capacity-building and empowerment, can assist in mobilizing the formal and informal systems in communities, components of which may be sustained over time.
INTRODUCTION: The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities.
METHODS: The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million.
RESULTS: In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%.
DISCUSSION: While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women.
BACKGROUND: Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates. METHODS: We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine women's group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309. FINDINGS: From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% Cl 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls. Interpretation Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women's groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
SETTING: Nsanje District in the Southern Region of Malawi. OBJECTIVES: - To determine the time taken, cost-effectiveness and cultural acceptability of bicycle ambulances (BAs) and established community transport plans (CTPs) in the referral of obstectric cases.
- To determine whether the presence of bicycle ambulances and established plans decrease home delivery rates. METHODS: We conducted a community-based case control study in Traditional Authority Tengani in Nsanje District. We used both qualitative and quantitative methods to collect data from ten villages within a 5-kilometre radius of three Basic Essential Obstetric Care (BEOC) facilities. Four villages were enrolled as 'cases' while the other six were controls. Of the four 'case' villages, two were provided with bicycle ambulances and two developed community transport plans; the six control villages lacked both bicycle ambulances and community transport plans. Prior to the intervention, 30 homogenous focus group discussions (FGDs) explored experiences and perceptions of modes of transport with elders, chiefs, women of child bearing and their partners. Retrospective interviews were conducted with women delivering six months prior to the study (n=92) to obtain baseline data, whilst prospectively 157 deliveries were registered. RESULTS: Approximately 90 minutes of travel time was required with all forms transportation studied. Important cultural beliefs deterred most pregnant women from using the bicycle ambulances. People believe that publicising the onset of labour summons evil spirits resulting in obstructed labour. This explains why general medical cases used BAs more frequently than obstetric cases. However, home delivery rates in case villages decreased from 37% to 18% (P<0.005). CONCLUSIONS: In this study we were unable to demonstrate any benefit for obstetric referral systems when BAs and CTPs were introduced. The dearth of international literature coupled with these findings highlight the need for further detailed studies prior to wide-scale adoption of transport schemes.
PRELIMINARY STUDIES: Twenty-one focus groups and a survey in two rural communities revealed socioeconomic and cultural barriers to utilization of emergency obstetric services.
INTERVENTIONS: To facilitate the use of services, 20 community educators were trained and an education campaign was conducted beginning in 1994. Educational activities emphasized the need for women with obstetric complications to use obstetric services at two local health facilities and one teaching hospital. Communities were also mobilized to set up loan and transport programs.
RESULTS: Awareness of obstetric complications increased in both communities and for all complications: increases ranged from 5% (for obstructed labor) to 63% (for hemorrhage). Fourteen of 39 project communities established new loan programs (six communities already had them). Loans were granted in only nine communities. Transport systems were established in nine communities. Referrals to the teaching hospital of women with major obstetric complications from two health facilities in the study area increased from three in 1990 to 11 in 1995 in one community and from four to eight in the other.
COSTS: The cost of the mobilization activities was approximately US $6500.
CONCLUSION: Community education and mobilization can help increase awareness of obstetric complications.
PRELIMINARY STUDIES: Focus group discussions revealed that a lack of funds often contributed to a delay for women receiving treatment for obstetric complications.
INTERVENTIONS: Improvements were made in health facilities and transport, then, beginning in 1992, meetings were held to mobilize communities to establish emergency loan funds. Per capita levies were set and repayment was enforced by the most paramount chief of the area. Funds were managed by existing village development committees and loans were granted to women who could not pay hospital bills immediately.
RESULTS: Of the six chiefdoms contacted, two successfully established loan funds. Utilization of Bo Government Hospital by women with complications from the two chiefdoms with loan funds increased from five in 1992 to 12 in 1993. Utilization from other chiefdoms remained basically unchanged. Of women from loan fund chiefdoms, half paid their hospital bills in full and one-third paid in part.
COSTS: The cost of community mobilization was about US $472.
CONCLUSIONS: The establishment of loan funds depended on strong community leadership and required substantial mobilization efforts. Where community loan funds are established, utilization of emergency obstetric care may increase.
PRELIMINARY STUDIES: Focus group discussions in the community identified difficulties in paying for transport as a major barrier to seeking and reaching emergency care for obstetric complications.
INTERVENTIONS: After emergency obstetric services in local health facilities had been upgraded, the clans in Ekpoma were mobilized in 1995 to set up emergency loan funds for women with complications. Funds were managed entirely by the clans, with ongoing monitoring and supervision by project staff. Two percent simple interest was charged.
RESULTS: Of the 13 clans contacted, 12 successfully launched loan funds. Total donations amounted to US$793, of which four-fifths were contributed by the community. In the 1st year of the operation, 456 women/families requested loans (ranging from US$7 to US$15), and 380 (83%) were granted. Three-hundred and fifty-four (93%) loans were repaid in full. In addition to being used for transport, loans were used to help pay for drugs, blood and hospital fees.
COSTS: The cost of establishing the loan fund was US$1360, including initial donations to the loan funds. The PMM project paid 55% of the total.
CONCLUSIONS: With relatively little outside financial input, communities can set up and administer loan funds for emergency obstetric transport and care. However, sustaining the funds over the long term requires continuing effort and involvement with the communities.
PRELIMINARY STUDIES: Focus group discussions and a village case study in Kebbi State revealed delay in the transport of women with obstetric complications. Among contributing factors identified were shortages of vehicles and fuel, and unwillingness of drivers to transport women at affordable fares.
INTERVENTIONS: The cooperation of the local transport workers union was enlisted to address the situation. In 1993, drivers were sensitized and trained and a revolving emergency fuel fund was established. Prior to these activities, emergency obstetric services at nearby facilities had been upgraded.
RESULTS: Over two years, 29 women with obstetric complications were transported. Of these, only one died. Mean cost of transport to patients was US $5.89. Mean time from the onset of complications to treatment was 9 h. Substantial numbers of non-obstetric patients in need of emergency care were also transported. Although defaulting eventually resulted in depletion of the fuel fund, the reimbursement system had become sufficiently well-established that most drivers no longer requested funds in advance.
COSTS: Cost of the transport intervention was US $268, with 72% coming from project funds.
CONCLUSIONS: Improving transport to emergency care does not necessarily require ambulances. Commercial transport owners and communities can be mobilized to provide affordable emergency transport for women with complications.
PRELIMINARY STUDIES: Focus group studies in the Ashanti region showed that people avoided utilizing health facilities because of lack of confidence in the services and concern about the availability of drugs and supplies, among other reasons.
INTERVENTIONS: After services at the health center were upgraded, community education activities began in early 1994. These activities were carried out through existing mechanisms--e.g. Ministry of Health (MOH) outreach workers and village health workers, public health nurses and midwives, and village health committees. They addressed a variety of audiences, including women's and church groups, emphasizing early recognition and treatment of obstetric complications, and the improved availability of services.
RESULTS: The number of women with obstetric complications admitted to the health center rose from 26 in 1993 to 73 in 1995. It was the impression of the health center staff that women were also coming for treatment more promptly.
COSTS: The cost of this intervention was US$1950. This was mostly project funds, with the government and community together contributing approximately one-fifth.
CONCLUSIONS: Once services are available, community education and information activities can enhance utilization. The cost of such activities can be reduced, and sustainability promoted, by involving MOH personnel and community groups.
To examine the remains of the Community-Based Reproductive Health Project (CBRHP) implemented by CARE-Tanzania to address high maternal mortality in two rural districts.
METHODS:
In early 2007, data were collected from 29 villages and used to assess sustainability of emergency transport systems, retention of village health workers (VHWs), and their potential impact on maternal health. Surveillance data from the Ministry of Health were reviewed to assess changes in prenatal and service use indicators.
RESULTS:
From 2001 through 2006, the CBRHP-trained VHWs have continued to provide education and referrals to women in their communities including prenatal and emergency obstetric care; six villages with emergency transport systems have continued for more than 5 years providing free or low-cost transport to health facilities. Selected maternal and infant health indicators, such as early prenatal care, identification of pregnancy-related danger signs, and data on maternal and infant outcomes, improved in the two targeted districts over time.
CONCLUSIONS:
The two components of CBRHP, work of VHWs and community-financing for emergency transport systems in six villages, have continued. Both of these promote maternal health and linkages with the health delivery systems. Surveillance data show changes in maternal health indicators that were targeted by the district-wide CBRHP interventions. Programs such as CBRHP, with focus on capacity-building and empowerment, can assist in mobilizing the formal and informal systems in communities, components of which may be sustained over time.
