Activity/Partner

The CHANGE Project partnered with the Safe Motherhood Demonstration Project (SMDP) that is supported and implemented by the Ministry of Health Kenya, The Population Council, and the Department for International Development (DFID).

Background

In settings where maternal mortality is highest, the "universal barriers" of cost, distance and access as factors limiting skilled care use have been well documented. Activities to improve birth preparedness and complication readiness at household and community levels have been a standard component of programs to improve maternal survival. A decade of program experience with community mobilization activities, mainly community education, transport and financing schemes have been effective in strengthening links between women who need skilled care and facilities and health workers who can provide it.

Some community and social mobilization interventions have promoted birth preparedness cards as one method of increasing timely use of skilled care.

Programs in Egypt, Bangladesh, and several other countries have developed birth preparedness cards, and some of these have also created guides to using the cards and recordkeeping forms. Program planners designed most of these, primarily for "reporting-up" data to donors. Community members were involved in conventional pre-testing of the images and language used on the cards.

Standard elements on birth preparedness cards help women and families plan for safer births. These are based on detailed, multi-country research into barriers to use of skilled care:

• Basic information on danger signs of obstetric complications and emergencies;
• Choosing a preferred birth location;
• Choosing a preferred birth attendant and making advance arrangements with that provider;
• Knowing the location of the nearest source of skilled care for both normal births and emergency care;
• Making advance arrangements for transport to skilled care site;
• Obtaining basic safe birth supplies for home or facility (even women who deliver at facilities are often required to provide certain supplies before being admitted);
• Saving or arranging alternative funds for costs of skilled and emergency care;
• Identifying a companion/chaperone to be with the woman at birth or to accompany her to emergency care source;
• Identifying a compatible blood donor in case of hemorrhage;
• Obtaining "permission" from the head of household to seek skilled care in the event that a birth emergency occurs in his absence; and
• Arranging a source of household support to provide temporary family care during emergencies

What is Birth Preparedness Plus?

The CHANGE Project recommends adding further essential elements to the standard list. Several of these additions are particularly important in areas where HIV is a major contributing factor to maternal morbidity and mortality:

• Basic information on newborn danger signs;
• Choosing a source of routine and skilled early postpartum care for both mother and newborn, and making advance arrangements with that care source;
• Obtaining an HIV test for woman and partner as early in pregnancy as possible, to determine need for PMTCT interventions during pregnancy, birth, and postpartum; and
• Arranging medical and social support if HIV test is positive.

The format of the birth preparedness plus cards is also new. A model "linked" card allows households, communities and skilled providers to prepare for each birth and monitor skilled care needs. The cards can be "anchored" in women's groups or other community groups that reach out to women and families and to health centers.

Objectives

The CHANGE Project partnered with the Safe Motherhood Demonstration Project to:

• Design birth preparedness cards and supporting materials that reflect the elements in CHANGE's Birth Preparedness Plus approach;
• Facilitate the adaptation and use of the birth preparedness card design selected by partners during the six month fieldtest; and
• Suggest indicators to measure the utility of the "linked" birth preparedness plus card and feasibility of scaling up from pilot intervention.

Setting

The Safe Motherhood Demonstration Project (SMDP) is a Department for International Development (DFID) funded project in 4 districts in Western Province. The Population Council implemented the project in partnership with the Ministry of Health, the University of Nairobi, and the Kenya Medical Training College. The overall goal of the project is to develop and implement a safe motherhood model that can be applied to the majority of the country to reduce maternal and perinatal morbidity and mortality. One of the six key program objectives was to improve access to basic essential obstetric care at all levels by improving individual, community and institutional preparedness and readiness for obstetric complications. The project began in March 2000 and ended in March 2003. Pilot interventions took place in Vihiga, Kakamega, Bungoma, and Lugari Districts in Western Province. Activities in Kakamega and Vihiga began in July 2000, and a year later in Bungoma and Lugari.

From the beginning, the project utilized a multi-level participatory approach to program planning. Results from the baseline survey and recommendations from a 3-day internal review meeting, including from national to grassroots level participants, were consolidated to form the basis for the proposed interventions. Approximately two hundred and fifty maternal care providers participated in one-week "skills updates" – the 5 standard lifesaving skills (LSS) plus infection prevention.

Kenya has a strong national women's association network, called Maendeleo ya Wanawake Organisation (MYWO), which translates roughly as Progress/Development/Improvement for Women. This network is active in Lugari District, with a particularly dynamic district-level group leader. MYWO provided a potentially important foundation for rapid dissemination of the birth preparedness plus cards and home visits/ health center reporting on a relatively large scale.

The Baseline Survey

The baseline survey included review of over 400 patient records and interviews with more than 5,000 respondents. Methods included focus group discussions (FGDs) and antenatal care and postnatal care exit interviews with women of reproductive age, adolescents, male partners/husbands and health center committee members. Approximately 800 skilled maternal care providers and 60 TBAs were also interviewed. No complication narratives were conducted.

Baseline results clearly supported the need for improvements in birth preparedness to reduce delays in seeking skilled obstetric care. Nearly 70% of women delivered in their own home attended by a TBA: 31%, a relative: 17%, self-assisted:15%; and at the home of a TBA: 5%. Two percent delivered on the way to a facility. Almost 30% delivered at a health facility, 12% at a health center and 15% at a hospital.

No mention is made in this study of how long it took women and families to decide to seek transport once they recognized that a complication was occurring. Nearly half did not have money to pay for transport once the decision was made. For complications and emergencies most families used bicycles (42%) and cars (28%), although some also traveled by matatu (public bus) (16%), on foot (9%) or wheelbarrow (5%). After reaching the referral site, many women had to wait for a referral. Nearly 4% of women waited more than 4 hours, 9% waited between 2 and 4 hours and 20% waited 1 to 2 hours. Some women had to wait even after a decision was made for advanced care; 12% waited over five hours, and many others waited between 3 to 5 hours.

Reasons for dissatisfaction with delivery once women did reach a health facility included complications at delivery: 32%, loss of baby: 3%, and 65 % for reasons related to poor attitudes among maternity care providers – negative provider attitude: 31%, disrespect: 23%, inadequate explanation: five percent, and poor environment: six percent. The focus group discussions showed that client/provider interaction and poor provider attitude was a widely perceived problem regarding use of services. In addition, cost of care was mentioned, and up to one-third of women attending a facility for birth brought self-purchased drugs and supplies that they know they would need, in addition to money for hospital fees.

The summary statement in the baseline report is "families aware of the need for birth preparedness can go a long way to reduce delays in seeking care."

Methods and Tools

The CHANGE Project assisted project staff with the design of a "linked" birth preparedness intervention in Lugari District, one of the four project districts. Lugari District does not have a government hospital, so the activity worked at the health center level.

The CHANGE Project provided several versions of birth preparedness plus cards and the following:

• Guide for use of the birth preparedness card;
• Recordkeeping forms to help women's group members track birth preparedness and births;
• Guide for use of recordkeeping forms;
• Health center birth preparedness recordkeeping form that group members give to facility-based providers so they know the timing of expected births in the community, and can follow those who do not come to clinic; Set of suggested process indicators used to evaluate the utility of these tools is also included; and
• Pregnancy Calculator Wheel, for use by women's and community groups. The wheel is a simplified version of a similar tool used by skilled providers to calculate estimated date of delivery and other information about the progress of pregnancy. CHANGE research in Kenya indicated that women and families felt they could better prepare for delivery if they had a more reliable estimate for delivery date than they were now able to get from either skilled providers or TBAs.

The "linked" community birth preparedness cards were "anchored" in women's groups or other community groups that served as the center-point for two-way links to skilled care – to families and facilities. The groups introduced the cards to women and families and discussed birth preparedness resources, social support and families' plans. The groups also made periodic visits to health centers to report expected births and potential obstetric problems to skilled care providers.

Community-initiated local adaptations to the CHANGE birth preparedness plus model card. Several model cards were shared with the District Health Medical Team and women's groups in Lugari district for consideration. Everyone was enthusiastic about the card and active in adapting the card for their use. Many changes were suggested at the district-level, and these changes were incorporated into the adapted card.

For example, in the section on the card about advance planning for transport in obstetric emergencies they added, "identify and contact nearest neighbor with cellular telephone." This reflects local, participatory adaptation of the card to incorporate their resources and realities. More than 4,000 cards and supporting materials were produced and distributed in Lugari for fieldtesting in October 2002. The birth preparedness plus cards and all supporting materials are available in English and Kiswahili.

Key Findings and Program Implications

The initial evaluation findings from The Population Council Kenya's program suggest that birth preparedness cards appear to stimulate demand for facility-based care by skilled providers. The evaluation showed a significant improvement in facility-based deliveries in the districts where birth preparedness cards were distributed.

Conclusions

Very few maternal survival projects have demonstrated evidence of significant improvements in utilization of skilled care. Additional program evaluations of linked birth preparedness card activities could confirm their contribution to increased use of skilled care.

The full baseline research report produced by The Population Council as part of their Safe Motherhood Demonstration Project (SMDP) - "A Demonstration Project on Approaches to Providing Quality Maternal Care in Kenya: Findings from a Baseline Survey in Four Districts in Western Province, Kenya" (2002) is available from The Population Council, Nairobi, Kenya.

Tools (Birth Preparedness Plus)