1. A COMMUNITY-BASED MATERNITY CARE PROGRAM IMPROVES UTILIZATION OF ANTENATAL CARE AND REFERRAL OBSTETRIC SERVICES IN KONO DISTRICT, SIERRA LEONE: 12-MONTH OUTCOMES M. Bailor Barrie, M.B.Ch.B., 1 J. Daniel Kelly, M.D. 1,2 1 Wellbody Alliance, Koidu Town, Sierra Leone 2 Baylor College of Medicine, Houston, TX, USA

2. Background  Why maternal deaths?  Utilization of services  Emergent obstetric services  Drop-offs in ANC visits  Home-based deliveries  Lack of referral system

3. Program Goal  Implement a community- based program designed to increase utilization of maternal health services.  Support PHUs  Strengthen the referral system  Support Koidu Government Hospital  Prior experience in community-based program implementation  Adapted our model to maternal health  In Kono District, we work in partnership with the Ministry of Health and Sanitation

4. Methods  In August 2011, WA trained 45 former traditional birth attendants and traditional health care providers to serve as community health workers.  WA launched its maternal mortality reduction program in September 2011 at three peripheral health clinics in Kono District, Sierra Leone.  They received monthly incentives for accompanying pregnant women to the clinic for their antenatal (ANC) care, delivery, and postnatal care, tracing those who missed appointments, referring women with pregnancy- related complications to the clinic, and educating them about the value of facility-based care.

5. Methods  Clinic staff performed deliveries and decided when to refer women with pregnancy- related complications from the clinic to the district hospital.  We analyzed data routinely collected from ANC and delivery registers to compare service utilization 12-months before and 12-months after implementation of the program.

6. Results  The average number of first and fourth ANC visits increased from 48.3 to 56.9 per month and from 22.5 to 30.7 per month, respectively. *statistically significant 1st ANC visit4th ANC visit Facility2010-112011-122010-112011-12 Manjama183181141184 Small Sefadu1421218497 Koeyer*255381*4587* Total580683270368

7. Our program demonstrated higher rates of women being initiated and retained in antenatal care. Conclusion

8. Results  During the first year of the program, 83 women with complications were successfully referred to the district hospital compared to 27 in the preceding year.  Emergent caesarean sections decreased from 11 to 8.  No maternal deaths occurred among the women served by the program.

9. Referral rates to the hospital dramatically improved. Conclusion

10. Results  Facility-based deliveries increased on average from 27.4 to 31.5 per month. *statistically significant Facility-based deliveries PHUs 2010-112011-12 Manjama107105 Small Sefadu10282 Koeyer*120191 Total 329378

11. Home-based deliveries remain a common practice, and further studies need to develop an intervention that de-incentivizes them. Conclusion

12. Limitations  Quality of facility-based care  Strength of overall health system and referral services  Cultural barriers of home-based deliveries  Supervisor system of community-based program  Variable performance of facilities

13. Story of Edna

14. Further investigations need to be conducted to fully understand the reasons for Koeyer’s success Why was Koeyer successful?

15. Way forward  Strengthening of facility-based care  Essential to the development of a community-based program  Accompaniment of family members to initial ANC visit to discuss value of facility-based delivery  Incentive packages for mother and child if facility- based delivery occurs  Expansion of emergent obstetric referral services  Restructuring of supervision system  Integration of community health work