1. Funded by Assessing the capacity of community midwives to provide maternal and newborn health services Alice Natecho, MPH, MAS Director Fountain Africa Trust (anatecho@fountainafrica.org) Dr. Pamela Godia PhD, Intervention Manager PSP4H Dr. Robert Wekesa, MBChB; MMed, Director Health Services Fountain Africa Trust Presented during the AMREF Health Africa International Conference at Safari Park Hotel Nairobi, Kenya 24 November 2014

2. Funded by Outline Introduction Methodology Findings Conclusion and proposed interventions

3. Funded by Introduction-1 Maternal and infant mortality remains one of the greatest challenges in Kenya where the maternal mortality ratio is 488/100,000 live births (KDHS 2008/9). Over half of pregnant women in Kenya deliver at home with unskilled assistance Low use of postnatal care services Contraceptive Prevalence Rate-low (46%) KDHS 2008/9

4. Funded by Introduction - 2 Pop Council, 2013

5. Funded by Introduction-3: Village Midwives Case Studies CountryEvaluation Period/ years MMR Reduction Sir Lanka1940-19501967 - 577 Malaysia1949-1961520 - 200 Trends in MMRate Rural –Urban in Indonesia

6. Funded by Introduction- 4: Justification Given the poor MNH indictors, and experiences from the three countries in Asia, Fountain Africa with PSP4H chose to strengthen the community midwifery model, which was launched by government in 2006. The model uses community midwifes who provide health services at community level. The current model has had challenges of sustainability – It heavily relies on supplies from gov’t facilities. See graph

7. Funded by Intro- 5: Erratic supply of Long Acting FP-Methods CM training update on LARC provision (2011) Population Council &DRH /MOH(2012): Strengthening the Delivery of Comprehensive Reproductive Health Services through the Community Midwifery Model in Kenya. APHIA II OR Project in Kenya. Population Council: Nairobi, Kenya.

8. Funded by Objectives of the study Overall Objective To assess the feasibility and effect of nesting a private sector model within a community midwifery programme on maternal and new-born health services

9. Funded by Specific Objectives Assess the capacity of community midwives to provide MNH services Explore community members perception of the community midwifery model Determine the influence of social networks among community midwives on increasing access to skilled maternal health services Increase the knowledge and skills of CMs in MNH services and in entrepreneurship

10. Funded by Study Design and Methodology A quasi- experimental design Sites Bungoma County and Butere Mumias Sub County in Kenya Phases Baseline Intervention Evaluation

11. Funded by Data Collection Quantitative data: 4 structured questionnaires CMs’ screening tool CMs’ Knowledge and service provision tool List of essential equipment and supplies tool Workload data collection tool (previous 12 months) Qualitative data: KII, In-depth interviews, and FGDs

12. Funded by Findings Demographic information on Community Midwives  72 CMs identified (Bungoma – 43 (59.7%), Butere- Mumias (Kakamega) – 29 (40.3%)  Sex (Females- 86%, Males-14%)  Mean Age- 61.4 Yrs  Qualification (Enrolled nurse/midwives (85%) and formerly MoH employees- (88%)  Experience (Average years as CMs -11 yrs

13. Funded by MNH Services and average No. of clients seen by CM per month BungomaB-MumiasCMs Total Clients FP2220721,512 ANC12872720 Delivery4372216 Postnatal care5572360 Treatment of STIs6672432 Immunization4211721,440 Growth monitoring for babies2416721,440 Cervical cancer screening61372720 Post rape care10.572 General OP - child3624722,232 General OP – Adults4752723,528 Total12,672

14. Funded by Cost of CM’s services Median price per visit – Kshs. BungomaBMTotalUS$ Family planning - Long term200.00 2.3 Family planning – Short-term50.00 0.6 ANC 1st Visit50.00 0.6 ANC - Revisit30.0020.0025.000.3 Delivery725.00650.00687.008.0 Postnatal care50.000.0025.000.3 Treatment of STIs350.00500.00425.004.9 Immunization20.00 0.2 Growth monitoring for babies0.0010.005.000.1 Cervical cancer screening50.00100.0075.000.9 Post rape care50.00100.0075.000.9 General outpatient - Adults300.00425.00365.004.2 General outpatient - Children250.00 2.9

15. Funded by Client’s ability to pay for services offered by CMs (%)

16. Funded by CM willingness to Join a Network Yes, ….because I will access training, to help me get the license and get a better place for delivery-IDI 10, Bgm Reasons cited Networking with other CM Learning Improving supplies Financial assistance Market their services

17. Funded by Management of CMs finances

18. Funded by Provider Knowledge on ANC Awareness on least no. of ANC visit is high but less than a half know the timing precisely Least number of visits women should make during their entire pregnancy

19. Funded by Providers’ Knowledge on Labour and Delivery What to Be Done after Delivery (sig. diff. btwn counties on PPFP, Perineal care, Nutrition) 28.8% P= 0.01; p=0.03; Danger Signs of APH (sign. diff btwn BGM & BM)24.7% P=0.01 Danger Signs Post-Partum Haemorrhage (PPH)32.6% Action on retained Placenta (sign. diff btwn Counties) 22.5% p< 0.05 Action on obstructed Labour (sign. diff btwn Counties) 17.7% P<0.05 Puerperal Sepsis during Prep (sign. diff btwn Counties) 30.% P<0.05

20. Funded by Knowledge of CMs on Danger signs in Postnatal Period

21. Funded by Providers’ Knowledge on FP How the contraceptives work to prevent pregnancy ProportionsButereBungomaTotalP-value %% Suppressing or preventing ovulation58.672.166.70.234 Thickening the cervical plug/mucus to prevent sperm penetration 37.932.634.70.639 Inhibiting egg transportation34.523.327.80.297 Changing the endometrial lining prevent implantation / thinning of uterine walls 13.825.620.80.227 Don’t know0.014.08.30.036*

22. Funded by Perception of the CMs services by the community Very essential Community members (irrespective of their age and gender) support the work of community midwives ‘It is very essential ….. when it is at night and a pregnant woman is in labour; not all pregnancies go to their due dates there are others which come early so there would be no preparedness. So if you are within this area the first people to be contacted are the domiciliary midwives around………….. FGD-MEN, COMMUNITY LEADER R4…we normally call them sister, people in the community are able to differentiate them from the TBAs R6….we appreciate them because they assist us in case of an emergency. FGD-WOMEN 18-25

23. Funded by Conclusion & Proposed Interventions The recent baseline survey demonstrated that: CMs have great potential in improving access to MNH services there are many gaps in health service delivery and financial management that need to be addressed Preliminary results already shared with CMs & SHs The CMs have already registered a Network Planned training activities to focus on the gaps identified especially in EMoC/LAFP Methods and Business skills The County MOH very supportive of the initiative at all levels

24. Funded by 1.Community Midwives in Bungoma County and Butere Mumias sub County 2.The County Departments of Health in Bungoma and Kakamega 3.The Private Sector Innovation Programme for Health 4.Cardno Emerging Markets 5.UKaid Acknowledgement