Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Homabay and Migori Districts, Kenya

Transcription

1 Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Homabay and Migori Districts, Kenya Prepared by: Family Care International Kenya P.O. Box Nairobi, Kenya and Family Care International 588 Broadway, Suite 503 New York, NY USA October 2007

2 ACKNOWLEDGEMENTS Family Care International would like to acknowledge the Bill and Melinda Gates Foundation, which provided financial support for the implementation and evaluation of the Skilled Care Initiative. FCI would also like to extend our sincere gratitude to the Government of Kenya, particularly, the Ministry of Health and its staff, for their guidance, support, and active participation throughout the design, implementation and evaluation of the Skilled Care Initiative. In particular, FCI would like to acknowledge the Division of Reproductive Health for their support and collaboration in this effort. Extensive thanks are also dedicated to the Office of the Provincial Medical Officer of Health, Nyanza Province, for allowing the Provincial Health Management Team and Homabay and Migori District Medical Officers, together with their District Health Management Teams to be involved in this initiative. In addition, we would like to thank the Medical Superintendents of Homabay and Migori District Hospitals for their supportive participation. We would also like to express very special heartfelt appreciation to the Provincial Administration through the Offices of the District Commissioner in Homabay and Migori for their extraordinary collaboration and support throughout the project s evaluation activities in both districts. In addition, we would like to note our deepest gratitude to all the District Officers, Chiefs, and Assistant Chiefs in Homabay who were actively involved in the project s behaviour change communication strategy and activities. FCI would like to express our sincere appreciation for the support of the University of Nairobi, through Professor James Oyieke, and to Dr. Solomon Orero who, with other colleagues, updated skills of mid-level health care providers on Emergency Obstetric Care, and who were extensively involved in the design and implementation of project activities. Their insights, expertise, and commitment were vital to these efforts. Special thanks are also due to the Central Bureau of Statistics (CBS), the National Council on Population and Development (NCPD), and to Resource Use and Capacity Building Consultants (RUCBIC), Ltd. for their technical support in the baseline and endline household surveys. In addition, FCI would like to acknowledge Mr. Tom Omurwa and Mrs. Caren Oyugi, KMTC Homabay Deputy Principal, for their coordination of the baseline and endline facility surveys, respectively. Thanks are also due to other government departments in Homabay and Migori, including the Survey Department of Kenya- Homabay and the Ministry of Education for their support with vehicles and transport during the evaluation research. Since it is not possible to mention everyone individually, Family Care International would like to thank all those who contributed in one way or another to the successful of Skilled Care Initiative project in Nyanza Province. Finally, FCI would like to extend our deepest gratitude to community members in both Homabay and Migori for their deep engagement in and support throughout the implementation of this project and related evaluation activities. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya

3 TABLE OF CONTENTS Executive Summary... i I. Background and Rationale... 1 A. Maternal Mortality... 1 B. Increasing Skilled Attendance at Delivery... 1 C. Maternal Health in Kenya... 2 D. The Skilled Care Initiative... 3 E. The Project Context: Homabay and Migori Districts... 4 F. Skilled Care Initiative in Homabay and Migori: Overview of Project Interventions... 5 II. Evaluation Design and Methods... 9 A. Health Facility Survey... 9 Sample Design and Estimation Data Collection B. Household Survey Sample Design and Estimation Data Collection C. Data Analysis III. Findings A. Antenatal Care Capacity to Provide Antenatal Care Provision of ANC Utilisation of ANC B. Normal Delivery Care Capacity to Provide Normal Delivery Care Facility Readiness Index for Normal Maternity Care Provision of Normal Delivery Care Utilisation of Normal Delivery Care Association between facility readiness and utilisation by women for delivery care C. Complicated Delivery Care Capacity to Provide Complicated Delivery Care Facility Readiness Index for Complicated Delivery Provision of Complicated Delivery Care Utilisation of Complicated Delivery Care D. Postpartum Care Capacity to Provide Postpartum Care Provision of Postpartum Care Utilisation of Postpartum care E. Factors Associated with Skilled Care-Seeking during Childbirth Exposure to and Awareness of SCI Interventions Demographic and Socio-Economic Factors Associated with Skilled Care-Seeking during Childbirth Association of Demographic and Intervention Exposure with Skilled Care-Seeking during Childbirth IV. Discussion and Interpretation of Findings A. Quality and availability of Skilled Maternity Care B. Utilisation of Skilled Care during Pregnancy, Childbirth, and the Postpartum Period V. Conclusion and Recommendations Annexes...62 Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya

4 Background and Rationale EXECUTIVE SUMMARY Each year, over 500,000 women die from complications of pregnancy and childbirth. The majority of these deaths occur either during or shortly after delivery, and most could be prevented. Experience has shown that the assistance of a skilled attendant during childbirth and immediately afterward is a critical intervention to save women s lives and avert maternal disabilities. Although the use of skilled care is widely recognised as a key strategy for improving maternal survival, there is a dearth of evidence from operations research to guide the design and implementation of strategies to increase rates of professional care during delivery in lowresource settings. As a result, little or no improvement has been observed in skilled attendance rates in many settings, and 60 million women in the developing world still give birth each year without skilled care attended by a traditional birth attendant, a family member, or no one at all. In Kenya, use of skilled care during delivery appears to have decreased during recent decades. The Skilled Care Initiative in Homabay and Migori Districts In 2001, the Ministry of Health and Family Care International launched the Skilled Care Initiative in Homabay and Migori districts, Nyanza Province, Kenya. Aimed at testing and evaluating strategies to improve maternal health outcomes, the Skilled Care Initiative was specifically designed to: Improve the availability and quality of maternity care through health systems interventions. These interventions included upgrading the health infrastructure, including surgical facilities, where needed; addressing equipment and supply gaps; training providers in clinical and interpersonal skills in routine and emergency obstetric care; providing resources to strengthen referral systems and improve health management systems. Increase utilisation of maternity services through facility- and community-level behaviour change interventions. These interventions included strengthening antenatal counselling on birth preparedness and conducting behaviour change communication (BCC) campaigns on the benefits of skilled maternity care. The Skilled Care Initiative included a rigorous evaluation, using pre-test/post-test, quasiexperimental design. The intervention design differed slightly in the two districts. Health facility interventions were implemented in both districts, however, community-level BCC campaigns were only introduced in Homabay district, and the evaluation design was aimed at assessing the added value of the BCC campaign on women s care-seeking before, during, and after childbirth. Two surveys were performed to measure the outcome of the intervention. A facility-based survey was conducted to measure the availability and quality of skilled care, facility infrastructure, equipment and supplies, provider readiness, and referral systems. A population-based household survey was administered to assess changes in service utilisation and related knowledge, attitudes, and care-seeking behaviours during pregnancy and childbirth in a randomly selected cohort of the women living in the two districts. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya i

5 Findings Capacity to provide maternal health services A series of composite indexes were created to assess each facility s readiness to provide both routine and emergency obstetric care. Derived from variables related to essential infrastructure, supplies, equipment, and provider training and skills related to each element of maternal health care (antenatal care, normal delivery care, emergency obstetric care, and postpartum care), these composite indexes provided an overall picture of the capacity to provide quality services. Drawing on these composite indexes, improvements were observed in the capacity to provide the full range of maternal health services, including basic services, such as antenatal, delivery, and postpartum care, as well as care for obstetric complications. The largest improvements were observed in the capacity to provide normal delivery care and care for obstetric complications, particularly among mid- and lower-level health facilities, which were a primary focus of the intervention. The increased readiness was mainly related to improved infrastructure, obstetric equipment, referral capacity, and to a lesser extent provider knowledge and skills. The availability of essential drugs and supplies, which were not targeted through the intervention, generally worsened. Provision of maternal health services Concurrent with the strengthened capacity to provide maternal health care, increases in the routine provision of basic services was observed in both districts. Although the vast majority of health facilities were routinely providing antenatal care at the outset of the project, a number of facilities did not routinely provide delivery care, and many did not provide postpartum care for new mothers. There were large improvements in the routine provision of both delivery care and postpartum care at mid- and lower-level health facilities in both districts, and in the endline survey, the majority of sites had provided delivery care within the previous month. Although improvements in the capacity to provide care for complicated deliveries were observed, there was little increase in the provision of basic essential obstetric care (EOC) functions at many health facilities a result that may have been due to low caseloads, lack of essential drugs or skills to provide care, or other factors. Comprehensive essential obstetric care (CEOC) was available at the district hospital in Homabay as well as private hospitals in Migori. Utilization of services Patterns of and changes in use of maternal health services were different across the two districts. In Homabay, where the community-level BCC campaign was carried out, significant increases were observed in the use of antenatal care during pregnancy and postpartum care for newborn and maternal care. However, no change in care-seeking during delivery was observed. In Migori, a small, but significant, increase in skilled care-seeking during delivery was observed, along with increases in use of postpartum care for newborn and maternal care; however, no significant change in antenatal care occurred. An encouraging outcome in Homabay was the increase in young women (aged 15-19) who delivered in a facility. At baseline, 33% of young women delivered at a facility, and this Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya ii

6 increased to 39% at endline, 11% points higher than for all women. In Migori, the percentage of young women who delivered at a facility was the same as for all women. A striking finding from the research is the predominant use of hospitals for delivery care to the relative exclusion of mid- and lower-level health facilities. In Homabay, more than half of all institutional deliveries in the district take place at the District Hospital. In Migori, 32% of all deliveries take place at the hospital. These patterns have important cost implications for women, as the costs of transport to and care at hospitals are considerably higher than at lower levels of the health system. Although the intervention package resulted in large improvements in the capacity of other facilities to provide such care, evaluation results suggest that more time is needed to achieve a shift in community members utilisation of mid- and lower-levels of the health system for maternal health care. Exposure to behaviour change interventions and association with care-seeking The endline survey confirmed that women in both districts were exposed to counselling on birth preparedness during antenatal consultations, and that women in Homabay had measurably more exposure to community-level BCC campaign activities. Household discussion and planning for birth increased in both districts, but more so in Homabay. Known socio-economic and demographic factors, such as education, wealth, and (younger) age were significantly associated with seeking skilled care during delivery. However, evaluation results showed that certain intervention factors were also significantly associated with use of skilled maternity care. Women in both districts who had received counselling on birth preparedness during antenatal care were considerably more likely to deliver at a facility. Household planning for delivery was also significantly associated with use of skilled care, as was male involvement in decision-making and planning for delivery. However, there was a reduction in the use of skilled care among the poorest income groups, even among women who had high levels of household preparation for birth. This was a change from baseline, when the poorest women who prepared for delivery were almost as likely to deliver with skilled care as the richest women. These findings, and the increasing significance of wealth in a multivariate regression model, suggest that the high cost of deliveries in Kenya is an obstacle to women seeking skilled care. Conclusions and Recommendations The Skilled Care Initiative in Homabay and Migori districts is one of the few maternal health interventions with a rigorous evaluation component. As such, it provides a wealth of information on the effectiveness of the intervention package and its impact on maternal health care-seeking, and it illuminates the challenges of improving and evaluating such strategies, given the multi-faceted determinants of both the availability and quality of maternity care and the factors that influence women s care-seeking during childbirth. Key issues for subsequent efforts to increase rates of skilled attendance during childbirth in Homabay and Migori districts, and nationally in Kenya, include: The importance of focused antenatal care, including individualized birth preparedness counselling on place of delivery. Women who received counselling on place of delivery and danger signs during pregnancy were more likely to deliver at a health facility. Given the fact that the vast majority of women in Kenya have at least one antenatal care visit during pregnancy, it is critical to ensure that birth preparedness counselling is given. This is a relatively low-cost intervention in comparison with Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya iii

7 community-level mobilisation and sensitisation campaigns. As such, it should be a key element of any skilled care strategy. The need to improve national logistics systems and the availability of essential drugs and supplies for obstetric care. Gaps in essential supplies and drugs were found at all levels of the health system and for all elements of the continuum of essential maternal and newborn health services. It is crucial that forecasting and purchasing systems at the national level be reviewed and strengthened to address these gaps. The content of the drug kit should be reviewed and updated, as needed, to ensure that all facilities providing maternal health services, receive uninterrupted stocks of these essential items needed for obstetric care, as providers, no matter how skilled, cannot save women s lives without these inputs. The importance of strengthening mid- and lower-level health facilities. Peripheral health facilities are the most accessible, especially for the rural poor. In addition, the costs of care both to women and to the health system are lowest at these sites. Traditionally, however, these sites have received little investment and support, and many, if not most, are challenged by a crumbling physical infrastructure, shortages of skilled personnel, serious gaps in essential obstetric equipment, and limited referral capacity. As a result, they are often bypassed by communities in preference for hospital-level care. Such care-seeking patterns result in higher costs to women and households, as well as to the health system as a whole. In addition, such patterns diminish the likelihood that the majority of women will either receive skilled care during normal deliveries or reach an appropriate source of care if complications arise. Changing entrenched patterns of utilising the health system will take time, but it can only be achieved through an intensive and sustained effort to ensure that mid- and lower-level health facilities are a viable and reliable source of quality care before, during, and after childbirth. The need to improve financing of maternal health services. The vast majority of women incurred out-of-pocket expenditures for maternal health services, even at mid- and lower-level sites that officially provide services free of charge, and these expenses increased over the period studied, despite the change in cost-sharing policy. The costs of complicated delivery care threaten to impoverish a household and may be a strong deterrent against health care-seeking. To increase skilled attendance rates, it is critical to address the main costs to women, which may range from out-of-pocket expenditures for drugs and supplies to payments for services or attendant fees, or transport to reach facilities that are too far away from the communities they serve. The need to improve the training and deployment of skilled attendant cadres. Overall, there is a shortage of skilled attendants, which has negative consequences for the availability and quality of maternity care. Facilities providing maternal health care need sufficient staffing to ensure round-the-clock care, as communities lose confidence in a site that is not reliably open. In addition, it is crucial to review the content of pre-service training programmes to ensure that essential competencies of a skilled attendant are acquired, and address overall manpower shortages within the health system to make quality, client-centred care available to the women who need it. The importance of focusing on routine elements of maternal health services, in addition to complications. While improvements were observed in the areas of antenatal care, normal delivery care, and postpartum care, there are still gaps in the content of these routine services gaps that reduce the potential benefits of these health interventions in terms of preventing maternal mortality. Many women do not receive essential elements of focused antenatal care, and postpartum care visits are rarely used as an opportunity to Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya iv

8 assess the health status of new mothers and ensure that they are recovering well from childbirth. Given that a large proportion of maternal deaths take place in the early postpartum period, such missed opportunities can cost women their lives. Overall, the results of the project underscore the need for context-specific approaches that are based on the capacity of the health system and maternity care utilisation patterns of communities. Such approaches hold great promise for improvements in the availability of skilled maternity care and increasing the likelihood that women will be able to receive care that prevents complications and access life-saving care when complications arise. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya v

9 I. BACKGROUND AND RATIONALE A. MATERNAL MORTALITY Maternal mortality remains one of the health indicators with the greatest disparity between developed and developing countries. 1 While the lifetime risk of maternal death for women in the developed world is 1 in 2,800, for women in Africa the figure is one in 16. Extreme inequalities also exist within countries. It is well documented that certain groups the poor, the uneducated, adolescents, marginalized groups, and those living in rural and isolated areas face extreme disadvantages in accessing health services and bear a disproportionate burden of negative health outcomes. 2 Demographic and Health Survey data from more than 50 countries confirm these disparities: women in the richest quintile are five times more likely, on average, to deliver with assistance from a trained professional (doctor, nurse, or midwife) than those in the poorest quintile. 3 While inadequate access to maternal health care takes an obvious toll on women, it also has significant adverse effects on broader development goals. At least 30-40% of infant deaths can be attributed to inadequate care during pregnancy and delivery. 4 A woman s death has severe consequences for all her children, especially girls; her children may be pulled out of school to take care of household chores or to contribute to household income, and they are likely to receive less food and health care. 5 The economic cost of maternal death and disability the loss of income and productivity by women, their families, and their communities can also be enormous. 6 B. INCREASING SKILLED ATTENDANCE AT DELIVERY Almost 20 years after the Safe Motherhood Initiative was conceived, there is compelling historical, clinical, and epidemiological evidence suggesting that increases in skilled attendance rates are associated with reductions in maternal death rates. 7 Although most of the analyses showing this association are based on data from middle- or high-income countries, statistical analyses have shown an inverse relationship between maternal mortality and skilled attendance rates across countries with differing income levels. The experiences of several low-income countries, such as Sri Lanka and Malaysia, suggest that major reductions in maternal mortality can be attained through increased rates of skilled attendance at delivery. 8,9 In fact, experience shows that even in the absence of hospitals, first-level maternal and newborn care can bring maternal mortality below 200 per 100,000; in optimal circumstances it may actually reduce maternal mortality to levels of 90 per 100, In light of this strong correlation, skilled attendance has been identified globally as a key indicator for measuring progress. The Millennium Development Goals (MDGs), adopted by the United Nations in 2000, are eight quantified goals for reducing global poverty. Among these is MDG 5, to improve maternal health, which aims to reduce maternal mortality by three-fourths by the year Skilled attendance at childbirth is being used as the proxy indicator to measure progress towards this target. While there is no silver bullet for reducing maternal mortality, the most promising approach is increasing use of skilled maternity care through comprehensive, health systems-based approaches. While skilled care is now globally recognized as one of the most promising strategies for reducing maternal mortality, there is little evidence-based guidance for implementing this approach in low-resource settings. As Miller et al. note in their article, Where is the E in Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 1

10 MCH?, There is no clear evidence on the best way to ensure appropriate care of women in developing countries who require life-saving interventions in the delivery and postpartum period. 11 C. MATERNAL HEALTH IN KENYA In 2004, Kenya s population was estimated to be 32.8 million with a growth rate of 2% per annum and a total fertility rate of The 1998 Kenya Demographic and Health Survey showed that 39% of all women in Kenya use a contraceptive method, and just 32% use modern methods. 13 Children under the age of 15 years constitute approximately 43.5% of the population, while 49.9% of the population were female at the end of Kenya has a crude birth rate (CBR) of 34 live births per 1,000 persons and a crude death rate of 14 per 1,000. The infant mortality rate is 77 per 1,000 live births. Life expectancy at birth was 57.4 years in 1987, but has fallen to 47 years due in part to the AIDS epidemic that is ravaging the country. Kenya has an extensive network of approximately 4,700 health facilities, with the public sector accounting for 51% of the health system. 15 While eight out of ten facilities offer antenatal care, an average of about 38% of health facilities in Kenya offer normal delivery care; this service is provided at only 64% of health centres and 15% of dispensaries. Only 65% of hospitals in Kenya provide caesarean section delivery. 16 Although the global Safe Motherhood Initiative was launched in Kenya in 1987, maternal mortality remains a serious problem. Estimates of maternal mortality range from 414 maternal deaths per 100,000 live births in the 2003 Demographic and Health Survey to 1,000 deaths per 100,000 live births. 17, 18 There are considerable variations on this figure from province to province, and even more between districts. Some districts have maternal mortality ratios that are up to three times the national average. 19 Demographic and Health Survey data in Kenya suggest that the maternal health situation has been deteriorating during recent decades. For example, the proportion of births attended by skilled attendants in health facilities has declined from 50% in 1989 to 44% in 1998 and 42% in The level of facility delivery varies from province to province: three-quarters of births in Nairobi take place in facilities, but only one-quarter of births in Western Province take place in health facilities. In North Eastern Province, less than 10% of births take place in health facilities. The majority of births are assisted by traditional birth attendants (28%) and relatives/friends (22%), compared to doctors (11%) and nurse/midwives (30%). 21 Although skilled attendance at birth is low in Kenya, use of antenatal care (ANC) is high. Eighty-eight percent of women in Kenya receive at least one antenatal check-up during pregnancy. The first ANC visit happens at a median pregnancy gestation of 5.9 months. 22 Priority has been given to the reduction of maternal mortality in Kenya in a number of health sector policy and strategy documents. For example, the National Reproductive Health Strategy for articulated two objectives specific to maternal health, including: Reduce maternal mortality from 365 to 170 per 100,000 by the year 2010; and Increase professionally-attended deliveries from 45% in 1995 to 90% by the year The major components of the strategy include addressing: safe motherhood and child survival; management of STDs/HIV/AIDS; meeting unmet needs in family planning; Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 2

11 promotion of adolescent and youth health; management of infertility and cancer of the reproductive tract; and gender issues and reproductive rights. Within these categories, the strategy calls for establishing a functional referral system; improving the management of obstetric and medical complications of pregnancy, delivery and care of newborns; and strengthening facilities at appropriate levels for the management of complications of unsafe abortion. The National Population Policy for Sustainable Development of 2000 also emphasises the reduction of maternal mortality, and the Kenya Essential Package for Health (KEPH) and the National Second Health Sector Strategic Plan (NHSSP-II) both have identified increasing the proportion of births assisted by skilled attendants as a clear priority. Until July 2004, a cost-sharing policy was in place to ensure sufficient revenues for health service delivery, and service revenues were often used at the facility level to purchase additional supplies and drugs to supplement the contents of the drug kit. However, the costsharing policy was ended in view of worsening poverty in the country. With the end of the cost-sharing policy, all health services, including maternal health care, are provided free of charge at all government health centres and dispensaries, with the exception of a nominal fee for patient/client cards. These charges are 10 Kenya shillings (Ksh) at dispensaries and 20 Ksh at health centres. Government hospitals, however, are permitted to charge a fee for normal deliveries (Ksh 500), and can set fees for other services, such as Caesarean section, in consultation with their boards. D. THE SKILLED CARE INITIATIVE In 2001, the Ministry of Health (MOH) and Family Care International (FCI), with support from the Bill and Melinda Gates Foundation, launched the Skilled Care Initiative a fiveyear, multi-faceted project aimed at improving maternal health outcomes in Homabay and Migori districts, Nyanza Province. The specific objective of the Skilled Care Initiative was to increase rates of skilled attendance in the intervention districts. As illustrated in Figure 1, project activities focused on two main areas: improving the availability and quality of maternity care, and promoting increased utilisation of maternity services. The project was part of a larger-three country initiative aimed at testing strategies for increasing rates of skilled attendance at childbirth; similar interventions were implemented and evaluated in one district in Burkina Faso and one district in Tanzania. The project focused on improving maternity care where the need is greatest in the health centres and dispensaries closest to women and to motivate women and their families to use these services. It also aimed to strengthen obstetric care at the first referral level the hospitals where women are referred with more serious complications. The project also had a strong evaluation component in order to test the effectiveness of the interventions. As a result, the intervention design was slightly different in the two districts. In Homabay district, a package of health facility interventions aimed at increasing the availability, quality and utilisation of maternity care were complemented by additional community-level interventions to promote the use of services. In Migori district, only the health facility-level interventions were introduced. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 3

12 Figure 1. SCI Conceptual Framework E. THE PROJECT CONTEXT: HOMABAY AND MIGORI DISTRICTS Nyanza Province suffers from one of the highest levels of maternal mortality in Kenya. Estimates of maternal mortality range from 1,300 to 2,000 deaths per 100,000 live births. Maternal health indicators are particularly poor in Homabay and Migori districts. In Nyanza Province as a whole, the total fertility rate is 5.6 children per woman, and only 21% of currently married women use a modern method of contraception, compared to 32%, nationally. HIV prevalence is also estimated to be considerably higher in Nyanza than other provinces in the country, and particularly among the Luo ethnic group. 24 The 2003 DHS survey found that 15% of women and men of reproductive age in Nyanza were HIV positive, compared to 6.7% nationally. Homabay and Migori are two of the 12 administrative districts that form Nyanza Province in western Kenya. Homabay is the smaller of the two districts with a total area of 1,160.4 square kilometres, and an estimated population of 288,540, of whom 57% are female. Fortyseven percent of the population is below the age of 15, and 23% are between the age of 15 and 25 years. The average population density for Homabay district is 270 persons per square kilometre. Migori district is twice the size of Homabay, with a total area of 2,505 square kilometres (of which 475 square kilometres cover a portion of Lake Victoria). Migori district s population is estimated to be 565,080 of whom 52% are female. Forty-six percent of the population is below the age of 15, and 24% are between 15 and 25 years of age. The average population density for Migori District is 280 persons per square kilometre. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 4

13 Poverty * is widespread in both districts; 77% of Homabay s population is estimated to be living in poverty, as is 59% of the population in Migori District. The mainstay of the economy for both districts is agriculture, with most residents involved in crop cultivation, fishing, and livestock rearing. The main cash crops are cotton, pineapple, sugarcane, and tobacco, and subsistence crops grown include maize, sorghum, beans, and cassava. There are several agro-based industries in Migori District including the South Nyanza Sugar Factory (SONY), the Prinsal Fish Processing Company, British-American Tobacco, and Mastermind Tobacco Companies. The overall infrastructure in Homabay District is slightly less developed than that in Migori district, however, few households in either district have landline telephone connections, and most of these are concentrated in urban centres. In both districts, the vast majority of the population is Luo, however, the population of Homabay is more homogenous. Although the majority of the population is Christian, traditional beliefs and practices remain quite prevalent in this part of Kenya. As summarized in Table 1, there is a network of health facilities in the two districts. These include hospitals, sub-district hospitals, health centres, sub-health centres, dispensaries, and a range of private clinics that operate at varying levels. Coverage is much better in Migori district, which has a large number of dispensaries and an extensive network of private and mission-run facilities, including three such hospitals, as well as numerous small clinics. Table 1. Number and type of health facilities in Homabay and Migori Districts District GOK Hospitals Mission/ Private Sub-District Hospitals and Health Centres GOK Mission/ Private Facility type GOK Dispensaries and Clinics Mission/ Private Private clinics/ Nursing Homes Homabay Migori Total Total F. SKILLED CARE INITIATIVE IN HOMABAY AND MIGORI: OVERVIEW OF PROJECT INTERVENTIONS The Skilled Care Initiative was implemented in Homabay and Migori districts from late 2001 to late Baseline evaluation studies were conducted from late 2001 to early 2003, and the majority of project interventions were implemented from 2003 to late Endline evaluation surveys were conducted in As described above, project interventions in both districts included health facility-level * The World Bank defines poverty as those with a daily per capita income of less than one dollar in purchasing power parity (PPP). Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 5

14 interventions to increase the availability, quality, and utilisation of skilled maternity care throughout pregnancy, childbirth, and the postpartum period. In Homabay district, these interventions were complemented by a community-level BCC campaign to increase use of skilled care before, during, and after childbirth. Health systems interventions introduced at public health facilities and selected private or mission facilities in the two districts were specifically designed to: Strengthen the physical infrastructure for maternity care: Solar panels were installed at 19 rural health facilities to enable them to provide care around the clock. In addition, structural repairs were made to 9 health facilities to address leaking roofs, crumbling walls, broken windows and doors, etc. Water catchment tanks were supplied to 36 facilities in the two district to improve the availability of water. In addition, support was provided to the Homabay District Hospital to convert unused space within the maternity ward to serve as an operating theatre. Address equipment gaps: Based on gaps identified through baseline research, a package of essential obstetric equipment was provided to each health facility equipment such as blood pressure gauges, weighing scales, delivery kits, delivery beds, autoclaves/ sterilisers, examination lamps, adult and newborn resuscitation equipment, and tap-fitted water storage containers to improve infection prevention. Operating theatre and caesarean section delivery kits were provided to both district hospitals. Improve provider skills: A total of 102 maternity care providers (53 Homabay, 49 Migori) were trained in a two-week, competency-based course in Emergency Obstetric Care (EMOC), which covered both routine maternity care, as well as the management of obstetric complications. To address key quality of care gaps illuminated by communitylevel research, providers were also trained on individualised birth preparedness counselling, maternity care for adolescents, and caring, compassionate treatment of maternity clients. Other skills covered in the training included focused antenatal care, care for normal deliveries, and postpartum care. In addition to the EMOC trainings, four trainings in postabortion care to treat incomplete abortion were conducted to equip 43 staff (22 Homabay, 21 Migori) with the knowledge and skills to manage incomplete abortion using manual vacuum aspiration (MVA) and to provide comprehensive counselling to women with abortion complications. To support the trained providers in the maintenance of their new skills, district health managers and FCI conducted regular follow-up visits to provide further on-the-job training and guidance. In addition, a number of job aids and obstetric care learning tools were developed, including clinical flow charts and a distance learning tool on emergency obstetric care. Strengthen referral systems: Because import duties and radio licensing fees are prohibitively high in Kenya and could not be supported through the project budget, mobile telephones were purchased for facilities that lacked any means of communicating with the district hospital to refer patients or to get guidance on managing a complicated case. Each facility was provided a logbook to monitor the use of the telephones. Introduce quality improvement approaches: To further improve the quality of care at health facilities with high maternity caseloads, COPE (Client-Oriented, Provider- Efficient services) for Maternal Health Services, a quality improvement approach developed by EngenderHealth was introduced at both district hospitals and seven midlevel health facilities (health centres and sub-district hospitals). The COPE process involved all staff in identifying gaps in the quality of care, as well as in identifying simple, low-cost measures that could be implemented at the health facility to strengthen attention to clients rights and to improve the quality of care. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 6

15 Strengthen supervision and health service management: At the start of the project, record-keeping was extremely weak in both districts; no facilities had standard registers for recording antenatal, maternity, or postpartum service delivery, and many deliveries at health facilities were never recorded. In view of this gap, district health information officers and record-keeping officers from each district hospital worked with FCI to design and develop register formats for these three maternal health services. The registers were printed in 2004 and distributed to each health facility in the two districts. Staff from all facilities were trained in their use. In addition to record-keeping interventions, each district health management team was oriented to the content of EMOC and postabortion care trainings to enable them to provide better support to facility-based staff. Although a range of supplies and drugs are used in obstetric care, the project did not support the purchase of items outside the existing logistics systems in use in the two districts, as such support would have been unsustainable. To complement health systems interventions, the MOH and FCI also launched intensive behaviour change communication and mobilisation efforts in Homabay to encourage healthseeking behaviours and build community support for the use of skilled care. These behaviour change communication interventions were specifically designed to: Heighten awareness of the risks associated with pregnancy and childbirth, Promote birth preparedness and planning for delivery, Strengthen recognition of and responses to obstetric complications at household and community levels, and Promote the use of skilled care throughout pregnancy, childbirth, and the postpartum period. Based on in-depth qualitative research conducted among women, men, community leaders and maternal health providers, the behaviour change communications efforts included both facility-level counselling on birth preparedness in both districts, as well as a community-level campaign in Homabay which targeted key groups, including women, husbands, female elders, and community leaders. The community-level behaviour change communication (BCC) campaign included: Participatory theatre: Interactive drama was a centrepiece of the effort to promote skilled care messages. Participatory drama was often performed in a two-part format, the first being performed as a play, and the second consisting of a forum in which audience members are involved in a dialogue about the problem depicted in the play and in identifying alternative solutions or actions. Drawing on the initial qualitative research and families accounts of the life-threatening delays that take place when obstetric complications occur, the MOH and FCI worked with two local theatre groups in Homabay to develop several storylines that conveyed the importance of advance preparations to ensure safe delivery and that emphasised the benefits of seeking care from skilled providers in health facilities. Other topics explored through the dramas included household discussion and decisionmaking about pregnancy and delivery, seeking care for complications, and care during the postpartum period. The community-level campaign began in mid-2004, but became very intensive during an eight-month period in 2005 (March through October) when performances were held every week in different locations. They were scheduled to coincide with other community events, such as market days, special open days at health facilities when clinic services were offered free-of-charge, and community-level meetings Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 7

16 or barazas which provide a forum for discussing key issues affecting the community. During the course of the BCC campaign, at least one or two events were held in each of Homabay s 67 sub-locations, reaching approximately 21,000 community members. Working with local leaders: The project also targeted local chiefs and assistant chiefs, religious leaders, and women s groups with skilled care messages, encouraging these opinion leaders and groups to educate their constituencies and members about birth preparedness, the benefits of skilled care at delivery, the risks associated with pregnancy, and the importance of early postpartum care for new mothers. With each of these groups, the MOH and FCI explored with leaders how they could use their position to heighten awareness about maternal health issues and address barriers that prevent women from using skilled care. For example, with religious leaders, the MOH and FCI explored how religious teachings and beliefs have contributed towards fatalistic attitudes and reluctance to seek skilled care when complications arise, and how religious leaders could address these barriers with their followers. Similarly, in dialogue sessions with chiefs, assistant chiefs, and women s group leaders, the MOH and FCI explored the importance of community-level safety nets, such as emergency loan funds and transport schemes, that could be established to improve access to health facilities during delivery. Approximately 3,800 local leaders and community members were reached through barazas, and about 2,500 were reached through meetings with women s groups and church groups. Involving communities in health facility improvements: Communities were involved in the effort to address critical infrastructural gaps at health facilities such as repairing the roofs, constructing foundations for new water catchment tanks, and installing security bars for solar equipment. Reaching approximately 1,100 community members, these mobilisation events provided an important opportunity to communicate skilled care messages and involve community members in discussing community-level strategies for ensuring that women have ready access to skilled care during pregnancy, childbirth, and the postpartum period. To support the community-level behaviour change activities, a variety of printed educational materials were developed including a skilled care informational booklet, a leaflet on postpartum care, and a set of four posters that promoted birth preparedness, skilled care during delivery, care-seeking for complications, and early postpartum care. These materials reinforced messages conveyed through drama and meetings, and provided essential information on danger signs during pregnancy, preparing for birth, and seeking skilled care during delivery. The booklets and leaflets were distributed in bulk to all health facilities in Homabay and were distributed at all community-level events and dialogue sessions. Approximately 22,000 copies of the skilled care information booklet were distributed, along with 10,000 copies of the postpartum care leaflet. In addition, two flipcharts were also produced through the project one on maternal health and the importance of skilled maternity care and the other on postabortion care to aid health providers in their counselling and outreach efforts. The flipcharts and posters described above were distributed to all health facilities in Homabay. Some promotional materials were also developed including cloth bags, t-shirts, and special khangas (lessos) promoting the benefits of facility delivery. During certain periods in 2004 and 2005, women who delivered at a health facility in Homabay were given either a bag or a khanga. In addition, in mid- to late 2005, 4,200 special t-shirts and 8,200 khangas with skilled care messages were distributed during the community-level campaign activities. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 8

17 II. EVALUATION DESIGN AND METHODS SCI used a rigorous methodology to evaluate the availability and quality of skilled care in the intervention districts, its financial and cultural accessibility, and changes in use of skilled care over time. The pre-test, post-test, quasi-experimental design included the following components: Facility assessments in the intervention and comparison districts to collect information on the quality, availability, and utilisation of maternal health services. Household surveys covering a random sample of households in each district to collect information on the use of skilled care at delivery, and knowledge, attitudes, and careseeking behaviours during pregnancy and childbirth. A. HEALTH FACILITY SURVEY Facility surveys were conducted in Homabay and Migori districts at baseline and endline. The specific objectives of the health facility surveys were to: Assess the availability, use, and quality of maternal health services provided to women and newborn babies at all levels of the health care system and to identify gaps in these services Guide the design of project interventions by identifying possible strategies for improving the coverage and quality of maternal health services and to assist in prioritising interventions in training, logistics, community education and outreach, as well as other areas as appropriate Evaluate the impact of SCI project interventions on the availability, use, and quality of maternal health services at health care facilities by comparing baseline and endline data. The World Health Organization s (WHO s) Safe Motherhood Needs Assessment methodology was selected from among a number of internationally developed methodologies for evaluating the quality of maternal health services in the two districts. The WHO Safe Motherhood Needs Assessment methodology is a collection of tools designed to describe the availability, use and quality of each of the four pillars of safe motherhood family planning, antenatal care, clean/safe delivery, and essential obstetric care at each level of the health system. This needs assessment methodology was selected for two reasons. First, it covers the entire spectrum of maternal health care and safe motherhood, as opposed to solely obstetric care or primary health care, more generally. Secondly, this assessment methodology prioritises the collection and analysis of data by district, primarily because the district health system is recognised by the WHO as a mechanism for linking families and communities with health centres and hospitals in a functional and cost-effective manner. This ensures that maternal health services are available as close as possible to people s homes. Drawing on instruments developed by Unicef, the Prevention of Maternal Mortality Program, the Population Council and MotherCare, additional questions were added to the set of WHO instruments to better explore key issues related to staff training, supervision, and record-keeping, as well as to explore providers knowledge and skills related to the management of obstetric complications. Testing Approaches for Increasing Skilled Maternity Care: Key Findings from Homabay and Migori Districts, Kenya 9