Post on 15-Dec-2015
transcript
TBA/Midwife Alliance
The Ponlok Thmey Project:CARE-CambodiaUSAID/CambodiaCambodia Ministry of Health, Provincial
Health Departments and Operational Districts; commune and village leaders
Midwives and TBAsCommunity mothers and families
TBA/Midwife Alliance
In support of Cambodia Ministry of Health’s core strategies to “enhance health sector development in order to improve the health of the people of Cambodia, especially mothers and children, thereby contributing to poverty alleviation and socio-economic development”
(Ministry of Health Sector Strategic Plan 2003-2007)
Objectives of the Safe Motherhood Initiative
Promoting deliveries by skilled attendants
Promoting access to emergency obstetric care
Alliance activities
Replicated from activities conducted in CARE-Bangladesh
First implemented in Mongkol Borei OD, Banteay Meanchey Province in late 2003
Extended to additional ODs and provinces in 2004
Evaluation methods and strategies (1)
Review of original and adapted designs of the alliance
Review of implementation processesAssessment of quality of activities
relating to strengthening the partnership between TBAs and midwives
Assessment of factors that facilitated implementation of alliance activities
Evaluation methods and strategies (2)
Assessment of factors that acted as barriers and/or constraints to effective programming
Assessment of effectiveness of the alliance from a perspective of cost input and program output
Documentation of results as measured by qualitative anecdotal evidence and quantifiable outcomes
Evaluation methods and strategies (3)
A consideration of potential program impact on health services and on maternal/child health outcomes
Delineation of lessons learnedDevelopment of recommendations for
the way forward
Evaluation methods and strategies (4)
Conduct of in-depth interviews with project stakeholders at all levelsProvincial governmentLocal leadership (commune/village)CARE program partners MidwivesTBAsWomen and families
The alliance in context
Cambodia ranks 130th (of 175) on the Human Development Index (United Nations, 2003)
Score = 5.556 (medium level of human development)
The alliance in context
Cambodia ranks 92nd (of 122) on six indicators of women’s well being
(The Woman’s Index, 2004)
and 92nd (of 117) on the overall (combined) index
(The Mother’s Index, 2004)
The alliance in context
Cambodia’s birth rate: 27.13 births/1,000 population and 3.51 children per woman (2004 estimates)
The alliance in context
Maternal mortality ratio: 437/100,000 (2003 estimate)
Lifetime risk of maternal mortality of 1 in 17
32% of births attended by skilled personnel
The alliance in context
Infant mortality ratio of 95 – 97/1,000
(2003 estimate)
Cambodia ranks 147th (of 163) countries on four indicators of child well-being
(The Children’s Index, 2004)
MCH interventions that form the context of the alliance activities
VCCT and PMTCTSocial marketing of health products,
including home birth kitsHealth education to promote behavior
change in maternal-child health and nutrition, including
MCH interventions that form the context of the alliance activities
Birth preparednessAntenatal and postnatal careIron and vitamin A supplementationPromotion of exclusive breastfeedingBirth spacing
Community-based interventions that form the context of the alliance activities
Mobilization of village health support groups Training of TBAs to perform clean deliveries
and to refer complicated (if not all) cases Pilot testing of strategies to improve transport
and referral systems Establishment of equity funds to enable
utilization of health services by those in greatest financial need
Interventions at the level of the skilled provider (1)
Upgrading facilities (health posts, centers and hospitals)
Establishment of maternity waiting homes (Sre Ambel District, Koh Kong province)
Implementing creative arrangements and strategies to ensure 24/7 access to skilled attendance at health facilities
Interventions at the level of the skilled provider (2)
Strengthening capacity of midwives; emphasis on Life-Saving Skills
TBA/midwife partnerships
Behavior change strategies (1)
Social marketing of health products, including home birth kits
Health education on maternal and child health and nutrition via Village Health Support Groups and Village Health Volunteers – includes birth preparedness
Training TBAs to perform clean deliveries and to refer complicated cases to HCs and midwives
Behavior change strategies (2)
TBA/midwife partnerships: encouraging TBAs to refer expecting mothers to midwives by offering them a small incentive to do so
Improving transport and referral systems, including maternity waiting homes in one setting
Establishment of equity funds (including a first Health Center based fund) to subsidize health service utilization
Strengths of the Alliance (1)
Excellent cooperation between all levels of provincial and local government and CARE staff in both planning and implementing MCH activities, including the TBA/midwife alliance
Strengths of the Alliance (2)
Substantial evidence of behavior change on the part of TBAsAdvocacy for antenatal care and maternal
nutritionReferrals for health center or hospital
delivery in the presence of danger signs
Strengths of the Alliance (3)
Adoption of safer birth practicesAdherence to principles of clean deliverySafe cord care practicesAdvocacy for immediate and exclusive
breastfeedingAmendment in recommendations for
certain cultural practices
Strengths of the Alliance (4)
Number of deliveries by midwives is slowly increasing
Both midwives and TBAs report that there is good communication between the provider cadres
Some improvement in statistical recording and reporting of births
Some evidence of increased enthusiasm and commitment to duty on the part of government (HC) midwives
Constraints and Barriers (1)
Infrastructure of a majority of health facilities is not necessarily conductive toSafety of personnel or clients, particularly at
night timeAvailability of on-site personnelBest practices for birth
Constraints and Barriers (2)
Constraints to “best practices”Lack of running water/electricity (affecting
ability to maintain a sterile environment)Lack of refrigeration to maintain a cold chain
(affecting potency of medications)Limited space to accommodate supportive
caregiversSome deliveries accomplished in recumbent
posture (episiotomies may be performed)
Constraints and Barriers (3)
Little evidence re: encouragement for postnatal care
Substantial challenges to transportation; limits to effective, efficient and timely referrals to health centers of hospitals
Financial costs involved in both transportation to and receipt of health care services
The long-standing tradition of TBA services in the villages
Advocacy for TBA presence and practice
“The woman’s right to choose”Women not fully aware of essential
differences in knowledge and skills between TBAs and midwives
Manner of practice of some midwives is questionable/uncomfortable
Questions of “best practice” on the part of midwives
There is some anecdotal evidence that midwives
a) perform routine rather than selective episiotomy
b) use oxytocin in the first stage of labor
c) routinely separate mothers from family caregivers at the time of birth in HCs.
Shortcoming of alliance activities
Midwives rarely capture the opportunities of the “teaching moment”; i.e., rarely engage TBAs in the process of cross-learning.
Cost-effectiveness of the Alliance
Informal considerations – based on anecdotal evidence from interviewsTBAs did not express a concern about the
loss of business incomeSeveral TBAs indicated that would continue
to refer, in the absence of incentive, because of their new learning
The community has a new expectation for service – therefore referrals need to continue
Cost-effectiveness of the Alliance
The most remarkable, and likely sustainable over the long-term, effect of the alliance is the behavior change on the part of TBAs that now supports timely recognition of problems and timely referral to health facilities; two of the three “delays” that are known to impact maternal mortality, combined with supportive acceptance/encouragement by midwives when referrals are received.
Lessons learned
The intervention cannot drive the system.
Best practice cannot be assumed and must be continually fostered as a professional value.
Certain strategic investments are worth the risk.
RecommendationsRelated to enhancement of alliance activities (1)
24/7 coverage at health centers must be a first priority for PHDs and ODs.
Health center facilities must be upgraded to a level that supports best practice.
Communities should be encouraged to be creative in the identification of solutions for increasing access to HC and hospital facilities.
Recommendations related to enhancement of alliance activities (2)
Access to health messages should be enhanced for younger women
Provision of (by midwives) and participation in (by women) should be more strongly emphasized in program activities
RecommendationsRelated to scale-up and replication of the TBA/midwife alliance and dissemination of the model
The international definition of midwife should be considered for adoption (essential competencies used as basis for assessment of equivalency in education and practice) Strengthen the professional association ICM membership
Midwives should be encouraged and further educated to adopt evidence-based practice as the standard of care, and to share that information with alliance partners
RecommendationsRelated to scale-up and replication of the TBA/midwife alliance and dissemination of the model
Present activities that define the TBA/midwife alliance should be sustained; the model should be scaled up in each of CARE’s MCH intervention districts, and the model should be disseminated to CARE countries and the wider global community