Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia

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Abstract

Background

A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia’s poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas.

Methodology

Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0–5 months of age using a ‘before-and-after’ evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention.

Results

Mothers’ mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95% CI 1.38–1.99) and SBA (aOR 1.72; 95% CI 1.38–1.99) were at least 60% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95% CI 1.62–2.79) and a SMAG (aOR 4.87; 95% CI 3.14–7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95% CI, 1.20–2.19) and receiving ANC from a skilled provider (aOR 4.01; 95% CI, 2.88–5.75) were significant predictors for SBA at delivery and PNC.

Conclusions

Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.

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Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

Uta Lehmann, Marjolein Dieleman, Tim Martineau (2008)

Background Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making. Methods This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review. Results The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies. Conclusion There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.

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Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets

Rose NM Mpembeni, Japhet Z Killewo, Melkzedeck Leshabari … (2007)

Background Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health. Methods Cross sectional study which employed quantitative research methods. Results We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72–6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75–3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25–2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65–5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors. Conclusion Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness.

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The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study

Araya Medhanyie, Mark Spigt, Yohannes Kifle … (2012)

Background Community health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services. Methods A cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women’s utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis. Results HEWs have contributed substantially to the improvement in women’s utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seems insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP. Conclusions The HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs’ support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women’s participation in income generating activities, access to radio and education could be targets for future interventions.

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Author and article information

Contributors

Choolwe Jacobs:

ORCID: http://orcid.org/0000-0002-7741-1962

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SoftwareRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Charles Michelo: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing

Mumbi Chola: Role: InvestigationRole: ValidationRole: Writing – review & editing

Nicholas Oliphant: Role: InvestigationRole: MethodologyRole: ValidationRole: Writing – review & editing

Hikabasa Halwiindi: Role: InvestigationRole: Writing – review & editing

Sitali Maswenyeho: Role: InvestigationRole: MethodologyRole: Writing – review & editing

Kumar Sridutt Baboo: Role: InvestigationRole: Writing – review & editing

Mosa Moshabela: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing

Bruce A. Larson: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 16 January 2018

Publication date Collection: 2018

Volume: 13

Issue: 1

Electronic Location Identifier: e0190145

Affiliations

[1 ] School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

[2 ] Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia

[3 ] Department of Epidemiology & Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia

[4 ] UNICEF, Lusaka, Zambia

[5 ] Department of Global Health, School of Public Health, University of Zambia, Lusaka, Zambia

[6 ] Africa Health Research Institute, Kwa-Zulu Natal, Durban, South Africa

Boston University School of Public Health, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: choolwe2003@ 123456yahoo.com

Author information

Choolwe Jacobs http://orcid.org/0000-0002-7741-1962

Article

Publisher ID: PONE-D-17-24854

DOI: 10.1371/journal.pone.0190145

PMC ID: 5770027

PubMed ID: 29337995

SO-VID: ebe4cec2-5ab6-4545-b690-8c40b802910d

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 1 July 2017

Date accepted : 9 December 2017

Page count

Figures: 1, Tables: 3, Pages: 15

Funding

Part of this research was supported by UNICEF through the Health for the poorest Population (Grant # 43207625). Additional support includes the African Union Scholarship for Female Students (to CJ) ( http://www.scholarshipsbar.com/african-union-scholarship-for-female-students.html). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability Data is available on request due to ethical restrictions on sharing the data because it contains potentially identifying participant information. On reasonable request, the ethics committee at the Tropical Diseases Research Centre (TDRC; Ref No: TRC/C4/07/2015) in Zambia, can be contacted on Telephone number +260 212 615444. Mailing Address: Tropical Diseases Research Center, P O Box 71769, Ndola, Zambia.

Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia

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Most cited references 37

Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets

The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study

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