World vision respectful maternity care icm africa july 2013

The effect of midwives embracing respectful maternity care on increasing facility births,

Alamata rural town district, Northern Ethiopia

Dr Margaret Njenga – World Vision Kenya

3rd ICM Africa conference July 14 – 19th July 2013

Ethiopia: MNCH Health indicators

• Total Population = 82 million (2011 DHS) • Under-five mortality rate (per 1000 live births) = 98 (2011 DHS) • Neonatal deaths: % of all under-5 deaths = 34 (2010) • Infant mortality rate (per 1000 live births) = 63 (DHS 2011) • Stillbirth rate (per 1000 total births) = 26 (2010) • Lifetime risk of maternal death (1 in N) = 67 (2010)

– ( in developed country = 1 in 3,800) • Total fertility rate (per woman) = 4.8 (DHS 2011) • Adolescent birth rate (per 1000 women) = 79 ( DHS 2011) • Maternal Mortality Ratio (per 100,000 live births) = 676 ( DHS 2011) • Contraceptive prevalence rate = 28.6% (DHS 2011)

Sources: DHS, MICS, MMEIG and other National Surveys

Skilled attendant rate

How World Vision Works

• Community based

• Do not provide health services

• Aim to increase MNCH knowledge & demand for health services

• Aim for sustained behavioural change

• Work in partnership

• Advocate for most vulnerable child

• Fills the Gap identified by local health services & WV

• Working relationships with HC staff, midwives, TBAs & CHWs

• Together identify issues and plan actions

• Agree on what WV will fund & support

Project Area

• Alamata rural town is situated in Northern Ethiopia, in the southern Tigray zone about 120kms south of the Mekelle, the capital of the Tigray Region

• It is a peri urban context

• The HC serves a population

of 37,600

Why Respectful Maternity Care RMC ?

• Recent studies have highlighted abuse and mistreatment of pregnant and labouring women

• Disrespectful treatment is a clear barrier to facility birth

• Childbearing women have a right not to be abused, hit, slapped, exposed or abandoned

Midwives and Nurses need support to provide RMC

In the same studies Midwives & nurses reported:

• Not being paid on time or for overtime

• Not having adequate staff for the workload

• No support from management

• No support for involvement with professional association support

Promoting RMC - Midwives and nurses struggle to provide RMC if they are not respected and valued

www.popcouncil.org/projects/334_kenyaDignifiedBirthCare.asp

Background to project (2009 – 2011)

• Identified as worst performer for facility delivery in the region 2005 – 2008

(80% birthed at home)

• Poor equipment, stock out of supplies, unhygienic

• Poor understandings of how to change behaviours

• High antenatal care coverage BUT

• Low facility delivery

• Women came to facility only if complications

• Preferred delivery with TBA

• Shortage of staff especially after hours

• Service charge

Commitment to change

• Alamata HC asked WV for help

• Meetings held with district administration, women’s association, community, pregnant women & TBAs

• Identified solutions

• Agreed political imperative for the region and country

Agreed actions

• Create awareness of benefits of facility delivery

• Link TBAs to midwives

• HEW, WDA to track all pregnant women

• Understand cultural and other barriers to facility delivery

• Incentives offered – towel, soap

Community based interventions

• Located all TBAs in area

• Provided awareness training on risk of home delivery

• Integrated TBAs with women’s association and microfinance loan for alternative income

• Provided TBAs with opportunity to join the WDA

• Encouraged TBAs to accompany women in labour

• HEW & WDA to track all pregnant women

• Improved referral processes including communications for labouring women to contact ambulance

Political Will

• The Maternity Unit’s promise to not let any mother die

“No mother should die giving life”

• Political leaders, communities and husbands also held accountable for any mother’s deaths at home

Pregnant women’s feedback • Don’t speak harshly

• Provide better privacy

• Fear of the unhygienic delivery & facility (HIV)

• Eat and drink what they want

• Allow coffee ceremony before/after the birth

• Reduce/remove fees

• Provide transport

They valued TBAs but now understood the difference

“ I didn’t know the difference between a TBA and a midwife before this training. I thought they were the same”

Over life of project TBAs changed their beliefs, attitudes & behaviours

• With awareness training and support most TBAs agreed to not deliver at home & to promote facility birth

• Most began an alternative income generation activity

“I felt guilty about what I had done in the past”

Commitment at health facility

• Welcoming, respectful

atmosphere

• TBAs relationship with women valued

• Non harmful customs allowed ie: celebrations, coffee ceremony, praying, eating porridge

• Delivery room privacy

• Ambulance transport for labouring women

• Investment in improved quality (staff training and equipment)

• Cleaner toilets and delivery room

• Increased midwifery and nurse staffing levels

= RMC

Respectful Maternity Care

Being allowed to:

• Eat porridge

• Pray

• Have a coffee ceremony before/ after birth

“I feel at home”

A coffee ceremony is underway following the birth of this mother’s second child. The first was born at home. When asked how did she feel after the birth of her baby she said “I feel at home”

Results over 4 years (2009 – 2012)

• Staff were pleased but surprised by rapid change

• Many interventions contributed - not just RMC

• District now sharing lessons learnt with 8 other districts

Alamata Town Health Centre Champion lead midwife

Sr Sindayew

Conclusions

• Providing respectful maternity care can contribute to an increase in access to midwives and births in facilities

• Increased political commitment along with a functional community health system are key to meeting MDGs 4 & 5