Taking Critical Services to the Home: Scaling Up Home-based Maternal and Postnatal Care, Including Family Planning, Through Community Midwives
Council research aims to improve access to skilled delivery care, newborn care, and post-delivery family planning services among women living in remote and resource-poor areas.
A community midwife at a commissioning ceremony in 2006. Participants include the midwife; Dr. Enoch Kibuguchi, then assistant minister for health; Dr. Nicholas Muraguri, head of community strategy, Kenya Ministry of Health; and Dr. Josephine Kibaru, head, Kenya Division of Reproductive Health.
Increasing access to safe delivery and family planning services within rural communities increases the opportunities for women to have positive outcomes for their pregnancies as well as to plan and achieve their desired family size. With support from the US Agency for International Development and Kenya’s Ministry of Health, the Population Council (FRONTIERS program) supported the scale-up of a community-based model that enabled women to give birth safely at home or be referred to a hospital when attended by a self-employed skilled midwife living in the community. The Council identified an expanded package of safe motherhood services—including postpartum family planning—which is provided by the community midwives with minimal supervision and supply of commodities. Midwives received refresher training on family planning and obstetrics, bicycles to expand their access, and supplies and commodities to encourage home visits. They also received business training to enable them to become self-employed health care providers.
The feasibility and utilization of the midwifery package was documented in four districts initially (1/07–3/08) and has since been implemented countrywide in 20 districts in six of Kenya's eight provinces. The model also is recognized as a strategy of improving access to skilled attendance at birth in major national documents, including the National Reproductive Health Policy 2008, the National Health Sector Strategic Plan II, and the community strategy for implementation of the Kenya Essential Package for Health (KEPH Level I).
Nearly 400 midwives countrywide have been oriented and provided with essential materials to provide services. There has been a steady increase in the proportion of attended deliveries and postnatal assessments since community midwives were introduced in 2005. The program has demonstrated that the community midwifery approach is feasible, acceptable, and effective. As part of a follow-on project (3/10–10/11), the Population Council and Kenya's Ministry of Health are working together to test the feasibility and acceptability of increasing the scope of the services offered by the community midwives to include comprehensive reproductive health services, HIV testing, and family planning services.
Recommendations for future implementation of the model include:
Support skills development to maintain quality of care. Professional bodies such as the nursing council, professional associations, and the Ministry of Health need to establish systems to ensure continued professional competency in providing high-quality health care in the community. Such systems could include specified hours for continuous professional development per year that include theory and clinical practice.
Support community midwives in achieving financial sustainability. For this model to continue within the public health system, providing a monthly stipend would enable midwives to replenish supplies and allow them to offer services to low-income clients who could not pay full service fees. It is also important to explore developing alternative health financing models that could support the community midwife model, such as the output-based aid (OBA) approach, currently being pilot-tested by the Government of Kenya, or a social franchising model, such as that being undertaken with private midwives in other countries.
Strengthen business skills. All community midwives must be provided with basic business skills to enable them to improve their abilities to run the services, regardless of the health financing model through which they are supported. In addition, district health management teams should link with the local offices of microfinance enterprises to support networks of midwives in developing their business and savings skills.
Strengthen and support the links between community midwives and the formal health sector through district health management teams. The community midwife is a potentially important source of information about health status and services at the community level for the health care system. To strengthen links, it is important that appropriate tools for data collection exist in the community, and the MOH would benefit tremendously by developing and providing such tools to collect these data.
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Duration: 1/2007 - 10/2011