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Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

ABSTRACT: Background:Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. Methods:A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. Results:Less than one third of pregnant women (30.7%; 95% confidence interval CI?=?21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI?=?13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI?=?6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI?=?12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA - yet only 42.9% (95% CI?=?33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P?=?0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI?=?70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI?=?61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months. Conclusions:We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

SUBMITTER: Guenther T

PROVIDER: S-EPMC6596344 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

Guenther Tanya T Nsona Humphreys H Makuluni Regina R Chisema Mike M Jenda Gomezgani G Chimbalanga Emmanuel E Sadruddin Salim S

Journal of global health 20190601 1

<h4>Background</h4>Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelin ...[more]

PMID: 31275568

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Project description:The objectives of this review were to evaluate the effect of home visits by trained community health workers (CHWs) to successfully identify newborns and young infants (up to 59 days of age) with serious illness and improve care seeking from a health facility. The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Abstracts of all articles were read by two authors independently and relevant articles selected. Data were extracted in a pretested questionnaire by two authors independently. Statistical analysis was performed using Review Manager software. A meta-analysis of included randomized controlled trials (RCTs) was carried out. Pooled estimates (risk ratios (RRs) with 95% confidence intervals (CIs)) of the evaluated outcome measures were calculated by the generic inverse variance method. Seven articles were identified for inclusion in the review. None of them compared the diagnosis of serious illness in young infants by health workers to a 'gold standard' diagnosis. Three studies were available for evaluating the ability of CHWs to identify seriously ill young infants/signs of serious illness. These studies suggest that sensitivity to identify serious illness ranged from 33.3 to 90.5% and specificity from 75.61 to 98.4%. For the outcome of improved care seeking from a health facility, after pooling the data from six RCTs with 4760 subjects in the intervention and 4398 subjects in the control arm, there was a significant improvement in care seeking in the home visit arm (RR=1.35; 95% CI=1.15 to 1.58). Moderate quality evidence indicated that home visits by trained CHWs were associated with improved care-seeking for sick young infants from health facilities by appropriate health care providers in resource-limited settings. However, there is a lack of data regarding successful identification of serious illness. Evidence from validation studies supports the implementation of home visits by trained CHWs for improving outcomes in sick newborns and young infants in resource-limited areas. Further well-designed studies evaluating the effect of home visits by CHWs on successful identification of seriously ill newborns and young infants should include verification by a 'gold standard'.

Project description:BackgroundUganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear.ObjectiveWe aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda.MethodsHousehold surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator.ResultsOf the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy.ConclusionsMost women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village.

Project description:BACKGROUND:Home visits by Community Health Workers [In Uganda Community Health Workers are given the collective term of Village Health Teams (VHTs). Hereafter referred to as VHTs] is recommended to improve maternal and newborn care. We investigated perceived maternal and newborn benefits of home visits made by VHTs, combined with mobile phone consultations with professional health workers for advice. METHODS:A qualitative study was conducted in Masindi and Kiryandongo districts, Uganda, in December-2013 to March-2014. Study participants were drawn from the intervention arm of a randomised community-intervention trial. In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs; 5 group discussions and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers. Data were analysed using latent content analysis techniques. RESULTS:Majority women and VHTs contend that the intervention improved access to maternal and newborn information; reduced costs of accessing care and facilitated referral. Women, VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practices. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community. A minority of VHTs perceived the implementation of recommended maternal and newborn care practices as difficult. Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs. For a range of reasons, a number of professional health workers were not always available on phone or at the health centre to address VHT concerns. CONCLUSIONS:Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted. Our study highlights potential benefits of combining home visits with phone consultations between VHTs and professional health workers. However, the challenge of attitudinal change among VHTs towards certain strongly culturally-embedded behavioural post-partum practices, resistance from part of the professional health workforce to collaborate with VHTs and the problematic availability of professional health workers are important systemic problems that need to be addressed. TRIAL REGISTRATION:Current Controlled Trials NCT02084680. Registered 14 March 2014.

Project description:BackgroundThe protective effect of insecticide-treated bed nets against individual-level malaria transmission is well known, however community-level effects are less understood. Protective effects from community-level bed net use against malaria transmission have been observed in clinical trials, however, the relationship is less clear outside of a controlled research setting. The objective of this research was to investigate the effect of community-level bed net use against malaria transmission outside of a bed net clinical trial setting in Lilongwe, Malawi following national efforts to scale-up ownership of long-lasting, insecticide-treated bed nets.MethodsAn annual, cross-sectional, household-randomized, malaria transmission intensity survey was conducted in Lilongwe, Malawi (2011-2013). Health, demographic, and geographic-location data were collected. Participant blood samples were tested for Plasmodium falciparum presence. The percentage of people sleeping under a bed net within 400-m and 1-km radii of all participants was measured. Mixed effects logistic regression models were used to measure the relationship between malaria prevalence and surrounding bed net coverage. Each year, 800 people were enrolled (400 <5 years; 200 5-19 years; 200 ≥20 years; total n = 2400).ResultsFrom 2011 to 2013, malaria prevalence declined from 12.9 to 5.6%, while bed net use increased from 53.8 to 78.6%. For every 1% increase in community bed net coverage, malaria prevalence decreased among children under 5 years old [adjusted odds ratio: 0.98 (0.96, 1.00)]. Similar effects were observed in participants 5-19 years [unadjusted odds ratio: 0.98 (0.97, 1.00)]; the effect was attenuated after adjusting for individual-level bed net use. Community coverage was not associated with malaria prevalence among adults ≥20 years. Supplemental analyses identified more pronounced indirect protective effects from community-level bed net use against malaria transmission among children under 5 years who were sleeping under a bed net [adjusted odds ratio: 0.97 (0.94, 0.99)], compared to children who were not sleeping under a bed net [adjusted odds ratio: 0.99 (0.97, 1.01)].ConclusionsMalawi's efforts to scale up ownership of long-lasting, insecticide-treated bed nets are effective in increasing reported use. Increased community-level bed net coverage appears to provide additional protection against malaria transmission beyond individual use in a real-world context.

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Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

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Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

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