Thoughts From the Last Mile

VillageReach recently conducted a maternal and neonatal health needs assessment in Kwitanda, Malawi in order to understand the barriers (actual and perceived) to accessing quality maternal and neonatal health services in the community. After three years of building infrastructure, making connections in the community, and demonstrating success in improving child health outcomes, particularly for malarial and diarrheal disease in Kwitanda, VillageReach is preparing to expand our program to include maternal and neonatal health services. Expansion into this area is an exciting opportunity for VillageReach to improve health outcomes among this vulnerable population.

Maternal and infant health outcomes are worse in Balaka district (where Kwitanda resides) than Malawi overall in most important indicators. For example, almost a third of women in Balaka give birth at home while, nationally, less than a quarter do. Given the high rate of home birth it’s not surprising that only 63% of Balaka women have a skilled attendant present at their birth (versus 79% nationally). Additionally, the postnatal period is crucial for both the health of the mother and infant, but only about a third of Balaka women receive a check-up within the first two days of giving birth compared to 43% of women nationally. Luckily, over 90% of women in both Balaka and receive some prenatal visits before giving birth; nonetheless, the proportion of Balaka women who receive prenatal care is slightly less than the national average.

In Malawi, many newborns like the one pictured here (left) are delivered by traditional birth attendants in rooms that often look similar to the one above (right). While some mothers prefer the comprehensive care provided by TBAs, others are wary of their ability to handle obstetric complications.

In order to design a program aimed at improving maternal and neonatal health outcomes for the Kwitanda community, it is essential to have an understanding of the unique needs of the community. While the Balaka-level information is illuminating, it doesn’t tell us what’s happening in Kwitanda specifically and, more importantly, it doesn’t tell us why. So we conducted three focus groups in Kwitanda with the following groups: women who recently gave birth at a health center, women who recently gave birth outside a health facility, and community health workers as well as several key informant interviews. Here are some of our most important results:

Some women prefer to give birth with a traditional birth attendant rather than in a hospital. We expected cost and transportation to be barriers preventing women from giving birth in a health facility – and they were (several women gave birth on the way to the hospital since they could not arrive fast enough). But some women also prefer to giver birth with a traditional birth attendant (TBA) rather than in the hospital. There are familial and cultural traditions that encourage women to utilize TBAs as well as the fact that TBAs are often located closer to the women’s homes. But in addition, women cite fears about harsh treatment from hospital nurses as a major reason they’d prefer to give birth with a TBA. First time moms in particular are drawn to the support and one-on-one attention they can receive if giving birth with a TBA. Even some mothers who have delivered a previous child at a hospital say they’d rather deliver their next child with a TBA.

Women recognize that traditional birth attendants are not prepared for every complication. Despite some preference to give birth with TBAs, many women recognize that TBAs are often ill-prepared for complications during labor and delivery and that there are advantages to delivering at a hospital. One woman, who experienced complications while giving birth at a hospital, said she believes she might have died had she given birth with a TBA instead. Women also pointed to the fact that if you give birth in a hospital, you have access to crucial post-natal care not available with a TBA.

Women wish that prenatal care were more accessible. The good news is that most women are attending at least some prenatal care visits at a health center. However, women wish that they could receive care in their villages without having to travel to the health centers. Some women said they would prefer to receive prenatal care from community health workers close to home. Currently, community health workers treat childhood illnesses at “village clinics” – women sited this as something that this could be a useful model for prenatal care.

Not all women know when to get postnatal care. Women had heard mix messages about when to visit a health center for postnatal care: some said it was 6 weeks after giving birth; others said they were told to bring their child after one week for immunizations; and some knew that if they gave birth at home or on the way to the hospital they should go for a check-up the next day. In addition, women pointed out that the getting to a health center or hospital for a check-up right after giving birth wasn’t always easy because of the difficulty of walking or finding transport while simultaneously recovering from labor and delivery.

Women face difficult decisions when deciding where to give birth. In addition to major cost and transportation barriers, women have to weigh family, cultural and emotional factors into their decision-making. While women tend to have more positive experiences accessing prenatal care in a health facility (compared to labor and delivery) women would still prefer a model that allows them to receive care from a community health care worker closer to home. The Health Systems Group at VillageReach is processing all the information we’ve gathered and actively discussing possible interventions and solutions. We’re excited to update you soon!

Every year, more than 1.4 million children die from pneumonia, accounting for more than 18% of deaths in children under-five.

Pneumonia can be caused by viruses, bacteria, or fungi and is a type of acute respiratory infection that affects the lungs and limits oxygen intake in infected children. Streptococcus pneumoniae – or pneumococcal disease – is the most common cause of bacterial pneumonia in young children. Beyond pneumonia, the bacterium can also cause meningitis and sepsis, either of which can be fatal or permanently debilitating.

Pneumonia can be spread through infected air-borne droplets produced by a child’s cough or a sneeze. A child might also contract the infection through exposure to infected blood during birth. While a healthy immune system would enable a child to fight off this infection, a child with a weakened immune system resulting from malnutrition (as is prevalent in low- and middle-income countries) may require antibiotics to heal. Immunization remains the most effective way to prevent infection.

Since 2000, the pneumococcal vaccine has been readily available in the US and Europe. It has remained prohibitively expensive for low- and middle-income countries where most of the mortality burden is borne. Additionally, the pneumococcal vaccine administered in developed countries was determined to be ineffective in developing countries where it failed to target the bacterium strains present in developing countries.

Without vaccination or effective treatment – currently only 30% of kids in developing countries who need antibiotics receive them – pneumococcal disease threatens to compromise the economic vitality of many countries. Families are overburdened caring for children disabled by the disease and health systems are overextended trying to care for patients with sepsis, meningitis, and pneumonia.

Aiming to eliminate the 10- to 15-year delay between vaccine availability in high- and low-income countries, GAVI (Global Alliance for Vaccines and Immunization) was created; the organization is a public-private partnership striving to increase access to immunization in poor countries. Born out of a unique collaboration between the Bill and Melinda Gates Foundation, UN agencies, and leaders of the vaccine industry, as well as bilateral aid organizations, GAVI funds immunization programs in 70 countries. The organization estimates it will help avert at least 650,000 future deaths by 2015 and as many as seven million by 2030.

Pneumococcal vaccines are among those delivered by GAVI funds. Fifteen developing countries are already rolling out these vaccines with GAVI support. Mozambique was among 18 additional countries approved for the program in September 2011. Preparing for a new vaccine introduction is intense work. Infrastructure needs to be developed and/or refined: refrigerated storage space may need to be constructed to support the cold chain space, and transport routes and information systems must be developed, waste management systems need to be established, staff need to be trained, and a supervision system must be in place.

So, lot’s of work ahead! However we’re excited that the VillageReach Dedicated Logistics System might help support the distribution of pneumococcal vaccines next year in Mozambique. We are confident that our work with distribution, supervision, and information management will help to ensure that vaccines get to the health centers, that health workers are trained to administer the new product, and that the right quantities reach the right facilities to balance supply and demand. GAVI recipients have produced impressive rates of immunization and VillageReach is thrilled that our work may help reduce the burden of pneumonia among the under-five population.