135th Annual APHA Conference November 2007, Washington DC Increasing Use of Skilled Care at Childbirth in Low-Resource Settings: Evidence from the Skilled Care Initiative Authors: Ellen Brazier, Brahima Bassane, Djénéba Diallo, Rod Knight, Margaret Perkins, Angela Mutunga, Tuntufye Mwakajonga 135th Annual APHA Conference November 2007, Washington DC

The Skilled Care Initiative 5-year operations research project implemented in Burkina Faso, Kenya, and Tanzania to test and evaluate strategies for increasing skilled care during childbirth through: Improving the availability & quality of maternity care Promoting the use of skilled care before, during, and after childbirth. The Skilled Care Initiative was a 5-year, operations research project aimed at testing approaches for increasing the number of women who receive skilled care before, during, and after childbirth. It was implemented in Igunga district from 2001 to 2005. The project aimed to: Improve the quality and availability of skilled maternity care in Igunga district Evaluate the effectiveness of health systems and community-level interventions and Exploring the association of each on women’s use of skilled care during pregnancy, childbirth, and the postpartum period. As such, the project had a rigorous evaluation methodology, which included baseline and endline surveys at both health facility and population levels.

The SCI Evaluation Design Pre-test, post-test study with household and facilities surveys measuring: Quality and availability of skilled care Knowledge, attitudes, and care-seeking behaviors during pregnancy and childbirth Factors associated with household preparation for delivery and delivery at a health facility explored through univariate and multivariate analysis.

Changes in Facility Readiness for Normal Delivery Care

Changes in Facility Readiness for Complicated Delivery Care

Percent of Births at a Health Facility

Distribution of Births across Health System

Delivery at Facilities Among Poor Women

Understanding Women’s Care-Seeking During Childbirth: A Causal Pathway EXPOSURE TO MESSAGE AWARENESS ACTION Exposure to birth preparedness message during ANC counselling Awareness about safe motherhood Household planning & discussion for skilled delivery care Exposure to birth preparedness message through community campaign Husband involvement in decision-making Use of skilled delivery care

Changes in Antenatal Counselling on Birth Preparedness

Changes in Exposure to Community Campaign on Birth Preparedness

Changes in Safe Motherhood Awareness

Changes in Husband Involvement in Decision Making

Changes in Household Planning for Delivery

Safe Motherhood Knowledge Factors Associated with Planning for Delivery Husband Involvement in Decision- making ANC Counselling on BP Community Exposure to BP Safe Motherhood Knowledge & Awareness INTERVENTION FACTORS PLANNING AND DISCUSSION FOR DELIVERY KEY All countries Tanzania Migori KN Burkina Tanzania only SOCIO-DEMOGRAPHIC FACTORS Education Wealth

Factors Associated with Delivery at a Facility ANC Counselling on Birth Preparedness Husband Involvement in Decision- making Education Wealth DELIVERY AT A HEALTH FACILITY Household Planning and Discussion KEY All countries Burkina Kenya Kenya & Tanzania Migori KN Tanzania Homabay, KN INTERVENTION FACTORS SOCIO-DEMOGRAPHIC FACTORS Age

Conclusions & Lessons Learnt Effective behaviour change interventions for increasing skilled attendance include: Focused antenatal care, including individualized birth preparedness counselling Male involvement in maternal health care-seeking Household discussion and planning for delivery Knowledge — or lack thereof — was not a factor in women’s use of skilled maternity care

Key Recommendations for Scaling Up Skilled Attendance Strategies Strengthening mid- and lower-level facilities (staffing, provider skills, equipment, drugs, infrastructure, quality and content of services) Improving the quality of ANC visits, including birth preparedness counselling Promoting household discussion and preparation for birth Engaging husbands in improving maternal health I’d like to wrap up by outlining some key priorities and recommendations that emerge from our work and results in Igunga. There are some clear priorities in terms of what we can do to increase skilled attendance during childbirth. These include: Strengthening the content of antenatal care and ensuring that it includes birth preparedness counselling. While improvements were observed in this area in Igunga, the opportunities afforded by women’s antenatal care visits are not always used effectively to promote skilled attendance at birth. This represents a low-cost intervention that we can easily implement in any district. We also need to find ways to engage husbands where we can. If they accompany women to antenatal care, and women want to include them in counselling discussions, let us find ways to do so. Let us also work with community-based partners to encourage them to reach men with messages about the importance of skilled care during childbirth and to encourage men to help plan and prepare for delivery. A third clear priority is strengthening mid- and lower-level health facilities. These facilities are the most accessible, especially for the rural poor. In addition, the costs of care—both to women and to the health system—are lowest at these sites. Thus, it is strategic to ensure that they are equipped in terms of human and physical resources to provide high-quality care throughout pregnancy, childbirth and the postpartum period. Fourthly, we need to pay attention to routine elements of maternal health services, in addition to complications. While improvements were observed in the areas of antenatal care, normal delivery care, and postpartum care, there are still gaps in the content of these routine services—gaps that reduce the potential benefits of these health interventions in terms of preventing maternal mortality. Many women do not receive essential elements of focused antenatal care, and postpartum care visits are rarely used as an opportunity to assess the health status of new mothers and ensure that they are recovering well from childbirth. Similarly, skills that should be routinely practiced, such as monitoring labour progress with the partograph, and active management of third stage, are often not performed. These are gaps in routine care that we have to work on if we want to achieve changes in maternal health in Tanzania. Fifth, as we all know too well, we face a shortage of skilled attendants, which has negative consequences for the availability and quality of maternity care. We need to review the content of pre-service training programmes for mid-level health cadres to ensure that essential competencies of a skilled attendant are acquired. We also need to invest wisely in in-service training and ensure that providers who are trained in LSS put these skills to practice and stay in positions where they can use them to save women’s lives. Sixth, we need to work at the national level to address the challenges we all face in ensuring adequate stocks of essential obstetric drugs and supplies. While this project did not work on improving the essential drugs and supplies, it is still clearly a problem at these facilities. This is a challenge that directly affects women’s lives, as even the most skilled person amongst us here to day can do little to save a woman’s life it the drugs and supplies we need are not available. Lastly, we need to engage partners from other sectors in the effort to make motherhood safe. We cannot achieve Millennium Development Goals for maternal and child health without broader improvements to roads, water availability, infrastructure, and other areas. We cannot reach Millennium Development Goals if we don’t start working both within and beyond the health system to address these critical priorities. Thank you very much.

Acknowledgements FCI would like to acknowledge and express sincere thanks to: Ministry of Health partners in Burkina Faso, Kenya, and Tanzania The Bill & Melinda Gates Foundation Now that we have shared these findings we will be offering our recommendations. However, before we do that, we would like for you all to offer your recommendations as well.