November 8, 2016 | ,

Delivering new traditions for greater health

A traditional midwife breaks from decades of practice to help usher in a healthier generation. 
Three women stand together, two of whom hold young children in their arms.
Evaline Awuor (R) stands next to Agnes Obala (C), a traditional birth attendant (midwife) from her village, who encouraged Evaline to pursue a facility birth. Photo: PATH/Celina Kareiva.

Editor’s note: A wide-reaching project in Western Kenya is having a profound effect on the lives of children and adults by tackling a complicated web of health issues. Meet some of the individuals benefiting from the PATH-led APHIAplus Western project, short for AIDS, Population, and Health Integrated Assistance, which is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID).

Evaline Awuor’s labor began at night. By 10 p.m. her labor pains were unbearable, so her mother called for Agnes Obala, a traditional birth attendant (TBA), who had been practicing in the village of Kakangutu West for nearly three decades.

Evaline was doing what so many other mothers had done before her, following an age-old practice of giving birth at home instead of going to a hospital. Her family had always used the services of TBAs, and no birth-related complications had ever arisen.

But when Evaline’s mother contacted Agnes, an elderly woman who sports a toothy grin, the practiced birth attendant gently scolded her.

As a result of a community forum and health messaging discouraging home deliveries, Agnes had stopped practicing.

“With this era of HIV, when clients are brought to me, I am not able to tell if they are HIV positive or negative,” says Agnes. “So when they come to me, I will tell them: ‘It’s not right for me to attend to you. Because of the transmission of HIV, I could put you [and the child] at risk.’”

Instead, Agnes encouraged the family to contact the village’s community health worker (CHW). Upon hearing the news, Micheal Ouma Ogat, a community health volunteer (CHV) for Kakangutu West, promptly hopped on a motorbike shared by local health workers, and rode to accompany Evaline to Kauma Health Center, where he stayed with her through the night.

“She was so appreciative,” remembers Micheal of the first-time mother.

It wasn’t always this way

Just a year earlier, Evaline would not have been met with the same caliber of services.

A health worker takes notes in a form while a group of people sit around watching.
A community health volunteer helps people as they sign in for services as they arrive at Kauma Health Center. Photo: PATH/Celina Kareiva.

In January of 2015, Kauma Health Center, a stout yellow building at the end of a red dirt road in rural Homa Bay, hadn’t had a single facility-assisted birth. The trend continued through December, despite the fact that many mothers were visiting the facility for antenatal care (ANC). Increasing skilled deliveries and facility births have been shown to reduce maternal mortality rates, allowing for earlier identification of delivery complications, so staff at the health center were desperate to reverse this trend.

“[Many women] were delivering in the home,” recounts Micheal. “One reason is that women [often live] far from the facility. The topography is not accommodating. And secondly, most births come at night, so they could never make it to the facility in time.”

A meeting, a motorcycle, and pregnancy maps

A group of health care workers stand outside near a Kauma Health Center sign. One man sits in the foreground.
Facility staff convened a gathering at Kauma Health Center to discuss how the community and staff could increase antenatal care visits and facility births. Photo: PATH/Celina Kareiva.

Despite a loyal cadre of health volunteers and health care workers, Kauma Health Center was struggling to encourage the use of their facility for ANC visits and facility deliveries. There were many factors to blame: The maternity ward was open only during the day, forcing mothers to travel long distances to a referral hospital, or deliver alone in their homes. Many mothers also did not know the value of skilled deliveries. Using TBAs had long been the practice, and because they lived among the women they served, TBAs were often more accessible.

And so the facility staff convened a meeting with the local CHVs and CHWs. With the support of PATH under the APHIAplus Western project, which is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID), the facility staff reviewed their performance over a range of health outcomes. Though they had struggled to generate demand for maternal and child health services, the CHVs knew their communities better even than the nurses and physicians of Kauma Health Center. Their insight proved critical.

After much deliberation, the team agreed to grow the number of staff by two, so a nurse was always on hand for overnight and weekend deliveries. The facility acquired a motorbike in case the ambulance they shared with a neighboring district wasn’t available. They also decided to meet each month to reflect and correct any concerning trends. And they began an ambitious monthly initiative to map all the pregnant mothers within the vicinity of Kauma Health Center.

Since CHVs already went door-to-door to share various health messages and to refer clients for more complicated conditions, pregnancy mapping proved a natural extension of their duties. Tracking expectant mothers ensured that none of them defaulted on the four recommended ANC visits.

“With the mapping initiative we know [when each mother is expecting], and we visit them, to remind them when their time comes, not to go anywhere else,” says David Mboya, a community health extension worker for Kauma Health Center.

A blue and orange bar chart titled "Increase in skilled deliveries across all counties."
This bar chart shows the number of deliveries that occurred within an APHIAplus Western facility in each month from January 2011 to August 2016. Bars are colored by province and county and show that deliveries in both provinces have increased, Nyanza more so than in Western. APHIAplus data compiled by Emily Beylerian. Graph: PATH/Sara McSorley.

Strengthening systems for stronger communities

APHIAplus Western aims to strengthen health systems, a component of which is forging linkages between the community and facility. Kauma Health Center staff and CHVs agreed to debut a 24-hour referral system. In addition to now operating their maternity ward morning and night, CHVs accompany mothers to the facility, often staying with them until they deliver.

“It’s a sign of companionship. When a mother sees that, she [knows] she’s accepted and needed in that environment,” says nurse Rael Okello. She points toward a chart where a dramatic spike can be seen in both ANC visits and facility deliveries. In September, eleven mothers gave birth at Kauma Health Center, a ten-fold increase over 2015. In that same month, eight mothers attended the four recommended ANC visits.

A woman carrying a baby in her arms walks by a group of health care workers.
The Kauma Health Center has seen a substantial increase in health facility–assisted births and ANC visits in the last year alone. Photo: PATH/Celina Kareiva.

“We would like, when our clients see the CHVs in the community, that they come to the facility and see the same faces. It wins [over] their confidence,” says Maureen Obuya, a program associate for PATH’s Kenya Country Program.

And now, the facility is beginning to attract women from outside the county because of the quality of their services.

“It’s not business as usual. It’s a shift. As a government facility they [Kauma Health Center] no longer just wait for clients to come to them. . . . They are working the NGO way,” says Maureen with a chuckle. “Doing teamwork, ensuring that everyone is accountable for what they are delivering.”

The AIDS, Population and Health Integrated Assistance (APHIAplus) program is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID).

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  • Celina Kareiva is a project coordinator on both the Menstrual Health and Applied Behavioral Communication work teams at PATH.
  • Emily Beylerian is a data analyst and an associate in the Results Management, Measurement, and Learning department at PATH.