Evaluation of the TBA/Midwife Alliance

Evaluation of the TBA/Midwife Alliance Judith T. Fullerton, Ph.D., CNM, FACNM Nov/Dec, 2004

TBA/Midwife Alliance • The Ponlok Thmey Project: • CARE-Cambodia • USAID/Cambodia • Cambodia Ministry of Health, Provincial Health Departments and Operational Districts; commune and village leaders • Midwives and TBAs • Community mothers and families

TBA/Midwife Alliance • In support of Cambodia Ministry of Health’s core strategies to “enhance health sector development in order to improve the health of the people of Cambodia, especially mothers and children, thereby contributing to poverty alleviation and socio-economic development” (Ministry of Health Sector Strategic Plan 2003-2007)

Objectives of the Safe Motherhood Initiative Promoting deliveries by skilled attendants Promoting access to emergency obstetric care

Alliance activities • Replicated from activities conducted in CARE-Bangladesh • First implemented in Mongkol Borei OD, Banteay Meanchey Province in late 2003 • Extended to additional ODs and provinces in 2004

Evaluation methods and strategies (1) • Review of original and adapted designs of the alliance • Review of implementation processes • Assessment of quality of activities relating to strengthening the partnership between TBAs and midwives • Assessment of factors that facilitated implementation of alliance activities

Evaluation methods and strategies (2) • Assessment of factors that acted as barriers and/or constraints to effective programming • Assessment of effectiveness of the alliance from a perspective of cost input and program output • Documentation of results as measured by qualitative anecdotal evidence and quantifiable outcomes

Evaluation methods and strategies (3) • A consideration of potential program impact on health services and on maternal/child health outcomes • Delineation of lessons learned • Development of recommendations for the way forward

Evaluation methods and strategies (4) • Conduct of in-depth interviews with project stakeholders at all levels • Provincial government • Local leadership (commune/village) • CARE program partners • Midwives • TBAs • Women and families

The alliance in context • Cambodia ranks 130th (of 175) on the Human Development Index • (United Nations, 2003) • Score = 5.556 (medium level of human development)

The alliance in context • Cambodia ranks 92nd (of 122) on six indicators of women’s well being (The Woman’s Index, 2004) and 92nd (of 117) on the overall (combined) index (The Mother’s Index, 2004)

The alliance in context • Cambodia’s birth rate: 27.13 births/1,000 population and 3.51 children per woman (2004 estimates)

The alliance in context • Maternal mortality ratio: 437/100,000 (2003 estimate) • Lifetime risk of maternal mortality of 1 in 17 • 32% of births attended by skilled personnel

The alliance in context • Infant mortality ratio of 95 – 97/1,000 (2003 estimate) Cambodia ranks 147th (of 163) countries on four indicators of child well-being (The Children’s Index, 2004)

MCH interventions that form the context of the alliance activities • VCCT and PMTCT • Social marketing of health products, including home birth kits • Health education to promote behavior change in maternal-child health and nutrition, including

MCH interventions that form the context of the alliance activities • Birth preparedness • Antenatal and postnatal care • Iron and vitamin A supplementation • Promotion of exclusive breastfeeding • Birth spacing

Community-based interventions that form the context of the alliance activities • Mobilization of village health support groups • Training of TBAs to perform clean deliveries and to refer complicated (if not all) cases • Pilot testing of strategies to improve transport and referral systems • Establishment of equity funds to enable utilization of health services by those in greatest financial need

Interventions at the level of the skilled provider (1) • Upgrading facilities (health posts, centers and hospitals) • Establishment of maternity waiting homes (Sre Ambel District, Koh Kong province) • Implementing creative arrangements and strategies to ensure 24/7 access to skilled attendance at health facilities

Interventions at the level of the skilled provider (2) • Strengthening capacity of midwives; emphasis on Life-Saving Skills • TBA/midwife partnerships

Behavior change strategies (1) • Social marketing of health products, including home birth kits • Health education on maternal and child health and nutrition via Village Health Support Groups and Village Health Volunteers – includes birth preparedness • Training TBAs to perform clean deliveries and to refer complicated cases to HCs and midwives

Behavior change strategies (2) • TBA/midwife partnerships: encouraging TBAs to refer expecting mothers to midwives by offering them a small incentive to do so • Improving transport and referral systems, including maternity waiting homes in one setting • Establishment of equity funds (including a first Health Center based fund) to subsidize health service utilization

Strengths of the Alliance (1) • Excellent cooperation between all levels of provincial and local government and CARE staff in both planning and implementing MCH activities, including the TBA/midwife alliance

Strengths of the Alliance (2) • Substantial evidence of behavior change on the part of TBAs • Advocacy for antenatal care and maternal nutrition • Referrals for health center or hospital delivery in the presence of danger signs

Strengths of the Alliance (3) • Adoption of safer birth practices • Adherence to principles of clean delivery • Safe cord care practices • Advocacy for immediate and exclusive breastfeeding • Amendment in recommendations for certain cultural practices

Strengths of the Alliance (4) • Number of deliveries by midwives is slowly increasing • Both midwives and TBAs report that there is good communication between the provider cadres • Some improvement in statistical recording and reporting of births • Some evidence of increased enthusiasm and commitment to duty on the part of government (HC) midwives

Constraints and Barriers (1) • Infrastructure of a majority of health facilities is not necessarily conductive to • Safety of personnel or clients, particularly at night time • Availability of on-site personnel • Best practices for birth

Constraints and Barriers (2) • Constraints to “best practices” • Lack of running water/electricity (affecting ability to maintain a sterile environment) • Lack of refrigeration to maintain a cold chain (affecting potency of medications) • Limited space to accommodate supportive caregivers • Some deliveries accomplished in recumbent posture (episiotomies may be performed)

Constraints and Barriers (3) • Little evidence re: encouragement for postnatal care • Substantial challenges to transportation; limits to effective, efficient and timely referrals to health centers of hospitals • Financial costs involved in both transportation to and receipt of health care services • The long-standing tradition of TBA services in the villages

Advocacy for TBA presence and practice • “The woman’s right to choose” • Women not fully aware of essential differences in knowledge and skills between TBAs and midwives • Manner of practice of some midwives is questionable/uncomfortable

Questions of “best practice” on the part of midwives There is some anecdotal evidence that midwives a) perform routine rather than selective episiotomy b) use oxytocin in the first stage of labor c) routinely separate mothers from family caregivers at the time of birth in HCs.

Shortcoming of alliance activities • Midwives rarely capture the opportunities of the “teaching moment”; i.e., rarely engage TBAs in the process of cross-learning.

Cost-effectiveness of the Alliance • Informal considerations – based on anecdotal evidence from interviews • TBAs did not express a concern about the loss of business income • Several TBAs indicated that would continue to refer, in the absence of incentive, because of their new learning • The community has a new expectation for service – therefore referrals need to continue

Cost-effectiveness of the Alliance • The most remarkable, and likely sustainable over the long-term, effect of the alliance is the behavior change on the part of TBAs that now supports timely recognition of problems and timely referral to health facilities; two of the three “delays” that are known to impact maternal mortality, combined with supportive acceptance/encouragement by midwives when referrals are received.

Cost-effectiveness of the alliance • Certainly of “cost/benefit” if not “cost-effective.”

Lessons learned • The intervention cannot drive the system. • Best practice cannot be assumed and must be continually fostered as a professional value. • Certain strategic investments are worth the risk.

RecommendationsRelated to enhancement of alliance activities (1) • 24/7 coverage at health centers must be a first priority for PHDs and ODs. • Health center facilities must be upgraded to a level that supports best practice. • Communities should be encouraged to be creative in the identification of solutions for increasing access to HC and hospital facilities.

Recommendations related to enhancement of alliance activities (2) • Access to health messages should be enhanced for younger women • Provision of (by midwives) and participation in (by women) should be more strongly emphasized in program activities

RecommendationsRelated to scale-up and replication of the TBA/midwife alliance and dissemination of the model • The international definition of midwife should be considered for adoption (essential competencies used as basis for assessment of equivalency in education and practice) • Strengthen the professional association • ICM membership • Midwives should be encouraged and further educated to adopt evidence-based practice as the standard of care, and to share that information with alliance partners

RecommendationsRelated to scale-up and replication of the TBA/midwife alliance and dissemination of the model • Present activities that define the TBA/midwife alliance should be sustained; the model should be scaled up in each of CARE’s MCH intervention districts, and the model should be disseminated to CARE countries and the wider global community

Evaluation of the TBA/Midwife Alliance