Mobilising Access to Maternal Health Services in Zambia

This 24-page report discusses the experience and post project evaluation of the Mobilising Access to Maternal Health Services in Zambia (MAMaZ) programme, which was designed to identify and document effective ways to stimulate demand for maternal and newborn health care services among economically poor rural communities in Zambia. The report provides an overview of the programme and "reflects on the challenges addressed, the design of the programme and its initiatives, the key results and the lessons that have been learned along the way." The evaluation found that the integrated and comprehensive approach used by MAMaZ to address barriers faced by rural families was an effective and sustainable way to increase access to maternal and newborn health services.

According to the report, few prior interventions focused on improving maternal and child health by addressing the multiple barriers at household and community levels that hinder accessing care, such as routine maternal care, emergency services, and appropriate home-based care of pregnant women and their babies. The MaMaz project was designed to work with communities to build wide social approval for behaviour change and to assist communities to develop their own, locally appropriate emergency response systems, while collecting evidence to inform scale up and replication of the approach.

The project report identifies a number of areas of "innovation" and discusses the implementation experience, lessons learned, and results from each:

The volunteers
Community volunteers were at the centre of the community mobilisation activities. The project evaluation found that there was a low rate of drop-out and a high rate of intention to continue, which is cited as resulting from volunteer self-motivation, quality and relevance of training, and the volunteers' own altruistic belief that they can save lives and effect change. Volunteers noted the participatory and practical aspects of the training and the interesting and easy use of these methods in their community was especially effective. Other lessons learned include the need to support volunteers’ work with appropriate equipment and tools, and the benefits of a peer network of other volunteers.

The training approach
MaMaz used a learner centred and participatory training approach designed for quick understanding and the ability to pass along information in the community. "The use of communication body tools enabled community members to remember the maternal and newborn danger signs, and to memorise the five actions in a safe pregnancy and delivery plan, and were perhaps the most striking and memorable aspects of the MAMaZ training approach." The report outlines key lessons, such as the value of cascade training methods to reach very large areas, and the importance of training materials and information to reflect the actual issues and concerns of the community, in ways that are familiar and relevant - such as local proverbs and expressions. The evaluation found that the approach not only contributed to the process of change envisioned as resulting from the project, but also built sustainable capacity of those involved at the district and national levels.

The Emergency Transport Scheme
Informal emergency transport vehicles (bicycle ambulances, oxcarts) were used to transport women to medical facilities in an emergency, at the onset of labour, or near to their due date. The report notes that such transport systems are vital for people to be able to act in response to demand-promoting initiatives. "The MAMaZ transport schemes worked because they were embedded within a broad community engagement approach and were supported by a range of other systems."

The Social Fund
The Social Fund complemented the community engagement by providing top-up amounts for the community savings schemes and small grants for community-led projects, such as purchase of bicycles for riders to accompany the bicycle ambulances, spare parts, income generating activities to help support the women delivering at a medical facility, and upgrading of medical facilities. According to the evaluation, while the funds granted were very small, the Social Fund enabled the community to tackle barriers to care specific to their community. The report also notes that women were active participants in discussions about what to use the Social Fund for, and that the process contributed to inclusivity by benefitting socially excluded individuals, such as young mothers, single mothers, and those particularly in need of resources.

A whole community approach: inclusion and addressing sensitive issues
According to the report, going door to door enabled volunteers to begin engaging with men, and "by the end of the programme many men were knowledgeable about and supportive of the work of the community volunteers." Particular attention was also paid to engaging with community leaders and traditional chiefs, as well as accessing hard to reach members of the community. For example, volunteers organised their work schedules in such a way that far away households were included in door-to-door visits and persisted in returning to households where they had initially met resistance from the residents." The report also discusses how the focus on maternal health allowed discussion to be opened up on other social issues, such as how gender violence and alcohol abuse affect maternal health. Such sensitive issues were addressed in non-threatening ways, i.e. through song.

Generating evidence
The evaluation found that MaMaz "demonstrated important improvements in key health practices and highlighted statistically significant differences between the intervention communities and control sites. In the implementation districts, the number of babies delivered by a skilled birth attendant (SBA) rose from 43% (baseline) to 70% (endline)...in sharp contrast, there was a rise of only 6% in the control areas." Community members demonstrated behaviour change and improved knowledge of maternal and newborn danger signs. During the baseline, "about 67% of women in both intervention and control districts were at a health facility when their complication arose. This had increased to 83% in the endline survey and was 10% higher than in the control group." The community monitoring system showed extensive improvements in, and use of, community systems established by the programme as well as evidence of increased social capital and cohesion within participating communities.

In conclusion, the evaluation found that the project was successful in increasing use of maternal and newborn health and emergency obstetric care services, including "an increase in skilled birth attendance rates; increase in post-natal care within six days; and increased use of modern family planning methods." At the same time, the initiative had other positive benefits, such as prompting community willingness to address wife battering and other social problems, increased co-operation and support among community members, and greater capacity to reach out to the least-supported.