A paucity of skilled health providers is a considerable impediment to reducing maternal, infant, and under-five mortality for many low-resource countries. Although evidence supports the effectiveness of community health workers (CHWs) in delivering primary healthcare services, shifting tasks to this cadre from providers with advanced training has been pursued with overall caution-both because of difficulties determining an appropriate package of CHW services and to avoid overburdening the cadre. We reviewed programs in Rwanda, Afghanistan, Nigeria, and Nepal where tasks in delivery of health promotion information and distribution of commodities were transitioned to CHWs to reach underserved populations. The community-based interventions were complementary to facility-based interventions as part of a comprehensive approach to increase access to basic health services. Drawing on these experiences, we illuminate commonalities, lessons learned, and factors contributing to the programs' implementation strategies to help inform practical application in other settings.

Introduction Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two‐thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self‐administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before‐and‐after study was to determine the effectiveness of advance distribution of misoprostol for self‐administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. Methods Cross‐sectional household surveys were conducted pre‐ (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. Results Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large‐scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self‐reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. Discussion The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self‐administration.

BackgroundComplications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services.MethodsA national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills.ResultsThe average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not.ConclusionsWhile designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0439-x) contains supplementary material, which is available to authorized users.

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Executive SummaryMaternal, perinatal and neonatal mortality remain high in Malawi and throughout subSaharan Africa. The Health Foundation funded community and facility interventions aimed at reducing this burden. MaiKhanda was set up as an independent NGO in Malawi to deliver both interventions with technical support from IHI and WCF. The community intervention involved mobilisation of rural communities through women's groups, and later, maternal and neonatal health task forces. 729 women's groups completed a participatory learning and action cycle to identify and prioritise maternal and neonatal health problems, decide upon local solutions/advocate and lobby for alternatives, and, implement and evaluate such strategies. The facility intervention involved coaching of health facility staff in quality improvement methodology, including Plan-Do-Study-Act cycles, change ideas, bundles and packages and death reviews to improve obstetric and newborn care at 29 health centres (randomised) and 9 hospitals (not randomised).The community and facility interventions were evaluated via a two-by-two factorial cluster randomised controlled trial. All pregnant women in surveillance areas were eligible to take part and consenting women were followed-up to two months after birth via a low-cost community surveillance system using village-based key informants. Primary outcomes were maternal, perinatal and neonatal mortality. A separate non-controlled time-series evaluation of the quality improvement work at the 9 hospitals was under-taken with maternal and neonatal case-fatality rates as primary outcomes. Parallel process evaluations seeking to understand the processes, mechanisms, and intermediate outcomes of the interventions and the context within which they succeeded or failed were also undertaken and are reported in full. A preliminary cost-effectiveness analysis was also undertaken.Both the interventions underwent changes throughout the evaluation period (2007)(2008)(2009)(2010) and could have had sub-optimal dosages. Implementation could also have been improved. There were also political, management and resource challenges in the three districts (Lilongwe, Salima and Kasungu), and at the health facilities, which may have accounted for the lower impact of the interventions than hoped for. Our 21 main findings are as follows. Each of these is extensively discussed with respect to its implications, precision, potential bias, and relevant literature, in chapter 5.Impact on death rates in the overall population and within health facilities 1. The randomised controlled trial suggests neonatal mortality decreased by 22% in areas with both the facility intervention at the health centre and the community intervention in surrounding villages compared with control areas; and, that perinatal mortality decreased by 16% in areas with the community intervention relative to those without the community intervention (see section 4.1). (section 4.2.4). This seems likely given the lack of observed effects on deaths at the health centres and hos...