Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi

Abstract

Background Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO’s Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. Methods A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. Results Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA – yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months. Conclusions We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi

“…In most instances, families sought care directly from health facilities, with less than 15% of cases being identified and referred by HSAs to the first level health facilities. This was not unexpected, given that HSAs are trained to conduct home visits during the first week of the postnatal period and that coverage levels of home visits are low, even with substantial program support [19][20]. However, an estimated one-third of expected cases were missed, particularly very young infants less than 7 days old, which suggests there is a problem identifying and bringing young infants for care in the vulnerable first week of life.…”

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi

“…22 However, an evaluation of the role of HSAs in community-based maternal and neonatal care showed that only 30% of pregnant women received a home visit during pregnancy and only 11% received a postpartum visit within 3 days of delivery. 23 Furthermore, there was evidence of inequity, with women of higher socioeconomic status being more likely to receive home visits while pregnant. 24 In Neno District, Malawi, since 2007 an additional cadre of CHWs work alongside the HSAs on HIV and TB.…”

The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh

“…Well trained health workers who have good supervision and receive regular payment can engage the community in health-related empowerment. Our CHWs conducted home visits and held group sessions to a much greater degree than in most CHW programs [31][32][33].…”