WRA Zimbabwe equipping communities with maternal, newborn and child healthcare knowledge and skills
By WRA Zimbabwe’s Dr. Christina Mudokwenyu-Rawdon, Caroline Maposhere and George Mandongwe
More pregnant women are coming in for prenatal care during the first trimester at Sidhakeni and Sherwood Health Centres in Kwekwe District, Midlands Province, Zimbabwe. This notable achievement happened after White Ribbon Alliance Zimbabwe (WRA Zimbabwe) conducted self-care and respectful maternity care (RMC) educational sessions for community-based health care workers, aiming at improving maternal, newborn and child health (MNCH) in the Sidhakeni and Sherwood communities.
Prior to the sessions, women did not customarily book early for antenatal care and delivery at health facilities, mainly because many health workers were not providing quality, respectful maternity care. Women also lacked knowledge and skills of positive self-care practices. Some booked late for antenatal care, while others opted for home deliveries putting their and babies’ lives at risk of complications and death.
Respectful maternity care and self-care are powerful tools in reducing the number of maternal, newborn and child mortalities and morbidities in Zimbabwe and beyond.
Zimbabwe’s maternal mortality ratio currently stands at 614 per 100,000 live births. This is nine times greater than the global target under Sustainable Development Goal 3, where Zimbabwe, together with other 193 countries, committed to reducing their maternal mortality ratios by at least two-thirds by 2030. Addressing such a big challenge also requires that babies are delivered by a skilled birth attendant, and in Zimbabwe’s context, this requires deliveries to take place at health facilities.
Pregnancy and/or childbirth is an emotionally and physically vulnerable time for women. When expectant mothers are mistreated at health facilities, they may shun skilled maternity care. Furthermore, when they relate their experiences to friends and relatives, a single experience of disrespect and abuse can spread through a community quickly, discouraging skilled maternity care. In contrast, when women are treated respectfully, they will seek these services and encourage others to do the same. Respectful maternity care and self-care are powerful tools in reducing the number of maternal, newborn and child mortalities and morbidities in Zimbabwe and beyond.
To set the stage for the discussion, WRA Zimbabwe produced a video in which 75 antenatal and postnatal women from selected health facilities in Harare shared their experiences of disrespect and abuse while seeking maternity care. During the educational sessions with the community-based health care workers and Health Centre Committee members, WRA Zimbabwe showed the video, which featured women reporting problems such as physical and verbal abuse, lack of confidentiality and privacy, discrimination, denial of care and detention in health facilities.
To compliment the community-based self-care and provider-targeted respectful maternity care initiatives, WRA Zimbabwe decided to also focus on the Health Centre Committees (hereafter referred to as committees) — key structures that act as links between the community and the health centre.
Zimbabwe is organised in a way that enables its citizens to participate in health decisions at all levels of governance. WRA Zimbabwe noticed, however, that despite their existence, committee structures did not have clearly defined roles on how to effectively represent women, promote women’s rights and monitor disrespect and abuse of women at health facilities. It was also clear from talking to the women and others that they knew little about the committees or the members that are meant to represent childbearing women’s rights. It is based on this evidence that WRA Zimbabwe conducted a baseline survey and focus group discussions whose findings were used to develop an RMC training programme for 21 committee members from Sherwood and Sidhakeni clinics in Kwekwe District.
Findings from the survey
The survey conducted shows that Sherwood and Sidhakeni committee members were indeed ignorant about the health and rights of childbearing women. “What we only know as a committee is that, for our clinic to receive more [funding], we must have a lot of deliveries and ANC bookings. We have really not questioned or advocated for the quality of maternity care,” said Mr. Chitate, the committee chairperson at Sherwood Clinic.
Other committee members said they did not know how to include more maternal and newborn health issues in their meetings and acknowledged that they had never actively advocated for them. Notes from various committee meetings reviewed by the survey team indicated that members spent a lot of time addressing administrative issues like budgeting for resource-based funding which clinics receive every quarter, addressing clinic security issues and accommodation for staff and for women in the maternity homes. The findings also showed that the committees were not very clear about their roles and functions, and that they did not have clear mechanisms or skills to solicit feedback from community members using health care services. Additionally, while processes were established to support the setup and initiate operations of the committees, there wasn’t adequate funding to offer committee members training or orientation on how to execute their duties.
When WRA Zimbabwe asked committee members if they would like to be trained in RMC, they all welcomed the idea and indicated the need to know more about their roles and functions including advocating for improved MNCH services. The chairperson from Sidhakeni explained, “We need to know how far we should go as a committee. At times, we do not know what our work is or that of District Health Executive supervising the staff. We do not want to get into their territory.”
Health workers speak out
The members of the health centre staff at Sidhakeni and Sherwood were also interviewed and confirmed the need for health centre committee members to be trained on their roles and responsibilities. “While we appreciate the support from health centre committee members, some of them think that they are here to supervise us as health workers. They do not know our job descriptions and do not know about health, yet at times they interfere in our work. They take petty complaints like patients complaining of not getting an injection when they expected it or not getting certain privileges because they are known by the health centre committee members. It is important for them to get training on what their boundaries should be,” said one health worker.
The health workers also encouraged WRA Zimbabwe to train committee members so that they are able to act as an effective bridge between the clinics and the community.
“At times, community members need someone who is not a nurse or health worker to explain some issues to them. An example is when we refer maternity cases to the general hospital; some feel that they have been chased away from the clinic. It is necessary for the committee members to be informed about how the maternity referral system is organised and implemented so that they reinforce information at community gatherings,” said another health worker. WRA Zimbabwe noted that health care workers had not been oriented on how to work with the committees and therefore were not clear on how committee members could be most effective in their role as advocates.
Despite the challenges, health workers were appreciative of the committees and commended them for being actively involved in supporting the smooth running of the health centres. “Our committee is very active,” said a health worker at Sidhakeni clinic. “They help us to solve problems like water shortages and clinic security. The committees helped with the construction of the waiting maternity home with financial support from local donors. At Sherwood, the nurse commended the committee treasurer for going to town frequently to source for quotations and procure supplies. “This leaves me, a nurse, with time to attend to patients,” she said.
At Sidhakeni, the village head, who is also committee member, organised the villagers to contribute money to pay the clinic guard who opens the gate for waiting mothers when they come to deliver at night. Committees at both clinics have made transport available for mothers who need referral.
Change is happening
Because of these engagements with different stakeholders, there has been progress. The committee members and health workers have been trained on maternal, newborn and child health issues, including the rights of women seeking maternity services at health facilities and self-care practices. More women have been empowered and are booking early for antenatal care, using maternity homes - a birth preparedness strategy - and are giving birth at health facilities.
With the training of Sidhakeni and Sherwood health workers in RMC and the empowerment of their communities in self-care, WRA Zimbabwe is working toward reducing the maternal and newborn mortality in these communities and in Zimbabwe at large.
Village Health Workers and Health Centre Committee Members trained; Women empowered
- WRA Zimbabwe trained 21 health centre committee members, emphasizing maternal, newborn and child health issues, including the rights of women seeking maternity services at health facilities. When they conducted a follow-up visit 5 weeks later, they found committee members were clearer on their role of advocating for the rights of child bearing women and mobilizing of resources to promote quality maternity care at health facilities.
- WRA Zimbabwe also equipped village health workers (VHWs) in both clinics with knowledge and skills to reach out to expectant mothers in the community with information on how to take better care of themselves during pregnancy and take action for birth preparedness. The training provided the VHWs with self-care fact sheets as well as the District Health Executive (DHE) with the self-care training manual developed by WRA Zimbabwe and adopted by the DHE as a resource for use in training more VHWs in the in Kwekwe District .
- WRA Zimbabwe developed case studies of women who were reached by the community-based health workers. Through discussions on self-care practices, the women recounted how community health workers empowered them with health information which led to them seeking care at the health facility.
- To scale the project to other parts of the country, WRA Zimbabwe trained more than 300 health care providers — ranging from nurses, midwives, senior-level managers, village health workers and health centre committee members — in respectful maternity care (RMC). Each health worker was given a copy of the video and RMC posters to use as education and advocacy tools so that they could train others in their districts.
- WRA Zimbabwe conducted follow-up visits to assess RMC impact and found that all the institutions were operating at different stages of implementing RMC activities according to their plans, influenced by institutional set up and availability of resources. Notably, all intuitions are striving to promote RMC so that all women seeking maternity services receive high-quality, respectful and dignified care. Women met during the follow up visits reported improvement in maternity care — they said midwives are more compassionate now and are treating them with respect.
- The video highlighting cases of disrespect and abuse women experience while seeking maternity care is also being used as a citizen-led accountability tool at the national level to educate senior nursing officers who are policy makers (Provincial Nursing Officers, Principal Matrons, Principal Tutors, professional associations as well nurses and midwives regulatory bodies) so that the campaign for RMC is promoted within the Ministry of Health and Child Care.
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