|Making Motherhood Safe (World Bank, 1993, 161 pages)|
Women's lives can be saved and their health improved if communities, families and women themselves can be motivated to adopt life-saving and health-promoting practices, including utilization of health services in a timely and appropriate manner, compliance with treatment and referral, and effective home-care. Since 1987, the major safe motherhood information, education and communication activities have been related to advocacy and the policy dialogue process, with the objective of encouraging international and national decision makers and program planners to put safe motherhood on their agendas. These information, education, and communications activities have increased awareness of the dimensions and consequences of maternal mortality and morbidity, and have had some impact in the expansion of activities in the policy and program areas. However, if change is to come, safe motherhood-related information, education, and communications activities must move from policy-level advocacy to community-level action. Although there has been little experience to date in either pilot or national level safe motherhood information, education, and communications programs, a great deal can be learned from information, education, and communications activities in the areas of family planning and child survival. Following are suggested guidelines drawn from the safe motherhood information, education, and communications projects that have been implemented and from information, education, and communications programs in other areas.
What Role Can Information, Education, ant Communications Play in a Safe Motherhood Program?
Information, education, and communications activities can serve various functions in a safe motherhood program, including:
· Advocacy for new policies and programs, or to ensure that the women's health perspective is incorporated into the policymaking and prograrnming process.
· Institutional strengthening in such areas as client counselling to improve the quality of services and, hence, to improve utilization.
· Program support to inform people about services or products, to improve demand and utilization.
· Motivation for health promotive behaviors, increased utilization of family planning services, improved maternal diet, compliance with referrals and recommendations, and exclusive breastfeeding of newborns.
Information, education, and communications activities are critical any time a program is focussed on modifying the practices of program beneficiaries (women) or program personnel (health workers) or on generating demand for underutilized services.
What Should the Expectations Be for the Information, Education, and Communications Components of Safe Motherhood Programs?
All maternal health problems could benefit if information, education, and communications activities were included as part of the programmatic solution. Information, education, and communications can help prevent maternal mortality, or, more broadly, be used to enhance maternal health and nutritional status, as well as the health of the newborn.
Prevention of Maternal Mortality
In prevention of maternal mortality, information, education, and communications aims to improve early recognition of danger signs, problems and emergencies by women, family members and communities; and improve knowledge of the services available to respond to these problems, whom to contact, how to contact them, and the means available to travel to the facility.
Knowing about danger signs is of little use unless one also knows what to do in response. The community must know what available services have to offer in terms of both emergency and non-emergency care. In many settings, it is not enough to ensure that the woman is informed, since she is not always in a position to make decisions about her care, particularly in emergencies. Influential people in the home and community must also know what to do.
Reminder sheets/cards can be produced with visual depictions of the danger signs of pregnancy and delivery and visual cues that indicate when and where treatment should be sought. These cards, which can be distributed by outreach and clinic-based health care providers, can be discussed and left with pregnant women, their husbands, mothers-in-law and others who would be in a position to detect a problem and assist in seeking care.
At the district hospital in Port Harcourt, Nigeria, the incidence of women diagnosed with vesicovaginal fistulae, a common sequelae of prolonged labor, is alarmingly high. Prolonged labor was also suspected of contributing to maternal mortality. A radio campaign was developed to alert women and communities to the dangers of a labor lasting longer than 24 hours. During the several years following the radio campaign, the incidence of vesicovaginal fistulae decreased significantly at the hospital serving women within the catchment area of the radio messages. There was no corresponding decrease of vesicovaginal fistulae at hospitals outside the reach of the radio campaign (Harrison 1986).
As part of a maternal health project in rural Bangladesh, a three-pronged strategy is being put into place to respond to pregnancy and interpartum problems, with support from Save the ChildrenUSA and the USAID-funded MotherCare Project. Families will be made aware of key danger signs and of the importance of timely compliance with emergency referral. traditional birth attendants will work with the formal health system in identifying and counselling their "at risk" clients. And, women's savings groups will explore the creation of emergency transport funds for pregnant constituents (Winnard 1991).
Information, education, and communications can also motivate communities to mobilize available resources and develop organized responses when maternal health problems and emergencies occur. This includes organizing transportation networks, as well as ensuring that these services are known and used.
Linking women in need with private and public, human and financial resources within or outside the community is key to supporting emergency referral networks. A note of caution: it does no good to set up community-level emergency support if referral-level facilities are not equipped to handle the emergencies.
In Faisalabad, Pakistan, postpartum hemorrhage is a major cause of maternal mortality. Over 80 percent of births are attended by traditional birth attendants. An emergency ambulance service was created by the Punjab Medical College to bring lifesaving treatment to women with postpartum complications. Despite the high maternal death rate, the service was poorly utilized. An intensive campaign to increase awareness of the ambulance service was undertaken, targeting lady health visitors, traditional birth attendants, doctors, and influential community members. On the advice of traditional birth attendants, expectant mothers were included as an audience for the second phase of the campaign. Expectant mothers requested that elder female family members be educated, as they often discouraged utilization of referral services. The campaign disseminated information through television, radio, newspapers, billboards, and posters and at Mohalla meetings (street camps). Within a year of the communication campaign, requests for the service had increased significantly (Bashir 1991).
In rural areas around Accra, Ghana, communication efforts are targeted to commercial transport workers. They usually are unwilling to transport emergency cases or charge substantially higher prices to do so. The campaigns aims to increase their awareness of maternal health problems and their critical role in saving women's lives (Ward personal communication 1991).
Information, education, and communications also aims to motivate traditional birth attendants to use safe births kits, adopt safe birth and postpartum practices, refer women in a timely manner when problems occur, and decrease harmful traditional practices.
Generally, traditional birth attendants are receptive to learning new skills, especially if it will increase their prestige and therefore their client base. Often, informing women what they should expect from their traditional birth attendant will give an added incentive to traditional birth attendants to offer a particular service or to use such tools as safe birth kits. Ensuring that traditional birth attendants refer women with problems to the health care system depends on the relationship between the traditional birth attendants and that system. Each of these issues - traditional birth attendants' receptivity to training, informing women what to expect from traditional birth attendants and improving the relationship between traditional birth attendants and the health system - is an information, education, and communications challenge. When marketing safe motherhood kits, commercial advertising (e.g., radio messages) and an easily recognized brand image can be devised.
In Bangladesh, traditional birth attendants' unhygienic birth practices result in high rates of neonatal deaths and relatively high levels of maternal deaths from tetanus. As a result a "userapproved" safe birth kit which would be acceptable to the family and traditional birth attendant was developed. The initial concept was pre-tested with pregnant women, family members, and traditional birth attendants. Blue and red were chosen as the predominant kit colors, an additional razor blade was added at the request of traditional birth attendants so they would not have to use the same blade to cut the umbilical cord and their fingernails, an illustration of a healthy mother and healthy baby became the logo, and the price was preprinted on the kit to reduce anticipated discrepancies in the eventual cost to consumers (Christian Commission for Development in Bangladesh/PATH 1990).
In rural Quetzaltenango, Guatemala, where over 75 percent of all births are attended by traditional birth attendants, maternal mortality is high. Studies conducted by the Instituto Nutricional de Centroamérica y Panama (INCAP) found the following problems: lack of recognition of and response to high-risk pregnancies and births by traditional birth attendants, injection of oxytocics to "enhance" labor, and lack of confidence in government health services for referral of complications. An innovative "Guatemalan solution" to improve maternal and newborn health is being tested. The program will focus on improving traditional birth attendants' technical and counselling skills through use of a participatory, experiential training approach; increasing the capability of district-level health staff to identify and manage obstetric problems; improving communication and referral between traditional birth attendants and other maternal health care providers; and increasing knowledge of risk, danger signs, and obstetric emergencies at the community level (Schieber 1991) (see appendix 2, Quetzaltenango Project).
Information, education, and communications also promotes awareness and use of maternity waiting homes or birthing facilities near transport or referral-level facilities where these exist.
If the design of the maternity waiting home/birthing facility has been worked out with potential beneficiaries, and if community leaders and health care providers recognize the utility of the waiting home, it will be credible and better utilized.
In Tanjungsari, Indonesia, a pilot project is experimenting with the use of community birthing centers. The centers are on main roads and have access to transport to referral facilities in the larger cities. Preliminary qualitative research indicates that a number of issues would influence women's use of the facilities. For example, women prefer delivery in the squatting position; hence the beds that were originally bought for the centers are being removed. In Tanjungsari, community leaders have encouraged women to use the new facility, which has led to fairly high level of utilization (Alisjahbana 1991).
Improving the Health Status of Women and Newborns
In improving the health status of women and newborns, information, education, and communications should aim to promote awareness and use of family planning services by men and women; and promote healthy behaviors by women and families during pregnancy and the postpartum period, such as improved diet and immediate and exclusive breastfeeding.
Promoting healthy behavior by women necessitates enhancing their ability to follow through on what is being promoted. Therefore, it is important that the specific action to take is clear, that a recognized benefit is offered and that the obstacles they face in changing their behavior are addressed. As stated previously, information, education, and communications programs should focus concurrently on influential household members and community decision makers in order to promote behavior change among women. For instance, husbands and mothers-in-law often play a key role in determining the diet of pregnant women. Putting the newborn to the breast, a practice rooted in many varying birthing traditions, provides another example; establishing consensus among the "keepers" of those traditions is essential to the success of activities aiming to promote immediate and exclusive breastfeeding.
As part of the USAID-assisted Integrated Child Development Services Program in India, action cards were developed and given to women as soon as they recognized they were pregnant. The cards covered basic actions pregnant women should take during pregnancy, such as eating more food, going to a feeding center for additional food, if necessary, taking iron tablets, and obtaining tetanus toxoid injections. Radio spots were addressed to men and mothers-in-law to help women follow this advice (Griffiths1991).
In Thailand, a study investigated the effects of improving the education and counselling of pregnant women regarding diet and weight gain during pregnancy in a controlled setting. A sample of 603 pregnant women in a Khmer refugee camp were assigned to an intervention group and 580 to a control group. The control group participated in a pre-existing educational program, and received rations, supplements, and non-interactive and non-judgmental feedback on weight gain. The intervention group received discriminating feedback about weight gain and counselling on how to increase weight gain and participated in discussions on actions they could take to improve pregnancy outcomes. Knowledge improved among women in the intervention group and their attitudes toward weight gain changed. The incidence of low birth weight infants decreased, weekly weight gain improved, and support from spouses, which was found to be an important factor behind improving the women's nutritional status, also improved. These effects were noted only for those women who attended classes for more than three months (Roesel and others 1990).
Information, education, and communications should also increase awareness of the need for and increased use of formal public (and private, if available) maternal care, both for preventive and curative services.
Offering a desired product, whitewashing walls, adding room dividers, offering more than one health service, and changing the hours of service delivery are among the many service modifications which can meet the women's needs and preferences. To be effective, such improvements must be based on what current and potential service users think of existing services. Research into the attitudes and behaviors of service providers is also important to enhancing understanding of the modifications required to improve the quality of care. Once an "improved" service is available, information, education, and communications activities can be used to promote it and generate demand.
In Cochabamba, Bolivia, formative research conducted among clinic personnel and community members highlighted vast differences in their perceptions of existing services (see discussion below on Cochabamba). Based on the results of this research, clinics will offer more privacy, ensure greater respect for women's cultural perspective and try to maintain a warmer temperature. Following delivery, care providers will return the mother's placenta to her for burial; previous neglect of this important tradition had discouraged women from delivery in the clinics (CIAES 1991).
The Center for Child Survival, University of Indonesia, has undertaken a project to increase access to and consumption of iron and folate tablets to reduce maternal anemia. Besides increasing the supply of iron and folate tablets among the usual public sector clinic dispensers, traditional birth attendants have been identified as new private sector distributors. Radio spots, a reminder sheet for the woman, and counselling cards, which tell women where to obtain the tablets, why and how to take the tablets, and what to do about side effects, have been developed to create demand and increase compliance (Moore and others 1991).
Information, education, and communications should also promote awareness and use of alternative safe birth facilities, when these exist.
Promoting use of alternative facilities is particularly important in settings where the majority of women deliver in hospitals, leading to overcrowding and associated problems related to quality of care. Some women could deliver safely in alternative facilities. Information, education, and communications can be used to help make this an attractive option.
In urban Jamaica, rising demand for hospital delivery has resulted in overcrowding and reduced quality of care. However, pregnant women in rural areas, often at greater risk due to higher parity, underutilize the available option of hospital or midwife-attended home delivery. The Ministry of Health proposed the creation of alternative community-level birth locations for anticipated normal childbirths in urban areas and to increase attended deliveries among high-risk rural women. Qualitative research assessed the determinants of women's choice of childbirth location and attendant, the acceptability of the option of midwife-attended births in maternity rooms attached to community clinics, and the factors that would motivate pregnant women to change birth location (Wedderburn and Moore 1990).
Although few women could identify specific intrapartum risks or dangers, they perceived hospital care to be more safe and to offer better access to emergency care, leading them to prefer hospital deliveries. Privacy, personal attention and social support were stated prerequisites for use of the proposed alternative birth locations. Poor attitudes of maternal health care providers were identified as a source of dissatisfaction of rural women with hospital birth and a major barrier to prenatal care use. Based on the study results, the Ministry of Health has revised plans for the locations of several proposed pilot maternity rooms. A media campaign to address documented barriers to improved maternal health care use, and in-service education of maternal health care providers to improve counselling skills, are being considered (Wedderburn and Moore 1990).
Information, education, and communications can also train modern maternal health care providers in the public (and private) sectors to improve the management of maternal health problems and enable them to counsel women more effectively.
Counselling is the process during which most service users make decisions to comply with or disregard instructions, prescriptions and health-promotive advice. Effective counselling is not didactic. It must be based on an understanding of the perspectives, needs and limitations of service users, and should aim to provide them with full information on the health alternatives available to them. Effective counselling also involves discussing and negotiating with clients the most appropriate and effective healthy behaviors to follow under their particular set of circumstances. If counselling is not a cornerstone of programs designed to bring clients and service providers together, all efforts may be wasted and even have a negative impact on service use.
MotherCare and the Federal Ministry of Health in Nigeria have developed a project that focuses on the training of midwives in lifesaving skills and caring and attentive counselling. The increased quality of care brought about by the project will be promoted by an information, education, and communications campaign, which will inform people where they can find the improved facilities and service providers. Initial formative research has supported the premise that service use was limited and that both demand generation and improved quality of care were needed (Conroy 1991).
In addition, information, education, and communications should advocate an awareness of the need for and effectiveness of incorporating women's preferences into the design and promotion of family planning and maternal health services.
Formative research can help to bring the preferences of women and influential family members, community decision makers, and health care providers, to light. These perspectives are the basis of any effective information, education, and communications program. Formative research is usually qualitative in technique, employing focus group discussions, indepth interviews and observation to determine what people think, how they behave, and, more importantly, why.
The MotherCare-supported Cochabamba Reproductive Health Services Project in Bolivia illustrates the importance of formative research. Faced with underutilization of what seemed to be extensive and convenient maternal health services, the project conducted a qualitative study to shed light on the beliefs and practices of the low income urban and periurban population of Cochabamba, as well as those of health care providers. The study exposed near absolute dichotomy between women's beliefs and practices and those of health care providers. For instance, women stated a preference for private, warm and enclosed rooms for delivery, but health centers offered impersonal, crowded, cold and ventilated environments. Women preferred delivering in the vertical position, while health providers favored horizontal delivery. Several additional differences were identified and prioritized, based both on important community practices rejected by the health system and health service practices rejected by the community. Improved case management, training and information, education, and communications interventions will be designed to help modify the practices of both the community and the medical service system and help bring them closer together, with the objective of improving quality of care and service utilization, and maternal health (CIAES 1991; Restrepo 1991).
What Are Specific Maternal Health Topics for each Target Audience?
While specific themes for information, education, and communications in maternal health will vary somewhat across settings depending on maternal health needs, available infrastructure and other contextual factors, the uniformity of themes that will need to be addressed is striking. While general themes will be similar, their details and the manner in which related information, education, and communications programs are implemented will vary on a setting-specific basis, and according to the target audience being addressed. Depending on the project's broad goal, the specific problems being addressed, and the role(s) identified for information, education, and communications in a program, planners should think about undertaking communication activities for at least three main audiences: communities (especially women), health care providers - both traditional and "modem" and policymakers/program planners.
Following is a list of basic topics that should be considered for each of the three main audience groupings. It is important, however, that the inclusion of any topic in a program be based on, and tailored to, the local problem and local perceptions.
· Promote healthy behaviors directly to women, families and communities. Family planning Early recognition of maternal health problems, danger signs, and risks Recognition and treatment of STDs and HIV prevention
·Appropriate self care (diet, rest) Maternal tetanus toxoid immunization Compliance with advice or medical regimens prescribed, for example iron supplementation, completion of treatment regimens or referral for additional care, and contact tracing (STDs)
· Breastfeeding and an appropriate transition to artificial contraception
· Promote recommended/appropriate use of maternal health care: Timely, regular use of recommended source of preventive prenatal and postpartum care
· Use of trained birth attendant and hygienic birth practices Timely use of recommended source of treatment for prenatal, intrapartum, or postpartum conditions
· Use of recommended birth locations (including birth centers) and attendant
· Determine parameters of and promote an "improved product":
· Form and source of iron and folate supplementation
· Alternative birth location/birth attendant
· Redesigned maternal care locations, schedules, practices
· Safe birth kit and other innovative community-level technologies
· Increase community awareness and organization Development of community emergency transportation schemes and other means to increase women's access to needed care Promote acceptance of alternative service provision (maternity huts, traditional birth attendant distribution of iron and folate tablets)
· Develop mechanisms to increase women's role in family planning and maternal health care decisionmaking
· Improved acceptance of fee-for-service or co-payment
· Maternal Health Care Providers
· Traditional health care providers
· Promote beneficial practices Promote family planning Encourage safe, hygienic birth techniques Increase recognition of prenatal, intrapartum, and postpartum danger signs Promote use of safe birth kits Improve timeliness of referral to recommended source of additional care Encourage provision of additional maternal health services (iron and folate tablet distribution)
· Discourage unsafe birth practices and other practices which harm maternal health: Eliminate harmful delivery practices Decrease use of labor-enhancing drugs Reduce incidence of female circumcision Decrease use of unsafe abortion techniques
Modern health care providers
· Promote family planning counselling and service delivery
· Improve ability to provide quality maternal health
Increase priority assigned to maternal care/components of care
Improve counselling skills
Improve recognition of risk factors, treatment of problems and appropriate
referral for additional care
Improve awareness of and attitude toward traditional beliefs and practices of service users
Maintain traditional breastfeeding intervals
· Improve acceptance of referrals from traditional practitioners
· Policymakers and program planners
· Promote development of comprehensive family planning and
maternal health programs, including communication strategies:
Increase awareness of need for and benefits of improved maternal health care policy and programs to policymakers, health and media professionals, and public interest groups
Increase awareness of the health benefits of family planning
Increase networking and disseminate state-of-the-art information about successful maternal health care activities in other countries
Promote intersectoral coordination and increase awareness of specific maternal care issues (e.g., components, quality and required coordination of maternal care; appropriate delegation of clinical tasks)
Increase awareness of the need for and effectiveness of incorporating women's preferences into the design and promotion of family planning and maternal health services
· Institute "awareness campaigns" to promote female education
How Cost-effective Are Information, Education, and Communications Programs in the Area of Safe Motherhood?
Currently there is no specific information on the cost-effectiveness of safe motherhood information, education, and communications components, but estimates can be made from other areas, such as nutrition, health and family planning. Efforts in these areas have shown that information, education, and communications activities, when implemented systematically and when based on the consumer's point of view, can be highly effective, and at limited cost. Communication efforts have led, for example, to significantly higher rates of: a) contraceptive use, b) caloric and protein intake of young children, c) use of oral rehydration salts, and d) use of improved facilities, such as the village-level integrated health service delivery posts in Indonesia. The changes in practices brought about as a result of information, education, and communications efforts have led to improvements in the nutritional status of young children, lower fertility rates and lower diarrhea mortality rates among children. It is likely that similar results could be achieved in the area of safe motherhood.
On a per beneficiary basis, the cost of information, education, and communications interventions are among the lowest. Though the research, printing and even media costs associated with information, education, and communications are by no means cost free, they are far lower than those of drugs, food or medical equipment. And, although information, education, and communications as a sole intervention can be effective, when combined with other interventions, there is a synergistic effect - both investments become more effective. In addition, by implementing an information, education, and communications component that encourages families, communities and health services to do more or to utilize their own resources better, more expensive program elements can be better targeted. The biggest waste of resources associated with health care programs occurs when drugs are supplied but not taken and when services are available but underutilized. Information, education, and communications helps to provide a sound return on investment in health services.
· Establish a clear mandate for information, education, and communications activities from the outset of project design. Too often, information, education, and communications activities are added late and suffer from improper development. Likewise, the impact of other program activities is not maximized, because they have not had communications support, or because the consumer's perspective, often solicited by the communication team, had not been included, requiring major, costly adjustment mid-project.
· Carefully diagnose the overall sociocultural environment into which maternal health communications will fit. This will prevent programs from excluding an important influential, attempting to change practices not amenable to change for deep-rooted cultural reasons, and insensitivity to the position of women in certain social contexts.
· Undertake well-designed qualitative research to provide women's perspectives on maternal health issues, as well as those of other important influentials such as traditional birth attendants, health workers, husbands, and mothers-in-law. While this may appear costly at the outset of the program, it helps avoid expensive mid-project correction. Since epidemiologic concerns are generally not the concerns of women, and women's perception of their physiology may be far different from the western model, the success of a program is dependent on the extent to which each set of priorities can be modified to create a set of priorities shared by both program planners and potential beneficiaries. This qualitative research should inform all aspects of the project - not just the information, education, and communications activities.
· Pretest messages and modify in light of experience.
· Take a comprehensive, strategic approach to addressing women's health problems. Seldom is there one answer. The strength of a program often resides in planning multiple but complementary actions all focused on a common objective. The outcome of combining the consumer and medical perspectives on a problem should form the basis of this comprehensive strategy.
· Focus the information, education, and communications activities on modifying or strengthening practices. Too often, information, education, and communications programs provide program beneficiaries with abundant and good information, but it does not lead to action; the beneficiaries often do not receive a clear indication of the aspects of the information that are most important, or how it is relevant to their lives. The information provided must be targeted and clear in terms of the actions people should take, and why.
· Information, education, and communications strategies should move beyond conventional health education approaches because women often do not utilize services, and may have low literacy skills and different perceptions of problems. The use of innovative means to reach women and creative message expression have been elements of most successful programs.
· Involve maternal health care workers in the redesign of maternal health services based on women's preferences. While not necessarily an information, education, and communications strategy, programs that use qualitative research to involve health workers in revamping services often improve their empathy with women and, hence, their communication with women and women's families. Improving this communication, either indirectly or through training, is key to ensuring quality of care and women's satisfaction with services.
· Mix locally planned and run activities with a centrally run and managed information, education, and communications program. This lesson seems particularly critical to women's health programs, since so many of the activities needed to reduce maternal mortality require both community involvement - to find locally viable solutions - and the involvement of the medical community - to ensure the availability and quality of services. From the outset, information, education, and communications programs must operate on both levels and build in flexibility and funds for local activities.