Communities Take Action: Postabortion Care in Kenya
In Kenya, maternal health complications are a leading cause of morbidity among women. Kenya’s Rift Valley Province has consistently had the highest level of abortion-related outpatient morbidity in the country since at least 2003. These realities necessitate interventions to prevent unintended or mistimed pregnancies and to ensure access to quality care for women with postabortion complications
The RESPOND Project designed an intervention package aimed at increasing awareness and use of postabortion care (PAC) services and improving family planning, reproductive health, and maternal health outcomes. Known as the
Community Mobilization for Postabortion Care (COMMPAC) intervention, this package builds on efforts by The ACQUIRE Project (2005–2007) to address PAC and increase family planning (FP) uptake by focusing on the central role that communities can play in improving access to services.
- Increasing community knowledge of the danger signs of abortion-related complications, locations of services, and FP–related information and services
- Building capacity to address PAC and FP needs
- Encouraging involvement of the marginalized in community action
- Mobilizing communities to prevent and treat incomplete abortion
- Strengthening service delivery points providing PAC and FP
TIMELINE of the Project (click on image to see larger version)
- Communities Take Action in Kenya: Strengthening Postabortion Care
- Community mobilization and service strengthening to increase awareness and use of postabortion care and family planning in Kenya (article in the International Journal of Obstetrics and Gynecology, July 26, 2014 pp 8-13)
A baseline data collection exercise was carried out from May to June 2010 in Naivasha District to provide a benchmark against which the RESPOND intervention may be measured during endline evaluation. The evaluation used a quasi-experimental design with intervention and control groups covering six study sites within Naivasha District, with measurements taken at baseline and endline. The baseline data collection comprised three components
- A community-based survey of approximately 600 women between the ages of 18 and 49
- An inventory of all public and private health facilities in the study area (n=11
- Interviews with providers working at the identified facilities
Results included the following
- There is a clear need for PAC services at the evaluation sites
- Utilization of health services during pregnancy and delivery is limited
- Knowledge of FP is high, but actual use is significantly lower
- Reasons for nonuse of FP highlight the need for the intervention
- Exposure to community interventions in general is low
- Health facilities in Naivasha could feasibly offer PAC services
- Government health facilities are patronized by a considerable proportion of women
Design the Strategy
- MOH Community Strategy w/District Health Management Teams (DHMTs)
- Community Health Extension Workers (CHEWs) and Community Health Workers (CHWs) as primary links—sustainable structures
- Facilitated Community Action Cycle for PAC
- Trained CHEWs/CHWs
- Supported them to conduct community mobilization
- Support groups to develop and implement action plans
- Mentoring to build capacity of CHEWs/CHWs
- Trained providers in comprehensive PAC services
- Built provider-community partnerships
Community Action Cycle - The Community Action Cycle is a highly participatory process in which community members learn how to take action for their own health.
Create and Test
A set of community behavior change communication flip cards was created for the CHEWs and CHWs to use in house-to-house outreach visits and on community dialog and action days.
Topics covered included
- FP methods
- Misconceptions and negative rumors about FP
- Danger signs
- The three delays
There was also a plan to hold community–facility linkage meetings with the trained CHEWs and CHWs to discuss progress on their action plans and to jointly resolve problems
Mobilize and Monitor
More than 630 community members participated in the mobilization sessions.
In addition, two community–facility linkage meetings were held with the trained CHEWs and CHWs to discuss progress on their action plans and to jointly resolve problems (including negative rumors about FP methods, religious opposition, long distances to the nearest facility, poor roads, lack of trained providers, unfavorable facility hours, lack of partner support, poor provider attitudes, and lack of equipment and supplies.
None of the local dispensaries had the capacity to provide PAC at the project’s inception.
Accordingly, in partnership with the MOH, the RESPOND Project improved the service capacity in facilities serving the communities in the intervention group. This was achieved by training 16 providers (clinical officers and nurses) at existing Naivasha dispensaries and health centers in PAC and by training 20 providers in FP. The clinical officers and nurses had received previous training in related health procedures; as part of the project, they received an additional week of PAC training and a week of FP training.
The PAC training included instruction regarding surgical procedures and manual vacuum aspiration; issues related to patient comfort, privacy, hygiene, and cleanliness in the diagnostic, waiting, and recovery areas; relevant medications, instruments, and supplies; and post-procedure counseling. The FP training included instruction on patient intake, insertion and removal of intrauterine devices and implants, and provision of oral and injectable contraceptives, and condoms. Community problem diagnosis also provided insights to the project as to how services could be refined to meet the communities’ perceived needs.
Evaluate and Evolve
The evaluation consisted of pre-post quasi-experimental design- baseline was in June 2010 and endline was in January 2012.
The control group for comparison consisted of a matched pair of three units each, with each unit containing approximately 5,000 people or five villages with two CHEWs & 50 CHWs.
The quantitative and qualitative measures were as follows:
- Community survey of 593 women aged 18–49
- Exposure to PAC community mobilization
- Sources of care: maternal and child health (MCH),
Best Practices & Challenges
- Country-led by DHMT, using MOH Community Strategy and structure
- Community engagement is important to success
- Building skills and capacity = taking action for their health
- Work with local social community networks
- Community empowerment must be combined w/quality service improvements
- Link facilities w/communities to increase use of health services throughout pregnancy
- CHEWs/CHWs/community groups have other responsibilities
- Wide geographic coverage
- Lack of incentives; equipment and supplies
- Stigma surrounding abortion
- Insufficient time for intervention
Article about the intervention:
Community mobilization and service strengthening to increase awareness and use of postabortion care and family planning in Kenya - authors - Chi-Chi Undie, Lynn M. Van Lith, Mercy Wahome, Francis Obare, Esther Oloo, Carolyn Curtis. (International Journal of Gynaecology and Obstetrics, 2014 July (I), pp. 8-13.
Banner Photo: M. Wahome/EngenderHealth
Secured commitment with Naivasha District Health Management Team
Finalized training manual and behavior change communication cards, and trained staff in Community Action Cycle
Identified units and selected CHWs and CHEWs for training
Trained CHWs and CHEWs
Baseline evaluation carried out
June 2010- June 2011 - Community engagement, Developed action plans, Carried out action plans (Round 1)
Action plans (Round 2), Ongoing mentoring and support