Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project

Abstract

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context–mechanism–outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by ‘bridging’ communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a ‘buzz’ for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs’ motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective.

Community health workers’ involvement in mother-child care during the postpartum period in the Missed Opportunities in Mother and Infant Health (MOMI) project in the Kaya health district: a contribution analysis

“…Therefore, they were motivated to help their community in matters of health. We found, as in the other MOMI project countries (Kenya, Malawi, Mozambique), that the trust between CHWs and their community motivated them to provide an effective bridging function [20].…”

Influences of health facility type for delivery and experience of cesarean section on maternal and newborn postnatal care between birth and facility discharge in Malawi

“…In addition, the issues of facility under-staffing [25], over-burdening of the providers by existing workloads [25] and demotivation by the lack of organizational-level accountability, support and incentive structures [26] need to be addressed. These factors likely contribute to shortened length of stay at the facility after delivery, which in turn, could lead to less mothers and newborns being checked before discharge due to time and space constraints.…”

Community Health Workers’ Involvement in Mother-Child Care During the First Year After Birth, in Kaya Health District, Burkina Faso: A Contribution Analysis

“…Sensitization through social networks with an appropriate timetable as implemented by the female CHW proved positive for behavioral change and raised attention to PPC [28,29] . Monitoring and supervision were revealed to be an important factor of success for the interventions [12] . Women in rural areas had a higher rate of home visits than women in urban areas.…”

“…However, most of these evaluations have focused on the effectiveness, feasibility [8,9] or impact of these programs [10] Few impact evaluation studies have examined the context and mechanisms that led to the observed results [11,12] . In addition, the majority of these evaluations used counterfactual elements or control versus intervention groups to attribute an observed result to a given program [13] .…”

“…However, in complex interventions, it is often di cult to fully attribute observed effects to the intervention [14][15][16][17] . It would therefore be interesting to determine the contribution of each component of an intervention or a programme to the achievement of the obtained results, in order to optimize and improve strategies for public health interventions [11,12,14] .…”