The woman’s water breaks. She’s having a baby! She tells her partner they need to leave home right away, and so begins their mad dash to the hospital.
This scene is familiar to most people in higher-income countries, where, if they haven’t been through it themselves, they’ve seen numerous iterations of it in romantic comedies and TV sitcoms. In Zambia however, the onset of labor often has a much more ominous tone. Millions of Zambians cannot run out into the road and hail a taxi immediately. There may be no road in the village. And with health facilities usually many kilometers away, the distances are too far for mothers to travel.
The tendency for births to occur in homes rather than clinics is a major reason why infant and maternal mortality are serious problems in Zambia, but stakeholders from all sectors are working together toward a solution.
Partnering for Success
“Every two minutes, a woman dies from complications related to pregnancy and childbirth,” declares Naveen Rao, Lead, Merck for Mothers. “As one of the largest healthcare companies in the world, Merck has a responsibility to help reverse this trend.” That’s why Merck has invested $500 million over ten years in the Merck for Mothers program, which is focused on eliminating maternal mortality.
Africare/Zambia communicates with local communities and traditional leaders to learn what challenges cause births to occur at home. While communities identify multiple obstacles, distance is the most prominent. A method Africare has used in Liberia and elsewhere in Zambia to overcome this distance is Maternal Waiting Homes (MWHs), accommodation adjacent to clinics where women stay as their delivery approaches so necessary care is immediately available.
With financial support from Merck for Mothers, since July 2013 Africare/Zambia has partnered with local communities, the University of Michigan and Merck employees deployed through the Richard T. Clark Fellowship for World Health program to research how to best establish self-sustaining MWHs with community approval and on-going community participation.
The RTC Fellowship program allows partnering non-profits to obtain support from seasoned Merck employees that can directly contribute to project goals. Africare always focuses on achieving sustainable impacts, so Merck’s Darrell Penn and Lisa Meehan were brought on board to emphasize this aspect in the research. Africare in turn gathered data on other research questions and provided guidance on the ground. “Africare’s welcome was really heartwarming, which is nice – but it also helped us to be effective in our research,” explained Lisa. “Their willingness to explain situations and provide background meant we could be effective more quickly.” Darrell and Lisa immediately proved themselves to be valuable additions to the team. In the words of Eden Ahmed Mdluli, technical specialist in Africare’s Office of Health and HIV/AIDS, “Darrell and Lisa have supported us tremendously. We have most appreciated them, their time and work with us.”
Preparing for Success
For projects like MWHs to succeed, you need to do more than build four walls and a roof and then wipe your hands clean. The homes need to be as valuable to communities as possible to ensure they are well-used and well-maintained into the future. With this understanding in mind, extensive research through questionnaires, interviews and focus groups was conducted to plan for all aspects of the MWHs’ construction and continued operation.
Using measurement tools developed for the specific research goals in the target communities, Africare and the Merck Fellows systematically queried all project stakeholders. We sought the opinions of health clinic staff. We spoke with traditional birth attendants, who deliver babies within homes. We visited religious and elected leaders. We spoke with husbands, and we of course spoke with women.
Darrell and Lisa, the project’s Merck Fellows, focused specifically on MWH long-term sustainability. Are communities willing to pay for the upkeep and use of MWHs? What income-generating activities could be organized as sources of MWH revenue? If women gardened while at the homes, could their produce be sold to support their operation? Finally, who would manage the MWHs, the adjacent clinic staff or local community committees? “The research partners at the University of Michigan and the in-country research team showed considerable courage by affording the Fellows the latitude needed to test novel approaches,” commented Darrell. “The community members also showed a great willingness to let us into their lives and expose us to their traditions.”
The community is the active agent of change and should drive the planning, construction and sustainability of MWHs. Most studies of community interventions examine the effectiveness of interventions on a passive audience, but here we collaborated with the community to gather a deep evidence base for an intervention that effectively protects new mothers and children.
Arriving at Conclusions
The University of Michigan is presently analyzing all the data, and formal results will be finalized this spring. However, the data already strongly support a few overall conclusions. First, for more women to deliver in clinics there must be a comfortable place for them to stay. Moreover, local communities are eager to contribute to MWHs, with leaders offering local labor and materials for construction. Finally, the research reaffirms Africare’s conviction that combining expertise with world-class organizations and local communities strengthens our impact on the people we serve.
“By working alongside Africare, the communities it serves and the University of Michigan, our Fellows were able to develop strategies to make mothers’ waiting homes financially viable,” says Brian Grill, Executive Vice President of the Merck Foundation. “We’re proud to be part of such an important project, and equally proud to be part of the solution.”