Taking Pregnancy Testing To Women’s Doorstep: How Village Health Workers Are Bridging the Maternal Health Divide In Rural Mutare

By Michael Gwarisa

Zimbabwe is currently on a positive trajectory regarding maternal health amidst indications of a decline in maternal mortality at the back of numerous interventions by the government and several partners. Data from the Zimbabwe Statistics Agency (Zimstat) Vital Statistics report of 2023 shows that infant and maternal mortality rates have declined by 20 and 36 percent respectively. The 2022 Population and Housing Census data shows that maternal mortality in Zimbabwe reduced from 960 per 100,000 live births in 2010, to 363 in 2022.

Despite the milestones recorded, rural women remain heavily exposed to a myriad of challenges resulting in pregnancy and birth complications that in most cases lead to negative health-maternal health outcomes. Rural women are more likely to receive late or no prenatal care owing to several factors ranging from poverty, distance barriers, and lack of skilled human resources in rural facilities to attend to pregnancy complications amongst a host of other issues.

Due to high poverty levels, pregnant rural women who are unemployed and without any income, fail to pay even the smallest amounts of levy at the clinics. This compromises the health of both the pregnant woman and the unborn child as women delay booking at the Antenatal Clinic (ANC).

However, for women in Mutare district including those in rural Mutare, the introduction of community pregnancy testing initiatives has seen more women booking at the ANC within the first 12 weeks of their pregnancies as more women are being referred to the facility on time.

Jane Muyambo (28) from Mambondiyani Village in Dora has not had her period for past month, and is anxious to know what could be happening to her.  She knows about the Community pregnancy test programs being conducted by Village Health Workers (VHWs), and is ready to take her test.

On this particular day, Village Health Workers are gathered at Dora Clinic for a meeting. This does not deter Jane from her quest. She walks to Dora Clinic where a Village Health Worker conducts a pregnancy test which turns out to be a positive pregnancy result.

I am now relieved,” says Jane. “I have been wondering all along without certainty but now I am certain of what to do, and I can start preparing for my unborn baby now.”

Following her positive pregnancy result, the next step for Jane is to be initiated into the voucher system, a brainchild of the Expanded Side of the Extended Supply side of the Community Results Based Financing (ESsCRBF) program where all her Antenatal Clinic (ANC) related costs are catered for free of charge.

She also gets free HIV testing and counseling. The health workers tell her to bring her spouse for testing just to be sure of both their HIV status, and to protect the baby in the event one of them is HIV positive.

Another beneficiary from the program, Margret Rupondo (33), from Nyadongo Village in Dora, Mutare District, recounts how getting an early pregnancy test in the comfort of her village nine months ago reversed what could have probably turned out to be a negative health outcome.

“I delivered three of my Children here at Dora Clinic. However, on my fourth child, I had a birth complication. My baby was very big, and the chances of requiring a Caesarean section were very high. Because I was coming here for all my ANC visits, the nurses were monitoring me, and when the time was due, i was transferred to Sakubva District Hospital in Mutare where I delivered my baby through normal delivery under the watchful eyes of midwives and a doctor. All this was done for free,” said Margaret.

Mutare is one of the piloting districts for the Extended Supply side of the Community Results Based Financing together with Centenary, Mangwe and Gokwe South. Control districts are Mazowe, Chiredzi and Mutoko. The ESsCRBF is being implemented by the Ministry of Health and Child Care (MoHCC) and Cordaid Zimbabwe, through financial support from the World Bank (WB). With the expanded role of VHWs, the program seeks to improve coverage of key indicators through the direct contact of VHWs and other community health workers working closely with the local leadership.

Under the program, VHWs are incentivised to identify certain patients early including pregnant women, and channel them to services. Their statistics are recorded and submitted to the national database. The incentivised indicators include early diagnosis of pregnancy and referral for ANC booking before 12 weeks of gestation, promoting the use of long-acting reversible contraceptive methods (LARCS) methods of family planning, and referral to the health facility, following up postpartum mother/baby pairs, and referring for postnatal services, working closely with carers and community leaders to identify victims of sexual violence and referring them for post-exposure services within 72 hours, giving under 5s Vitamin A when due, Identifying EPI defaulters and referring to services, screening under 5s for malnutrition using MUAC tapes and referring early for IMAM, Identifying IMAM defaulters and referring to the health centre and treatment of under 5s with diarrhoea using ORS and Zinc and referring severe cases.

In Mutare district, implementation of the ESsCRBF started from January 26, 2023 with training of 63 VHWs in four clusters. The district received pregnancy test kits, urine specimen jars, VHW manuals, and National VHWs Registers and National VHWs referral books.

Mrs Irene Goba, the team lead for Village Health Workers in Dora said testing for 
pregnancies in communities has created a bond between Village Health Workers, and 
women and now more than ever, the number of ANC bookings has gone up.

“Once we discover a woman is pregnant, we ensure we hold her hand from up to the day she delivers her child. We make sure the woman books at the ANC before 12 weeks and we make a follow-up to ensure she makes all her eight ANC visits that are recommended for a pregnant woman. At seven months, we also check with her to ensure she buys her baby’s preparation on time because we are cognizant that a baby can be born at seven months,” said Mrs Goba.

Mrs Goba said the ESsCRBF activities were motivating VHWs as well as boosting their confidence and commitment to integrated Primary Health Care. The program has also improved healthcare service demand, defaulter tracking and coverage is first ANC 12 weeks and below, institutional deliveries, Post Natal Care, LARCS and the Expanded Program on Immunisation (EPI).

Dora Clinic being one of the benefiting facilities has witnessed a massive increase in institutional deliveries following the introduction of the community Pregnancy testing initiative.

Etty Runesu, the Nurse in Charge at Dora Clinic said the program has empowered Village Health Workers to quickly identify pregnant women in communities.

“Before the RBF subsidies, we used to record a lot of Home deliveries in Dora, After RBF, we managed to have 60 to 70 percent institutional deliveries at our clinic and some being referred to Sakubva District Hospital,” said Sr Runesu.

Apart from booking early at ANC, the community pregnancy testing initiative has helped reduce transmission of HIV from the mother to the child, as mothers are initiated on treatment early and the child is also protected through available Prevention of Mother of Transmission of HIV (PMTCT) options.

Meanwhile, Mutare District is one of the biggest districts in Manicaland with 55 sites comprising Mutare Rural with 41 facilities and Mutare City with 12 urban sites. The district has a total 674 trained Village Health Workers. Of the trained VHWs, 538 are under the Health Resilience Fund (HRF), and 136 are Global Funded. Mutare Rural has 642 Village Health Workers.

Mrs Guwira the DNO for Mutare says the testing pregnancies in communities has worked

Mutare District Nursing Officer, Mrs Margaret Guwira said the Extended Supply Side of the Community RBF initiative to test for pregnancy at the community level was a game changer to the maternal health trajectory in the district.

“In these programs, we are looking ANC, we are looking at the first ANC below 12 weeks and we have seen a sharp increase from 2022 of mothers coming to book below 12 weeks. We are also looking in terms of institutional deliveries, we also saw an increase in mothers coming to deliver comparing 2022 and 2023. We are also looking at Post Natal Care (PNC) activities by day that is Day 3, Day  7 and then 6 weeks,” said Mrs Guwira.

Since introduction of the ESsCRBF, ANC bookings below 12 weeks have jumped from 2300 to 2900 in Mutare district between 2022 and 2023. In terms of institutional deliveries, the numbers went up to 1078 in 2023 from 10080 in 2022. Post Natal Care (ONC) visits were 9861 for Six weeks visit in 2023. For the seven days, a total 400 were recorded in 2023. 4313 went for the three-day PNC visit.

Dr David Muchirewewsa, the District Medical Officer for Mutare said the ESsCRBF has come in handy as they are witnessing improvements in maternal and infant health indicators.

“We have seen an improvement in terms of clinical management of patients because of the continuous support and supervision that we are doing quarterly for the health facilities. This has seen most of our facilities having near-zero maternal mortality within the health facilities. So it means with RBF, we have been able to manage our fatalities within the health facilities,” said Dr Muchirewesa.

He also commented on how the RBF in general has been instrumental to the development and up scaling of maternal health services. One of the big achievements he spoke about was the construction of maternity or waiting mothers’ shelters. He said, previously, most mothers delayed coming to the hospital to deliver. However, the waiting mothers shelters have reduced the first delay by accommodating the pregnant mothers within  health facilities. Almost all the facilities in the entire district have actually able to construct a maternity waiting home, which are functional.

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