Background

MAHMAZ Overview

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Problem Statement

The maternal mortality rate in Zambia remains high at 398 maternal deaths per 100,000 live births, with rural Zambia experiencing much of this burden. For this population, distances and physical barriers limit access to health facilities for pregnant women.

  • In Zambia 31% deliveries happen at home with 42.1% in Southern Province and 27.2% in Eastern Province.
  • If a complication arises while a woman is delivering in the village, she may not be able to get to health facility in time to get the care she needs. If a complication arises during delivery at a health facility, a skilled birth attendant can manage the complication or refer the woman to a higher level health facility.

 

Overarching Theory (Implementation & Intervention Effectiveness)

When women who live in remote communities have access to quality mothers’ shelters they will be more likely to deliver at a health facility and receive quality delivery and postpartum care.

  • The World Health Organization strongly recommends ‘skilled care at every birth’ as a fundamental strategy to reduce maternal deaths.
  • Mothers’ Shelters represent a potentially useful but little used strategy to improve access to skilled obstetric care, particularly for women living farthest from the health facility. While a seemingly sensible approach, there is insufficient evidence of the effectiveness of Mothers’ Shelters in improving access to delivery services and improving maternal outcomes.

 

Intervention: Core Model

Though mothers’ shelters are intended to bring women closer to quality delivery and postpartum care, many are under-utilized because they have fallen into disrepair and lack basics like beds and clean water.

  • Guided by findings from formative evaluations, the Core Model was designed as a non-medical intervention designed to ensure that mothers’ shelters are responsive to community standards of safety, comfort and services offered.
  • The core model was designed and vetted by community leaders, members, and district and provincial health professionals. The model prioritizes quality and availability of resources and services across three overarching categories:

1) infrastructure, equipment and supplies; 2) policies, management & finances; and 3) linkages and services.

 

 

Construction

An integral component of our project design was ensuring that sites selected for construction of mothers’ shelters were adjacent to high-quality health facilities equipped to manage complications and demand generated by the mothers’ shelter.

  • Mothers’ shelters are used to bring women closer to quality delivery and postpartum care. If a complication arises during delivery at a health facility, a skilled birth attendant can manage the complication or refer the woman to a higher level health facility. However, many of them have fallen into disrepair and lack basics like beds or clean water.
  • To address this problem, the project is constructing or renovating 12 shelters across Southern and Eastern Provinces using high-quality, lasting materials to ensure that the structures will last for many years.

 

Evaluation Purpose

Our multi-layered evaluation strategy allows us to answer whether well-constructed, well-resourced, and well-managed mothers’ shelters can increase access to high quality intrapartum care and improve delivery outcomes among women that live the furthest from health facilities.

  • The program aims to produce replicable and actionable results that can inform the efforts of policymakers in Zambia and elsewhere to improve maternal and newborn health through larger-scale implementation of mothers’ shelters.
  • The data produced by this project will be used as evidence for programmatic decisions made by the Ministry of Health to scale-up the initiative across Zambia, and invest in the long-term sustainability of mothers’ shelters.

 

 

Formative Evaluation

In order to design an intervention that was responsive to the needs of the community we needed to understand existing barriers to delivering at a health facility, community perceptions and utilization of the MS, and to generate community ideas on how to make MS more acceptable and sustainable.

  • The formative evaluation was conducted in Kalomo, Choma, Pemba, and Zimba and results were used to develop the Core Model and Sustainability Framework.

 

Impact Evaluation

The MAHMAZ project will conduct an in-depth impact evaluation across all MAHMAZ and ZAMs sites to help the maternal health field answer a long-standing question—whether mothers’ shelters can be both an effective and sustainable solution to overcoming distance barriers to timely, quality maternal healthcare.

  • Specifically, the impact evaluation seeks to answer whether the core model can increase access to high quality intrapartum care among mothers living more than 10 km from facilities.
  • The impact evaluation will guide our understanding of changes in utilization of mothers’ shelters and delivery location, access and maternal health outcomes, and factors associated with long-term sustainability of the shelters.

 

Implementation Evaluation

The MAHMAZ Project aims to produce replicable and actionable results that can inform the efforts of policymakers in Zambia and elsewhere to improve maternal and newborn health through larger-scale implementation of mothers’ shelters.

  • In order to make appropriate recommendations to the Zambian government, we must be able to explain the ways in which our package of interventions was or was not effective. The Implementation Evaluation helps us identify the factors that influenced our successes.

 

Sustainability

Mothers’ Shelters in Zambia have been used to bring women in remote communities closer to quality delivery and postpartum care. However, many shelters have fallen into disrepair because there has not been a targeted effort to ensure their sustainability

  • To address this issue, MAHMAZ has created a framework that targets the operational and financial sustainability of the homes through: 1) Supporting local communities to effectively manage the shelters; and 2) Testing a variety of income-generating activities to promote their long-term financial sustainability.
    • To address the operational sustainability of the shelters, the project team is building the capacity of local communities to govern the shelters by establishing and training community-elected Governance Committees and Management Units.
    • Financial sustainability of the shelters is critical to their success beyond the life of the project. To address this, the project is supporting communities to implement various income generating activities to cover the operational costs of the shelters.
  • The project has also developed a multi-tier strategy to engage Zambian government at the district, provincial, and ministerial level. The program aims to produce replicable and actionable results that can inform the efforts of policymakers in Zambia and elsewhere to improve maternal and newborn health through larger-scale implementation of mothers’ shelters