In this week's episode co-host Lucy Nyaga, together with guests Amina Baraka, a Nursing Officer in charge of Vihiga County Referral hospital and Fatuma Iman, a Reproductive Health Coordinator in Garissa County discuss their involvement in the ‘Quality Improvement (QI) of integrated HIV, TB, and malaria services in Antenatal and Postnatal care (ANC and PNC)’ programme funded by the Global Fund with funding from Takeda Pharmaceuticals. The project is supporting 61 health facilities across 3 counties to provide capacity building, mentorship and to generate evidence to inform decision-making and policymaking to support improvements of maternal, new-born and child quality of care. 

Lucy Nyaga

Country Director, Liverpool School of Tropical Medicine, Kenya 

My name is Lucy Nyaga. I am the Country Director, Liverpool School of Tropical medicine, in Kenya. I have a background in Medical Anthropology and Public Health with extensive experience in promoting implementation of research results into policy and practice with a special focus on MNH.  With twenty years’ experience working in health programming, my experience and expertise in MNH has involved managing and implementing programmes that incorporate implementation research to inform effective programming and policy influence. Working with a range of organizations ranging from governments, academic and research institutions, UN agencies, and national & INGO, I have led and contributed to key MNH research that has led to policy influence in Eastern Africa. 

https://www.lstmed.ac.uk/about/people/lucy-nyaga 

https://www.linkedin.com/in/lucy-nkirote-2062832b/ 

TWITTER HANDLES 

@Lucynnyaga 

@MOH_Kenya 

Amina Anyango Baraka

Nursing manager Vihiga County Referral Hospital

In Vihiga County Referral Hospital we offer a range of reproductive health services to the women and their families. These include antenatal care during pregnancy, intrapartum care, and postnatal care to include contraceptive use. 

Despite all these interventions, the data available still show that a large number of maternal and neonatal deaths occur during birth and 48 hours after. 

The major causes of the mortalities being hypertensive disorders of pregnancy and haemorrhage. The audits have showed that in many circumstances either there is delay in seeking the needed care or delay in the health facility to initiate the appropriate interventions. 

In this regard the provider ability to do correct diagnosis and intervene appropriately is key. Thus we regularly do training needs assessment to ascertain the provider gaps. In the community we hold dialogue days and verbal autopsies to determine the possible causes of ill health and mortalities and factors influence the uptake health services.

Fatuma Iman Maalim 

Mrs. Fatuma Iman Maalim holds a Master of Science Degree in Community Health & Development and a Bachelor of Science Degree in Nursing. She has 35 solid years of experience working with the Ministry of Health - Kenya, 18 Years’ experience working in Maternal Newborn Health programme and 1 year in ANC/PNC programme. 

Mrs. Fatuma, is the County Reproductive Health Coordinator Garissa. She overseas and coordinates Reproductive, Maternal, Newborn, Child, Adolescent Health and Gender Mainstreaming services in the entire county. She is a Master trainer, a Manager, a Mentor & a Decision maker. She is also the focal person of the World Bank’s Transforming Health Systems for Universal Care (THS-UC) Project. Before devolution Fatuma was the Provincial Reproductive Health Coordinator, covering the entire Garissa, Wajir and Mandera districts. Garissa County is among the most underdeveloped counties in Kenya, with the highest Maternal and Neonatal mortality burden of 646 out of 100,000 and 24 out of 1000 respectively (KDHS 2019). 

Personal Twitter handle - @fatmaimaan1 

Organisation Twitter handle - @garissahealth 

Articles – Core authored a cross – sectional study on “The determinants of staff retention after Emergency Obstetrics and Newborn Care training in Kenya.” BMC Health Services Research (2022) 22:872. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08253-2

Research Paper:- Knowledge, perceptions and practices on utilization of maternal waiting-homes among women of reproductive-age in Garissa township constituency Garissa County  (2018)

To listen to the audio along with the transcript click here

Hello listeners and welcome to the connecting citizens to science podcast.

I'm Dr.

Kim Ozano and together with a selection of co-hosts from around the world, we discuss

the ways in which people and communities connect with research and science.

We hear from patients and survivors, health workers, policy makers, scientists,

and implementing research organisations about the methods and approaches that

they apply to co-produced knowledge to address current global health challenges.

Thank you for listening and onto this week's episode.

Hello listeners.

And welcome back to the connecting citizens to science podcast

or welcome for the first time.

Thanks for joining us.

This month's series is all about improving the quality of antinatal and postnatal

care in Nigeria, Kenya, and Tanzania.

And today we are going to Kenya to hear more about the work they are doing there.

So Kenya attained, lower middle income status in 2014 and while the good news is

that poverty rates declined, the absolute number of poor people did increase.

And the majority of those are women.

So the focus to improve services for women is more crucial than ever before.

Despite progress in health policy and service delivery infrastructure Kenya's

maternal mortality ratio remains high at 342 per hundred thousand live births.

And recent analysis shows why disparities of maternal and neonatal

health indicators across and within the counties, with access to scaled

birth attendance during childbirth ranging from a low 22% to a high 93%.

So some real variation across the country there.

So today's episode, we will be talking about in-service capacity

strengthening on antinatal care and postnatal care and quality improvement

methodologies in 61 health facilities across three target counties.

The project which is supported by global fund will provide technical

assistance generate evidence to inform decision making and policy

making in support of maternal and neonatal health quality of care.

Our guests today are Amina Baraka, who is a nursing officer in charge of

Vihiga county referral hospital, and Fatuma Iman, who is the reproductive

health coordinator at Garissa county.

Amina and Fatima will be talking about improving the quality

of ANC and PNC antenatal care and postnatal care in Kenya.

They will be having a particular emphasis on their own county

experiences of quality improvement.

Thank you very much for listening and let's introduce our co-host.

Hi, Lucy.

How are you today?

Hello, Kim.

Good afternoon from Nairobi.

Good day to all our listeners across the globe, wherever

you're listening to us from.

My name is Lucy Nyaga I am the country director Liverpool School

of Tropical Medicine in Kenya.

I have a background in medical anthropology and public health with

some extensive experience there nearly 20 years, uh, working in programming

and, uh, most of this, uh, time that I've worked on programming, I've worked

on aspects of maternal and newborn health . And so I'm really happy

to be here to be speaking with our guests and I hope that our listeners

will be happy and enjoy listening to us and our experiences from Kenya.

Thank you, Kim.

Wonderful.

Thanks very much.

So let's meet our guest.

Fatima, how are you today?

Uh, tell us a bit about yourself, your background and where you are.

I am Fatuma Iman I come from the Northern region of Kenya, which is

called Northern part Garissa county.

I am a nurse by profession.

I have a basic degree in nursing and a master of science in

community health and development.

I have worked with the ministry of health for the past 35 years.

Uh, previously I've been coordinating maternal newborn health reproductive

health in the entire Northern Kenya, which was three counties [place names].

Garissa county is among the 15 counties with high burden, with the high,

burden of maternal mortality in Kenya.

It is the one, uh, it's among the counties, which has made Kenya not to

the, our indicators are all the time low.

And this is because of, we have a porous border with Somalia and Ethiopia , we

have high insecurity levels and 80% of our community are nomadic pastoralists.

This is where now we want to reach our mothers who are in the rural

area at least to have quality maternal and newborn care services.

I have been working 35 years with the ministry, uh, around 20 years, I've been

coordinating maternal newborn health and the last two years with the this

global fund of LSTM, I've been involved in the antenatal and postnatal program.

I'm a mother of two, and I have a grandson of one and a half years old.

My first born is a nurse and my second born is a student

medicine in her second year.

That's all about me.

I think that's a great position to be in, within the family to have

so many people interested in health.

So thank you for sharing that about yourself and your background.

It sounds like you when planning services, you have to consider lots

of different cultures and backgrounds with the, I think you called it

a porous border, is that correct?

Yes.

We border with Somalia and Somalia remember from 1991, they

never had a stable government.

We host the largest refugee camp in Garissa county, which is called Dadaab

I think you have heard, so we have many different populations in the refugee

setup which we serve as a county.

Thank you very much.

And just before we move on, could you tell me within the refugee campus,

what are some of the things you have to consider when you're thinking about

providing services to that population?

Normally those, the refugees are under the UNHCR support, but

there are three camps normally one is managed by MSF, another one is

managed by Kenya red cross, and the other one is managed by IRC.

They report to us, we train them when we are training our healthcare workers.

We do support provision and when we are doing any programs, we normally

include them in all our activities.

But by and large, it's not the government of Kenya which supports

them, they're supported by the UN and those specific implementing agencies.

But we have a role in their, in the management of maternal newborn

health they're contributing to our maternal newborn indicators.

Thanks very much.

Uh, thanks, Fatima.

It sounds like you are, uh, kind of dealing with lots of

different stakeholders and lots of different factors.

So I look forward to hearing about that but, um, Amina over to you.

Could you tell us a bit about yourself, where you are and a little

bit of your background, please.

Thank you.

Kim my name is Amina Anyango Baraka a nurse midwife working in Vihiga county

referral hospital in Vihiga county.

I'm a principal nursing officer and, uh, currently I am the

nursing director of the hospital.

I have been in service for the last 28 years and, uh, serving in various

capacities as MOH at one time and then as a service provider, as I

began my service, I've also been involved in, uh, reproductive health.

I've done higher diploma in reproductive health, apart from my, uh, bachelor's

degree in nursing and currently doing masters in midwifery at the Moro.

And then I have been working in the area of RMNH.

I would like to clarify MOH.

Uh, we normally use it here in Kenya ministry of health and RMNCH is

productive maternal and newborn health.

For almost a period over 15 to 18 years, I've been a trainer at

the decentralized training center, uh, for reproductive health training

at Kakamega county referral hospital.

Before I moved back to Vihiga, uh, in their program, I've

been a, I I'm a master trainer.

I am a mentor and, uh, I am also a supervisor in the facility of the,

uh, reproductive health services and nursing as a forest Kenyans training

system is, uh, um, designed, mostly nurses are also trained in midwifery and

therefore I double in both, uh, serving the nursing fraternity and also, uh, the

midwifery fraternity in the hospital.

We have been actively engaged in terms of mobilization with the stakeholder

forums to source for funding to support reproductive health services.

Also as staff progression and or training in terms of, uh, ensuring that their

skills and knowledge is kept up to date and also, uh, development of, uh,

standard operating procedures for the facility and also the implementation

of the guidelines that are developed at the county and the national level to

ensure that we adhere to the standards and the expectation of WHO as well.

Uh, basically I'm a mother of three, two daughters and one son, uh,

none of them has given me Mjukuu or a grandchild for that matter.

I have a first born who is an engineer, a girl she's based

at the audit, uh, in Nairobi.

I have a son who is a lawyer, 28 years old.

And my last born is in form 4 four the [school name].

Thank you very much.

It sounds like you have a very multidisciplinary household.

Um so that sounds also very useful.

Could you tell us a little bit more about the stakeholder forum?

In Kenya, we have quite a number of interrelated, intersectoral

groups that work together to attain a certain achievement.

So we have quite a number of stakeholders who come together.

We put up our agenda together, sometimes we bring all our resources together and

then we define the direction that we want to take as a county and eventually

as a country in terms of improving our indicators, uh, at the end of the day.

So it's kind of a coordination forum to bring all interested parties

in health, together for decision making.

It sounds like you have a lot of experience in delivering training

and supervision and mentorship, which is wonderful and quite new to our

connecting citizens to science podcast.

Are the communities you work with and the, the patients and the mothers

and the children involved in kind of helping to develop that training

or helping to develop services.

Yes, we do involve the community.

In the community, we have the community strategy and in the community strategy,

we select people who are from those communities whom will give the, basic

trainings on simple matters, primary matters, uh, concerning health.

And, uh, they also act as a bridge between us.

They bring us the information from the community, what the community

are going through, what are some of the things they're experiencing

that are related to health?

We therefore go down and investigate if they bring us issues.

And then we also give them feedback on how we plan to respond to their issues.

Uh, we also do exit interviews to our clients at certain points, so

that they tell us, what is the feel?

How do they perceive the services that we do offer to them?

Uh, we also have in those forums, we also invite.

Uh, people, uh, their community own resource persons, the people they think

can assist them in making decisions.

So in those forums they're able to share with us, what are some

of the difficulties they have in terms of health service delivery.

And we are able to, uh, come up with the plans and implement whatever

strategy that can assist them in terms of alleviating their problems.

And just in terms of where your situated, what is

the population like there?

So in Vihiga county, we have a population of about 600,000

people with a population density of about 1200 per square kilometer.

That means it is a very densely populated environment and, the latest health

indicator survey shows that we have a maternal mortality of about 49 women

per 100,000 births, most of our maternal mortalities are within the postpartum

period, but we are still not able to reach these women in the critical time, the four

weeks, the six weeks and moving forward.

Uh, you find because of the population density, uh, the issues

of health problems still remains a very big challenge to this county

So it sounds like we have two very different context here where you are

Amina, it sounds very urban, um, with many different challenges and, and Fatima, you,

you have the border issues there as well.

So just, uh, quickly before we move on Fatima, is there any other considerations

you have to think about when trying to get the views of the communities you

work with so that they can inform service delivery or be involved in research?

Uh, thank you very much in our county, what we use basically the

community strategy we have Village health committees and the village health

workers, community health workers, and village health Workers, VHC then

on top of that in our county, we use religious leaders because most of the

mothers, sometimes they believe more when the religious leader says the

importance of delivering in a hospital.

They take more from the religious sector than us.

However, in every 10 household, we have a community health extension worker.

They create demand for this mothers to attend anenatal care, skilled

delivery and postnatal care.

However, still our numbers are low because majority of the mothers are in the rural

area because they have animals, they look for pasture and water and more.

So our land is dry land.

We don't have rain all the time.

We are in a drought season most of the year.

So majority of our communities are in the hard to reach area.

We normally do an integrated outreach services whereby you do immunization

antenatal, postnatal care and sometimes we have designed a mobile clinics

whereby uh, there were some vehicles where they spend in a, a unit or

a village for some weeks, and even some mothers deliver inside those.

We have them beyond zero vehicle, which is, which runs like a mobile clinic.

We make at least most of our communities to get services.

However, still we are not at the standard where we can say we can

reach everyone in this county.

I think that's really important for us to understand moving forward

in the episode, I'll hand over to Lucy now to explore the program that

you're working on right now to try to improve both quality and reach of

services from mother and children.

When you look at what we are trying to do this global funded

program, the quality improvement of integrated HIV, TB, and malaria

services into antenatal and postnatal care, I think the key focus of this

project is the capacity strengthening.

So what has the project introduced to address some of those gaps?

We are trying to work on the, uh, human resource capacity.

There have been a training on the master trainer.

Then the mentorship program so that we have mentors in the various

facilities where we work that are able to continually update the skills

of the other service providers.

So that even when we get other providers leaving, the team that is remaining

behind already has the, have the skill and knowledge that is required for

the continuity and sustainability of the services that are there going on.

So there has been a support on the postnatal care and

antenatal care mentorship using the participatory approach.

The program has been able to support us with the, the humanistic

models that we require for that participatory approach, and also

supported us in the training itself.

Every two weeks at minimum sessions of mentorship with the providers

in each department, so you raise the areas of concern that they

think we need to talk about again.

So project also supports evidence generation to support the

scale up of intervention packages.

Everything has come back to the improving of maternal and newborn

health is through the mentorship and the skills that, where they practice

in their own facilities after training.

Thank you, Fatma, just for the sake of Garissa because of your

different contextual landscape being nomadic , facilities being very far apart.

How do you see this program and the interventions of mentorship the

equipment that is there, how does it help that mobile population?

By the way, this is the way to go, because when you have one or two

staffs in one of the farthest corner or of the county, every time you cannot be

calling for this guy or this nurse to be coming for a class based training.

In Garissa we have a pool of mentors across cutting from the county

level and the county referral hospital and the subcounty level.

So, what we are anticipating is at least we do rotational.

We go to them at their facilities, not calling them at the, at

the headquarter level, whereby service delivery will be disrupt.

So our plan is at least to make a rotational basis where the mentors can

go around in the far flank facilities and the capacity build our staffs,

mentoring them and on job training.

That one will sustain better than with withdraw that staff from the

facility, where are he or she's working.

Would you say there's something different with this program

compared to how you've been doing other programming work, is there

anything different in your counties?

The other programs approach were not doing this detailed, uh, mentorship

supports, but, uh, with LSTM and this global fund program what we have is

we have cross cutting, uh, energy.

The goodness with this program of ours is we have a scheduled, a program that,

uh, topics where our healthcare workers, they have their scheduled, like this

week in that date of that week in Garissa county referral, where we are doing a

mentorship on the newborn Rosa station.

In another facility, we have a, a mentorship.

The use of magnesium sulphate so this one is a continuous one

compared to the other other partners.

What we do with them is maybe after one month or after three months where we,

we come a quarter, then we say, what have we achieved and what we have not.

But the goodness with this one is consistent.

And where we see there's a facility or a subcounty, which is

silent all the way from LSTM, uh, technical assistant at the Nairobi.

They tell us Fatma, what is happening with that facility?

Then I, I, I, I crosscheck with the facility, what is happening.

So sometimes the, when the workload is, is too much, they might forget the

scheduled mentourship which was planned.

So I see this one is like, uh, we are focused on a daily basis if I say.

Just to add on what Fatma say, the process has given us the opportunity

now to drive the agenda forward.

It is basically we are the trainers.

We are the mentors.

This approach, it is very flexible.

We are able to look at ourself as a county or as a subcounty or as a facility.

What are the appropriate, times for us and what is our key need for this

time that we want to address in this process of training and mentorship

or on job training for our ourselves.

So this to me will.

Enhance sustainability and we'll also demystified the thinking that

people who go for training, they are able are the people to carry the, the

knowledge and the people to implement.

So all of us, we become knowledgeable in various aspects.

If you are trained through mentorship, then you should also be able to

train others through mentorship, as opposed to the previous school of

thought then again, uh, the engagement with our county government again now

creates that feeling that they also need to embed this in our budgets.

So that in case the equipment that was do supported by a program or by a partner is

worn out, then we need to have in our work plans, a system that is able to replenish

the same so that we don't stall because a partner has not come in to support us.

I think it's really the program is, uh, from your explanation is really

coming out to, you mentioned about interventions of this program, how will

these interventions benefit the health service providers, the communities

and also the policy makers, how will those interventions benefit them?

Okay.

The benefits to the healthcare provider is this healthcare provider now will have

self esteemed since he or she has been trained, she has been doing mentorship

and somebody has been supervising her.

This healthcare will worker will have confidence in the management of maternal,

newborn, postnatal and antenatal care and HIV and in the event he has,

or he, or she has some doubts, they normally consult the mentors or ourself.

The community also, they will see the mothers have been managed well, because

if a mother has gone to a health facility and she has complained of headache

and some signs of high blood pressure.

If this healthcare worker has not been mentored or trained on the signs and

the, or signs and symptoms and the management of eclampsia, uh, he, or

she might say the mother has malaria or any other thing, this mother might

be mismanaged and goes back home.

But this is the healthcare worker whom, who, whom have been trained and

capacity built on the management of a patient with, uh, a eclampsia or

preeclampsia he or she will manage.

Now we will have a reduced number of maternal complications and

in the long run, it'll improve maternal quality care and reduce

maternal mortality at our county level and our health facility level.

And now the community will see at least that facility or that county, uh, at least

the staffs are, are competent in managing maternal and newborn complications.

And in the long run this now reproductive maternal and, uh,

newborn indicators in the country.

Do you have a challenge you anticipate when implementing this

program at capacity building level for healthcare providers, maybe even

at community level, maybe at policy level, are there anticipated challenges?

I think for us, the challenge is basically I would look at competing tasks

because, uh, which still goes back to the, uh, inadequate number of human resource.

Sometimes when you want to engage, you find there is so much,

and the clientele is that big.

So sometimes you don't really get enough time to really engage with the mentees

you did expect, that can be a challenge.

Then I am just also seeing a scenario where the turnover might

affect the management as well.

And sometimes depending on the, uh, area of interest, then the management that is

brought in is not really in support and issues like the political environment.

Again, uh, you know, some of these posting and staff changes

are also politically instigated.

So those can also be a, a problem in terms of ensuring sustainability

for, for the program, uh, where the equipments that we use are worn out again.

That can probably also because, uh, the participatory approach requires

some of the few equipments that we use for demonstration before

we go to the actual patients.

But I think all in all, uh, With the proper engagement and continuous support

supervision for the mentorship as well.

And the management engagement, we should be able to, uh, continue.

Fatma for those, uh, aspect, um, uh, just came to my mind in

terms of the challenges that you're mentioning, staff turnover, you

know, the issues of overload.

This program is covering just a fraction of, the facilities, is

there a, a possibility that through, you know, technical working groups,

facilities that are not directly being supported can utilize the

staff to mentor other facilities?

we have that provision and that's why in the mentorship we have the

county coordinators are also part of us.

And then when they're part of us, they're able to identify the facilities

that really need the support of the mentors and organize with the

sub county coordinators and then pick a mentor for those facilities.

So that is already inbuilt and it is possible.

Uh, and it is actually doable and it's we have actually in Vihiga uh, that is part

of, uh, an area that we are exploring and we have started working on this.

Thank you very much.

I think I would want to stop there.

I'll give it back to Kims to the next phase over to you Kim.

Thank you very much, Lucy.

So we've heard a lot about the training that's being done and

the mentorship and how the program is going, which is wonderful.

From your extended experience a lot of people listening to this podcast

are researchers and wanna know how they can work with communities better.

Whether that community is the nursing population or human resources for health.

What advice would you give them?

First of all to use the entry points to the county level and, uh, get

the county management, uh, involvement, don't just go to the facilities without

the county agreement, have an agreement with the county so the advice I give them

is pass to have the leadership meeting, then give their, their area of interest.

They can say, we want to work in that area or that area then before doing anything

else, uh, they sign an MOU ,that me as an organization, we are going to do B, C, D,

then the county should do a one to three.

Then maybe the first thing to start with after they signing the memorandum

of understanding is to do a baseline assessment to those selected or the

facilities that they want to work on and know how that facility is performing.

After getting the go ahead from the county level, at the county level, we

have the person in charge of the community health units, community health strategy.

Then we can scale down to the community level, explain to them, in the community

strategy, we have open days, we are called community dialogue days.

We can call for the community, like in a meeting outside, it can be in a school

and at three, or even in the health facility that we are this organization.

We want to support the implementation of quality of improvement in antenatal

and healthcare and HIV program.

Uh, so that you also know the demand of the community direct from the their mouth.

Now this one will be the partners and the ministry of health together.

We can meet the community and get the words from their own mouth, we have

common understanding and the deliberations

So just building on that, any piece pieces of advice, when you're

speaking with communities that can really help to understand their experience.

Communication, you need to really understand one thing, which is key is

their academic and, uh, educational background is also very important because

language barrier can be a very big problem and, uh, if you want to reach them and

you are not able to address them in a language that they're able to understand,

it can be an impediment in that direction.

Sometimes like cosmetics, we may end up talking things that are

only understood by ourselves.

So we must be able to break our, uh, the issues into simple

local people's understanding.

Culture is another issue.

Uh, if you are the culture you are coming from a background that uh, maybe

consider certain words, uh, as very normal, you go to another community.

We have several, several dialects, uh, Vihiga is predominantly

Luhya, but in Vihiga alone, we are having about four dialects.

So, and one word dialect may have a word that means an

obscenity in another, uh, dialect.

So you really need to understand the language and also the

culture and connotation.

There are those groups that will even want, uh, to carry like their

placenta back, home and bury.

So they, they are quite a number of cultural issues that we need to understand

as we come to, to engage with them.

You go to other communities, they don't really expect women to, to

address certain issues with men.

So those are things that we may need to also consider as, uh,

we want to engage with them.

And, and, uh, more importantly, the male involvement in this community

is very key because they're the holders of the economy of the family.

So again, uh, if you don't engage the man, most of the times and more, or

so the, the mothers in law also have a say, then sometimes if you address

the, the women who are still in reproductive age alone, then you are

not able to really get to the problems.

Thank you very much for the, that advice really important is, uh,

considering language, education, culture, beliefs, and, uh, different

power dynamics in the families as well.

So thank you for that.

And that's a wonderful place to end this episode.

So thank you very much to our guests for joining us and sharing their

wonderful insight and experience.

Thank you to Lucy, our co-host who has been great as always.

And, uh, finally thank you to our listeners.

Once again, please do light share, rate and subscribe so we

can continue to learn from these valuable insights across the world.

Thank you listeners, and, uh, see you next time.

Goodbye everyone.