Interview: Antonella Leakono, Nurse at Longewan Dispensary

Antonella Leakono is a nurse at Longewan Dispensary. Sarah Manyeki (M&E Officer for the project in Kenya) spoke to her about the changes she has noticed since the Community Health Workers (CHWs) were trained, and some of the challenges she faces in her work at the dispensary.

When was the community health unit formed?

The unit was launched on 7 December 2013 although the CHWs had started being functional in August 2013.

In your opinion, how many CHWs are active?

Out of the 25 CHWs, only eight of them are active. They are active in terms of referrals, identifying and referring immunisation defaulters, bringing expectant mothers to the clinic and following up on the referrals. Other services that they offer include escorting women to the facility to seek family planning services and growth monitoring for children.

What changes have you noted since the CHWs started doing their work?

Antonella said that hospital delivery before the CHWs started doing their work was at zero but currently, an average of seven women are delivering at the facility per month. The number of women seeking antenatal care services has also increased from 15 to 45 per month, children going to the clinic for growth monitoring has also increased from 0 to 100 and those seeking family planning services have increased from 10 to 40.

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Interview: Evalyne Ngise, Nurse at Arjijo Dispensary

Evalyne Ngise works at the Arjijo Dispensary, she was deployed there in 2010. Sarah Manyeki (M&E Officer for the project in Kenya) had a short interview with her on the 26 June 2014

How many CHWs were trained and of those how many are active?

“The only person who can answer that question precisely is the CHEW, but I think 25 CHWs were trained. Out of this number, I have only noted 1 CHW who is outstandingly active and her name is Mama Faith (Rosemary)”

Asked why she said that the CHW is outstandingly active, she based it on the number of referrals by the CHW and the follow up calls that she makes.

What changes have you noted since the CHWs were trained?

“Since the CHWs were trained, there has been a big improvement. The number of outpatients seeking services has increased from 40 people per month to a minimum of 98 people and an average of over 100. Number of women seeking antenatal services has increased from 1-2 per month to 9-10 per month. The CHWs have also been trained on assessing malnutrition (using the MUAC provided by the MoH) and are therefore referring the children to the facility. They are also following up on immunization and once they identify that a child does not have a scar, then they refer them to the clinic, so far we have received 2 from Katunga village this month and another one who is scheduled to come next week from Sepeyo village (they can not immunize all the time, have scheduled immunization days to avoid wastage)”

“It is now more common to see men coming to the clinic to request for a HIV test. In the last month, we witnessed an upsurge in the number of women seeking Family Planning services. Very many women had a Norplant implanted on them. In the past, there were misconceptions on Family Planning. Many women however prefer depo because it has privacy and not many husbands will allow their wives to practice Family Planning in this community although some men have embraced the change.”

On skilled birth deliveries she said “from 2010 when I was deployed here to late last year, only 2 deliveries had been conducted at the dispensary. Currently, I conduct between 2-3 deliveries per month” She however said that she does not encourage women to give birth at the dispensary. “I prefer visiting the women at the comfort of their homes to assist them from there because the facility’s maternity is not well equipped, there is no delivery bed, beddings and the beds there are not in good shape” She was however quick to note that the County Government of Laikipia has pledged to assist the dispensary with Kshs. 240,000 from their development kitty and this money will be used to equip maternity. “I have ordered for a delivery bed, 4 beds, blankets and pipes for installing piped water system inside the dispensary”. This will be a great relieve for her and for the women. I came to learn later that she had been called to assist 4 more women during the month but could not attend them due to distance and lack of transportation.

According to Evalyne, the community is now more aware of the health issues, “it is now a common occurrence for community members to walk in to the clinic and request for water treatment tablets” she noted. This she attributed to the sessions being offered by CHWs.

What are the challenges experienced?

Despite all these there are a few challenges and the major one is staffing. “As you must have noted, I work alone at this dispensary. Sometimes I am invited for workshops or I have to go out for training which can be as long as fourteen days and there is none to relieve me. This is very disappointed for those community members seeking services during my absence, some walk as far as from Lariokorok Village only to find there is no one and then walk back. I am forced to work through out without having off days and this is very tedious.” She said. Lariokorok after enquiry, I learnt that its 24 kilometers to and fro.

“Another challenge is that the CHWs have no kits. This means that even for the simple cases like headaches, they (CHWs) have to refer” Evalyne added. She felt that if the CHWs are provided with kits, then her workload could be reduced. She also said that the facility is not well equipped. “we have no laboratory and this means that even the simplest cases like the ANC test profiles have to be referred to Doldol Hospital, most of the clients end up not going (to Doldol for tests) because they do not find it as an emergency”, she said.

Referrals are another headache because of the transportation issues. Asked about the sub county ambulance, “Most of the time the ambulance is not available. Most of the time we are forced to transport the referral cases using motorbikes which is very uncomfortable for me and for the patients,” she said.

Recommendations and closing remarks

Asked on what she would recommend, she was fast to point out that there is need for more staff, equip the maternity which is on the pipeline and provide the CHWs with kits. She also highlighted the issue of a gas cylinder used to refrigerates the immunization drugs. “We only have one cylinder in this facility. We are therefore forced to skip immunizations sometimes when the gas is finished and have to wait for an extra cylinder from the Doldol sub county Hospital” She said that a second cylinder would be of great help.

On her closing remarks, she said that “the CHWs are doing a commendable job in referring cases and making up follow up calls, enquiring whether the nurse is available before referring and consulting on what to do for the simple cases as well as finding out the clinic and immunization days on behalf of the community” She however said that the CHWs need to do the household visits more often especially to the women with small children to identify cases of malnutrition.

Small steps generate bigger changes

By Loretta Pilla, Anglican Overseas Aid

The Road Less Travelled (TRLT) is an integrated maternal and child health and community development project working with nomadic pastoralist communities in Kenya and Ethiopia. The project is led by Anglican Overseas Aid in Kenya, partnering with the Mother’s Union of the Anglican Church of Kenya and the Maasai and Samburu nomadic pastoralist communities in Laikipia and Samburu counties. TRLT’s holistic approach focuses on improving core maternal and child health (MCH) outcomes, and applies methods to address education and literacy, as well as improve access to water, food security, and sustainable livelihoods. The desire to achieve health equity through the empowerment of women underpins all activity. Three years on it’s exciting to see people’s lives changing for the better in Longewan Ranch in Samburu County, especially for women.

Longewan Dispensary, Samburu county.  Image: Loretta Pilla/AOA, 2014

Longewan Dispensary, Samburu county.
Image: Loretta Pilla/AOA, 2014

Understanding women’s empowerment

Transforming women’s lives in a patriarchal environment is a difficult but essential challenge for TRLT. Empowerment is not a simple task; it is a multi-faceted process. Adequate support needs to be in place before starting the process. A sense of belonging and increased self-esteem are factors that contribute to a woman’s status in community. Her respect subsequently grows within families, communities and the broader society. TRLT, through its partnerships, provides the necessary support, information, resources, and creativity to allow women to find solutions to their own problems.

Challenges for women’s health

Initiating the process to improve women’s authority, one cannot ignore the cultural, social and environmental milieu which can inhibit progress. In Samburu, women traditionally birth at home away from qualified nurses. There are many constraints to attending clinics, including lack of nurses, distance, refusal by husbands, and women’s own beliefs that delivering at a clinic is a sign of cowardice.

Antonella Leakono has been the only nursing officer in charge of Longewan Dispensary for five years. As a Samburu woman, she recognises the need to invest in community health programs to achieve better health over the long haul for the people of her community.

“The biggest child health issues in this area are malnutrition, pneumonia, and diarrhea,” Antonella explains. “For women of reproductive age, it is anemia and infections related to giving birth at home.”

Causes of infections can include the use of unsterilised instruments during the delivery such as a knife for cutting the umbilical cord. Raising awareness on MCH remains a challenge, an almost impossible task for one Ministry of Health staff member, like Antonella, to tackle on her own.

Providing support: Instigating change

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

At the frontline of change are community health workers (CHWs) who have been trained collaboratively by TRLT and the Ministry of Health to provide frontline health services. Although the 18 Longewan CHWs do not have the same qualifications of a community health nurse, these volunteers spend approximately six hours per day, three days per week, visiting and caring for families, whilst also looking after their own. In one month, the 18 CHWs visit up to 248 households, and provided community members with pain killers, vitamins such as zinc, and oral rehydration solutions.

Carolin, the TRLT link person who has been trained as a CHW, explains that: “We educate women on importance of visiting clinics and on immunisations. Through trainings in the area of maternal neonatal child health, nutrition and first aid, we have the skills to identify danger signs such as bleeding during pregnancies, if a child is malnourished or if a child is not breastfeeding properly”. The work of the CHWs make significant contributions across many of TRLT’s goals in improving women’s health through women’s empowerment in the region. Yet their impact is far greater than just basic health services. They have an effect on community socio-economic standards generally, along with influencing the esteem with which women are regarded.

Empowerment through education and training

In Samburu, only 15% of women can read and write in Maa and/or Swahili.  Hosea and Cecilia are two CHWs in Longewan who have started to facilitate free adult literacy and numeracy classes for men and women. Currently, 24 women and three men attend the classes. Literacy plays an important role in determining women’s health, and their ability to seek healthcare. Improved literacy levels expand women’s access to knowledge, economic resources, and political power.

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.  Image: Loretta Pilla/AOA, 2014

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.
Image: Loretta Pilla/AOA, 2014

TRLT, in partnership with Equity Bank, have organised business training and financial management classes to improve men and women’s ability to save and better manage their assets. Poverty is intrinsically linked with poor health as it forces people to live in inadequate environments. By empowering women with the skills to manage their finances, it makes them less dependent on their husbands, and more likely to financially invest in their family’s health.

Identifying child malnutrition and anemia in pregnant women as a need, CHWs have also been involved in broadening the diet of community members through kitchen garden awareness training conducted in partnership with the Department of Agriculture. TRLT’s seed bank initiative encourages community members to produce their own food, whilst supporting others in their community. TRLT provides start up seeds from which community members grow their own crops. Once the crop has gone to seed, they are expected to keep a proportion for their next harvest, whilst distributing the remaining to others who can then start their own garden.

Saving Lives, Healthy Children, Improved Economy

In combination the CHW activities have an impact far greater than each individual task. Encouraging women to go to clinics for checks and to birth reduces risk of infection and even mortality. Improving diet, and working with the Ministry of Health on vaccination campaigns, leads to healthier children more resistant to debilitating diseases. Literacy education increases confidence and the ability to make and apply decisions that affect mothers’ lives. Starting-up small-scale economic activities generates disposable income to be spent on improving family well being. Along with reducing demand, and associated costs, on curative health services, the total effect contributes to the social health and well being, improves productivity adding to societal wealth, and accordingly strengthen the entire community.

The road ahead: Working together with the community health workers

The cohesion and commitment of these CHWs is palpable. They are being seen as community leaders, and regarded by their peers, both male and female, as equals because of the competencies and authority they provide. Moreover, the carry on effects of their work – empowering women and their communities through an integrated maternal and child health approach – is invaluable.

“People want to live a good life, so they see the value of our work in the community,” Cecilia explains. “The level of knowledge in the community is slowly increasing. People are beginning to change.”

 

If these hands could talk

I remember gazing at the hands of a traditional birth attendant in pastoralist Laikipia, Kenya, and wondering about the stories they might hold. How many newborns had these hands supported into the world? What challenges had been faced by the women they helped through childbirth, in their remote rural homes far from any health clinic? Beneath the rough and wrinkled surface, how much loss had they absorbed through these experiences?

The hands of a traditional birth attendant in Laikipia County, Kenya.  Image: Hannah Ford / AVI

The hands of a traditional birth attendant in Laikipia County, Kenya. Image: Hannah Ford / AVI

Sub-Saharan Africa has the highest maternal mortality rate, bearing the burden of more than 50 per cent of the world’s maternal deaths. One in 39 women in this region faces the risk of dying in childbirth in their lifetime.

Yet less than half of all mothers in sub-Saharan Africa have the support of a trained midwife, nurse or doctor during childbirth. Even fewer mothers from the marginalised nomadic pastoralist communities of Kenya and Ethiopia have access to skilled birth attendants. While evidence has shown that access to skilled care during pregnancy, birth and post-delivery, is key to saving lives, many women don’t have an option.

For the past two years, I’ve had the privilege of working on The Road Less Travelled project and coordinating this blog. I have learnt so much during this time. As I reflect on my experiences, what stands out to me most is the strength and resilience of the pastoralist communities at the heart of the project – and especially that of the mothers. They want what all women want for their children: the chance to survive and thrive.

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Hospital deliveries in Afambo: a success story

Abdella Isse, Monitoring & Evaluation Coordinator for the Afar Pastoralist Development Association, sat down with mother of six, Kulsuma Ahmed, to talk about her experiences of giving birth in Afambo in the Afar region of Ethiopia.

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Many pastoralist women such as Kulsuma Ahmed, pictured above, from Afambo in the Afar region of Ethiopia, give birth at home. It is the cultural norm within the nomadic Afar community, despite not being the safest delivery setting for mothers and their newborns.

In the portable dome-shaped huts in which nomadic families live and women give birth, sanitation and hygiene are constant issues, water is not always readily available, and mothers are a long way from skilled medical support if they run into complications. Communities often live 30-40 kilometres from the nearest road.

Traditional birth attendants (TBAs) usually assist women during pregnancy and childbirth due to challenges of distance and lack of health facilities. The percentage of deliveries assisted by qualified health personnel in the Afar region is just 6.2 percent – compared to the national average of 18.4 percent.1

The Afar Pastoralist Development Association (APDA), Anglican Overseas Aid’s partner in The Road Less Travelled project, has been working with pastoralist women to educate the community about the benefits of attending a health facility at the time of birth. This education is delivered to the pastoralist women through the organisation’s Women’s Extension Workers and Health Extension Workers.

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Photo exhibition: Motherhood Matters

Image: Kate Holt / Anglican Overseas Aid

Image: Kate Holt / Anglican Overseas Aid

Take a journey along the road to safe motherhood in sub-Saharan Africa with ‘Motherhood Matters’, a stunning exhibition of photographs on display at Federation Square in Melbourne in the lead-up to Mother’s Day in May.

Where: The Atrium at Fed Square
When: 5 – 13 May, 24 hours
Price: Free

Download the exhibition poster and help us spread the word

Gain an insight into the experience of mothers in rural African communities, learn about some of the challenges they face and find out about the vital work being done to improve maternal health in Kenya, Ethiopia, Uganda, Tanzania and Rwanda.

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Mobilising communities in the fight for safe motherhood

Momina sits on the bed in the hut where she will give birth to her third child. The bed is a traditional Afar “oloiyta” made of thatched sticks and slightly raised. She is ready to deliver any day now.

“The baby has been moving around a lot,” Momina says. She is nine months pregnant, and is visited twice a week by a Women’s Extension Worker (WEW) from the Afar Pastoralist Development Association (APDA) – the Ethiopian partner of Anglican Overseas Aid in The Road Less Travelled project.

Momina is nine months pregnant and waiting to give birth at home, with the support of a trained traditional birth attendant. Image: Kate Holt / Anglican Overseas Aid

Expectant mother, Momina, is waiting to give birth at home in the remote Afar region of Ethiopia.
Image: Kate Holt / Anglican Overseas Aid

The WEW has monitored Momina throughout her pregnancy, and provided antenatal care. However, this has not always been the case for women giving birth in the Afar region of Ethiopia. In one district surveyed by the project, 66 percent of women reported having received no antenatal care during their most recent pregnancy. (Read more in our Baseline Report).

As a country, Ethiopia has one of the highest ratios of maternal mortality in the world, in 2011 recording 676 maternal deaths for every 100,000 live births.1 For women in the Afar, the risks of injury or death during childbirth are even greater.

Due the remoteness of the Afar pastoralist communities and their nomadic lifestyle, communication, transport and access to health services has in the past been extremely limited or non-existent. There are also significant cultural or attitudinal factors that affect the care mothers receive during pregnancy, delivery and post-delivery.

APDA is improving the chance at life for Afar mothers and their children, by mobilising members of the community in the fight for safe motherhood. With a 20-year history working within the pastoralist setting, the organisation is uniquely positioned to facilitate relief and development activities that are relevant to the community, and implemented by the community.

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Solar power to support safer birthing practices

Safe birthing kits will be delivered to pregnant women in remote communities of Kenya, along with solar lamps which will help during night births and in caring for babies post-delivery. Image: John Simiyu Nasongo

Mothers’ Union is working together with nomadic pastoralist communities in Laikipia and Samburu districts of Kenya to strengthen the birth plans of pregnant women. In consultation with the Ministry of Health, plans are now being considered to distribute safe birthing kits which will give mothers and babies a better chance at safe delivery in remote regions.

The first 200 kits will be distributed to pregnant women in their first trimester, along with instructions for use and the recommendation that it is best to give birth in a clinic or hospital where a skilled birth attendant is on duty. Distribution of the birthing kits will be supported by trained community health workers, whose role will include educating women about safe birthing practices and connecting them to health services in their region.

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