First Delay:
Decision to seek care
Traditional beliefs/cultural norms (belief that deliveries should be conducted in the presence of family elders if a problem was anticipated) Lack of birth preparedness Lack of male/spouse involvement in birth preparedness plans Lack of community's understanding of danger signs during pregnancy and child birth Perceived low quality of care at health facility Challenges in deciding when to seek care
| Increase community demand for MNH services
Community sensitization using safe-motherhood health messages Birth preparedness information given during ANC visits to encourage women and their families to financially plan for health facility use when needed Involvement of men, chiefs, and headmen as “change champions” Provision of pamphlets and education on “danger signs” during pregnancy and childbirth (e.g., postpartum hemorrhage, pre-eclampsia) Engagement of community volunteers and SMAGs to assist with community mobilization to encourage health facility deliveries when needed
| Health messages needed consistency and continuity to have full impact Financial and resource challenges for families and program were reported Overzealous chiefs enforced penalties on families not using health facilities for deliveries to put pressure on them SMAGs needed sustained support systems to continue volunteering and assisting communities
| MOH to increase funding for MNH programs to start with community engagement Government stakeholders to continue collaborations to assist with collective funding for MNH programs Engage Ministry of Chiefs and Traditional Affairs to assist with MNH agenda Deliver health communication messages through radio and community drama programs to raise knowledge and awareness of danger signs and where to seek and use MNH care Provide financial incentives for community volunteers
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Second Delay:
Reaching the health facilities
Distance to health facilities Bad roads and difficulty of access, especially during rainy season Lack of transportation Lack of communication when transportation was needed
| Increase access to high-impact MNH services
Awareness to plan financially for communication and transportation to health facility Government to improve road access and ambulances SMGL program provided boats and ambulances Community assistance from people with vehicles; reimbursements made for fuel Health facility staff assisted with their mobile phones during emergencies SMAGs provided with bicycles to assist women to go to the health facilities Construction of MWHs
| Impassable roads are still a challenge especially in the rainy season Some roads through the game reserves were impassable Vehicle breakdowns and maintenance needs were reported often Mobile phone receptivity due to poor or unavailable network Some SMAGs did not receive bicycles MWHs used for other clinical services when empty
| Continue to engage other government sectors, such as the Ministry of Transport and Communication Program plans to include repair and maintenance of vehicles Plan for training and reimbursement of drivers is imperative for programs Delegate MWHs to SMAGs for maintenance through community cooperatives for sustained use
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Third Delay:
Receiving care at the health facility
| Improvements in quality of MNH services
Improved staff capacity and attitudes through training and supportive supervision Improved infrastructure of labor and operating rooms Hired anesthetist and laboratory technicians Obstetric/gynecologists reimbursed to provide mentoring and supportive supervision to new physicians Nurse/midwives trained, mentored, and supervised in EmONC Refresher courses in procurement/logistics of medicines and equipment Improvement of referral policy and ambulance use Provision of consumable supplies and equipment Supported availability of blood and blood products within reach
| Increased number of patients at health facilities Failure of some equipment due to lack of maintenance and poor electricity supply Supervision and placement of nurses and midwives not hired through the MOH became a challenge Sustainability challenge to continue with staff salaries of hired midwives
| Availability of policy and guidelines of MNH care Adequate human resources Improved infrastructure and maintenance as per demand Training and supportive supervision for EmONC and mother-friendly services Plan for continued procurement and repair of equipment Referral monitoring and counter-referrals
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