Community-based delivery of maternal care in conflict-affected areas of eastern Burma: perspectives from lay maternal health workers.

In settings where active conflict, resource scarcity, and logistical constraints prevail, provision of maternal health services within health centers and hospitals is unfeasible and alternative community-based strategies are needed. In eastern Burma, such conditions necessitated implementation of the "Mobile Obstetric Maternal Health Worker" (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. Lay Maternal Health Workers (MHWs) are central to the MOM service delivery model and, because they are accessible to both the communities inside Burma and to outside project managers, they serve as key informants for the project. Their insights can facilitate program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Focus group discussions (n=9), in-depth interviews (n=18), and detailed case studies (n=14) were collected from MHWs during centralized project management meetings in February and October of 2007. Five case studies are presented to characterize and interpret the realities of reproductive health work in a conflict-affected setting. Findings highlight the process of building supportive networks and staff ownership of the MOM project, accessing and gaining community trust and participation to achieve timely delivery of care, and overcoming challenges to manage and appropriately deliver essential health services. They suggest that some emergency obstetric care services that are conventionally delivered only within healthcare settings might be feasible in community or home-based settings when alternatives are not available. This paper provides an opportunity to hear directly from community-based workers in a conflict setting, perspectives seldom documented in the scientific literature. A rights-based approach to service delivery and its suitability in settings where human rights violations are widespread is highlighted.

The MOM Project: delivering maternal health services among internally displaced populations in eastern Burma.

Alternative strategies to increase access to reproductive health services among internally displaced populations are urgently needed. In eastern Burma, continuing conflict and lack of functioning health systems render the emphasis on facility-based delivery with skilled attendants unfeasible. Along the Thailand-Burma border, local organisations have implemented an innovative pilot, the Mobile Obstetric Maternal Health Workers (MOM) Project, establishing a three-tiered collaborative network of community-based reproductive health workers. Health workers from local organisations received practical training in basic emergency obstetric care plus blood transfusion, antenatal care and family planning at a central facility. After returning to their target communities inside Burma, these first-tier maternal health workers trained a second tier of local health workers and a third tier of traditional birth attendants (TBAs) to provide a limited subset of these interventions, depending on their level of training. In this ongoing project, close communication between health workers and TBAs promotes acceptance and coverage of maternity services throughout the community. We describe the rationale, design and implementation of the project and a parallel monitoring plan for evaluation of the project. This innovative obstetric health care delivery strategy may serve as a model for the delivery of other essential health services in this population and for increasing access to care in other conflict settings.