In the small southern African country of Lesotho, about one out of every four adults is HIV positive, and high rates of maternal mortality and morbidity threaten the country’s young mothers. The rough, mountainous terrain and lack of roads exacerbates the situation, preventing many people from easily accessing the medical services needed to curb the epidemics.

To help address these problems, Partners In Health Lesotho (PIHL) is training community health workers, many of whom are traditional birth attendants—local traditional midwives—as Maternal Mortality Reduction Project Assistants (MMRPA). MMRPAs  provide women living in rural mountain villages with access to comprehensive services including HIV testing, counseling, and treatment; methods of preventing HIV transmission from mother-to-child; and prenatal (prebirth), delivery, and general post-birth health care; immunizations; as well as general reproductive health services.

In May 2009, PIHL, in partnership with the Elton John AIDS Foundation, began to pilot a Maternal Mortality Reduction Project in a catchment area that includes 71 villages around PIHL’s health center in Bobete. PIHL hired and trained 100 local women to serve as a link between the clinic and pregnant women—who are literally their neighbors. The MMRPSs locate and accompany the expectant mothers through their pregnancy and birth to ensure that they have full access to the clinic’s comprehensive services. This includes bringing the women to the clinic to deliver their babies.

Traditional birth attendants are a part of Lesotho’s traditional midwifery community and PIHL seeks not to replace them, but to further their education and employ them in an expanded role as community health workers in the communities of which they are already a part. And as families traditional pay traditional birth attendants for delivering babies, the PIHL program provides a cash incentive for each woman an MMRPA accompanies, replacing the income lost when women choose to deliver at the health center.

In the first year of the program, the MMRPAs completed their training, surveyed their villages, and began to visit pregnant women in their homes. They accompanied pregnant women for 383 first prenatal care visits, 442 follow-up prenatal care visits, and 153 deliveries at the clinic. Clinic deliveries have steadily risen in response to MMRPA outreach, with an average of 15 women per month giving birth at Bobete health center in 2010.

The advantages of delivering in the Bobete clinic are significant, particularly in preventing the transmission of HIV during childbirth. Delivering with the assistance of a skilled nurse decreases the risk of maternal mortality and morbidity, and infants with health issues can receive immediate medical attention.


A 2010 training for Maternal Mortality Reduction Project Assistants in Nohana, Lesotho.


Participants of a recent training for Maternal Mortality Reduction Project Assistants in Nohana.

To enable more women to deliver at the health center, PIHL constructed housing near the clinic that can shelter expectant mothers. Rough terrain separating the remote villages from the health center can make the journey virtually impossible for a woman with labor complications, so this waiting house makes it possible for women to make the journey before labor begins.

As an extra incentive, PIHL also provides new mothers who fulfill certain criteria (get tested for HIV, attended at least three prenatal visits, and deliver their baby at the clinic) with a new baby package, which includes clothing (hat and sweater), pins, and a bathtub. During the programs first six months, PIHL distributed 60 new baby packages.

PIHL believes that the accompaniment of the MMRPAs and the general knowledge and care delivered during the prenatal visits will encourage each woman to deliver her baby at the clinic, and that in doing so families in the Bobete catchment area will see a decrease in HIV mother-to-child transmission rates, as well as maternal and infant mortality and morbidity rates. Last fall, a MMRPA training was held in another rural mountain community, Nohana, and the PIHL team has already begun scaling up the program at two additional health centers. The team plans to implement the maternal mortality reduction project at a total of eight rural health facilities. 

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