In Lesotho, A New Level of Accompaniment

Masechaba Molefsame was well into her third trimester of pregnancy when she entered a rural health center in southwestern Lesotho, not far from the South African border, in April.

Molefsame made the trek in hopes of delivering her child in a safe and clean environment. But until that point, the Mohalinyane Health Center had never delivered a baby. Inadequate equipment and supplies, including food for patients, insufficiently trained staff, and subpar infrastructure had deterred women from delivering there.

Molefsame, however, had heard that her country’s Ministry of Health was working on a transformative national initiative to ensure that all health centers throughout the small, mountainous country are ready to deliver high-quality care to women and children—from an expectant mother’s first antenatal visit through her child’s vaccinations and beyond. As part of the reform, Partners In Health/Lesotho clinicians were working diligently to train staff and improve infrastructure at the Mohalinyane Health Center, including the on-site maternal waiting home, in the weeks before Molefsame walked in the door.

Now it was time to see if the health center was ready to deliver.

Improving outcomes by working in the community

Lesotho is struggling to address some of the most pressing health challenges in the world. In recent years, the country has lost ground on important measures of health. Between 2000 and 2010, maternal mortality nearly tripled, from 419 to 1,155 per 100,000 live births. In the same period, the child mortality rate climbed from 110 to 119 per 100,000 live births.  Meanwhile, nearly one in four people in the country has HIV—the prevalence of the virus has held steady at 23.6 percent since 2004. This HIV crisis has helped fuel a nationwide tuberculosis epidemic—Lesotho is one of few sub-Saharan countries where TB incidence has climbed by more than 10 percent over the past two decades.

Between 2000 and 2010, maternal mortality nearly tripled, from 419 to 1,155 per 100,000 live births.

In 2006, the government of Lesotho invited PIH to help tackle some of these challenges, beginning by supporting the Ministry of Health in a handful of rural health centers. Following the PIH approach, the goal was to design and implement a comprehensive program that addressed the social determinants of illness, such as poverty, hunger, and poor work conditions, that prioritized equity, and expanded access to care for vulnerable patients in a small number of districts. PIH/L’s initial strategy focused on bringing the health system to the people who needed it by improving services at hard-to-reach mountain clinics. Village health workers (VHWs) were vital in this strategy, forging trusting relationships between patients and clinicians and overcoming cultural and economic barriers that impeded access to care.

As the years went on, PIH/L’s ambitions expanded. In 2009, in the village of Bobete, the organization piloted its Maternal Mortality Reduction Program (MMRP)—a truly integrated approach to maternal care that weaves comprehensive accompaniment and active case finding with antenatal care, HIV testing and counseling, family planning, and an array of other clinical services. Identifying patients as early as possible allows PIH/L to help prevent pregnancy-related complications, mother-to-child transmission of HIV, and other problems that claim the lives of mothers every day in Lesotho.

A cornerstone of the program is maternal waiting homes. Many pregnant women walk hours on treacherous mountain paths, sometimes in the snow, to reach clinics. Doing so while in labor could spell disaster—or keep women from trying to reach a facility at all. Maternal waiting homes provide a comfortable space for soon-to-be moms so that when labor begins, they are only a few feet from trained medical staff and a well-stocked health facility.  

Addressing maternal mortality is a gate for us to address all aspects of women’s health.

“We improved infrastructure, we treated patients with dignity, we addressed transportation challenges and we made sure expectant mothers were accompanied to the clinics before their due date,” PIH/L Director Dr. Hind Satti said. “Focusing on these issues and properly training staff made a significant difference. Addressing maternal mortality is a gate for us to address all aspects of women’s health—empowering women, which impacts their children’s and families’ health.”

The program was a major success. The year before the program launched, only 46 women delivered at Bobete Health Center. The year after, more than 215 women delivered at the facility. PIH/L expanded the program to seven different health centers, and each health center saw noticeable jumps in the number of facility-based deliveries. The program also yielded significant improvements in the number of women being tested for HIV, child vaccination rates, TB detection efforts, and family planning.

PIH/L’s approach and successes caught the attention of the country’s leaders.

The question: How did PIH/L achieve substantial, sustainable progress toward key health indicators in some of the most rugged parts of Lesotho, while the rest of the country was losing ground on the same measures? Could Lesotho adopt the PIH/L model at a national level?

A new level of accompaniment

The first "reform baby" and her mother, at the Mohalinyane Health Center in Mohales Hoek District, Lesotho. (Photo by Likhapha Ntlamelle / Partners In Health)

In late 2013, PIH/L and the Ministry of Health began collaborating on a plan to scale up the maternal mortality program so that all health clinics would be able to deliver a comparable level of care to what PIH/L had been delivering for years. While PIH/L will be intimately involved in training staff and providing technical assistance, the health centers will remain under the purview of the Ministry of Health. The national reform will occur in three phases over five years.

The first phase, happening now, focuses on bolstering infrastructure, improving the supply chain, designing monitoring and evaluation systems, training staff, and building a system to support a cadre of VHWs who will be vital to earning the trust of communities. The first phase focuses on four districts.

The second phase will bring the reform to the country’s six remaining districts, rigorously document outcomes from phase one, and disseminate those findings so the program can be modified as needed.

The third phase, expected to occur in 2018, will focus on evaluating and analyzing the impact of the program. Thorough documentation may prove invaluable for other poor countries struggling with maternal and child mortality.

“This program will show that it is possible to deliver better services for patients and better outcomes at a lower cost when you work with, and work in, the communities,” Satti said.

In the first few months of the reform, nearly 2,000 VHWs have been trained, and a new national VHW policy has been approved. The team has conducted more than 50 baseline assessments and trained dozens of nurses.

Among those nurses is Justinah Kuotso at the Mohalinyane Health Center, one of the first health centers to undergo the reform. It was Kuotso who accompanied Masechaba Molefsame when she arrived at the clinic in late April. After a week and a half in the maternal waiting home, Molefsame went into labor. Staff worked together seamlessly to deliver a healthy baby girl—the first child delivered under the national reform.

In Lesotho, it is tradition not to name a baby until after the umbilical cord has fallen off. In the days after the delivery, staff at the health center affectionately dubbed the newborn “Reform Baby.” In the following weeks, several more babies, including a set of twins, were safely delivered at clinics throughout the four districts where the reform began.

In Lesotho, the challenges are still immense, and resources still limited. But with a generation of “Reform Babies” on the way, Lesotho has reason to hope for a bright and healthy future.