Evaluating the Missed Opportunities in Maternal and Infant Health (MOMI) project in Burkina Faso, Kenya, Malawi and Mozambique using a realist approach

Postpartum care (PPC) remains a neglected area of care in interventions focussing on improving maternal, neonatal and child health in sub-Saharan Africa. The MOMI project, started in 2011, aimed to strengthen health systems to... [ view full abstract ]

Postpartum care (PPC) remains a neglected area of care in interventions focussing on improving maternal, neonatal and child health in sub-Saharan Africa. The MOMI project, started in 2011, aimed to strengthen health systems to improve the uptake and delivery of evidence-informed PPC both in communities and health facilities of four African countries: Burkina Faso, Kenya, Malawi and Mozambique.

In each country, a package of postpartum interventions to increase demand for PPC and to improve delivery of PPC was designed and tailored to implementation gaps identified through participatory methods. A realist approach was followed to understand what worked, for whom, how and in what circumstances in the design, implementation, delivery and sustainability of PPC and to draw comparisons between countries. Data was collected in each country using a case study methodology and monitoring data collected through routine systems. Observations and interviews with community members and stakeholders at all levels of the system were undertaken and triangulated with various data sources.

We tested and refined programmes theories represented by Context-Mechanism-Outcome configurations in each setting and from there, developed four middle-range theories relevant to all settings. Indeed, the results of the MOMI evaluation suggest that if community level interventions lead to postpartum healthcare seeking for a critical mass of women, a “buzz” for change is created. Reinforced by social cohesion and local dialogue, norms shift and appear to create a critical tipping point leading to a social movement that holds a collective belief in the acceptability of and perceived value of attending for PPC that outweighs the costs. Our findings further supported the concept of social capital as having an important effect on demand for postpartum services mediated through the community health workers who could bridge trust between communities and the formal health sector. For the supply side interventions, the impact of MOMI was dependent upon the accountability systems that operated and largely did not favour postpartum care. In general it was found that where integration had been attempted, the staff in the better resourced health facilities were observed to have more clearly defined professional roles with little overlap between maternal and infant healthcare and therefore the combined provision of the services was less easily achieved. In smaller facilities individual healthcare workers were often co-located, knew about each other’s roles and expected to perform overlapping functions to account for absences. Therefore service integration was performed more intuitively by healthcare workers in smaller rather than larger facilities.

The MOMI evaluation shed light on the mechanisms of success and failure of implementation that are very relevant to policymakers and implementers in the field of maternal and child health. We further discuss the challenges and limitations encountered during the evaluation process, from the field to data analysis, and how our evaluation strategy aimed to address these (e.g. evaluating implementation strength to explain findings; adopting a realist reasoning in an African setting).