Combined community and health system strategies to increase institutional deliveries: An emerging practice in Mozambique

Low institutional delivery rates are associated with increased risk for maternal mortality. In Mozambique's Nampula province in 2011, only 63% of deliveries occurred in a facility. Strengthening Communities through Integrated Programming (SCIP) developed a practice to mitigate barriers to institutional delivery in the Nampula district of Mogovolas. This emerging practice may offer lessons regarding community access to services.

The two-part emerging practice combines community and health systems strengthening. One: a facility nurse conducts discussions in the community to improve knowledge and demand for safe delivery practices. Two: a facility nurse trains traditional birth attendants (TBAs) in safe delivery, risk identification, and referral to facilities, and provides supervision to TBAs to support skills application in the community. Monitoring data on institutional deliveries from January 2011 to March 2012 was analyzed across 34 communities in the Muatua health facility's catchment area. Due to constraints, the practice described above was implemented in varying completeness across these communities, allowing for a comparison of effect. Seven communities implemented both practice components, 10 implemented one, and 17 implemented none.

Institutional deliveries increased across the communities, possibly explained by other SCIP efforts. Where the practice was fully implemented, the highest increase was observed, at 247% (from 46 deliveries to 160). In communities where no component was implemented, there was an increase of 134% (from 26 deliveries to 61).

Preliminary data suggest the practice positively contributes to increased institutional deliveries. Analysis of the comparative advantages of practices combining community and health system strengthening is recommended.