High-risk pregnancy referral cards deployment at scale

Assessing effectiveness of using high-risk pregnancy referral cards for social behaviour change via identification of pregnancies at risk and referral to primary health care facilities

About

This project assessed and confirmed that the High-Risk Pregnancy (HRP) cards that were originally developed by Philips Foundation, Philips Design the International Committee of the Red Cross for use in fragile environments could also be beneficial in more stable environments.

The HRP cards are part of a toolkit developed to address the fact that 20% of pregnancies are at risk globally and more than 90% of deaths due to preventable causes occur in low-resource settings. The HRP cards are a tool to help the conversation between pregnant women and their care givers (e.g., midwives, community health workers, birth companions) to identify at-risk pregnancies and make timely referrals from the community to the health system.

After earlier validation with ICRC in several fragile communities, this study was deployed with the Kenya Red Cross Society in four Kenyan counties and reached over 280,000 people.

Partners

How

A quasi-experimental pre- and post design was conducted, using a mixed-methods approach with qualitative and quantitative methods. Study sites comprised of two intervention and two control sub-counties selected from two Kenyan counties, Bomet and Siaya. These were complemented with more practical implementation studies in the counties Isiolo and Lamu.

The objectives of the HRP cards include:

To increase awareness of healthy pregnancy behaviour amongst pregnant and women of reproductive age.
To increase identification of at-risk pregnancies both at the community and primary health care level.
To increase the number of at-risk pregnant women seeking appropriate medical support in time (during pregnancy and/or delivery).

The research objective of the project was to assess the effectiveness of the use of the high-risk pregnancy cards in identifying and referring at-risk pregnancies at community and primary health care level. Specifically, to determine:

The effect of use of HRP cards on awareness of healthy and at-risk pregnancy in the community.
The association between use of HRP cards and high-risk pregnancy referrals to primary health care facilities.
The association between the use of high-risk pregnancy referral cards and utilization of ante natal care services at primary health care level.
The proportion of at-risk pregnancies correctly identified, using the high-risk pregnancy referral cards at facility and community level.

Results

The project was actively deployed by the Kenya Red Cross in all four counties. More than 700 health workers, community health volunteers and birth attendants were trained and provided with HRP cards. Poster versions of the cards were printed and distributed to 100 health facilities. Apart from household visits by trained health workers, activation also included the establishment of mother-to-mother support groups and male involvement initiatives. In total, over 280,000 people (including family members of pregnant women) were reached.

The study confirmed that the use of a visual aid focused intervention is a practical and relatively efficient approach to improve the awareness of healthy habits, risks and danger signs among women of reproductive age in the community. Appropriately designed visual aids are highly effective, transparent, and ethically desirable tools for improving decision making, changing attitudes, prompting good habits and reducing risky behavior. the inclusive design of the HRP cards aided in adoption by the community health volunteers (CHVs) and acceptability by health workers and community members. Use of the cards was positively associated with an increase in healthy habits, risks and danger signs knowledge among women or reproductive age and men in the community.

Learnings and next steps

The assessment study provided insights on various outcome aspects:

Behavior change

The cards were used to support the reorientation and adoption of roles and new practices of traditional birth attendants/birth ambassadors (TBAs). An additional effect was the reduction in the number of home births assisted by TBAs, due to timely referral to higher level health facilities.
The provision and use of HRP cards enriched the role of community health workers and strengthened their position in the referral system.

Knowledge transfer

A marked increase was observed in knowledge among CHVs, TBAs, pregnant women and community members in general.
Increased knowledge of healthy habits and pregnancy risk factors among women of reproductive age between baseline and endline.

Antenatal care utilization

The use of the HRP cards led to an increased number of referrals of at-risk pregnancies to the health facilities.
A reduction in the number of high-risk complications in pregnancy was observed, which was attributed to the timely referrals resulting from the use of the HRP cards.

Link between CHVs and primary health facilities

CHVs reporting more completed referrals which facilitated proper follow up of women with risks in pregnancy.

Scalable implementation

As an important observation for scalability of the intervention, the HRP cards were seamlessly embedded and adding value to the existing structure and routine activities around pregnancy care. It does not need to be a stand-alone intervention that requires high additional resources to be implemented; it can add complementary value to humanitarian and healthcare systems already in place.