The MOM Project: Delivering Maternal Health Services among Internally Displaced Populations in Eastern Burma

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A 2008 Reproductive Health Matters.
                                                        All rights reserved.
                                         Reproductive Health Matters 2008;16(31):44–56
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 The MOM Project: Delivering Maternal Health Services
among Internally Displaced Populations in Eastern Burma
     Luke C Mullany,a Catherine I Lee,b Palae Paw,c Eh Kalu Shwe Oo,d Cynthia Maung,e
             Heather Kuiper,f Nicole Mansenior,g Chris Beyrer,h Thomas J Leei
                       a Assistant Professor, Johns Hopkins Center for Public Health and Human Rights, Baltimore
                         MD, USA. E-mail:
                       b Field Director, Global Health Access Program, Mae Sot, Tak Province, Thailand
                       c Karen Department of Health and Welfare, Mae Sot, Tak Province, Thailand
                       d Secretary, Karen Department of Health and Welfare, Mae Sot, Tak Province, Thailand
                       e Director, Mae Tao Clinic, Mae Sot, Tak Province, Thailand
                       f Co-Director, Global Health Access Program, Berkeley CA, USA
                       g Project Coordinator, MOM Project, Center for Public Health and Human Rights, Johns
                         Hopkins Bloomberg School of Public Health, Baltimore MD, USA
                       h Professor and Director, Center for Public Health and Human Rights, Johns Hopkins
                         Bloomberg School of Public Health, Baltimore MD, USA
                       i Director, Global Health Access Program, Berkeley CA, USA

     Abstract: Alternative strategies to increase access to reproductive health services among internally
     displaced populations are urgently needed. In eastern Burma, continuing conflict and lack of
     functioning health systems render the emphasis on facility-based delivery with skilled attendants
     unfeasible. Along the Thailand–Burma border, local organisations have implemented an innovative
     pilot, the Mobile Obstetric Maternal Health Workers (MOM) Project, establishing a three-tiered
     collaborative network of community-based reproductive health workers. Health workers from local
     organisations received practical training in basic emergency obstetric care plus blood transfusion,
     antenatal care and family planning at a central facility. After returning to their target communities
     inside Burma, these first-tier maternal health workers trained a second tier of local health workers
     and a third tier of traditional birth attendants (TBAs) to provide a limited subset of these
     interventions, depending on their level of training. In this ongoing project, close communication
     between health workers and TBAs promotes acceptance and coverage of maternity services
     throughout the community. We describe the rationale, design and implementation of the project
     and a parallel monitoring plan for evaluation of the project. This innovative obstetric health
     care delivery strategy may serve as a model for the delivery of other essential health services in
     this population and for increasing access to care in other conflict settings. A2008 Reproductive
     Health Matters. All rights reserved.

     Keywords: antenatal care, childbirth, emergency obstetric care, misoprostol, internally displaced
     populations, Burma

  N eastern Burma, decades of conflict between                        funding and information, and recruits through
  the military junta and ethnic minority groups                       extensive human rights violations such as forced
  has resulted in approximately 560,000 inter-                        displacement, forced labour and destruction of
nally displaced persons.1,2 In areas known as                         food supplies. Over 3,000 villages in eastern Karen
‘‘black zones’’, the junta attempts to cut off food,                  state have been destroyed since 1996.1 These

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

violations and associated high child and infant           reproductive health outcomes occurring within
mortality rates have been well documented.3,4 Such        their target communities. The maternal mortal-
conditions present substantial logistical barriers        ity ratio for this region has been estimated at
to health care delivery through standard models           approximately 1,200 per 100,000 live births,13
(the national health system is ranked 190th out           and stands in stark contrast with neighbouring
of 1915), and have severely curtailed the ability         Thailand, whose maternal mortality ratio is
of international non-governmental organisations           44.14 Initial efforts to reduce the risk of maternal
to provide humanitarian assistance.6,7 The 2005           mortality focused on training programmes for
withdrawal from Burma* of the Global Fund to              traditional birth attendants (TBA). While these
Fight AIDS, Tuberculosis and Malaria and other            programmes provided basic materials and educa-
major international non-governmental organisa-            tional messages on clean delivery and recogni-
tions (Medicines sans Frontières France, Interna-        tion of danger signs during pregnancy, capacity
tional Committee of the Red Cross) highlights the         to provide emergency obstetric care, a primary
need for alternative strategies to reach internally       intervention for preventing maternal mortality
displaced persons in the border regions.8                 and morbidity, was lacking.
   In the past decade, due to efforts led by the             Recognising this limitation and the urgent need
Inter-Agency Working Group on Reproductive                for new approaches relevant to their setting, in
Health in Crisis (IAWG)y and the Reproductive             August of 2005 these border-based organisations
Health Response in Conflict Consortium, the inter-        decided to pilot a unique delivery model of an
national community has begun to recognise the             integrated package of selected maternal and
impact that conflict has on women’s reproduc-             newborn health and family planning interven-
tive health outcomes and the need for specific            tions. The project aims to increase access to
interventions to address these vulnerabilities. In        proven interventions among internally displaced
conflict settings, women are disproportionately           persons by developing capacity among a cadre
affected and have poorer pregnancy outcomes               of mobile maternal health workers who could pro-
than women living in stable areas.9 While improve-        vide a more comprehensive approach to repro-
ments have been made with regard to refugee care,         ductive health services. This Mobile Obstetric
much less progress has been made for internally           Maternal Health Workers (MOM) Project is a col-
displaced persons,10 and reproductive health ser-         laborative effort between the Johns Hopkins
vices are normally unavailable in these unstable          Center for Public Health and Human Rights in
settings.10,11 Improving access to critical services in   the USA, Mae Tao Clinic (a training centre for
such settings, however, is possible. For example,         hundreds of health workers from eastern Burma),
the Reproductive Health Response in Conflict Con-         Burma Medical Association, Global Health Access
sortium, in collaboration with the Averting Mater-        Program in the USA, and local Burmese health
nal Death and Disability Program at Columbia              organisations. This paper describes the rationale
University, has recently demonstrated the feasi-          for this innovative model of delivering maternal
bility of strengthening facility-based emergency          health and family planning services, provides
obstetric services in 12 conflict-affected settings.12    an overview of the programme structure, train-
   On the Thailand–Burma border, organisations            ing and roles of the health care providers in the
such as the Karen Department of Health and                project, and outlines the planned monitoring and
Welfare and the Back Pack Health Worker Team              evaluation activities.
support a range of health programmes for inter-
nally displaced persons in eastern Burma, and are
cognizant of the substantial burden of adverse            Context, key approaches and rationale of
                                                          the MOM Project
                                                          The significance of the MOM Project is perhaps
*Burma is also known as Myanmar. We use Burma             most evident when viewed from within the cur-
throughout this report in accordance with the prefer-     rent international maternal health policy con-
ence of the 1990 General Elector winner, the National     text, where it emerges as a meaningful response
League for Democracy.                                     to unresolved problems in reaching populations
  IAWG was formerly known as the Inter-Agency Work-       in conflict settings. Leading voices in the inter-
ing Group on Reproductive Health in Refugee Settings.     national debate on the most appropriate strategies

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

to improve reproductive health largely focus            tems.19,20 Given the substantial barriers in eastern
upon skilled attendants providing facility-based        Burma and other similar conflict settings, alter-
services,15,16 e.g. in the recent Lancet series on      native context-specific strategies to facility-based
maternal mortality and morbidity.17 Increasing the      and skilled attendant care are urgently required.21
proportion of women delivering in a facility with          Adhering to international policy as closely as
a skilled attendant and access to comprehensive         possible, given these obstacles, the MOM Project,
emergency obstetric care16 are also long-term goals     a three-year pilot was launched in August 2005
for communities in eastern Burma. Meaningful            in 12 target communities of internally displaced
efforts towards these goals, however, will only be      persons in four states (Mon, Karen, Karenni and
possible after the cessation of violence and prog-      Mon) of eastern Burma (Figure 1). A three-tiered
ress towards reconciliation.                            collaborative network of community-based mater-
   For example, the Karen Department of Health          nal health workers was established, in which
and Welfare’s experience indicates that immo-           health workers from local organisations received
bile facilities in the conflict zones of Burma          practical training in basic emergency obstetric
would likely face destruction or displacement           care, evidence-based antenatal care and family
in short order. Since 1998, of the 33 clinics that      planning at a central facility. These specially-
Karen Department of Health and Welfare over-            trained maternal health workers returned to their
sees, 11 have been forced to relocate, five of          communities to train a second tier of local health
them between October 2006 and April 2007.               workers and a third tier of traditional birth atten-
Since permanent structures are more likely to           dants (TBAs). This approach aims to increases
be destroyed, the Department must instead oper-         the overall coverage of pregnancies attended by
ate their clinics as ‘‘mobile’’, semi-permanent         individuals with the capacity to provide at least
structures that can be rapidly dismantled when
threatened by conflict. Further, a central facility
model in this environment would only provide            Figure 1. Map of eastern Burma showing
real access to care for the few thousand people         approximate location of 12 MOM Project
residing in the immediate surrounding area. The         pilot sites
populations served by the Department are sub-
ject to frequent displacement, with nearly one
in ten displaced per year,4,13 and over 3,000 vil-
lages destroyed or relocated since 1996.1 A mobile
clinic can shift with these population move-
ments, whereas a stationary facility would be
abandoned. Additionally, security constraints, lack
of infrastructure and a widely dispersed popu-
lation result in extremely long transit times for
patients, who mostly travel on foot. A centralised
facility would require patients to overcome great
obstacles to reach care. Thus, permanent facilities
are unfortunately not currently a viable option in
this setting.
   The MOM Project has also had to provide mater-
nal health care under circumstances where there
is no foreseeable access to skilled birth atten-
dants, as defined by the WHO, whose definition18
explicitly excludes non-accredited individuals,
even if they are able to provide interventions
that improve pregnancy outcomes. Consideration
of roles for other types of providers not explicitly
meeting this definition could reduce the acute
shortage of health personnel, especially in com-
munities with failed or non-existent health sys-

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

one component of basic emergency obstetric care,        overall strategic direction and oversee imple-
antenatal care or family planning. This is achieved     mentation. The actual implementation of the
by implementing basic interventions through the         project is directed by a team of local project
less-trained providers, and more complex inter-         coordinators and staff drawn from the Mae Tao
ventions through the higher-trained providers, all      Clinic, Karen Department of Health and Welfare
of whom strive to provide highly mobile services        and Burma Medical Association.
to women at the village level, either in rudimen-          A range of target communities were selected
tary mobile clinics or, more often, at home. The        for inclusion in the pilot phase based on a number
emphasis on mobility and bringing services to           of criteria. First, the participation of four ethnic
women’s homes allows the services to rely less on       communities was encouraged to foster collabo-
facilities and to move with villagers in the event      ration and enhance the relevance of the model for
of population displacement. Such emphasis in            eventual scale-up in an ethnically diverse region.
the development of the MOM project is relevant          Second, sites within the four communities were
and necessary for any future scale up to a broader      selected based on their catchment population
population where forced displacement is consis-         (4,000–8,000), lack of basic emergency obstetric
tently reported.4,13                                    services and the availability of health workers
   The project consists of two main phases: Phase 1     for training. Additionally, sites were considered
(Design/Training – August 2005 to September             if they had: 1) support from the local health
2006) including selection of sites and workers,         department and village leaders, 2) sufficient num-
development of curricula for each of the three          bers of candidate health workers who could be
levels of worker, and a six-month training phase        trained as maternal health workers and avail-
for maternal health workers, followed by shorter        able local health workers to be trained in a
training for local health workers and TBAs when         subset of these skills, and 3) an already existing
maternal health workers have returned to the field.     mobile clinic under the management of the local
Phase 2 (Implementation (ongoing) – October 2006        health department.
to September 2008) was initiated in late 2006,             Twelve sites (eight Karen, two Shan, one Mon,
with the network of workers actively identifying        one Karenni) were selected, with an estimated
pregnant women, providing a range of antenatal          total population of 60,000 (Table 1). While indi-
services, attending births, providing postpartum        cators specific to the selected pilot areas have
care to both mother and newborn, and delivering         not been published, retrospective household
family planning services. A parallel monitoring         surveys in a broader area of eastern Burma,
and evaluation component to the project col-            including Karen, Karenni, and Mon regions, indi-
lects information through a range of qualitative        cate high infant (89 per 1,000 live births), child
and quantitative approaches.                            (218 per 1,000 live births) and maternal mortality

Organisational structure and
target populations
In August 2005, members of the Mae Tao Clinic,
Burma Medical Association and local ethnic
health departments from Shan, Mon, Karenni
and Karen states met at MOM Project head-
quarters in the border town of Mae Sot, just
inside Thailand, to discuss the programme
components and finalise implementation plans.
Local partners were joined by representatives
from long-term technical assistance partners
in the USA, including the Johns Hopkins Center
for Public Health and Human Rights and Global
Health Access Program. A Steering Committee
was established with representatives from each
of the participating organisations to provide

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

(1,200 per 100,000 live births), and crude birth       Experience and background training were not
rates of 35–45 per 1,000 population.3,4,13             considered in the selection of TBAs.
Maternal health workers, health workers and
TBAs are distributed amongst the villages
within each site, and maintain a central loca-         Maternal health worker training
tion with semi-permanent structures for storage        Training the identified maternal health workers
of supplies, monitoring and evaluation materi-         was the primary capacity-building activity during
als, and space for training sessions. The sites do     Phase I. A total of 33 maternal health workers
not include areas serviced by the Back Pack            were trained: 30 women and three men. Prior to
Health Worker Team, which usually focuses on           the MOM training, all trainees had completed at
the most unstable settings (‘‘black zones’’),          least four months of basic health training, with
where maintaining even mobile clinics is not           the majority having had a six-month course.
possible. All of the MOM sites are located in          Almost all workers (30) had completed two years
areas affected by ongoing conflict, although the       of fieldwork, with 11 trainees having over five
intensity of conflict varies across sites and tem-     years’ experience and one having worked for
porally within sites. Significantly, none of the       20 years as a medic. All had completed the sixth
sites has feasible referral options beyond their       standard of education, with 23 having reached
target area; for example, none can reliably trans-     tenth standard or, equivalently, completed sec-
port a patient to a regional facility or to hos-       ondary school education.
pitals in neighbouring Thailand.                          Their training included both classroom and
                                                       practical components. The Steering Committee
                                                       and project coordinators designed the curricu-
Selection of health workers                            lum, drawing upon guides and manuals by the
The Steering Committee developed selection             World Health Organization (WHO), UN Popula-
criteria for the three provider levels, with one       tion Fund (UNFPA), US Agency for International
maternal health worker per 2,000 persons, one          Development, JHPIEGO, International Federation
health worker per 500 and one TBA per 200. For         of Gynecologists and Obstetricians, Reproduc-
each site, ethnic health leaders chose 1–4 mater-      tive Health Response in Conflict Consortium and
nal health workers directly from the community;        Averting Maternal Death and Disability Proj-
each of whom had completed some prior train-           ect,22,23 and advice from members of an exter-
ing (usually 6–12 months), had some working            nal advisory committee. Guidelines were also
experience and wrote and spoke Burmese (in             adapted to take account of context-specific logis-
addition to their own ethnic language). The            tical constraints (e.g. lack of refrigeration) and
selected maternal health workers received spe-         cultural and political sensitivities (e.g. ethnic
cialist training in Thailand. From among these,        health leaders decided that counselling for and
a team leader was selected to manage inven-            promotion of family planning should initially
tory of supplies, supervise field activities of        be directed to married women only). The final
other maternal health workers, health workers          component of the capacity-building was in
and TBAs, and data collection, maintain contact        participatory educational methods, including:
with the ethnic health departments and MOM             1) training-of-trainers to enable maternal health
project staff in Mae Sot, and return to Thailand       workers to transfer their knowledge and skills
every six months to retrain. Ethnic health leaders     to the other tiers of providers when back in
also selected 4–20 local health workers per site       Burma, and 2) small group discussions and role-
who were required to have some basic health            play to increase effective communication with
training and experience providing services in          community members through counselling and
their community. Maternal health workers and           to dispel community misconceptions (e.g. about
local health workers were asked to commit to           contraceptive methods).
three years of fieldwork. TBAs were identified            The classroom training focused on familiar-
from among those actively attending births             ising the trainees with basic maternal health
and recognised by their community as some-             knowledge, including evidence-based antenatal
one to call upon for antenatal care, delivery,         care, normal and complicated deliveries, post-
post-natal or other reproductive health services.      natal and post-abortion care, neonatal care and

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

resuscitation, and family planning. The two-            protocol developed to care for patients at Karen
month training consisted of six hours per day           Department of Health and Welfare clinics who
for a total of 198 classroom hours, and included        were severely anaemic from trauma or other
lectures, case studies, role-play and clinical sim-     causes. This protocol takes advantage of recent
ulations. Classroom training was then followed          progress made in the development of heat-stable
by four months of hands-on experience gained            rapid diagnostic tests to screen blood for malaria,
through intensive participation in provision of         syphilis, hepatitis B and C, and HIV. Because of
maternal health and family planning services at         the inability to store blood in the field, maternal
Mae Tao Clinic, with over 2,000 deliveries per          health workers conduct community education
year, under the supervision of local senior repro-      about the need for blood transfusions in advance,
ductive health workers and expatriate physicians.       and recruit prospective donors from community
   The practical portion emphasised skills deve-        volunteers, thus maintaining a ‘‘walking blood
lopment for blood transfusion and the six               bank’’. When needed, they can request donors
basic emergency obstetric procedures: antibi-           with matching blood type, conduct confidential
otics, parenteral magnesium, manual removal of          screening, and give appropriate counselling and
placenta, manual vacuum aspiration, misopros-           treatment as needed.
tol for prevention and treatment of post-partum            Periodic follow-up information-sharing and
haemorrhage and vacuum extraction. Full imple-          training workshops are scheduled throughout
mentation of vacuum extraction was delayed              the MOM project. For all maternal health work-
because of the relative difficulty of the procedure,    ers these require a return to Thailand annually
lack of experience among senior Mae Tao Clinic          and for team leaders, every six months. Follow-
medics in the use of portable devices such as the       up training allows time for review of clinical
Kiwi OmniCupR vacuum extractor, and consid-             work in the field, discussed below, supplemented
erable effort and time being needed for the other       with practical training and supervision in the
five components. Trainees rotated through labour        reproductive health department at Mae Tao
and delivery and outpatient and inpatient repro-        Clinic. This is also an opportunity to coordinate
ductive health departments, with exposure to            logistical arrangements for re-supplying areas
specific interventions tracked for each trainee.        and for the MOM office staff to review data col-
Outpatient maternal and newborn health expo-            lection tools and make updates. Finally, periodic
sure included training in clean and safe delivery,      reviews of progress and capabilities of mater-
antenatal and post-natal care, and post-abortion        nal health workers allow for the addition of new
care, and emphasised the effective delivery of          training modules and new interventions in the
essential interventions such as iron folate sup-        existing platform.
plementation, malaria screening and treatment
during pregnancy, insecticide-treated nets, de-
worming of mothers, and birth preparedness              Health worker training in the field
counselling, including nutrition and essential          Returning to the field sites in June 2006 was
newborn care. Family planning training included         a lengthy process, with some maternal health
counselling and education on provision of               workers requiring up to six weeks to reach their
modern contraceptive methods, including male            target communities, as security constraints post-
condoms, contraceptive injection, oral contra-          poned movement or forced circuitous routes.
ceptive pills and emergency contraception.              Upon arrival, the maternal health workers con-
   Blood transfusion is normally considered a           ducted a series of meetings with local authori-
component of comprehensive emergency obstet-            ties, village heads, religious leaders, traditional
ric care only performed at facilities capable of        healers, women’s and other civil society groups,
caesarean section.16 However, blood transfusion         and local health workers and TBAs, to explain the
was included for two reasons. First, in this popu-      programme. The meetings followed an informal,
lation high rates of anaemia and especially             participatory approach, allowing stakeholders to
malaria3 increase the likelihood of severe mor-         offer opinions and make recommendations. This
bidity and mortality from post-partum haemor-           process of informing and sensitising the commu-
rhage.24 Second, the transfusion component of           nity was envisioned as a necessary and appro-
the MOM Project was adapted from an existing            priate step to secure support for the project.

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

   Community leaders then recruited health work-        basic components of antenatal, delivery and
ers at each site. Maternal health workers con-          post-natal care.
ducted two-month trainings for a total of 131              Maternal health workers conducted 22 TBA
health workers, aged 18–30 years old, mostly            trainings for 288 TBAs recruited by community
unmarried women, all of whom had some prior             leaders. Previous training was not a requirement
health training and experience. The training was        for TBAs to participate, and their prior experi-
based on the maternal health workers’ curricu-          ence and training varied substantially. The TBA
lum, but included only provision of antibiotics         training followed a seven-day curriculum cen-
for sepsis and administration of misoprostol for        tred on evidence-based antenatal care, essential
prevention of post-partum haemorrhage from              newborn care, clean delivery and the impor-
the components of emergency obstetric care.             tance of their role in strengthening communi-
Eventually, however, health workers will learn          cation and working effectively with maternal
all aspects of basic emergency obstetric care           health workers and health workers.
and blood transfusion through continued regu-
lar training and experience working with mater-
nal health workers in the field.                        Service provision
   During field activities, maternal health work-       The transition to the second phase began in
ers rely on health workers to assist in achiev-         each area when maternal health workers had
ing the goal of having, at every birth, no matter       completed training health workers and TBAs.
the location, an attendant with the capacity to         Pregnant women are most commonly identi-
provide basic emergency obstetric care. Employ-         fied first by TBAs, who inform them about the
ing communication strategies such as regular            MOM project and the additional services avail-
meetings between the maternal health workers            able through maternal health workers and health
and health workers and monitoring of expected           workers. These services can be broadly grouped
delivery dates increases the likelihood of a            into antenatal, labour and delivery (including
maternal health worker in attendance. Atten-            basic emergency obstetric care), and post-natal
dance at birth by a maternal health worker is           and other services. Primary responsibility for
the primary objective, but when movement is             delivering these interventions is distributed
restricted, primarily due to security concerns,         through the three-tiered network (Table 2).
the health workers trained in the more limited             TBAs also inform health workers and mater-
set of basic emergency obstetric care compo-            nal health workers directly about all pregnant
nents are an option. The greater number of health       women identified in their areas. Identification
workers compared to maternal health workers             of a pregnant woman prompts a series of ante-
(average 4:1 ratio), facilitates greater dispersion     natal care services provided directly by the
of emergency obstetric services throughout the          network of workers during home visits, includ-
target area.                                            ing malaria screening with the ParacheckR
                                                        rapid diagnostic test (Orchid Biochemical Sys-
                                                        tems, Goa, India), and provision of long-lasting,
TBA training in the field                               insecticide-treated nets, de-worming pills and
The communities of eastern Burma have an infor-         specific counselling on nutrition, birth prepared-
mal network of TBAs who provide some care               ness and preparation for care of the newborn,
to the vast majority of pregnant women. Fol-            breastfeeding and family planning. Depending
lowing recommendations from UNFPA, WHO                  on which tier of worker is present at the time of
and others,14 TBAs are supported in the MOM             delivery, women have access to: safe and clean
Project as playing a crucial role in strengthen-        delivery (with TBAs); antibiotics, if needed, and
ing the link between pregnant women and the             misoprostol plus safe and clean delivery (with
maternal health and other health workers.               health workers); or the full range of basic emer-
However, recognising 1) the importance of               gency obstetric care services (with maternal
TBAs who have early contact with pregnant               health workers). These services may be provided
women, 2) the scarcity of human resources               at the central site or, more usually, the woman’s
and 3) lack of facilities, TBAs in the MOM              home. While one of the overarching goals is
Project are also called upon to provide the most        to increase the proportion of women delivering

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

with the assistance of a maternal health worker,        There are no MOM pilot areas that can reliably
this is not always possible. In cases where a           refer to facilities where caesarean section is avail-
health worker or TBA is responsible for assisting       able. After delivery, regular post-natal visits take
the delivery, referral to the maternal health worker    place in which attendees check both mother and
might occur for any complications. Referral to          neonate, providing family planning supplies,
maternal health workers (by word of mouth)              treatment for infection, post-partum vitamin A,
might result in either the maternal health worker       promotion of essential newborn care, early
going directly to the woman’s home or the               and exclusive breastfeeding, nutrition counsel-
woman travelling to the local mobile clinic.            ling, and recognition of signs of severe illness. In

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

addition, MOM workers are able to provide family        and other data forms that are routinely collected
planning during antenatal care or post-natal or         by the three cadres of MOM workers.
post-abortion visits.                                      Analysis of the cluster sample surveys (base-
                                                        line completed in late 2006, interim and endline
Supervision                                             surveys to be completed in January 2008 and
                                                        December 2008, respectively) will enable assess-
Activities and service provision by health work-        ment of access over time to a range of interven-
ers and TBAs are overseen by the maternal               tions offered by the MOM project. The surveys
health workers and the maternal health workers’         include questions on background and demo-
team leader in each site. Direct supervision of         graphic variables, pregnancy history, antenatal
these workers is not possible by the MOM staff          care coverage, including access to malaria and
in Mae Sot or by members of the Steering Com-           anaemia screening, iron/folate supplementa-
mittee, as security constraints substantially limit     tion, de-worming, distribution of long-lasting
travel. Thus while periodic field visits are made       insecticide-treated nets, number of antenatal
as part of the qualitative monitoring and evalua-       care visits, and knowledge of family planning
tion components (see Monitoring and Evaluation,         methods, current use and unmet need. The latter
below), oversight of TBAs and health workers is         will help the MOM project direct family plan-
largely done by maternal health workers during          ning services in the target population.
day-to-day direct observation of their work and            These surveys also include questions on vital
through periodic follow-up trainings. Maternal          events and human rights violations experienced
health workers themselves are supervised first          at the individual and household level. Rights
by their team leader during ongoing implemen-           violations to be monitored in this setting include
tation of field activities, and by MOM Project          forced displacement, destruction or theft of
staff during annual follow-up trainings.                household food supplies, forced labour of house-
                                                        hold members by the Burma military, direct
Remuneration                                            physical attack by troops and landmines. This
Compensation levels for all workers are decided         methodological approach has been previously
in accordance with the policies of the ethnic           described4 and will allow estimation of important
health organisations. Maternal health workers           associations between access to MOM project com-
and health workers are both paid a monthly sti-         ponents and human rights violations. Rape as a
pend for their work in the field, in addition to a      tool of the military junta, particularly in Shan
monthly food allowance, which in some cases is          State, has been well documented.25 Questions on
combined with existing funds at the clinic level to     rape are not, however, included in the current
provide food for all health workers in the clinic.      modules of the MOM project as gender congru-
TBAs receive a per diem allowance during both           ence between surveyor (independent from MOM
initial and follow-up training sessions. Survey         project workers) and respondent is not guaran-
team members receive similar compensation               teed and the limited length and time frame
during the time in which they are conducting            allowed for each interview is not conducive to
surveys in the field (typically a two-month period).    establishing the level of trust required to ade-
                                                        quately collect such sensitive information.
                                                           These surveys will also allow estimation of
Monitoring and evaluation:                              neonatal and infant mortality rates,3 but as
quantitative methods                                    they will cover only about 2,800 households
Evaluation of the MOM project is conducted              per survey period, they are not a priori pow-
through collaboration between the technical assis-      ered to detect any changes in mortality risk
tance partners, Global Health Access Program            during the MOM project period. The survey
and the Johns Hopkins Center for Public Health          workers recruited as part of the MOM survey
and Human Rights. Quantitative components               team are from the village-based clusters to
include annual, population-based, cluster-sample        which they are assigned, but are separate from
surveys (conducted by a separate group of data          the three tiers of MOM project health pro-
collectors) and three periodic reviews (baseline,       viders. Given the uncertain security environ-
interim and endline) of pregnancy-tracking logs         ment of the target populations, the inclusion

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

of members of the internally displaced commu-           Monitoring and evaluation:
nity as part of the monitoring team is essential        qualitative methods
to increased overall acceptance and participation       Qualitative methods of monitoring and evalua-
by community members.                                   tion during follow-up trainings in 2007 and 2008
    In addition to the cluster-sample surveys, peri-    for maternal health workers in Thailand will
odic review of pregnancy-tracking logs routinely        include a series of focus group discussions to col-
filled by maternal health workers and health            lect information on barriers to provision of care,
workers will provide further information regard-        challenges arising during project implementation,
ing the access to antenatal care, labour and            and to strategise how to overcome these obstacles.
delivery, and post-natal interventions. For each        The broad topics to be discussed include relation-
pregnancy attended by a maternal health worker          ships with the community, health workers and
and/or health worker in the programme areas,            TBAs, problems and successes in the delivery of
a pregnancy record is generated for tracking
                                                        obstetric interventions, supplies and communi-
the progress of women from pregnancy through
                                                        cation, using case reports. Such reports might
post-partum care. Clinical records will provide
                                                        include particularly difficult or complicated cases,
indicators, including of access to maternal health
                                                        including maternal death. Experience with man-
services (antenatal, peripartum, post-natal), com-
                                                        aging such cases will be shared, and, in the
ponents of basic emergency obstetric care and
                                                        absence of a more formal approach (e.g. mater-
family planning uptake. These charts will also
                                                        nal death audit), will help highlight areas to be
facilitate estimation of the proportion of total
                                                        further addressed during follow-up training.
deliveries attended in catchment areas attended
                                                           Periodic site visits by local members of the
by MOM workers, and the proportion of births
                                                        MOM Steering Committee will also be conducted
requiring each emergency obstetric intervention.
                                                        to each of the service delivery areas, primarily
The extraction of data from these pregnancy
                                                        to supplement information provided through
records will also allow comparison of health
outcomes between areas and over time. These             communications between field workers and local
include post-partum haemorrhage, puerperal              MOM staff. Information collected during these
sepsis, abortion complications, malaria during          visits will include updates on logistical and
pregnancy, and case-fatality rates for preg-            implementation challenges, assessment of the
nancy complications managed by MOM health               level of activities and interventions provided,
workers. Early neonatal mortality will also be          and changes in the security situation. They will
estimated from these pregnancy records and              not be used for evaluation purposes due to dif-
provides an opportunity for internal validation         ficult and fluid security constraints, resulting in
of the neonatal mortality data estimated from           irregularity of visits, but also because verbal
the cluster-sample surveys described above.             assessments by project workers are subjective
    TBAs are also involved in project monitoring        in nature and short visits cannot capture all the
and evaluation through the use of basic forms in        activities being implemented.
a prospective manner to collect information on
pregnancies, live births and deaths during the first
week of life. These simple, picture-based forms         Conclusions
have been developed and implemented in a range          The two key features of the MOM Project are
of Thai/Burma border TBA programmes26 and are           as follows. The first is the necessity of unbun-
based on previous picture-based forms used in           dling health care from facilities, because of the
community programs in Cambodia and Vietnam.             constraints inherent in conflict settings. This
This third source of data on vital events provides      was illustrated in eastern Burma during the
yet another point for triangulation of data, fur-       devastating 2006–2007 escalation of the conflict
thering internal validation. In this internal dis-      in northern Karen State. The military junta
placement setting, opportunities for real-time          forced the already displaced population of one
supervision of data collection and other moni-          of the MOM Project sites (Na Yo Hta) to scatter
toring and evaluation tasks is limited, and such        once more into the surrounding jungle.27 The
replication of data is essential for gaining con-       central site being used by maternal health
fidence in the estimation of outcome indicators.        workers for coordination of activities, supplies

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

              and training was burned by the military. MOM            and even without comprehensive care (such as
              project workers moved with the population and           caesarean section).
              provided services during four months of dis-               This approach reflects the realistic constraints
              placement due to active fighting. Continuity of         of the setting, recognises the integral role of a
              care and delivery of services under such con-           variety of care providers, including TBAs, and
              ditions can only be achieved within a structure         promotes a tiered-structure that may facilitate
              that emphasises mobility of service provision to        the progressive realisation of more standard com-
              the population, rather than centralised services        prehensive models of reproductive health services.
              that must be accessed by the population.                A more comprehensive approach, for example,
                 The second key feature is that all compo-            would move beyond the current MOM focus on
              nents of pregnancy and delivery care are pro-           maternal health services and family planning
              vided by the more intensively trained maternal          to include efforts to reduce sexually transmitted
              health workers, while lesser-trained workers still      diseases, HIV/AIDS and gender-based violence,
              contribute to overall coverage by providing a           as recommended by the Inter-Agency Working
              crucial subset of interventions. This model creates     Group on Reproductive Health in Crisis.28 The
              the flexibility necessary to provide community-         forthcoming evaluation of this programme will
              based service delivery. Given the substantial           provide important insights into the feasibility and
              burden of mortality and morbidity facing women          effectiveness of this approach and may help guide
              in this setting, this approach may have an impor-       the development of further strategies for increas-
              tant public health impact despite the limitations       ing access to care in other conflict settings.

                   A MOM Project maternal health worker provides post-natal care during a home visit in the
                                                  Mon pilot community

LC Mullany et al / Reproductive Health Matters 2008;16(31):44–56

Acknowledgements                                              Bloomberg School of Public Health, Global Health
The MOM Project is funded by grants from                      Access Program/Planet Care, the Hussman
the Bill and Melinda Institute for Population                 Foundation, and the Foundation for the People
and Reproductive Health at the Johns Hopkins                  of Burma.

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Résumé                                                  Resumen
De nouvelles stratégies sont nécessaires sans           Se necesitan con urgencia otras estrategias
délai pour élargir l’accès des personnes déplacées   para ampliar el acceso a los servicios de salud
aux services de santé génésique. Au Myanmar            reproductiva entre las poblaciones desplazadas
oriental, la persistance du conflit et le manque          internamente. En Birmania oriental, debido al
de systèmes de santé en état de marche empêchent      conflicto continuo y la falta de sistemas de
de mettre l’accent sur les accouchements en               salud en buen estado de funcionamiento, resulta
maternité avec une assistance qualifiée. Le long        inviable poner énfasis en la prestación de
de la frontière avec la ThaRlande, des organisations     servicios en establecimientos con asistentes
locales appliquent une initiative novatrice, le projet    calificados. A lo largo de la frontera entre
des agents de santé maternelle et obstétricale          Tailandia y Birmania, organizaciones locales
mobile (MOM), qui établit un réseau à trois niveaux    implementaron un piloto innovador, el Proyecto
d’agents communautaires de santé génésique. Les        de Trabajadores de Salud en Cuidados Obstétricos
agents de santé des organisations locales ont suivi      Móviles (MOM, por sus siglas en inglés), y
une formation pratique aux soins obstétricaux            ası́ establecieron una red colaboradora de tres
d’urgence ainsi qu’aux transfusions sanguines,            niveles de trabajadores comunitarios en salud
aux soins prénatals et à la planification familiale     reproductiva. Los trabajadores de salud de
dans un établissement central. De retour dans            organizaciones locales recibieron capacitación
leur communauté à l’intérieur du Myanmar, ces          práctica en cuidados obstétricos de emergencia, ası́
agents de santé maternelle du premier niveau ont         como transfusión sanguı́nea, atención antenatal
appris à un deuxième niveau d’agents de santé          y planificación familiar, en un establecimiento
locaux et à un troisième niveau d’accoucheuses          central. Después de regresar a sus respectivas
traditionnelles à assurer un sous-ensemble limité       comunidades en Birmania, estos trabajadores de
de ces interventions, en fonction de leur formation.      primer nivel en salud materna capacitaron a un
Dans ce projet, une communication étroite entre les      segundo nivel de trabajadores de salud locales
agents de santé et les accoucheuses traditionnelles      y a un tercer nivel de parteras tradicionales para
encourage l’acceptation des services de maternité        que proporcionaran un subconjunto limitado
et leur couverture dans toute la communauté.             de estas intervenciones, de acuerdo con su nivel
Nous décrivons la raison d’être, la conception et       de capacitación. En este proyecto en curso, la
l’application du projet ainsi qu’un plan parallèle       comunicación estrecha entre los trabajadores
pour l’évaluer. Cette stratégie innovante de            de salud y las parteras tradicionales fomenta
prestation des soins obstétricaux peut servir de         aceptación y cobertura de los servicios de
modèle pour d’autres services de santé essentiels       maternidad por toda la comunidad. Describimos
et pour élargir l’accès aux soins dans d’autres         las justificación, el diseño y la implementación
situations de conflit.                                    del proyecto y un plan de monitoreo paralelo
                                                          para la evaluación del proyecto. Esta innovadora
                                                          estrategia de prestación de servicios obstétricos
                                                          puede servir de modelo para la otros servicios
                                                          de salud esenciales en esta población y para
                                                          ampliar el acceso a la atención médica en otros
                                                          ámbitos en conflicto.

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