Ministry of Health

Community Midwifery Services in Kenya

Implementation Guidelines

Second Edition

August 2012
 Ministry of Health

Community Midwifery Services in Kenya

Implementation Guidelines

Second Edition

August 2012
Foreword
Globally, there has been some modest improvement in reducing maternal and neonatal
mortality rates over the last decade as shown by United Nations reports. However, in Kenya,
more effort is still needed in order to make any meaningful progress towards the
attainment of especially MDG 5 which targets achieving a significant reduction of maternal
mortality ratio (MMR) to 147/100,000 live birth by 2015. The Kenya Demographic Health
Survey (2008/09) indicates that the maternal mortality ratio in Kenya has remained
unacceptably high at 488/100,000 live births. It is worth noting that neonatal mortality rate
only reduced marginally from 33 to 31 per 1000 live births between 2003 and 2008/09.

The slow progress in achieving maternal and newborn health (MNH) targets in Kenya has
been attributed to limited availability, poor accessibility and low utilization of skilled birth
attendance during pregnancy, child birth and postnatal period, low coverage of basic
emergency obstetric and newborn care and poor involvement of communities in maternal
and newborn care.

The community midwifery model was commissioned by the Minister for Health in 2006 as
an attempt to increase access to skilled assistance at birth. The first edition of the
community midwifery guidelines were developed in 2007. These guidelines have been
revised in order to standardize the implementation of community midwifery services as a
strategy for improving skilled attendance in the provision of maternal and newborn health
care at the community level. The revised guidelines address key policies that are outlined in
the Kenya Health Policy (2012-2030) regarding the provision of essential packages for health
in line with the new constitution, Vision 2030 and the Community Health Strategy.

The Kenya Health Policy, which seeks to contribute to the attainment of Vision 2030 aims to
provide equitable and affordable health care of the highest affordable standard to all
citizens. It emphasizes a shift of focus to preventive and promotive health care. Major
strategies include improving access, realizing equity goals and providing quality services as
well as strengthening the institutional framework for effective delivery of health services.

The revised guidelines also highlight the role of the community midwife in the provision of
continuum of care during normal pregnancy, childbirth, postpartum period, and in
counselling for and providing family planning services as well as newborn care and referral.
The community midwife’s role in linking with community health workers, community health
extension workers, local committees, facility staff and county teams is also highlighted.

The revision of the guidelines was a collaborative effort and I wish to acknowledge all
individuals and institutions who were involved. In particular, UNFPA is acknowledged for
having supported the process of revising and printing of the guidelines.

Dr. S.K. Sharif, MBS; MBChB, M.Med, DLSHTM, MSc.

Director of Public Health and Sanitation
Ministry of Public Health and Sanitation

i
Community Midwifery Implementation Guidelines
Acknowledgements
The revision of this guideline was through a consultative process that involved various
organizations and individuals who play different roles in reproductive health particularly
maternal and newborn health care in Kenya. The revision process took into account existing
materials and resources on maternal and newborn health.

In particular, the following institutions and organizations are acknowledged for having taken
part at various stages of the development of this revised edition: the Division of
Reproductive Health (DRH), Nursing Council of Kenya, Population Council, Department of
Nursing, Division of Community Health Services, Jhpiego- APHIAplus zone 1, National Nurses
Association of Kenya (Midwifery Chapter), KOGS, University of Nairobi, WHO, UNICEF Kenya
and Kenyatta University (OBGYN Dept).We would also like to acknowledge the role of
UNFPA for providing technical and financial assistance towards the development of both the
community midwifery guidelines and the orientation package. Individuals who participated
in the revision of the guidelines and the institutions they represented are listed in Annex 7.

Thank you all for supporting the process of improving maternal and newborn care by
increasing access to skilled attendants.

Dr. Bashir Issak

Head, Division of Reproductive Health
Ministry of Public Health and Sanitation

ii
Community Midwifery Implementation Guidelines
Abbreviations and Acronyms
AMREF African Medical Research Foundation
ANC Antenatal Care
CBHC Community Based Health Care
CBO Community Based Organization
CDF Constituency Development Fund
CHAK Christian Health Association of Kenya
CHEW Community Health Extension Worker
CHW Community Health Worker
CM Community Midwife
CMs Community Midwives
DHMB District Health Management Board
DHMT District Health Management Team
DRH Division of Reproductive Health
DRHTST District Reproductive Health Training and Supervision Team
EOC Essential Obstetric Care
FBO Faith Based Organisation
HIV Human Immunodeficiency Virus
KEPH Kenya Essential Package For Health
KDHS Kenya Demographic and Health Survey
KOGS Kenya Obstetric and Gynaecological Society
KEM Kenya Enrolled Midwife
KECHN Kenya enrolled Community Health Nurse
KRCHN Kenya Registered Community Health Nurse
LATF Local Authority Transfer Fund
MDG Millennium Development Goal
MNH Maternal and Newborn Health
MOH Ministry of Health
NHSSP National Health Sector Strategic Plan
NNAK National Nurse Association of Kenya
PMTCT Prevention of Mother to Child Transmission
PRHTST Provincial Reproductive Health Training and Supervision and Team
SWAp Sector Wide Approach
UNFPA United Nations Population Fund

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Table of Contents
Foreword ................................................................................................................................... i
Acknowledgements.................................................................................................................. ii
Abbreviations and Acronyms .................................................................................................. iii
1. Introduction ......................................................................................................................... 1
1.1 Background .................................................................................................................... 1
1.2 The Policy Context ......................................................................................................... 1
1.3 KEPH Tiers of Care and Service Cohorts ........................................................................ 2
1.4 Organization of Health Services Delivery ...................................................................... 3
1.5 Implementation Experience with the CM Model .......................................................... 4
2. Community Midwifery Model .............................................................................................. 4
2.1 Definition ....................................................................................................................... 4
2.2 Selection Criteria ............................................................................................................ 5
2.3 Roles and responsibilities of the community midwife .................................................. 5
2.4 Practice Setting ............................................................................................................ 11
2.5 Scope of Practice.......................................................................................................... 12
2.6 Training ........................................................................................................................ 12
3. Process of Implementing Community Midwifery Services ................................................ 13
4. Institutional Framework and Implementation Mechanism............................................... 15
4.1 Strategic level............................................................................................................... 15
4.2 Operational level.......................................................................................................... 16
4.3 Tactical level - Management of Level One Services .................................................... 17
5. Quality Assurance .............................................................................................................. 18
5.1 Concepts ...................................................................................................................... 18
5.2 Quality Assurance Core Components .......................................................................... 19
5.3 Core Services ................................................................................................................ 19
5.4 Supportive Components .............................................................................................. 21
5.5 Tools for monitoring quality assurance ....................................................................... 22
6. Sustainability of Community Midwifery Model ................................................................. 22
6.1 Critical Sustainability Factors ....................................................................................... 22
6.2 Community Midwifery Financing ................................................................................. 23
6.3 Entrepreneurship ......................................................................................................... 25
6.4 Replenishing Supplies .................................................................................................. 27
Annexes .................................................................................................................................. 28
Annex 1: Clinical attachment ............................................................................................. 28
Annex 2: Basic requirement of equipment and supplies.................................................. 29
Annex 3: Patient referral form .......................................................................................... 30
Annex 4: Monthly summary reporting form..................................................................... 31
Annex 5. Quality assurance tool ........................................................................................ 33
Annex 6: Criteria for licensing Community Midwives ....................................................... 35
Annex 7: Participants involved in the revision of the CM Guidelines .............................. 36

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1. Introduction
1.1 Background
The maternal mortality ratio in Kenya is unacceptably high. According to the Kenya
Demographic Health Survey of 2008/2009 there were 488 maternal deaths per 100,000
live births. Many of these deaths could have been averted if women had timely access to
skilled attendance and essential obstetric and neonatal care. Neonatal mortality rate is
31 per 1,000 live births, with majority of the deaths occurring within the first week of
life. Infant mortality rate is 52 per 1000 live births. Only 2.6% of infants are exclusively
breastfed by 6 months. Less than 5% of pregnant women and under-fives sleep under
insecticide treated nets to prevent malaria. Contraceptive prevalence rate is at 46% and
70% of women have unmet need for family planning in the first year postpartum (KDHS
2008/09).

Evidence from a number of studies globally has shown a reduction in maternal and
perinatal mortality when women have access to a skilled attendant providing a
continuum of care from pregnancy, at birth and during the postnatal period. In Kenya, as
in most of sub-Saharan Africa, although the majority ( 92%) of women attend antenatal
clinic at least once during pregnancy, more than half ( 56%) give birth at home without
any skilled assistance, and only 10% of those delivering at home receive any type of
postpartum care (KDHS, 2008/2009).

The main focus of strategies to increase skilled attendance in East and Southern Africa
has been to provide comprehensive antenatal care, ensure that pregnant women are
prepared for the birth and strengthen obstetric care provided within facilities. Although
many facilities have improved the quality of care available, many women are still not
using the facilities for childbirth and still prefer to deliver in their own homes. This calls
for an approach that can address the issue of childbirth at home and a skilled attendant
to assist the women. The community midwifery model addresses this gap by ensuring
that skilled care is available during pregnancy, labour and child birth and follow-up of
both mother and baby postnatally in the community.

The Community Midwifery Model (CMM) uses skilled out of work or retired licensed
health care professionals who are resident within a given community and seeks to
contribute towards the achievement of Millennium Development Goals (MDGs 4 and 5).
The Community Midwifery model also contributes directly to the overall goals of the the
National RH Policy of 2007, National Road Map for Accelerating the Attainment of the
MDGs Related to Maternal and Newborn Health in Kenya] and , the Community Health
Strategy.

1.2 The Policy Context

Kenya Health Policy (2012-2030)
The community midwifery model is aligned to the Kenya Health Policy (2012 – 2030)
which seeks to support the provision of equitable, accessible, affordable and quality
health and related services at the highest attainable standards to all Kenyans using the
primary health care approach. The health policy objectives are to: eliminate

1
communicable conditions; halt, and reverse the rising burden of non-communicable
conditions; reduce the burden of violence and injuries; provide essential health care;
minimize exposure to health risk factors and strengthen collaboration with health
related sectors.

Kenya Health Sector Strategic and Investment Plan

The Kenya Health Sector Strategic and investment plan (KHSSP) for the period 2012-
2018 provides the overall framework for implementing health sector priorities and high
impact interventions. The mission of the strategic plan is to “deliberately build
progressive, responsive and sustainable technologically driven evidence-based and
client-centred health system for accelerated attainment of the highest standard of
health to all Kenyans”. The plan emphasizes the implementation of interventions and
prioritization of investments that relate to maternal and newborn health which are
considered to be major impact areas for which progress was not attained in the previous
National Health Sector Strategic Plan for the period 2008 to 2012.

Kenya’s new constitution, Service Delivery levels and Essential Package for Health
The adoption of a new constitution by Kenya in 2010 introduced a rights based approach
in the provision of services and a redefinition of governance levels for all services
including those delivered by the health sector. Thus, it is expected that the health policy
and its strategies will integrate human rights norms and principles in the design,
implementation, monitoring and evaluation of health interventions and programmes.
Respect for human dignity, attention to the needs and rights of vulnerable groups, equal
access to health care systems are examples of key issues to be observed in designing and
implementing health care interventions and in offering health services. Therefore, in
accordance with the devolved system of government to be implemented under the new
constitution, four levels (or tiers) of care are recommended.

1.3 KEPH Tiers of Care and Service Cohorts

Kenya Essential Package for Health refers to an approach for integrating various
programmes into a single package of interventions that seek to improve the health
status of the population. KEPH is a life cohort based approach. The Kenya health policy
and the KHSSP define the priority services that are necessary to be provided at the
following 4 distinct levels/tiers of care:
 Community level: The foundation of the service delivery system, with both
demand creation and specified supply services that are effectively delivered at the
community.
 Primary care level: The first physical level of the health system, comprising all
dispensaries, health centres & maternity /nursing homes. It is the 1st care level,
where most clients’ health needs should be addressed.
 County level: The first level hospitals, whose services complement the primary
care level to allow for a more comprehensive package of services.
 National level: The tertiary level hospitals, whose services are highly specialized.

2
Specific KEPH cohorts are:
 Pregnancy and the newborn (up to 28 days)
 Childhood (29 days – 59 months)
 Children and Youth (5 – 19 years)
 Adulthood (20 – 59 years): The economically productive period of life
 Elderly (60 years and above)

KEPH services offered at community level

The KHSSP (2012-2018) and the 2006 Community Health Strategy outline the services
that could be offered at the community level. These include: immunizations, child
health, maternal and newborn health, screening for diseases, water and Sanitation,
provision of basic curative care, prevention of HIV/STIs, and family planning among
others. These services are offered by key providers at the community level; namely
Community Health Workers (CHWs), Community Health Extension Workers (CHEWs) and
Community Midwives. The range of services includes provision of education and
information on preventable and promotive activities & basic curative care interventions.

1.4 Organization of Health Services Delivery

The KHSSP 2012-2018 target for a community unit (CU) is 5,000 persons, giving an
overall target of 8,000 CUs. Fig. 1 outlines how health services are organized at all levels.

Figure 1: Organization of health services delivery

Management Service Delivery

NATIONAL MOH HQs & NATIONAL REFERRAL SERVICES (16 units)

Comprise all secondary and tertiary referral facilities providing:
(16 units) PARASTATALS  Highly specialized health care, for area / region of specialization
 Training and research services for issues of national importance

COUNTY HEALTH SERVICES (489 units)

COUNTY HEALTH Comprise all level 4 (primary) hospitals offering:
HOSPITAL
MANAGEMENT MGT TEAM  Comprehensive in patient diagnostic, medical, surgical and rehabilitative care & RH
 Specialized outpatient services and
(47 units)  Management and supportive services for referrals from lower levels
 Support to the County Referral System with other referral facilities

SUB COUNTY HEALTH PRIMARY CARE SERVICES (7,568 units)

Comprise dispensaries, HCs including:
HEALTH MGT FACILITY MGT  Disease prevention and health promotion services
TEAM  Basic outpatient diagnostic, medical surgical & rehabilitative services,
(285 units)  Inpatient services for emergency clients awaiting referral, clients for observation,
and normal delivery services and
 Facilitating referral of clients from Communities, and to referral facilities

COMMUNITY HEALTH SERVICES (8,000 units)

COMMUNITY HEALTH Comprise community units in the county. They comprise individuals, HHs and
communities who carry out appropriate healthy behaviour and:
COMMITTEE  Provide agreed health services,
(8,000 units)  Recognize signs and symptoms of conditions requiring referral, and
 Facilitate community diagnosis, management &referral.

Source: KHSSP July 2012 – June 2018 (Draft). Ministry of Medical Services and Ministry of Public Health & Sanitation

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1.5 Implementation Experience with the CM Model
In the original community midwifery model, a community midwife was expected to
conduct a delivery in a woman’s home. However, findings from recent evaluations show
that women in labour are increasingly demanding to give birth at the community
midwives’ homes. Common reasons cited by women include lack of privacy in their own
homes, inability to keep away children and inadequate space especially where the family
stays in one room. Other reasons cited include long distances, high cost and
uncooperative staff in some facilities. On the other hand, community midwives cited
insecurity (especially at night), long distances and requests from clients to deliver at the
community midwives’ homes as reasons that explain the rising number of deliveries that
take place in their homes1.
In addition, findings from a recent study showed that community midwives have now
improved clients’ access to a comprehensive package of RH/HIV services. These are:
ANC, delivery, post-natal care services including long-term family planning methods, HTC
among others2. The results also showed that although the majority of women in the
reproductive age group are interested in receiving services from community midwives,
few of them are willing to pay for the full cost of these services. For instance, over 90%
of clients were interested in receiving delivery services from community midwives, and
yet only 15% of previous clients and 8% of potential clients3 were willing to pay for
modest increases in the current prices. Hence the need to address sustainability issues
of the community midwifery model.

2. Community Midwifery Model

2.1 Definition
According to a joint statement by WHO, the International Confederation of Midwives
(ICM), and the International Federation of Obstetricians and Gynaecologists (FIGO), a
‘Skilled Birth Attendant’ (SBA) is defined as ‘‘an accredited health professional such as a
midwife, doctor or nurse who has been educated and trained to proficiency in the skills
needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate
postnatal period, and in identification, management and referral of complications in
women and newborns’’ (WHO, 2004).
Midwifery is a healthcare profession in which providers offer care to childbearing
women, labour, childbirth and during the postpartum period. They also care for
newborn and assist mothers to breast feed (WHO, 2012). This Community midwifery
model recognizes deliveries/births conducted by skilled birth attendants at home.

1
Strengthening the Delivery of Comprehensive Reproductive Health Services at the Community Level in
Kenya: Findings of Formative Study; February 2011. Ministry of Public Health and Sanitation/ USAID
2
Willingness to pay for midwifery services: in “Strengthening the Delivery of Comprehensive Reproductive
Health Services through the Community Midwifery Model in Kenya” -2012; APHIA II OR Project in Kenya.
Population Council and Ministry of Public Health and Sanitation, Nairobi, Kenya.
3
In the study cited, previous clients are those who were assisted by community midwives during their last
delivery while potential clients are those who were interested in receiving future assistance from
community midwives during child birth.

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2.2 Selection Criteria
In selection of potential candidates for community midwifery services, the following
prerequisites are essential and should be verified with the relevant professional body4:
 A health professional with evidence of one of the following qualifications:
o Registered Nurse/ Midwife; Enrolled Nurse/ Midwife Registered
o Clinical Officer
o Medical officer
 A retired or out of employment health professional with obstetric/midwifery
skills.
 Has residency within the community to be served.
 Evidence of retention on a professional register (Nursing Council of Kenya, Kenya
Clinical Officers’ Council, the Medical Practitioners and Dentist Board)
For example, see criteria for licensing nurses and midwives by the Nursing Council of
Kenya in Annex 5.

Additional criteria:
The community midwife will be expected to undertake the following activities:
 Get involved in the running of health related or welfare activities within the
community as a sign of the community’s trust in them
 Be ready to be supervised and monitored by the District Health Management
Training and Supervisory Teams ( RH Coordinators)
 Link with the health care system through the nearest health facility for support
such as updates, transport, supplies, equipment and their sterilization
 To work closely with the community leaders and community groups to identify
the most common health problems and work together for a solution.

2.3 Roles and responsibilities of the community midwife

The roles and responsibilities of the community midwife are divided into three key
areas:
 Providing care to women and their family members
 Serving as a link between level I and the formal health system
 Data collection and reporting

4
Adapted from WHO /FCH/RHR/03.11 Working with Individuals , Families and Communities to Improve
Maternal and Newborn Health

5
a) Care provided to women and their families
Under this component, the roles and responsibilities of the community midwife are
divided into two broad areas, namely health promotion activities and service provision
in maternal and newborn as well as other reproductive health service areas.

Health Promotion Activities

Roles and responsibilities of a community midwife in health promotion activities include:
 Provision of information and education on preconception care and early
initiation of antenatal care to women.
 Provision of information on the importance of when and where to seek health
care services during pregnancy, labour and childbirth and the postnatal period
for mother and baby
 Provision of information on importance of testing for HIV and referral for HCT
and PMTCT
 Educating women and their families on the importance of an individualized birth
preparedness and postnatal plan.
 Assisting a woman and her family to prepare a birth, postnatal care plan
including postpartum family planning
 Educating women on the identification of danger signs in pregnancy labour,
childbirth and postnatal period
 Educating women on how to recognize danger signs in the newborn including
sepsis to ensure family seeks early treatment
 Provision of education to clients on how to prepare or plan for emergencies
(funds, support, permission, etc)
 Provision of reproductive health knowledge among women and their male
partners
 Provision of information on the importance of health timing and spacing of
pregnancies
 Provision of information on the importance of breastfeeding.
 Provision of information on the availability of family planning commodities
 Educating women on the importance of completing immunization schedules for
infants/children and TT schedule for women.
 Linking with civil society and the provincial administration in advocating for
skilled attendance for various maternal and newborn care services.

Service provision in maternal and newborn areas and other RH areas

Roles and responsibilities of a community midwife in service provision in maternal and
newborn as well as other reproductive health service areas include:
 Dissemination of key messages to support safe pregnancy and delivery of a
healthy newborn and early childhood care
 Monitoring of pregnancy through FANC (including birth planning and emergency
preparedness, IPT and ITNs for malaria, PMTCT, tetanus toxoid).

6
  Following up with the link facility to ensure that antenatal profile is done
 Giving care to women with uncomplicated labour and delivery (Essential
Obstetric Care)
 Stabilizing women and/or their newborns who have complications prior to
referral. Some of the key drugs to use include oxytocin, antibiotics and MgSO4
and IV fluids.
 Provision of essential newborn care – warmth, resuscitation, , early initiation of
breast feeding, hygiene, etc.
 Provision of targeted postnatal care to women. Specific services to include
information on danger signs, early detection and treatment of problems, Vitamin
A supplements in accordance with WHO guidelines5,6, care of breasts, advise on
caring for the newborn among others.
 Counseling and testing for HIV among the pregnant and postnatal mothers.
 Supporting HIV care including ART adherence, EID, opportunistic infections
management and linkages to HIV support centres and local support groups
 Counseling women on exclusive breast feeding and Lactational Amenorrhoea
Method (LAM) as well as on broader aspects of nutritional counseling
 Receiving or visiting women in labour and assisting them during childbirth.
Working closely with CHEWs and CHWs and recognising the role of each in the
provision of various health services at the community level.
 Promoting the principle of task-shifting in service delivery between community
midwives and community health workers such that the tasks which the latter
group cannot handle are referred to the former. For example, CHWs may
distribute and counsel clients on condom use and also advise women on the
need for skilled attendance at child-birth while community midwives could insert
long acting FP methods and conduct deliveries.
 Counseling women and partners for FP and provision of contraceptives
 Provision of minor curative services as defined in the community heath strategy
 Referral of clients who need for example long acting family planning methods
such as implant, IUCD to other community midwives with appropriate skills or to
facility based skilled providers.
 Referral of clients to health facilities for laboratory tests, immunizations, etc
 Receiving referrals from community health workers for further management.
 Coordination of activities with the health extension workers and community
health committees
 Actively participating in maternal and perinatal death surveillance, review and
response at the community level by using, for an example the verbal autopsy tool
and notification of maternal deaths at the community.

5
WHO Guidelines (2011):Vitamin A supplementation for infants and children 6-59 months of age.
6
WHO Guideline: Vitamin A supplementation in postpartum women. World Health Organization, 2011.

7
b) Linkages and Networks at Level I and with formal health system
The community strategy recommends the delivery of maternal and newborn health
interventions at the community level. Working in close collaboration with the
Community Health Extension Worker (CHEW) and the CHW, the community midwife is
the principal actor in the provision of maternal and newborn health services at the
community level.

In order to work effectively and to enable families access these services, the community
midwife is required to link with other players at the community level and also to
establish regular contacts with various teams as well as the formal health system. As
shown in Fig.2, the community midwife plays a central role and can be instrumental in
facilitating linkages with other key stakeholders.

Figure 2: linkage between social and health service networks7

Convergence Maternal and Newborn Health,

of efforts HTC/ART, Nutrition, Rep. Tract & organ
cancers, FP, RH, Child-health/EPI/IMCI

HMTs
Community, Civil society
Social organisations,
CMs Hospitals,
Health Service
(CHEW) Health
Network development & and centres, Network
health committees CHW
Dispensary

The CM provides the links to the household with special focus on the
pregnant woman, new mother and newborn

Linkage between Local health committees and the community midwife

Local health committees usually organize activities that are often intended to make
significant contributions to the health status and wellbeing of the target community. By
virtue of her/his technical skills in health care provision, the community midwife will be
a co-opted member of the local health committee and a key advisor on maternal and
newborn health issues. The operations of the community midwife will be governed by
the existing policies and structures.
The main role of the local health committees will be resource mobilization (from the
local community and from outside sources to support the work of a community midwife

7
Adapted from WHO /FCH/RHR/03.11 Working with Individuals , Families and Communities to Improve
Maternal and Newborn Health

8
and RH activities in general), educating households on matters pertaining to disease
prevention and control and environmental sanitation and hygiene; family planning,
environmental conservation, food supply and nutrition.
Other roles include providing leadership support for safe pregnancy and childbirth and
facilitating the acquisition of key infrastructure for community health workers and
community midwives such as equipment, IEC materials; supplies such as ITNs, condoms,
household registers, chalkboards and drugs for the treatment of common conditions.
The local community through their health committees will also be responsible for
providing security and where possible they will organize or facilitate transport for the
community midwife to be able to attend to cases promptly or during referral of
emergency cases to health facilities.

Health facility linkage with a community midwife

The health facility in-charges and the facility management teams supported by the
DHMTs or by county and sub-county authorities will provide support to the community
midwife by:
 Overseeing the performance of the community midwife and other extension
workers
 Supplying the community midwife with drugs, equipment and other supplies
 Facilitating referral of clients (or women) with complications or other forms of
emergency to static health facilities by availing transport.
 Providing stationery or forms to the community midwife for monthly reports.
 Strengthening infection prevention and control efforts e.g. in the disposal of
sharps and sterilization of equipment, etc.
 Organizing for in-service training/Continuing Professional Development, involving
the CM in relevant stakeholder meetings, verbal autopsies among other roles.

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Community Midwives and Community Health Workers
Community midwives and other CHEWs will provide overall support to community
health workers with a view to building their skills and knowledge in the core basic and
technical components outlined in their curriculum and training manuals. The
components are divided into two; basic modules and technical modules as outlined in
the Textbox 1.

Text Box 1: Core components under the partnership between community midwives and
other CHEWs with community health workers
Basic Components or Modules Technical Components or Modules
 Community Health, Development and  Water sanitation and hygiene
Partnerships  Community nutrition
 Communications, advocacy, social mobilization  Integrated community case
and networking management
 Management and use of community health  Maternal and Newborn health
information  Family planning
 Governance, leadership and management  HIV/AIDS/STIs, TB and malaria and
 Basic health promotion and disease prevention  Non-communicable diseases
 Basic case management and life-saving skills

Within the maternal and new born health components, the community midwife will
equip the CHW with appropriate skills and knowledge to be able to:
 Advise the woman on preparing the household before delivery (e.g. water,
firewood )
 Advise on items required for the delivery (warm water, clean cloths, pads etc)
 Assist the woman and her family to identify somebody to assist her after childbirth
 Advise family to look out for danger signs in mother and baby (especially in the
first three days)
 Advise the mother/family to register the baby’s birth with the local administration
 Advise on taking baby to health facility for immunizations and growth monitoring
and women for postnatal care
 Map where all pregnant and newly delivered women live
 Encourage the woman’s family to provide social support in pregnancy/ postnatal
period
 Report on any deaths of mothers and infants in the community including any
stillbirths

Referral system
A referral system is an interlinked network of service providers and facilities that provide
a continuum of care for acute and chronic illnesses. A community midwife should be
conversant with referral protocols and be able to refer the client using a referral form
(see Annex 3) to the most appropriate health facility. In the event of an emergency, the
Community Midwife should initiate management, secure transport and alert the
receiving facility.

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c) Data Collection and Compiling of Reports
A community midwife will be able to:
 Compile data, write and submit reports to the local health management teams and
committees promptly.
 Register or advise the woman on where to register the birth
 Notify the civil registration office/health facility of any death in the community
 Share monthly reports with the link health facility using the appropriate register(s)
or document(s) from the ministry of health. The report should include; Number of
women assisted during childbirth; Number registered for birth certification;
Number of Stillbirths (FSB and MSB) and any maternal deaths.
 Document the number of referrals; reasons for referral for both mother and
newborn; means of transport used; source of funds for transport; person
accompanying patient and the outcome of the referral process (if known).

2.4 Practice Setting

Health facility delivery is still the recommended practice. In the event that this is not
possible, a community midwife shall render services in the community where she/he
resides. Thus, a community midwife being a skilled provider may conduct normal
deliveries at the woman’s home or at her/his (i.e. community midwife’s) home.
Among other considerations, the decision regarding the place of delivery at the
community level has to take into account the provisions in the new constitution
especially articles 32, 43, 53-57, 174 and 232 that emphasize freedom of conscience,
belief and opinion, respect and dignity; the client’s right to services including emergency
medical treatment; right of access to quality care; and roles and functions of various
government agencies and institutions in the context of a devolved system of
governance.
In the course of her/his practice, situations could arise where a community midwife may
be required to accompany a client or woman to a health facility. In situations where a
community midwife accompanies a woman in labour to a nearby health facility for
delivery, such a delivery will be considered as a facility based delivery and will be
recorded or notified as such.
A private practitioner may be licensed as a community midwife (see Annex 6) on
condition that she/he assists a woman during childbirth at the woman’s home or in
her/his home. Private practitioners’ who may be licensed as a community mid-wife will
not be allowed to refer women in labour to their private clinics to avoid conflict of
interest and a clash of public health objectives and market or business driven
preferences except in emergencies (where such referrals are permissible under article
43 of the new constitution which states that “....a person shall not be denied emergency
medical treatment”).

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2.5 Scope of Practice
The Community midwives scope of practice is preconception care counselling, normal
pregnancy, childbirth, postpartum, new born care and family planning. Community
midwives will practice within the guidelines and protocols developed by regulating
bodies. Sometimes a woman’s pregnancy moves out of “normal” and her care must be
transferred to a specialist. Even in such a case, supportive care from a midwife will still
be necessary.

Drugs, equipment and supplies

Community midwives will stock and administer the following drugs: oxytocin, antibiotics,
anticonvulsants, analgesics, local anaesthetics, routine haematinics, IPTp in malaria
endemic zones, antihelminthics, PMTCT ARV prophylaxis during labour, intravenous
fluids as per guidelines, antihelminthics, Tetracycline eye ointment, Vitamin K. They
should have sufficient equipment and supplies to be able to perform procedures such as
vaginal examinations, deliveries, perineal tear/episiotomy repairs, injections. (Annex 2)

2.6 Training
All midwives at retirement, resignation or departure of formal employment are qualified
and experienced. However, it is important to note that the environment they start
working in as Community Midwives differs from the formal health facility setting.
Therefore, all skilled health providers who are interested in practising as community
midwives will undergo orientation training before they are accredited/ allowed to
practise in this capacity.
All potential community midwives must complete the following steps:
 Orientation
 Clinical attachment in a busy health facility for skills updates.
 Certification and
 Licensing.

Orientation:
The orientation will focus on the following core skills:
 Maternal and newborn care
 Maternal and perinatal death surveillance and response.
 Recording and reporting data.
 Infection prevention and control
 Family planning
 communication and referral
It is recommended that the community midwives can undertake the following
trainings/orientations:
 Entrepreneurship and marketing skills
 Interpersonal and communication skills.

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Clinical attachment
The practical attachment should be at a busy health facility where there is a high client
load and a range of maternal and newborn health care services provided. The
Community Midwife will be provided with a log book to record required procedures
which should be carried out under supervision. The content to be covered by community
midwives during clinical attachment is outlined in Annex 1.

Certification
Once the Community Midwife has satisfactorily completed all the procedures outlined in
the log book, they will be certified by the Ministry of Health. A regulatory body such as
the (Nursing Council of Kenya or its equivalent) will then issue a license to the health
provider to practice in the community (see Annex 6 for an example of licensing
requirements for community midwives by the NCK). The community midwives will be
required to have relevant regular updates and refresher courses in order to meet
requirements for retention.

3. Process of Implementing Community Midwifery Services

Following proper steps is key to successful implementation of the community midwifery
model. Any county or sub-county entity wishing to start the community midwifery
model or programme should be guided by the following steps or process activities:
Preparation and awareness creation, rapid assessment, reaching consensus,
identification and selection of skilled professionals, implementation and interventions,
follow-up and supervision, monitoring and evaluation and building sustainability
mechanisms.
These steps are detailed in Figure 3 below. Although the steps are organized
chronologically, several actions within each broad step overlap in time and may also be
revisited over time.

13
Figure 3: Implementation Steps for the community midwifery model

A. Preparation, advocacy and creation of awareness: –Key persons or officials in the

departments responsible for reproductive health matters especially maternal and newborn P
health activities and those responsible for community health services introduce and discuss the
need for the community midwifery model in their respective counties/sub-counties or districts
H
with appropriate teams and committees. A plan of action is prepared at this stage. A
S
E
B. Rapid Assessment of maternal and newborn health and services available in the
community/catchment area. Where do majority of the deliveries take place? Who assist women
during childbirth? What are the distances, terrain, transport and communication to the facility?
What hinders optimum utilization of the health facility? Are there professional midwives in the 1
community? Any costs to implement and sustain community midwifery? What challenges are
likely to occur? These should be written up into a short report.

C. Reach consensus –Present findings of assessment and plans at county/sub-county or district

stakeholders’ meeting. This meeting should include representation from DRH, Division of
Community Health Services, officials from county/sub-county or district administrative units
development partners, facility in charges, facility development committees, Community health
committees, CBOs, FBOs, provincial administration and others.

D. Identification and selection of professionals in the community with midwifery knowledge P

and skills.
H
A
E. Implementation of Interventions such as refresher /updates on maternal and newborn care S
for efficiency. This involves a two-week programme on theory and clinical attachment, provision
E
of initial supply of consumables, basic equipment and stationery.

2
F. Follow up and supervision: Closely monitor the activities of the community midwife and assist
in problem solving through the community system, health facility in-charge, and the local
community unit committee and hospital management team as well as through established
county and sub-county health committees and teams.

G. Monitoring and Evaluation: Use of documentation outlined in the community strategy for P
KEPH Level One Services. Periodic evaluation of the impact of the community midwifery model
through in-depth interviews and FGDs with users and providers should be carried out.
H
A
S
E
H. Sustainability mechanisms: Planning for community midwifery activities should be 3
integrated into county or sub-county health facilities’ annual work-plans which constitute the
national health plan and may lead into a SWAp funding mechanism. This will ensure
community midwives’ have equipment, supplies, and stipend for CM services. 3

14
4. Institutional Framework and Implementation Mechanism
For successful implementation of the community midwifery model, all levels (national,
county, sub-county or district and community) have to play complementary and
supportive roles to each other. Good working relationships should be nurtured through
all the phases of programme planning and implementation. Key activities that are critical
in the implementation are addressed under the respective levels of the health care
system.
In accordance with the new constitution and the Kenya Health Policy (2012-2030) four
levels are critical in the management and coordination of health services, namely the
national level, county level, sub-county or primary care level and the community level.
For purposes of simplicity the national or strategic level will deal with policy
stewardship. The county level will provide leadership and management functions while
the community level will be responsible for the day to day running of the community
midwifery activities.

Recognizing that maternal and newborn health is a broad social issue and that a
reduction in maternal and newborn morbidity and mortality will only occur when all line
ministries and other stakeholders work together towards achieving the MDGs, this
chapter is divided into three sections. Each section describes activities at different levels:
strategic, operational and tactical.

4.1 Strategic level

Policy and Stewardship
Key activities at national level revolve around policy and stewardship, creating an
enabling environment which includes licensing, certification and clear policies on the
linkage between the community and the formal health care system. The Ministry of
Health (MOH) will provide overall stewardship and linkage to other line ministries. The
MOH will ensure that the KHSSP and other relevant policy documents (e.g. the
Community Health Strategy and RH policy) are disseminated to counties, sub-counties or
districts and within community units.
Specifically the strategic level will:
 Provide leadership, advocacy and coordination of reproductive health activities at all
levels and among stakeholders.
 Create procedures and regulations(through professional boards and councils for
skilled providers willing to work at the community level) (see NCK criteria in
appendix I)
 Disseminate and distribute policy briefs and discussion papers on emerging MNH
issues such as the implementation of community midwifery in the region
 Advocate for increased funding for RH including stipends for CM.
 Provide support for implementing and scaling up Community Midwifery through the
County Health Management Teams and Regional Training and Supervision teams.
 Mobilise resources including lobbying for increased finances and personnel for
community level activities

15
 Lead/coordinate/ monitor and evaluate Community Midwifery as part of the wider
community approach – joint assessment of progress and enhanced learning
 Organise periodic forums for disseminating results and sharing experiences - to
enable sustainability as well as mutual accountability
 Develop advocacy materials on CM for distribution at county and sub-county levels
 Lead the development of generic IEC and BCC materials for the community
Thus, the key roles of the strategic level will be: coordination, supervision, monitoring,
evaluation training, quality assurance and resource allocation.
As outlined in the previous chapter, the process of implementing the community
midwifery model goes through three broad phases, namely phases I, II and III. Sub-
section 4.2 (operational level) and 4.3 (tactical level) outline the specific actions or tasks
of the main institutions involved in the implementation of the model.

4.2 Operational level

The operational level provides leadership and management in mobilizing resources and
the infrastructure and systems to support the introduction and sustainability of the
community midwifery model. “The County/ sub county Health Management Team and
District Health Management Boards (HMT and HMB) in conjunction with the county/sub
county stakeholders forum, provides governance and technical support respectively to
all Level One Services that include planning, implementation, monitoring and
supervision” (MOH 2006). These institutions through the County/sub county RH Training
and Supervision Team8 will address the following issues in 3 phases:

Phase 1
 Complete an SMNH assessment to identify gaps and challenges to increasing skilled
attendants at birth and the availability of Level One Health Services in the
community.
 Identify community strengths and opportunities in the provision of MNH care
 Create awareness among key sectors on the rationale of community midwifery
model and their respective roles in reducing the high maternal and perinatal
morbidity and mortality
 Create awareness and build consensus on the local situation, strengths, weaknesses
and challenges in maternal and newborn services.
 Share international, national and regional information on the current situation on
maternal and newborn health care services at stakeholders’ forum
 Reach consensus on the way forward and incorporate into County/sub county health
plans – the roles of the various sectors and local government, advocacy and resource
mobilisation
 Involve all stakeholders in improving the well being of families: social services,
provincial administration, planning, and women organizations, CBOs and FBOs

8
Much of the coordination at the operational level is expected to be carried out by the officials in charge
of reproductive health and community health services at the county and sub-county levels.

16
Phase 2
 Facilitate identification and recruitment of Community Midwives
 Identify potential local facilitators to conduct updates and on-job training for CMs
 Facilitate training of trainers for Community Midwives
 Train Community Midwives according to guidelines
 Register all Community Midwives working in the district
 Ensure all Community Midwives have the appropriate licensing documents
 Organizing capacity building and CPD/in-service training
 Identify sources of supplies, equipment and essential drugs
 Provide Community Midwife with necessary equipment
 Ensure re-supply of consumables through facilities and or District stores,
 Support supervision
 Details for communication set up
 Referral mechanisms for emergencies agreed with VHC and HF Management Boards

Phase 3
 Lobby to CDF and other community funds such as LATIF for increased funding
 Coordinate on-going support supervision
 Coordinate monitoring and evaluation implementation of MNH activities
 Compile monitoring data and produce periodic reports
 Facilitate collaboration with stakeholders and secure resources for the program
 Review community level IEC/BCC materials and make recommendations to the
strategic level

4.3 Tactical level - Management of Level One Services

This level will work closely with the operational level. The level of support from
operational level to the tactical level will entail skills transfer, capacity building, resource
deployment, supervision and coordination among other roles. This level will perform the
following tasks in three phases:

Phase 1
 Create awareness and build consensus on the local situation, strengths, weaknesses
and challenges in maternal and newborn services.
 Share regional and district information on the current situation on maternal and
newborn health care services
 Emphasise local status of maternal and newborn indicators and care services.
 Encourage dialogue between community and health service providers
 Strengthen community involvement in decision making
 Establish a link between health sector and community
 Identify cultural beliefs and practices that promote health care seeking behaviour

17
Phase 2
 Discuss the role of the community in the referral system
 Identify existing innovations that worked in the past (revolving funds/ cost
sharing etc)
 Define referral mechanism and provide support to community midwives to:
o Carry out her/his job at night
o Deal with complications when they occur
o Ensure availability of community phone
o Provide linkage to health facility vehicle (where they exist)
 Link with administration to ensure birth and death registration
 Strengthen linkage between the community and the formal health sector.

Phase 3
 Lobby for CDF for increased funding
 Build a health social fund to meet transport and communication expenses for
emergencies
 Monitor community health status and promote early detection of ill-health and
timely action
 Set up maternal and perinatal death review/verbal autopsy sub committee

5. Quality Assurance
5.1 Concepts
In the health sector, quality assurance refers to the practice of managing the way
services are provided to make sure they are kept at high standard. In the context of this
document, the purpose of quality assurance is to assess the performance and quality of
community midwifery services. The quality assurance practice described in these
guidelines is based on the performance and quality improvement (PQI) framework
shown in Fig.4. It was developed by the USAID supported performance improvement
consultative group9.

9
Source: JHPIEGO (2004): Site assessment and strengthening for maternal and newborn health programmes.

18
Figure 4: The Performance and Quality Improvement Process
GET AND MAINTAIN STAKEHOLDER AGREEMENT

CONSIDER DEFINE DESIRED

INSTITUTIONAL PERFORMANCE
CONTEXT
Mission FIND ROOT SELECT IMPLEMENT
CAUSES INTERVENTIONS INTERVENTIONS
Goals GAP
why does the what can be done to
performance gap close the gap?
exist?
Strategies

Culture DESCRIBE ACTUAL

PERFORMANCE
Client &
Community
perspectives
MONITOR AND EVALAUTE PERFORMANCE

Source: JHPIEGO (2004): Site assessment and strengthening for maternal and newborn health programmes.

Quality assurance for CM will take into account the structures, processes and outcomes
to improve the performance and quality of RH services in the community.

5.2 Quality Assurance Core Components

Assessment of the quality of community midwifery activities will focus on three
components:
 Core services that a community midwife ought to provide
 Supportive services that are critical to the provision of community midwifery
model
 Tools for monitoring quality assurance

5.3 Core Services

In accordance with the scope of practice, a CM will provide the following core services:
focused antenatal care, labour and delivery, postpartum care, new born care, FP services
& referral. Key aspects (of these components) to be assessed for quality of care are
outlined in Text Box 2.

19
 Text Box: 2: Quality of care elements for Key MNH components at the Community level
Focused Antenatal Care Labour and Delivery
Find out if CMs are offering the following services: Find out if CMs are offering the following services:
 Early initiation of ANC & 4 timely ANC visits  Monitoring of labour using partograph
 Individualised Birth Plan & Emerg. Preparedness  Clean delivery
 Assessment of danger signs e.g. pallor, oedema  Skilled delivery/care
 History taking (including Previous BOH)  Recording duration of labour, delivery time
 Health messages on FP, BF  Counselling and testing for HIV
 Use of LLINs  Provision of ARV prophylaxis; follow up care
 ANC profile- HB, urinalysis, blood group; VDRL  Antibiotics for premature rupture of membranes
 CT for HIV and follow up care (PMTCT)  Verbal autopsy
 Provision of ARV prophylaxis,  Counselling and referral of clients to facilities for
 IPTp provision in malaria endemic areas PPIUCD (if requested by client)
 Referral for Tetanus Toxoid
 Iron and folic supplements
 Identification of danger signs and First Aid/referral
 Deworming (esp. hookworm)
Post partum care Family Planning
Find out if CMs are offering the following services: Verify the status of the following quality of care indicators
 Early initiation of breast-feeding ; EBF  Equipment and Commodities inventory for FP
 1st PN exam for Mother and Baby (24-48hours)  Condition of Room/where FP services are given
 Counselling on FP method mix  Availability of IEC Materials and activities on FP
 CT HIV and follow up care  Evidence of supervision in the past one month
 Initiation of infant on NVP during breast feeding  Availability of protocols and guidelines on FP
 Mother counselled to return at six weeks  Use of information from clients in the past 3 months
 Encouraging partner involvement  Service Statistics (No. of clients who received FP services
 Use of national guidelines, SOPs, IEC materials from a CM in last 4 completed quarters)

New Born Care Referral

Find out if CMs offer the following services: Assess the CM’s referral activities in terms of:
 Hand washing with soap and water by care giver  Use of referral form/notes
 Recording of Apgar Score assessment  Recording of personal details of clients/patients referred
 Check-up within 24-48 hours after birth  Whether accompanied by CM, relative, etc or not
 Care of the normal newborn (e.g. clearing airway)  Whether mode of referral is socially and culturally
 New born resuscitation acceptable
 Newborn phy. exam including assessing for LBW  Accessibility to the majority of people in the community
 recognition of danger signs  Affordability by the majority of people in the community
 PMTCT: ensure ARV prophylaxis at birth  Appropriateness to majority of people in the community
 Early initiation & support for EBF/infant feeding  Availability on daily basis
 Community based IMCI  Whether managed by local health committees
 Growth monitoring  Availability of revolving fund for emergency transport
 Referral for immunization  Community involvement in referral
 Hygienic cord care  Linkage with a health facility
 Directory of referral sites/facilities with contact details
Source: 1) Maternal, Newborn Health, Child Survival and Development Retreat (With a focus on high impact interventions): Workshop Report; Nakuru;
15-17 March 2010; Ministry of Public Health and Sanitation.
2) Liambila W., Obare F., Birungi H., Wayua Muia R., Maina J., Maina M., Awuor C., Mohamed I., (2011) Linking HIV – Positive Family Planning
Clients to Treatment and Care Services in Kenya; APHIA II OR Project in Kenya/ Population Council: Nairobi, Kenya.
3) WHO (2009): Framework for Developing Model Integrated Community-Level Health, Promotion Interventions in Support of WHO Priority
Programmes Regional Office for Africa, Brazzaville.

20
5.4 Supportive Components
These include:
 Effective leadership
 Availability of equipment, infrastructure and supplies
 Availability and access to policies guidelines, IEC materials e.g. job aids
 Availability of transport, communication facilities
 Effective infection prevention measures
 Evidence of documentation and reporting
 Participation in local maternal and perinatal death review meetings
 Effective health management information system
 Continuing professional development
 Interpersonal communication
 Clients friendly services and feedback
 Mutually supportive linkage with community health workers that promotes task-
shifting with a view to freeing a community midwife from activities that could
effectively be done by a community health worker as she or he concentrates on
performing technical tasks within the community such as providing long acting family
planning methods (e.g. implants and IUCD) and deliveries.
 Effective supportive supervision:
Community midwifery model requires monthly supervision primarily by the link
facility and quarterly by the county/subcounty or district level health management
team. The areas for supervision will include assessing knowledge and skills in the
area of practice to be verified or observed such as infection prevention and control.
Continuing professional development (CPD) of the CM will also be assessed. Log
books will be reviewed to verify CPD progress. CMs require at least 40 hrs of
continuing professional development per year.
 Monitoring and evaluation:
The community midwife (CM) will be expected to report on routine service data to
the facility in-charge on monthly basis. The CM will use the following tools in
compiling the report: Monthly summary reporting forms, patient case notes, referral
forms, community verbal autopsy, antenatal register, delivery register, post natal
register, community midwifery supervisory book, FP Register and birth and death
notification forms. Periodic evaluations of the impact of the model will be done
through review of records, in-depth interviews, community surveys and focus group
discussions.
 Availability of action plan or programme of work by community midwives

21
5.5 Tools for monitoring quality assurance
The tool for monitoring quality assurance is found in Annex 5. Some
Examples of issues to look at are: Management processes, equipment, supplies,
infrastructure, Referral System and RH training/updates in:
 Life savings skills (EmoNC)
 Family planning
 PMTCT
 Partograph use
 FANC
 Post rape trauma counselling

6. Sustainability of Community Midwifery Model

The Ministry of Health’s interest in sustaining the community midwifery model is to
ensure that current programme activities and the proposed ones together with the
benefits they produce are continued long after the initial funding would have stopped
especially from development partners. In this section, three important issues are
addressed, namely, the critical sustainability factors for the community midwifery
model, financing strategies and entrepreneurship.

6.1 Critical Sustainability Factors

Sustainability factors which are critical in ensuring the programme’s success are:
(i) Target group knowledge, attitudes and practice
The degree to which the principal target groups are knowledgeable and motivated to
utilize community midwifery services and their benefits improves sustainability. Low
knowledge, poor motivation and non-use of services are a threat to sustainability.

(ii) Service quality

The degree to which high quality services can continue to be provided in the future is a
pointer towards programme sustainability. Low quality or the absence of key services
can be a threat, while high quality may increase demand for services and support.

(iii) Management support

Management support for activities such as planning and supervision enhances the
chance of sustaining programmes. Weak or missing support services can be a threat to
sustainability.

(iv) Organizational capacity

Effective organisation and coordination of the community midwifery model will
contribute greatly to the sustainability of programme activities.

(v) Policy makers commitments

High, broad-based commitment by policy makers is conducive to sustainability; low,
narrow-based commitment is a threat.

22
(vi) Retention of community midwives
Attrition or loss of community midwives is a threat to sustainability. Their retention will
ensure continuity and stimulate interest in expansion and growth of the programme.

(vii) Adequacy of Revenue

Inadequate income is obviously a threat especially to community midwives who are in
private practice. Community midwives should constantly assess revenue trends, threats
and opportunities with regard to revenue generation especially with regard to funds
meant to support interventions and purchase supplies.

(viii) Programme expenditure

High programme costs are a threat to the sustainability of the community midwifery
model. As with revenue, community midwives should monitor expenditure trends and
make individual efforts to contain costs and improve efficiency in financial management.

6.2 Community Midwifery Financing

Availability of adequate financial resources is critical to efficient and effective
implementation of the community midwifery model. This section identifies and
discusses various sources of financial resources that could support the implementation
of the community midwifery model.

Government (Treasury Allocations)

The need for the government to finance the community midwifery activities is critical.
Services provided by the community midwives have strong components of public goods
(such as preventive activities, health education) and some of them have negative
externalities (e.g., the infectious nature of HIV/AIDS, STIs, immunizable diseases, etc).
Private sector health markets have little incentive in providing public goods, and
therefore, government financing is crucial in enhancing the provision of equitable
services and in sharing healthcare costs across all populations.

The Government may allocate funds to support the implementation of the community
midwifery activities through three potential mechanisms; namely: Health Sector Services
Fund (HSSF), Output Based Aid (OBA) and direct budgetary allocations to community
units under the primary health care/rural health vote or sub-vote.

Health Sector Services Fund (HSSF)

HSSF is a scheme established by the government to disburse funds directly to rural
health facilities to enable them improves services to their local communities. The Fund is
operated by the Ministry of Public Health and Sanitation (MoPHS). The scheme was
established in December 2007 through a legal notice issued by the Minister for Finance
to give local facilities the autonomy to manage their resources and to enable the
communities to participate in health care delivery systems. According to the legal notice
that established the scheme, the funds will be sourced from the exchequer, from grants
or donations, from cost-sharing revenue and from any income generated from the
activities of the fund itself.

23
HSSF provides direct financing to health centres and dispensaries. The fund provides
resources for medical supplies, rehabilitation and equipment and is disbursed in four
installments per year. Since the HSSF targets to benefit all Kenyan households that seek
medical care, local health facility management committees, may decide to use part of
the money as an incentive to community midwives for certain outputs or tasks such as
deliveries, or for the first post partum check-up visit made within 24-48 hours, etc.
This option could be implemented by enhancing the current disbursement levels by a
certain percentage that will be determined on the basis of the number of community
midwives available in each county or sub-county/district/community unit.

Output based Aid (OBA)

Community midwifery activities could be linked to pro-poor financing strategies such as
the Output based aid or Approach (OBA). The OBA is designed to test the best
mechanism of delivering and targeting public subsidies in ways that promote quality
care and maximize utilization by the population living in poverty. The OBA concept is
based on financing agreed upon outputs with pre-defined quality rather than pre
defined inputs by selling vouchers for safe motherhood and neonatal health (SMNH) and
Family Planning services at subsidized prices to clients.

In Kenya, the OBA Voucher Scheme provides access to high quality health services to
poor people as well and, perhaps more importantly; it gives them the opportunity to
choose the health facility – public or private-they wish to go to. The program focuses on
subsidizing maternal and newborn care and family planning services to members who
purchase vouchers and present them to accredited voucher service providers. The
program makes use of a competitive voucher scheme in delivering health services to the
target population during pregnancy labor, childbirth and puerperium including family
planning and new born care.

Despite the intended benefits of this program, there are still a number of clients who
purchase the OBA vouchers but are unable to access the static health facilities due to
various factors such long distance and cultural factors. The CMs operate at the
community level within the reach of the households. Linking CM to OBA program could
address some of these constraints. Since OBA is one of the flagship government
programmes for realising vision 2030, it is anticipated that linking the CM to the OBA
scheme will address sustainability goals of the community midwifery model.

Direct Budgetary allocation to Community Units

As a strategy to strengthen the effort of the Ministry of health (MOH) to reverse the
poor maternal and newborn indicators at the community level, the MOH could allocate
more funds to community units. This will support the provision of various basic curative,
preventive and promotive activities including giving incentives to community midwives
for their labour costs and as a modest compensation for the medical (consumable)
supplies they use in addressing various needs of clients.

These funds could either be channelled through the departments that are in-charge of
reproductive health services or community health services at the national, county or
sub-county levels.

24
Details on the levels and frequency of disbursement and the nature of activities to be
supported could be worked out by the Division of Reproductive Health and the Division
of Community Health Services in collaboration with the department of policy and
planning and local health management teams and committees.

Private financing for community midwifery services

This could be in the form of personal payments made directly to practising community
midwives. User fees fall under this category. Private financing for the community
midwifery services is in line with the guiding principles of RH policy, especially regarding
the need to build participatory approaches with the local community and foster
partnerships in the delivery of RH services.

National Hospital Insurance Fund (NHIF)

This scheme has great potential in attracting additional financial resources to the
community level. The anticipated NHIF reforms, including increasing the benefit package
to cover out-patient services, has the potential to support community midwifery
activities through the link facilities where community midwives are attached.

External Sources (Support from Development Partners)

External funds could support mainly commodities, supplies, training, drugs and technical
assistance. External finance may promote allocative efficiency by targeting funds to
intended purposes or activities. These resources can also be used in enhancing equity
goals and in supporting the establishment of community midwifery activities in
underserved areas.

Donations by Foundations and Charities

A deliberate effort to forge partnerships with foundations and charities could be made,
with a view to engaging them to fully participate in community midwifery activities.

Leveraging of Local Development Funds

In recent years, local leaders have used the Constituency Development Fund (CDF) and
LATF funds to build various infrastructure, including health facilities. With good
justification, it is possible to revisit the initial objectives of these funds and redirect the
strategies towards supporting high impact interventions.

6.3 Entrepreneurship
To sustain the CMs’ services, it has been estimated that the charge for a total package of
ANC, childbirth and PNC should be at least $23 (or about Kshs.2,000) per client. Another
solution for improving the sustainability of the community midwifery model is to
facilitate clusters of CMs to pool their resources through a ‘Merry-Go-Round’. This
approach will enable them to buy supplies in bulk or to purchase equipment that can be
shared. A Merry-Go-Round is an income-generation and resource-mobilization activity
whereby members in a group contribute to a common kitty at specific intervals.

The group contribution is then distributed to members in turns until all members have
had a share. In some counties or districts, CM groups have also linked themselves to

25
local microfinance enterprises (such as the Lugari and Murang’a district midwives) and
benefited from the continuous motivation received from the microfinance field offices.

Business skills training

On average, the CMs were charging approximately US$7 for assisting in childbirth, which
was well below the cost of materials used and did not reflect the time spent. Other
services such as ANC, PNC and newborn care services were being offered free.
Community-wide poverty was cited as the main reason for low or non-payment of fees
and failure to pay debts.

As the majority of CMs do not have any business skills, they lack the capacity to view
their services as a business opportunity that could be used to sustain their livelihood.
There is need to develop a short training module and to conduct business management
skills training for the CMs. The training will equip the midwives with knowledge and skills
to be able to provide midwifery and other services as a business. The training is
expected to:
a) Equip the trainees with entrepreneurship skills and relevant concepts to manage
a successful community midwifery business, including setting realistic prices for
the services provided and identifying strategies for getting paid for the services
provided;
b) Sensitize the trainees with (practical) application of the entrepreneurship and
relevant skills and strategies to develop or initiate successful business.

A training workbook on business skills for beginners could be adapted for use as a
training document in a group training workshop. The workbook has five modules (Text
Box 3) and was designed to help trainees review the business ideas, with the aim of
equipping them with the relevant business management skills.

Tex Box 3: Training workbook on business skills- Possible Modules for adaptation
Module Possible content of the Community Midwifery business skills training
 Personal experience in business
Introduction to
 Characteristics of a good and bad entrepreneur
entrepreneurship
 Self assessment as an entrepreneur
 Knowing your customers
Marketing  Knowing your competitors
 Location of the business
 Cost of business
Organization  Control of quality
 Control of debtors
 Cost of materials
Financing  Projection of income
 Keeping a cash record
Planning  Making a business implementation plan
Source: Annie Mwangi and Charlotte Warren 2008 Taking critical services to the home: scaling-up
home-based maternal and postnatal Care, including FP, through community midwifery in Kenya.
FRONTIERS Final Report; Washington DC.

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6.4 Replenishing Supplies
Replenishing consumable supplies such as drugs, pads, dressings, syringes, needles
among others remains one of the biggest challenges community midwives face. Often
the capacity of community midwives to replenish life-saving drugs such as antibiotics,
anticonvulsants, analgesics, routine haematinics, IPTp in malaria endemic zones, and
basic equipment such as speculum is limited.

Trained midwives should be provided with a range of essential equipment and supplies
by MOH (see annex 2 for the list of recommended equipment and supplies). Although
development partners may assist in offering the initial set of required start-up medical
supplies during the intervention period, subsequently, MOH through county and sub-
county /DHMTs and the link health facilities will be responsible for ensuring that these
supplies are available and that re-fills are obtainable when needed by the community
midwives. In return, the midwives will be required to submit monthly reports on the
number of clients reached.

It is recommended that a social franchise model, which involves a network of providers

(in this case community midwives) be established for community midwives who operate
their own clinics. This arrangement will help to guarantee a steady flow of supplies to
community midwives. The arrangement will also help them standardize payments
(based on services provided). The other advantages of using a social franchise include
quality assurance, rapid scale up of the number of providers (by encouraging others to
join), creates a mechanism for supervision, offers cost-effective services (compared to
other service delivery options) and promotes equity goals (to serve all population groups
emphasizing the poor and those in need).

A social franchise also provides a platform for communicating messages to generate

awareness and demand for services offered by the members of the franchise. In
addition, a franchise ensures that key commodities and supplies are available all the
time and are accessible by those in need.

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Annexes
Annex 1: Clinical attachment
In ANC Clinic
(a) Understand focused antenatal care (diseases prevention and health promotion , IBP)
(b) Participate in Health talks
(c) Head to toe examination including palpations to identify the gestation, lie, presentation
and position
(d) Breast examination
(e) TT immunisation, heamatinics, IPT for malaria ITN
(f) PMTCT
(g) Assist 5 women prepare an individualized birth and postnatal plan
(h) Record all procedures in the appropriate documents (ANC card and registers)

Labour and delivery

(a) Admit women in labour (history taking)
(b) Manage labour using a partogragh
(c) PMTCT
(d) Assist mothers during childbirth (10)
(e) Active management of third stage of labour (AMTSL)
(f) Manual removal of retained placenta
(g) Suturing of any simple tears or episiostomy
(h) Record all procedures in the appropriate documents (delivery, PNC, ANC card)
(i) Familiarize with the data collecting tools
Post natal
a) Carry out complete postnatal check on mother before leaving hospital
b) Carry out complete postnatal check on the baby before discharge
c) PMTCT care and follow-up (know where to refer CCC/support groups etc)
d) Record all procedures on appropriate documents (ANC/PNC card and register)
e) Postnatal check at 14 days
f) Postnatal check at 6 weeks
g) Family planning advice - LAM and transition to other methods
h) Breastfeeding support
i) Essential newborn care - specifically in nursery
j) Health education/counsel the woman eg on danger signs for both mother and newborn
k) Immunisations /child welfare clinic

Documents
o Monthly summary reporting forms
o Patients case notes
o Referral forms
o Partographs
o Maternity Register
o Post natal register
o Mother Child Health Booklet

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Annex 2: Basic requirement of equipment and supplies
The community midwife will have the custody of a minimum of two delivery kits each kit
equipped with the following instruments and supplies

Delivery Kit  Injection oxytocin (5mg/ml)

a) Instruments
 Magnesium sulphate
 Foeto scope
 Calcium gluconate
 Artery forceps (2)
 AntibioticsSuture
 Cord scissors (1)
 Disinfectant (e.g. Hibitane)
 Episiotomies scissors (1)
 Pads/gauze
 Needle holder (1)
 Sodium hypochlorite
 Toothed dissecting forceps
 Baby Weighing scale
 Small galipot (1)
 Bucket with lid for
 Cord ligature (1)
decontamination
 Large kidney dish (1)
Vaginal examination kit
 Mackintosh (1 metre² thick
plastic/rubber)  1 kidney dish

 Suction /mucous extractor  2 gallipots

(penguin)  1 green towel
 Large metal tray with lid  1 speculum
 Newborn Ambu-bag
 Sponge holding forceps
 Blood pressure machine
 Swabs
 Stethoscope
 Thermometer Items for mother/family to ensure are in
 Mackintosh apron the home before birth:
 Clean cloths for drying baby
b) Supplies and drugs  Cloths for wrapping baby
 Gloves  Nappies
 Syringes (2ml, 5ml and 10ml)  Pads
 Needle (21G)  Warm water
 Lignocaine 1%

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Annex 3: Patient referral form
To ……………………………………………………………………….
Dear Sir/Madam

I am referring: …………………………………………………………………………………….……………..………
Age: ………… Para: ……….……..……. Last delivery: ……….……….... LMP: ………….……………….

EDD: ……Gestation: ……………..…… Presented on (date/time) ……………………………………..

With a history of: ……………………………………………….……………………………………………………….

……………………………………………………………………………………………………………………………………

………………………………………………………………………….………………………………………………………..
Last examination (findings)
………………………………………………………………………….………………………………………………………..
…………………………………………………………………………….……………………………………………………..
…………………………………………………………………………….……………………………………………………..
Treatment given…………………………………………………………………………………………………………..
Reason for referral:
………………………………………………………………………………..……….…………………………………………
………………………………………………………………………………..………………………….………………………
……………………………………………………………………………….………………………….……………………….
Thank you.

___________ _________________ ______________ ________________

Village Name printed Signature Date and time of referral

Tear off here and send back to referring provider with escort or relative
To (midwife)………………………………… Date and time……………………… …
Diagnosis:
Management: ………………………………………………………………………………………………………….
Outcome: ……………………………………………………………………………………………………………………..

Thank you.

_____________________ ___________________ _________________

Facility Name printed Signature

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Annex 4: Monthly summary reporting form
Indicate month of data covered in the report………………………………………
County ………………….District: ………………….Division ………………….
Location ………………….Sub-location-………………….Village………………….
Facility linked to ………………….
Antenatal Services Number seen Number referred for
service
First ANC visit
Second visit
Third Visit
Fourth Visit
ANC Profile
Tetanus Toxoid
PMTCT (counselled & tested)
IPT
Anaemia
TB Screening
PET
Eclampsia
APH
Labour and childbirth Complication
Post Partum Haemorrhage
Prolonged/ Obstructed labour
Retained Placenta
Sepsis/Infection
Ruptured Uterus
Malpresentation
Others Specify

Total Number of clients

Assisted childbirth
Mode of NUMBER
delivery LIVE BIRTHS FSB MSB TOTAL
SVD

BREECH

Totals

31
Postnatal services

Assessments NUMBER
Seen Referred TOTAL
Within 24 hrs
Within 3 days
Within 7 days
Within 2 weeks
Within 4-6 wks
Other (specify)
Totals

Neonatal services:

Assessment Number
Seen Referred Total
Babies assessed within 24 hours
Babies assessed within 3 days
Babies assessed within 7 days
Babies assessed within 2 weeks
Babies assessed within 4 – 6 weeks
Referred and reasons for referral
Congenital Abnormalities
Jaundice
Infection
Immunization and growth monitoring
Problems associated with Asphyxia
Prematurity
Low birth wt
Other
Totals

Number of times in contact with the facility linked to…………………………….

Number of community activities attended………… Number of professional updates…..

Midwife’s Name……………….…. Signature………………… Date…………………

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Annex 5. Quality assurance tool
Activity No Yes Comment

CHC and facility Meetings attendance (Evidence

minutes)
Supportive supervision mechanism in place
(Evidence of the supervisor’s notes).
Verbal autopsy Committee in place and meetings
as per guidelines.(Evidence- Minutes, Copies of
completed MPDR forms)
Evidence of Infection prevention and control
measures (eg. Use of decontamination etc)
Documentation and reporting of RH Services
conducted by CM (records)
Utilisation of data generated on RH services for
planning and decision making in Community
midwifery(records, trends)
Appropriate data storage facilities in place (e.g.
cabinet, drawer, cupboard etc)
Current individual work plan for RH activities
Certificate of retention with their respective
regulatory bodies.
Awareness of Roles and responsibilities
Continuing Professional Development
(see- booklet- for updates)
RH training/updates in the last one year.
 Life savings skills (EmoNC)
 AMSTL
 Family planning
 PMTCT
 Partograph use
 Adolescent sexual and reproductive health
 FANC-
 Post rape trauma counselling
 RT/Organs cancer screening & Counselling

Equipment Available Available Not Comment

and but not available
satisfactory satisfactory
General Equipment
Weighing scale – Adult and infant
Functional Portable light/Torch
Digital clinical Thermometer
Blood pressure machine
Stethoscope
Foetal scope

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 Availability of FP
Records
Registers for ANC, CWC, PNC, FP,
Delivery
Mother and child health booklets
Partographs are accurately and
consistently completed
Birth/Death Notification forms
Monthly reports on RH services well
completed

Maternity unit-(ante-natal, labour wards and post natal)

Equipment: Not Available & Available Comments

available not usable & usable

Vaginal Examination Kits –

comment on the no.
Delivery Kit
Resuscitation equipments
Bulb syringe for suction
Ambu bags(newborn and adult)

Referral System
Purpose: To evaluate efficient and effective referral of clients occurs and to assess Knowledge
and practice among CM on referral process

no. Details

Protocols and guidelines on the referral of clients is in

place and known to the staff
CM has access to ambulance or a reliable form of
transport.
The CM accompanies clients during referrals
Existence of functional communication system to alert
the facility of an imminent referral and the telephone
numbers available
CM has forms and registers for recording cases for
referral
Functional feedback mechanism between CM and the
referral facility
Clients records completed by CM
Total
Comment on strengths, weaknesses and recommendations of the facility in the referral process

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Annex 6: Criteria for licensing Community Midwives
Maternal mortality rate is a major public health problem in Kenya. As per the Kenya demographic health
survey of 2008/09 there were 488 maternal deaths per 100,000 live births. Many of these deaths could be
averted if women had access to skilled attendance and essential obstetric care on time. The proportion of
Kenyan women benefiting from institutional care is low partly due to physical and financial issues, while
others prefer the convenience and familiarity of community based health providers or relatives to facility
based services, hence the need for the Nursing Council to develop a policy document to licence nurses and
midwives to offer community midwifery services. This is an effort to compliment government efforts to
th
achieve the 5 millennium development goal.

Criteria for Licensure

1. Must be a Kenyan citizen
2. Must be a registered or enrolled community health nurse or midwife by the Nursing Council of Kenya
3. Must be holding a current practice licence.
4. Must be either, retired, resigned, unemployed or a licensed nurse private practitioner.
5. Must be trained on essential obstetric care and certified by the DHMT.
6. Must present a letter of introduction form the DHMT.
7. Private practitioners may be licensed as community midwives on condition that they deliver the
mothers in their homes.
8. Must have had a 6 months experience in a maternity set up post registration/ enrolment.
9. Must have worked for at least 10 years post registration/enrolment.
10. Must submit, together with application and recommendation letter latest curriculum vitae detailing:
i. Date of registration/enrolment
ii. Registration/enrolment number
iii. Continuing education in the last one year.
iv. Name and address of last employer. (if any)
v. Last date of employment
vi. Areas of practice (deployment) since qualification.
vii. The applicant should also present:
a. Certified copies of registration/license and enrolment certificates
b. Copy of ID card
11. Indicate the nearest health facility where he/she can refer his clients to.
12. Appear in person for initial application and renewal of the license at the Council offices.
13. Will pay the prescribed fee for licensure and license will be renewable every three years.
14. Always carry on them the license when performing the community midwifery services.
15. A midwife undertaking community midwifery must not, except in grave emergency, undertake any
treatment which is outside his/her normal professional practice.
16. A nurse midwife undertaking community midwifery must refer to the nearest health facility all cases
he or she is unable to manage.
17. The midwife must keep custody of all clients’ records and submit a copy to the DHMT at the end of
every month.
18. If the client dies, the midwife in attendance at the time of death or who was called immediately shall
notify the DHMT and police within 48 hours. A midwife undertaking private practice must bear any
legal liability relating to his/her practice.
19. A nurse/midwife undertaking community midwifery must observe rules and regulations set from time
to time by the Nursing Council of Kenya and the DHMT.

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Annex 7: Participants involved in the revision of the CM Guidelines
Number Name Institution/Organization
1. Dr. Issak Bashir Head DRH/MOH
2. Dr. Shiphra Kuria MOH/DRH
3. Dr. Nakato Jumba MOH/DRH
4. Dr. Dan Okoro UNFPA/DRH
5. Dr. Nande Putta UNICEF/DRH
6. Ruth Muia MOH/DRH
7. Judy Maua MOH/DRH
8. Alice Mwangangi MOH/DRH
9. Jane Koech MOH/DCHS
10. Agnes Mutinda MOH/Dept. of Nursing
11. Annie Gituto MOH/DRH
12. Anne K. Njeru MOH/DRH
13. Elizabeth Washika MOH/DRH
14. Milcah Akala Jhpiego-APHIAplus Zone 1
15. Patience Ziroh Jhpiego- APHIAplus Kamili
16. Dr. Marsden Solomon FHI360
17. Jones Abisi FHI360
18. Wilson Liambila Population Council
19. Dr. J. Lavussa WHO
20. Clarice Okumu MOH/DRH
21. Angela Njiru MOH/Nairobi –PMO
22. Lucy Gitonga MOH/Department of Nursing
23. Louisa Muteti Midwifery Chapter
24. Mary Nyawira Nyamboki Nursing Council
25. Catherine Gachanja MOH/RHC Muranga
26. Jane Makona DPHN/RHC- Lugari District
27. Dr. Stephen Mutiso Kenyatta University
28. Margaret Njoroge KMTC

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 For more information, please contact:
Division of Reproductive Health
Old Mbagathi Way
P. O. Box 43319 - 00100
Nairobi, Kenya
www.drh.go.ke

UNFPA