From Local Action to National Results: How Community Health Workers Are Helping to Improve Maternal Health in Rwanda
Only two decades after the genocide in Rwanda, the country’s health sector has made remarkable progress towards improving people’s health and wellbeing, particularly among women and children. Rwanda’s maternal mortality ratio decreased from 1,020 deaths per 100,000 live births in 2000 to 290 deaths per 100,000 live births in 2015, making Rwanda one of the few countries that achieved Millennium Development Goal 5A. To maintain progress in the era of the Sustainable Development Goals (SDGs), Rwanda aims to reduce preventable maternal deaths by strengthening cross-sector involvement in the health system.
One strategy that Rwanda has used to improve maternal health is engaging voluntary community health workers (CHWs) known as Animatrice de Santé Maternelle (ASMs). Supervised through community health centers, ASMs work in collaboration with two other voluntary CHWs to monitor health at the most local level, undertake health promotion activities and connect people—especially those living in rural areas—with the formal health system as necessary. The percentage of births assisted by skilled birth attendants in Rwanda increased from 26.7% in 2000 to 69% in 2010, and during that same period, the rate of contraceptive use increased from 4% to 45.1%. Evidence indicates that ASMs have played an important role in achieving these outcomes.
Who are Rwanda’s ASMs?
Every village of roughly 300-450 residents has one male CHW and two female CHWs—one of whom will become the ASM for that village who is specifically in charge of maternal and newborn health. The other two CHWs lead community health efforts for other community members with a focus on children between the ages of one and five years. The three CHWs are active members of their communities and are elected by members of the village. When an existing CHW steps down from his or her position, the village leaders collaborate with the health center to organize an election. Qualifications of ASMs include:
- Being between the ages of 25 and 50 years old
- Attaining at least a primary school education level
- Exhibiting strong interpersonal skills and a passion for maternal health
- Residing in the village where they work
- Having flexible schedules in case they are needed for service provision and training
During community gatherings and home visits, ASMs provide several services for pregnant women and infants, including:
- Registering all women of reproductive age and identifying those who are pregnant in the community to encourage antenatal care attendance and facility-based deliveries
- Promoting healthy behaviors during pregnancy and the postpartum period
- Accompanying women in labor to the health facility
- Disseminating misoprostol as a uterotonic to pregnant women for self-administration following birth in case they deliver unexpectedly at home
- Making early postpartum home visits to identify danger signs and refer women to the health facility as needed
Depending on their availability and personal schedules, ASMs dedicate time to visit each household in the village at least once per month. Ideally, ASMs are reachable at all times given the unpredictable nature of childbirth.
Collaboration with health facilities
There are roughly 45 villages in the catchment area of a community health center, translating to about 45 ASMs who report to one of 420 community health centers in Rwanda. ASMs report monthly to health centers on key maternal and newborn health indicators in their communities such as the number of pregnant women and deliveries, incidences of maternal mortality and morbidity and their causes, mosquito net usage and iron supplementation.
ASMs affiliated with a particular health center meet every month to discuss overall maternal health challenges and goals. Using mobile technology, ASMs remind pregnant women about their upcoming antenatal care appointments and share that information with health centers. Using the same technology, ASMs can call for an ambulance in cases of obstetric emergencies and facilitate referrals to higher level care.
Challenges and opportunities
Despite the remarkable contribution of ASMs to Rwanda’s improved maternal health landscape, much remains to strengthen their role in care provision and health promotion. For example, there are some village residents who avoid ASMs entirely, considering them to be unskilled, which leads to difficulties in monitoring maternal health in communities. Additionally, the limited number of training programs for ASMs, heavy workloads and poor financial incentives hinder the motivation and impact of ASMs. Addressing these challenges to support the ASM program could help Rwanda achieve the SDGs and sustain recent progress in maternal health.
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