Here is the report that I wrote for the workshop I did a couple weeks ago. I'm not allowed to publish the names of the villages, so that's what all the "A" and "A2's" are. It's long and maybe boring (and poorly formatted for blogspot). There is a personal update at the end if that's all you're interested in.
Maternal and Child Health Workshop
October 28th, 29th, and 30th 2009
Goals and Objectives
Monitoring and Evaluation
Suggestions for Future Workshops
This project was very rewarding. The purpose of this report is to help volunteers replicate it in their sites. Although each site poses unique public health problems, maternal and child health is an area that deserves attention in rural Morocco. I welcome questions and criticisms.
Isolated by towering mountains, the communities of XXX face different public health problems due to their geographic location and economic situation. Tounfite is the local hub: a souq town. It has a large health clinic, a maison d'accouchement, and a place for women to stay pre and post delivery. A and T have a small health clinic and are an hour from Tounfite. T2 and L have a clinic and are about two hours from Tounfite. T3 has no clinic and is approximately four to five hours from Tounfite (two hours from the L clinic). There is a health clinic in A2; T4 and B are about seven kilometers from A2. Tounfite is two to three hours away. Communities that are further from Tounfite must be more self-reliant. Generally speaking, the region is underdeveloped due to its lack of natural resources and harsh environmental conditions that make agriculture only marginally productive. The main sources of income for these communities is herding sheep.
Most women give birth in the home, with the help of their mothers or other female relations, resulting in high rates of maternal and infant mortality. The number of pre-natal visits is also low. Furthermore, lack of access to Ministry health care means that common illnesses, such as diarrhea, can be fatal. Therefore, preventive health measures are crucial.
This workshop was the second in two years. Last year’s training, hosted by Mara Hansen, focused primarily on birthing. Given the difficulty of training women to be midwives in three days and other health issues facing the communities, the focus for this year’s training was slightly altered. In addition to pregnancy and birthing, more general health issues such as hygiene, oral rehydration liquid, and family planning were covered. Furthermore, the training focused on enabling the women to be health care advocates in their communities. Thus, the women were asked to simulate teaching exercises in order to build these skills. Finally, without the assistance and support of men in these communities, a comprehensive solution will not be found. Thus, on the final day of the training, community leaders from each village were invited to create a community action plan to be implemented following the training.
• Volunteers (Duncan Gromko, Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan) were responsible for recruiting women, planning the workshop curriculum, securing Ministry permission, assisting in lessons, and ensuring that all logistical issues were taken care of.
• Ministry of Health employees (MOH Khenifra representative, two Tounfite sage-femmes, and Agoudim doctor) were responsible for conducting the training. MOH Khenifra representative gave introductory remarks and a quick lesson on hygiene. Tounfite sage-femmes did the majority of the lessons, focusing on birthing and pre/post-natal care. Agoudim doctor did a lesson on basic hygiene, first aid, and oral rehydration. The Ministry also provided a space for the lesson and photocopies of the lesson booklet.
• 25 women from rural communities (A: 5, T2: 3, B: 2, T3: 2, L: 2, T4: 1, A2: 2, T5: 3, Tounfite: 4, A3: 1)
• 7 community leaders were in attendance for the final afternoon session
• Two Tounfite women cooked food for and hosted the women for three days and four nights
Goals and Objectives
To improve maternal and child health in the villages of XXX by teaching 25 women basic health lessons and creating opportunities for them to become community health advocates.
• 25 women will demonstrate understanding of the following topics
o The importance of pre/post natal visits to the medical clinic
o Healthy pre/post natal practices in the home
o Identification and referral of high-risk patients to local birthing centers (maison d’accouchement)
o Safe home birthing practices
o Preventing infant diarrhea, oral rehydration
o Different contraceptive methods (birth control pill, condoms, IUD, the shot)
• Two midwives and one doctor will acquire new instructional methods and increase their ability to promote healthy behaviors among rural populations
• 25 women and 10 community leaders will create community action plans to bring the lessons from the training back to their communities
Long term objectives:
• Number of pre-natal visits to local health clinics (Tounfite, A2, A, and L) will increase
• Number of births in maison d’accouchement in Tounfite will increase
• Number of infant deaths related to diarrheal diseases will decrease
• Contraceptive methods will be used more frequently and with greater efficacy
• Each village will hold community wide meetings, conducted by the women from the training, volunteers, community leaders, and Ministry of Health staff, to disseminate the lessons from the training
• May – Informally propose project to Ministry of Health
• June and July – Recruit women to attend workshop
• July – Discuss curriculum with doctor and sage-femmes
• September – Formal approval from Ministry of Health
• October 20th-27th Finalize workshop logistics
• October 28th-30th Workshop
• November and December - Community meetings
Transportation for women - 600 Dhs
Lodging/food for women - 3,000 Dhs
Pay for women - 2,400 Dhs
Photocopies - 400 Dhs (Ministry of Health)
Break food, misc. - 400 Dhs
Using Tounfite maison d'accouchement (In kind)
Time of Tounfite Ministry of Health Staff (In kind)
Printing photos - 60 Dhs
Gifts for trainers - 180 Dhs
Total - 7,040 Dhs
Pre-natal care: home
Identifying risky pregnancies
Pre-natal care: sbitar
Healthy practices: preparing for birth
Healthy practices: birthing
Community groups meet to formulate action plan
Community groups present plan to larger group
Transportation for the women was fairly straightforward. Mostly, they were responsible for finding their own transport. They were reimbursed at conclusion of training.
Feeding of women was difficult. Having a Moroccan family host and feed the women (women who had no family in Tounfite) was critical. It took a lot of responsibility off of the hands of the volunteer. It was expensive, but well worth the expense. We took care of break food (tea, peanuts, pastries), which was easy for volunteers who were not participating in the training to be responsible for. Having seven volunteers there to take care of various unexpected odds and ends was important.
Organizing and participating in this training was very rewarding. The women were very appreciative and enjoyed the training. On the final day, there was a celebration dinner with an ahaydus, where the women sang praises of the volunteers.
The final session of the training, with community leaders attending, was the most important session of the training. Hopefully, it will provide the women (and volunteers) with community partners to help with further education efforts. During the session, each community group made an action plan as to how they would disseminate information to the appropriate people. The group was asked to review the lessons of the training and decide which lessons were most important in their community, based upon their health needs. Inviting men and asking them to take a stake in the health of women in their community was critical to the success of the training. It will make future work much easier. At the conclusion of the training, each community group was asking me when I was going to come to their village to do a smaller version of the workshop with them.
Another highlight from the final meeting was a particularly impassioned speech made by a 23 year-old woman from T4, named Turia. She stood up in front of women and men and demanded that people take better care of their women. She said that men had a responsibility to provide for their women. She said that women ought to stand up for one another (and themselves) when they witness oppression. She emphasized the importance of the community helping itself and not waiting for outside help to come and save it. It was a moving speech that was an excellent way to conclude the training.
The most difficult part of the training was the difficulty of sticking to the schedule. Events beyond anyone's control demanded that lessons be moved around. For example, each of the sage-femmes was called away to Khenifra on one of the training days, leaving the other to teach lessons by herself. Another difficulty arose when, on Thursday morning, a woman came into the maison d'accouchement in labor. With only one sage-femme at the center, we were momentarily left without a trainer. But, in this instance and others, we were flexible and made productive use of the time.
Language was a small problem. On the first day, the sage-femme leading the training was a Tamazight speaker, which made the lessons and communication easy. On the second day, the sage-femme and doctor who led the sessions were Arabic only speakers, necessitating a translator. While the translator did an admirable job, it is difficult to have as fluid of a conversation speaking through a translator.
Shame about the health topics covered was a small problem. Males were excluded from the training room for the sensitive training sessions, reducing that problem. On the last day, when men were invited, some people were uncomfortable. One man opened up the training booklet (which contains some graphic pictures), stood up, and left. He was the only one to leave, however. Although people were uncomfortable for this session, I believe that was unavoidable. The only thing I would change is to be sure that the training booklet remains closed.
Some of the women were not actively participating in the lessons. One woman fell asleep. There are a couple explanations. First, asking these women to concentrate for hours on end is inherently problematic. Most of them haven't been in a school setting for years. Second, recruiting women is difficult. It is not easy to predict (especially as a male) who will actively participate in the training. The more time spent before the training evaluating potential trainees, the better.
Organizing the training was a lot of work. Having the help of six other volunteers was critical.
Another challenge during the training was the use of handout (visual aids) that corresponded with the lessons of the training. The trainers did not consistently utilize the materials and the women had a difficult time following along. A large flip-chart, that corresponded with the handouts, would make it easier for trainees to follow along.
A three day workshop is inherently limiting. It was difficult to fit the entire curriculum into the three days an ensure that all of the women were absorbing all of the information. Narrowing the breadth of the training may be necessary.
Monitoring and Evaluation
Monitoring the ability of this training to reach its goals and objectives is both important and difficult. It is important to monitor the success of the training because doing so will inform volunteers’ future work. It is difficult because there are many complicating variables. Furthermore, the success of this training is not entirely captured by measureable numbers. Simply promoting women’s health in such a public manner was a success in itself.
The objectives for the training were mostly met. Most women were actively engaged in the lessons and were able to explain the topics to each other and volunteers when asked. There was a minority of women who did not focus on the lessons for the entirety of the training (one woman fell asleep), but these women were the exception, not the rule. Furthermore, expecting middle age women who have not been in a classroom setting for 30 years (if ever) to focus for three straight days is asking a lot. The women did remarkably well at focusing. The instructors of the training (Ministry of Health staff) deserve credit for making the lessons interesting and engaging. The objective of each community deciding upon a community action plan was also met as discussed above.
It is too early to judge whether the long-term objectives for the training have been met. Pre-natal visits and births in the maison d’accouchment can be measured by comparing Ministry statistics from before and after the training. This will not be a perfect indicator, however, as there could be other factors contributing to an increase in pre-natal visits (ie the Lougagh nurse is new; one can expect that he will get more visits as the community gains trust in him). In addition to comparing Ministry statistics, there is another method of measuring pre-natal visits and births in the health clinic. Each woman was given ten “referral” cards: a small sheet of paper with a picture of a pregnant woman going to the health clinic. Each card has the woman’s name on the back. The women were instructed to give the cards to pregnant women when they recommend a health clinic visit. The pregnant women will then give the card to the health clinic staff, to be later counted by a Peace Corps volunteer. If this system is effective, it will give a clear indication of the training’s reach and effectiveness. Three weeks after the training, early returns from the referral cards are very positive. Ten cards have been turned into the A health clinic (referrals from five different trainees) and two cards have been turned into the L health clinic (one trainee). In addition to providing volunteers with a means of monitoring activity, they also give trainees motivation to make referrals.
It will be difficult to judge whether or not deaths from diarrheal diseases decrease or contraceptive devices are used more effectively. Statistics are not currently kept on this sort of thing. Witnessing behavior change will be the surest way to judge if those lessons were effective.
If the community wide meetings hosted by women from the training, Ministry of Health staff, community leaders, and Peace Corps volunteers are held, that will be a clear indication of the training’s success. These meetings will force the communities to engage about the health issues facing them and how they can be most effectively addressed. If the meetings are well-run, then they will allow other objectives to be met. Three weeks after the training, one community meeting has been held with several others planned for the coming weeks.
Suggestions for Future Workshops
Although the workshop was interactive and engaging, improvements could been made. Any activities that force the women to stand up and physically be involved are positive. If time had permitted, the schedule would have included an entire "teach back" session, where the women are asked to teach other trainees lessons that they had just learned. This would reinforce the lessons in their heads and give them the skills for talking to other women.
Another suggestion for keeping the women engaged is to include stretching breaks with the tea breaks. Anything to get the women to stand up and move around for five minutes.
A final way of addressing the problem of inattentive women is a better recruiting and vetting process. The more time that a recruiter can spend with the women before mentioning the workshop, the better. I mentioned a speech given by Turia at the final session. In addition to that speech, she was critical in bridging the cultural gap between the Ministry of Health staff and the women. Other women were also important contributors to raising the energy level of the training and helping other women understand the difficult concepts. Recruiting is a critical step in making the training a success. Invite active, strong women. Having a variety of ages is also helpful: older women have more experience, but younger women tend to be more active. Invite community leaders who you can imagine working with after the training.
In future trainings, it would be helpful to give the women a "test" at the conclusion of the training to more formally gauge their competencies. Furthermore, having feedback from the trainees at the conclusion of the training would be a good way to improve future workshops.
The workshop was a very rewarding project. Hopefully, it will be a catalyst for creating wide-spread behavior change in a number of communities. It is important to emphasize, however, that the workshop is only a first step. If villages do not follow through on their community action plans, the reach of the workshop will be limited.
For any volunteer that identifies maternal and child health as a community health priority, I recommend considering a project similar to this workshop. It is an effective way of addressing the problem. However, it is critical to tailor the project to the community's assets and deficits. A community that has easy access to a functional maison d'accouchement needs a much different training than one with no access. It is also critical to consider the ability of the Ministry of Health staff to lead the training. In Tounfite, our staff is very capable and did an excellent job with the training. Two of the trainers attended last year's workshop, meaning that they had experience. Furthermore, it is important to have a common language between the MOH staff and the volunteer so there can be fluid communication about the curriculum and problems that arise during the course of the workshop. Another consideration is the size and location of the workshop. This was a large workshop in our souq town. It would be easier to facilitate a smaller workshop in the town of the women. Depending on the situation, it may be easier and more effective to have several small trainings, rather than one large one.
It is also important to consider the strengths of the volunteer. As a man, it was easier for me to persuade community leaders to attend the final session. It was also easier for me to make contacts in outer douars for recruiting. On the other hand, it was more difficult for me to thoroughly vet the women before the training. Also, I was unable to be in the training room for most of the training. An effective training is going to utilize male and female volunteers.
This workshop would not have been possible without a long list of people. Rachida, Wafa, and Selua (Ministry of Health staff: Tounfite) did an outstanding job conducting the training; they reached out to the women and made it engaging and interactive. The Ministry of Health in Khenifra, in particular Sidi Aissa gave me permission to use their facilities, workers, and provided training booklets for the women. Sidi Aissa also helped me figure out the paperwork at the Ministry and led an excellent opening session at the workshop. The entire Tounfite health clinic staff was helpful as well, thanks to Lahcen, the Medicin Chef. Mamaksu and Baha worked day and night for 4 straight days to provide the women with food and housing. My programming staff, Mostafa Lamqaddam and Rachid Lamjaimer, provided advice and support. The volunteers who helped on the project: Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan did everything I asked them to do and plenty of things I forgot to ask of them. Mark and Joyce Gromko, Mary Ellen Newport, and Kristin and David LaFever all contributed financially. Kristin and David LaFever and Mara Hansen deserve thanks for showing me how to run a workshop last year.
Had first follow-up community meeting in my village (A) with men. It went quite well. I'm hoping to do similar meetings in 3-4 other villages. And meetings with women as well. I have three scheduled for next week. The main lessons are: pre-natal visits, birth in Tounfite (not in house), hygiene, and birth control.
On Monday I painted two rooms of my host family's house. I liked doing it because it was the first time that I've had a skill that people here valued (I've done lots of painting work before).
On Wednesday the local police (in Tounfite) called me during lunch and told me to come immediately to Tounfite (one hour away). They told me to bring my ID card. I told them that it expired months ago and that I had already applied to them for a new one. They had my old copy. When I got to the office, they asked me for my card. I explained to them again that they had taken my old card. They asked if I had a photocopy of the card, and I told them that it was in their files. They looked through my paperwork and sure enough, there it was. They said I could go home. Very typical.