APE (Community Health Worker) Plays Critical Role Reducing Maternal and Neonatal Mortality in Remote Rural Areas

Adolfo Guambe with baby Laura and APE, Judith, talking to Hortencia who is holding her other twin, Albert.

Six months ago, Belamina Judith, a community health worker, received an emergency phone call from Antonio Manuel. His wife, Hortencia, was expecting twins and had gone into labour before she had a chance to reach the hospital.

Straightaway, Judith trekked for one hour across sandy pathways that cut through a landscape of endless palm trees to reach Hortencia’s home, in Catine, a remote locality in the district of Homoine, in the southern province of Inhambane. She found Hortencia had given birth to a baby girl at home with the help of her mother-in-law, but the second baby was still inside and hardly moving.

As the only public transport for the day had already gone, Judith organized a private taxi that cost 1,000 meticais (around US$20). They travelled together on the bumpy dirt tracks with the baby girl still joined to Hortencia by the umbilical cord. Hortencia was suffering acute labour pains with the second unborn baby. It took them four hours to reach the health centre. “I had to tell the driver to go slowly,” says Judith.

Mardel Juma, a child radio producer in the capital, Maputo
Mardel Juma, a child radio producer in the capital, Maputo, and an activist (volunteer) for sexual and reproductive health gives talks at schools and community centres to sensitize young people about all preventable illnesses. In the future, Mardel would like to continue to make radio programmes but also wants to be a doctor.
"I want to work in rural areas because so many doctors are concentrated in cities" — Mardel, 14.

When they arrived at the health centre, a midwife attended to Hortencia, and Judith waited for four hours until Hortencia finally gave birth to a boy. But as the boy had difficulties breathing, Hortencia and her babies were rushed by ambulance to the hospital in Homoine, at which point Judith made the journey back home alone.

Six months later, Judith is holding baby Laura, who is trying her best to play with Judith’s smart phone, while Judith chats to Hortencia, who is cradling baby Albert. The babies look healthily chubby, belying their traumatic entry into the world.

Hortencia looks well too, although she complains of aches, hardly surprising as she has a heavy workload which includes fetching water twice a day, each trip taking over one hour. Moreover, Hortencia is a mother of six children; and she lost two children under the age of 5 years due, she says, to “fevers”. “They died at home as there were no APEs in those days,” says Hortencia, who has also had one miscarriage.

As they chat and play with the twins, the warm rapport between Hortencia and Judith is obvious. Hortencia comments that Judith looked after her well during her pregnancy, and visited her soon after she returned home from hospital in order to give her chlorhexidine gel to stop infection of the umbilical cord. Judith then visited Hortencia every couple of days during the first 28 days after giving birth, a critical period as more than one third of all child deaths occur during the first 28 days.

Hortencia concedes, “She (Judith) had told me to go to the maternity waiting home at the eighth month, but I didn’t make it.” Hortencia, however, made three out of the four recommended antenatal visits at the health centre. She also remembers clearly the long trip to the health centre. “She (Judith) kept telling the driver to go more slowly. And when she returned home, she phoned me regularly at the hospital to ask how we were.”

Hortencia is just one of many who appreciate the work of community health workers, known as Agente Polivalente Elementar (APE), or ‘Multi-use elementary agent’ in English. The Chief Doctor at Homoine hospital, Milton Mozambique, says, “We need more APEs as they are playing a major role in reducing child and maternal mortality.”

APEs have also been trained to use a health application called “upScale” on smartphones provided to them, which has improved child case management.

He adds that the APEs have also been trained to use a health application called “upScale” on smartphones provided to them, which has improved child case management. “We are able to monitor the APEs’ management of each case through the application.”

The smartphone programme, is implemented by the Ministry of Health with the support of Malaria Consortium and UNICEF and financial support of UKAID. As well as receiving vital information through the smartphone which is used for health prevention, diagnosis and treatment of childhood illnesses, the APE must enter all the data about each case he or she treats.

Nurse Edita Joao agrees that since she first started working as a nurse 19 years ago, she has seen a huge improvement in mother and child health care, partly due to the APE programme. She highlights that, “The APEs are contributing to family planning and sensitizing pregnant women to come to the health centres to deliver.”

Last year, the hospital at Homoine reported two cases of maternal mortality, one of whom was a woman who had spent three days in labour and had sought treatment from a traditional healer before coming to the hospital. “The baby was born alive but the mother died 30 minutes later,” says nurse Joao.

Like all APEs throughout the country, Judith only had to be able to read and write and be elected by the community to qualify for APE training. The course consists of four months basic training, a further two weeks of training to use the smart phone application, Commcare, and, last year, another two-week training was introduced with UNICEF support on how to care for pregnant women and new mothers and their infants. This training included how to use chlorhexidine gel for umbilical cord care and misoprostol to prevent and treat postpartum haemorrhage.

“About 60 per cent of Mozambique’s population live more than eight kilometres from a health facility, a national commitment to deploy APEs in remote communities is a critical step to improve access to health care.” — James McQuenPatterson, UNICEF.

UNICEF Chief of Health and Nutrition, James McQuen Patterson, highlights how APEs help bring health care closer to people in need. “As about 60 per cent of Mozambique’s population live more than eight kilometres from a health facility, a national commitment to deploy APEs in remote communities is a critical step to improve access to health care.”

As for Judith, she too appreciates the fact that she was selected to be an APE.

“Now I know how to diagnose and treat children for fevers and other illnesses at home” — Judith, APE, Inhambane.

APE Judith with baby Laura Although the work is demanding – sometimes she has to walk about three hours to make home visits and she only receives 1,200 meticias a month (about US$20) – she says it is worth it. “I have been able to improve the health of my community and also my own children. She remembers how, like Hortencia, she lost two of her children to fevers, possibly malaria, one on the way to the hospital. “Now I know how to diagnose and treat children for fevers and other illnesses at home.” She has also learnt how to refer cases of malaria, diarrhoea and pneumonia with complications.

“It has made a big impression on me that both Hortencia and Belamina (Judith) lost children during a time when there was no APE and now with the APE programme, their children are surviving” — Adolfo Guambe, Public Health Officer and Coordinator of the APEs

Adolfo Guambe, the public health officer and coordinator of the APEs at provincial level, who uses the opportunity to help Judith enter some data on her smart phone, says he is encouraged with the work of the APEs. “It has made a big impression on me that both Hortencia and Belamina (Judith) lost children during a time when there was no APE and now with the APE programme, their children are surviving.”

Judith also feels encouraged by the number of women she has been able to convince to deliver at the hospital. “Most women now give birth at the hospital, she says.