Follow Us HCI Project on FacebookHCI Project on TwitterHCI Project on Vimeo
Why Register?     Register      Login

Kenya | ANC and PMTCT Demonstration Collaborative in Kwale District

Collaborative Profile
District Health Management Teams; APHIAplus

Topics: Maternal, Newborn and Child Health, PMTCT

Region and Country: Kenya

Date improvement activities began: 
March, 2011

Improve evidence based antenatal care and PMTCT services at facility and community levels in Kenya.

Implementation package/interventions: 

Root cause analysis conducted by the participants revealed 2 main categories for causes of weak utilization of maternal health services – health facility and community root causes. The health facility causes include staff shortage, poor staff attitude and shortage in medical supplies. At the community level, causes included long distance from the health facility, lack of transportation, cultural and gender factors, such as the need to obtain the husband’s approval to seek ANC, that prevent pregnant women from seeking care on time. The QI teams explored several innovative change ideas for improving utilization of maternal health services, some of which include improving health facility services to attract community members and integrating ANC services within ongoing immunization outreach visits in order to reach pregnant women who cannot come to the health facility. Some of the changes teams have been testing are listed below.
Teams have engaged in process mapping and tracked ANC clients from arrival, noting the time at each service delivery point and recording movements to ascertain the total time taken from arrival to departure. Time-wasting steps were eliminated and other services integrated to reduce movement of clients. The initial, average time of three hours 35 minutes has been reduced to one hour.
To improve outreach, some teams have begun doing outreach on weekends when more staff are available and have made changes to make examination of mothers in outreach sites more acceptable and comfortable. For example, Kwale Hospital mobilized the community to raise funds to purchase an examination couch and a classroom was given out to be used by the outreach team and the community donated curtains to ensure privacy of mothers during examination. Teams have also formed ANC support groups where expectant mothers meet regularly to discuss issues related to safe motherhood including having a birth plan. After delivery, the mothers graduate to a breastfeeding support group. Teams have also redesignated TBAs to birth companions. They now make sure pregnant women in their villages attend early ANC, complete at least four ANC visits and accompany them to the dispensary to deliver.
Teams have also made use of mobile technology, and health workers give their mobile phone numbers to traditional birth attendants so that they can call the health workers anytime they have a client to bring to the facility for ANC visits or delivery. Additionally, in Shimba Hills, facility personnel are calling pregnant women to remind them of their ANC appointment, birth preparedness and health facility delivery. This is done a week before the appointment date. Contact numbers and consent to call the women are taken during the initial ANC visit.
To improve the quality of services provided, teams have set aside specific facility rooms to be used exclusively for deliveries and not for mixed services. Other teams have solicited and received support to construct delivery rooms.


Teams are tracking the following indicators: percentage of pregnant women completing four antenatal visits; percentage of pregnant women with first ANC visit at <16 weeks of gestation; percentage of pregnant women receiving at least three months of iron and folate supplements; percentage of pregnant women whose blood pressure, blood group & haemoglobin levels were documented; percentage of pregnant women receiving counseling for birth planning, danger signs and family planning; percentage of HIV+ pregnant women receiving ARV prophylaxis.

Number of sites/coverage: 

This collaborative is in Kwale District which has a total population of 160,000. HCI is working in 21 facilities.


Coaches are comprised mainly of senior staff from the District Health Management Team who were trained by an HCI consultant in quality improvement. Coaches also served as facilitators for the all learning sessions. Having coaches assume this role has not only assured capacity-building of the district staff, but also allowed for active participation of the attendees, with whom they had built rapport through coaching visits.

Learning sessions & communication among teams: 

The first learning session was conducted in September 2011 . The second learning session was held in February 2012. Some change ideas discussed included the following: Integrating ANC in outreach visits. Teams discussed challenges of integrating ANC in outreach visits, defining criteria for selecting sites for outreaches, ideas on how to find privacy and space for clinical examination during outreaches, arranging transport for outreaches, ensuring adequate care at the facility when staff was gone for outreaches etc.; Formation of ANC support groups where pregnant women can meet and discuss issues related to safe motherhood; Engaging TBAs as community linkages with pregnant women and encouraging TBAs to bring in pregnant women to the facility for ANC. Giving phone numbers to TBAs so that they can contact the facility anytime they have to bring a client to the facility; Contacting pregnant women by phone to ensure completion of the recommended 4 visits. The third learning session of the project was held in August 2012.While the previous learning sessions included teaching, this one was reserved for sharing experiences. The participants included representatives of the quality improvement teams, health workers, administrative officers, community members, DHMT members from Kwale, Kinango and Msambweni Districts, HCI staff, representatives from the provincial health offices and the Ministry Headquarters.


To date, a number of improvements have been seen. There has been a remarkable increase in the availability of iron and folic acid in participating health facilities. This improvement came as a result of collaboration between the national-level Kenya Medical Supplies Agency (KEMSA) and district-level staff as well as from the decision of the health facilities to use their own funds to replenish the supply of folic acid to avoid stock outs. Kwale County was recognized on a national level as having the best data quality in the country, the DHMT credits the quality improvement efforts in the district for the improvement in data quality. USAID/Kenya and its national partners paid a visit to the implementation sites for the HCI collaborative to learn about the QI approaches used and recognized the successful outcomes achieved and recommended the application of the improvement approach at a national scale. The remarkable improvement in the administration of folate and iron supplements for pregnant women was documented in a HCI flyer entitled ‘Improving iron and folate availability for Antenatal Care in Kenya’ available below.
The percentage of pregnant women delivered by skilled birth attendants increased from a low of 33% in January 2011 to 50% in June 2012 of the estimated number of pregnant women in the district. The percentage of pregnant women completing at least 4 ANC visits increased from 37% to 54% of the estimated number of pregnant women in the district from January 2011 to June 2012. The percentage of pregnant women starting ANC in first trimester also increased from 7% to 21% in the same period.
Regarding the quality of ANC services, all women receiving ANC services in the district have their blood pressure measured in every visit as opposed to only 32% before the start of the QI collaborative in Kwale. More than 80% of pregnant women attending ANC have their haemoglobin level measured and their blood group recorded now up from 34% in January 2011. More than 95% of those attending ANC receive regular supply of haematinics now as opposed to 23% at the beginning of the project.
Community linkages have also been strengthened as referrals by community representatives, such as CHWs and TBAs, increased from 13 in January 2011 to 79 in June 2012.
Other achievements include opening of three new laboratories in the district with the help of various stakeholders