Global Forum, Day 3

Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum

Today's question:

Community or lay health workers are health care providers who have no formal professional or paraprofessional tertiary education but are usually provided with job-related training.They can be involved in either paid or voluntary care. The term 'lay health worker' is therefore very broad in scope and includes, for example, village health workers, promotoras, treatment supporters and lay counsellors. Lay health workers may take on a wide range of different health-related tasks including giving help and advice about child health, child illnesses, pregnancy and medicine taking. In some studies, lay health workers also treat or refer people for particular health problems.


Many low- and middle-income countries established large lay health worker programmes in the 1960s and 70s but interest in this cadre waned in many settings in the 1980s. The 1990s saw a revival of interest in the contributions that lay or community health workers could make within primary health care, particularly in improving maternal and neontal health. Large numbers of lay health workers are now being trained in many settings.

Systematic reviews have indicated that lay health workers have promising benefits across a range of health issues, including promoting immunisation uptake and breastfeeding and reducing child morbidity and mortality. The focus of our discussions on days 3 and 4 is on the range of practices or tasks that should be undertaken by lay health workers to help accelerate progress towards the goal of reducing maternal and newborn mortality and morbidity. For example, in what ways can lay health workers contribute to improving antenatal care for women? How should this cadre be involved in newborn care? Are there examples of innovative programmes in which the range of tasks undertaken by lay¨health workers have been expanded or that utilise innovative technologies or organisational models to improve the provision of care by lay health workers?

To maximise health gains, community or lay health workers need to work closely with professional providers within the health system. We also hope to discuss how lay workers should work with professionals to improve maternal and newborn care. Should teams of lay and professional providers be established in primary care facilities? Should nurses be responsible for supervising the work of community health workers? How should decisions be made about the range of tasks that community health workers undertake?

My comments:
I don't have enough knowledge of maternity services in the countries that are of particular concern to WHO for this discussion to speak with confidence on reducing maternal and perinatal mortality and morbidity.

I do have knowledge of lay support of women in my care, and that is the picture I want to focus on today.

I am not referring to lay birth attendants, doulas. I am referring to the friends and family - trusted members of an individual woman's community - who make themselves available to support and assist the mother. Every situation is slightly different, and it would be difficult to generalise in describing what is done; what 'practices or tasks' are undertaken by these people. Anything that needs to be done. Anything except what the mother needs to do.

What does the mother need to do? Which 'practices or tasks' cannot be delegated to a health worker of any description?
In pregnancy -- attend to her own health, nutrition, ... Healthy mothers have healthy babies, generally.  The professional health worker role is one of education and monitoring.  Family and community support is practical.

In labour and birth -- the mother feels the movements and sensations within her body; accepts the work of childbearing; acts in harmony with her own natural, hormonally mediated processes; and gives birth.

After birth -- the mother welcomes her baby, and allows her natural maternal instinct to guide in bonding and breastfeeding and nurture of the baby.

The principle that is obvious in my mind is that the mother trusts anyone who enters her 'domain', whether they are professional or lay people.

The homebirth setting is a model of primary maternity care in which professional and community or lay support and services can be demonstrated. In midwifery we talk about 'woman-centred care'. The WOMAN is at the centre of the care.

A 2-dimensional drawing is a very limited representation of the model, but it's still worth considering in this context.  There are two main partnerships that each woman, in the ideal situation, will have.

• The ongoing loving and mutually supportive partnership with her husband, the father of her child.
• The special time-limited partnership with her known midwife, who is committed to being with her in this current pregnancy-birth episode.  

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Personal linkages are made by the mother and her husband/partner to community support and family as they choose.

Professional linkages are accessed by the midwife, when and if needed.

This is, of course, and ideal model. Many pregnant women don't have a trusted support team, or even a reliable or loving husband/partner. Many women don't have a known and trusted midwife.

left click to enlarge

The picture then changes to a building - a public hospital - at the centre of the page.  The woman, and many other women, move between loosely linked service providers, who are often over-stretched and unable to attend to everyone's needs.  A lay health worker who is employed by the public hospital or health service may be the only person who approaches a woman in a compassionate and caring way.

Getting back to today's question, how may lay workers be used in maternity services to improve outcomes for mothers and babies?  My conclusion is that the key to safety and wellbeing in the pregnancy-birth continuum is the midwife primary carer.  This role cannot be delegated.  Lay workers can give much-appreciated support and assistance to the mother, but the partnership between a woman and a known and trusted midwife, who has access to specialist service providers as needed, is the key to improving outcomes for mothers and babies.