Birthing Kits Project: A Case Study on ‘How To Make D.I.Y. Development Work Better’
Here’s a story that highlights the challenge of integrating piecemeal charity with long-term sustainable development goals:
We recently got a very small amount of charity funds, $2,000 Canadian Dollars (~ $1,559 USD), from a volunteer group based in Toronto. The funds were specifically designated for birthing kits. My supervisor asked that I oversee the disbursement of these funds, including managing the procurement and distribution of the kits, while monitoring the number of women who received them. Birthing kits are typically provided to support clean and safe delivery at home when women do not have access to health care facilities. They contain basic items such as sterile towels, forceps, sterile cord ties, and surgical blades. The idea is that a trained midwife or community health worker could use the kit to assist with home delivery.
It seems that a member from the volunteer group with a background in health promoted the idea of collecting funds for the kits. She was hoping to obtain pictures of happy, smiling women with the kits. Birthing kits are fad-y — a quick Google search brought up websites of organizations solely focused on the distribution of birthing kits and even a blog by a group based in Australia that is entirely about birthing kits. It is easy to see the appeal of birthing kits as an intervention. They are very simple and cost-effective items which can yield a large impact by reducing maternal and infant mortality in the right context.
However, the issue is that birthing kits may not be appropriate for the specific context in which my non-governmental organization (NGO) works. The Malawian government has been aggressively encouraging women to deliver at health care facilities. Although access to health care facilities is far from ubiquitous for Malawian women (only slightly less than half of the population lives within a 5-kilometer radius of a health care facility), home deliveries do often happen. However, there are accessible health care facilities in the area which our NGO targets and it would only be appropriate for us to promote the use of these facilities for deliveries.
Moreover, the promotion of deliveries at health care facilities is a major objective of a large Maternal Newborn and Child Health (MNCH) project that our NGO is carrying out with a budget of over $1.5 million and a four-year timeline. Among several other objectives, the project aims to promote the utilization of health care facilities for antenatal services including childbirth. It would be contradictory to promote birth at health care facilities through this project while also promoting birth at home through the distribution of the birthing kits to community members.
Initially, it seemed like we had found a simple solution to the conundrum. We would provide birthing kits to the health care centers. The same materials which are found in the kit are used for deliveries that take place at local health care centers. Since these facilities often run on a shoe-string budget, by providing them with these supplies, we would be giving needed economic assistance. Pregnant women in the community would be contacted and encouraged to visit the centers as usual.
We had to negotiate this idea with the woman who sent in the funds. She initially had reservations because she was stuck on the idea of providing birthing kits for home deliveries, but in the end, she agreed with what we proposed. This negotiation could have been avoided if that group has not initiated fundraising for the kits without actually consulting our organization first. This put us in a difficult position because although, on one hand, we did not want to turn down funds that could potentially benefit the community — however small the amount — the extra project would require an additional allocation of staff resources. It was only fair of us to request that the funder readjust their aims in a way that was more aligned with our organizational goals.
Yet, after discussion with local experts, I realized that even the idea of distributing the kits directly to facilities was short-sighted. Although public hospitals and clinics provide care free of charge in Malawi, they are spread out widely and are supplemented by private clinics, typically run by religious organizations such as the Christian Health Association of Malawi (CHAM), which charge a small fee-for-service. In the area that we were targeting, the women only had private clinics in the vicinity. We chose this location based on it being in our target zone and at the same time not overlapping with the catchment area of the large MNCH project that we are carrying out, for which we are required to work with public hospitals and clinics. To improve access to maternal health services, the Malawian government was reimbursing all private facilities for costs relating to deliveries and antenatal care. Pregnant women throughout Malawi were able to receive free care even when seen at a private clinic.
This system was working well until last October when the government stopped reimbursing the clinics. The clinics subsequently stopped providing maternal health services for free and the number of women accessing these services fell rapidly. I recently met with a woman who holds a leadership position at a local health care organization. To illustrate the impact that the recent decline in government funding has had, she commented that at a health care center where typically about two hundred women would deliver per month, in the past month only two women had given birth. To avoid the costs associated with delivering at a facility, women are delivering at home or at the roadside without infection control measures or a skilled birth attendant, leading to an increased risk of death for the mother and the infant.
This is a shame, especially considering that an exorbitant amount of governments funds are continuously eaten up by corrupt officials. It seems that every week, the front pages of the local newspapers feature a scandal relating to the misallocation of money. Even a portion of these misallocated funds would have had the potential of providing substantial assistance to the country’s flailing social services, including its health care system.
The costs for delivery at one of these private healthcare centers is 2,800 Malawian Kwacha, which based on the current exchange rate comes out to a little more than $4. For less than the cost of a latte in New York City, a woman could avoid dying during labor. The materials that go into the birthing kit themselves would cost a little less than $2. However, supporting the health care facility in the costs relating to the delivery would be more cost-effective than simply providing the kits, given that the facilities re-use many of the materials after sterilizing them, which is obviously a much cheaper method than buying new materials for each patient. For the amount that we have, I calculated that we could potentially support 390 deliveries at a health care facility.
When I suggested this idea to my supervisor, she was initially hesitant. She had already put up a fight to distribute the birthing kits to health care facilities instead of homes and worried that suggesting to do away with the birthing kits idea altogether would not be easily met with agreement. The funder specified that they wanted to see pictures of women with their birthing kits. At the same time, it would be in the lightest terms silly — or if, more critically put, unethical — to distribute the kits in a way that provided a good communications strategy for the group even if it was not the most beneficial way of using the funds for the community.
Purchasing individual birthing kits would not only be a less cost-effective approach than reimbursing the facility for the costs of deliveries and allowing them to re-use supplies, but it would likely not be practical. The health care facility may not have the storage space for several hundred pre-packaged kits and it would instead make more sense for them to receive the individual items that go into the kits in bulk. Moreover, the facilities likely have to assemble the kits in a specific way for the procedures. If the kits were given to them pre-packaged, it may mean that they would have to go through the hassle of having to unwrap the kits and re-assemble the items at the time of delivery. This is an additional burden on their staff, as well as ours since we would need to package the kits.
The issue of whether we simply reimburse the cost of delivery or will have to provide the kits is yet to be resolved. But needless to say, a fair amount of negotiating and compromise will be required.
Another key consideration that needs to be made when carrying out this project is the basic fact that we are working with a very limited amount of funds. The method requiring the least logistical effort for distributing the funds would be to tell the health care center to that we would reimburse directly them for the first x number of women that come in to deliver at their facility. Yet, this would be an ill-fated approach. Since this is a one time gift and the funds will run out in two months or so, it would confuse the community if women were having the costs of their deliveries paid for at the facility for some period of time and then not after that. We needed to make sure that it was clear to the recipients that they were receiving assistance as part of a special project.
We decided that it may be best if we conducted community outreach to pregnant women, encouraged them to use the health facility for their delivery, and then promised them that this would be at no-cost by signing them up for the program. The women signed up for the project would receive a voucher which they could take to the health facility. The implementation for this would be a little complicated since the health facility would need to keep track of who had a voucher and submit reimbursement requests only for those women, as opposed to any woman who comes in for delivery. Moreover, we would need to track the use of vouchers on our end. If a woman does not use her voucher by a given amount of time past her due date, the assumption would be that she had her child elsewhere and thus that voucher would be expired, which would allow us to give out a voucher to another woman. We even considered tying the receipt of the vouchers to attendance at the four required antenatal care visits. The required record keeping and data collection would require more staff time, so there would need to be a cost-benefit analysis.
However well-intentioned the proposed birthing kits project was, it was naive. It did not fit in with our NGO’s larger development goals, the specific context in the areas in which we work, and the political climate in Malawi. Although this group will likely be amenable, I have come across many stories of private individuals or small groups implementing poorly thought out projects in the name of charity.
There is some critique of what I call ‘Do-It-Yourself (DIY) Development’, by which I am referring to small ad-hoc projects initiated by individuals from the West in the developing country context that are outside of the professional framework.
Some argue that these projects are a poor use of resources since they are not aimed at long-term sustainability. I differ from this view and believe that there is room within the larger development framework for well-intentioned individuals to help in whichever way they can. Examples of DIY development projects that I’ve come across by volunteers visiting Malawi include organizing summer activities for youth in a village, rejuvenating school buildings by applying new paint and making basic fixes, and providing sewing classes for women as a means for entrepreneurship.
These projects were carried out in a few months or so. Sure, they were not meant to be long-lasting interventions. They are certainly not replacements for sustainable structural interventions which are the focus of most development organizations. But, there was value in what little was done. It would be easy to dismiss the birthing kit project with its budget of a little more than fifteen hundred dollars as something that will require more work than it is worth, especially when we are in the process of carrying out a comprehensive MNCH project with a budget of over a 1.5 million dollars. Yet, if even one maternal death is prevented because of the funds, then it is worth it for us to use them.
There are best practices that should be used when initiating your own charity project. By this, I am referring to common sense guidelines such as first consulting whoever you intend to be working with before you roll out a project to determine the feasibility of an idea and speaking with multiple local experts to get a good sense of the cultural and political context. In many ways, the ideal and most humble way to give charity is to find an organization that is doing work which you respect and regularly donate a consistent amount, however small. If you would like to do work on the ground, find a long-running volunteer organization with a reputable model, for example, Habitat for Humanity.
That being said, at times people may wish to contribute something unique. For example, I had a friend who spent several months in Ugandan giving breakdance classes. While these classes were only available while he was in the country, that fact did not negate the value of what he offered for the time that he was there. The youth were excited to have a professional breakdancer from the U.S. teach them some moves and were inspired by the community organizing and social justice values which he had learned from his work with inner-city youth in Chicago and which he taught them alongside the dance lessons. The youth, as well as my friend, appreciated the cross-cultural education that the experience provided for them.
Frankly, people at times want to embark on these kinds of projects for their own personal development in addition to providing help. There is a criticism of this type of so-called ‘volunteer tourism.’ The harshest critics will claim that for the price that someone paid for their plane ticket, they could have contributed a substantial charity donation. Yet, I believe that if someone is doing it in lieu to a trip to the Caribbean, for example, and it leads to them developing further as a global citizen and humanitarian, then it cannot be all bad.
‘DIY Development’ may not be a completely bad thing, it just needs to be carried out with a lot of consideration and deference.
Mariam Azam was a 2015–2016 Global Health Corps (GHC) fellow in Malawi.
Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.
