Care Coordination Midwife

The care coordination midwife plays one of the most essential roles in our integrated service delivery model. She is stationed at our community primary care clinic and develops relationships with women throughout the ANC journey. When high-risk patients need to be referred to a higher care facility during ANC, she organizes and coordinates the referral. Furthermore, during the time of labor, she decides, based on a patient’s history, which level of care to refer a given patient to. We have found that such support is necessary to drive positive health seeking behavior at critical junctures and reduce delays in families accessing appropriate care.


Partnership with key facilities and organizations in the health system

Many organizations that deliver community based services refer patients to higher level facilities when needed. However, most of the time, the patient is on their own after the referral is made. For people living in peri-urban communities, navigating the health system, particularly in large cities, is daunting. Instead of merely referring out patients to the larger health system, we have established deep operational linkages with selected private sector, welfare, and public sector hospitals. When we make a referral, we not only provide transport to the family to access that care, but also follow-up with our partners on specific cases. We also have operational linkages with the expanded program of immunization of the Sindh Government, who we work with to conduct immunization campaigns in the community, and Greenstar, who we work closely with to deliver family planning services.


Reducing Logistical barriers to care-seeking

Households in peri-urban communities have many logistical barriers to care-seeking. Transport options are limited and women find it difficult to access care when their husbands are at work during the week. When we asked the community for key barriers to care seeking during the design period of our service delivery program, transport emerged as the major barrier. We provide transport to women not only during ANC but also during referral to higher level facilities and at the time of labor.