Solving maternal mortality: bridging the gap between knowing the right thing to do and doing it righ

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Solving maternal mortality bridging the gap
between knowing the right thing to do and doing
it right
USAID Mini-University September 12, 2008

• Patricia Gomez
  
• Natalie Hendler
• ACCESS Program/Jhpiego

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Interventions for maternal and newborn care
Clinical care
Outreach services
Family community
Infancy
Postnatal period
Pre- pregnancy
Pregnancy
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Objectives

• At the end of the session participants will be
  able to
• Discuss the problem of global maternal mortality
  and morbidity
• Describe major causes of mortality and their
  interventions (knowing the right thing to do)
• Discuss technical and programmatic best practices
  (doing it right)

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Knowing the right thing to do
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The problem women are dying giving birth

• gt200 million pregnancies per year globally, and
  up to 50 are unplanned
• 50 million induced abortions and 20 million
  unsafe abortions
• 530,000 maternal deaths/year (1 per minute) 99
  occur in developing countries
• 1 maternal death 30 maternal morbidities

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We know the causes of maternal mortality, nearly
all preventable
AbouZahr 2003 WHO, 2007
Includes anemia, malaria, and heart
disease. Includes ectopic pregnancy, embolism,
and anesthesia-related complications.
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We know when most mortality occurs
Ronsmans and Koblinsky 2006
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We know who receives services

• Services are not universally available and
  accessible
• gt 35 of women receive no antenatal care
• 50 of births attended by unskilled provider
• 70 receive no postpartum/newborn care

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We know that interventions do not reach those in
greatest need

• Progress in skilled care coverage is too slow and
  should be accelerated
• Cost-effective, simple approaches at the family
  and community level can save many lives
• Coverage of care is low and lower for the poor

Source Neonatal Lancet team, March 2005
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Skilled birth attendants know the right thing
to do and can do it right

• Accredited health professional - such as a
  midwife, doctor or nurse - who has been educated
  and trained to proficiency in the skills needed
  to manage normal (uncomplicated) pregnancies,
  childbirth and the immediate postnatal period,
  and in the identification, management and
  referral of complication in women and newborns
• World Health Organization, 2004

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The higher the proportion of deliveries attended
by a skilled attendant in a country, the lower
the countrys maternal mortality ratio
Maternal deaths per 100,000 live births
skilled attendant at birth
DHS, WHO, UNICEF, UNFPA 2001
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Experience from the 1960s in Malaysia, Sri Lanka
and Thailand
7200 new midwives registrations
18,314 new midwives
From 2,500 beds to 10,800 in small community
hospitals
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How have we done delivery with a skilled birth
attendant
Source DHS 2001-2006
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How have we done C-section RatesRegional
estimates
Source DHS 2001-2006
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What SBAs can do to save mothers lives
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But are we doing the right things prevailing
practices survey
Personal communication, Sanghvi, 2005
Interviews with 4300 mid career faculty in 16
countries in Asia, Africa, LAC
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Supervisors who are not confident in key skills
Sanghvi, Bluestone 2006
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Key intervention Partograph

• Decreases incidence of
• obstructed and
• prolonged labor
• and fistula
• infection
• newborn asphyxia

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Key intervention Active management of third
stage of labor (AMTSL)

• Can reduce postpartum hemorrhage by up to 60
• Consists of
• Oxytocin 10 IU IM
• Controlled cord traction
• Uterine massage

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Key intervention Emergency obstetric and
newborn care (EmONC)
Basic EmONC IV uterotonics IV antibiotics IV
anticonvulsants Manual vacuum aspiration Assisted
delivery Manual removal of placenta Newborn
resuscitation
Comprehensive EmONC BEmONC surgical capability
and blood transfusion
Photo ACCESS/Afghanistan
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Key interventions can be carried out many
points on the household to hospital continuum of
care
Socio-cultural Environment
Policy
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Interventions for maternal and newborn care
(answers)

• Skilled obstetric care (partograph, AMTSL)
• Immediate newborn care including resuscitation
• EmOC to manage complications
• Antibiotics for preterm premature rupture
  membranes
• Corticosteroids for preterm labor

• Emergency newborn care for illness, especially
  sepsis management and care of very low birth
  weight babies

Clinical care

• 4-visit ANC package
• Malaria intermittent preventive treatment
• Detect and treat bacteriuria

• Postnatal care to support healthy practices
• Early detection and referral of complications

Outreach services

• Folic acid

• Counseling and preparation for newborn care and
  breastfeeding, emergency preparedness

• Clean home delivery
• Simple early newborn care

• Healthy home care
• Extra care of low birth weight babies
• Case management for pneumonia

Family community
Infancy
Postnatal period
Pre- pregnancy
Pregnancy
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Doing it right
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Doing it right Implementing key interventions

• Interventions need to be
• Evidence-based, or based on expert opinion and
  best practices
• Easily taught to various categories of providers
• Feasible in low resource settings
• Affordable
• Sustainable
• Can be scaled up to achieve impact

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Programming for Maternal Health

• Moving research into practice
• The evidence shows us what works. How do we help
  countries implement these best practices so that
  women and children can benefit from new findings?
• Example of the ACCESS program in Tanzania
• Key intervention Prevention and control of
  Malaria in Pregnancy (MIP)
• Best practice Addressing MIP using platform of
  Focused Antenatal Care (FANC)

• MIP
• IPTp 2 doses of SP
• ITN use
• Case management

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Program Design Framework
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Advocacy

• Introducing and orienting relevant stakeholders
  to the program
• Advocacy meetings with national, regional and
  district level stakeholders
• Ongoing meetings with MoHSW, donor and other
  NGO/FBO partners, i.e. Safe Motherhood Working
  Group
• Gaining commitments of support
• Additional funding for FANC training and supplies
  built into District Health plans
• Policy work developing and updating guidelines
  dissemination
• Orienting providers to national malaria control
  and antenatal care guidelines
• Addressing new issues such as IPT for HIV women

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Training

• Competency-based
• Developed a FANC 6-day training
• Both classroom and hands-on clinical skills
  learning
• Cascade approach TOT
• Developed national trainers and district trainers
• In-service and pre-service training
• Trained 2,213 providers
• Updated all nurse-midwifery schools to include
  FANC

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Supervision Quality Improvement

• Supervision
• Accountability
• Implementation of new practices following
  training
• Feedback and reinforcement for health workers
• Facilitative supervision training for Regional
  and District RCH Coordinators
• Updating national supervision tools
• Consistency supporting regular facility visits
  by supervisors

• Quality Improvement
• Management tools and checklists based on
  performance standards
• Nationally approved FANC standards
• Internal and external assessments
• Facilities self-evaluate until ready for external
  evaluation and recognition

Paradigm Change
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Logistics

• Equipment and supplies avoiding stockouts
• Addressing stockouts of SP
• Advocacy efforts for SP push
• Reinforcing commodity ordering skills of FANC
  providers
• In 2007, 53 of sentinel sites (n30) had SP
  stockouts in 2008, only 21 had stockouts
• Continuing ANC needs RPR test kits, blood
  pressure cuffs

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Demand creation

• Informed clients leads to quality services
• Take home IEC materials for ANC clients
• Disseminating messages through religious leaders

• Supporting the White Ribbon Alliance
• Improving interpersonal communication skills of
  providers

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Monitoring and Evaluation

• Seeing improvements over time
• Comparing results in areas of intervention vs.
  no intervention
  

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Partnerships Integration

• Partnerships engaging the right people
• MoHSW RCH services, National Malaria Control
  Program, National AIDS Control Program, Human
  Resources Development Directorate, Health
  Services Inspectorate Unit, IEC Unit
• ACCESS partners IMA World Health, WRA of
  Tanzania, T-MARC
• Funding partners USAID PMI, PEPFAR Child
  Survival
• Other donors African Development Bank
• Other implementing partners JSI/DELIVER, MEDA,
  Ifakara Health and Research Centre, JHU-CCP, RTI,
  EGPAF, FBOs, etc.
• Integration how other services integrate into
  the program, and how the program integrates into
  other services
• PMTCT / VCT
• Family Planning
• Basic and Comprehensive Emergency Obstetric and
  Newborn Care
• Nutrition

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Outcomes

• Program Success
• Preliminary results from 2007-08 Malaria
  Indicator Survey show that IPTp2 has increased
  to 57 from 2004-05 DHS of 22 (National-level
  data)
• ACCESS Program-specific Results

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Thank you!
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Resources
www.accesstohealth.org www.globalhealthlearning.o
rg www.thelancet.com www.rollbackmalaria.org ww
w.who.int www.jhpiego.net