Implementing Best Practices in Essential Obstetric and Newborn Care Using the Improvement Collaborat

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Implementing Best Practices in Essential
Obstetric and Newborn Care Using the Improvement
Collaborative Approach

• Jorge Hermida, MD, Kathleen Hill, MD
• Lani Marquez, MHSc

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Workshop Agenda

• Introduction Using the Improvement Collaborative
  Model to Implement and Spread Essential Obstetric
  and Newborn Care (Presentation 100-145 pm)
• Nuts and Bolts of Implementing an EONC
  Improvement Collaborative (Presentation and
  Discussion 145-230 pm)
• Break (230-250 pm)
• Nuts and Bolts of Implementing an EONC
  Improvement Collaborative, continued
  (Presentation and Discussion 250-330 pm)
• Wrap-up (330-400 pm)

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Why the Urgent Need to Improve Essential
Obstetric and Newborn Care?

• Every year, half a million women and four million
  newborns die of pregnancy and birth-related
  complications worldwide
• Newborn deaths (lt 1 month) represent nearly 40
  of the 11 million early childhood deaths
  worldwide

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Life-time Risk of Maternal Mortality
12,800
194
116
1160
Source WHO, UNICEF and UNFPA. Maternal
Mortality in 2000 Lancet Neonatal Survival
Series, 2005
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Interventions to prevent and treat
life-threatening maternal and newborn
complications exist and are known
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Known Interventions to Prevent and Treat Maternal
and Newborn Complications
Antenatal

• Birth preparedness
• Iron/folate
• Tetanus toxoid
• Intermittent preventive therapy (IPT) in
  malaria-endemic areas
• Treatment of prenatal infections (urinary tract
  infection Gonorrhea/Chlamydia Syphilis
  Bacteriuria)
• Steroids for fetal prematurity
• Identification/referral high-risk pregnancies

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Known Interventions to Prevent and Treat Maternal
and Newborn Complications
Intrapartum

• Partograph
• Infection prevention
• Eclampsia management
• Sepsis management
• Hemorrhage management

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Known Interventions to Prevent and Treat Maternal
and Newborn Complications
Immediate Post-Partum

• Active management of third stage labor
• Prompt treatment of maternal hemorrhage
• Treatment of maternal and newborn infections
• Essential newborn care thermal protection,
  early/exclusive breastfeeding clean cord care
  vaccination Vitamin K
• Newborn resuscitation
• Care of low birth weight (LBW) infant

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Evidence-based Interventions to Reduce Maternal
Deaths
Magnesium Sulfate
Active Management of the Third Stage of Labor
Family Planning and Postabortion Care
Eclampsia 12
 
Severe Bleeding 24
Unsafe Abortion 13
Antibiotics
Infection 15
Indirect Causes 20
Tetanus Toxoid Immunization Clean delivery
Obs. Labor 8
Iron supplements, Malaria Intermittent Treatment
and Antiretrovirals for HIV
Other Direct Causes 8
 
Partograph Cesarean section
Source WHO 1997
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Evidence-based Interventions to Reduce Newborn
Deaths
Tetanus Toxoid Immunization of Mother Clean
Delivery Cord Care Early Exclusive
Breastfeeding Antibiotics for mother and baby
Syphilis Control Folate Supplementation
Cong. Anom 7
Infection 36 Sepsis/Pneumonia Tetanus Diarrhea
Malaria Control Antenatal Corticosteriod Treatment
of Bacteriuria
Complications of Prematurity 27
Other 7
Asphyxia 23
Kangaroo Mother Care Birth Spacing Maternal
Nutrition
Warming Resuscitation Skilled Birth Attendants
Low birth weight is a significant contributor in
4070 of neonatal deaths.
Adapted from Lancet 2005
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A Fundamental Shift in the 1990s from the Risk
Approach to Universal EONC

• Risk Approach
• Risk screening through antenatal visits
• Determination of risk level with care focus on
  high risk
• Butmaternal and newborn complications are
  usually not predictable by antenatal risk
  screening
• Universal Access to Essential Obstetric Newborn
  Care
• Every pregnant woman and her fetus, independent
  of risk level should have access to a facility
  that provides Basic EONC, including referral to a
  Comprehensive EONC facility, 24 hours day, 7 days
  a week

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• Antenatal Care management of complicated
  pregnancies (anemia, diabetes), birth
  preparedness, Iron, folate, Tetanus, IPT
  (anti-malaria), nutrition, PMTCT/ARV, STIs.
• Normal delivery care labor monitoring using
  partograph
• Immediate post-partum care active management 3rd
  stage labor, Essential Newborn Care (thermal
  protection, early exclusive breastfeeding, cord
  care, eye care, and universal vaccination

Non-complicated EONC (prevention and detection
of complications)

• Basic EmONC
• Initial medical treatment of obstetric
  complications magnesium sulphate,
  oxitocin/uterotonics, antibiotics
• Manual procedures removal of placenta, repair
  of tears
• Assisted vaginal delivery
• Post abortion care

Essential Obstetric and Newborn Care (EONC)
EmONC
Management of obstetric and newborn
complications and emergencies

• Comprehensive EmONC
• C-section
• Anesthesia
• Blood replacement
• Newborn resuscitation
• Neonatal LBW care

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Pathway to Maternal and Newborn Survival
Life threatening illness
Survival
Quality Essential Obstetric and Newborn Care
Care-seeking decision process
Accessibility to Adequate Care
Recognition of the problem
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Health Services Do Not Regularly Implement Best
Practices
Examples from Baseline Assessments by Facility
Teams in Latin America

• 7 Ecuador 10 Bolivia, 0 Nicaragua
• 23, Honduras
• 18 Nicaragua
• 15 Nicaragua
• 5 Ecuador

• Use of partograph in hospitals
• Deliveries where personnel washed hands
• Deliveries with active management of 3rd stage
• Deliveries where standard newborn care was
  provided
• Standardized post-partum care first two hours

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Health Services Do Not Regularly Implement Best
Practices
Examples from Niger EONC Collaborative Baseline
Assessment in 15 Sites (April 2006)

• of providers meeting AMTSL standards in
  simulated case study 23
• of providers meeting newborn care standards in
  simulated case study lt 10 (final analysis
  pending)
• of prenatal visits with recorded BP 55
• of SBAs trained in AMTSL 8
• of SBAs trained in newborn care 4

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Common Barriers to Delivery of Quality Essential
Obstetric and Newborn Care

• Weak local leadership
• Lack of formal EONC standards
• Inaccessible EONC services--financially,
  geographically, and culturally
• Inadequate EONC inputs/infrastructure
• Poorly organized patient care processes
• Non-functioning referral/counter-referral
  mechanisms
• Inadequate supervision/lack of continuous
  training
• Poor staff motivation
• Poor provider competence

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What knowledge and changes are needed to
overcomethese barriers to deliverquality
essential obstetric and newborn care?
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The Collaborative Modelfor Improving Essential
Obstetric and Newborn Care
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What is an Improvement Collaborative?

• An Improvement Collaborative is an
  organizational model for rapidly improving health
  care quality in a targeted technical area in
  multiple settings, leveraging shared learning
  among teams

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Improvement Collaboratives

• Rapidly adapt and spread evidence-based standards
  to multiple sites
• Support improvement teams to simultaneously test
  and identify effective changes for implementation
  of specific interventions (e.g., effective
  partograph use)
• Promote regular communication and friendly
  competition between sites to actively disseminate
  and share effective changes for implementation of
  best practices
• Support participating sites to regularly collect,
  analyze, and share core common indicators

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Improvement Collaboratives Are a Powerful
Mechanism for Scale-up

• Collaboratives may be planned to apply an
  intentional scale-up strategy from the outset
• Collaboratives can create a cadre of national and
  local champions who can spread achievements at
  scale
• Collaboratives can influence national leadership
  to adopt and mandate best practices
• Sometimes, collaboratives may choose to start at
  scale

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Experience of EONC Improvement Collaboratives
from the Quality Assurance Project (QAP)
Nicaragua, Honduras, Ecuador, Benin, and Niger
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Current Coverage of QAP EONC Collaboratives
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Benin Prenatal Care
Proportion of Prenatal Visits Managed According
to Standards, 9/10 Primary Health Centers, Oct
04-Dec 05 Average number monthly cases analyzed
180

• Key Changes Implemented
• Systematic screening for risk factors
• Introduction of systematic anti malarial IPT
• Improved antenatal record

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Latin American EOC Collaborative Correct Use of
the Partograph

• Key changes
• Self-guided training, use of CD-Rom
• Coaching in partograph
• Monitoring of partograph during clinical rounds
• Recognition of those performing to standard
• Monthly monitoring and posting of results

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Latin American EOC Collaborative Active
Management of the Third Stage of Labor

• Key changes
• Dissemination of clinical evidence
• Local training in referral hospital,
• in particular on cord traction
• Local champions to promote AMTSL
• MOH included AMTSL in official norms
• Monthly monitoring and posting of results

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Benin -- Active Management of the Third Stage of
Labor
Proportion of Births Managed According to AMTSL
Standards 9/10 Primary Health Centers, Oct 04 to
Dec 05 Average number of monthly cases analyzed
180

• Key changes implemented
• Training SBAs in AMTSL
• Stocking of Pitocin
• Adaptation/monitoring of Partograph
• Monitoring of PPH

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Latin American EOC Collaborative Immediate Care
of the Newborn

• Key changes
• Clinical training at referral hospital
• Assigning specific tasks to personnel
• Monitoring of clinical records
• Monthly monitoring and posting of results

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Niger Newborn Vaccination

• Key changes Implemented
• Stocking of OPV/BCG
• Systematic vaccination times
• Monitoring vaccinations on record

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Maternal Mortality in Honduras Country versus
Focus QA Regions

Source Quiroz Claudia, Secretaria de Salud.
Vigilancia de la mortalidad materna en Honduras,
2004-2005. Borrador
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Nuts and Bolts of Implementing an EONC
Collaborative
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Nuts and Bolts of Implementing an EONC
Improvement Collaborative

• 1. Organizing an EONC Improvement Collaborative
• 2. Establishing a Framework for Measurement and
  Reporting
• Break
• 3. Implementing and Managing a Collaborative
• 4. Spreading Best Practices Beyond a Collaborative

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1. Organizing an EONC Improvement Collaborative
Key Tasks

• Develop objectives and aims
• Situational analysis/pre-assessment of EONC
  services
• Engage local leadership and stakeholders
• Select international best practices for
  implementation in the collaborative
• Adapt international best practices to local
  setting and develop operational plan (change
  package) for local implementation

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1. Organizing an EONC Improvement Collaborative
Key Tasks, continued

• Plan management structure for the collaborative
• Develop collaborative management tools (organize
  monitoring plan/database, web-based reporting if
  appropriate, etc.)
• Select sites and organize teams
• Identify mechanisms for communication and sharing
• Identify mechanisms for spread and
  institutionalization

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Some Issues for Discussion

• Trade-offs between breadth and depth in defining
  the technical scope of the collaborative
• Challenges and opportunities for fostering
  national and local leadership
• Challenges and opportunities for adapting
  international best practices to a particular
  country
• Feasible mechanisms for communication and sharing
  among teams in different sites

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2. Establishing a Framework for Measurement and
Reporting Key tasks

• Define standards to be implemented through the
  collaborative
• Define indicators to measure compliance with
  selected standards
• Develop data collection plan
• Identify processes for teams to analyze and act
  on data
• Define how teams will report and share results

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Some Issues for Discussion

• Advantages and limitations of self-assessment as
  a data collection method
• Advantages and disadvantages of external
  assessment as a data collection method in a
  collaborative
• Strategies for overcoming the poor quality of
  medical records
• Other methods for measuring the effects of
  improvement activities

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Break 230-250 pm
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3. Implementing and Managing a Collaborative Key
tasks

• Develop detailed work plan and timeline
• Create implementation package for key improvement
  objectives (training strategy/materials,
  monitoring tools, coaching guidelines, reporting
  forms, etc.)
• Organize learning sessions
• Orient and train teams in clinical content,
  measurement, and improvement methods

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3. Implementing and Managing a Collaborative Key
tasks, continued

• Support implementation of improvements during
  action periods
• Support teams to function effectively
• Facilitate ongoing sharing of experiences and
  results, both among teams and with the leadership
• Disseminate collaborative results

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Some Issues for Discussion

• Different training strategies for increasing
  provider competence with the technical content of
  the collaborative
• Sustainable mechanisms for providing ongoing
  technical training
• Supporting teams to develop skills in continuous
  quality improvement and motivating teams to
  sustain gains
• Strategies for managing a collaborative at scale

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4. Spreading Best Practices Beyond the
Collaborative Key tasks

• Convene final meeting of teams to review
  achievements and lessons
• Share lessons with larger national audience
• Implement focused spread strategy for
  dissemination of collaborative gains to new
  regions and sites
• Support national adoption of updated EONC
  policies, standards, and operational guidelines

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Some Issues for Discussion

• Sustaining the sharing/learning aspects of a
  collaborative after the collaborative has ended
• Supporting collaborative gains at the national
  policy level
• Strategies for spreading an improved system of
  EONC to larger portions of the health system

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Wrap-up

• Review of key discussion points
• Organizing an EONC collaborative
• Establishing a measurement and reporting
  framework
• Implementing and managing the collaborative
• Spreading best practices and institutionalizing
  improved EONC beyond the collaborative
• Final audience questions and comments

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For more information on the Latin American EOC
Collaborative, contact Jorge Hermida
atjhermida_at_urc-chs.comFor more information on
the Benin and Niger EONC Collaboratives,
contactKathleen Hill atkhill_at_urc-chs.com