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Transcript of Model Maternities Initiative: Model Maternities Initiative: Providing Humanistic Maternal and...
Model Maternities Initiative:Model Maternities Initiative:Providing Humanistic Maternal and
Newborn Care in Mozambique
Veronica Reis, MD, MPH – MCHIP MozambiqueLidia Chongo, MD – MoH Mozambique
USA, April 6, 2010
Purpose of the session
Share the development of a new initiative in Maternal and Child Health in Mozambique
Discuss challenges and lessons learned of implementing interventions in a poor resource context
Topics
• Background• The concept and rationale
behind Model Maternities Initiative
• Overview of the interventions• Progress achieved and
challenges• Successful approaches and
lessons learned• Moving forward
3
Photo: Ismael Miquidade
Total population: 20.53 million (2007)
Life expectancy at birth: 42 years
Maternal Mortality ratio: 408/100,000 lb
Neonatal mortality rate: 48/1,000 live births
Major cause of death (all ages): malaria
HIV prevalence rate: 16.2%
Background: general health situation in Mozambique
Source: 2007 Census, DHS 2003
Trends in MMR and MDG 5
Trends in Neonatal / Infant / Under five Mortality
6
Neonatal Mortality
represent 40% of Infant Mortality.
Causes of Maternal Mortality
Source: National Needs Assessment 2007
Causes of Neonatal Mortality in Mozambique, %
Source: Child Mortality Study, 2009
Background: situation of SRH and MHC in Mozambique
Indicator 2007 2008 2009
Percentage of deliveries by a skilled birth attendant
54% 55% 55%
Intra-hospital maternal mortality ratio473/100,000
LB*196/100,000
LB149/100,000
LBHealth facilities that provide basic emergency obstetric care, per 500, 000 inhabitants
1.13 1.44 5.9
Percentage of pregnant women who had at least two doses of IPT in an ANC visit
27% 77% 51.1%
Percentage of HIV+ pregnant women who had ARV drugs in the last 12 months (as PMTCT)
17.1% 32% 45.7%
Contraceptive prevalence rate (17% 2003 – DHS)
Source: Joint Evaluation of Health Sector performance, 2010*Needs assessment in SRH, 2008
Health infrastructure shortfall
Particulars Percentage
Population living within 30 min of a health facility
36%
Health facilities that have electricity
49%
Health facilities that have running water
48%
Health facilities that have means of communication for referral
43%
Health facilities providing EmOC based on WHO recommendations
38%
Source: MoH, National Integrated Plan to Achieve MDGs 4 and 5 / Needs Assessment??
Coverage of high-impact interventions
Particulars Percentage
AMTSL Not practiced in general
Partogram Not filled systematically
C-section rate in facilities providing CEmOC
2%
Exclusive breastfeeding up to 6 months
30%
ENC Not reported
MCHIP Mozambique Objectives 2009-2010
12
Strengthen EMNC and BEmONC services, including PPFP, in selected healthcare facilities in all provinces, as well as key integrated RH/MCH services in selected healthcare facilities in selected provinces.
Strengthen BEONC and CEONC in an integrated manner in pre-service institutions for MCH mid-level nurses.
Assist the MOH on the development of modular, integrated in-service training package for RH/MCH.
Model Maternities Initiative: concept and rationale
• Model Maternities Initiative are built on the principles of “humanization and quality of Maternal and Neonatal Health (MNH) care”.
• Humanization of MNH care is an approach that:– centers on the individual,– emphasizes the fundamental
rights of the mother, newborn and families
– promotes birthing practices that recognize women’s preferences and needs.
FROMTechnocratic
model
TOHumanistic
model
Model Maternities Initiative: concept and rationale
Symbols of the “technocratic Model”
The body as a machine
Separation between the body and the mind
Symbols of the “technocratic Model”
Centered on the professional
Disempowerment of the woman
Symbols of the “Technocratic Model” Use of no evidence based practicesUse of no evidence based practices
Symbols of the “Technocratic Model”
Woman “solitary”
Separation between father - mother - newborn - family
MNH Humanistic Model includes:
Respecting beliefs traditions and culture
The right to information and privacy
Choice of a companion during childbirth
Liberty of movement during the labor
MNH Humanistic Model includes:
Choice of position for childbirth
Newborn on “Skin-to-skin” care
Use of evidence based practices
Guarantee of Emergency Obstetric and Neonatal Care, if necessary
MMI: Foccus on humanistic care and scale-up high-impact
interventions
• Antenatal care: Tetanus Toxoid, Iron Folate, Intermittent preventive tx (IPT) for malaria
• PMTCT• Normal deliver: Use of partograph; clean delivery; newborn
care, include skin-to-skin care; AMTSL and mother/newborn monitoring on the immediate post-partum
• Post-natal care: Visit within 2-3 days for mother and newborn• Post-partum family planning / Birth spacing• BEmONC: Intravenous antibiotics, oxytocics, MgSO4, manual
removal of placenta, assisted vaginal delivery, removal of retained products, newborn resuscitation, Kangaroo Mother care and antibiotics for newborn
• Referral to CEmONC facility
22
MMI Implementation Methodology
Standards-Based Management and Recognition (SBM-R) approach that follows four main steps:
1. Setting performance standards based on national norms and international references
2. Implementing standards through a systematic methodology
3. Measuring progress
4. Recognizing achievement of the standards
Model Maternities Initiative: Selected Facilities (Pre-service training sites)
Health Facility that provide delivery care
Total Model Maternities
Central Hospitals 3 3
Provincial Hospitals 7 7
General Hospital 4 4
Rural Hospitals 26 11
District Hospitals 7
Urban Health Centers
98 9
Rural Health Centers
820
Total 966 34
MMI Standards by Area and M&E Selected indicators
ÁREAS CONTENTS STANDARDS
1. Managment 092. Information, Monitoring and Evaluation 053. Human and Material Resources 044. Health work conditions 065. Health Education and Community
envolvment 04
6. Antenatal and Post-natal Care 117. Labor, Delivery and Neonatal Care 258. BEmONC 099. Training 04
TOTAL OF STANDARDS 79Selected Indicators 32
Key indicators for M&E of MMI
Indicator Baseline (2009)
MCHIP Target (2010)
% of pregnant women who received at least 2 doses of IPT
51% 70%
% of HIV+ pregnant women who received prophylaxis (PMTCT)
45% 60%
Number of births by SBA 113,704 10% above natural growth*
% of deliveries with partogram completely filled
0 50%
% of newborns with skin-to-skin care and early breastfeeding
0 60%
% of birth with AMTSL 0 60%
% of severe pre-eclampsia and eclampsia treated with MgSO4
<10% 60%Source for baselines: NHIS, 2010 *Natural population growth:2.4%
• Policy and strategy development: National Plan for Humanization of Healthcare; Guidelines for Maternal and Neonatal Death Audit Committees;
• Evidence-based training packages for EMNC and basic EmONC developed/translated/adapted
• Quality EMNC and BEmONC standards (SBM-R) developed and refined after trainings
• 1 TOT and 3 Regional MNH trainings on EMNC, basic EmONC and SBM-R approach: total of 29 trainers and 90 health professionals trained
27
Progress achieved on 8 monthsAugust 2009 – March 2010
• Each of the 34 maternities has at least 2 people trained
• 11 nurse training institutes has at least 1 preceptor trained
• 20 of the 34 maternities have carried out base line assessments and developed work plan to improve the quality of MNH services
• Provincial Godfathers/Godmothers for SRH and MCH involved in all trainings
28
Progress achieved
Training of Trainers – August 2009
Model Maternities Initiative National and Regional training
29Photos: MCHIP Mozambique
Model Maternities Initiative Baselines and Action Plans
30
Photos: MCHIP Mozambique
Model Maternities Initiative
31
Promoting birth in vertical position, skin-to-skin care,
early breastfeeding...
Photos: MCHIP Mozambique
Successful approaches
• Working together with preservice training institutes and inservice trainers
• Create a pool of trainers that also act as supervisors• Leave room for the provinces to organize most aspects of
cascade training will help them grow• Identify champions at central and provincial level• Be attentive and clarify critical managerial and technical
issues along the way (eg, how to better organize labor and delivery rooms; how to conserve oxytocin; how to ensure sistematic use of partogram; how to introduce new practices like birth on the vertical position, skin to skin care, AMTSL…)
Some Lessons learned
Involvement of heads of wards/services is a critical determinant of adoption/ implementation of MMI in Moz facilities.
Ensure retention of clinical skills by sustained training/supervision is critical for the humanization and quality improvement process.
Never take for granted that existing SRH/MCH supervisors have the required skills for do the supervision. They often need additional training on such skills.
• Increase the number of health professionals trained • Ensure retention of clinical skills by sustained
training/supervision• Support Maternities on the humanization and quality
improvement workplan implementation and on the sistematic measure of progress
• Improve recording of data (general M&E, SBM-R, etc) • Support the MoH on the recognution process• Improve documentation of lessons learned and best
practices from MMI implementation, at facility level• Support MoH to implement national scale-up of MMI
Moving forward and overcoming challenges
THANK YOU!
Where there is a Wish... there is a Way
Mozambique MOH