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

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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

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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

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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

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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

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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

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Progress achieved

Training of Trainers – August 2009

Model Maternities Initiative National and Regional training

29Photos: MCHIP Mozambique

Model Maternities Initiative Baselines and Action Plans

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Photos: MCHIP Mozambique

Model Maternities Initiative

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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