REDUCINGMATERNAL MORTALITY

A M AT E R N A L - C H I L D H E A LT H Q UA L I T Y I M P R O V E M E N T I N I T I AT I V E O F T H E

M I N I S T R Y O F H E A LT H A N D S O C I A L S E R V I C E S

I N C O O P E R AT I O N W I T H W I N D H O E K C E N T R A L H O S P I TA L / I N T E R M E D I AT E H O S P I TA L K AT U T U R A ,

I N T E R M E D I AT E H O S P I TA L O S H A K AT I

A N D H E A LT H Q UA L I N T E R N AT I O N A L

Launched in October 2013 to improve MCH quality of care and health outcomes, in order to reduce:____________________________________

Maternal mortality (phase 1)Neonatal moralityEarly childhood mortality

First Stage: Reducing Maternal MortalityWhy is this a concern?

Maternal mortality in Namibia remains too high.

U.N. Millennium Development Goal (MDG 5) calls for reducing maternal mortality by 75% from 1990 to 2015.

During this period Namibia’s maternal mortality rate actually increased, but is now decreasing.

We are back to the 1990 level.

Namibia’s maternal mortality rates (maternal deaths per 100,000 live births)

◦ Data source

1990 180 (The Namibian)

1992 224 (Baseline/UN)

2000 271 (WHO)

2005 310 (World Bank)

2006-2007 449 (WHO)

2008 180 (UNICEF)

2010 200 (World Bank)

2015 56 MILLENNIUM DEVELOPMENT GOAL

0

50

100

150

200

250

300

350

400

450

500

1990 1992 Baseline 2000 2005 2006-2007 2008 2010 2015 MDG GOAL

Maternal Mortality Rate: NamibiaMaternal Deaths per 100,000 Live Births

Medical concerns

Post-partum hemorrhage

Preeclampsia, eclampsia

Prolonged, obstructed labour

Puerperal sepsis

Pre-term and post-term deliveries

Ante-partum hemorrhage

Prior Ceasarean sections

Ectopic pregnancies

Abortion complications

HIV

Socio-demographic factors

Young patients

Late entry into antenatal care

Language barriers

Cultural barriers (patients’ reluctance to ask for help)

Patients lack funds to travel

Procedural concerns

Need for Standard Operating Procedures

Adherence to standards of care

Need for ongoing quality management processes

Delays in referring patients

Communication between facilities

Clinical operational concerns

Staffing levels

Staff training

Medication

Equipment

Supplies

Environment

Distance to health facilities

Availability of transport

Many factors contribute to maternal mortality.

Initial phase of MCH QI Initiative:

Focus, in order to have an impact soon. Focus on an area where we have some control. Maternal services (Labour and Delivery), where key medical issues arise.

Initially chose 4 SOPs—identified by MCH QI Committees of pilot sites (WCH/IHK and IHO):

Post-partum hemorrhage

Preeclampsia/eclampsia

Prolonged/obstructed labour

Puerpersal sepsis

Then the Committees added 2 more SOPs:

Post-term pregnancy

Induction of labour

The 29-31 July 2014 Tsumeb Workshop added 3 more, now under development:

Premature rupture of membranes

Antenatal hemorrhage

Managing patients with a previous caesarean section

Challenge: Where to start?

Recognize that future work will need to address:

Additional medical conditions.

Additional settings (all regional and district hospitals and health centers).

Non-medical factors (operations, procedures, patient empowerment, environment of care).

How are we are working in Maternity Services to reduce maternal mortality?

Nationwide:

- Defining standards of care

Asking each facility to:

- Create an MCH QI committee. (Initially meet monthly. Later, meet quarterly.)

- Measure performance through audit of patient charts, tracking data on the number and causes of maternal deaths. Establish baseline performance data.

- Implement improvement projects (PDSA). Set goal, analyze problem, test change, adopt successful strategies.

- Re-measure performance regularly (quarterly) to assess progress and drive improvement.

Laying foundation: MCH QM Committees at Windhoek Central/Katutura, and Oshakati

This initiative began in October 2013

Focused on 6 conditions related to maternal mortality

Drafted resources: SOPs, training materials, chart audit tools

Tsumeb Workshop to Finalise Maternal Standard Operating Procedures, 29-31 July 2014

13 Participants

Windhoek Central/Katutura Complex and Intermediate Hospital Oshakati

MoHSS Quality Assurance

MoHSS Maternal Child Health

HEALTHQUAL International

Finalised 6 SOP’s related to maternal mortality->

Tsumeb Workshop completed SOP’s on:

- Post-Partum Hemorrhage

- Preclampsia/Eclampsia

- Prolonged/Obstructed Labour

- Puerperal Sepsis

- Postterm Pregnancy

- Induction of Labour

They will be reviewed at a Ministry of Health meeting on 15 August and then distributed.

Also prepared: training materials (Power Point presentations, pre/post tests), chart audit tools, and resource manual/toolkit.

Among the future steps being pursued:

Complete 3 more SOPs: • Antepartum Hemorrhage, • Premature Rupture of Membranes, • Management when there was a previous Caesarean section

Roll out maternal mortality QI initiative in all district and regional hospitals—implement SOPs and ongoing QM process at each site.

Using SOPs as foundation to build ongoing MCH QM programs in each facility.

Future steps…

Then address other MCH concerns in a similar manner:

• Neonatal mortality

• Early childhood mortality

Acknowledgements

Maternity Services leadership and staff of Windhoek Central, Katutura and Oshakati Hospitals

Tsumeb GroupIntermediate Hospital Oshakati: Dr. Telmore Muti, Dr. Saara Kalume, SRN Diina Fernandes, SRN Ester Newaka, RN Ester Ikweya; Windhoek Central Hospital/Intermediate Hospital Katutura Complex: Dr. Albertina Amupala, Sr. Veripunia Katjatenja, Sr. Gerta Eichas, Sr. Cornelia Beukes Collie; Ministry of Health and Social Services: Ms. Christine Gordon, Dr. Apollo Basenero, Dr. Peter Sikana

Ministry of Health-Leadership: Dr. Forster, Deputy Permanent Secretary-QA Unit: Mrs. Gordon and Dr. Basenero-Maternal-Child Health Unit: Dr. Sikana

Thank you

for your commitment to improving maternal-child health.