Model Maternities Initiative:Providing Humanistic Maternal and Newborn Care in MozambiqueVeronica Reis, MD, MPH – MCHIP MozambiqueElvira Xavier Luis, MD – MoH Mozambique

USA, April 6, 2010

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Purpose of the Session

To share the development of a new initiative in Maternal and Child Health in Mozambique

To discuss challenges and lessons learned of implementing interventions in a poor resource context

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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

Photo: Ismael Miquidade

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Background: General Health Situation in Mozambique

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%Source: 2007 Census, DHS 2003

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Trends in MMR and MDG 5

Source: MoH, National Integrated Plan to Achieve MDGs 4 and 5

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Trends in Neonatal/Infant/Under Five Mortality

Neonatal Mortality

represents 40% of Infant Mortality.

Source: Multi Indicators Cluster Survey, 2008

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Causes of Maternal Mortality

Source: National Needs Assessment 2007

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Causes of Neonatal Mortality in Mozambique, %

Source: Child Mortality Study, 2009

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Background: Situation of SRH and MHC in Mozambique

Indicator 2003-7 2008 2009

Percentage of deliveries by a skilled birth attendant

47.7%● 55.3%** 55%

Percentage of pregnant women who had at least two doses of IPT in an ANC visit

27% 43%** 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%● 12.2%**Data not yet

available

Source: Joint Evaluation of Health Sector Performance, 2010 **MICS 2008 *Needs assessment in SRH, 2007●DHIS 2003

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%

Essential Newborn Care Not reported

Source: Needs Assessment 2008

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MCHIP MozambiqueObjectives 2009-2010

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

MCHIP Objective 1

MMI is an initiative led by the Minister of Health to create facilities that are models not only for quality patient care but also that serve as top of the line clinical training sites for improving health care worker education.

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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.

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Symbols of the “Technocratic Model”: The body as a

machine Separation

between the body and the mind

FROMTechnocratic

TO Humanistic Model

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Symbols of the “Technocratic Model”

Centered on the professional Disempowerment of the woman

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Symbols of the “Technocratic Model” Use of no Evidence Based Practices

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Symbols of the “Technocratic Model”

Woman “solitary”

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Separation Between Father – Mother – Newborn – Family

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MNH Humanistic Model Includes:

Respecting beliefs traditions and culture

The right to information and privacy

Choice of a companion during childbirth

Freedom of movement during labor

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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

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MMI: Focus on Humanistic Care and MNH High-impact Interventions

Antenatal care: Tetanus Toxoid, Iron Folate, Intermittent preventive treatment (IPT) for malaria

PMTCT Normal delivery: Use of partograph; clean delivery;

newborn care, include skin-to-skin care; AMTSL and mother/newborn monitoring in 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 the newborns

Referral to CEmONC facility

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MMI Implementation Methodology

Standards-Based Management and Recognition (SBM-R) approach that follows four main steps: Setting performance standards

based on national norms and international references

Implementing standards through a systematic methodology

Measuring progress Recognizing achievement of the

standards

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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

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MMI Standards by Area and M&E Selected Indicators

ÁREAS CONTENTS STANDARDS

1. Managment 92. Information, Monitoring and Evaluation 53. Human and Material Resources 44. Health work conditions 65. Health Education and Community

envolvment 4

6. Antenatal and Post-natal Care 117. Labor, Delivery and Neonatal Care 258. BEmONC 99. Training 4

TOTAL OF STANDARDS 79MNH Selected Indicators 32

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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% 61%

% of HIV+ pregnant women who received prophylaxis (PMTCT)

45% 60%

Number of births by SBA on the selected Model Maternities

113,704 128,076(10% above natural

growth*)

% of deliveries with partograph completely filled

0 50%

% of newborns with skin-to-skin care and early breastfeeding

0 50%

% of birth with AMTSL 0 50%

% of severe pre-eclampsia and eclampsia treated with MgSO4

<20% 40%

Source for baselines: NHIS, 2010 *Natural population growth:2.4%

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Progress Achieved in 8 MonthsAugust 2009–March 2010

Policy and strategy development: National Plan for Humanization of Healthcare; Guidelines for Maternal and Neonatal Death Audit Committees

Evidence-based training packages for MNH developed/ translated/ adapted

Quality MNH standards developed and refined after trainings (SBM-R)

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 MMI—A Work in Progress…

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 MCH involved in all trainings

Training of Trainers – August 2009

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Model Maternities Initiative National and Regional Training

Photos: MCHIP Mozambique

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Model Maternities Initiative Baselines and Action Plans

Photos: MCHIP Mozambique

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Promoting Humanistic Care and High-impact Interventions

Companion during childbirth,Birth in vertical position,

skin-to-skin care, early breastfeeding...

Photos: MCHIP Mozambique

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Successful Approaches

Working together with preservice training institutes and inservice trainers

Creating a pool of trainers that also act as supervisors

Letting the provinces organize most aspects of cascade training will help them grow

Identifying champions at central and provincial level Being attentive and clarify critical managerial and

technical issues along the way (e.g., how to better organize labor and delivery rooms; how to conserve oxytocin; how to ensure systematic use of partograph; how to introduce new practices like birth on the vertical position, skin to skin care, AMTSL…)

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Some Lessons Learned

Involvement of heads of wards/services is a critical determinant of adoption/ implementation of MMI in Mozambique facilities.

Ensuring the retention of clinical skills by sustained training/supervision is critical for the humanization and quality improvement process.

Never take for granted that existing MCH supervisors have the required skills for do the supervision. They often need additional training on such skills.

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Moving Forward and Overcoming Challenges

Increase the number of health professionals trained Ensure the necessary supervision Support the implementation of the Maternities´

workplan for humanization and quality improvement Ensure the systematic measurement of progress Improve recording of data and M&E Support the MoH on the recognition process Improve documentation of lessons learned and best

practices from MMI implementation, at facility level Support MoH to implement national scale-up of MMI

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THANK YOU

Mozambique MOH

Where There is a Will... There is a Way!