part i: safe motherhood kristen cotter, msiv. africa: % of all maternal death: 48% lifetime risk: 1...

Part I: Safe Motherhood

Kristen Cotter, MSIV

Africa: % of all Maternal

Death: 48% Lifetime risk: 1 in 20 MMR: 830

Developed Countries: % of all Maternal

Death: 0.5% Lifetime risk: 1 in 2500 MMR: 20 (per 100,000 live births)

WHO/UNICEF/UNFPA, 2000

Why care (and act)?

529,000 maternal deaths in 2000 Often leading cause of adult female death Great disparity

– MMR 50x higher in developing countries

Infant health & survival affected Maternal deaths are avoidable

Causes of Maternal Death Worldwide

20%

8%

7%

13%

13%

15%

25%

Indirect

Other direct

Obstructed labor

Unsafe abortion

Eclampsia

Sepsis

Hemorrhage

Note: #1 cause of Maternal Death in USA doesn’t even make the top 5.

The Making Pregnancy Safer Initiative(Safe Motherhood Initiative)

Vision: All women go safely through pregnancy and childbirth, and that their infants are born alive and healthy.

Goal: To reduce maternal mortality by 75% from 1990 levels by the year 2015.

www.WHO.org

The old hope (1987 Nairobi S.M. Conference). . .

The key to reducing maternal mortality was in the community– Risk assessment by trained non-doctor

Low risk delivery with TBA High risk referred to skilled attendant

– Antenatal care by TBAs

New realizations (1997 Columbo Technical Consultation). . .

Every pregnancy faces risk No data to show that training TBAs lower MM Key to lowering MM: Health Infrastructure

Clean, Safe Delivery

with Skilled Attendance

for all women

Key Components of Safe Motherhood

Skilled attendance (now 62%) Health systems

– Policies– Essential supplies of medicines and equipment– Infrastructure– Referral system– Monitoring & evaluation– Supervision & training of staff– Records

Involving communities

Part II: Safe Motherhood Needs Assessment

Kikoneni and Dzombo Locations

Kwale District, Coast Province,

Kenya

Kristen Cotter

March – May 2003

ICRH Background

Branch of Univ. of Ghent SOM,

Dept. of OB/Gyn Kenya programs include:

– HIV prevention (sex workers, workplace, youth)– Voluntary Counseling & Testing (VCT)– Prevention of Mother-to-Child Transmission of

HIV– Safe Motherhood

Kikoneni and Dzombo LocationsBackground

Pop. 44,647 2 hours outside of Mombasa Estimated HIV seroprevalence: 9% 49% ♀, 29% ♂ never attended school 8% ♀, 17% ♂ educated past primary school Home building materials:

– Grass/palm roofs 74%– Mud and wood walls 64%– Earth floors 75%

Kenya Background

MMR: 1000 per 100,000 live births Lifetime risk of OB death: 1 in 19 Fertility rate: 4.7

– Rural: 5.2– No education: 5.8

♀ using modern contraception: 32% Births in health facility: 42%

(WHO/UNICEF/UNFPA 2000, DHS 1998)

Design and Methodology

Survey tools developed and used in similar settings– MEASURE Evaluation– WHO Safe Motherhood Needs Assessment

Adapted by ICRH staff Professionally translated & back-translated into Swahili Locations

– Kikoneni Health Centre (KHC)– 3 Dispensaries– Mobile Clinic

Interviewer: Diana Ngombo (clinical & PH nurse, ICRH staff)

Overview of Assessment

Retrospective Review of KHC clinical records– ANC Register– FP Register– Maternity Admissions Register

Cross-Sectional Surveys– Facilities Assessment (drugs, equip., supplies)– Human Resources (provider knowledge, training)– ANC Client Exit Interviews– TBA Interviews

Limitations

Sample sizes small Multiple translations Non-random sampling

– ANC clients in register, but only 12-22% had lab results recorded– Women who come to clinics for ANC or delivery are different from

general community

Descriptive only. Cannot be generalized. Without community-wide survey, prevalence cannot be

determined (though we tried) Observation bias & social desirability bias Population Council tool problematic

WHO Pillars of Safe Motherhood

Pillar #1 ANC Pillar #2 Clean, safe delivery Pillar #3 Emergency Obstet. Care Pillar #4 Family Planning

Pillar #1: Antenatal CareReview of ANC Register

New ANC clients at KHC 44 pt/mo Age 22.4 yrs Parity 2.0 children Age of nulliparous pts 18.6 yrs Adolescent pts 33% Gestational age at presentation 26 wks

– 3rd trimester 45%

Previous children dead 12%

Pillar #1: Antenatal CareReview of ANC Register

Lab results Anemia (Hb<10.0) 92%

– Mild (Hb 8.1-9.9) 32%– Moderate (Hb 5.1-8.0) 57%– Severe (Hb <5.0) 2%

Syphilis 2% Malaria 9% Helminths 38% Schistosomiasis 5% Negative Rhesus 3%

Pillar #1: Antenatal CareHC Provider Management

Iron “all”– Non-Anemic: 200 mg tid for 1 week– Anemic: 200 mg tid for 1 or 2 weeks– Referral at Hb ≤5.0– Barriers: stock shortages, cost

Folate “all”– 5 mg tab for 1 week– Stock shortages, cost

Pillar #1: Antenatal CareHC Provider Management

Multi-Vitamins “some”– 1 tab bid or tid for 1 week

SP (Sulphadozine Pyrimethamine) “all”– 3 tab stat, twice during pregnancy

Deworming “all,” “some”

Pillar #1: Antenatal CareCost of 1st ANC visit

Service/Supplies KShConsultation + labs 160ANC card 20Iron x 2 weeks 20Folate x 2 weeks 20Vitamins x 2 weeks 20Ketrex 20SP FreeTetanus toxoid FreeTetanus (syringe) 10__________Total KSh 270 (= US$3.50)

(26% of Kenyans live below $1 per day)

Pillar #1: Antenatal CareANC Exit Interview, KHC

KHC Mobile Transportation Walked 80% 83% Time 66 min. 66 min.

Client-Provider Meeting time 14 min. 7 min. Advised to return 94% 100%


KHC MobilePhysical Exam Abdominal exam 100% 100% Fetal heart beat 100% 100% BP check 97% 100%Medical Hx 100% 100%Medications SP 97% 50% Iron 91% 42%Investigations Blood 69% 13% Urine 69% 13%


Counseling Topic KHC MobileBirth plan (place) 17% 0Benefits of delivering in a health facility 9% 0Nutrition Counseling 6% 8%FP or child-spacing 3% 13%STIs, HIV, AIDS 3% 33%Transportation in event of emergency 3% 0Action if bleeding or seizures 0 0Infant care 0 8%

Pillar #2: Clean safe delivery

Safe Attendance =

Trained attendant+

Enabling environment

(Equipment, Drugs, Facilities)

Pillar #2: Clean safe deliveryBasic OB Equipment

All 4 All 4 3/4Sphygmo- Delivery set Scrub basin manometer IV fluid sets Suture set Stethoscope Sponge forceps Suturing trayGloves Forceps bowl ContainersNeedles & receiver Stretchers & syringes Vaginal speculum

Adult scales Suture needles & materialsBaby scales Thermometer Fetal stethoscope Padded tongue bladeExamination table


2/4 1/4 0/4IV catheter sets Tourniquets AmnihookStopwatch/Watch Straight Catheter Foley catheterSterilizer Partographs Nitrazine paperAntenatal forms Centrifuge or Sterile packing Tape measure hemoglobinometer material

Urine testing Towels or cloth equipment Oxygen tank

Sterile 4x4 gauze MVA Vacuum extractorProtective gown Bulb syringe


KHC equipment scores Absolute Minimal for Delivery 1.00 Basic Equipment 0.67 Partographs 1.00 ANC 1.00 APH 1.00 Eclampsia 1.00 Infection 1.00


KHC equipment scores (con’t) Complicated Deliveries

& Lacerations 0.73 Dysfunctional Labor 0.60 PPH 0.50 Normal L&D 0.44 Storage 0.00

Pillar #2: Clean safe deliveryMedication

Normal L&D 1.00 ANC 0.50 Dysfunctional Labor 0.50 Complicated Deliveries & Lacerations 0.33 PPH 0.33 Infection 0.33 APH 0.00 Eclampsia 0.00

Pillar #2: Clean safe deliveryFacilities

Water– KHC: rainwater & borehole pump– Dry sinks & showers & toilets

Electricity– generator house, but no generator

Pillar #2: Clean safe deliveryAttendant knowledge

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

perform menstrual extractions

check hemoglobin

suture (repair) cervical lacerations

perform internal versions

perform prenatal risk screening

bimanually compress the uterus (internal)

suture (repair) 3rd/4th degree lacerations

perform reflex testing

perform external versions

perform vacuum extractions

bimanually compress the uterus (external)

use partographs to manage labor

first assist at C/Section

manually remove placentas

start IV infusions

suture (repair) episiotomies

suture (repair) vaginal lacerations

perform speculum examinations

perform bimanual examinations

Skill

Percent

Pillar #2: Clean safe deliveryCoverage

Kenya (DHS 1998) 42% 31 KHC births ÷

659 expected births (K’neni Loc)= 5% 74 KHC births ÷ 994 ANC clients (KHC)= 7% ANC clients reporting last birth in health facility

– Mobile Clinic (1 of 14) 7%– KHC (12 of 29) 41%

Limitations!– Other birthing facilities?– ANC clients are not a random sample!

Pillar #2: Clean safe deliveryPreference & Demand

Final decision-maker if referral needed– Husband 100%

Why women choose TBAs instead of health facility (according to TBAs)– Can deliver at home85%– Cheaper/free 31%– Natural to them 8%

Pillar #2: Clean safe deliveryTraditional Birth Attendants

Married women with >4 children 60% never went to school 3.2 deliveries per month (0.9 last month) Most have other primary occupations Learn by apprenticeship (“gift from God” or goats) 4 of 13 had attended training Herbal medicines & spiritual practices included

– Also provided for men and non-pregnant women


Equipment: 54% razors

46% gloves

39% soap

ANC PE: 82% assess baby’s position Delivery prep: 62% sterilize equipment

54% wash hands

Eating/drinking encouraged during labor


When bear down?– Woman feels urge to push 85%– Excessive pain/screaming 54%– Water breaks 46%– Urge to defecate 39%– Crowning 23%


Sometimes insert hand into vagina39% Episiotomies 0 Perineal tears 31%

– Tx: warm saline baths/compresses Manual version for malpresentation 54% Razors to cut cord 100%

– Boil 70%– Wash 31%


How to make placenta come out– Press on abdomen 69%– Wait 31%– Beaded necklace 15%

Pillar #3: Emergency Obstetric Care

Attendant knowledge– Clinical case scenarios

“ANC pt at 32 wks gestation, c/o swollen hands & feet and increased HAs”

“Pt c/o malaise 48 hrs after delivery”

– History-taking– Physical Exam– Action

Pillar #3: Emergency OB CareAttendant knowledge

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

APH Action

Infection Action

PPH Action

PPH Identification

Dysfunctional Labor Identification

Eclampsia Action

Infection Ask

APH Identification

Infection Follow Up

PIH Action

PPH Urgent Action

Kn

ow

led

ge

ca

teg

ory

Calculated score

Pillar #3: Emergency OB CareReferral System

Transportation– No formal system– Family arranges matatu or car

KSh 2000

– 2+ hrs from referral to hospital– Dispensaries refer directly to Msambweni

Pillar #4: Family PlanningFP Register, KHC

Fertility– Kenya TFR (DHS 1998) 4.7– Mean parity of ANC pts (Register) 2.0– Mean gravida of ANC pts (Exit) 3.7 & 3.4– TBAs 5.7 children

Counseling opportunities– 3% of ANC pts at KHC (Exit)– 13% of ANC pts at MC (Exit)– 15% of PNC pts for TBAs (TBA)


Attendance: 96.7 visits/month

0

50

100

150

200

250

300

350

400

2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4

nu

mb

er

of

cli

en

ts

Unspecified

Return

New


Last birth in health facility: 41.4%Last birth in health facility: 41.4%

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Q1 2001 Q2 2001 Q3 2001 Q4 2001 Q1 2002 Q2 2002 Q3 2002 Q4 2002

Quarter

CY

P p

rov

ide

d

Norplant

Condom

OCP

Depo

Couple Years of Protection: with Norplant

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Q1 2001 Q2 2001 Q3 2001 Q4 2001 Q1 2002 Q2 2002 Q3 2002 Q4 2002

Quarter

Pe

rce

nta

ge

of

dis

trib

uti

on

ev

en

ts

Norplant

Condom

OCP

Depo


Distribution Events: Depo Condoms


Coverage Female pop. of Kikoneni Location: 7533 Females of Reproductive Age: ~5,251 FP visits: 2321 for 2001-2002 0.22 visits per Female of Repro Age Ratio of 1 visit per 4.55 women

Limitation: Not a community-wide survey

Conclusions: Pillar #1 Antenatal Care

Med Hx, PE, ANC cards, & adequate time with provider offered to nearly all ANC clients

Lab coverage is low: 69% KHC, 12.5% MC Coverage of SP for IPT: 97% KHC, 50% MC Anemia: 92% Helminths: 38% Minimal counseling, including STIs/HIV Late gestational age at presentation for ANC HIV testing & PMTCT not yet available

Conclusions: Pillar #2 Clean Safe Delivery

67 women have delivered at KHC since 2001= 7.4% of ANC clients at KHC= 5.3% of expected births for Kikoneni LocationKenya MOH goal for 2010: 80% births with skilled attendance

KHC is well equipped and staff well trained to provide normal delivery services.

No water & electricity at KHC, though infrastructure in place

Few deliveries at dispensaries

Summary of Pillar #3Emergency Obstetric Care

KHC referred 9.5% of maternity pts Referrals from dispensaries are rare. Few/no

complications seen in last year. Pre-referral management of complications score

poorly If KHC is to provide “basic OB care,” more

equipment & drugs are needed Transportation: 1.5 to 3.0 hours from referral to

arrival at hospital

Summary of Pillar #4:Family Planning

97 visits per month at KHC Norplant’s addition to MM raised CYP

substantially Condom distribution is low ANC clients counseled on FP during

pregnancy: 3% KHC, 13% MC 15% of TBAs provide FP advice during PNC

Recommendations

Policy considerations– Iron dosing, transportation, Rh- referrals, PNC. . .

Quality of Female Reproductive Health Care– Labs, delivery, ed., condoms. . .

Staff Training and Development Community-based Opportunities

– Gender, empowerment, men, delayed marriage. .

Questions? Responses?

[email protected]

Part III: Parting thoughts on INHL

How I squeezed INHL into med school

Summer between 1st and 2nd year– Spanish language school

IHMEC conference in Honduras CAMC Family Medicine in Honduras MPH (“year off”), with internship in Kenya 4th year elective in Paraguay

Opportunities & Resources

www.ihmec.org– International Health Medical Education Consortium– Links to hundreds of INHL organizations, rotations, volunteer-

seeking groups, etc.– Join!

http://nhsc.bhpr.hrsa.gov/ambassadors/training-abroad.cfm

– Spanish language learning and serving opportunities http://www.aamc.org/students/medstudents/

overseasfellowship/ – Fellowship for 1 year of mentored clinical research in developing

countries, for graduate students in health sciences

MPH Programs

Strong INHL programs– Harvard– Johns Hopkins– UNC Chapel Hill– Tulane University

Usually 1 year with MD

Things to Read

Mountains beyond Mountains, The Quest of Dr. Paul Farmer, a man who would cure the world, 2003, by Tracy Kidder

Alma Ata Declaration, 1978

Thank you!

[email protected]

part i: safe motherhood kristen cotter, msiv. africa: % of all maternal death: 48% lifetime risk: 1...

Documents

cause of maternal death

maternal mortality

safe delivery

health infrastructureclean

tbahigh risk

health facility

safe motherhoodkristen

nondoctorlow risk delivery