Dilys Walker, MD, Associate Professor Depts of Global Health and Ob/Gyn

University of Washington School of Medicine Mini-Med School, February 14, 2012

Putting the BASIC Back into Basic Emergency Obstetric Care

Seattle, USA

Huehuetenango GUATAMALA

GUATAMALA H u e h u e t e n a n g o

G u a t a m a l a C i t y

Millennium Development Project Global Maternal Health Millennium Summit (September 2000)

A new global partnership to reduce extreme poverty by 2015

Between 1990 and 2015: MDG 4: Reduce under-5 mortality rate by 2/3 MDG 5: Reduce maternal mortality ratio by 3/4

Maternal Mortality Ratio 1980–2008

Country 1990 2008 Change Globally 320 251 -78% Bolivia 439 180 -41% China 87 40 -46% Vietnam 158 64 -40% Morocco 384 124 -32% Afghanistan 1,261 1,575 +25% Zimbabwe 232 624 +169% Ivory Coast 580 944 +63% United States 12 17 +42%

Maternal Mortality Ratio/100,000 live births. Lancet 2010; 375(9726):1609–1623..

B E S T

WO R S T

Maternal Mortality The World’s Best and Worst

Maternal Mortality Burden of Disease

Major Causes Maternal Death What can be done?

http://www.usaid.gov/our_work/global_health/mch/images/MaternalMortality.gif

Oxytocin Maternal compression

Tetanus toxoid Immunization Clean delivery Antibiotics Magnesium

sulfate Partogram

Family Planning Postabortion care

Iron supplements Malaria—intermittent treatment Antiretroviral for HIV

http://www.usaid.gov/our_work/global_health/mch/images/MaternalMortality.gif

Major Causes Infant Death What can be done?

Access to contraceptives, to avoid unintended

pregnancies

Access to skilled care at the time of birth

Timely access to emergency obstetric care in the event of

complications

Reducing Maternal Mortality Key Strategies

The case of Guadalupe…

What new technologies are available for babies?

Low tech resuscitation simulation

baby

Resusci-tation

materials

Windup fetal

monitor

Solar energy kit

Alterna-tive to forceps

Low-tech ultra-sound

What new technologies are available for mothers?

Non-Pneumatic anti-shock garment

Uniject Bakri-Balloon

tamponade

Cell phone apps

PartoPants

Most effective intervention?

Skilled attendants at childbirth

Saving Mothers and Babies Skilled Attendants at Birth

What is happening in Mexico?

Move towards institution-based birth Births with skilled birth attendant

Mexican Perspective Over last 3 decades, proportion of births attended by MDs dramatically:

Cuadernos de Salud Reproductiva. República Mexicana, México, pp. 73-91.Suárez, Leticia, 2010. Salud Materno Infantil en Chávez A. y Menkes C (eds.), Procesos y tendencias poblacionales en el México contemporáneo.

Una mirada desde la ENADID 2006, Secretaría de Salud (en prensa)

Majority of maternal deaths occur in metropolitan area hospitals: • 60% among women 20–34 • 90% had prenatal care • From preventable causes—hemorrhage, preeclampsia

1974 2006 1997

89.5% 84.3%

54.7%

Associated with Quality of Care

What’s been happening in Mexico?

Fuentes: OMS: 1955-1978, INEGI/SSA: 1979-2202, CONAPO: NV 1955-2002

Between 1940 and 1990, maternal mortality dropped 71%. Since 1993, curve has flattened out.

ROSA MARIA NUÑEZ URQUIZA. Propuesta “Transción Epidemiológica Materna-perinatal” a la Fundación CARSO. .

Delays/Omissions/Failures in delivery of appropriate care

What happens? Where?

Family Planning

Prenatal Care Referral 2nd

Referral Delivery Postpartum

RN

Maternal Deaths in Mexico Characteristics

• In institutions • During delivery • Cared for by physicians QUALITY OF CARE

A health professional with the competencies for care during normal birth and the capacity to recognize, manage and refer complications in the woman and newborn.

Skilled Birth Attendant Definition

How can you be sure that a SBA will use the right technology

for the right problem at the right time? ?

Basic Emergency Obstetric Care Standards

Basic EmOC IV/IM: antibiotics

oxytoxics anticonvulsants

Manual removal of placenta Assisted vaginal delivery Removal of retained products

Maine D, Lancet 2007; 370: 1380–82

How to train providers to assimilate evidence-based practices?

Adult Learning Theory

Strategies: Disseminate written materials Didactic sessions

Repetitive reminders On-site facility visits

Clinical audits Interactive sessions/

Simulation-based learning

2004

More Effective

Ineffective

SIMULATION

System adapted from aviation for use in health system

Increase Knowledge

OBJECTIVES for medical

environment

Halamek LP et al. Time for a New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment PEDIATRICS Oct 2000. 106(4): e45.

Improve technical

skills

Improve coordination of care between

providers

Assure efficient

mobilization of resources

Limitations of Simulation Cost Centralization Transportation

How can we bring simulation to where it is most needed?

Simulation Training in Obstetric and Neonatal Emergencies Dilys Walker, MD Susanna Cohen, CNM

Programa de Rescate Obstetrico y Neonatal Tratamiento Optimo y Oportuno

• In-situ simulation-based training • High fidelity (environmental

and psychological) • Low-tech (Parto-PantsTM)

Concept

• Team training (Team STEPPS) • Evidence-based practices

(AMTSL, MgSO4 for preeclampsia, delayed cord clamping, algorithms)

• Humanized birth

PRONTO

Dynamic Activities

PRONTO

Skills Stations

Module I • PPH—mild atony, • Delayed PPH— retained placenta • PPH—severe atony & meconium aspiration • Incomplete AB/IPV • Placenta previa

Module II • Shoulder dystocia • Eclampsia

PRONTO Simulations

Simulations

Now it’s your turn

It all comes together…

Simulation Debrief • What did we see? • How was the treatment of baby?

— Contact with mom — Delayed cord clamping — Early lactation — Immediate care of newborn

• How was the treatment of mom? — AMTSL — Episiotomy — Limpieza — Contact

• How was identification and treatment of hemorrhage?

• How did they work as a team?

PRONTO

PRONTO

Where are we now? Implementation Research • Matched cluster, randomized, controlled trial in Mexico

(12 matched pairs) • Aim to measure impact on perinatal mortality

and serious obstetric complications (index) — Chiapas, Guerrero, Mexico — Maternal/neonatal indicators — Follow-up 1 yr post-training

PRONTO

Guatemala • Matched pair, cluster-randomized,

implementation study to — perinatal mortality — institution-based obstetric care among indigenous populations in Guatemala

• Implement in 4 districts in Guatamala with highest rates of MM (60 small clinics)

• 3 elements in package — PRONTO — Social marketing to institution-based delivery — Obstetric nurse liaison with traditional midwives

Other Local Efforts Impacting Global Maternal/Neonatal Mortality

Testimonials

www.prontointernational.org dilys@u.washington.edu

Results Common Recurrent Weaknesses/Errors in Practice

Hemorrhage • AMTSL/ delayed cord clamping • Timely diagnosis/differential diagnosis • Coordinated care • Medications

(Oxytocin, Carbetocin, Ergonovine, Misoprostol) — Storage — Administration (pre vs post) — Maximum

Preeclampsia • Diagnosis • Loading and maintaining MgSO4 • MgSO4 and/or antihypertensive • Dosing antihypertensive, choice • Valium, Dilantin, phenobarbitol

Results Common Recurrent Weaknesses/Errors in Practice

General • Calling for help • Fundal pressure • Uterine limpiezas • Episiotomy • Position for birth • Domestic violence • Hierarchy • D&C vs MVA

Results Common Recurrent Weaknesses/Errors in Practice

Results Strategic Planning Achievements

• Alarm system • Medication availability • Medication refrigeration • Ambulance functionality • Disseminate algorithms • Ultrasound access/training • Neonatal resuscitation training • Team work dissemination • Implement AMTSL

PRONTO

Guatemala GUATAMALA

H u e h u e t e n a n g o

G u a t a m a l a C i t y