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Community-BasedInterventionsforMothersandNewbornsFindingtheRightBalance.pdf

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Harshad Sanghvi, MD JHPIEGO

Community-Based Interventions for Mothers and Newborns: Finding the Right Balance

Overview

Section A

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Maximizing the Opportunities for Reaching MDG 5

!  Ensure skilled care at facilities �  Doctors, midwives, and non-physician clinicians must be

competent on graduation; champion a major shift in pre-service training to focus on needs

�  Ensure that skilled care is fully supported by policy, logistics, and reward

!  Support immediacy of care–taking care to people �  Skilled care closer to women—including at-home birth

!  Special emphasis on PPH/PE/PAC �  Basic emergency obstetric and newborn care

!  Implement a comprehensive package of evidence-based, community interventions

Human Resource Issues in Africa

!  Of 46 African countries, 36 have critical staff shortages

!  An increase of more than 200% is needed to meet 2010 level of need

!  This is not likely to happen unless we: �  Multiply training output: not

just numbers but capability �  Make a serious commitment

to task shifting/sharing �  Revamp HR policies including

retention and reward

Productivity

!  Assessment of the Situation and Needs of General and Minor

Surgery Services in Mozambique

!  Ministry of Health of Mozambique, Jhpiego—CDC

�  All provincial, general, rural, and district hospitals of the country (47 facilities)

�  A sample of type 1 health centers, with maternity and inpatient beds (70 facilities)

Productivity

Type of hospital

Mean productivity: number of surgical

procedures per surgeon per day

Provincial 0.86

General 1.41

Rural 1.05

Correlation between surgical output and availability of

surgical personnel

Implication: increasing workforce does not automatically lead to increased access to care

Selected Drugs Availability in Birthing Areas (Tanzania)

7 Source: EmOC situation analysis. (2006).

What We Need

8 Source: Lois Schaeffer. (2007).

Every skilled provider has

rights

Action: We must ensure that skilled providers are

fully supported

AMTSL

!  Missing the opportunity to maximize on a cost-effective intervention

!  Practice of AMTSL: 7% of facility births

!  Use of uterotonic only: 25% oxytocin, 64% ergometrine, 3% both

!  Policy recommends insufficient dosage of oxytocin

!  Most ergometrine stored inappropriately

!  Harmful practices in third stage in more than 1/3 of facility births

9 Source: National survey of facility-based management of third stage of labor, Tanzania. (2006).

AMTSL

!  Correct practice of AMTSL: 16% of facility births

!  Harmful practices in third stage �  Fundal pressure

10% �  Cord traction

without countertraction 33%

10 Source: National survey of facility-based management of third stage of labor, Bangladesh. (2008).

Technologies

Section B

Harmful or Ineffective Technologies That’ve Taken Off

!  Medical, midwifery, and NPC schools must promote evidence- based and cost- effective practices

Harmful or Ineffective Technologies That’ve Taken Off

!  Ineffective �  The high risk approach for predicting most obstetric and

immediate newborn complications

!  Harmful �  Routine episiotomy �  Chest compression for basic newborn resuscitation

!  Wasteful �  Therapeutic course of antibiotics for prophylaxis after CS

!  Less effective, harmful and more costly �  Routine EFM �  Routine GA for C-sections �  Diazepam, lytic cocktail, for eclampsia

Some Effective Technologies that Are Languishing

!  Medical, midwifery and NPC schools must embrace change and support safe introduction of new, lifesaving technologies

Some Effective Technologies that Are Languishing

!  Some are new; some are not so new

!  FP/RH

�  Emergency contraception �  Implants, DMPA, IUDs,

PPIUD

!  Maternal and newborn health �  AMTSL �  Misoprostol for preventing

and treating PPH �  Misoprostol for treatment

of incomplete abortion, abortion

!  Maternal and newborn health (continued) �  Magnesium sulfate,

antihypertensives to prevent and treat eclampsia

�  Partogram �  Vacuum extractor �  Backup availability of

laryngeal mask for safer GA, resuscitation

�  PMTCT

Proven Interventions for Maternal Survival

!  Active management of the third stage of labor

!  Misoprostol

!  Magnesium sulfate !  Calcium

!  Clean delivery !  Antibiotics !  Tetanus toxoid

!  Nutrition counseling !  Iron folate !  Iptp, malaria control

!  Partogram !  Cesarean

section

!  Family planning !  Postabortion care

Source: April 1, 2006. WHO analysis of causes of maternal deaths: A systematic review. The Lancet, Vol 367.

SBM-R: A QI Approach

Performance Support System: Designing Interventions

Knowledge, Skills, Information

Resources, Capacity

MOTIVATION INCENTIVES

Strengthening of Management Systems, Provision of Resources

Training, Information

Task Shifting Improves Performance

!  EmOC Services: first referral Unit Surat, India

!  Baselines are self assessments �  First assessment was at 2

months after training �  Second at 6 months

Standards Based Management and Recognition Approach, Jhpiego

Nigeria: Bringing about Change

!  Births with SBA and use of AMTSI

!  An FGD session with older women

564

635

2517

2240

3969 3950

500

1000

1500

2000

2500

3000

3500

4000

Number

Oct-Dec, 2006 Jan-March, 2007 April-June, 2007 July-September, 2007 Quarter

Number of Deliveries by SBAs and Use of AMSTL

Deliveries by SBAs AMTSL

Nigeria: Bringing about Change—Newborn Care

Nigeria: Bringing about Change—Postnatal Care

Trend in Percentage of Standards Achieved

13 IHS sites

Accreditation threshold

% o

f ac

h ie

ve d s

ta n d ar

d s

Facilities and Providers for MNH

WHO estimate Afghanistan, 2009 Ethiopia, 2005

1 SBA per 5,000 population— approx 150–175 pregnancies

5,400 About 2,000

16,400

1 HC/10,000 population: 2700 HC

2,700 8,200 519*

4 Bemoc functioning facilities per 500,000 population

216 656

1 CEmOC functioning facility per 500,000 population

54 164 124*

Increasing Access to Facilities

Poor access to low-quality services

Improved access to crowded and lower-quality services

Successful Task Sharing/Shifting

!  Physician

!  Examples

�  Family planning: IUCD, Minilap/TL �  Cervical cancer: the single-visit approach �  Obstetric surgery �  Anesthesia

!  If we wish to successfully shift tasks traditionally done by physicians to nurses, midwives, we must also shift some of their tasks to others —including community workers and volunteers

midwife/nurse/NPC

Examples

!  Tasks that have been successfully transferred to trained community- level workers �  Health information and education

!  Birth-preparedness and complication-readiness education !  Condition-specific education: for example, PPH, PE,

malaria �  Fulfill unmet need for universal coverage by distributing:

!  Iron, folate, Vitamin A, calcium !  Antiworm treatment !  Intermittent preventive treatment of malaria !  Family planning commodities: OCs, condoms !  Misoprostol

Examples

!  Tasks that have been successfully transferred to trained community- level workers �  Provide additional care

!  Injectable contraception !  Gentamycin for newborn infections !  (Parenteral antibiotics for puerperal sepsis)

�  Detection of common ailments !  High blood pressure !  Diabetes !  Proteinuria

MIP Partnership Exxonmobil-Jhpiego

!  Akwa Abom State, Nigeria

Clinic

MIP performance

standards developed and implemented

Community

MIP skills and responsibilities implemented

through community directed

intervention

Training, supervision

mobilization, Commodities

Referrals, records, feedback

MIP Partnership Exxonmobil-Jhpiego

!  Akwa Abom State, Nigeria

!  CDI is a practical way to reach women who would not normally have attended ANC and be protected from malaria

!  Health staff play a crucial role in community mobilization to guarantee malaria-control services

IPT2 coverage LLIN coverage

Control ANC clinic 18.7% 3.8%

Intervention ANC clinic 21.4% 0.4%

Community distributors 92.2% 76.8%

Source: Breiger, Orji, Okeibunor, Otolorin, Ishola, Rawlins. (2010).

Integrated Counseling, Testing for HIV: Mozambique

!  72 lay counselors trained in HIV testing in nine centers

!  Quality supervised by clinic-based coordinators

!  209,851 people counseled �  170,645 (85%) tested in 18

months

!  The acceptance rate for testing is almost four times that in the clinic

21 Source: Bossmeyer. (2010).

Nepal Maternal Mortality Study, 1998 and 2009

1998 2009

MMR 539 247

PPH 37% 19%

Eclampsia 14% 21%

% birth with SBAs 17% 19%

Source: Nepal maternal mortality study. (2008–2009).

Treating PPH and Eclampsia: the Price of Delay

!  The sooner treatment starts, the better the survival rates

!  Treatment is relatively simple if instituted immediately

�  Uterotonics, bimanual compression, aortic compression �  Magnesium sulphate and antihypertensive, delivery

!  Delayed treatment—especially beyond two hours—requires intensive care for shock, DIC, renal shutdown, respiratory failure, electrolyte disturbance, sepsis, pneumonia, and multi-organ failure �  Even in best centers, mortality is high

!  Can we ensure immediacy of treatment where many births are occurring at home and where skilled care is not available?

Doing it Right

!  Technologies that can expedite care for PPH where it occurs

!  Technologies appropriate for peripheral level services, even for home birth

Need Potential technology

PPH detection Brass V drape, pad

Prevention Misoprostol, oxytocin in uniject

Treatment Misoprostol Hydrostatic (condom) tamponade

Safe transfer Antishock garment

Retained placenta

Intra-umbilical oxytocin

“Cool” storage for oxytocin

Clay water pots (used extensively in Africa for storing HIV test kits

Community-Based Distribution of Misoprostol Nepal

!  Impact on mortality

!  18,761 pregnant women were dispensed misoprostol by FCHVs with no significant adverse events or misuse or incorrect use

!  Proportion of deliveries protected by a uterotonic rose from 10.4% to 72.5% �  Largest gains were among the poor, illiterate, and those living

in remote areas

!  Institutional deliveries increased from 9.9% to 16.0%

!  MMR among 13,969 misoprostol users was 72/100,000 �  Significantly lower than among non-users (304/100,000), as well

as the national level of 281/100,000

25 Source: Rajbhandari, Hodgins, Sanghvi. (March, 2010). IJGO.

CBD Misoprostol: Indonesia, Nepal, Afghanistan

!  CBD of misoprostol is safe, acceptable, feasible, and programmatically effective

!  Universal coverage for uterotonic protection against PPH is possible if we are willing to trust, educate, and support non-literate community volunteers

!  Women have a right to be protected against PPH even if they choose to or are forced by circumstances to have home birth

Engaging the Community

Our wives will not die anymore because of bleeding, if they take this drug after birth of the baby and before expulsion of Baar (placenta). We must support and encourage you. Thank you for distributing the drug to our district.”

—A community leader

Preeclampsia

Section C

Massive Unmet Need for Early Detection of PE

Country % Unmet need for

BP check % Unmet need for proteinuria check

Bangladesh 53.1% 70.5%

Bolivia 24.5% 50.9%

DRC 38.8% 57.8%

India 52.5% 56.8%

Indonesia 13.9% 63.0%

Kenya 22.8% 38.9%

Malawi 28.6% 81.3%

Mozambique 48.7% 73.9%

Nepal 43.8% 77.7%

Zimbabwe 14.0% 39.8%

Source: DHS.

Solution

!  Detecting high blood pressure and proteinuria in the community

3 Source: Sanghvi, Crocker, Mongale.

Magnesium Sulphate

Use of Magnesium Sulphate and Case Fatality Rate in Eclampsia, Sadar Hospital, Purulia, West Bengal, India, 2002–2006

Trained 46 MO, 55 nursing personnel

Single Dose of MgSO4 for Treatment of Eclampsia

!  DHAKA

!  A randomized trial with 401 patients comparing efficacy of loading dose alone versus standard regime

!  Outcome �  Recurrent convulsion rate: 4.0% versus 3.5% �  Case fatality rate: 4.5% versus 5.0%

!  Conclusion: for majority of patients, a single-loading dose alone will suffice

!  Implications: this simplified treatment makes it possible to treat eclampsia even at home or at most peripheral centers

An Integrated Community Care Package

!  Volunteer community educators and distributors

!  Birth preparedness/ complication readiness education

!  Primary prevention of: �  Anemia (iron, foliate,

antiworm) �  Preeclampsia, (calcium

supplementation, HBP detection)

�  Malaria (IPT, bed nets)

!  Prevention of PPH: community distribution of misoprostol

!  PMTCT

!  Birth kits

!  Birth registration

!  Vitamin A distribution

!  Basic newborn care

!  Family planning CBD

Skilled Providers

!  Skilled providers must support community interventions

Important Note

!  Maternal and newborn survival is not about the best care that exists

!  It is about the best care you can take to the majority of women

�  Even if they have births at home

Zambia: female nurses performing male circumcision

Afghanistan: trained orderly performing newborn resuscitation

Mozambique: community health worker taking HIV testing to people’s homes

Maximizing the Opportunities for Reaching MDG 5

!  Ensure skilled care at facilities �  Doctors, midwives, and non-physician clinicians must be

competent on graduation; champion a major shift in pre-service training to focus on needs

�  Ensure that skilled care is fully supported by policy, logistics, and reward

!  Support immediacy of caretaking care to people �  Skilled care closer to women, including at-home birth

!  Special emphasis on PPH/PE/PAC �  Basic emergency obstetric and newborn care

!  Implement a comprehensive package of evidence-based, community interventions

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