Transcript CMMB’s Involvement in AIDS 2012 and Related Events

Combining Tradition and Technology
for Safe Motherhood:
Success with Traditional Birth Attendants (TBAs) in
Bridging the Human Resource Gap in
a Very Resource Limited Emergency Setting in South Sudan
Juma Hayombe,
Project Manager,
Safe Motherhood Project
CCIH 2014
Presentation Contents
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Background
Objectives
Design and Implementation
Outcome
Success stories
Next steps
Discussion/recommendations
Introduction and background
• Globally, an estimated 287,000 women die in child
birth, there are 2.6 million still births, and 3 million
newborn deaths (WHO, UN 2013).
• 80% of the maternal deaths occur in 20 countries in
the developing world (WHO, 2013).
• Most of the deaths are associated with emergency
and humanitarian conditions; inadequate
infrastructure and personnel; and cost of services.
• Despite spirited effort and huge milestones, MDG 4
and 5 remain unmet
Introduction-South Sudan
• Maternal and neonatal outcomes are worse in South
Sudan as decades of political unrest has left few sites
with infrastructure and other resources for training
of HCWs and for providing maternal care services.
• The youngest country in the world, South sudan got
independence in July 2011, 6 years after
comprehensive peace agreement (CPA) with Sudan in
January 2005 following decades of fighting.
• According to HMIS report 2012, only 11% of
deliveries occur in the facility, the rest 89% occur at
home/community.
Introduction Cont.
• Of the facility deliveries, 26%(or 2.5% of the total
deliveries) are conducted by skilled birth attendants
(HMIS Report 2012).
• Most facility ANC and deliveries are manned by
MCHW and TBAs, (HMIS 2012).
• At 2,054 per 100,000 live births (SSHHS-2010), MMR
in South Sudan is the highest in the world.
• Local causes of maternal deaths are bleeding,
obstructed labor, post-abortal/partum sepsis, and
other pregnancy conditions in that order.
The Safe Motherhood Project
• In January 2013, CMMB with support from AMHF, a
private US donor initiated a two-year emergency Safe
Motherhood Project in Ezo County.
• Ezo County has the highest MMR in South Sudan at
2,327 per 100,000 live births.
• One of the ten counties of Western Equitoria State,
South Sudan, it borders Central African Republic and
Democratic Republic of Congo.
• The population of Ezo is estimated at 310,000, and
includes refugees and IDPs from Lords Resistance
Army (LRA) attacks from 2008 to date.
Project Objectives
The project has four objectives:
 Renovating and outfitting Ezo PHCC to offer EmONC
services on 24-7 basis.
 Improving knowledge base and skill set for HCWs,
TBAs and the community leaders on SM.
 Creating linkage, networking and referral systems
between community, TBAs, PHCC/CU and Ezo PHCC.
 providing communication and transport in maternal
and neonatal emergencies.
Objectives cont.
• These objectives aim at addressing 3-delays that
result in poor maternal and neonatal outcomes.
• The three delays are;
 Delay in decision making at the households.
 Delay in accessing health care facilities.
 Delay in access to and provision of appropriate
quality treatment at the facilities.
• The project is modeled on RESCUER- Rural Extended
Services and Care for Ultimate Emergency Relief in
Eastern Uganda that used TBA referral and linkage.
Design and Implementation
• Project started with hiring of expatriates to provide
project leadership (1 Doctor and 2 midwives).
• At Ezo PHCC, a new labor suite was built, a room
renovated to become maternity ward, and
equipments and other supplies were procured.
• The activities were cascaded and now operates in 20
facilities (2PHCC and 18 PHCU), and with 40 TBAs,
selected by facility health committees.
• TBAs, CHWs, CHPs and community leaders have been
trained on Safe Motherhood.
Design and Implem. cont.
• Facility based mentorship HCWs on quality service
provision is conducted on quarterly basis.
• Two Rickshaw ambulances operate and transport
patients in emergency.
• The TBAs map and link the pregnant women for ANC,
and conduct home visits in pregnancy and to postpartum mothers/infants.
• They also assist CHWs in providing ANC services at
the facilities.
• Standard medicines- TT, IPPT, LLITNs, folic/ferrous,
and de-wormers are provided during ANC.
TBA Supplies and Roles
Supplies
Roles
• Safe delivery kit with disposable
single use items modeled on
UNFPA/maama kit.
• Solar charged mobile phones
• Solar lighting source
• Gumboots, aprons
• Bicycles
• Medicines- Paracetamol and
misoprostolol
• Mapping and linking Pregnant
mothers to PHCC/CU for ANC
• home visits for pregnant and
postnatal mothers
• Assisting with ANC at PHCC/CU
• Referring high risk pregnancies
• Conducting simple uncomplicated
deliveries
• Calling for emergency transport
Design and Activities cont.
• High risk mothers are identified using agreed criteria
by TBAs and referred to Ezo PHCC.
 Emphasis is laid on facility deliveries for timely
reporting of adverse events and ease of evacuation
in emergency.
• The project has made use of technology in
transportation, solar-lighting, solar phone charging,
and in mobile communication.
• SMP has been in operation for 18 months, and is set
to end in 6-months.
Where We Work
MAP OF SOUTH SUDAN
Facility Committee
TBAs Outfitted
TBA Training Session
TBA Issued with bicycles
Outcomes to Date
• The project has recorded marked improvement in
core target: ANC attendance, mother-infant pair
attended, and maternal and neonatal outcomes.
• ANC and birth records in facilities have improved.
• 300-500 monthly ANC attendance from under 50 is
now being recorded.
• 150-200 deliveries occur every month at home and
in the facilities.
• 40-60 referred to Ezo PHCC maternity unit every
month and the number is increasing.
Cadre
Before
Now
Doctors
0
1
Midwives
0
2(2)
MCHWs
10
10
CHWs
22
22
TBAs
40
40
Trained leaders
0
20
CHPs
0
20
• TCNs are responsible for
project supervision.
• PHCC has new labor suite,
renovated maternity,
supplies stocked, clean
piped water system.
• 2 Rickshaw ambulances are
operational.
• EmONC services are
available on 24-7 at no cost
to women.
Outcome cont.
• 5-10 TBA calls are made monthly for emergency
evacuation.
• Maternal mortality stands at 0 for over 3200
deliveries recorded.
• Facility deliveries range 40-50% compared national
rate of 11% and is set to increase.
• The project still birth rate is 12 per 1,000 births.
 Every still birth and neonatal death are reviewed
monthly to identify preventable causes.
Table-Outcomes
Oct –Dec 2013
Jan-March 2014
Follow up/linkage
804
782
ANC Attendance
356
919
Total Deliveries
590
503
Facility deliveries
247
199
Home deliveries
296
304
Referrals-Other
94
151
Emergency referrals
17
20
Emergency calls
25
19
Surgical Interventions
6
11
Maternal deaths
0
0
Still births
6
7
ANC Attendance Jan-Apr 2014
800
700
600
500
Ezo PHCC
Other PHCC
400
Total
F-ANC
300
200
100
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
Rickshaw Ambulance
Labor Suite
TBA visit following a referral
TBA visit following a referral
Kangaroo Care being demonstrated
F-ANC
FP
Training
In
Midwifery
BEOMNC
EmONC Services
EQUITY FOR WOMEN
Emergency
Transport
Community
/communi
Safe Motherhood-Normal Setting
EmONC Services
Emergency
Transport
Communicati
on
Community
Programs
Safe Motherhood-Resource limited settting
Success Stories
Brief stories on these(Presentation, Management )
• Lady in coma
• Severe poly-hydramnios
• Abruption placenta
• Cord prolapse
• Prolonged labor, commonly cervical dystocia
• Others; Retained placentas, incomplete abortions etc
 We have recorded no surgical or theatre related
complications
Program Challenges
• Supply chain and logistical difficulties resulting in delays in
delivery of medicines inherent in such emergency situations.
• Cultural/traditional practices, beliefs and norms that
encourage home deliveries and keeping of newborn for 6
months in the homestead.
• Unreliability of mobile telephone network.
• Only about 25% mothers attend ANC four times or more, with
an average 2.2 sessions.
• Literacy levels of TBAs; can not fill cards &registers.
• Bad roads, and other essential elements of dignified
livelihood lacking.
Future Plans
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BCC and male involvement initiatives.
Initiate mobile outreach services to improve quality of ANC.
Open more sites for BEmONC services.
Holding maternity units for sparse population, bad road, no
phone network – Bagidi.
• Train more of skilled birth attendants and take in newly
qualified nurse/midwives for fellowship.
• Have the supplies built into the government supply chain.
• Utilize the android mobile phones GIS system to map and
document emergency calls.
Discussion
• We know what works: infrastructure, equipmentsambulance, and supplies; trained and motivated
health providers; affordable EmONC services.
• MDG 4 and 5 may not be achieved due inadequate
resources for these.
• What we don’t know is what to do in the absence or
scarcity of the resources.
• MoH policies don’t address resource gaps.
• Use of TBA is a centuries old practice that presents
mixed outcome in the literature review.
Discussion cont.
• Primary Surgery, popular book authored (1990) by
renown medical specialist advocates use of TBAs.
• TBAs interventions based on referral system have
been successful in Brazil, Guatemala and Uganda.
• Yet, some countries banned in the 90’s and others
recently despite evidence numerous home deliveries.
• Malawi in 2010 banned TBAs, maternal deaths
increased, and the ban got lifted.
• In many countries there has been a change in
nomenclature-HHPs, CHWs, but TBA like activities
continue.
Discussion cont.
• Why did previous TBA interventions fail?
• Simple; means of communication, affordable means
of transport; and accessible EmONC was not part of
the package.
• The pre-technology ban in 80’s and 90’s may have
been acceptable, review needed in tech. era.
• Community misoprostol distribution strategy will
use among other cadres, TBAs and is being put to
scale. There is need to re-consider TBAs role in the
evolving scenario.
Discussion cont.
• There is need to tie African MOH policies to
resources and practice.
• 80% of maternal deaths occur in 20 countries
offering perfect opportunity to focus programs.
• Simple technology-tradition/community based
models could provide the much needed push for
MDG achievement.
• These are low-cost solutions with immediate
outcomes.
• They are scalable with potential for substantial
impact in resource poor settings.
Conclusion/Recommendation
• The huge resource gap in maternal care is a reality.
• MDG 4 and 5 remain unmet.
• Immediate/mid-term solutions need to be put to
scale to prevent maternal deaths.
• Combining technology with tradition/community is
as effective response to maternal mortality.
• The project further recommends operations research
around such technology-tradition based models.
References
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14.
South Sudan HMIS report, 2012
South Sudan Household Survey (SSHS) 2010
Reproductive Health Needs assessment report, 2012
Maurice King et al.; Primary Surgery 1,
http://maternalhealthinuganda.weebly.com/traditional-birth-attendants.html
http://www.theguardian.com/katine/katine-chronicles-blog/2010/mar/30/traditional-birth-attendants-ban
Traditional birth attendants are an effective resource; http://dx.doi.org/10.1136/bmj.e365 (Published 18 January 2012): BMJ
2012;344:e365 World Health Forum. 1995;16(4):409-13.
Matthews MK, Walley RL, Ward A, Akpaidem M, Williams P, Umoh A; Training traditional birth attendants in Nigeria--the
pictorial method.
http://www.ncbi.nlm.nih.gov/pubmed/8534350
Traditional birth attendants filling the blank space. Ngal E. M.
http://amplifyyourvoice.org/u/elngala/2012/12/11/traditional-birth-attendants-filling-the-blank-space-in-rural-cameroon
Ngozo C. Malawi: Uncertainty over role for traditional birth attendants. Global Issues March 2011.
www.globalissues.org/news/2011/03/15/8880.
Bisika T., The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi; East African
Journal of Public Heath; Issue 2008 5(2): 103-110
Marilza et al; The safe motherhood referral system to reduce cesarean sections and peri-natal mortality - a cross-sectional
study [1995-2006]: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256099/
Marge et al; Issues of programming for Safe Motherhood: http://pdf.usaid.gov/pdf_docs/pnack513.pdf
Acknowledgements
RASKOB FOUNDATION
Questions?
“Together, we can change the
fate of mothers at birth and
achieve MDG.”
Thank you