Transcript University of KwaZulu

Dr Sisana Majeke (PhD) and ESMOE Board
Inspiring Greatness

Key findings:

1500 maternal deaths per year

4867 maternal deaths were reported in 2008-2010

3959 maternal deaths were reported in 2005-2007

3296 maternal deaths were reported in 2002-2004
(NCCEMD Saving Mothers report, 2008 – 2010).
5000
4000
3000
2000
1000
0
2004
2005
2010

MMR 310 /100000 live births (2008)

MMR 330/100000 live births (2009)

The institutional MMR has increased across all
levels of care when compared with
2005-2007 (Saving mothers report, 2008-2010).
 Major

causes of maternal deaths
Top 3 preventable causes of maternal deaths,
accounted for almost 70% of Maternal deaths:
◦ Non-pregnancy related infections (HIV&AIDS) (
40.5%)
◦ Obstetric haemorrhage (14%)
◦ Hypertension (14 % )


Prioritization of the prevention of these
conditions is essential
The biggest impact can be made on
preventing maternal deaths-MDG 5
Institutional MMR/100000 live births
400
350
300
250
200
150
100
50
0
Health Care
Level 1 Hospital
Level 2 Hospital
Centre
2005-2007
2008-2010
Level 3 Hospital

Patient related
◦ Accessing health care services
◦ Unsafe miscarriages

Administrative
◦
◦
◦
◦

Transport between facilities
Access to ICU
Access to blood
Inadequate staff
Health care providers
◦ Not assess patients properly
◦ Delay in referral
◦ Not follow standard protocols



32000 perinatal deaths per year
PNMR 34/1000 births
Primary obstetric causes
◦ Intrapartum asphyxia and birth trauma
◦ Spontaneous preterm birth
◦ Hypertension

Major neonatal death causes
◦ Hypoxia
◦ Immaturity
o 8 234 Early Neonatal Deaths –Neonates with LBWT
(Saving Babies report 2008-2009 written by
NaPeMMCO)





Reduce deaths due to HIV/AIDS
Reduce deaths due to Haemorrhage
Reduce deaths due to Hypertension
Improve Health worker training
Strengthen Health System
Each stresses prevention and emergency care

Train all health care workers involved in maternity care in the
ESMOE-EOST programme and obstetric anaesthetic module, with
emphasis on the following:
◦ Standardised observation and monitoring practices which stipulate the
frequency of observations and aid interpretation of severity e.g. early
warning monitoring charts. These would enable earlier detection of
haemorrhagic shock following delivery and after CS; and also enable
earlier interventions for complicated pre-eclampsia.
◦ The skills of safe labour practices; use of and interpretation of the
partogram , AMTSL, use of uterotonic agents, safe CS, and additional
surgical procedures for complicated CS.
◦ To achieve competence in the management of obstetric emergencies
e.g. PPH, eclampsia, acute collapse.

Train all health care workers who deal with pregnant women in
HIV advice, counselling, testing and support (ACTS), initiation of
HAART, monitoring of HAART and the recognition, assessment,
diagnosis and treatment of severe respiratory infections.








“Essential steps in the management of common
conditions associated with maternal and neonatal
mortality” guideline
“Guidelines for Maternity Care in South Africa”
second edition 2007.
Life Saving Skills manual (RCOG)
Facilitators guide (Adapted RCOG guide)
Mannequins
Posters
CD/DVDs
Emergency Obstetric Simulation Training (EOST)
◦ Scenarios
◦ Scoring sheets

Use principles of adult learning
◦
◦
◦
◦


Lecture
Skills demonstration / DVD/ video
Skills practice
Scenarios
12 modules (90 minutes each)
Training
◦ 3 day workshops
◦ 2 day workshops
◦ 12 weekly in-service training meetings
1. Resuscitation Maternal
7. Obstructed labour
2. Resuscitation Neonatal
8. Interpreting CTGs
3. Sepsis and Shock
9. Obstetric complications
4. Eclampsia and pre-eclampsia
10. Surgical skills
5. Haemorrahge
11. Complications of abortion
6. Assisted delivery
12. HIV in pregnancy


Pre-test and post test May & August 2008
Significantly increases knowledge and skills




2005-2007: 80% of anaesthetic related
maternal deaths clearly avoidable
2008-2010: 90% of anaesthetic maternal
deaths possibly or probably avoidable
Most in district hospitals
Problems
◦ Complications of spinal anaesthesia
◦ Failed intubation

Obstetric Anaesthetic module developed in
2010, tested 2011
ESMOE Board
Master Trainer
Training
Certification
Quality assurance
(monitoring)
Updating/
Editing
Province:
Supply personnel for training
Coordinate training
workshops
Master trainers
At hospitals with interns
Medical officers
Ad. midwives
Intern training
Certified
Registered by HPCSA
COSMOs skilled
EOST at hospital:
Midwives & doctors
Documented
Part of CEO KRA’s
EOST at hospital:
Midwives & doctors
Documented
Part of CEO KRA’s
EOST at hospital:
Midwives & doctors
Documented
Part of CEO KRA’s

To significantly reduce maternal and neonatal
deaths in SA by improving obstetric and
neonatal emergency care


Target initially the Districts which are “most
in need” for emergency obstetric and
neonatal care training as targeting these will
have the most immediate effect on reducing
MMR and NNDR
Training of 80%+ of maternity health care
providers leads a significant reduction in
maternal deaths (MI decreased by 50%),
significant reduction in SBR (15%)
◦ Kenya, India, Sierra Leone, Zimbabwe, Bangladesh

Data
◦ DHIS births for each district
◦ NCCEMD maternal deaths per district
◦ DHIS Stillbirths and neonatal deaths

Criteria for selection
◦ Scoring system according to




MMR
SBR
Number maternal deaths
Priority in province
Top 25 districts according to Ins MMR
Score MMR
1=180-230; 2=230-280; 3=280+
Score SBR
1=25-27; 2=27+
Score MD
1=100-150; 2=150-200; 3=200+
Score Province
2=highest MMR; 1=second highest MMR
Province
Districts
FS
EC
NW
FS
LIM
NC
KZN
KZN
GP
FS
FS
MPU
Lejweleputswa DM
O Tambo DM
Bojanala Platinum DM
T Mofutsanyane DM
Capricorn DM
Frances Baard DM
Ugu DM
Uthungulu DM
Ekurhuleni MM
Fezile Dabi DM
Motheo DM
G Sibande DM
Total
8
8
7
7
7
6
6
6
6
5
5
5
Province
Districts
FS
EC
NW
FS
LIM
NC
KZN
KZN
GP
FS
FS
MPU
Total
Lejweleputswa DM
O Tambo DM
Bojanala Platinum DM
T Mofutsanyane DM
Capricorn DM
Frances Baard DM
Ugu DM
Uthungulu DM
Ekurhuleni MM
Fezile Dabi DM
Motheo DM
G Sibande DM
Maternal deaths
102
281
188
122
222
80
126
154
319
72
124
112
1902 (38% all MD)
Province Districts
KZN
KZN
WC
FS
NC
NC
EC
NW
KZN
EC
NW
NC
LIM
uMgungundlovu DM
eThekwini MM
Central Karoo DM
Xhariep DM
J T Gaetsewe DM
Pixley ka Seme DM
Amathole DM
Dr K Kaunda DM
Uthukela DM
A Nzo DM
Ngaka Modiri Molema DM
Siyanda DM
Waterberg DM
Total
4
4
4
3
3
3
3
3
2
2
2
1
1
Province Districts
KZN
KZN
WC
FS
NC
NC
EC
NW
KZN
EC
NW
NC
LIM
uMgungundlovu DM
eThekwini MM
Central Karoo DM
Xhariep DM
J T Gaetsewe DM
Pixley ka Seme DM
Amathole DM
Dr K Kaunda DM
Uthukela DM
A Nzo DM
Ngaka Modiri Molema DM
Siyanda DM
Waterberg DM
Maternal deaths
117
391
6
11
35
24
191
65
86
48
93
22
78


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9 Districts with district ± regional hospitals
3 Districts with tertiary hospitals
(3 Districts with medical schools)
12 Districts give 50% of maternal deaths in
districts without medical schools
◦ remaining 32 Districts give the rest
Province
Core Districts
EC
FS
FS
FS
KZN
KZN
KZN
GP
LIM
MPU
NC
NW
Amathole DM
Lejweleputswa DM
T Mofutsanyane DM
Fezile Dabi DM
Ugu DM
Uthungulu DM
uMgungundlovu DM
Ekurhuleni MM
Waterberg DM
G Sibande DM
Frances Baard DM
Bojanala Platinum DM
Districts with Medical Schools
O Tambo DM
Capricorn DM
Motheo DM
EC
LIM
FS



Lack of master trainers
Funding
Staff shortages in the different districts and
hospitals


NDOH and PDOH will facilitate cooperation by
province and district respectively
Master trainers will be available and will be
trained on ESMOE-EOST
◦ 600 master training slots in 30 months



Doctors and midwives will be trained mostly
together in teams
Anaesthetic module will be included in the
scale-up, but not necessarily at the same
time as ESMOE-EOST
Funding available (DFID)


Ordered 25 districts to have ESMOE-EOST and
anaesthetic module scale-up
DOH to fund the 10 new sites

Step 1
◦ Baseline assessment and standard ESMOE-EOST
Training

Step 2
◦ Saturation training (80%+ all HCW in MNH trained)
 1 district in 2 months (5 districts/year)
 6x3-day workshops (30 master trainers)
 4x2-day workshops (20 master trainers)
 50 master training slots per district

Facilities and functionality audit
◦ Basic Emergency obstetric care
 Anticonvulsants, oxytocics, antibiotics,
 Manual removal of placenta, perform MVA, assisted delivery
 Bag and mask ventilate a neonate
◦ Comprehensive Emergency Obstetric Care
 Perform C/S and give blood transfusion


Ensure all sites have a doctor and midwife trained
in ESMOE-EOST and are doing EOST exercises
Trained in monitoring tools
◦ PPIP, MaMMAS and maternal near miss audits

Stepped wedge design
 Used where know intervention is effective but cannot
implement it everywhere at once
 Random allocation of order of sites is fairest way to
provide roster for intervention
 All sites have had Standard ESMOE-EOST training at
baseline
 Random allocation to saturation training
 All sites end up with saturation training
Stepped – wedge design
1
1
1
0
Perform
EOST
exercises
9
8
7
6
5
4
3
2
1
Base
Saturatio
n
Trained,
EOST
exercises
Phase 1
Districts
1
2
1
2
3
4
Time Epochs (2-3 months)
5
6
7
8
9
10
11
12
13
-


Baseline data collection complete at all core
districts
Fezile Dabe District completed saturation
training
•
•
The CHC health providers are also been
trained now from August 2012.
Midwives are encouraged to attend these
trainings for 2 days in their districts.
Thank you !!!