The remarkable journey of nurturing

Transcription

1 Maternal and Newborn Health URC s Maternal and Newborn Health Strategies n Implementing and Scaling Up Best Practices n Connecting Households to Health Facilities n Linking and Integrating Services n Advocating for Better Policies n Collaborating for Impact The remarkable journey of nurturing and giving birth to new life remains a perilous one for women in many countries. Each year, more than 350,000 women die from complications during pregnancy and childbirth, and an estimated 4.3 million newborns are born dead or die shortly after birth, according to the World Health Organization (WHO). Protecting the health and well-being of mothers and newborns is one of the world s most urgent needs. Protecting the health and well-being of mothers and newborns is one of the world s most urgent needs. (URC) and its nonprofit affiliate the Center for Human Services (CHS) work to ensure that mothers can give birth safely and that their babies have a healthy start to life by addressing the leading causes of maternal and newborn death and disability. We currently implement maternal and newborn health (MNH) programs in countries that include Afghanistan, Benin, Cambodia, Ecuador, Ethiopia, Ghana, Guatemala, Honduras, Kenya, Iraq, Mali, Nicaragua, Niger, the Philippines, Senegal, Tanzania, and Uganda. We draw on proven strategies to implement and scale up best practices, connect households to health facilities, link and integrate services, and advocate for better policies. Strong partnerships are integral to responding to the needs of mothers and newborns and to achieving the United Nations Millennium Development Goals; that s why we collaborate for greater impact through several international, regional, and national partnerships and initiatives. We strive to ensure that all our strategies translate into improved uptake of services, improved quality of services, and improved health outcomes for mothers and children around the world. Underlying Principles Each period of life pre-pregnancy, pregnancy, birth, newborn/postnatal, childhood and adolescence provides crucial windows of opportunity to connect people to the services they need. This continuum of care provides the foundation and conceptual framework for URC s approach to MNH. We assist countries in implementing an integrated care model that identifies gaps in health care delivery and opportunities for improvement in local health systems, focuses on national priorities, and builds on and maximizes existing resources. We also support services that integrate respectful and culturally sensitive care practices. November 2012

2 Quality Improvement URC uses a variety of approaches to improve MNH services. The fundamental concept underlying the field of improvement is that a system left unchanged can only be expected to produce the same results. QI approaches identify unnecessary, redundant, or missing parts of systems and improve quality by clarifying and/or simplifying procedures. QI methods emphasize changes in the systems delivering health care, rather than the provision of additional resources. Most changes focus on improving implementation of high-impact, evidence-based interventions. QI methods can be applied in one facility or community, several, or at the health system level; interventions can focus on one or more clinical topics or support services. Our key to success is the close and supportive relationship we have with country partners, including Ministries of Health, frontline managers, providers, and community groups. We work with these stakeholders to develop strategies to improve both what is done and how it is done, addressing both content and process in the design of better care. We apply quality improvement (QI) to facilitate shared learning; we provide our partners with necessary skills and tools to achieve lasting, positive changes, strengthening health systems and processes for delivering MNH services. The advantages associated with our technical assistance and sound development approach include well-adapted and locally workable solutions, a sense of ownership among stakeholders, and high levels of sustainability. Implementing and Scaling Up Best Practices The critical challenge for MNH is not in procuring expensive equipment and technology, but in creating and sustaining health systems that can deliver needed services. The most common killers of women and newborns in pregnancy and childbirth high blood pressure, hemorrhage, obstructed labor, infection, and asphyxia can be prevented or treated through the systematic application of low-cost tools and interventions. We provide the management support and technical expertise to take these interventions to scale, while addressing critical human resource challenges. For example, URC has successfully scaled up active management of the third stage of labor (AMTSL), a set of clinical steps to prevent postpartum hemorrhage, in Afghanistan, Benin, Ecuador, El Salvador, Guatemala, Honduras, Mali, Nicaragua, Niger, and Uganda. The US Agency for International Development (USAID) Health Care Improvement Project (HCI) introduced AMTSL in two districts in Mali in October 2009, led by a team that successfully implemented AMTSL at national scale in neighboring Niger. The team applied change ideas and tools that proved successful in Niger and could be quickly adapted for Mali. Results show that the percent of births covered by AMTSL in participating Mali facilities increased from around 25% in October 2009 to 100% in February 2012; at the same time, the rate of women experiencing postpartum hemorrhage significantly declined (Figure 1). Similarly, the USAID-funded Projet Intégré de Santé Familiale (PISAF) in Benin collaborated with the Ministry of Health in 2008 to improve the application of AMTSL, Figure 1: Postpartum Hemorrhage Rates Drop as AMTSL Coverage Increases, 41 Facilities, Kayes and Diema Districts, Mali, October 2009 February 2012 Postpartum hemorrhage rate Oct % Births covered by AMTSL % Postpartum hemorrhage Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Percent of Births Covered by AMTSL October 2009 February

3 Minutes after birth at Malalai Hospital in Kabul, Afghanistan, a mother and child share their first look. Through the USAID Health Care Improvement Project, URC is helping improve management of the leading birth complications for mothers and newborns at the hospital. As a result, its maternal mortality rate dropped by half; the rate of newborn asphyxia (trouble breathing) at birth dropped by a third. Photo by: P. Annie Clark, Senior Quality Improvement Advisor, URC. essential newborn care, and infection prevention methods in one region of the country. As performance of AMTSL rose from 73% to 98% of births in 17 facilities in less than a year, postpartum hemorrhage dropped by more than half. PISAF is now working to scale up an integrated family health package, a set of high-impact interventions that includes AMTSL, across two other regions, using lessons from the pilot in the first region. In the Kostroma region, our programs have contributed to a 60% reduction in early newborn mortality since URC helps implement and scale up emergency obstetric care for common newborn complications such as resuscitation of newborns who have trouble breathing and special care for low birth weight infants and essential care for all newborns, such as immediate and exclusive breastfeeding. In Russia, HCI s predecessor projects, Quality Assurance Projects II and III, worked in the Tver Oblast to improve care in a range of newborn health care practices, including infection control in hospitals, newborn resuscitation, promotion of immediate breastfeeding, and prevention of hypothermia and respiratory ailments. After the QI methods produced significant improvements in infant and newborn health in demonstration sites, we helped scale up the practices to the entire region. Six years after our technical assistance ended in 2002, newborn care in the oblast continued to improve and newborn mortality continued to decrease (Figure 2). In the Kostroma region, our programs have contributed to a 60% reduction in early newborn mortality since 2008, achieved in part due to HCI-supported training and improvements in care practices and protocols and in part to investment in facilities and equipment by management. Respectful and Culturally Sensitive Childbirth Care Policy-makers and program managers often focus on overcoming financial and geographic barriers to safe childbirth care. Yet little attention has been paid to the reason why many women avoid giving birth in health facilities: culturally insensitive, disrespectful, and/or abusive care by health workers. In 2010, URC s USAID Translating Research into Action (TRAction) Project led a review that provided substantial qualitative evidence of disrespectful, abusive, and/or culturally insensitive childbirth care, especially in facility settings, in over 30 countries. In 2011, the project awarded implementation research grants to the Population Council and the Mailman School of Public Health at Columbia University to study the manifestations and potential drivers of disrespect and abuse in childbirth in two countries and to test ways to reduce disrespect and abuse in facility-based childbirth. We also partner with the White Ribbon Alliance for Safe Motherhood on the Respectful Care Charter, advocating universal rights for childbearing women. URC has worked for several years to implement culturally responsive childbirth care in Ecuador, Guatemala, and Nicaragua through highly participatory teams composed of members of indigenous groups, traditional birth attendants, and professional providers who collaborate to make facility childbirth services more responsive to cultural preferences, such as the use of traditional clothing or birth positions. Drawing on work supported by URC, Ecuador s Ministry of Health developed the Guide to Culturally Adequate Delivery Care, which was distributed to facilities nationwide. Maternal and Newborn Health 3

4 Figure 2: Infant Mortality Rates Decline, Tver Oblast, Russian Federation, Percent Infant Mortality Rate Neonatal Mortality Rate Early Neonatal Mortality Rate URC project completed, Figure 3: Percentage of Pregnant Women Who Have an Emergency Plan Increases, 11 Priority Districts, San Marcos, Guatemala, September 2007 February Conducting Research on Key Challenges and Solutions in Maternal and Newborn Health URC and CHS have a long and robust history of addressing MNH challenges through operations and implementation research the study and development of approaches to effectively and efficiently implement and scale up proven interventions. We have conducted more than 150 descriptive and intervention research studies and evaluations, many published in peer-reviewed journals, focused on a range of priority MNH topics, such as approaches to overcome the know-do gap between best practices and their sustainable delivery in complex, real-life systems. Percent Interventions: Training health personnel in counseling Organizing group talks with community members on how to recognize pregnancy danger signs and create an emergency response plan to receive skilled medical care With a highly active research portfolio, particularly through the HCI and TRAction projects, we continue to evaluate best practices and partner with organization to study their implementation in complex systems across a range of topics, including malaria, respectful care at birth, performance-based financing in maternal and newborn care, task-shifting, integration of care, and equity-based care. 0 Sept Nov Jan March May July Sept Nov Jan Connecting Households to Health Facilities An effective continuum of care requires strong connections between homes and health facilities. Community health workers (CHWs), traditional birth attendants (TBAs), and other community stakeholders as well as members of the formal health system, such as a supervising nurse from a health post or ambulatory health center, are essential components to ensuring access to care for those who need it. URC s strategies include bringing care closer to the home through outreach services such as community case management and referrals, building capacity and coordination of health workers at community and facility levels, and educating communities about healthy behaviors at home. In Guatemala, for example, we strengthened the links between local communities and facilities for integrated community-based obstetric and newborn care. The Promotion of Essential Obstetric and Neonatal Care (ProCONE) model, implemented under the Calidad en Salud (Quality in Health) project and HCI, connected more than 4000 community centers, 900 health posts, and 165 facilities through community emergency plans. Through the model, the projects facilitated meetings where community members gathered and discussed response plans for when something life-threatening occurs, such as when a woman has complications during labor and needs transportation to the nearest place where she can receive skilled birth care. The project also helped pregnant women and their families create individual emergency plans and recognize signs of labor complications. In 11 priority districts in San Marcos, the percentage of women who had an emergency plan in place increased from 20% in September 2007 to 90% in January 2009 (Figure 3). We also expanded this initial package of services to include family planning, newborn resuscitation, and nutrition. 4

5 In Ecuador, CHS works to reduce maternal and newborn deaths through a strong platform of community-based care firmly linked to primary and referral levels. The Essential Obstetric and Newborn Care Project in Cotopaxi, funded by the USAID Child Survival and Health Grants Program, establishes parish-level micro-network teams composed of TBAs, health center providers, and local representatives. Meeting on a regular basis, the teams reinforce links between care levels and support quality maternal and newborn care accessible throughout the province. In Afghanistan, HCI is building the capacity of provincial health authorities to provide CHWs with training, job aids, and monthly simulation sessions for providing postnatal care and counseling to Afghan families in five provinces. In Kunduz province, CHWs compliance with postnatal care and counseling standards has improved from about 60% in December 2010 to over 90% a year later among participating CHWs. Improved counseling by CHWs led to an increase in the proportion of pregnant women able to cite at least two pregnancy and postpartum danger signs (from 50% in May 2010 to 89% in October 2011) and at least two newborn danger signs (from 20% in May 2011 to 92% in October 2011). Ongoing monitoring, including evaluation interviews with pregnant women who received counseling, provides the CHWs with constructive feedback. We also work directly in communities to raise awareness among women and families of key healthy practices during pregnancy and childbirth and to increase the demand for maternal and child health services. In the Philippines, URC s USAID-funded Health Promotion and Communication (HealthPRO) project worked with the Department of Health (DOH), local government units, and local NGO implementing partners to develop and disseminate health messages on safe motherhood, family planning, and child health. HealthPRO implemented a comprehensive communications strategy that includes assistance for local health education events, health classes, and group counseling; development and distribution of print materials and media messages; capacity development of health care providers in interpersonal communication and counseling; creation of job aids for health care providers; community theatre; and information and service provision via a health promotion bus that tours the country. We also work to address barriers to care, such as financial and transportation constraints. In Cambodia, the USAID Better Health Services (BHS) project spearheaded health equity funds (HEFs), a health financing scheme that targets poor households (identified by the Cambodian government) An Ethiopian woman cradles her newborn while a health worker provides counseling and support. Photo by: Nathan Golon, Maternal and Newborn Health in Ethiopia Project. to give them financial and social support so they can access government services. HEFs cover the direct costs of health services and medications as well as transportation reimbursement for patients. Now available in 58 of Cambodia s 77 districts, HEF support substantially increased the use of public health services. In 2010, 70% of poor women covered Maternal and Newborn Health in Ethiopia Partnership The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), led by Emory University with URC directing its QI component, uses an integrated program of maternal and newborn health training, QI, and health communications to strengthen the delivery of maternal and newborn health services. Working in six districts in the Oromia and Amhara regions, community QI teams use participatory decision-making to identify, implement, and test ideas. The combined training and QI interventions improve teamwork and communication among frontline health workers and between pregnant women and families, fostering a sense of ownership in the community and increasing demand for quality care and referral to facilities for complications. Between November 2010 and February 2012, MaNHEP communities identified more than 14,000 pregnant women, representing nearly 80% of all expected pregnancies. The percent of identified pregnant women who received at least one antenatal care visit either at home or in facilities increased from 39% to 83% during this same period. Maternal and Newborn Health 5

6 by HEFs gave birth in a public hospital or health center twice as many as in the two years before the program. BHS is now piloting community-based health insurance and conditional cash transfers for antenatal care, delivery, postnatal care for mothers and newborns, growth monitoring and promotion for children, and immunizations. Linking and Integrating Services Both mothers and children benefit from integrated approaches that address the full range of care needs, such as family planning, prevention and treatment of HIV/AIDS and malaria, and nutrition counseling and support. Family Planning In Afghanistan, Benin, Cambodia, Guatemala, Honduras, Mali, Nicaragua, the Philippines, and Uganda, we ensure that providers offer family planning counseling to women and men immediately after delivery so that they leave the hospital with a modern family planning method. In Afghanistan, where women have more than six births on average, HCI is working with five hospitals to improve the quality of postpartum family planning services and establish a system that includes quality counseling to empower women to select a modern family planning method during the postpartum period. HCI helped hospital staff review and re-design tools, such as questionnaires and client cards for counselors. In In 2010, 70% of poor women covered by health equity funds gave birth in a public hospital or health center twice as many as in the two years before the program. Mali s Kayes region, family planning counseling was usually not part of postpartum care before HCI s program began in Now, women receive family planning counseling as a routine part of such care in 41 facilities. HIV/AIDS Antenatal care serves as a vital entry point for maternal and newborn care in general and for HIV/AIDS prevention and treatment in particular. URC is working with health facilities in several countries to integrate provider-initiated HIV counseling and testing services into antenatal care and build referral networks for HIV-positive women to prevent motherto-child transmission of HIV. We work with health facilities to ensure that all pregnant women receive four antenatal care visits and encouragement to receive an HIV test during their first visit. For example, in South Africa, URC project-supported sites reached more than 96% of pregnant women with HIV counseling and testing services during their first antenatal visit. Malaria To prevent malaria infection in pregnant women and other household members, we support mass door-to-door insecticide-treated bed net hang-up campaigns in Ghana through the USAID-funded Promoting Malaria Prevention and Treatment (PROMPT) project. In one region, the campaign increased net ownership from less than 30% to more than 80%. In addition to distributing almost seven million insecticide-treated bed nets with local partners, ProMPT led an initiative to train almost 9000 health workers nationwide in preventing and treating malaria in pregnancy. The project is also introducing supportive supervision to ensure that health workers continue to correctly manage malaria in pregnancy and home-based management of malaria by CHWs, so that caregivers can easily access malaria treatment in their communities. Nutrition During pregnancy, undernutrition can have a devastating impact on a child s growth and development. Babies who are malnourished before birth have a higher risk of dying in infancy and are more likely to face lifelong cognitive and physical deficits and chronic health problems. Ensuring proper nutrition for mothers and children, particularly within the critical day window between a mother s pregnancy and her child s second birthday, is key to nurturing healthy families. URC supports a range of nutrition initiatives in Benin, Cambodia, Guatemala, Kenya, Mali, the Philippines, and Uganda to improve the nutritional status of mothers and children. International guidelines recommend immediate-upon-birth and exclusive breastfeeding until the age of six months and complementary feeding from six months until two years. We help advocate for and improve infant and young child feeding (IYCF) practices through the development of curricula, job aids, and educational materials. Our materials formed the basis of UNICEF s The Community IYCF Counselling Package, which helps guide the local adaptation, design, planning, implementation, and scale-up of community-based IYCF counseling and services in a variety of country contexts. We also work with country governments directly to educate mothers and fathers, drawing from several behavior change communication methods. For example, BHS worked with Cambodia s National Nutrition Program to produce one TV and two radio 6

7 Facilitating Public-Private Partnerships In Guatemala and the Philippines, we are working with foundations, companies, NGOs, academia, faith-based organizations, and the government to help provide health care information and services for hard-toreach populations. These counseling cards were developed through NuLife, a nutrition program, to provide tools for community health workers to counsel pregnant women and mothers on infant and young child feeding. ads to promote breastfeeding of children until at least the age of two. These ads complement both existing MOH ones on early and exclusive breastfeeding and a UNICEF campaign on complementary feeding on children between the ages of 6 and 24 months. During pregnancy, poor and rural women are often unable to obtain or eat an adequate diet, leading to deficiencies in necessary micronutrients, such as iron, Vitamin A, and folic acid, which can lead to labor and delivery complications and birth In addition to distributing almost seven million insecticide-treated bed nets with local partners, ProMPT Ghana led an initiative to train almost 9000 health workers nationwide in preventing and treating malaria in pregnancy. defects. Micronutrient supplementation during pregnancy can improve birth outcomes. In Kenya, we worked with health facilities to purchase missing essential micronutrients and to include counseling on the need to take iron and folate tablets as part of antenatal care services. From February to July 2011, the number of mothers receiving folate during antenatal care services rose 40%, and those receiving iron doubled. By November 2011, more than 80% of women received both as part of antenatal care. The relationship between malnutrition and HIV is a vicious one: HIV infection can cause malnutrition and wasting, Through the Multi-Sector Alliances Program (Alianzas) in Guatemala, we are working with Research Triangle International to build public-private partnerships for health and education service delivery. USAID s $6 million initial investment resulted in more than $18 million in partnerships with the private sector. We use the funds to promote access to and the availability of maternal and child care; train institutional and community health providers to offer maternal and child health services, including obstetric care; increase access to information, education, and communication on maternal and child health; promote exclusive breastfeeding; and improve immunizations coverage. while poor nutrition can hasten the infection s progression. Through the USAID-funded NuLife Food and Nutrition Interventions for Uganda, we worked with local partners to assess the nutritional status of pregnant or lactating women and children with HIV/AIDS and treat those who are undernourished with ready-to-use therapeutic food. We trained and supported CHWs to identify and follow up with discharged patients for ongoing care and support. CHWs encouraged mothers to attend antenatal care visits; to receive routine counseling and testing; and, if HIV-positive, to participate in services for the prevention of mother-to-child transmission of HIV. We provided information on appropriate maternal and infant feeding methods and supported community-based growth promotion and monitoring for children under 36 months. Collaborating for Impact URC engages in numerous international, regional, and national partnerships and advocacy efforts to deliver needed tools and services, including: 1,000 Days partnership, which advocates for improving nutrition for mothers and children in the 1,000 days between the start of a woman s pregnancy and her child s second birthday. During this period, better nutrition can have a life-changing impact on a child s future and help break the cycle of poverty. Maternal and Newborn Health 7

8 Success Story: Advocating for Better Policies in Ecuador URC supports country governments to form national policies, strategies, and guidelines that incorporate proven best practices, helping translate them into manageable steps. In Ecuador, for example, where some decision makers and health care providers questioned the safety of introducing AMTSL, we initiated a dialogue with the MOH about the international evidence supporting AMTSL and the importance of including it in national guidelines. The MOH agreed to pilot AMTSL in one province in 2003; the pilot s success facilitated its spread to facilities in four other provinces by 2005 and its inclusion in Ecuador s national obstetric care standards the following year. Baby-Friendly Hospital, a global effort by UNICEF and WHO to ensure that all maternities, whether free-standing or hospital, become centers of breastfeeding support. In Guatemala, URC works with the MOH, UNICEF, and Plan International to apply QI methods to support breastfeeding. There and in Nicaragua, we worked closely with facilities to achieve Baby-Friendly Hospital certification. Care that Counts, a regional QI initiative for orphans and vulnerable children (OVC) services. In partnership with PEPFAR (the President s Emergency Fund for AIDS Relief) and USAID, we are working with six countries in sub-saharan Africa to engage national stakeholders, program implementers, and donor agencies to improve the quality of OVC programming. With support from this initiative, Cote d Ivoire, Ethiopia, Kenya, Malawi, Mozambique, Nigeria, Swaziland, Uganda, and Tanzania have developed outcome-based OVC standards. Haiti has also joined the initiative. The Fistula Care Project, an initiative that provides corrective procedures for obstetric fistula, a serious maternal disability that has devastating effects on women and girls. We are working in partnership with EngenderHealth to identify and refer women in Benin for fistula repair and to reintegrate women into their communities after surgery. Helping Babies Breathe (HBB), an initiative of the American Academy of Pediatrics that emphasizes skilled attendance at birth, assessment of every baby, temperature support, stimulation to breathe, and assisted ventilation as needed, all within The Golden Minute after birth. We provide support for implementing HBB in Afghanistan, Guatemala, Ecuador, El Salvador, Honduras, Iraq, Nicaragua, and Uganda. Kangaroo Mother Care (KMC), a method of care for low birth weight and premature infants that emphasizes skin-to-skin contact and exclusive breastfeeding. In the KMC method, the newborn, wearing only a diaper, socks, and a hat, is placed skin-to-skin against the mother or father s chest, simulating the environment of a warm incubator. URC helped introduce and scale up public hospital KMC programs in Ecuador, El Salvador, Guatemala, Honduras, and Nicaragua. WHO Patient Safety program, which coordinates, disseminates, and accelerates improvements in patient safety worldwide. In 2009, URC staff participated in an international expert consultation to develop the first draft of a safe childbirth checklist and supported its field testing in Mali in In 2013, we will partner with this program through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project to roll out use of the checklist in Sub-Saharan Africa. Center for Human Services 5404 Wisconsin Ave., Suite 800 Chevy Chase, MD TEL FAX Established in 1965, URC is a global company dedicated to improving the quality of health care, social services, and health education worldwide. With our non-profit affiliate, the Center for Human Services (CHS), URC manages projects in more than 40 countries, including the United States. Based in Chevy Chase, Maryland, URC has over 850 employees worldwfide. For more information about our work, please visit our website at: 8