A Systems Approach to Lifesaving Maternal and Newborn Care Kate Cassidy, SMGL USAID Initiative Manager Mona Mehta Steffen, SMGL USAID M&E Advisor Mini-U Presentation - March 4, 2016
Maternal & Newborn Mortality Globally, in 2014, over 300,000 women and 3 million newborns died from complications of pregnancy and childbirth 62% of maternal deaths and 39% of newborn deaths occur in sub-saharan Africa Nearly all of these deaths are preventable with skilled care before, during, and after childbirth
Hemorrhage Women are not dying because of diseases Eclampsia we cannot treat They are Infection dying because societies have yet to make the decision that Obstructed Labor their lives are worth saving Sequelae of unsafe abortion Mahmoud Fathalla, MD Indirect causes Father of the Safe Motherhood Movement Why do Women Die?
USG Response: Partnership for MH Saving Mothers, Giving Life is a five-year initiative launched in 2012 that strengthens health services at the district level by combining the capabilities & resources of diverse partners to accelerate the reduction of maternal & newborn mortality Saving Mothers, Giving Life Goal: Decrease Maternal Mortality in SMGL areas by 50%
Founding Partners Founding Partners US Government
SMGL Countries and Phases Phase 1 1/12-9/13 Phase 2 10/13-9/15 UGANDA ZAMBIA Refined model scaled-up in: 10 Ugandan districts 18 Zambian districts Cross River State, Nigeria Phase 3 10/15-9/17 National (and State) Scale-up & institutionalization
MMR & NMR in SMGL Countries UN figures (2015) Maternal Mortality Maternal Mortality Ratio (deaths per 100,000 live births) Number of deaths per year Newborn Mortality Newborn Mortality Rate (deaths per 1,000 births) Number of deaths per year Uganda 343 5,700 22 34,602 Zambia 224 1,400 29 17,783 Nigeria 814 58,000 39 260,000
Using a Systems Approach 1. Delays in the decision to seek care We are taking an integrated 2. Delays in accessing appropriate care in a timely manner health systems approach to addressing the three 3. Delays in receiving high-quality delays respectful care at a health facility
Using a Systems Approach Work with both public and private sectors Focus on labor, delivery & first 48 hrs postpartum Build on existing national/state/local platforms Integrate HIV/AIDS, maternal, and newborn health services
Using a Systems Approach Determine the ecology of safe delivery services in a given area by assessing public and private service delivery points Ensure access to comprehensive emergency care within 2 hours should a complication arise Rationalize financial and technical inputs to maximize coverage and quality of services Count, analyze, and report all maternal and newborn deaths
Key Interventions DEMAND Training Community Health Workers & mobilizing community leaders Communicating & promoting services, birth planning and healthy behaviors ACCESS Renovating facilities (BEmONC and CEmONC), maternity wards, surgical theaters and waiting homes Providing transportation vehicles &/or vouchers
Key Interventions QUALITY Hiring physicians, nurses & midwives with government uptake Training & mentoring providers on AMTSL, EmONC, ENC, HBB, QI On-the-job practice and drilling QI Teams/respectful care HEALTH SYSTEMS SUPPORT Improving supply chain management, equipment & supplies Training in data collection & reporting Building staff housing, where appropriate
Results: Proof of Concept The results after the first year were striking
Other Health Outcomes Uganda Case fatality rate 18% 17% Perinatal mortality rate Case fatality rate 35% 14% Perinatal mortality rate Zambia
Uganda Key Highlights 4,076 trained as part of village health teams to educate women & their families about the risks associated with giving birth at home Doubled the number of facilities practicing the active management of third stage labor (AMTSL) In SMGL districts, 72% of women now live within 2 hours of an EmONC facility Mama Kits 15,655 were distributed to enable clean childbirth
Zambia Key Highlights Hired 19 healthcare workers Trained 199 providers and 302 mentors 13.5% increase in scores on knowledge tests Every SMGL-supported facility in the pilot districts now conducts regular maternal death reviews 100% 98% of SMGL-supported facilities did not experience stockouts of oxytocin in the last 12 months 87% of SMGL-supported facilities did not experience stockouts of magnesium sulfate in 12 months
Strengthening HIV services Managing Mother-to-Child Transmission of HIV +18% In Zambia +28% In Uganda ART for PMTCT ARV prophylaxis for infants +29% In Zambia +27% In Uganda
What Did We Learn? Saving Country the lives ownership of pregnant must women be realized requires from a the functioning national to health the district system: levels of the MOH Build all political, public health, and Integrating There is no HIV- magic and MNH-related bullet services can community commitments and result Coordination better health of both outcomes public and than private when inputs provision is soloed actions and outputs onmakes foundation for a stronger of whole zero Robust System M&E strengthening provides powerful is not cheap proof of but effect: it is an investment Capture health and outcomes a public health good tolerance for preventable maternal and newborn deaths Tally expenditures
Results: Mid-Initiative 41% 38% Progress Reduction increase improving in in facility MMR* newborn delivery health (district -5% wide) -5% -6% 100% 39.3 80% 2012 60% 40% 2014 20% 37.3 31.2 29.6 28% 264 462 37% 8.4 26% Perinatal Mortality Rate Total Stillbirth Rate Institutional Neonatal (per 1,000 *Maternal live births) deaths 17% (per 100,000 1,000 births) live births Mortality Rate 0% (per 1,000 live births) 2012 *includes 2014low birth weight neonates Percent deliveries in EmONC facilities Percent deliveries in lower-level 7.9 100% 80% 60% 40% 20% 0% 53% 43% increase Reduction in facility Progress in improving in newborn MMR* delivery health (facilities only) -29% 37.9 2012 2014 27.0 26% 37% -37% 30.5 19.4 146 28% 311 Perinatal Mortality Rate Total Stillbirth Rate Institutional Predischarge (per 1,000 births) *Maternal (per deaths 1,000 per births) 100,000 live births Neonatal Mortality Rate 2012 (per 2014 1,000 live births) 7.7 62% +2% Percent deliveries in EmONC facilities Percent deliveries in lower-level facilities 7.8
Select Mid-term Outcomes 20 +81% ZAMBIA Women receiving ART for PMTCT -53% Maternal Mortality Ratio in SMGL facilities +32% C-Section Rate -45% Case Fatality Rate -29% Facility Perinatal Mortality Rate
Select Mid-term Outcomes +417% Deliveries supported by transport vouchers UGANDA -45% Maternal Mortality Ratio in SMGL facilities +31% C-Section Rate -47% Case Fatality Rate -41% MMR In SMGL Districts -6% Facility Newborn Mortality Rate 21
Progress In Nigeria Health facility assessments completed in all facilities providing delivery services in Cross River State Results shared and implementation plans crafted with key stakeholders Intervention clusters identified based on access and availability of services GIS mapping of all facilities and travel time in progress Work plan to implement SMGL in select private facilities through Merck for Mothers
SMGL - Nigeria CrossRiver State Facilities
SMGL Challenges Encountered Inconsistent and slow flow of funding Turnover of implementing partners Slower progress in achieving impact on newborn mortality Sustainability
A Call to Action: together we can save mothers and newborns! Thank you! www.savingmothersgivinglife.org