HUMANIZING CHILDBIRTH IN MOZAMBIQUE Panel - Respectful care: A dimension of quality maternal care Presenter: Dr. Veronica Reis, MCHIP Technical Advisor Wednesday, 10 October, in Room Aurelia (A) Hall 10. 13h45

FIGO World Congress, Rome 7th–12th October 2012

Session Objective

To share the results of efforts undertaken in Mozambique to promote the quality and humanization of health care, particularly in the area of childbirth.

Mozambique: Popula tion: 20 million Life expecta ncy a t birth: 45 yea rs Ma terna l morta lity: 408/ 100,000

lb Neona ta l morta lity: 48/ 1,000 lb

Source: 2007 Census, DHS 2003.

General Concepts and Considerations

“Humanization of Maternity Care” is an approach that: Centers on the individual Emphasizes the fundamental

rights of the mother, newborn and families

Promotes evidence-based practices that recognize women’s preferences and needs

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Background, 2006–2008

Initiated implementation of a Quality and Humanization improvement process in MCH services, in 6 provinces/18 HF (primary and secondary level), using the Jhpiego Standards-Based Management and Recognition (SBM-R®) approach.

Results: By the end of 2008, selected health facilities doubled or tripled their performance and were operating at a higher quality level, adhering to established evidence-based standards.

31 Manjacaze Hospital–Gaza

SBM-R: Standards-Based Management and Recognition

It is a practical approach that follows four main steps:

1. Setting performance standards based on national norms and international references

2. Implementing standards through a systematic methodology

3. Measuring progress to guide improvement toward standards

4. Recognizing achievement of the standards

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Model Maternities Initiative (MMI): A Work in Progress…

Q ua lity and Humaniza tion improvement process expa nded in 2009 to the 34 la rgest hospita ls throughout the country (MMI)

MMI – a ims to crea te fa cilities tha t a re models for ma ternity ca re a nd tha t serve a s model clinica l tra ining sites

Nationa l Plan for the Huma niza tion of Hea lthca re launched by the MO H in 2010

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020406080

100Results from 2007–2008

MMI Promotes Practices that Recognize Women’s Preferences and Needs…

Photos: MC

HIP M

ozambique

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Scaling-Up of High-Impact Interventions

Implementation of the MMI Process (Measurement of Performance and Elaboration of Action Plan)

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Photos: MCHIP Mozambique

MMI Adopted Standards by Area

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AREAS CONTENTS STANDARDS

1. Managment 8 2. Information, monitoring and evaluation 5 3. Human and material resources 4 4. Health work conditions 9 5. Health education and community involvment 4 6. Antenatal and postnatal care 14 7. Labor, delivery and neonatal care 23 8. BEmONC 9 9. Training 4

TOTAL OF STANDARDS 80

Key M&E Result Indicators Selected for MMI

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INDICATORS

% of pregnant women who received a t lea st 2 doses of IPT % of HIV+ pregnant women who received prophylaxis (PMTCT) Number of births by SBA in the selected Model Ma ternities % of women with companion during labor and birth % of deliveries with pa rtograph completely filled %of women giving birth in a semi-vertica l or vertica l position % of newborns with skin-to-skin ca re % of newborns with ea rly brea stfeeding % of birth with AMTSL % of severe pre-eclampsia and eclampsia trea ted with MgSO 4

Source for ba selines: NHIS, 2010 *Na tura l popula tion growth:2.4%

Some Results from MMI (Average of all 34 HF, Oct 2009–Dec 2012)

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Baseline(Oct. - Dec. 09)

1st Quarter (Jan- Mar 10)

2nd Quarter(Apr - Jun 10)

3rd Quarter (Jul- Sep 10)

4th Quarter (Oct- Dec 10)

% women with companion during labor 0.0 21.7 26.0 28.8 34.2% women with companion during birth 0.0 19.4 23.2 25.5 26.8% women giving birth in semi-vertical /

vertical position 0 18.1 21.7 23.3 29.5

0

20

40

60

80

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Humanization of care: Birth position; companion during labor and birth

Weighted avg. attainment of all quality standards, baseline and follow-up

50% 32%

Some Results from MMI (Average of all 34 HF, Oct 2009–Dec 2012)

Baseline(Oct. - Dec. 09)

1st Quarter (Jan -Mar 10)

2nd Quarter (Apr- Jun 10)

3rd Quarter (Jul -Sep 10)

4th Quarter (Oct- Dec 10)

% births with partograph completely filledout 0.0 22.6 29.1 33.1 37.9

% births with AMTSL 0.0 86.1 86.1 73.9 78.4% cases severe PE / E treated with Mg.

sulfate 20.0 87.2 74.1 76.4 70.0

0

20

40

60

80

100

Maternity care high impact interventions: partograph use; AMTSL; use of magnesium sulfate

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Some Results from MMI (Average of all 34 HF, Oct 2009–Dec 2012)

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Baseline(Oct. - Dec. 09)

1st Quarter (Jan -Mar 10)

2nd Quarter (Apr- Jun 10)

3rd Quarter (Jul -Sep 10)

4th Quarter (Oct- Dec 10)

% newborns with skin-to-skin contact 0.0 77.0 81.0 72.4 76.8% newborns with immediate breastfeeding 0.0 77.3 77.3 72.2 77.3

0

10

20

30

40

50

60

70

80

90

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Newborn high-impact interventions: Skin-to-skin contact; immediate breastfeeding

Correlation between Humanization and Quality Improvement and Maternal Death

91 (0.51%) 80 (0.52%)

59 (0.33%)

80 (0.45%)

71 (0.40%)

49 (0.31%)

0102030405060708090

100

Jul-Sep09 Oct-Dec09 Jan-Mar10 Apr-Jun10 Jul-Sep10 Oct-Dec10

% of SBMR related to PPH % of SBMR related to SPE/ E

% of AMTSL use # maternal deaths

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Correlation between Humanization and Quality Improvement and Fresh Stillbirths

95 (0.53%)

36 (0.23%)

110 (0.61%)

89 (0.50%)

86 (0.48%)

49 (0.31%)

0

20

40

60

80

100

120

Jul-Sep09 Oct-Dec09 Jan-Mar10 Apr-Jun10 Jul-Sep10 Oct-Dec10

% of SBMR related to labor care% of use of partograph for labor# of cases of fresh stillbirth (+ FHR at admission with 5 minute APGAR of 0)

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Client Satisfaction

One Mozambican mother allowed to accompany her daughter during childbirth at a health center said: “This is what I can call true independence, 2010!”

One young Mozambican woman, who gave birth to her first daughter in a squatting position and was accompanied by her partner, is now sharing her experiences with other women and communities in Mozambique, affirming, “We women must speak up to fight for our rights.” And the father of the baby said: “ It was the most incredible experience of my life, 2010.”

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Main Lessons Learned and Successful Approaches from Mozambique…

Working together with pre-service/ in-service training institutes and professional organizations creates a more sustainable training process.

Developing a pool of trainers and supervisors is an important approach.

Identifying champions is crucial for the smooth implementation of interventions.

Being supportive and clarifying critical managerial and technical issues along the way is important for success.

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Lessons Learned and Successful Approaches from Mozambique…

“Political will" is critical for quality improvement and humanization of health services.

Community and media involvement is very important in this process.

It’s necessary to mobilize resources to support the process implementation. 46

THANK YOU!

Conclusion

Humanizing health care can improve quality of care and increase service utilization and client satisfaction!