PROGRESS UPDATE ON ESSENTIAL STEPS IN MANAGING OBSTETRIC EMERGENCIES (ESMOE)

1. PROGRESS UPDATE ON ESSENTIAL STEPS IN MANAGING OBSTETRIC EMERGENCIES (ESMOE) Dr SisanaMajeke (PhD) and ESMOE Board Inspiring Greatness

2. INTRODUCTION AND BACKGROUND • 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).

3. MATERNAL DEATHS

4. INTRODUCTION AND BACKGROUND Cont... • 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).

5. INTRODUCTION AND BACKGROUND Cont... • 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

6. Institutional MMR per level of care

7. Avoidable factors, missed opportunities and substandard care • 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

8. PERINATAL DEATHS • 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 • 8 234 Early Neonatal Deaths –Neonates with LBWT (Saving Babies report 2008-2009 written by NaPeMMCO)

9. KEY RECOMMENDATIONS 5H’s • 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

10. Health worker training • 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.

11. Essential Steps in Managing Obstetric Emergencies (ESMOE) Package • “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

12. ESMOE FORMAT • 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

13. ESMOE Modules

14. ESMOE Pilot 2008 • Pre-test and post test May & August 2008 • Significantly increases knowledge and skills

15. Obstetric Anaesthetic Module • 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

16. EQUIPMENT

17. Master Trainer Training Quality assurance (monitoring) Updating/ Editing Certification Province: Supply personnel for training Coordinate training workshops Master trainers At hospitals with interns Medical officers Ad. midwives Intern training Certified Registered by HPCSA 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 COSMOs skilled ESMOE Board

18. Scaling-up of ESMOE-EOST&Monitoring and Evaluation

19. Aim scale-up ESMOE-EOST • To significantly reduce maternal and neonatal deaths in SA by improving obstetric and neonatal emergency care

20. Process ESMOE-EOST Scale-up • 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

21. Selecting “Most in need” (Phase 1) Districts • 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

22. Scoring

23. Highest scoring districts (12)

24. Highest scoring districts (12)

25. Next 13

26. Next 13

27. “Most in need” Phase 1 Districts • 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

29. Constraints to scale-up • Lack of master trainers • Funding • Staff shortages in the different districts and hospitals

30. Assumptions • 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)

31. National Health Council • Ordered 25 districts to have ESMOE-EOST and anaesthetic module scale-up • DOH to fund the 10 new sites

32. Method • 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

33. Baseline assessment and Standard ESMOE-EOST training(till end 2012) • 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

35. Saturation training(October 2012 – March 2015) • 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

36. Stepped – wedge design Saturation Trained, EOST exercises Perform EOST exercises Phase 1 Districts Time Epochs (2-3 months)

37. Progress • Baseline data collection complete at all core districts • FezileDabe District completed saturation training

38. Training of CHC Health Providers The CHC health providers are also been trained nowfrom August 2012. Midwives are encouraged to attend these trainings for 2 days in their districts. Thank you !!!