Combining Tradition and Technology for Safe Motherhood:

1. Combining Tradition and Technology for Safe Motherhood: Success with Traditional Birth Attendants (TBAs) in Bridging the Human Resource Gap in a Very Resource Limited Emergency Setting in South Sudan Juma Hayombe, Project Manager, Safe Motherhood Project CCIH 2014

2. Presentation Contents • Background • Objectives • Design and Implementation • Outcome • Success stories • Next steps • Discussion/recommendations

3. Introduction and background • Globally, an estimated 287,000 women die in child birth, there are 2.6 million still births, and 3 million newborn deaths (WHO, UN 2013). • 80% of the maternal deaths occur in 20 countries in the developing world (WHO, 2013). • Most of the deaths are associated with emergency and humanitarian conditions; inadequate infrastructure and personnel; and cost of services. • Despite spirited effort and huge milestones, MDG 4 and 5 remain unmet

4. Introduction-South Sudan • Maternal and neonatal outcomes are worse in South Sudan as decades of political unrest has left few sites with infrastructure and other resources for training of HCWs and for providing maternal care services. • The youngest country in the world, South sudan got independence in July 2011, 6 years after comprehensive peace agreement (CPA) with Sudan in January 2005 following decades of fighting. • According to HMIS report 2012, only 11% of deliveries occur in the facility, the rest 89% occur at home/community.

5. Introduction Cont. • Of the facility deliveries, 26%(or 2.5% of the total deliveries) are conducted by skilled birth attendants (HMIS Report 2012). • Most facility ANC and deliveries are manned by MCHW and TBAs, (HMIS 2012). • At 2,054 per 100,000 live births (SSHHS-2010), MMR in South Sudan is the highest in the world. • Local causes of maternal deaths are bleeding, obstructed labor, post-abortal/partum sepsis, and other pregnancy conditions in that order.

6. The Safe Motherhood Project • In January 2013, CMMB with support from AMHF, a private US donor initiated a two-year emergency Safe Motherhood Project in Ezo County. • Ezo County has the highest MMR in South Sudan at 2,327 per 100,000 live births. • One of the ten counties of Western Equitoria State, South Sudan, it borders Central African Republic and Democratic Republic of Congo. • The population of Ezo is estimated at 310,000, and includes refugees and IDPs from Lords Resistance Army (LRA) attacks from 2008 to date.

7. Project Objectives The project has four objectives: • Renovating and outfitting Ezo PHCC to offer EmONC services on 24-7 basis. • Improving knowledge base and skill set for HCWs, TBAs and the community leaders on SM. • Creating linkage, networking and referral systems between community, TBAs, PHCC/CU and Ezo PHCC. • providing communication and transport in maternal and neonatal emergencies.

8. Objectives cont. • These objectives aim at addressing 3-delays that result in poor maternal and neonatal outcomes. • The three delays are; • Delay in decision making at the households. • Delay in accessing health care facilities. • Delay in access to and provision of appropriate quality treatment at the facilities. • The project is modeled on RESCUER- Rural Extended Services and Care for Ultimate Emergency Relief in Eastern Uganda that used TBA referral and linkage.

9. Design and Implementation • Project started with hiring of expatriates to provide project leadership (1 Doctor and 2 midwives). • At Ezo PHCC, a new labor suite was built, a room renovated to become maternity ward, and equipments and other supplies were procured. • The activities were cascaded and now operates in 20 facilities (2PHCC and 18 PHCU), and with 40 TBAs, selected by facility health committees. • TBAs, CHWs, CHPs and community leaders have been trained on Safe Motherhood.

10. Design and Implem. cont. • Facility based mentorship HCWs on quality service provision is conducted on quarterly basis. • Two Rickshaw ambulances operate and transport patients in emergency. • The TBAs map and link the pregnant women for ANC, and conduct home visits in pregnancy and to post-partum mothers/infants. • They also assist CHWs in providing ANC services at the facilities. • Standard medicines- TT, IPPT, LLITNs, folic/ferrous, and de-wormers are provided during ANC.

11. TBA Supplies and Roles Supplies Roles Mapping and linking Pregnant mothers to PHCC/CU for ANC home visits for pregnant and postnatal mothers Assisting with ANC at PHCC/CU Referring high risk pregnancies Conducting simple uncomplicated deliveries Calling for emergency transport • Safe delivery kit with disposable single use items modeled on UNFPA/maama kit. • Solar charged mobile phones • Solar lighting source • Gumboots, aprons • Bicycles • Medicines- Paracetamol and misoprostolol

12. Design and Activities cont. • High risk mothers are identified using agreed criteria by TBAs and referred to Ezo PHCC. • Emphasis is laid on facility deliveries for timely reporting of adverse events and ease of evacuation in emergency. • The project has made use of technology in transportation, solar-lighting, solar phone charging, and in mobile communication. • SMP has been in operation for 18 months, and is set to end in 6-months.

13. Where We Work MAP OF SOUTH SUDAN

14. Facility Committee TBA Training Session TBAs Outfitted TBA Issued with bicycles

15. Outcomes to Date • The project has recorded marked improvement in core target: ANC attendance, mother-infant pair attended, and maternal and neonatal outcomes. • ANC and birth records in facilities have improved. • 300-500 monthly ANC attendance from under 50 is now being recorded. • 150-200 deliveries occur every month at home and in the facilities. • 40-60 referred to Ezo PHCC maternity unit every month and the number is increasing.

16. TCNs are responsible for project supervision. • PHCC has new labor suite, renovated maternity, supplies stocked, clean piped water system. • 2 Rickshaw ambulances are operational. • EmONC services are available on 24-7 at no cost to women.

17. Outcome cont. • 5-10 TBA calls are made monthly for emergency evacuation. • Maternal mortality stands at 0 for over 3200 deliveries recorded. • Facility deliveries range 40-50% compared national rate of 11% and is set to increase. • The project still birth rate is 12 per 1,000 births. • Every still birth and neonatal death are reviewed monthly to identify preventable causes.

18. Table-Outcomes

19. ANC Attendance Jan-Apr 2014

20. Labor Suite Rickshaw Ambulance TBA visit following a referral TBA visit following a referral Kangaroo Care being demonstrated

21. Safe Motherhood-Normal Setting Training In Midwifery FP F-ANC Community/communi EmergencyTransport BEOMNC EmONC Services EQUITY FOR WOMEN

22. Safe Motherhood-Resource limited settting Community Programs Emergency Transport Communication EmONC Services

23. Success Stories Brief stories on these(Presentation, Management ) • Lady in coma • Severe poly-hydramnios • Abruption placenta • Cord prolapse • Prolonged labor, commonly cervical dystocia • Others; Retained placentas, incomplete abortions etc • We have recorded no surgical or theatre related complications

24. Program Challenges • Supply chain and logistical difficulties resulting in delays in delivery of medicines inherent in such emergency situations. • Cultural/traditional practices, beliefs and norms that encourage home deliveries and keeping of newborn for 6 months in the homestead. • Unreliability of mobile telephone network. • Only about 25% mothers attend ANC four times or more, with an average 2.2 sessions. • Literacy levels of TBAs; can not fill cards &registers. • Bad roads, and other essential elements of dignified livelihood lacking.

25. Future Plans • BCC and male involvement initiatives. • Initiate mobile outreach services to improve quality of ANC. • Open more sites for BEmONC services. • Holding maternity units for sparse population, bad road, no phone network – Bagidi. • Train more of skilled birth attendants and take in newly qualified nurse/midwives for fellowship. • Have the supplies built into the government supply chain. • Utilize the android mobile phones GIS system to map and document emergency calls.

26. Discussion • We know what works: infrastructure, equipments-ambulance, and supplies; trained and motivated health providers; affordable EmONC services. • MDG 4 and 5 may not be achieved due inadequate resources for these. • What we don’t know is what to do in the absence or scarcity of the resources. • MoH policies don’t address resource gaps. • Use of TBA is a centuries old practice that presents mixed outcome in the literature review.

27. Discussion cont. • Primary Surgery, popular book authored (1990) by renown medical specialist advocates use of TBAs. • TBAs interventions based on referral system have been successful in Brazil, Guatemala and Uganda. • Yet, some countries banned in the 90’s and others recently despite evidence numerous home deliveries. • Malawi in 2010 banned TBAs, maternal deaths increased, and the ban got lifted. • In many countries there has been a change in nomenclature-HHPs, CHWs, but TBA like activities continue.

28. Discussion cont. • Why did previous TBA interventions fail? • Simple; means of communication, affordable means of transport; and accessible EmONC was not part of the package. • The pre-technology ban in 80’s and 90’s may have been acceptable, review needed in tech. era. • Community misoprostol distribution strategy will use among other cadres, TBAs and is being put to scale. There is need to re-consider TBAs role in the evolving scenario.

29. Discussion cont. • There is need to tie African MOH policies to resources and practice. • 80% of maternal deaths occur in 20 countries offering perfect opportunity to focus programs. • Simple technology-tradition/community based models could provide the much needed push for MDG achievement. • These are low-cost solutions with immediate outcomes. • They are scalable with potential for substantial impact in resource poor settings.

30. Conclusion/Recommendation • The huge resource gap in maternal care is a reality. • MDG 4 and 5 remain unmet. • Immediate/mid-term solutions need to be put to scale to prevent maternal deaths. • Combining technology with tradition/community is as effective response to maternal mortality. • The project further recommends operations research around such technology-tradition based models.

31. References • South Sudan HMIS report, 2012 • South Sudan Household Survey (SSHS) 2010 • Reproductive Health Needs assessment report, 2012 • Maurice King et al.; Primary Surgery 1, • http://maternalhealthinuganda.weebly.com/traditional-birth-attendants.html • http://www.theguardian.com/katine/katine-chronicles-blog/2010/mar/30/traditional-birth-attendants-ban • Traditional birth attendants are an effective resource; http://dx.doi.org/10.1136/bmj.e365 (Published 18 January 2012): BMJ 2012;344:e365 World Health Forum. 1995;16(4):409-13. • Matthews MK, Walley RL, Ward A, Akpaidem M, Williams P, Umoh A; Training traditional birth attendants in Nigeria--the pictorial method. • http://www.ncbi.nlm.nih.gov/pubmed/8534350 • Traditional birth attendants filling the blank space. Ngal E. M. http://amplifyyourvoice.org/u/elngala/2012/12/11/traditional-birth-attendants-filling-the-blank-space-in-rural-cameroon • Ngozo C. Malawi: Uncertainty over role for traditional birth attendants. Global Issues March 2011. www.globalissues.org/news/2011/03/15/8880. • Bisika T., The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi; East African Journal of Public Heath; Issue 2008 5(2): 103-110 • Marilza et al; The safe motherhood referral system to reduce cesarean sections and peri-natal mortality - a cross-sectional study [1995-2006]:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256099/ • Marge et al; Issues of programming for Safe Motherhood: http://pdf.usaid.gov/pdf_docs/pnack513.pdf

32. Acknowledgements RASKOB FOUNDATION

33. Questions?

34. “Together, we can change the fate of mothers at birth and achieve MDG.”

35. Thank you