Model Maternities Initiative: Providing Humanistic Maternal and Newborn Care in Mozambique

1. Model Maternities Initiative:Providing Humanistic Maternal and Newborn Care in Mozambique Veronica Reis, MD, MPH – MCHIP Mozambique Elvira Xavier Luis, MD – MoH Mozambique USA, April 6, 2010

2. Purpose of the Session • To share the development of a new initiative in Maternal and Child Health in Mozambique • To discuss challenges and lessons learned of implementing interventions in a poor resource context

3. Topics • Background • The concept and rationale behind Model Maternities Initiative • Overview of the interventions • Progress achieved and challenges • Successful approaches and lessons learned • Moving forward Photo: Ismael Miquidade

4. Background: General Health Situation in Mozambique Total population: 20.53 million (2007) Life expectancy at birth: 42 years Maternal Mortality ratio: 408/100,000 lb Neonatal mortality rate: 48/1,000 live births Major cause of death (all ages): Malaria HIV prevalence rate: 16.2% Source: 2007 Census, DHS 2003

5. Trends in MMR and MDG 5 Source: MoH, National Integrated Plan to Achieve MDGs 4 and 5

6. Trends in Neonatal/Infant/Under Five Mortality Neonatal Mortality represents 40% of Infant Mortality. Source: Multi Indicators Cluster Survey, 2008

7. Causes of Maternal Mortality Source: National Needs Assessment 2007

8. Causes of Neonatal Mortality in Mozambique, % Source: Child Mortality Study, 2009

9. Background: Situation of SRH and MHC in Mozambique Source: Joint Evaluation of Health Sector Performance, 2010 **MICS 2008 *Needs assessment in SRH, 2007 ●DHIS 2003

10. Coverage of high-impact interventions Source: Needs Assessment 2008

11. MCHIP MozambiqueObjectives 2009-2010 • Strengthen EMNC and BEmONC services, including PPFP, in selected healthcare facilities in all provinces, as well as key integrated RH/MCH services in selected healthcare facilities in selected provinces. • Strengthen BEONC and CEONC in an integrated manner in pre-service institutions for MCH mid-level nurses. • Assist the MOH on the development of modular, integrated in-service training package for RH/MCH.

12. Model Maternities InitiativeMCHIP Objective 1 • MMI is an initiative led by the Minister of Health to create facilities that are models not only for quality patient care but also that serve as top of the line clinical training sites for improving health care worker education.

13. Model Maternities Initiative: Concept and Rationale • Model Maternities Initiative are built on the principles of “humanization and quality of Maternal and Neonatal Health (MNH) care”. • Humanization of MNH care is an approach that: • centers on the individual, • emphasizes the fundamental rights of the mother, newborn and families • promotes birthing practices that recognize women’s preferences and needs.

14. FROMTechnocratic TO Humanistic Model Symbols of the “Technocratic Model”: • The body as a machine • Separation between the body and the mind

15. Symbols of the “Technocratic Model” • Centered on the professional • Disempowerment of the woman

16. Symbols of the “Technocratic Model” Use of no Evidence Based Practices

17. Symbols of the “Technocratic Model” Woman “solitary”

18. Separation Between Father – Mother – Newborn – Family

19. MNH Humanistic Model Includes: • Respecting beliefs traditions and culture • The right to information and privacy • Choice of a companion during childbirth • Freedom of movement during labor

20. MNH Humanistic Model Includes: • Choice of position for childbirth • Newborn on “skin-to-skin” care • Use of evidence based practices • Guarantee of emergency obstetric and neonatal care, if necessary

21. MMI: Focus on Humanistic Care and MNH High-impact Interventions • Antenatal care: Tetanus Toxoid, Iron Folate, Intermittent preventive treatment (IPT) for malaria • PMTCT • Normal delivery: Use of partograph; clean delivery; newborn care, include skin-to-skin care; AMTSL and mother/newborn monitoring in the immediate post-partum • Post-natal care: Visit within 2-3 days for mother and newborn • Post-partum family planning/birth spacing • BEmONC: Intravenous antibiotics, oxytocics, MgSO4, manual removal of placenta, assisted vaginal delivery, removal of retained products, newborn resuscitation, Kangaroo Mother care and antibiotics for the newborns • Referral to CEmONC facility

22. MMI Implementation Methodology • Standards-Based Management and Recognition (SBM-R) approach that follows four main steps: • Setting performance standards based on national norms and international references • Implementing standards through a systematic methodology • Measuring progress • Recognizing achievement of the standards

23. Model Maternities Initiative: Selected Facilities (Pre-service Training Sites)

24. MMI Standards by Area and M&E Selected Indicators

25. Key Indicators for M&E of MMI Source for baselines: NHIS, 2010 *Natural population growth:2.4%

26. Progress Achieved in 8 MonthsAugust 2009–March 2010 • Policy and strategy development: National Plan for Humanization of Healthcare; Guidelines for Maternal and Neonatal Death Audit Committees • Evidence-based training packages for MNH developed/ translated/ adapted • Quality MNH standards developed and refined after trainings (SBM-R) • 1 TOT and 3 Regional MNH trainings on EMNC, basic EmONC and SBM-R approach: total of 29 trainers and 90 health professionals trained

27. Progress Achieved MMI—A Work in Progress… • Each of the 34 maternities has at least 2 people trained • 11 nurse training institutes has at least 1 preceptor trained • 20 of the 34 maternities have carried out base line assessments and developed work plan to improve the quality of MNH services • Provincial Godfathers/ Godmothers for MCH involved in all trainings Training of Trainers – August 2009

28. Model Maternities Initiative National and Regional Training Photos: MCHIP Mozambique

29. Model Maternities Initiative Baselines and Action Plans Photos: MCHIP Mozambique

30. Promoting Humanistic Care and High-impact Interventions Companion during childbirth, Birth in vertical position, skin-to-skin care, early breastfeeding... Photos: MCHIP Mozambique

31. Successful Approaches • Working together with preservice training institutes and inservice trainers • Creating a pool of trainers that also act as supervisors • Letting the provinces organize most aspects of cascade training will help them grow • Identifying champions at central and provincial level • Being attentive and clarify critical managerial and technical issues along the way (e.g., how to better organize labor and delivery rooms; how to conserve oxytocin; how to ensure systematic use of partograph; how to introduce new practices like birth on the vertical position, skin to skin care, AMTSL…)

32. Some Lessons Learned • Involvement of heads of wards/services is a critical determinant of adoption/ implementation of MMI in Mozambique facilities. • Ensuring the retention of clinical skills by sustained training/supervision is critical for the humanization and quality improvement process. • Never take for granted that existing MCH supervisors have the required skills for do the supervision. They often need additional training on such skills.

33. Moving Forward and Overcoming Challenges • Increase the number of health professionals trained • Ensure the necessary supervision • Support the implementation of the Maternities´ workplan for humanization and quality improvement • Ensure the systematic measurement of progress • Improve recording of data and M&E • Support the MoH on the recognition process • Improve documentation of lessons learned and best practices from MMI implementation, at facility level • Support MoH to implement national scale-up of MMI

34. Where There is a Will... There is a Way! THANK YOU Mozambique MOH