Building Capacity To Reduce Maternal and Newborn Deaths in an … · 2019-05-07 · (BEMONC),Antenatal care, surgical skills, anaesthesia, and neonatal care. including KMC •Conducted

Building Capacity To Reduce Maternal and Newborn Deaths in an Urban setting:

CCBRT’s Maternal and Newborn Healthcare programme

in Dar es Salaam

Brenda Sequeira Dmello

2019 March

Outline

1. Urban challenge

2. The CCBRT approach, Theory of change

3. Interventions implemented

4. Results/Achievements

5. Residual gaps

6. Lessons from the field

CCBRT_MNHC_DPG 2/05/2019 2

Urban Challenge

• Population of Dar Es Salaam 5.83 million (NBS projection 2018)

• 94 % facility delivery rate in Dar es Salaam (Regional annual report)

• Government owned comprehensive health facilities congested (> 60 deliveries per day)

• Quality of care is a challenge (Too Little Too late)

Women waiting to deliver in crowded Regional maternity ward-Dar es salaam, CCBRT photo.

Mothers breast feeding sick neonates in a high care unit in DSM


Implemented in close collaboration with Regional/Municipal Authorities, selected the health facilities to be supported.

Selection of evidence based interventions aligned to ONE PLAN II, to strengthen BEmONC & CEmONC which at optimum levels interventions are estimated to reduce major causes of maternal mortality by 70% and 90%, respectively(Pollard 2013)

Use available resources, managerial, materials and intellectual to strengthen routine systems

Regional Led Approach

4CCBRT_MNHC_DPG 2/05/2019

Strategic Selection of Facilities

22 Highest volume Facilities selected by Local government for QI through CCBRT MNHC program conduct on average 80,000 deliveries every year. Total Number of Facilities in DSM=163Total deliveries in DSM~ 124,000

Source: DHIS2


Designing Facility Based Quality

Improvement in C/EmOC

6

3 municipal hospitals and Muhimbili National hospital

REDUCED MATERNAL AND PERINATAL DEATH

IMPROVED QUALITY OF CARE IN EMONC & CEMONC

Standards Based approach to Quality Improvement

Competency Training in C/EMONC

Continuum of Care interventions

Infrastructure + Essential Equipment

Quarterly coaching Perinatal Audits Reflection meetings Annual Regional

assessments

Increased utilization of Dispensaries & health centres

Redistribution of work load/decongestion

Referral systemStrengthening

CCBRT team TA +Training

CCBRT_MNHC_DPG 2/05/2019

• Standards Based Management and recognition (SBM-R) tool adopted -JHPIEGO),5 thematic areas included Normal labour , complications and postnatal care, support system and infrastructure

• Training for health care managers on utilization of the QI tool and approach

• Engaged with frontline workers -who do the work

• Prioritised Investments & Recognition of providers

• Started with 9 sites- reflected adjusted • Strengthened Facility QI teams- Focus on

managerial responsibility• Expanded to 22 facilities

7

Quality Improvement –SBM-R


• Training in emergency obstetric and new born care (BEMONC),Antenatal care, surgical skills, anaesthesia, and neonatal care. including KMC

• Conducted by national trainers supported by CCBRT OBGYN’s and training team of regional specialists and in-charges aligned to best practices

• On the job /one day refresher modules developed/adult learning principles adopted

• Use of checklists/standards.

• Collaboration with 7 Dar based nurse training institutes to support competency of exit graduates using competency assessments

8

Competency Based Training


Interventions across

• Neonatal strengthening• Promoted updates on Helping Babies Breathe, SOPs for sick newborn

• Instituted CPAP for improved sick baby care services and KMC

• Developed skills in equipment use and future training site for neonatal care training

• Instituted criterion based clinical audits in neonatal care

• Antenatal clinic Mobile ultrasounds : • 10 sites developing skills, testing protocols.

• Conducting a study to assess whether it improves pregnancy dating, experience of care, earlier ANC attendance and reduction of still birth rate

• Disability Inclusive Care

• Anaesthesia • Trained 24 nurse anaesthetic officers, Safe anaesthesia checklists developed ,

Utilized at 8 CEMONC HF, coaching, supervision tools developed and in use. Regional stakeholder task force in place, regional standards for anesthesiadeveloped


• Postnatal follow-up: mobile phone call

• Randomized intervention study found Day 3 post delivery phone call reminder significantly increased likelihood of attendance at postnatal clinic on Day 7

• Less than .25 USD per patient, possible for follow up of MH clients

• Referral System Strengthening

• Established closed user group phone lines , linkages with MNH and 22 sites

• Developed referral quality indicators improved. All sites now have log books recording outcomes

• Satellite Blood Banks to increase blood availability

• Launched 4 satellite blood establishments/ blood collection sites to increase blood availability in the region (w NBTS guidance)

• Collaboration with training institutes

• Established network with 13 nurse training schools and MUHAS

• Improving the skill at the exit to reduce the need for in-service training

Continuum of Care


Perinatal Death Data Analysis/Action

• Every still birth and neonatal

death reviewed.

• 8 sites

• Strengthen skills in review and

developing action plans

• Advocacy for follow up of action

plans at monthly meetings

• Database support11CCBRT_MNHC_DPG 2/05/2019

Impact Indicators


BEmONC Quality (SBM-R)

Increase in C-section rate* (8.1 in 2012, 15% in 2018) >1000% Increase in Vacuum assisted deliveries (.2 in 2012, 3.5% in 2018)


Decongestion Through Work Load Redistribution

• Improving quality of BEMONC resulted in increased utilization at health centres and dispensaries .

• Most deliveries absorbed by 2 upgraded health centres

• ~30% Decongestion achieved at three crowded Regional Referral Hospitals (RRH)

• A sample of three supported dispensaries represented in the graph show 84% -213% increase utilization

• Source of data facility utilization (total deliveries) is DHIS2 database

213%

84%


Other Achievements

Workforce development:- Trained 2,600 health

workers- Enhanced continuous

quality improvement initiatives

Service Delivery: - Provided on-the-

job coaching and mentoring to 750+ health workers

- Developed SOPs for labour and neonatal wards

- post-natal follow-up protocol

Data strengthening & data for action: - Conduct annual SBMR

assessments and follow-up

- Established maternal referral process

- Implemented Perinatal Problem Identification Program (PPIP)

Equipment, supplies & infrastructure- Provided essential

newborn and maternal health supplies and equipment

- Helped establish seven designated C-section theaters

660,204 deliveries conducted @ 22 Facilities (2011-2018) $ 5 million USD


Developed a Ten steps process to New Site start Up and QI

Step 1: Planning and site selection/activity planning with Regional Admin; morningmeetings with RHMT/CHMT teams

Co –implementation/engagement/sustainability. Done at beginning and provide quarterly feedback on agreed indicators

Step 2 Training of managers in QI process- SBMR tool /Training of start up teams

5 days training module (includes a benchmark practicum visit and review of adult teaching methodology)

Step 3 SBMR assessment/Gap analysis-develop infrastructure/equipment gap list

3 days per site, includes a day for feedback and joint facility Action planning –prioritization ~funds. Done by district 3 monthly Y1 then 6 monthly Y2 then yearly Y3

Step 4 Training of providers BEMONC/FANC (new sites)~Skills gaps one day refresher (old sites)

Start up -5 days at practicum facility1.PPH/Hypertension 2.RCH/audits 3.Prolonged labour/partograph 4.HBB/ENC/PNC 5.Vacuum /shoulder /breech.

Step 5 Procurement distributionEquipment gaps filing

Starts after step 3

Step 6 Coaching and mentoring On site by CCBRT/Regional team 3 days per site.

Step 7 Data collection Monthly DQA

Step 8 Facility QIT Monthly/Internal SBMR by in-charges, Weekly 5 RCH card audits by In-charges;

Step 9 Regional QIT meeting Quarterly-sharing lessons / share –use data/recognition

Step 10 Perinatal audits- action plan follow up &repeat step 6-9 in cycles every quarter

plan refresher training ~on skills gaps


Residual Program Gaps

Underutilization of the private comprehensive health facilities. 68% of deliveries conducted at CCBRT supported facilities ( vs 8% at 17 CEMONC private facilities, MNH did 5000, while MRT3 dis 13,000 deliveries),85% of still births arrived at CCBRT facilities with no fetal heart,

All birthing facilities must be safe. High number of perinatal deaths, early discharge 6-12 hours post delivery

likely that neonatal deaths at home missed


Training is NOT Enough

• ON site follow up for on the job coaching for at least 3 days essential to encourage, reinforce skills, correct miscommunications and observe practice

• Need a system for quarterly refresher – as Staff transition every 6 months - rapid response to new staff, new interns cause a drop in process indicators like vacuum, perinatal deaths and preventable errors. Suggest- Role of leadership/system of induction training.

• Adult training methodology works best –sharing experiences /demonstrations/drills/videos/case based learning and using facility trained specialists and in charges of labour ward yield good results and good for follow up. 18

Shortage of Staff

• With ratio of 1:10, monitoring is compromised• Current staffing it is almost IMPOSSIBLE to perform expected

standards • Important Issues: burn out, morale & disrespectful care

documentation challenges

• Too many activities per staff,

• Other activities like Supervision, research activities take some of best staff


Key Messages

• Together with the LGA -CCBRT have demonstrated positive change& have experiences and lessons to share with other Regions doing CEMONC

• Competency of staff and quality of care needs to be checked before service provision both for protection of Health care worker and patient.

• For optimum B/CEMONC services adequate workload staffing required

• Adequate skilled staff working on the FRONTLINE are a prerequisite for change to occur.


Thank you for Listening

PO Box 23310, Dar es Salaam, Tanzania

www.ccbrt.org

Telephone: +255 (0) 69999 0001

Email: [email protected]

www.facebook.com/ccbrttz @CCBRTTanzania

AcknowledgmentsTo the staff at the CCBRT partner health facilities for their hard work and best effort that made the program achieve significant success despite challenges.


http://www.ccbrt.org/

mailto:[email protected]

Building Capacity To Reduce Maternal and Newborn Deaths in an … · 2019-05-07 · (BEMONC),Antenatal care, surgical skills, anaesthesia, and neonatal care. including KMC •Conducted

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