KNOWLEDGE HUBS FOR HEALTH. Prepared by Dr Chris Morgan, Burnet Institute. on behalf of. Compass: The Women s and Children s Knowledge Hub.

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1 Working Paper Community- based care at birth what role can it play in maternal and newborn survival in high mortality settings? ANNEX: CONSOLIDATED SITE ANALYSES Prepared by Dr Chris Morgan, Burnet Institute on behalf of Compass: The Women s and Children s Knowledge Hub March 2010 KNOWLEDGE HUBS FOR HEALTH

2 Compass: Women s and Children s Health Knowledge Hub Potential for community-based delivery of maternal and newborn care in: Papua New Guinea, Solomon Islands, Lao PDR and the East Nusa Tenggara Province of Indonesia 2 Working Paper ANNEX

3 Compass: Women s and Children s Health Knowledge Hub Papua New Guinea community-based maternal and newborn care Pilly Mapira, January 2010 Introduction: This is a report of the analysis of community-based delivery of maternal and new born care in Papua New Guinea. The report includes a brief description of the maternal and new born status; national policy and national standards relating to the interventions able to be delivered at community-level and few representative programs that are providing some community-based delivery of maternal and newborn care services in the country. It also discusses the enabling and limiting factors that may affect a potential increase in coverage and scope of communitybased services in the country. Maternal and newborn status and practices in PNG While there has been a decline in child death rates (Infant and under-five mortality rate) in recent years, these improvements have not been shared by all. The poor and those living in rural areas with no access to comprehensive health care have missed out on these improvements. Also child survival gains are not evenly distributed throughout the country. Some districts/provinces have child mortality rates that are 3-4 times higher than the better performing districts/provinces. Moreover, perinatal mortality rate remains high with high rates of maternal mortality and homebased deliveries, often unattended by skilled health workers (table 1). The National Demographic Health Survey (DHS) conducted in 2006 reported a neonatal mortality rate (NNMR) of 29 deaths per live births in PNG (NSO, 2009). The most recent Health Sector Review 2001 to 2009 conducted by the National Department of Health (NDoH) confirms perinatal condition as being the second highest cause of all hospital deaths in 2008 (NDoH, 2009). Maternal mortality ratio is reported as the highest in the Asia Pacific region or may be among the worst in the world. Rates as high as 730 maternal deaths per birth is in stark contrast to the approximately 8 in maternal deaths in Australia or even the 40 per deaths in parts of sub Saharan Africa (WHO, 2007). Preventable complications such as excessive bleeding in particular post partum hemorrhage (PPH) and prolonged labour remain the leading causes of early maternal deaths (NSO, 2009 provides some evidence although the NSO study did not look at causes of maternal death, only self-reported delivery complications, that is: for women still alive). Prolonged labour can cause sepsis (which is also a common cause of maternal death) and severe long-term disabilities such as urinary fistula and other conditions that give women a poor quality of life and bring great hardship to them and their families (NSO, 2009). Risk factors of PPH such as anaemia and malaria in pregnancy are high and among the top 15 leading conditions of hospital admissions in PNG as well (NDOH, 2009). Other factors which do not directly cause maternal deaths but increase the risk include low acceptance of family planning, poor antenatal care, poor recognition of high-risk cases and of complications, unsupervised deliveries, high infection rate, poor nutrition during pregnancy and lactation, and low maternal education. Table 1 shows the National data of these indicators. 3 Working Paper ANNEX

4 Compass: Women s and Children s Health Knowledge Hub Table 1. Papua New Guinea National Data Indicators 2006 Mortality MMRatio (#) Newborn Mortality rates per 1,000 live births Literacy Women s Literacy (%) Men s literacy (%) Total (National) Family Planning (FP) TFR CPR % for currently married women Unmet need for FP Most common modern method of FP Maternal health care Antenatal care coverage (NDoH, 2008) Rates of Delivery in health facilities (%) Rates of Delivery in homes (%) Rates of Delivery by health professional (%) Rates of Delivery by TBAs ( % ) Rates of Caesarean section 2 Common delivery complications Excessive bleeding (%) Prolong labour (%) Injection 60% Source: 2006 National Demographic Health Survey National coverage of antenatal care (ANC) services is still lower (60%) than the anticipated 80% coverage with only three out of every five women receiving ANC (NDoH, 2009). There is marked variation between each province with Southern Highlands Province having the lowest coverage of ANC services (30%). Provinces within each of the four regions have ANC coverage below the national standard. These include the four other highlands provinces (Enga, Western Highlands, Eastern highlands, Chimbu), Morobe, East and West Sepik, Central and Gulf provinces (Annex 1). Rates of supervised health facility deliveries, and caesarean sections in 1 Men/women between the ages 6-24 years of age currently at school. > 24 yrs at school 2 Both complications have increased since 1996 and remain the major cause of early maternal deaths. Number of deliveries with complications have increased from 34% (1996) to 43% (2006). 4 Working Paper ANNEX

5 Compass: Women s and Children s Health Knowledge Hub these provinces are also reported to be very low and below the national averages (Annex 1). It is important to note that caesarean sections are only possible at hospital level facilities, and not available in all of them. At the national level, there has been no improvement in these indicators over many years with almost half of all the women giving birth in the village (Table 1). The number of outreach services has been poor and is decreasing nationally with provinces like Gulf, West Sepik and Morobe having the worst/lowest coverage (NDOH, 2009). Routine immunization coverage has also decreased or static at best. National Standards and Practices: Current NDOH thinking on policy and services at Village Health Volunteer (VHV) and Community Health Post levels (CHP) The NDOH recognizes the value of village health initiatives (VHI) and the contribution of VHV in their role in supporting the healthy living of individuals and families in their villages or communities. VHV activities in PNG date as far back as 1920 (NDOH, 2000). They have been working in partnership with health services, local level governments (LLGs), NGOs, churches, CBOs and the corporate sector in addressing problems that the villagers (community members) identify, in ways that they determine are appropriate for their community. A Review conducted in 1999 identified more than 25 health volunteer activities at village level in 15 provinces (NDoH, 2003). By 2002 there were more than fifty (50) VHV programs actively supporting and training VHVs in every province throughout the nation (NDoH, 2003). To date, the exact total number of trained VHVs in the country is unclear but reports from individual programs suggests between 50 to over 600 active VHVs operating within each program, depending on the coverage and scope of the services being provided (Kukhang, 2008; Smith, 2008). In most settings, VHVs activities are fading or vanishing- due to lack of funding for incentives, coordination and support from levels of authorities concerned. Recognizing the importance of VHV activities, a policy for VHI and VHV activities was endorsed in 2000 with inclusion of VHV in the national health Plan By 2003, the Minimum Standards for VHVs and VHV Programs (MSVHV) in PNG was issued. The policy and the standard guidelines provide a nationally recognized status and direction for working with, supporting and encouraging the quality and quantity in VHI and VHV activities. According to the guidelines, VHV are recommended to provide preventive and promotive health services. They are not recommended to provide any clinical services such as giving of injections or oral medications, although records show their involvement in the distribution of simple oral medications through VHVs called marasin meris (medicine women). Reports from evaluation studies (Smith et al, 2008; Kukhang, 2008) and interview with key informants further suggest that they are able and have been effectively providing such services in needed communities where access to first level facility or aid post is often difficult. In view of their capacity in the provision of range of community-based interventions, concerns have been raised to expand the roles VHVs. Report from a VHV technical committee meeting emphasized the potential of VHVs in delivering curative services and recommended that they should be involved in providing basic essential treatment including treatment of common conditions like malaria, anaemia, fever, diarrhea, asthma and supplementation of Vitamin A capsules to pregnant women, among others. However, according to the former national VHV Coordinator (Mrs Mariettta Tovakuta) these recommendations are yet to be endorsed. Provision of other community based interventions such as the use of oxytocin, ergometrine or misoprostol for the active management of third stage labour (AMTSL) and magnesium sulphate (MGSO4) for seizures of high blood pressure in pregnancy are restricted only to health facilities 5 Working Paper ANNEX

6 Compass: Women s and Children s Health Knowledge Hub where skilled birth attendant (midwives, MOs, HEOs) are available (NDoH, 2005). In fact, use of simple community-based interventions like oral (or rectal/vaginal) misoprostol has never been included in standard treatment manuals for management of PPH. Its use has been restricted to cervical ripening for labour induction only. However, in view of the increased PPH associated maternal deaths, recommendations have been made to avail its use for PPH treatment at the hospital and health facility levels but this is yet to be endorsed by the Technical Advisory Group including the Obstetric and the medical society of PNG. Nevertheless, few hospitals have been using them in conjunction with oxytocin for treatment of PPH after the third stage. This was according to interviews with the technical Advisor for Family Health services, Dr. Polume and Obstetricians from Simbu, Enga and Goroka hospitals This means, misoprostol use at the Aid post (the most peripheral basic health facility that links most communities to the health care system) or community level is not recommended and may not be possible as far as the Minimum Standards for District Health Services (MSDHS) in PNG is concerned. According to the MSDHS the basic functions and services of the Aid Posts include; Provision of clinical services: Treatment for common diseases (including intermittent malaria treatment in pregnancy and sexually transmitted infections diagnosis and treatment); First aid for emergency cases; Basic Obstetric Care/Delivery; Preventive services : Health Promotion and Education including outreach visits for promotive and emergency care; MCH patrols/antenatal/postnatal/family Planning/Nutrition including distribution of multivitamin supplements and/or iron and folate during pregnancy; Identify at risk cases and refer to health centre; Immunization; Management: Finance; Health Information; Supervision of Village Health Workers; An aid post is expected to be staffed with at least one community health worker (CHW) and serves a population ranging from depending on its geographical location (NDoH, 2003). Currently, there are about 3, 883 number of CHWs in the country (NDoH, 2009). This number is obviously lower than the acceptable range and raises more concern as population increases against an aging workforce. This has partly resulted in the closure of over 30% of the total 2672 Aid posts nationally (NDoH, 2009). Hence, most of the recommended communitybased interventions including outreach services have not been effectively implemented. In order to expand the functions and services provided at the aid posts level, the NDoH has plans for upgrading them into community health posts so midwives, paediatric nurses and general nurses can be accommodated to perform their roles accordingly at the community level. This was mentioned during the interview with Dr. Polume. This idea has been supported by the minister for health and a technical committee was set up to make sure these recommendations were endorsed. But to date nothing has eventuated. Programs providing community-based delivery of services East Sepik Women and Children's Health Project (ESWCHP) The ESWCHP is an NZAID funded project that operates with an aim of improving basic family health services, safe mother hood and rights for women and children in isolated locations where the permanent health system is unable to reach people. Save the Children PNG (SCiPNG) in partnership with the East Sepik Provincial Health Department (PDoH) and Church based organizations provides services for the ESWCHP. The 6 Working Paper ANNEX

7 Compass: Women s and Children s Health Knowledge Hub NZAID funding for the project is channelled through SCiNZ and Health Service Improvement program (HSIP) Trust Fund within the NDoH under the Strategic Partnership Agreement. The project has been operating continuously since 1995 developing and supporting a network of volunteers or Village Health Volunteers (VHVs) including Village Birth Attendants (VBAs) and Community Based Distributors (CBDs). The VBAs monitor the health of expectant mothers, refer high risk pregnancies to a health facility, and assist with village deliveries in cases where a health facility is not available. The CBDs provide family planning counselling, health education, and family planning supplies. Apart from the VBAs and CBDs are the Marasin Meri (MM) or medicine women, which include women who diagnose and treat sick patients in the rural areas. While their involvement in this area may be beyond their recommended roles and responsibilities, MM have been providing services before development of the Minimum Standards of VHVs and in areas where health facilities are not available. According to the most recent review of the project, 1, 073 VHVs have been trained over the last twelve years by the project. Of these 615 are active and report to operate in more than 400 villages (Smith, 2008). The project continuously provides refresher training for existing VBA/CBDs and full training for new VBA/CBDs. However, over the last four years there has been no VHV training. Lack of VHV supervision, refresher training, and basic supplies needed by VHVs and incentives threaten the quality and sustainability of the program. This may have and can contribute to the decreasing number of active VHVs. Nevertheless, the project has been successful in achieving some of its goals although there is little verifiable data to confirm this. Reports of ESP health sector review indicate that despite the closure of over 65% of government aid posts in the province, there have been some improvements including increased antenatal coverage and family planning acceptance (Smith, 2008). Anecdotal evidence further suggests other improvements. There have been good first aid practices in participating communities among others including increase in supervised delivery rates, decreased malaria incidence and significant drop in out-patients visits at health facilities (Smith, 2008). This suggests an increase in the number of health issues that can be dealt at the community level using cost effective interventions. In 2008/2009, with support from Burnet Institute, a trial of birth-dose vaccination delivered by VBAs, MMs or CHWs has been undertaken within ESWCHP. This shows that VBAs can successfully give hepatitis B vaccination using Uniject and manage this vaccine outside the cold-chain. This has made the vaccine available to between 30 and 50% of home-births infants who would otherwise not receive it at all. The project was less successful in promoting delivery of vaccine by those who would not normally attend the birth, such as MMs, and there was no increase in outreach home visits from health centre staff in the immediate post-natal period. Susu Mamas PNG Incorporated Susu Mamas PNG Incorporated is a non-profit, NGO that has been operating in the country for over 33 years. The organization is solely supported through charity and fund-raising activities. They also receive funding from other sponsors like the WestPac Bank. By January 2010, the NDOH has agreed to ensure ongoing funding of Susu Mamas services as per a deed of agreement that was signed between the NDoH and Susu Mamas Inc. As the name suggests, Susu (breast milk) mamas (mothers) Inc provides services/projects that promote mother and baby friendly practices through free education and counselling services. Range of topics are covered including breastfeeding, nutrition, infant feeding including HIV 7 Working Paper ANNEX

8 Compass: Women s and Children s Health Knowledge Hub positive mothers, hygiene practices, antenatal and postnatal care, immunization, family planning and voluntary counselling and testing (VCT). The services are provided by well trained and dedicated nurses and are mostly hospital-based. However, they also have other community-based projects where nurses visit communities and clinics or aid posts within the localities of the hospital. Currently they are operating in the highlands (Mt.Hagen General Hospital, WHP), Momase (Lae/Angau General Hospital, Morobe) and Southern regions (Port Moresby General Hospital- PMGH) of the country. The Port Moresby area has a number of projects. PMGH Project where Susu Mama nurses (SMN) visit the Labour, Post Natal, Antenatal clinics/wards, Special Care Nursery and the Children's Wards on a daily basis and conduct one on one counseling to mothers. Nurses hand out baby books and introduce our services so mothers can be followed up at the drop in centers (see below) or urban clinics. Drop In Centre Project: this is sort of a day clinic which is located within the grounds of PMGH and opened during the weekdays from 8am -4pm. SMNs provide counseling to parents or mothers and other family members call in willingly for advice, are discharged from the above wards or are referred in from other urban clinics. Nurses also provide telephone counseling from here. PMTCT and VTC services are also provided through this centre. Urban Clinic Project: Susu Mama Nurses visit 15 urban health clinics in and around the national capital district (NCD), daily on a roster system (according to the antenatal day of the clinic). Nurses spend approximately 3 hours at a clinic and provide group talks as well as one on one counselling. Outreach Projects o Settlements: SMNs visit settlement areas and conduct education sessions tailored to the specific requests of the community usually through church groups or women's group. Community outreach programs occur weekly on Wednesdays. There are currently 21 communities involved in this project. Selected community members (usually volunteers) are also invited for workshops so they can then provide similar services within their own communities (ownership). The workshops (usually 3 days) are conducted 5 times a year on the topics discussed above. About members participate per workshop. o HIV: Susu Mamas nurses assist HIV positive mothers and their babies by providing referrals, support and feeding options through the Drop In Clinic and continues with home visits of up to 3 hours 1 to 2 times per week. o Special Needs Mothers: Nurses conduct home visits to mothers identified with special needs, such as premature babies or multiple births. Visits are conducted as necessary. Train the Trainer project: Nurses conduct specialist seminars and workshops for medical students, nursing/midwifery students and other health workers. Seminars discuss the importance of and the mechanics of breastfeeding establishment. The SM projects have been successful in providing services to an increasing number of women. On average, susu mama nurses provide services to over women per month depending on the type of sessions (either group or individual session). For instance, in 2007, over 4000 women in and around Port Moresby have received one to one counselling and education sessions and 5000 people in group settings (SUSU Mama, 2007). Cumulatively, Susu Mamas have had contacts with mothers during 2007 and contacts with babies in the Port Moresby area alone. 8 Working Paper ANNEX

9 Compass: Women s and Children s Health Knowledge Hub Such increase in coverage of services can be reflected in the improved health outcomes observed in the National Capital District (NCD). While the impacts may not be directly related to the project, one cannot overlook their input. Susu mamas have in one way or the other contributed to the improved child and maternal health outcomes reported from the NCD area. The recent health sector review reports NCD as one of the very few province with improved maternal and child health indicators. Rates of antenatal coverage, health facility deliveries and vaccination coverage have increased far above the national average (NDoH, 2009). Prevalence of malnutrition including underweight is the lowest in the country (Annex 1). This suggests that a number of health issues can be dealt at the community level using cost effective interventions. The limitations on this finding are that there is no comparative discussion of trends over time in NCD to demonstrate improved coverage over time, and the introduction of SM program compared to other interventions that may have been implemented in NCD (e.g. urban clinics). Perhaps the greatest advantage that NCD has over other areas, is the increased availability and access to services where many in the country have none, although it is worth noting that there is some indication that measles vaccination coverage has reduced in NCD despite availability of services Enhancing Pregnancy Outcomes Another relevant study is the Enhancing Pregnancy Outcomes study carried out by PNG IMR in partnership with NDOH and UNICEF in two coastal/island districts of East Sepik Province and Milne Bay Province. This demonstrated the feasibility, and likely effectiveness in improved newborn outcomes, of community-based antenatal services including counselling, antimalarial presumptive treatment, micronutrient supplements and sexually transmitted disease diagnosis and referral. Services were provided by village health volunteers, supported by monthly outreach visits from local health centre staff. Enabling and limiting factors affecting a potential increase in coverage and scope of community-based services, including: There are strengths or opportunities within communities, government or other stakeholders that may enable an increase in the scope and coverage of community based interventions. There is renewed government commitment to improve rural health services (primary health care) in the new national health plan (NHP ) which is currently under review. The PNG medium term development strategy also gives priority to investment in primary health and encourages partnerships with churches and NGOs in the delivery of services. Its National Child Health Plan further emphasizes the importance of strengthening primary health care (NDoH, 2007). The health sector strategic plan and the corporate plan identifies as priorities-to fully immunize every child under one year, reduce malaria prevalence, reduce maternal mortality and reduce the rate of increase in HIV and STI which will require community-based service delivery to achieve the required targets in the PNG context. NDoH also recognizes the importance of increasing the range of interventions that can be delivered at the community level by peripheral staff. Discussions are underway, for instance, to avail the use of oral misoprostol fro PPH management at the community level possibly through the CHP system but are yet to be endorsed as mentioned earlier. The NHP also encourages partnerships with stakeholders in the delivery of health services. There is still good will and support from stakeholders including NGOs, FBOs, churches and donor agencies like WHO, UNICEF, Global fund, AusAID. In fact, 9 Working Paper ANNEX

10 Compass: Women s and Children s Health Knowledge Hub NGOs and churches have been instrumental in delivering and supporting community based services in most areas of the country. There is no doubt they will continue. In order to strengthen partnerships between all stakeholders, a private-public partnership agreement or policy is under review to ensure full participation of stakeholders in the planning and implementation of health interventions in PNG. The Healthy Island concept adopted by the GoPNG encourages communities to be responsible for their own health. Communities including churches, women s groups, community leaders, etc in most community have been actively participating and have the potential to deliver services. They are able and willing to participate in delivering services as long as they are empowered to do so. There are programs including the community action and participation (CAP) project that have been effective in empowering communities to participate actively in the planning and implementation of health programs (AusAID; GoPNG, 2004 draft). As long as such programs exist, individuals and communities can be encouraged and facilitated to improve and maintain their own health. LLGs also receive direct funding from the government who can support some of the community services provided there is adequate advocacy on health issues at the community level. There is also support from key members of the medical society in increasing the coverage and scope of community based interventions. Interviews with President of the Pediatric society, Dr. Mokela, Technical Advisor of the FHS, NDOH- Dr. Polume and Mrs. Marietta (former VHV National Coordinator) supports the idea of increasing the coverage of community based services including VHV activities and perhaps expanding their role to an extent that won t raise medico-legal implications. This will involve review of the VHV policy and other standard guidelines which are all underway. While there may be opportunities for increasing the coverage and scope of community-based services, there are also obstacles that may affect effective delivery of these services. These include; Lack of Funding: While funding may be available from the NDOH, quite often it not easy to access funds from HSIP. This was highlighted at the most recent (15 th -16 th, Dec, 2009) Annual Emergency Obstetric Care (EOC) organized by the NDoH. Over 10 provinces implementing the UNFPA funded EOC programs expressed their frustrations over difficulty in accessing funds from the HISP trust. This resulted in low coverage in most of the planned activities. Health worker shortage: This has been a major obstacle in the effective delivery of health services in the country as a whole. The current workforce ratio (Doctor, Nurses, HEO to 1, 000 population) of 0.58 is not enough to increase the coverage of services to rural areas of PNG where majority (over 85%) of the population lives especially in a context with increasing population and aging workforce (NDoH, 2009). Lack of coordination, supervision and training for whatever reasons (manpower, funding, geography, distance, etc) from the National, provincial and district level. Most health workers at the community level (paid or volunteers) are left on their own at most times leading to poor performance and lack of motivation. Lack of proper reporting system at all levels: This is important for monitoring progress and improving where necessary. 10 Working Paper ANNEX

11 Compass: Women s and Children s Health Knowledge Hub Lack of incentives for VHVs in areas where VHV activities are implemented. This has led to most VHVs loosing interests in performing their duties. They need to be compensated for their time and effort. Poor social and economic infrastructure including roads, bridges, clean water supply, run down health facilities, low literacy rates Natural disasters (floods, earth quakes, etc) and tribal conflicts which are common mostly in the highlands regions Political obstacle: Most district health managers and provincial health advisors are politically appointed irrespective of their level of expertise. Hence, resources are allocated using their own discretion and according to their level of understanding of a particular issue Moreover, there are also risks involved in increasing the coverage of community level services which may include the relative risks for expanding the role of volunteers or other peripheral stuff. The following are few points that may need to be considered. Medico-legal implications: Most VHVs are usually old, semi-skilled or semi-literate. Involving them in giving intravenous or intramuscular medications and vaccines which are usually invasive may raise questions especially when un-associated side effects occur. Lack of community confidence and participation: Such mishap (as above) may result in communities losing their confidence in a VHV s role in the provision of other services as well and lead to lack of community participation. Self confidence: one needs to consider how competent and confident the VHVs, for instance, will be in delivering services once their roles are expanded. Workload: Expanding roles of community health workers (paid or volunteers) and will require constant supervision and training. Who will be responsible for it and how will it be coordinated? Do we have enough stuff for this job? Sustainability issues: it is unclear how sustainable these services can be in the long run. Increased Staff turnover (due to retirement, death, illness) lack of incentives, unmotivated staff, may hinder progress of the programs. This will lead wastage resources in training of the already scarce resource and time. Acknowledgements Many thanks to Anna Bauze Burnet, for help in sourcing databases and reports and for comments on the final report. Many thanks also to staff from the Family Health Services and other sections in National Department of Health, including ex-staff member Ms Marietta Tovakuta, as well as to Save the Children in PNG and Susu Mamas PNG. 11 Working Paper ANNEX

12 Compass: Women s and Children s Health Knowledge Hub References 1. AusAID, GoPNG, PNG Women and Children s Health Project. A review of the Community Action and participation (CAP) Program (draft). 2. Kukhang.R.W, Evaluation of Village Birth Attendant program in Eastern Highlands Province, PNG. UNPNG, SMHS. 3. National Department of Health, Papua New Guinea Health Sector Review National Department of Health, Papua New Guinea Draft Vision, Mission and Values, National Plan National Statistics office, Demographic and Health Survey, 2006 National Report. Port Moresby, Papua New Guinea 6. National Department of Health, Minimum Standards for Village Health Volunteers in Papua New Guinea. 7. National Department of Health, Minimum Standards for District health Services in Papua New Guinea. 8. National Department of Health, VHV Technical Committee Meeting ( 4-7 th of November, 2008) Report. 9. National Department of Health (2005). Manual of Standard Management in Obstetrics and Gynaecology for Doctors, H.E.Os and Nurses in PNG 10. Smith.S.E, Mamood G.H., M. Tovakuta, Review of Strategic partnership between NZAID and the Government of PNG and Save the Children New Zealand. 11. WHO Country Profiles Enhancing Pregnancy Outcomes: a joint program of UNICEF PNG and the PNG National Department of Health, implemented by the PNG National Institute of Medical Research, UNICEF PNG, April Working Paper ANNEX

13 Compass: Women s and Children s Health Knowledge Hub Solomon Islands community-based maternal and newborn care Chris Hagarty, February 2010 Introduction This report has been prepared as part of a multi-site analysis (comprising Papua New Guinea, Indonesia, Solomon Islands and Lao PDR) to assess current status and future opportunities for improved community based delivery of services for maternal and newborn care. Upon completion, it is intended that the multi-site analysis will identify potential locations in which interventions can be developed, trialled and scaled-up nationally and regionally towards achievement of Millennium Development Goals 4 and 5. Abbreviations. AHC HIV NAP Area/Urban Health Centre Human Immunodeficiency Virus Nurse Aide Post NPP Solomon Islands National Population Policy, PHC RAMSI RHC Primary Health Care Regional Assistance Mission to the Solomon Islands Rural Health Clinic SIDHS Solomon Islands Demographic and Health Survey, SIPPA STI UNFPA UNICEF VCCT WHO Solomon Islands Planned Parenthood Association Sexually Transmitted Infection United Nations Population Fund United Nations Children s Fund Voluntary, Confidential, Counselling and Testing (for STIs and HIV) World Health Organization Background Solomon Islands has a population of approximately 500,000 people, comprising over ninety language and cultural groups spread across 350 of its 1,000 islands (Government of Solomon Islands, 2008). Topography consists mostly of mountainous, tropical rainforest and coastal areas comprising both tranquil, coral lagoons and rugged, inaccessible cliffs. Intra-island travel is difficult due to inadequately maintained roads and poor motor vehicle infrastructure. The main mode of inter-island travel is by sea, via public and private vessels which are poorly maintained and characterised by neglect for passenger safety, erratic 13 Working Paper ANNEX

14 Compass: Women s and Children s Health Knowledge Hub schedules and prohibitive costs relative to average household income. Likewise, air travel in small planes is expensive, and unreliable due to the provider s limited capacity to run their full service, which often disadvantages those in more remote locations. The Solomon Islands Government operates out of the capital, Honiara, and its Ministry of Health and Medical Services is responsible for the provision of health services throughout the country. Poorly resourced provincial governments communicate and support health services in the provinces, but have no official control over these. In 2000, ethnic conflict (known locally as, the Tensions ) between indigenous communities of the islands of Guadalcanal (on which Honiara is situated) and Malaita brought the government, law enforcement and subsequently, the economy, to near-collapse. As a result of insufficient leadership and security, and limited resources with which to maintain staff wages, many services ground to a halt, including health and education (Government of Solomon Islands, 2008). In 2003, after two years of consistent civil disruption, the Australian-led Regional Assistance Mission to the Solomon Islands (RAMSI) restored order to Solomon Islands, and the re-building of essential systems, including health, commenced. At this time, it was established that almost all health-system infrastructure, including medical and communications equipment, and transport had been misappropriated and/or destroyed during the conflict. Primary Health Care in Solomon Islands: The formal primary health care (PHC) system in Solomon Islands consists of a multi-tiered clinic structure which aims to facilitate appropriate referral from the community level up to the National Referral Hospital in Honiara. In addition to the National Referral Hospital, the system comprises approximately seven provincial referral hospitals, 14 area/urban health centres (AHCs), 123 rural health clinics (RHCs) and 61 Nurse Aide Posts (NAPs). Older documents also refer to 128 village health worker posts, and indeed, in the 1980s, village health workers were recruited and trained by the Ministry of Health and Medical Services in an effort to support the PHC system at the basic community level. However, the author s experience is such that this tier of the PHC system was rendered inoperative during the Tensions, and as a result, the PHC structure has since been revised to encourage communitylevel nurses (from RHCs and NAPs) to work in partnership with volunteer health committees from local communities to promote health messages and encourage health seeking behaviours (Solomon Islands Health Institutional Strengthening Project, circa 2003). While most of the PHC clinics and hospitals are operated by the Ministry of Health and Medical Services, a number of them are managed by church organisations, with shared government and self-funding mechanisms. These organisations provide services on behalf of the Ministry, in accordance with national policies and protocols, but are self-resourced, leading to most (although not all) having better equipment and resources than government-operated services. The PHC system is designed to provide Solomon Islands citizens with access to a minimum package of basic preventive, promotional and curative services. Through a structured referral chain based on a system of referral protocols, specialised health services and equipment can also be accessed. In practice, referral mechanisms are often subject to logistical constraints, such as transport to Honiara (to attend the National Referral Hospital) from a remote NAP being more readily available than to the appropriate RHC or AHC. This creates challenges for managing appropriate referrals and patient loads at hospitals and clinics where specialised services are offered. A further challenge which faces the referral and transport of patients within provincial PHC systems relates to a physical lack of sea-worthy vessels; available canoes comprise mainly 14 Working Paper ANNEX

15 Compass: Women s and Children s Health Knowledge Hub open-topped, fibreglass boats, which are often inadequate for transporting sick patients across frequently rough, open water and barely-submerged coral reefs. Furthermore, the rising global cost of oil is having a major impact on the availability of outboard motor fuel, which continues to pose a major challenge for provincial health service resourcing and operation. Maternal and newborn status and practices. Maternal mortality: The most recent (up to 2007), reported national maternal mortality ratio in Solomon Islands is 140 maternal deaths per 100,000 live births, however this figure is recognised as reflecting a number of capacity limitations in relation to maternal data recording, reporting and management. As such, UNICEF, WHO and UNFPA developed an adjusted maternal mortality ratio for Solomon Islands in 2005 of 220 maternal deaths per 100,000 live births (UNICEF, 2004). Despite considerable variance across provinces, nationally, the proportion of maternal deaths during home versus clinic deliveries in 2006 is similar (13:12 National Statistics Office, 2006). Table 1: National and sub-national maternal deaths Province Home Clinic Province Home Clinic Guadalcanal 6 3 Choiseul 1 1 Western 1 0 Isabel 0 1 Malaita 1 6 Makira 2 0 Temotu 0 1 Honiara 1 0 Central 1 0 Rennell 0 0 Source: National Statistics Office, Total Solomon Islands Anecdotally, the largest number of home delivery-related maternal deaths come from Guadalcanal and northeast Malaita, and are associated more with isolated communities being unable to access clinics during labour rather than out of any individual or community desire to deliver at home (personal communication, Maggie Kenyon, 14 th January, 2010). Neonatal mortality: Reported neonatal mortality ratio data (from 2004) is 23 per 1,000 live births (UNICEF, 2004). A more recent estimate of neonatal mortality is presented in the Solomon Islands Demographic and Health Survey, (SIDHS) as 15 per 1,000 live births (95%CI ), however this figure should be interpreted with consideration to potential sampling bias associated with the survey (Government of Solomon Islands, 2009). Higher neonatal mortality is associated with deliveries in rural, compared with urban settings, and with birth order, where risk of neonatal death in the first child is 92% higher than in second or third children (Government of Solomon Islands, 2009). The SIDHS also identifies perinatal mortality (deaths occurring from seven months gestation, until one week postpartum) as being a useful indicator of the utilisation and/or quality of delivery services (i.e. the degree to which complications arising during childbirth and immediately, postpartum are prevented or managed effectively). Out of 38 perinatal deaths identified during 15 Working Paper ANNEX

16 Compass: Women s and Children s Health Knowledge Hub the five years preceding the SIDHS, four were stillbirths and 34 were early neonatal deaths, resulting in a perinatal mortality rate in Solomon Islands of 14 per 1,000 pregnancies (Government of Solomon Islands, 2009). Fertility rates: The SIDHS identifies the fertility rate per woman (where a woman would live to the end of her child-bearing years) as 4.6 children, comprising 4.8 and 3.4 in rural and urban areas respectively (Government of Solomon Islands, 2009). This is slightly higher than 3.9, which was the fertility rate reported by UNICEF in 2007 (the same year that the SIDHS was completed - UNICEF, 2004). Delivery practices: Most recent (up to 2007) coverage of deliveries at which a skilled attendant 3 was present is reported as 85% (UNICEF, 2004). The SIDHS reports that of these, 4% of births are delivered with the assistance of a doctor, 66% are assisted by a nurse/midwife, and 15% are assisted by a nurse aide. Less than 1% of births are assisted by a traditional birth attendant (kastom midwife) or community healthcare worker. During 1.5% of births, the mother received no skilled assistance during childbirth (Government of Solomon Islands, 2009). Delivery assistance by a skilled attendant varied between urban and rural women (95% and 84% respectively), and varied considerably across provinces (Government of Solomon Islands, 2009). While the Solomon Islands Health Information System records hospital versus PHC clinic deliveries, home deliveries are not recorded. In fact, home deliveries attended by a PHC clinic nurse may be recorded as PHC clinic deliveries (JTA International, 2005). As such, the SIDHS is the most useful, available source for determining the proportion of births which take place in homes or clinics. The survey indicates that 85% of births occurred at health facilities, and 14% of births took place at home during the five years preceding the survey (Government of Solomon Islands, 2009). A mother s age, education, wealth and whether she resides in rural or urban areas are associated with place of delivery, where home births are more likely amongst older women, those with no formal education, those with limited economic capacity and those living in rural areas. Approximately 6% of births were delivered by caesarean section in the five years preceding the survey, associated with the age of the mother (more likely if younger), the order of the child (more likely in the first child) and the wealth of the mother (where wealthier women are more likely/able to access doctors for obstetric care - Government of Solomon Islands, 2009). Antenatal and post partum care: The SIDHS describes 95% attendance of pregnant women to antenatal care at some stage during pregnancy, however there remains some questions as to the timing of initial visits (median gestational age when women made their first visit was 5.6 months), and attendance at follow-up visits (20% of women did not receive the recommended four antenatal care visits - Government of Solomon Islands, 2009). Attendance at antenatal care was associated with education level and wealth of the mother. 72% of women who sought antenatal care did so from a trained nurse or midwife, and 2% received care from a doctor. Less than 1% of women received antenatal care from a traditional birth attendant as their most qualified provider, and approximately 3% of women who gave birth in the five years preceding the SIDHS received no antenatal care. 3 In this instance, the term skilled attendant refers to people with midwifery skills (for example, doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications (National Statistics Office, 2006). 16 Working Paper ANNEX

17 Compass: Women s and Children s Health Knowledge Hub Table 2: Percentage national and sub-national antenatal care coverage (ANC Cov), clinic deliveries (Clinic Del) and postnatal care coverage (PNC Cov), Province ANC Cov Clinic Del PNC Cov Province ANC Cov Clinic Del PNC Cov Guadalcanal Choiseul Western Isabel Malaita Makira Temotu Honiara Central Rennell Total Solomon Islands Source: National Statistics Office, Two postpartum care visits are recommended by the Ministry of Health and Medical Services during the first six weeks of an infant s life. The SIDHS identifies 26% of women having not received postpartum care for their last birth. 30% received postpartum care within four hours after giving birth, and 18% received postpartum care within the first two days. Accessing of postpartum care was associated with the age of the mother (more likely if younger), the birth order (more common in the first child), where the mother resides (more common in urban settings) and economic capacity (more likely in wealthier women - Government of Solomon Islands, 2009). In regards to postpartum care, 57% of women received this from a doctor, nurse or midwife, 14% from an auxiliary nurse/midwife, and less than 1% from another, unspecified healthcare provider. Approximately 2% of women received postpartum care from a traditional birth attendant/kastom midwife (Government of Solomon Islands, 2009). School attendance and literacy of women: Education and literacy amongst females is a recognised determinant for the reduction of maternal and early childhood mortality. The SIDHS indicates similar trends for school attendance amongst females and males for primary and secondary school (Government of Solomon Islands, 2009), however literacy rates among women were 78.4% compared with 84.7% of men aged 15 years or older. Female literacy differed slightly amongst those living in urban and rural areas; 86.2% and 76.9% respectively (Government of Solomon Islands, 2009). Family planning and contraception: As a core priority within the National Health Strategic Plan, , awareness and access to contraceptives is considered a right of all Solomon Islands citizens. Family planning services are delivered through PHC clinics, some church and non-government organisations, foremost among the latter being the Solomon Islands Planned Parenthood Association (SIPPA). These services distribute and broadcast family planning messages, and also offer varying degrees of contraceptive counselling and limited distribution/administering of commodities (the contraceptive pill, injectables, condoms and intrauterine devices), however despite a reported national coverage of family planning 17 Working Paper ANNEX

18 Compass: Women s and Children s Health Knowledge Hub services of 70% (National Statistics Office, 2006), contraceptive prevalence is low; with 7% of women in union aged years reported to be using contraception (UNICEF, 2004). Solomon Islands Planned Parenthood Association (SIPPA) SIPPA is a non-government organisation delivering clinical and educational family planning and sexual and reproductive health services to people throughout Solomon Islands. It operates a single clinic in each of Honiara, Malaita, Choiseul and Western Province, at which family planning and sexual and reproductive health information and counselling are available from trained nurse aides. As a member of, and through support from the International Planned Parenthood Federation (IPPF), SIPPA distributes/administers contraceptives, including male and female condoms, the contraceptive pill, injectables and intrauterine devices (administered by trained nurse aides where appropriate). In accordance with Solomon Islands law, SIPPA does not conduct abortions, but rather delivers pre-abortion counselling to those contemplating termination of their pregnancy. It does, however, provide treatment and care of post-operative complications resulting from an abortion. STI and HIV testing (VCCT) and treatment are also conducted from SIPPA clinics, utilising the Ministry of Health and Medical Services testing laboratories. SIPPA prides itself on the standard of confidentiality it offers to those receiving testing and counselling. While SIPPA does not currently deliver antenatal care services, it intends to initiate this as part of its five year strategic plan. In addition to these clinic-based services, SIPPA conducts outreach clinical services (as described above) to communities in Guadalcanal. In other areas of the country, SIPPA s outreach services are limited to community and youth-focused promotion of family planning measures, and awareness education and distribution of condoms to prevent STIs and HIV. The SIDHS demonstrates reasonable knowledge of a variety of contraceptive methods amongst married and sexually active, unmarried women and men, with the mean number of methods identified by respondents ranging from (Government of Solomon Islands, 2009). Table 3 outlines the percentage of respondents with knowledge of the main contraceptive methods available in Solomon Islands, and the percentage of those who have used these methods. 18 Working Paper ANNEX

19 Compass:Women sandchildren shealthknowledgehub Table 3: Percentage of SIDHS respondents with knowledge of the main contraceptive methods available in Solomon Islands, and those who have used these methods Married women Sexually active, unmarried women Married men Sexually active, unmarried men Knowled ge (%) Use (%) Knowled ge (%) Use (%) Knowled ge (%) Use (%) Knowled ge (%) Use (%) Female sterilization Male sterilization Contraceptive pill Injectables (depo-provera) Male condoms Female Condoms Intrauterine contraceptive devices (IUCDs) Traditional methods (rhythm, withdrawal, folk)) Lactational Amenorrhea Method (LAM) WorkingPaperANNEX

20 Compass:Women sandchildren shealthknowledgehub National standards and practices. A number of documents and policies guide interventions and practices for improved mother and child health outcomes in Solomon Islands. These also address community-level human resourcing, training and development, and provision of PHC services. I. Interventions. Family planning advice and services: The Solomon Islands National Population Policy, (NPP) adopts a human rights approach to addressing population expansion through social determinants with a view to influencing individuals to make informed choices about reproduction. The NPP s goals aim to ensure; Women have a higher social status than they do today, and participate in economy and society; Births are spaced to enhance the health of both mothers and children; Violence against women is eliminated; Universal basic education is achieved before the end of the next decade; Adult illiteracy, especially among women, will be substantially reduced; Laws on marriage and family are in harmony with emerging social values; Fewer infants and children die before they have had a chance to experience life; Fewer mothers die in childbirth from preventable causes; Women and men live longer and healthier lives (Government of Solomon Islands, 2009). Under the NPP, the National Health Strategic Plan identifies family planning and reproductive health as a key strategic area, and directs the promotion of free access to family planning services and increased use of family planning methods through; Improving health worker counselling skills to discuss sexual health issues, including family planning with men, women and young people; Improving uptake of contraceptive methods by empowering men, women and young people to exercise free choice; Reducing teenage pregnancy; and Allowing women a choice in family planning (Government of Solomon Islands, 2009). Through promotion of, and training in the National Family Planning Guidelines, service providers, including NGOs and churches, are being encouraged to play a more effective role in family planning. Currently, however, the overwhelming majority of family planning services are delivered by the government-run health services (personal communication, Maggie Kenyon, 14 th January, 2010). Improved family planning and reproductive health capacity of health workers is being met through a Diploma of Midwifery, which has been offered to Solomon Islands nurses since This year-long course comprises intensive, classroom-based theory followed by clinic-based practical training under trained, clinical supervisors (Cant, 2009, p. 7). 20 WorkingPaperANNEX

21 Compass:Women sandchildren shealthknowledgehub Antenatal care guidelines and practices: The Ministry of Health and Medical Services Solomon Islands Obstetric Guidelines, 2007 provides details of, and directs training in a package of services to be delivered by health service providers during antenatal care, including; Weight measured and recorded; Blood pressure measured and recorded; Information provided on how to recognise signs of problems during pregnancy; Blood and urine samples taken; Rubella immunisation (as required); Tetanus toxoid immunisation (two doses during a single pregnancy or as required depending on previous vaccination, up to five doses). Iron supplements (tablets or syrup); Administering of antihelminthic drugs (as required); and Referral to nearest medical assessment (where potential for complications are identified). In settings where multiple antenatal care visits are rare, measuring of weight (or alternatively, fundal height) may be of little use in monitoring foetal growth, however should be continued as an element of routine antenatal care, with a view to promoting earlier and multiple presentations to antenatal care. Vitamin A and iron supplements are given to women who are identified and diagnosed as being underweight, anaemic and those with recurrent diarrhoea and respiratory health issues. The SIDHS indicates that 50% of women were given iron supplements during their last pregnancy (26% for less than 60 days), while 16% of women received Vitamin A supplements immediately after giving birth (Government of Solomon Islands, 2009). It is unclear if this low figure may be attributed to neglect by birth attendants, lack of availability of supplements or the already Vitamin A-rich diet in Solomon Islands rendering supplements unnecessary. 42% of women received antiheminthic drugs during last pregnancy (Government of Solomon Islands, 2009). Malaria treatment during pregnancy: Endemic malaria continues to pose a major health concern among pregnant women and children under the age of five years, and is a considerable contributor to neonatal mortality in Solomon Islands (Government of Solomon Islands, 2009). One of the national Vector-Borne Disease Control Program s strategies is to adopt malaria prevention measures and treatment for pregnant women. The National Health Policy recommends that all pregnant women sleep beneath insecticide-treated mosquito bed nets (although the SIDHS indicated that only 37% of pregnant women slept beneath an insecticidetreated mosquito bed net the night before the survey was conducted). Antimalarial prophylactic medication is well-utilised for pregnant women in Solomon Islands, with 93% of women surveyed having received some, unspecified antimalarial prophylaxis (most likely chloroquine) during their last pregnancy in the preceding two years. Despite this high figure, however, less than 2% of pregnant women received one or more oral doses of SP/Fansidar (sulfadoxene/pyrimethamine) or Intermittent Preventive Treatment (IPT) through antenatal care visits during their last pregnancy (Government of Solomon Islands, 2009). 21 WorkingPaperANNEX

22 Compass:Women sandchildren shealthknowledgehub Solomon Islands malaria treatment and prophylaxis regime for pregnant women: Treatment regime in pregnancy 1st Trimester: Quinine Tablets (QN): Oral at 10mg/kg every 8 hours for 7 days. 2nd and 3rd Trimester: Artemether-Lumefantrine (AL): 2mg/kg/dose (A) & 12mg/kg/dose (L) - 6 doses over 3 days (refer to prescribed regimen) - Adult dose = 4 tablets. Prophylaxis in pregnancy Chloroquine (CQ): 5mg/kg once a week. Start at first antenatal visit. Source: Ministry of Health and Medical Services, 2008a Diagnosis and treatment of sexually transmitted infections (STIs): It is the responsibility of the provincial HIV and STI control programs, through the PHC system, to conduct outreach to promote, diagnose and treat STIs. While it is unclear how well, or how routinely this is linked to antenatal care visits, appropriate antibiotics for treatment of common STIs are included as essential medicines stock for PHC clinics (Ministry of Health and Medical Services, 2008b), and the health care providers in these settings are the same for STIs as for antenatal care, suggesting a logical overlap for diagnosis and treatment where providers are appropriately skilled. As described above, SIPPA provides confidential counselling, testing and treatment for STIs and HIV, and is planning to commence antenatal care from its existing and expanding network of clinics over the next five years (personal communication, Michael Salini, SIPPA, 14th January, 2010). This may provide an additional opportunity to link antenatal care with routine testing and treatment of STIs in pregnant women. 22 WorkingPaperANNEX

23 Compass:Women sandchildren shealthknowledgehub Medications for use during or immediately after complicated deliveries: The following medications appear on the PHC services essential medicines list. While some of the medications listed can be prescribed by those with specialist training only (presumably obstetricians), or by doctors, most can be administered by a trained nurse after consultation with a specialist or doctor (Ministry of Health and Medical Services, 2008b); Drug name Concentration, Form Prescriber details and use Ergometrine 0.5mg, tablets Available for use in hospitals, and can be prescribed by doctors and nurses with specialist training (potentially midwives). Can be administered by nurses without specialist training after discussion with a doctor. Magnesium sulphate 50%, injection Available for use in facilities where specialists (presumably obstetricians) are located, and can be prescribed by doctors and nurses with specialist training (potentially midwives). Can be administered by nurses without specialist training after discussion with a doctor. Oxytocin/Ergometrine (Synometrine) Oxytocin Benzylpenicillin 5MU Penicillin V Chloramphenicol sodium succinate Chloramphenicol 5IU/0.5mg, injection 5IU, injection 3g, injection 250mg, tablets 1g, DP injection 250mg, capsules Can be used at the NAP level and above, and administered by nurses. This range of antibacterials are available for use by nurse aides and above at all clinic levels. Metronidazole 250mg, tablets Available for use in AHCs and hospitals, and can be prescribed by doctors and nurses with specialist training (potentially midwives). Can be administered by nurses without specialist training after discussion with a doctor. Source: Ministry of Health and Medical Services, 2008b. The information in the table suggests that ergometrine and magnesium sulphate are not available to be used at the lowest clinic levels, such as RHCs and NAPs, and therefore are unlikely to be available for use in home deliveries. This places added importance upon PHC nurses and nurse aides to identify potential risks in pregnant women as early as possible in the pregnancy through antenatal care. 23 WorkingPaperANNEX

24 Compass:Women sandchildren shealthknowledgehub II. Peripheral health staff As described above, the PHC system is oriented to direct referrals from the community level up to the appropriate, required level of care. In terms of specialised antenatal care and support for potentially complicated deliveries, trained midwives and doctors may be located closer to the community than the National Referral Hospital in Honiara, such as at the RHC or AHC levels, depending on the need. The National Referral Hospital is where most of the medical specialists are based, and are supported by teams of generalist doctors, registered nurses and nurse aides. This structure is mirrored at the provincial referral hospital level, although without the medical specialists in most cases (depending on the size and available facilities of the hospital). Medical specialty teams, (including obstetrics and paediatrics) are required to visit provincial referral hospitals on a rotating basis, although in practice, these do not take place as often as intended. AHCs and RHCs are staffed by registered nurses who will usually comprise one or more trained midwives, and a supporting staff of nurse aides. Doctors from the provincial referral hospitals are required to visit AHCs on a rotating basis. NAPs are staffed by one or two nurse aides. RHCs and NAPs will be visited by a senior area and/or provincial nurse supervisor on a regular basis. Basic antenatal care services are available from all levels of the PHC system, however it must be understood that the infrastructure of RHCs and NAPs is far from adequate. Since the Tensions, the Ministry-directed requirement that communities which host a NAP are responsible for maintaining the clinic buildings is rarely observed, and many have succumbed to disrepair from white-ants and the elements. Additionally, chronically under-resourced provincial and national public service and housing departments/ministries have been unable to maintain staff housing, and many of the conditions which exist for nursing staff and their families are inadequate in terms of safety, hygiene and shelter (Cant, 2009). This results in an unmotivated nursing workforce, and periodic absenteeism from posts is not uncommon. While support and supervision to community nurses has been poor in the past, recent efforts to address this are succeeding in maintaining quality of antenatal care services. For example, annual refresher training in Honiara (focusing on multiple topics) is provided to registered nurses, attended by a rotating list of personnel each year, while other registered nurses and nurse aides receive visits and training from Provincial Reproductive Health and Family Planning Program Coordinators each year. Ongoing mentoring and technical support is also provided to remote clinic staff from senior area and/or provincial nurse supervisors, and in some cases, provincial doctors, through the solar-powered, two-way, HF radio network. The radio network is also employed in coordinating the referral chain where factors which could contribute to high risk pregnancy are identified. In addition to clinical care, community-level (RHC and NAP) registered nurses and nurse aides are required to work with, and support volunteer health committees in local communities to promote health messages and encourage health seeking behaviours through regular outreach visits. While community nurses had little guidance as to how to action this direction in the past, a healthy settings approach to health promotion in the community has recently been adopted as national health promotion policy, from which it is expected that roles and responsibilities for various personnel involved, and for communities, will be articulated. Although not common throughout the country, some provinces have a large number of kastom midwives, who are regularly called upon by communities to attend home births, but who do not operate within the formal PHC system. This practice most commonly takes place in remote areas where communities do not have easy access to a clinic, such as northeast Malaita and some parts of Guadalcanal (personal communication, Maggie Kenyon, 14 th January, 2010). 24 WorkingPaperANNEX

25 Compass:Women sandchildren shealthknowledgehub Community-level (RHC and NAP) registered nurses and nurse aides are required to identify kastom midwives in their area, and are encouraged to work with them to improve their skills and knowledge, particularly relating to pre- and post-delivery hygiene practices (Assenheim & Evans, 2003). There is little information collected at a national level as to whether such skills and knowledge building take place in all areas where kastom midwives operate, nor to the format or quality of such activities where they do occur. Indeed, there is little documented instruction on how community nurses should deliver skills and knowledge building to kastom midwives. In the mid 1980s, a one-year follow-up review of a training program for nurses to pass-on skills to identified kastom midwives revealed that none of the trained nurses delivered the skills building. It is understood that the perceived status discrepancy between nurses and kastom midwives may have been the barrier to this interaction; regardless, the result of this review was that few subsequent resources were devoted to actioning this intervention (personal communication, Maggie Kenyon, 14 th January, 2010). Opportunities for increasing community-based delivery of services The review of national and sub-national standards and practices associated with communitybased maternal and newborn care outlined above overwhelmingly confirms that the government-led PHC system is the major provider of family planning, antenatal care and birthing services throughout Solomon Islands. Where these services are delivered by other providers (such as church-run hospitals and clinics, and non-government organisations), these are done so through service agreements in-line with Ministry of Health and Medical Services guidelines and policies. As such, any interventions aimed at altering and/or improving the delivery of community-based maternal and newborn care practices must be undertaken through the full cooperation of, and engagement with the Ministry of Health and Medical Services, which is the only agency in Solomon Islands with the authority and reach to facilitate implementation at the service delivery, health worker training and health commodities supply and distribution levels. The geographical and social diversity of Solomon Islands is sufficient to enable trial and refinement of potential interventions to improve the delivery of community-based maternal and newborn care practices in a number of sites characterised by high and low maternal and newborn mortality, each of which may comprise both easily accessible urban, and more difficult to reach and resource rural settings. A number of other factors are in place in Solomon Islands which may facilitate implementation of interventions to improve the delivery of community-based maternal and newborn care practices. These include effective communication systems and periodic supervisory practices between community-level nurses and their clinical supervisors, and the necessary medicines which community-level nurses would need to be trained to administer being already available through the national essential medicines list. With its comprehensive network of clinics, staffed by trained nurses and situated at the community level throughout the country, the government-led PHC system in Solomon Islands offers an opportunity to develop, trial and implement improved delivery of community-based maternal and newborn care practices. Logistical challenges associated with training and supervising community nurses in the delivery of these improved practices, and resourcing same, would need to be considered and overcome. 25 WorkingPaperANNEX

26 Compass:Women sandchildren shealthknowledgehub Acknowledgements Burnet Institute would like to acknowledge the time and support of the following individuals and organisations who responded to our request for information and experiences relating to women s and children s health activities in Solomon Islands; Maggie Kenyon. Neva Wendt, Australian Council For International Development (ACFID). David MacLaren, James Cook University. Sue Cant, World Vision Australia. Sue Ndwala, World Vision Australia. Donna Webb, Australian Red Cross. Kathleen Walsh, Australian Red Cross. Beth Eggleston, Oxfam Australia. Ann Brassil, Family Planning, New South Wales (FPNSW). Anne Stewart, Family Planning, New South Wales (FPNSW). Michael Salini, Solomon Islands Planned Parenthood Association (SIPPA). Peter Azzopardi, Burnet Institute. 26 WorkingPaperANNEX

27 Compass:Women sandchildren shealthknowledgehub References. 1. (Assenheim and Evans 2003; UNICEF 2004; JTA International 2005; National Statistics Office 2006; Ministry of Health and Medical Services 2008; Ministry of Health and Medical Services 2008; Cant 2009; Government of Solomon Islands 2009; Solomon Islands Health Institutional Strengthening Project circa 2003) 2. Assenheim, V. and C. Evans (2003). Reproductive health, child health and nursing competencies standards: training materials, Solomon Islands Ministry of Health Institutional Strengthening Project. 3. Cant, S. (2009). Reducing maternal and child deaths: experiences from Papua New Guinea and the Solomon Islands, World Vision Australia, The University of Melbourne,. 4. Government of Solomon Islands (2009). Solomon Islands Demographic and Health Survey Noumea, Solomon Islands National Statistics Office, Secretariat of the Pacific Community, Macro International Inc. 5. JTA International (2005). Solomon Islands Health Status Assessment Report, Solomon Islands Minsitry of Health Institutional Strengthening Project. 6. Ministry of Health and Medical Services (2008a). Malaria: National drug protocol. Honiara, Solomon Islands Ministry of Health and Medical Services. 7. Ministry of Health and Medical Services (2008b). Solomon Islands Essential Medicines List. National Pharmacy Division. 8. National Statistics Office. (2006). "Social statistics: matermal health." Retrieved 4th January, 2010, from 9. Solomon Islands Health Institutional Strengthening Project (circa 2003). Primary Health Care Policy Review: discussion paper, Solomon Islands Minsitry of Health and Medical Services, Solomon Islands Health Institutional Strengthening Project,. 10. UNICEF. (2004). "UNICEF Solomon Islands country profile: statistics." Retrieved 4th January, 2010, from 27 WorkingPaperANNEX

28 Compass:Women sandchildren shealthknowledgehub Lao PDR - community-based delivery of maternal and newborn care: Louise Sampson, February 2010 Main maternal, newborn and child health indicators Lao PDR, (2005 unless otherwise indicated). Total population : 6.8 million Mortality Rate Alternate rate Life expectancy at birth - males (years) Life expectancy at birth - females (years) Neonatal mortality rate (1000 live births) Infant mortality rate / (1000 live births) Under-5 mortality rate (per 1000 live births) Maternal mortality ratio (per 100,000 live births) (WHO) Family planning TRF - Total fertility rate 4.1 ^ - CPR - Contraceptive prevalence rate modern 35 ^ - methods Unmet need for family planning 40% ^ - Maternal health care No ante-natal care (%) 71.5 ^ 64.9 Antenatal care coverage - at least one visit (%) 28.5 ^ 35.1* Births attended by skilled health personnel (%) 18.5^ 20.3* Rate of delivery in facilities (%) 12 ^ 17* Rates of delivery by TBAs (%) 12.1 ^ 17* Delivery at home (%) 81 ^ 83* Child health 1-year-olds with 3 doses Diptheria-Pertussis * - Tetanus (DPT) vaccine(%) Fully immunised children 14.2 * - Prevalence of tuberculosis (per 100, population) Children under five years of age stunted for age (WHO) (%) Literacy Women s literacy Men s literacy Water and sanitation Access to improved drinking water sources - (% 74 > 51* pop) Access to improved sanitation - (% pop) 49 > 44* Sources: + National Population and Housing Census 2005 ^ Lao Reproductive Health Survey 2005 (National Statistics Centre) * Lao PDR Multiple Indicator Cluster Survey 2006 (published Sept 2008); > Millennium Development Goals Progress Report Lao PDR (GoL/UN) 2008 (Note: national data sources are problematic. If two figures are available, both are provided). 28 WorkingPaperANNEX

29 Compass:Women sandchildren shealthknowledgehub Maternal and newborn status and practices Maternal deaths A woman giving birth in Lao PDR faces more risks than a woman giving birth in one of her neighboring countries. In Lao PDR, at least 3 women die every day due to pregnancy. That means 1,300 women die each year (WHO/UNICEF/UNFPA/The World Bank 2007). A woman s lifetime risk of maternal death is 1 in 33 for Lao PDR, the highest in SE Asia, and third highest in the Asia Pacific region. Despite multi-lateral efforts in the last decade by the government and donor partners to improve maternal and newborn health, maternal mortality remains high. MMR is difficult to measure accurately and there have been a number of statistical and sampling concerns in recent national surveys. The 2005 Census estimate was 405/100,000 (Census 2005). This is considerably lower than the estimate of 660 for the same year issued by international organizations based on the same survey data (WHO/UNICEF/UNFPA/The World Bank 2007), which has a range of uncertainty of 190 to The MMR of neighboring countries are: Vietnam (150), China (45), Myanmar (380, and Thailand (110) (WHO/UNICEF/UNFPA/The World Bank 2007). Despite the discrepancy in the varying figures for MMR, there are signs that progress reflects gradual improvement overall. The government estimate for MMR of 405 in 2005 is an improvement from the previous figure of 530 in 2002, and 750 in Neonatal and infant deaths Each year in Lao PDR it is estimated that 5,200 babies die in the first week of life and 6,400 are stillborn (WHO 2005). The neonatal mortality rate is 26/1000 births (LRHS 2005). The infant mortality rate (IMR) is 70/1000 babies born (Census 2005). As in many other countries, to achieve a decrease in infant mortality it is important to address early neonatal mortality (deaths in the first week of life, which are closely related to care in pregnancy, delivery and postdelivery), which accounts for a significant proportion of infant deaths (28% of Lao IMR in 2000, WHO 2005). Neo-natal and infant death as a proportion of overall mortality An interesting example of the age-patterns of mortality in remote communities is provided here. Annex 2 provides a longer summary of this mortality survey conducted by in 2008 by MCHC/ UNFPA in over 15,000 households in 424 remote and rural households in 7 provinces. Of all the reported deaths infant, child, adult and maternal in one year, neonatal and infant deaths comprise more than one third (36.3%) of total deaths in the community. All deaths of children under 5 (including the subsets of neonatal and infant) are 44% of total deaths, or about the same as the total adult deaths (46%, all adults over the age of 15, including death by old age ailments). This demonstrates that in remote areas, newborns and infants are disproportionately represented. 29 WorkingPaperANNEX

30 Compass:Women sandchildren shealthknowledgehub Neo-natal death (1-30 days after delivery) Infant death (>1 - < 12 months after del) Under five Child death (1-5 years) Older child death (6 - <15) years Adults deaths (>15 years) Maternal deaths Total deaths # of Reported Deaths 89 (89) 147 (125) 55 (43) 37 (34) 308 (276) 14 (13) 650 (580) Mean Age at Death 6. 5 days 4. 0 months 2. 0 years 7. 9 years years years years Median Age Death: at 2 days 3 months 2 years 7 years 47 & 48 years 30 years 13 years Source: Table V, Mortalities, p26, from Supplementary Report: The Age at the Time of Death and The Cause of Death of Residents Living in the 151 CBD Worker Catchment Areas & DRF/VHV Home Villages During 2008, MCHC/UNFPA, published Sept WorkingPaperANNEX

31 Compass:Women sandchildren shealthknowledgehub Skilled attendance at birth As the MMR is difficult to estimate with accuracy, the proportion of births attended by skilled birth attendants is used as a key process indicator for the MDGs. In Lao PDR, only 18.5% of women have a skilled provider at delivery (LRHS 2005), and only 12.5% deliver in a facility. Nationally, over 80% of babies are delivered at home. However, in rural and remote areas without roads (25% of villages, and 20% of the population, in the country are in this category), these numbers decline with only 5.3% of women delivering with skilled attendance and 96.5% of women deliver at home (LRHS 2005). It is, unsurprisingly, this latter category of rural and remote where the highest burdens of maternal, neonatal and infant mortality and morbidity exist. Nationally, the majority of deliveries are assisted by relatives i.e. 63.4% of the deliveries are assisted by relatives. A lower 12.1% are assisted by TBA s making clear that use of TBA s is not the most common practice in the country (LRHS 2005). Training a cohort of TBAs, or village health volunteers, usually needs to start from scratch, as was the case in SCA s successful primary health care program in Sayaboury Province. Links with a health facility measured by ante-natal and post-natal care access In comparison to other countries in the region where antenatal and postnatal care coverage is relatively high, in Lao PDR 71.5% of women have no antenatal care at all (measured as at least one visit). Therefore most women 71 % nationally and over 90% of rural women - have no links with the health system during pregnancy, making it unlikely she will deliver with skilled personnel, in a facility, or have access to quality neonatal and post natal care. Consequently, health facility staff (skilled or semi-skilled providers) will not know she is pregnant and she will not be on the list/on the radar for potential follow up care at home. Again, this is more pronounced in rural areas without roads, where 91.1 per cent of pregnant women do not see a provider during pregnancy. Reasons for not giving birth in the hospital are: 75.7% of women do not find it necessary to deliver in the hospital, while for 33.7% of home births, long distance from a hospital/facility was a factor. Only 5.5% of women mentioned cost as a barrier to delivery in a facility (LRHS 2005). In Laos, 27% of the population lives in urban areas, 52% in rural areas with road access and 21% in rural areas without roads (Census). From the National Health Survey 2001, 61.5% of villages are less than 4 km from a health facility, and only 14.2% are more than 16 km. Maternal health services are not being utilized by women in rural areas, even for those who live relatively near facilities, with road access (Figure 1.1, source LRHS 2005). This discrepancy women who live close to a facility who chose not to use it speaks to the heart of the policy debate currently within the country, described below. Site of care provision The scope of this paper is not required to consider skilled birth assistance, rather to consider care provided to mothers and newborns in the first week after delivery, and the feasibility of doing so in a community-based setting. However, decoupling birth assistance and post-birth care of mothers and newborns is not a practical construct, as the person providing assistance (birth either skilled or unskilled) will more than likely be the person providing care in the first days after birth, given the high proportion of births that occur at home. The correlation between of skilled care and care provided at a facility is strong across a number of reporting instruments, mainly due to a lack of systematic or sustained training of, and support to, any community based care alternatives such as TBAs or Village Health Volunteers. 31 WorkingPaperANNEX

32 Compass:Women sandchildren shealthknowledgehub Home-based care However, providing those services at facilities, and encouraging women to come to the facilities, is still the dominant paradigm as home-visits are non-existent in the public sector and available only to wealthier people who pay private or public providers on a an individual basis to attend them at home. Even most village heath volunteers who manage the village revolving drug kits (government program) require community members to visit their house, rather than going to visit the home of the sick person. However, the community-based distributors of contraceptives outlined below in Section 5, are a shining exception to this; a large program that has raised CPR from between 0-10% up to 50-60% though a program of home-based visits, by community people who have been trained as providers and who, importantly, are of the same ethnicity and speak the same language as women in remote villages. Language and culture are barriers as much as transport, cost and provider skill level. A one-party state places limitations on training community providers Laos is one of the world s few remaining one-party states. Further, even though the education sector has been deregulated, the health sector has not. NGOs, or private hospitals, are not allowed to open their own clinics, employ their own health staff, or provide any health services directly to the community. Further, they are usually not allowed to provide training directly. All assistance must be provided to train, or strengthen, existing government health staff or village level volunteers. Training of village level volunteers is usually constrained to by the ability of the district staff having time, skills and inclination to be the trainers, and providers of follow-up monitoring and supervision. Simply instituting a program of training village volunteers in simple post-natal care, for example, is not possible. All activities must be signed off and agreed through the central MOH and provincial DOH and must be seen to be in compliance with national policy. History of Village Health Volunteers After the 1975 revolution and the formation of the one-party state, there was a national network of Village Health Volunteer established, following the Chinese model of barefoot doctors and encouraging communities to take responsibility for their own health. Little or poor quality training was offered, relying on some existing skills of (male) ex-army medics and many of these positions existed in name only. Technically, there is meant to be a VHV in every village. Rather than being seen as a core part of health infrastructure, the community-level provider, VHVs have been ignored and unsupported, or required to deliver a range of disparate tasks through a number of non-coordinated vertical programs. TBAs have been trained mostly by NGO programs. Traditional birth attendants The majority of births are attended by relatives and friends, with TBAs only attending 12.1% of births nationally. However, in the 2008 Skilled Birth Attendance Report (MOH/UNFPA) it was notes that in the southern provinces, TBAs play a larger role. The LRHS (2005) cites province-by-province figures of TBA attendance at delivery: Attapeu (43%) Champassak (61%), Savannakhet (23%). The only northern province with TBA attendance at delivery of any note is 32 WorkingPaperANNEX

33 Compass:Women sandchildren shealthknowledgehub Sayaboury (11.2%), attributable to SCA s PHC program that includes a regular TBA training (and annual refresher) training components. Traditional birth attendants have varying role across different areas of Laos. The term is used loosely, from those women who traditionally attended births but have little formal skills and training, to those who have been trained effectively as lower-level skilled or community birth attendants through (mostly) NGO-supported programs. The latter category, community-level basic providers are competent to perform at least three of the five items of services under the New Born Care component of the National MNCH package. As far as is known, these only exist in Sayaboury under the SCA supported PHC program. : Immediate newborn care (thermal protection, cord care, assess breathing, initiation of exclusive breastfeeding, infection prevention, eye prophylaxis) Neonatal resuscitation Information and counselling on home care, breastfeeding, hygiene, advice on danger signs, emergency and follow-up New policy on TBAs However, this strategy of training local women as semi-skilled maternal assistants has been built into the new National MNCH Strategy. It allows for TBA training and/or upgrading so they can transition into the skilled category: TBAs can be registered locally so they are easier to support and supervise. TBAs can also be helped to train as Community Midwife (2 year course), if they have adequate schooling and are willing to undertake further training. When qualified these Community Midwives can be supported to establish accredited practices back in their home place that are linked into the formal service delivery network. However, the strategy document is a little confusing when outlining the transition between the current and the envisaged new system, perhaps because it will not be so clear in practice: Those TBAs that cannot be trained as community midwives can be assisted to re-focus their role as community birth supporter, to work with and assist SBAs for out-of-facility births, as well as accompany women to facilities or become a community volunteer MNCH worker. No more TBAs will be trained as TBAs. However on-the-job training in the key messages and supportive supervision will be required for existing TBAs until they case operating as a TBA or re-trained as appropriate (MOH, 2009, page 23) Therefore, the southern provinces in particular, which are also the poorest, most ethnically diverse and with the highest mortality rates, offer an current opportunity to engage with existing TBAs networks to expand their skill-sets for basic follow-up care, such as cord care, thermal protection, breastfeeding support, etc, to help neonatal and post-natal car. As in many places, those women who are established as TBAs will be culturally acceptable to the community and will speak the local language. Because of these reasons, cross-language training - Lao-ethnic language(s) will be required. No midwives trained for many years: current initiative started WorkingPaperANNEX

34 Compass:Women sandchildren shealthknowledgehub For a number of reasons, including the overall low status of nursing, national midwifery training lagged and then declined for a period from 1989 to For at least 15 years, there were no midwives trained at all in the country. As well, given the vast majority of women give birth at home, unattended, providers that are trained get little chance to maintain their skills. As Annex 3 outlines, as well as core EMCOR and other skills, it is midwives who should have the skills to provide neonatal care and maternal post-natal care in the first days and weeks following delivery. There are very few of these people in the country and the MOH/UNFPA has embarked on a major, long term initiative to train new midwives and res-kill existing health cadres. More than half of the nation s health workforce is currently low level auxiliary nurses, those trained in a 1-2 year basic course that no longer exists. It is estimated that the upgrading through the Skilled Birth Attendance Program will take between 5-10 years to produce enough people with sufficient skill levels to meet the needs of the national population. While the partners are to be congratulated on putting in place Laos first comprehensive program for midwifery, what happens in the time between the current situation and the time when there is large cadre of skilled providers at community, outreach and first facility levels, has not been answered. The standard MOH/WHO/UNFPA response is to take a long term view and maintain the status quo until the long term goals have been realized. Therefore: assessing current national need (82% of women and their babies do not get any neonatal or post-natal care) + current gaps in service provision (years to develop a large enough cadre of health personnel with these skills) would seem to indicate a 10 year window of opportunity to provide community-level care services across the country, using in the first instance, TBAs in southern provinces as the areas of highest priority. However, the current policy discussions and ways to operate in a one-party state make these opportunities very difficult to realize on the ground and sufficient time for assessment planning should be allocated for any initiative considered. 1. Poverty and ethnicity While all countries in Asia have multi-ethnic populations, meaning linguistic and cultural diversity across the populations in which health providers must try to deliver services. In Laos, both the range of ethnicities (between languages) and concentration of ethnic diversity (more than 50% of the national population) provides particular challenges to consider when discussing community-based care options. Less than half the national population speaks the national Lao language as their first language. This is profoundly different to Cambodia, for example, where more than 90% of the national population is ethnically Khmer, and speaks Khmer as their first language. In Laos, in one third of the country s provinces, more than 90% of the population is ethnic, and the second third of provinces, between 60-80% of the population is ethnic. Large populations of ethnic Lao people live in the four major urban areas and surrounding districts, but the rest of the country doesn t speak much Lao and the women often speak and understand very little Lao. This poses significant challenges for outreach and community based approaches. Having a program to access and train community-level providers in one district for example, means working with people who have Lao as their second (or third) language, and who may well speak different languages across the district. This is less prevalent in the northern 34 WorkingPaperANNEX

35 Compass:Women sandchildren shealthknowledgehub provinces where the larger ethnic groups of Khmu and Hmong dominate, but in southern provinces, one district of 50 villages could well have 5-10 distinct languages. It is possible to do this, as one of the case studies below demonstrates, but does mean that it takes more time and more money than in places with less linguistic and cultural diversity. Table 1. Poverty prevalence and percentage of ethnic minority populations in selected provinces. Provinces (9 of Laos 17 provinces) Ethnic minorities as % of provincial population Poverty prevalence as % of provincial population IMR (LRHS 2005) National IMR70/1000 U5MR (2005 LRHS 2005) National U5MR 98/1000 Phongsaly Oudomxay Luang Namtha Bokeo Huaphanh Sayaboury Luang Prabang Sekong Attapeu Source: (ADB 2006) Source: Lao Reproductive Health Survey 2005 (MOH/UNFPA) National standards and practices In 2009 the Ministry of Health issued the Integrated Package Maternal and Child Health Interventions, which is a policy level document delineating approved activities at the different levels. These are summarized in table form, across six components of care: (1) Non-pregnancy RH care; (2) Pregnancy care (3) Intra-partum (delivery) care; (4) Newborn care and (5) Postnatal care (6) Child health care. The full Table of Services is at Annex 1. For the purposes of this paper, Components (4) Newborn Care and (5) Post-natal Care are pertinent. The items of Service of these components are copied here. More than half of services are allowed to be delivered by community resources meaning at house of village level as either optional or essential parts of the MCHC National Package. This demonstrates that the policy environment does allow community-based care to be delivered for a number of key newborn and post natal-services, under the provision that skilled staff are available. 35 WorkingPaperANNEX

36 Compass:Women sandchildren shealthknowledgehub Item of services District District Central & Community Outreach Health Hospital Hospital Provincial Resources Services Centre B A Hospital Immediate newborn care (thermal protection, cord care, assess breathing, initiation of exclusive Δ Δ O O O O breastfeeding, infection prevention, eye prophylaxis) Neonatal resuscitation Δ Δ O O O O Newborn Information and counselling on home care, breastfeeding, hygiene, O O O O O O care advice on danger signs, emergency and follow-up Immunization according to the national guidelines (BCG, Hep B) O O O O Special newborn care if complications or high risk conditions (sepsis, severe Δ O O asphyxia, preterm birth, malformation, etc.) Information and counselling on home care, self care and nutrition, breastfeeding, hygiene, advice on danger O O O O O O Post-natal care signs, emergency and follow-up (same items in Newborn Care) Routine postpartum maternal care (within 7 days and up to 6 weeks) Δ O O O O Postnatal newborn care (within 7 days) Δ Δ O O O O O: Essential services (must be available at this level) Δ: Optional services (if skilled staff available) Community resources are defined as resources based in the community, not in a facility. The interventions allowed at community level are those considered by this study: Immediate newborn care (thermal protection, cord care, assess breathing, initiation of exclusive breastfeeding, infection prevention, eye prophylaxis), neonatal resuscitation, and information on home care, breastfeeding, hygiene, advice on danger signs, emergency and follow up. For the purposes of this study, the two columns on the left Community Resources and Outreach Services are the relevant levels. Outreach is meant to be done by Health Centre level staff at the village level, but due to HR constraints, is most often performed by District level 36 WorkingPaperANNEX

37 Compass:Women sandchildren shealthknowledgehub staff. To date, outreach has usually meant pre-arranged mass campaigns much as periodic immunization, rather than individual provision of services on an as needed basis. Excerpt from National Reproductive Health Policy MOH October 2005 Objective: To reduce maternal, infant and peri-natal mortality and morbidity. Strategy: Health Services Delivery Upgrade facilities and skills of health service providers at the district and sub-district levels to improve detection and early referral of emergency obstetric cases. Piloting establishment of maternity facility in selected ethnic remote village to be used as the village delivery room, with storage space for supplies and medicines. This will be an additional space for existing health dispensaries to accommodate pregnant women during delivery. Trained health professionals and birth attendants will operate this village maternity facility assisted by volunteers. Disseminate clinical practice guidelines on safe motherhood at all health dispensaries and health facilities. Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child Health Services The Items of Services chart has been provided above. The relevant sections addressing community level action in the National Framework refers mainly to information, education and communication (IEC), behavior-change communication (BCC), health promotion and demand creation for health services. The services given as examples to be delivered at community level are community based distributors could also be trained to distribute a limited number of drugs and commodities such as iron tablets, ORS, contraceptives, bednets, and soap in hard to reach areas Policy Conflict: the policy agenda is being driven by the World Health Organisation Making Pregnancy Safer initiative which promotes and prioritizes facility-based care, for ante-natal, delivery, neonatal and post-natal services. The WHO MCH Advisor, in interview for this paper, stated the position that accords with many interpretations of global policy, that: there is no international evidence that TBA s work and we do not support those interventions. Our aim is to encourage all women to come to a facility and leave when she and the baby are well. The Skilled Birth Attendance program (MOH/UNFPA) currently underway to upgrade midwifery skills across the nation, specifically recommends that the role of the TBAs is changed from delivery and post natal care to being the community educator (health promoter) about FP, pregnancy, and the need for skilled health personnel to attend the delivery. They could also have a role in community mobilization for emergency transport. Younger TBAs could be encouraged to undertake the 2 year training to become a community midwife (UNFPA, 2008, p13). Many women who are or would be TBAs would not have the basic education, or Lao language skills, to engage in this training. Of those that did, few would have the discretionary family income to pay for 2 years living costs while study was being undertaken at the regional Nursing Colleges. Programs providing community-based delivery of services Primary Health Care Program, Sayaboury Province, Save the Children Australia in partnership with the Ministry of Health. This is a long-term primary health care strengthening program. Using the principle of universality, there are no target districts or villages, rather the health system serving the entire province of 11 districts, over 460 villages and nearly 350,000 people has been strengthened. In 37 WorkingPaperANNEX

38 Compass:Women sandchildren shealthknowledgehub 2007, the PHC program extended into Luang Prabang Province, and is rolling out across districts in a phased manner. In a few years, the program will provide minimal support to the government health services for nearly three quarters of a million people, approximately 15% of the national population, demonstrating that initiatives under this program can be achieved at scale, rather than in a limited number of (overly) well-supported villages, a common NGO method of engagement. This program has been well-documented (Perks et al, 2006) and Sayaboury Province continues to lead the country in lowering key indicators. In 2009, the province had an MMR of 15.6/100,000 live births, compared with the national 405. IMR and U5MR are both less than half the national rates. The PHC program has a revolving scheme of training (and annual refresher training) TBAs, as well as training village health volunteers. The TBAs are trained in the three basic skills sets as outlined above in the Newborn and Post natal care Components of the National MNCH Core Package. The following must be noted: Facility-use is prioritized and promoted in the PHC program. TBAs are only trained in remote villages, those that are more than 5km or one hours walk from a health facility. Women who live in villages within this WHO-definition of health facility access are encouraged to come to the facility for all their health needs: ante-natal care, delivery and post-natal care. Follow-up care at home is not routine, so facility use is encourages by designing MCHfocused Centres as one-stop shops, training health providers to be open and welcoming, motivates women to feel confident to use the facilities, Training nurses and doctors in delivery skills, and neonatal and post natal skills occurs as well as training TBAs TBAs are seen as the back-up resource for attending births, and providing care to newborns and mothers in the days after delivery. TBAs and VHVs are also supported by the district health teams conducting mobile clinics in remote villages twice a year. Health promotion is also done at this time, and provides the opportunity for links and familiarity between the formal health service and the community so women feel more comfortable to go to a health facility. The training of VHVs and TBAs does not operate as a standalone program. The efforts to strengthen health planning, supervision and support visits by district staff, knowledge of referral paths, opportunities for refresher training. It would be difficult to assess the efficacy of standalone efforts without the coherent broader program. Maternal Waiting Homes There were a number of maternity waiting homes built across southern provinces from They were built adjacent to district and provincial hospitals. They did encourage a number of women from remote villages to come to the home and be able to access skilled care for birth. In the reporting, it is not easily seen whether women continued to stay at the home for some days after birth, or left soon after delivery. It can also not been seen to what extent the offer of free food and free accommodation helped the demand generation, since other options for women wanting to wait for their deliveries near a hospital involve spending some funds on food and/or accommodation, if they do not have relatives living in the town. Since external funding stopped at the end of 2008, usage has declined. The original model over-promised on expectations of sustainability, as women waiting for birth were (unrealistically) expected to weave fabric and sale of these materials was to generate an income to sustain food and other costs of operating the homes. 38 WorkingPaperANNEX

39 Compass:Women sandchildren shealthknowledgehub However, during a field trip in southern provinces in late 2009, it was observed some pregnant women, accompanied by their husbands and children, were using the buildings to sleep and cook in, having brought all their own bedding, utensils and food. This was one month after Typhoon Ketsana devastated some villages in these provinces and some women said that their homes no longer existed so the buildings may have been used as a post-emergency temporary shelter. Since the external funding ceased, the district and provincial health Departments, which have small but some discretionary budgets of their own, have not allocated any funding even to pay the minimal electricity and water supply utility bills for these buildings. Had the demand been stronger, evidence that this service was appropriate to the local context and well used, may have suggested that the departments would have continued the small cost of utilities in order to keep the buildings open. Community based distributors: increasing family planning access The National MCH Centre and UNFPA have partnered since 2006 on a program to increases contraceptive access in remote areas. They have established and trained dozens of community-based distributors in remote and (ethnically diverse areas). This is shining example of a community based program that has delivered on a key MDG indicator, increased contraceptive prevalence, having raised; a large program that has raised CPR from between 0-10% up to 50-60% though a program of home-based visits, by community people who have been trained as providers and who, importantly, are of the same ethnicity and speak the same language as women in remote villages. Language and culture are barriers as much as transport, cost and provider skill level. Opportunities for increasing community-based delivery of services There is scope for increasing community-based delivery of services, and as outlined above in section 3, the policy environment does allow for some community-based settings of key newborn and post- natal care. Therefore: assessing current national need (82% of women and their babies do not get any neonatal or post-natal care) + current gaps in service provision (years to develop a large enough cadre of health personnel with these skills) would seem to indicate a 10 year window of opportunity to provide community-level care services across the country, using in the first instance, women that identify as TBAs. In the second instance, young people who are enthusiastic, resilient, open to learning and, importantly, been assessed as appropriate and acceptable by the communities they serve, is the profile of successful family planning community based distributors. The five southern provinces as the areas of highest priority. These provinces are: Champassak, Attapeu, Sekong, Salavane, and Savannakhet. These are also the ones reporting the highest attendance of birth by TBAs, indicating an existing cohort of women. A program such as this should not be called TBAs, but rather be named Community MNCH Volunteers and could be trained in the community resources components of the National MNCH package, namely Immediate newborn care (thermal protection, cord care, assess breathing, initiation of exclusive breastfeeding, infection prevention, eye prophylaxis) 39 WorkingPaperANNEX

40 Compass:Women sandchildren shealthknowledgehub Neonatal resuscitation Information and counselling on home care, breastfeeding, hygiene, advice on danger signs, emergency and follow-up To this, it would make sense to add other components of the integrated MNCH Package, such as family planning and basic child health care such as ORS provision that have been demonstrated to work well at community level in rural Laos and do not need to be facility-based: FP / RH Information or counselling Weekly Iron and folate supplementation Condoms and oral contraceptives provision Injectable contraceptive provision Community IMCI: for example, ORS Community promotion of insecticide treated bed-nets However, the current policy discussions and ways to operate in a one-party state make these opportunities very difficult to realize on the ground and sufficient time for policy discussions, assessment and planning should be allocated for any initiative(s) considered. A secondary, but very useful and necessary option, would be to establish a small scholarship fund, to grant to village women from rural, ethnic communities a basic living stipend for two years, to enable them to complete the newly-established Community Midwife Diploma. They would be able to return to their own communities, and in their own language(s) and integrating local tradition(s) with their new MNCH skills, provide an on-site MCH service to women and their children along the lifecycle of newborn, infant, child and maternal health care needs. 40 WorkingPaperANNEX

41 Compass:Women sandchildren shealthknowledgehub Annex: MNCH Integrated Package and Delivery Channels in Lao Nonpregnancy RH care Pregnancy care at least 4 routine antenatal care visits Intrapartum care Item of services District District Central & Community Outreach Health Hospital Hospital Provincial Resources Services Centre B A Hospital Information or counselling O O O O O O Weekly Iron and folate Δ Δ Δ Δ Δ O supplementation Condoms and oral contraceptives O O O O O O Injectable Δ O O O O IUD Δ O O O Vasectomy, tubal ligation Δ O O Monitoring progress of pregnancy and assess maternal/fetal well being O O O O Detection & management of pregnancy problems (e.g. anaemia, hypertensive disorders, bleeding, malpresentation, O O O O multiple pregnancies) Iron & folate supplementation O O O O O O Two doses of TT immunization or at least three in the past O O O O O Use of insecticide-treated bed nets from prenatal to postnatal O O O O O O De-worming O O O O O O STI/HIV risk assessment and counselling O O O O Syphilis testing* O O O O Information and counselling on self care at home, nutrition, sexual activities, breastfeeding, family O O O O O O planning, healthy lifestyle Mobilization of delivery in health facility, birth and emergency planning, advice on danger signs and O O O O O O emergency preparedness Back up antenatal care if complications Δ O O Post-abortion care and treatment of abortion complications Δ O O First level delivery care including partograph, AMTSL, injectable antibiotics, oxytocin, magnesium O O O O sulphate, neonatal resuscitation Back up EmONC including above plus vacuum extraction, manual removal of placenta, manual vacuum aspiration O O O Back up/comprehensive EmONC including above all functions plus O O Caesarean Section, blood transfusion O: Essential services (must be available at this level) Δ: Optional services (if skilled staff available) 41 WorkingPaperANNEX

42 Compass:Women sandchildren shealthknowledgehub Newborn care Postnatal care Child health care Item of services District District Central & Community Outreach Health Hospital Hospital Provincial Resources Services Centre B A Hospital Immediate newborn care (thermal protection, cord care, assess breathing, initiation of exclusive Δ Δ O O O O breastfeeding, infection prevention, eye prophylaxis) Neonatal resuscitation Δ Δ O O O O Information and counselling on home care, breastfeeding, hygiene, advice on danger signs, emergency and O O O O O O follow-up Immunization according to the national guidelines (BCG, Hep B) O O O O Special newborn care if complications or high risk conditions (sepsis, severe asphyxia, preterm birth, malformation, Δ O O etc.) Information and counselling on home care, self care and nutrition, breastfeeding, hygiene, advice on O O O O O O danger signs, emergency and followup Routine postpartum maternal care (within 7 days and up to 6 weeks) Δ O O O O Postnatal newborn care (within 7 days) Δ Δ O O O O Promotion of breastfeeding and complementary feeding O O O O O O Micronutrient supplementation O O O O O O Routine immunization of the child O O O O O TT+2 immunization to women of reproductive age, neonatal tetanus O O O O O Outpatient care of the sick child (IMCI) Δ O O O O Hospital care of the sick child (IMCI) O O O Community IMCI O Use of insecticide-treated bed nets O O O O O O De-worming O O O O O O O: Essential services (must be available at this level) Δ: Optional services (if skilled staff available) 42 WorkingPaperANNEX

43 Compass:Women sandchildren shealthknowledgehub Supplementary Report for Lao site analysis: The Age at the Time of Death and The Cause of Death of Residents Living in the 151 CBD Worker Catchment Areas & DRF/VHV Home Villages During 2008, MCHC/UNFPA, published Sept Note: this data is from a project level survey done as part of a joint UNFPA/MCH Centre program to improve contraceptive access to communities living in remote villages across a number of provinces. As part of the project, an annual Demographic Family Planning & Vital Events Registration Survey is conducted annually. During the 2008 survey, a supplementary exercise was conducted to gather data on the Age, Time and Cause of Deaths for the year in each project village. The sample size was considerable: 15,369 households across 424 communities that comprise the Project Intervention Area in 7 provinces. Deaths were reported by age category: fetal (stillbirths, miscarriages and abortions) neonatal (less than one month), infant (1-12 months), early childhood (1-years), older child (6-15) adult (over 15 years), and maternal deaths. Neo-natal mortality Table II A: Age at the Time of Death for Neo-Natal Infants (UNFPA, 2009, p7) Actual Age at the Time of Death Region 1 Day 0-7 Days 8-14 Days Days Days Total Northern Region 12 (40.0%) 22 (73.3%) 5 (16.7%) 1 (3.3%) 2 (6.7%) 30 (100.0%) Southern Region 25 (42.4%) 44 (74.6%) 6 (10.2%) 3 (5.1%) 6 (10.2%) 59 (100.0%) Total (41.6%) (74.1%) (12.4%) (4.5%) (9.0%) (100.0%) Discussion sections from the report (pp7-9) This table illustrates that the frequency distribution of neo-natal mortalities is not evenly dispersed throughout the first month of life. If this was the case, it would be expected that 3.3% of all neo-natal mortalities occurred on each of the approximately 30 days during the first month following delivery. There is a much more unequal frequency distribution pattern. This table illustrates that 41.6% of neo-natal mortalities took place during the first day immediately after birth. Many of these newborn infants died within several hours after delivery. 75% all neo-natal mortalities took place within the first week of life. More than 85% of all neonatal mortalities took place during the first 2 weeks after delivery. It is reported that most of these deaths were not due to illnesses but were rather the result of conditions, often associated with the high risk status of their mothers. 43 WorkingPaperANNEX

44 Compass:Women sandchildren shealthknowledgehub Table IIIA: Cause of Death for Neo-Natal Infants Cause of Death Region Not Healthy No Strength/ Born Premature/ Died Immediately After Delivery Not Enough Breast milk/ Cannot Drink Fever & Chills Shock/ High Fever/ Cough/ Fever & Cough/Difficulty Breathing Diarrhea/ Dysentery Abdominal Pain/ Intestinal Illness Not Available (N.A.) Total Northern Region Southern Region Total (39.3%) (16.9%) (22.5%) (6.7%) (5.6%) (2.2%) (1.1%) (5.6%) (100%) Table IIIA illustrates the main causes of death for neo-natal infants. Although the cause of death frequency distribution pattern slightly varied between the Northern and Southern Region almost 80% [i.e. 70 or 78.7%] of all deaths were caused by 3 related conditions. This included being born premature, or having no strength, or simply not being healthy shortly after birth [i.e. 35 or 39.3%], dying immediately after birth [i.e. 15 or 16.9%], and not having enough breast milk or not being able to drink breast milk [i.e. 20 or 22.5%]. At times the cause of death reported was based on the Outreach FP Workers interpretation of the response provided by parents. Thus a neo-natal infant who was pre-mature and/or not healthy at the time of birth, and who died shortly afterwards, could have just as easily been described as dying immediately after birth. Similarly some of the neo-natal infants dying shortly after birth could be described as having no strength as well as not being able to drink breast-milk. Similarly approximately than 2/3 [i.e. 139 or 65%] of all infant mortalities takes place within the first 3 months of life. At the same time less than 15% [i.e. 29 or 13.6%] of all infant deaths occur in the last six month period in the infant age cohort group [i.e. months #7 - #12]. 44 WorkingPaperANNEX

45 Compass:Women sandchildren shealthknowledgehub Table II B: Age at the Time of Death for All Infants (p8) Month During Which Infant Mortality Occurred Total Age Region < 1 mon < 2 mos. < 3 mos. < 4 mos. < 5 mos. < 6 mos. < 7 mos. < 8 mos. < 9 mos. < 10 mos. < 11 mos. 1 < 12 mo Not Spec i-fied s Norther n Region 40.5 % 13.5 % 9.5% 5.4 % 9.5 % 12.2 % 4.1 % 1.4 % 1.4 % 0.0 % 1.4 % 1.4 % (100%) Souther n Region 42.1 % 12.1 % 11.4 % 7.1 % 3.6 % 7.9% 2.9 % 3.6 % 3.6 % 1.4 % 2.1 % 2.1 % (100%) Total % (100%) % % % % % % % % % % % 45 WorkingPaperANNEX

46 Compass:Women sandchildren shealthknowledgehub Table IVA: Fetal Mortalities During 2008 (p19) Note: it is interesting to note that in the same sample (15,369 households in 424 communities) there were a higher number of fetal mortalities (105) than neo-natal mortalities (89) during the year. Category of Fetal Mortality Region Miscarriage/ Natural Abortion Induced Abortion Stillbirth Total Northern Region Southern Region Total (65.7%) (15.2%) (19.0%) (100.0%) Neo-natal and infant death as a proportion of overall mortality (Table V Mortalities, p26): Neo-natal death (1-30 days after delivery) Infant death (>1 - < 12 Months After Delivery Under five Child death (1-5 years) Older child death (6-<15) years Adults deaths (>15 years)) Maternal deaths Total deaths # of Reported Deaths 89 (89) 147 (125) 55 (43) 37 (34) 308 (276) 14 (13) 650 (580) Mean Age at Death 6. 5 days 4. 0 months 2. 0 years 7. 9 years years years years Median Age at Death: 2 days 3 months 2 years 7 years 47 & 48 years 30 years 13 years 46 WorkingPaperANNEX

47 Compass:Women sandchildren shealthknowledgehub Lao definitions for skilled attendant s required skills and abilities Recommendation from: Report on Assessment of Skilled Birth Attendance in Lao PDR (MOH/UNFPA, 2008). Note: included here as the newborn care and post-natal care functions that this report has been asked to consider are components of what is being defined in Laos as a skilled birth attendant. The items of service have been boxed, below. Based on: Making Pregnancy Safer: the Critical Role of the Skilled Attendant, a Joint Statement by WHO, ICM and FIGO, Geneva 2004 All skilled attendants must have the core midwifery skills. The additional skills required will vary from country to country, and possibly even within a country, to take account of local differences such as urban and rural settings. All skilled attendants, at all levels of the health system, must have skills and abilities to perform all of the core functions listed below. Communicate effectively cross-culturally in order to be able to provide holistic womencentred care. To provide such care skilled attendants will need to cultivate effective interpersonal communication skills and an attitude of respect for the woman s right to be a full partner in the management of her pregnancy, childbirth and the postnatal period. In pregnancy care, take a detailed history by asking relevant questions, assess individual needs, give appropriate advice and guidance, calculate the expected date of delivery and perform specific screening tests as required, including voluntary counselling and testing for HIV. Assist pregnant women and their families in making a plan for birth (i.e. where the delivery will take place, who will be present and, in case of a complication, how timely referral will be arranged). Educate women (and their families and others supporting pregnant women) in self-care during pregnancy, childbirth and the postnatal period. Identify illnesses and conditions detrimental to health during pregnancy, perform first-line management (including performance of life-saving procedures when needed) and make arrangements for effective referral. Perform vaginal examination, ensuring the woman s and her/his own safety. Identify the onset of labour. Monitor maternal and fetal well-being during labour and provide supportive care. Record maternal and fetal well-being on a partograph and identify maternal and fetal distress and take appropriate action, including referral where required. Identify delayed progress in labour and take appropriate action, including referral where appropriate. Manage a normal vaginal delivery. 47 WorkingPaperANNEX

48 Compass:Women sandchildren shealthknowledgehub Manage the third stage of labour actively.4 Assess the newborn at birth and give immediate care. Identify any life threatening conditions in the newborn and take essential life-saving measures, including, where necessary, active resuscitation as a component of the management of birth asphyxia, and referral where appropriate. Identify haemorrhage and hypertension in labour, provide first-line management (including life- saving skills in emergency obstetric care where needed) and, if required, make an effective referral. Provide postnatal care to women and their newborn infants and post-abortion care where necessary. Assist women and their newborns in initiating and establishing exclusive breastfeeding, including educating women and their families and other helpers in maintaining successful breastfeeding. Identify illnesses and conditions detrimental to the health of women and/or their newborns in the postnatal period, apply first-line management (including the performance of life-saving procedures when needed) and, if required, make arrangements for effective referral. Supervise non-skilled attendants, including TBAs where they exist, in order to ensure that the care they provide during pregnancy, childbirth and early postpartum period is of sound quality and ensure continuous training of non-skilled attendants. Provide advice on postpartum family planning and birth spacing. Educate women (and their families) on how to prevent sexually transmitted infections including HIV. Collect and report relevant data and collaborate in data analysis and case audits. Promote an ethos of shared responsibility and partnership with individual women, their family members/supporters and the community for the care of women and newborns throughout pregnancy, childbirth and the postnatal period. Skilled attendants working at the primary care levels in remote areas with limited access to facilities should also be able to do the following: Use vacuum extraction or forceps in vaginal deliveries. Perform manual vacuum aspiration for the management of incomplete abortion. Where access to safe surgery is not available, perform symphysiotomy for the management of obstructed labour. Advanced (optional) functions that may also need to be performed by selected skilled attendants working at a referral facility include, but are not limited to, the following: Perform Caesareans sections. Manage complications during pregnancy and childbirth. Administer blood transfusions. The exact set of additional and advanced skills must be determined and agreed upon nationally, depending on need, country context and policy and regulatory framework. In some cases, where the skilled attendant is the only primary health care worker, additional functions may also include, for example, identification and management of gynaecological 48 WorkingPaperANNEX

49 Compass:Women sandchildren shealthknowledgehub problems, management of nutritional problems and initial treatment for injuries. 3 Core midwifery skills have been defined by the International Confederation of Midwives in a document entitled Essential Competencies for Basic Midwifery Practice, available at 4 Active management of the third stage of labour includes: using oxytocic drugs, clamping and cutting the chord, and applying controlled chord traction. 49 WorkingPaperANNEX

50 Compass:Women sandchildren shealthknowledgehub References 1. ADB, Health Facility Survey, July Committee for Planning and Investment, National Population and Development Policy (Revision of the adopted policy in 1999); Vientiane, Department of Personnel and Organization, MOH, (Draft) Strategic Framework and Implementation Plan for the Development of Human Resources for Health in Lao PDR, version 2.1, October MOH, National Reproductive Health Policy, October MOH, Integrated Package of Maternal and Child Health Care Interventions, MOH and WHO, Human Resources for Health, Analysis of the situation in the Lao PDR, Ministry of Health, Department of Organization and Personnel and WHO, June Ministry of Public Health, Human Resources for Health Staffing Standards, Requirements and Costs, Lao Peoples Democratic Republic, Draft , version Ministry of Planning & Investment (Department of Statistics), Ministry of Health, UNICEF, Multiple Indicator Cluster Survey (MICS) Perks, C., Toole, M.J., Phouthonsy, K: District health programmes and health-sector reform: case study in the Lao People s Democratic Republic, Bulletin of the World Health Organization; 2006, 84: Thomas,A and Louangkhot, N. Study on Gender and Ethnic Issues that affect the knowledge and use of Reproductive Health Services in six ethnic villages of Lao PDR, August UNFPA, Committee for Planning and Investment, National Statistics Centre, Lao Reproductive Health Survey 2005, UNFPA Project LAO/02/P07: Strengthening the Data Base for Population and Development Planning; Vientiane Capital, 2007, a 12. UNFPA, Fact Sheet: Maternal Health in Lao PDR, The Age at the Time of Death, and The Cause of Death of Residents Living in the 151 CBD Worker Catchment Areas & DRF/VHV Home Villages during 2008, Supplementary internal report, UNFPA, Sept WHO 2005 The World Health Report 15. WHO, ICM and FIGO, Making pregnancy safer: the critical role of the skilled attendant, a joint statement; Geneva WHO, UNFPA, UNICEF, The World Bank, Integrated Management of Pregnancy and Childbirth: Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors, Reproductive Health and Research WHO, UNFPA, UNICEF, The World Bank. Maternal Mortality in WHO Geneva WorkingPaperANNEX

51 Compass:Women sandchildren shealthknowledgehub Indonesia, East Nusa Tenggara (NTT) province - community-based delivery of maternal and newborn care interventions: Jenny Kerrison, December 2009 Introduction This report presents the analysis on selected community-based delivery of interventions in maternal and newborn health (MNH) in Indonesia and in the East Nusa Tenggara (NTT) province. Included in this report are: the national policies and laws; minimum health standards; information on peripheral health staff; and the current status of community-based delivery of services programs for maternal and newborn care. The programs reported are a mix of national programs introduced by the Government of Indonesia (GOI) and programs piloted by Save the Children and UNICEF. The GOI programs presented in this report are currently implemented throughout the country. The report also includes a general discussion on enabling and limiting factors that may influence scaling up of community-based delivery of interventions in NTT. The sources of information for this report were from published and unpublished documents such as powerpoint presentations made by Ministry of Health (MOH) at meetings attended by this author. Many of the documents were obtained through the help of two national research assistants in Indonesia. In addition, some of the information were from the author s personal experiences from more than eight years MNH work experience in NTT province. Maternal and newborn status and practices The maternal mortality ratio (MMRatio) in Indonesia for the period is estimated as 228 maternal deaths per 100,000 live births (see Table 1 below). As reported in the Indonesia Demographic Health Survey (IDHS), 2007, Indonesia has experienced a steady, small annual decline in maternal mortality ratio since 1994 (Statistics Indonesia et al., 2008, p ). The MMRatio was 390 per 100,000 births for the period ; 334 deaths per 100,000 for the period ; 307 deaths per 100,000 for ; and 228 deaths per 100,000 in However, the data needs to be considered with caution due to high sampling errors in 1994 to 2007 surveys and there may not have been much decline in MMR during that time period (Statistics Indonesia et al., 2007, p. 217). More women are birthing at facilities, as reflected in IDHS 2007 than in years prior to The IHDS 2007 revealed that home births (53% of deliveries) remained a popular choice for women in Indonesia. The second most common facility for delivery is private practice 4 (36%) and the third most common facility for delivery is the public sector (10 %). Nationally, facility-based delivery makes up 46 percent of deliveries (see Table 1 below) (Statistics Indonesia et al., 2008). The number of births assisted by skilled attendants (doctors, midwives, nurses) were 73 percent in 2007 IDHS and has increased in comparison to 66 percent in IDHS. The number of births by skilled attendants is below the national target of 90 percent set for 2015, as indicated in the Minimum Service Standards (MPS) (Ministry of Health, 2008a). Nationally, 13 percent of women delivered with the assistance of the obstetrician/gynaecologist; fifty-nine (59) percent of deliveries were assisted by nurse/midwife; and 24 percent by traditional birth attendants (TBAs). It was reported that one (1) percent of women delivered with no one assisting. The data for NTT are displayed in Table 1 below (Statistic Indonesia et al., 2008, 4 Private practice refers to: private hospital, clinic, doctors, obstetricians and gynaecologists, private midwives, private nurse and village midwives. These professionals provide services at their private practice site (Statistic Indonesia et al., 2008, p.136). 51 WorkingPaperANNEX

52 Compass:Women sandchildren shealthknowledgehub p.288). The age, level of education and wealth of women are influential factors on women s choice of birth attendants. Women with no education or limited primary school education are more likely to use TBA (Statistic Indonesia et al., 2008). Nationally, the Caesarean delivery rate is 6.8 percent of deliveries. Women in the lowest wealth quintile had the lowest number (1.8%) of Caesarean delivery and women in the highest wealth quintile had the highest number of Caesarean delivery (16.8%). The Caesarean delivery rate in NTT province is 4.2 percent, which is only 61 percent of the national rate (see Table 1 below). (Statistic Indonesia et al., 2008, p.137). Women in urban areas are more likely to receive Caesarean delivery than women living in rural areas. The differential in Caesarean delivery and other maternal health services between NTT and nationally suggest that the inequities in health care exist for women in NTT. Table 1: National & East Nusa Tenggara data Indicators 2007 Indonesia NTT Mortality (Statistics Indonesia et al., 2008) MMRatio 228 * 306 ** Newborn Mortality rates per 1,000 live births Literacy (CBS East NT, 2008) Women s Literacy % 87.4 (IDHS 08) 45.0 Men s literacy % Family Planning (Statistics Indonesia et al., 2008) TFR CPR % for currently married women Unmet need for Family Planning Maternal health care Rates of Delivery in health facilities (government hospital or health center) % * Rates of Delivery in private facilities % * (private hospital, clinic, doctors, obstetrician/gynaecologists, private midwives, private nurse, and village midwives who provide services at their practice site or in their WorkingPaperANNEX

53 Compass:Women sandchildren shealthknowledgehub homes) Rates of Delivery in homes* Rates of Delivery by skilled attendants % * delivery by obstetrician/gynaecologist % * delivery by nurses/midwives Rates of Delivery by TBAs % * Rates of Delivery by no one % * Caesarean delivery rate % * Sources: IDHS (Statistics Indonesia et al., 2003); *2007 (Statistics Indonesia et al., 2008). **MOH; #Riskesdas (Health research) NTT, The three most common causes of maternal deaths in Indonesia were: haemorrhage (30%); eclampsia (25%); and infection (12%). In relation to infant deaths, the three most common causes were: perinatal complications (36%); acute respiratory infection (28%); and diarrhoea (9%). Neonatal tetanus remains a problem in Indonesia and was reported as the fourth common cause of infant deaths (3 %) (Indonesia Household Survey [IHHS], 2001 cited in Untoro et al., 2009). Brief demographic data: NTT The NTT province has a population of around 4,534,319 million (Central Bureau of Statistics East Nusa Tenggara, 2008). The province has 19 districts and 1 municipality. NTT is one of several provinces in Indonesia with a high poverty rate. It was noted that 27.5 percent of the population live below poverty line with more poverty in rural areas than urban. The Human Development Index (HDI) in NTT is In contrast, the HDI for Jogyakarta (with the lowest MMR in the nation) with a population of around 3 million is 73.7 (GTZ, 2009). The province also suffers from lower education in men and women, highest total fertility rate, and lower maternal and newborn health. The prevalence of poor nutrition is 33.6 percent, which is a long way to achieving the national target of 20 percent by the year Of the 16 5 districts, Kota Kupang is the only district that has achieved the national target. Interestingly, only 55.8 percent of babies are weighed following birth. It was noted that 20 percent of babies have low birth weight with the largest number in district Sikka (38.1%). The prevalence of malaria is high in NTT with 14.9 percent of respondents suffering with malaria in the last month prior to the Riskesdes survey. The NTT province has a MMRatio of 306 per 100,000 live births and is one of four provinces with highest home births in the country (MOH, 2007). It ranked sixth highest in infant morality rate (IMR) in Indonesia (Statistic Indonesia et al., 2008, p.121). The majority of under-five deaths in children is infant deaths and most of the deaths occurred during the neonatal period. As expected, the NNMR is higher in rural areas and the highest number of deaths occurred in 5 The East NT had 16 districts during implementation of Riskesdes prior to the divisions of a further 3 districts. The 16 districts are: Sumba Barat, Sumba Timur, Alor, Lembata, Flores Timur, Sikka, Ende, Ngada, Manggarai, Manggarai Barat, Rote Ndao, Kupang, Timor Tengah Selatan, Timur Tengah Utara, Belu, and Kota Kupang. The three new districts that were not included in the survey were: Nagekeo, Sumba Barat Daya, and Sumba Tengah. 53 WorkingPaperANNEX

54 Compass:Women sandchildren shealthknowledgehub neonates born to mothers with no education and in the lowest wealth quintile. (Statistics Indonesia et al., 2008, p.120). Nationally, the neonatal mortality rate makes up 57% of under 5 years mortality rate. In general, neonatal mortality is improved for women who had antental care and delivery assistance from trained attendants (Statistics Indonesia et al., 2008, p. 122). Family Planning Maternal fertility patterns are important factors influencing children s survival. Children are six times more likely to die if their mother is aged 34 years, born with birth interval less than 24months, and in birth order three or higher. Children born to mother who are too young (less than 18years) and born with birth intervals that are too short are also at greater risks of dying. (Statistics Indonesia et al., 2008, p. 127). The family planning in Indonesia has stagnated nationally since the IDHS in The national TFR was 2.6 in 2007 (Statistic Indonesia et al., 2008) and 2003 (Statistic Indonesia et al., 2003). The IDHS 2007 reveals that fertility is higher for women in rural areas than urban and is highest in the lowest wealth quintile. In contrast, NTT province has experienced some deterioration in the family planning statistics and remained a province with the worst TFR in the nation. The TFR in NTT has slightly deteriorated over the last 10 years with a TFR of 4.2 in 2007 (Statistic Indonesia et al. 2008) and 4.1 in IDHS (Statistic Indonesia et al., 2003). Nationally, the CPR is 42.1 per cent and the most popular modern method of contraceptives is the injectables given 3 monthly (19.4 %). The national CPR was 61.4 percent, as reported in IDHS The total unmet need for family planning was 17.4 percent and nationally, the unmet need for FP was 9.1 per cent. Interestingly, nationally, the desired total fertility rate is to be kept low at 2.2 and in NTT province the desired TFR is 3.6. (Statistic Indonesia et al. 2008, p ). The three (3) most popular contraceptives used by women are: injectables (62% nationally and 44 % in NTT); pill (41 % nationally and 18 % in NTT); and Intra-uterine device (IUD) (14 % nationally and 9 % in NTT). The family planning situation in Indonesia would most certainly have been related to the decentralisation of BKKBN (World Bank, 2009, p.13) that significantly weakened FP services in NTT province 7. The family planning program in Indonesia remains fragmented by the division of labour between BKKBN and MOH whereby BKKBN is involved in mobilising the community and creating demands for FP, supplying contraceptives for the poor and training and equipment for health staff, and maintaining FP information system. The MOH is primarily responsible for providing clinical services. The MOH has plans to provide contraceptives for the poor, instead of BKKBN. The IDHS 2007 reports the missed opportunities for discussions and education on family planning with women with approximately 25 percent of nonusers of contraceptives who had visited a health care facility in the 12 months prior to the IDHS 2007 survey (Statistic Indonesia et al., 2008, p. 65). Sex education and knowledge of symptoms of sexually transmitted illnesses are generally poor among women in NTT. NTT ranked as the fourth highest province (1.1%) in Indonesia where men had sexual extramatrital partner in the last 12 months of the IDHS survey 2007 (Statistics Indonesia et al., 2008, p ). Burden of Poverty in NTT 6 The Indonesian Demographic Health Survey was conducted in The author of this report was a consultant in NTT province for more than 8 years between 1996 and 2008 and had first-hand knowledge of impacts of the weakened BKKBN agency in the province and several NTT districts. 54 WorkingPaperANNEX

55 Compass:Women sandchildren shealthknowledgehub The province lacks infrastructure for clean water supplies, toilets, drains for wastes water and waste collection and removal system. Many households (44.4%) has dirt floors and the majority of households continue to use wood as fuel (84.9%). Other types of fuel used for cooking are kerosene and gas that are found mainly in the larger towns and in Kupang City. (Riskesdes, 2008, p. v-xiv). In addition, the province has above national prevalence for many health problems such as: filiriasis, dengue fever, malaria, pneumonia, TB, measles, typhoid, hepatitis, diarrohea. NTT prevalence of correct attitute toward hand washing is below national prevalence. In regards non-communicable diseases, NTT province is one of the provinces with higher than national prevalence for: arthritis (ages over 15 years); asthma, cardiac/heart disease, diabetes mellitus, mental emotional disorder, low vision and blindness, dental-mouth problems. The prevalence of injury in NTT is higher than national. (Riskesdes, 2008b). National Policy, Standards and Practices Health planning is the responsibility of districts local government since decentralisation in the early 2000s and is governed by law (UU 32 tahun 2004). (Riskesdes 8, 2008). The MOH decree (No 284/MenKes/SK/III/2004) supports the compulsory use of the MCH book (Buku KIA) and states that the book must be used through pregnancy, postnatal period and for children under the age of five years. The MCH book is required to document and monitor maternal and child health. It is used as a tool for early detection of health problems in the mother and child. It is also a tool for communication and education for the mother, family and community in regards services; the health of mother and child including referral and the standard packet of MCH services; nutrition; immunisation and growth. The implication of this decree are that midwives, doctor, and specialist obstetrician, gynaecologist and paediatrician must document services provided to the mother and child under 5 years of age. The MOH data suggest that nationally only 27 percent of pregnant women received the MCH book in The NTT province performed better than national average with 48 percent of pregnant women who were in possession of the MCH book. Making Pregnancy Safer (MPS) is adopted nationally by the Government of Indonesia and implemented by the Ministry of Health. Two of the four main MPS strategies relate to community participation. The two strategies relevant to this report are: (i) Encourage women and family empowerment through improving their knowledge to ensure appropriate practices and utilisation of MNH services; and (ii) Encourage community involvement in ensuring the provision and utilisation of MNH services. (AIPMNH 2008). In support of MPS, the MOH introduced six key programs to reduce MMR, these are: Birth preparedness and complication readiness (Perencanaan Persalinan dan Pencegahan Komplikasi [P4K]) in all Puskesmas catchment areas; BEONC and CEONC; Midwife and TBA partnership; develop/strengthen blood transfusion unit in district hospitals; family planning services; adequate human resources (MOH, 2008b). There is a Governor s regulation no 42, 2009, that officially supports the maternal and neonatal health revolution in NTT. This legitimises the directions taken by the PHO to push for facility-based deliveries of all pregnant women. The national MNH handbook (Buku Panduan Praktis Pelayanan Kesehatan Maternal dan Neonatal) (2002) adopted by MOH, the National Clinical Training Network (JNPK), and midwife and medical associations, provides clinical skills guidelines and standards. The MNH handbook provides guidelines on use of Active Management of the Third Stage of 8 Riskesdes or riset kesehatan dasar is community-based, basic health research that was conducted in all districts in East NT by Health Research and Development Body (Balitbangkes), MOH, to provide provincial and district data for more accurate health planning. In Riskesdes 2007, a total of 9,206 households and 38,002 individual respondents were sampled. 55 WorkingPaperANNEX

56 Compass:Women sandchildren shealthknowledgehub Labour (use of oxytocin and controlled cord traction). The AMTSL is part of Basic Delivery Care practice and was included in pre-service education and introduced to midwives inservice training throughout Indonesia. In addition, use of ergometrine, magnesium sulphate and antibiotics are also included in the MNH handbook. Misoprostol prophylaxis to reduce postpartum haemorrhage (PPH) is not supported by MOH. Community-based distribution of oral misoprostol was piloted by World Health Organisation Collaborating Center in Bandung and JHPIEGO s Maternal and Neonatal Health (MNH) program in Indonesia. A total of 1,655 women were recruited for the pilot. The misoprostol tablets and safety information were distributed to women by midwives and trained community volunteers. Counselling on how to prevent PPH and provided free medical care for birth complications. The evaluation results showed that women were able to use the tablet accurately and 45 percent of women in the intervention group were less likely to require referral for PPH. Lessons learned included the need for a program coordinator at the implementing Puskesmas; and traning for midwives and community volunteers in use of the drug and control of distribution and storage. (Sanghvi et al., 2004). Unfortunately, recommendations to roll out the use of misoprostol in Indonesia was put on hold since The reasons for this are unclear. Early newborn care (ENC) is recommended during the first hour, first day and first week. This policy was promoted by MOH in a donors meeting in 2008 (MOH, 2008b). The Child Protection law no 23 year 2002, article 2 states that each child has the right to live, grow and develop, and participate with dignity and human values and receive protection from violence and discrimination. Article 8 states that the child has the right to receive health services and social insurance in line with physical, mental, spiritual and social needs. Law no 10 year 1992 on Population and Family Welfare dictates that family planning advice and services to young unmarried women and men are prohibited. The Government family planning services are only for married couples. In addition, the Australian policy on family planning is that Australian aid funds are not available for activities that involve abortion training or services, or research trials or activities, which directly involve abortion drugs. Also important to note: Australian aid funds can only be used to purchase contraceptives which are registered in Australia. (Commonwealth of Australia, 2002, p.3). AusAID has plans to revise this policy, which was still in use in early Health Law September 2009 (articles 75 77) states that abortion is illegal except in cases of medical emergencies and rape. Abortion can only be undertaken at six weeks of pregnancy except in medical emergencies. Women must obtain permission from their husband, unless in cases of rape. All women must undergo counselling pre and post abortion with trained counsellor. Only certified medical practitioners are allowed to conduct abortions. (Hull & Widyantoro, 2009). Intermittent malaria treatment in pregnancy national policy still in progress. In the medium term national development plan (RPJMN) , the main goals and targets relevant to this paper include improving access and quality of health services with specific focus on increasing the health of mother and children (MDGs 4 and 5). The national target for MMR is 102 per 100,000 live births and Infant Mortality Rate is 23 per 1,000 live births by The future challenges facing Indonesia are to increase access and quality of health services for maternal and child health through improving nutrition (with focus on pregnant women and children 0-2years of age), increasing knowledge of mothers, adequate health human resources, equipped health care facilities, and increase coverage and quality of immunisation, including increasing the quality of environmental health (Bappenas, 2009, p.15). The medium term Health Strategy will be available in early WorkingPaperANNEX

57 Compass:Women sandchildren shealthknowledgehub Minimum Service Standards in the Health Sector (MSS-Health) in districts/municipalities can be found in the Ministry of Health (2008a) of RI regulation no 741/Menkes/per/VII/2008. Article 2, item one states that Districts/Municipalities shall administer health services in accordance with MSS-Health.. The MSS-Health is a set of performance indicators and targets for key health services for The performance indicators and targets for primary health services, referral, and health promotion and community empowerment are displayed in Box 1 below. Box 1: Minimum Service Standards in the Health Sector in districts/municipalities (Ministry of Health of RI regulation no 741/Menkes/per/VII/2008) (Minister of Health, 2008a) Primary Health Services: o Coverage of pregnant women making four ante-natal visits shall be 95% by 2015; o Coverage of pregnant women with complications receiving treatment shall be 80% by 2015; o Coverage of birthings assisted by health workers with competence in obstetrics shall be 90% by 2015; o Coverage of women with puerperal infection shall be 90% by 2015; o Coverage of neonates with complications receiving treatment shall be 80% by 2010; o Coverage of infant visits shall be 90% by 2010; o Coverage of universal child immunisation (UCI) villages/wards shall be 100% by 2010; o Coverage of services for children under five years shall be 90% by 2010; o Coverage of provision of supplementary foods to breastfeeding children aged 6-24 months from poor families shall be 100% by 2010; o Coverage of malnourished children under the age of five years receiving care shall be 100% by 2010; o Coverage of health networking with children at primary school or equivalent shall be 100% by 2010; o Coverage of active contraceptive users shall be 70% by 2010; o Coverage of identification and treatment of the sick shall be 100% by 2010; o Coverage of primary health services for poor people shall be 100% by Referral Health Services o Coverage of referral health services for poor people shall be 100% by 2015; o Coverage of level 1 emergency services that must be provided at a District/Municipal health facility (hospital) shall be 100% by 2015; Health Promotion and Community Empowerment o Coverage of Desa Siaga Aktif shall be 80% by Peripheral Health Staff First level facility staff is the village midwife who works and lives in a community-built Polindes. The Minsterial decree no 900 year 2002 guides the conduct of midwives in midwifery services, family planning, and public health care. The decree stipulates that there should be one midwife per village and allows midwives to provide simple treatment to the community in locations where there is no medical doctor. The policy remains that there should be one village midwife to one village. However, this has not yet been achieved for various reasons such as: inability to attract and keep midwives in rural areas; and lack of support for midwives. The only paid staff working in the village is the village midwife. She provides midwifery service, family planning and public health care, including some general nursing care to non-midwifery 57 WorkingPaperANNEX

58 Compass:Women sandchildren shealthknowledgehub patients. If there is no doctor in the location, the midwife can perform simple treatments for the community in her catchment area. Health volunteers (cadres) make up the largest group of village volunteers based in the community. Cadres are an important part of the community health system and work mainly in the monthly Posyandu also known as Integrated Services Post. There must be a minimal of five (5) health cadres working in the Posyandu. The paid government health services staff who are also present at the Posyandu include: one Puskesmas midwife, one village midwife, one Sanitarium, one nutritionist, and one health promotion staff. The family planning fieldworker may also attend the Posyandu. At the Posyandu, the functions of the cadres are based on the five activities, these are: registration of mothers and babies/children under 5 years of age; weighing of children; recording of weights; nutrition and health education; administer simple health services e.g. vitamin A, oralit (dehydration fluids); iron tablet, re-supply of contraceptive pills to clients not new clients, and distribution of condoms. Cadres are not allowed to administer any injections or prescribe antibiotics and other prescribed drugs, as dictated by Law no 29 year 2004 governing medical practice (UU no 29 tahun 2004 praktik Kedokteran, BabIX, pasal 73) 9.. Good practice examples from Indonesia A number of interventions that are worth mentioning with its strong community approach are: P4K and Village Alert (Desa Siaga); and Saving Newborn Lives (SNL1 and SNL2). P4K program The national P4K program is community-based and has strong social component. It was introduced nationally in The P4K program has evolved from the Village Alert (Desa Siaga) program. The goal of the P4K program is to ensure that all women, her family, and her community are prepared for the baby s birth and possible complications. The components of P4K program are: birth planning and preparations for referral for management of obstetric and newborn complications with the identification of blood donor, transport and funds. Each pregnant woman is given a sticker completed with her details (see example in Box 2 below) that is prominently displayed in front of the woman s home. The sticker is essentially a birth plan and is completed with the woman and family. Information included on the sticker are: name, expected date of delivery, the birth attendant, place of delivery, support person at delivery, transport required, and the woman s blood group. The details on the sticker are displayed openly, so that the husband, family, village volunteers (cadres), TBA, and village midwife can monitor the pregnant woman s progress and to ensure that she receives regular antenatal, delivery and postnatal care, in line with service standards. From personal experience of this approach used in one village in NTT, this approach seems to be culturally acceptable to women and family and not seen as a violation of privacy. The use of stickers will also ensure that the midwife conducts birth planning, ensures the family has savings for emergency referral and are also expected to discuss family planning postnatally. This approach also ensures that midwives collect accurate data on pregnant women in her catchment area. The community leaders, cadres and TBAs are also involved in supporting aspects of the birth plan. 9 Law no 29 year 2004, chapter 9, article 73, no 2 refers to Each person is not allowed to use equipment, method or other approach in providing services to the community that could give the impression that the service provider is a registered doctor or dentist. This does not apply to health staff who have the right to practise under their professional regulations. Failure to comply with the law could result in a jail sentence of 5 years or a fine of Rupiah 150,000,000 (one hundred and fifty million rupiah) (AUD17,505) (exchange rate AUD1 = Rupiah 8,566). (Republic of Indonesia) 58 WorkingPaperANNEX

59 Compass:Women sandchildren shealthknowledgehub Box 2: Sticker (18 cm x 10 cm) used in P4K program Source: Departemen Kesehatan RI Pedoman Praktis. Program Perencanaan Persalinan dan Pencegahan komplikasi (P4K) dengan Stiker. Jakarta. Indonesia. p.4 The expected outcomes of the P4K program included: increased ANC coverage; increased delivery by skilled birth attendant; increased partnership between Midwife and TBA; early detection and management of complications; increased use of contraceptives postnatally; monitoring of maternal and newborn illnesses and deaths; and decreased maternal and newborn morbidity and mortality. Evidence on the effectiveness of the P4K program are not yet available. Other activities that supports the P4K program are: development of partnership between village midwives and cadres and TBAs; training for cadres to support the midwives by identifying pregnant women and updating data base and village map of target groups. Cadres also motivate women to deliver with the midwife and to use contraceptives post delivery. The partnership with TBAs is also important to reduce MMR. The TBAs are not allowed to deliver babies and are given the role of caring for the mother during and after delivery of baby. (Ministry of Health, 13 March 2008b). In 2008 in Sulawesi province, UNICEF had some success in the implementation of a partnership program between TBA and midwives. In a number of districts, the TBAs agreed to confine their practice to non-medical tasks such as reciting prayers, providing herbal drinks and providing postpartum care. All medical procedures are managed by midwives who pay the TBA s fees from their own funds. In 2008, community health insurance (Jamkesmas) funded by the national government for the poor has funding for delivery care by midwives. In NTT and other districts e.g. Papua, midwives shared some money from this income with TBAs, Puskesmas (if they use the Puskesmas for deliveries), and the Midwife Supervisor from the Puskesmas. In some districts, the doctor who is usually head of the Puskesmas also gets a cut from the delivery funds that midwives earn. A positive impact of this program was that in one district Galesong, Sulawesi, the deliveries by midwives at a health facility reached almost 100 percent. The competition between TBAs and midwives were notably reduced (UNICEF, 2008). 59 WorkingPaperANNEX