Saving Mothers. Giving Life A NORTHERN UGANDA PHOTO STORY

Transcription

1 Saving Mothers Giving Life A NORTHERN UGANDA PHOTO STORY

2 About USAID ASSIST The USAID Applying Science to Strengthen and Improve Systems Project (ASSIST) is a five year project ( ) funded by the American people through USAID s Bureau for Global Health, Office of Health Systems. The project is managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID- OAA-A URC s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T.H Chan School of Public Health; HEALTHQUAL International; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for Communication Programs; and WI-HER, LLC. The USAID ASSIST project works to strengthen health systems and improve patient outcomes through advancing improvement science. Over the last five years, the USAID ASSIST project in Uganda has progressed in improving patient outcomes at facility level in the technical areas of HIV, TB, maternal, newborn, and child health (MNCH), malaria, orphans and vulnerable children (OVC), and at national and sub national level supporting institutionalization of improvement by supporting USAID partners nationwide and the Ministries of Health (MOH) and Gender Labor and Social Development (MGLSD). For more information on the work of the USAID ASSIST Project, please visit or write assist-info@urc-chs.com. USAID ASSIST PROJECT Applying Science to Strengthen and Improve Systems DISCLAIMER The contents of this SMGL photo book are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.

3 Table of Contents 1 Background 2 Project goal, strategies, and interventions 2 Interventions 2 Community level interventions 3 Facility level interventions 3 The Quality Improvement Approach 4 FACILITY LEVEL INTERVENTIONS 5 Improving antenatal care services 5 Routine screening for obstetric complications during antenatal care visits 6 Reducing waiting times at laboratories for pregnancy related tests 7 Improving labor & delivery services 7 Active monitoring of the labor process using a partograph 10 Active management of the third stage of labor (AMTSL) 11 Helping baby s breath (HBB) and essential newborn care 15 Preterm delivery management through cortical steroid use and Kangaroo mother care 16 Spreading lessons learned and best practices on improving preterm labor & newborn care 19 Emergency preparedness for mother and newborn 21 Revitalizing district and health facility maternal perinatal death review (MPDR) audits 22 The Anaka Hospital MPDR success story 25 COMMUNITY LEVEL INTERVENTIONS 26 Improving uptake of early antenatal care services 27 Ensuring women with pregnancy signs in the community attend their first ANC visit during first trimester 31 Community Identification & refferal of pregnant women with complications for management at health facilities 32 Increasing health facility deliveries & community post natal care 32 Every pregnant woman has a birth plan and saves for emergency birth expenses & delivery at a health facility 35 Early community level post natal follow up visits to check for mother and newborn wellness 37 Launch of tools and sharing best practices 37 VOICES

4 Acronyms AMSTL ANC AOGU ASSIST CCT CeMONC DHO ENBC FY HC KMC MNH MNCH MOH MPDR MUAC NGO PEPFAR QI SMGL TEO URC USAID Active management of the third stage of labor Antenatal Care Association of Obstetricians and Gynecologists of Uganda USAID Applying Science to Strengthen and Improve Systems project Controlled Cord Traction Comprehensive Emergency Obstetric and Newborn Care District Health Officer Essential newborn care Financial year Health Centre Kangaroo Mother Care Maternal and Newborn Health Maternal, Newborn and Child Health Ministry of Health Maternal and Perinatal Death Review Mid-upper Arm Circumference Non-Governmental Organization President s Emergency Plan for AIDS Relief Quality improvement Saving Mothers Giving Life Initiative Tetracycline Eye Ointment University Research Co., LLC United States Agency for International Development

5 Background The Saving Mothers Giving Life (SMGL) project was a five year ( ) private public partnership (PPP) aimed at rapidly reducing maternal and newborn mortality in selected districts of Uganda, Zambia, and Nigeria. In Uganda, which has a maternal mortality ratio of 438/100,000 live births (UDHS, 2011), the USAID Applying Science to Strengthen and Improve Systems Project (ASSIST) provided continuous quality improvement support to the 12 month SMGL proof of concept phase in the four districts of Western Uganda (Kyenjojo, Kamwenge, Kabarole and Kibaale). During this phase, which began in January 2012, ASSIST generated best practices and lessons learned in Figure 1. Saving Mothers Giving Life (SMGL) model Reduce delay in seeking care Focus on labor, delivery & first 48 hours after birth Reduce delay in reaching care Comprehensive public & private health system strengthening Reduce delay in receiving quality care Integrate HIV/ AIDS, maternal & newborn services Figure 2. Saving Mothers Giving Life Northern Uganda intervention districts Koboko Moyo Yumbe Lamwo Kaabong Kitgum Marache Adjumani Arua Kotido Amuru Gulu Pader Agago Omoro Abim Moroto Zombo Nwoya Nebbi Otuke Napak Oyam Alebtong Kole Lira Kiryandongo Amuria Apac Dokolo Katakwi Bullsa Kaberamaido Soroti Nakapiripirit Amudat Amolatar Masindi Ngora Serere Kumi Kween Holma Bukedea Bulambuli Nakasongola Bukwo Pallisa Kyankwanzi Buyende Nakaseke Kaliro Kibuku Bundibugyo Ntoroko Budaka Sironko Mbale Bududa Kapchonwa Kibale Kamuli Kiboga Luweero Namutumba Butaleja Manafa Kayunga Luuka Tororo Kyenjojo Iganga Kabarole Kyegegwa Jinja Mubende Bugiri Mityana Wakiso Mukono Busia Mayuge Buikwe Kamwenge Gomba Kasese Butambala Ssembabule Mpigi Kampala Kalungu Bukomansimbi Rubirizi Ibanda Kiruhura Lyantonde Namayingo Mitooma Buhweju Masaka Lwengo Bushenyi Mbarara Kalangala Sheema SMGL-supported districts Rukungiri Rakai Isingiro Additional ASSIST districts Kanungu Ntungamo Kisoro implementing high impact, low cost, evidence based interventions in maternal and new born health (MNH) that were spread to six northern Uganda districts (Apac, Dokolo, Gulu, Lira, Nwoya and Pader) beginning in February Kabale 1

6 Goal To reduce annual maternal and newborn mortality 6 Apac districts in with 1.7 million people Dokolo Gulu Lira Nwoya Pader & 85,000 expected annual 118 health facilities 514 villages Strategies 1 To ensure quality of maternal new born and child health services: 2 To improve the processes of MNCH service provision: 3 To ensure an effective health system structure is in place: Capacity building & Technical training of health facility staff in MNCH Ensuring availability of essential supplies & commodities Implementing continuous quality improvement approaches at health facility and community levels. Strengthening regional and district based MNCH support structures Interventions Community level interventions to address the first delay (delay to seek care) and second delay [delay to access care) Ensuring women with pregnancy signs in the community attend their first antenatal care (ANC) visit during first trimester Community Identification of pregnant women with complications for management at health facilities Every pregnant woman has a birth plan and saves for emergency birth expenses & delivery at a health facility Early community level post -natal follow up visits to check for mother and newborn wellness 2

7 Interventions Facility level interventions to address the third delay (delay in receiving quality care) Routine screening Active monitoring Active management Helping Babies Preterm delivery District & facility for obstetric of the labor process of the third stage of Breathe (HBB) and management maternal and complications using a partograph labor (AMTSL) essential newborn through antenatal perinatal death during antenatal care cortical steroid review audits care (ANC), labor & use and Kangaroo delivery Mother Care (KMC) The Quality Improvement Approach ASSIST implemented the quality improvement approach to implement the SMGL program at each of the 118 supported health facilities and 514 communities, this approach is based on the Plan Do Study Act (PDSA) model briefly illustrated below: Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Defining the improvement aim Forming the improvement team Understanding the current system Developing the measurementsystem What changes can we make that will result in improvement? Act Plan Study Do Implementing and sustaining changes Testing changes Developing changes 3

8 Through SMGL, ASSIST engaged the district leadership and supported them build human resources capacity and reallocate resources towards the operationalization of comprehensive emergency obstetric and newborn care (CeMONC) services at 3 health center IVs (Pajule HCIV Pader, Ogur HCIV Lira & Lalogi HCIV Omoro ) Dr Jimmy Opee, in-charge Pajule HCIV, performing the first emergency caesarean section at the health facility in 16 years on 18/02/16 FACILITY LEVEL INTERVENTIONS 4

9 IMPROVING ANTENATAL CARE SERVICES Beatrice Ayoo, a registered midwife from Lacor Opit HCIII (Omoro district) taking BP and MUAC ROUTINE SCREENING FOR OBSTETRIC COMPLICATIONS DURING ANTENATAL CARE VISITS Improvement in screening for pregnancy induced hypertension 80 % 98 % January 2016 December 2016 ASSIST supported health facility teams to organize observation trays at the ANC booking tables containing: Blood Pressure (BP) machine, Stethoscopes, mid-upper arm circumference (MUAC) tapes and thermometers which are key in identifying complications like high blood pressure, fever (due to various causes), malnutrition, and others. 5

10 IMPROVING ANTENATAL CARE SERVICES REDUCING WAITING TIMES AT LABORATORIES FOR PREGNANCY RELATED TESTS During ANC visits, service providers draw one blood sample from each mother at the ANC clinic (instead of sending them to crowded laboratories for various tests); this one sample is used for multiple tests including: HIV, HB 15 (Anemia) screening, and syphilis (rapid plasma reagin testing). Improvement in screening for syphilis in pregnancy 20 % 70 % January 2016 December 2016 Improvement in screening for anemia in pregnancy at first ANC visit % 30 % January 2016 December

11 IMPROVING LABOR & DELIVERY SERVICES ACTIVE MONITORING OF THE LABOR PROCESS USING A PARTOGRAPH Beatrice Tino, registered midwife and acting in-charge maternity unit at Aduku HCIV (Apac district) monitoring the progress of a mother in active labor using a partograph Increasing accessibility, availability and utilization of partographs Partographs are used by service providers to monitor the labor process and inform timely obstetric action and are recommended by the ministry of health to be used by midwives for each labor and delivery process they conduct. ASSIST supported SMGL facilities in Northern Uganda to increase partograph use as a quality of maternal and newborn care tool through some of the changes below: Midwives attach a new partograph sheet to admission forms and admission books of each mother in active labor. Health facility in-charges utilize primary health care funds to photocopy and ensure partographs are available for the maternity units service providers. 7

12 IMPROVING LABOR & DELIVERY SERVICES ACTIVE MONITORING OF THE LABOR PROCESS USING A PARTOGRAPH Facilitating continuity of partograph use Sr Rose Aciro, in-charge maternity at Lira regional referral hospital displays a filled in partograph of a mother being handed over to the next midwife on shift To enhance continuity of partograph use, service providers physically hand over each laboring mother, her filled in partographs, and her admission sheets/book during shift change 8

13 IMPROVING LABOR & DELIVERY SERVICES ACTIVE MONITORING OF THE LABOR PROCESS USING A PARTOGRAPH Improving service provider skills in utilizing partographs to monitor progress of labor delivery ASSIST supported peer to peer learning sessions, health facility based coaching and mentorship visits where hands on training on plotting partographs was conducted by both more experienced midwives and ministry of health specialists including obstetricians and pediatricians. Health facilities assigned focal people among the maternity team who reviewed each partograph for completeness and quality before maternity shift handover. Improvement in partograph use to monitor the progress of labor across supported sites 30 % 90 % February 2016 December

14 IMPROVING LABOR & DELIVERY SERVICES ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR (AMTSL) Ensuring the provision of a uterotonic drug within the first minute of the third stage of labor Following guidelines from the ministry of health and lessons learned from SMGL phase 1, ASSIST spread best practices in AMTSL to supported SMGL northern Uganda sites including: Pre-packing Pitocin in a syringe by a service provider as a mother approaches the second stage of labor. Utilizing the cold chain boxes to store Pitocin within the labor ward and changing ice packs on a daily basis, to counter the cold chain barrier. Reminder notes and a USAID protocol followed by health care providers to improve AMTSL Improvement in provision of AMTSL across 20 SMGL supported sites 56 % 100 % February 2016 December

15 IMPROVING LABOR & DELIVERY SERVICES HELPING BABIES BREATHE (HBB) AND ESSENTIAL NEWBORN CARE A newborn resuscitation session at Lacor Hospital, Gulu district. ASSIST provided similar mentorships to lower health center service providers including enrolled midwives and nurses on newborn resuscitation Improvement in successful resuscitation of asphyxiated newborns at SMGL sites 63 % 92 % February 2016 December

16 IMPROVING LABOR & DELIVERY SERVICES Newborn resuscitation corner, Ogur HCIV, Lira district Newborn resuscitation corner at Lalogi HCIV, Omoro district HELPING BABIES BREATHE (HBB) AND ESSENTIAL NEWBORN CARE Timely resuscitation of asphyxiated newborns Health facility teams set up newborn resuscitation corners in the labor wards where they assembled equipment including: bag and mask ambubags and penguin suckers on trays accessible to service providers on birth of asphyxiated babies 12

17 IMPROVING LABOR & DELIVERY SERVICES HELPING BABIES BREATHE (HBB) AND ESSENTIAL NEWBORN CARE HBB skills labs set up to improve service provider skills in providing successful newborn resuscitation ASSIST supplied health facilities with Neonatalies (learning baby mannequins for newborn resuscitation) which maternity staff set up in a corner/ room in the maternity ward where they continuously practice their HBB skills during free time supported by more experienced service providers HBB skills lab at Anaka Hospital, Nwoya district HBB skills lab at Apac hospital, Apac district A midwife at Dokolo HCIV practicing new born resuscitation using a neonatalie stationed in the labor suite An ASSIST supported HBB skills training session at Lira Regional Referral Hospital 13

18 IMPROVING LABOR & DELIVERY SERVICES Essential newborn care tray at Pajule HCIV, Pader district HELPING BABIES BREATHE (HBB) AND ESSENTIAL NEWBORN CARE Ensuring the provision of a complete package of essential newborn care to every baby born ASSIST supported maternity ward teams compile a list of essential newborn care (ENBC) drugs, the drugs were pre-ordered from the facility stores, brought to the maternity store and assembled on a tray in an accessible spot in the labor suit Improvement in provision of Essential Newborn Care 57 % 99 % February 2015 December 2016 Drugs include: Gentamycin, tetracycline eye ointment and vaccines and used ones are replaced every after shift by the incoming service provider Reminder notes /protocols placed in strategic places on the delivery room walls notified service providers of the ENBC component 14

19 IMPROVING LABOR & DELIVERY SERVICES PRETERM DELIVERY MANAGEMENT THROUGH CORTICAL STEROID USE AND KANGAROO MOTHER CARE Following Association of Obstetricians and Gynecologists of Uganda (AOGU) guidelines, ASSIST supported health facilities to set up emergency trays for mothers in labor suits which included dexamethasone (corticol- steroids) for management of preterm labor. A job aid was also developed to guide service providers in dispensing these drugs. Improvement in management of preterm delivery and Kangaroo Mother Care 21 % 97 % February 2015 December

20 IMPROVING LABOR & DELIVERY SERVICES SPREADING LESSONS LEARNED AND BEST PRACTICES ON IMPROVING PRETERM LABOR AND NEWBORN CARE ASSIST-supported health facilities set up hygienic, warm and isolated kangaroo mother baby corners and rooms for the premature newborns 16

21 IMPROVING LABOR & DELIVERY SERVICES SPREADING LESSONS LEARNED AND BEST PRACTICES ON IMPROVING PRETERM LABOR AND NEWBORN CARE ASSIST-supported facilities improvise and set up neonatal intensive care units with incubators and technical mentorships for those with existing NICUs to improve the quality of care to premature newborns 17

22 IMPROVING LABOR & DELIVERY SERVICES SPREADING LESSONS LEARNED AND BEST PRACTICES ON IMPROVING PRETERM LABOR AND NEWBORN CARE At SMGL peer to peer learning sessions service providers were given hands on training in aspects of management of prematurity including KMC. These skills improved quality of KMC at supported facilities 18

23 IMPROVING LABOR & DELIVERY SERVICES EMERGENCY PREPAREDNESS FOR MOTHER AND NEWBORN During one of the SMGL peer to peer learning sessions, we learned about the importance of an emergency tray for newborns and mothers. When we returned, we requisitioned for an emergency tray which was locally made. This is stationed on a movable tray in the labor suite, when a mother is in labor we move it closer to the delivery bed and dispense drugs as necessary, each staff on duty replaces whichever drugs they use. With the emergency tray our mothers and newborns get the right care just in time. Sr. Ladwong Mary, in-charge maternity ward, Anaka Hospital, Nwoya district 19

24 IMPROVING LABOR & DELIVERY SERVICES EMERGENCY PREPAREDNESS FOR MOTHER AND NEWBORN A trolley donated by CURE International to Apac hospital was turned into an emergency trolley containing lifesaving drugs for both mothers and babies To ensure the continuity of emergency preparedness services, ASSIST shared an AOGU checklist of drugs needed on the emergency tray. We since assigned a focal person to check the drug stocks on a daily basis and ensure those used up are restocked, this way we don t waste time running around to find drugs from the maternity store which is far. Judith Acayo, enrolled midwife, Lacor Hospital, Gulu district 20

25 IMPROVING LABOR & DELIVERY SERVICES Dr. Stephen Oringtho, medical superintendent Anaka hospital (second left) explaining to MOH consultants Dr. Jolly Nankunda second right (Senior Pediatrician) and Dr. Lawrence Kazibwe right (Senior Gynecologist) about the facility MPDR process prior to a mentorship exercise REVITALIZING DISTRICT AND HEALTH FACILITY MATERNAL PERINATAL DEATH REVIEW (MPDR) AUDITS In 2000, the MOH in Uganda conceptualized and mandated districts and health facilities to conduct maternal, perinatal death review (MPDR) audits as a key component in identifying gaps within and outside the health facility where these deaths occur, this was mainly to inform process changes and community interventions to address these gaps and prevent future deaths. USAID ASSIST supported the establishment and functionality of MPDR committees at all 6 SMGL implementing districts and health facility levels (hospitals and HCIVS) 21

26 IMPROVING LABOR & DELIVERY SERVICES THE ANAKA HOSPITAL MPDR SUCCESS STORY Health workers were afraid of MPDR as they considered it as a vindictive process, they thought they would be arrested or blame placed on them. We began by selecting a committee, assigning a day for the meetings, sending reminders out for staff to attend and availing mothers and newborns files who were either near misses or deaths, ASSIST provided us with the initial audit books and mentorship on how to conduct meetings and we started our meetings at the hospital. As we continuously engaged and created awareness on the audit process they realized it was an improvement tool instead that helped them identify causal factors to deaths and put measures in place for improvement. Within two months of the meetings, we saw a reduction in perinatal deaths and a more positive attitude to MPDR. The district office then supported myself and other colleagues to go to lower health facilities to conduct these audits as soon as a death occurred. Overall the district has reported great improvement in service delivery as a result of the MPDR process. MPDR saves lives, I ve have seen it work and I call to my colleagues to embrace it Sr. Susan Akwanga, Young Child Clinic in charge and MDPR committee member Anaka Hospital, Nwoya district 22

27 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE The Minister of Health, Hon. Jane Ruth Aceng launches the National Maternal and Perinatal Deaths Surveillance and Response Guidelines (MPDSR) during the 4th National Quality Improvement Conference (29-31/8/2017) LAUNCH OF TOOLS AND SHARING BEST PRACTICES In August 2017, Uganda held its fourth National QI Conference to provide a platform for implementers, MOH, and others to share experiences and learning in improving quality in health care. During the conference, the Honorable Minister of Health Hon. Jane Ruth Aceng officially launched the new Maternal and Perinatal Death Surveillance and Response (MPDSR) Guidelines; the knowledge management portal; and the Health Services Standards. The MPDSR guidelines will help to strengthen the country s capacity to conduct effective maternal and perinatal death surveillance in an integrated manner across all levels of care. The knowledge management portal was developed over the existing MOH website and is open access. The MOH and partners will upload improvement tools, case studies, and other job aids that will help frontline health workers improve care. The Minister of Health, Hon. Jane Ruth Aceng issuing to key stakeholders the newly launched the National Maternal and Perinatal Deaths Surveillance and Response Guidelines (MPDSR) during the 4th National Quality Improvement Conference (29-31/8/2017) 23

28 COMMUNITY LEVEL INTERVENTIONS 24

29 IMPROVING UPTAKE OF EARLY ANC SERVICES A community map of Odokolit village, Ogur parish, Lira district ENSURING WOMEN WITH PREGNANCY SIGNS IN THE COMMUNITY ATTEND THEIR FIRST ANC VISIT DURING FIRST TRIMESTER Community mapping of women of reproductive age (WRA) Through the SMGL intervention, village health teams (VHTs) mapped women of reproductive age (15-49 years) within their catchment as well as community resources including markets, religious houses and Traditional Birth Attendants (TBAs) that would all aid in increasing first ANC first trimester visits as well as health facility deliveries, knowing where women lived and who they listened to eased identification of suspected pregnancies through home to home visits and community engagements. 25

30 IMPROVING UPTAKE OF EARLY ANC SERVICES ENSURING WOMEN WITH PREGNANCY SIGNS IN THE COMMUNITY ATTEND THEIR FIRST ANC VISIT DURING FIRST TRIMESTER Building capacity of VHTs to provide community MNCH services A VHT training session at Puranga HCIII, Pader district ASSIST conducted community level trainings that empowered VHTs with knowledge, skills and tools on identification, referral and support to women with suspected pregnancies; VHTs conducted home to home visits registering women with suspected pregnancies and referred them to health facilities for HCG testing and first trimester ANC. 26

31 IMPROVING UPTAKE OF EARLY ANC SERVICES A community facility QI coaching session at Acet HCII, Gulu district ENSURING WOMEN WITH PREGNANCY SIGNS IN THE COMMUNITY ATTEND THEIR FIRST ANC VISIT DURING FIRST TRIMESTER Establishing community facility QI teams ASSIST supported the formation and functionality of quality improvement teams that engaged health facility service providers and community health workers (VHTS) in implementing interventions to increase first ANC first trimester visits and facility deliveries. 27

32 IMPROVING UPTAKE OF EARLY ANC SERVICES ENSURING WOMEN WITH PREGNANCY SIGNS IN THE COMMUNITY ATTEND THEIR FIRST ANC VISIT DURING FIRST TRIMESTER Building capacity of VHTs to provide community MNCH services To allay myths and misconceptions surrounding early disclosure of pregnancy a barrier in first ANC uptake, ASSIST supported community level dialogue meetings and health education talks that engaged local leaders, pregnant women, their male partners and mothers in law, health facility service providers, VHTs, traditional birth attendants and district health office personnel who together shared facts and broke myths surrounding the timely service. A community dialogue meeting on early ANC and facility deliveries led by the district health education officer, Nwoya district 28

33 IMPROVING UPTAKE OF EARLY ANC SERVICES VHT training sessions led by Onek Michael (VHT supervisor) COMMUNITY IDENTIFICATION AND REFERRAL OF PREGNANT WOMEN WITH COMPLICATIONS FOR MANAGEMENT AT HEALTH FACILITIES Elupe Petua a midwife at Puranga HCIII, Pader district providing health education on danger signs to pregnant women and VHTs Using a job aid, ASSIST trained VHTs on common danger signs in pregnancy and provided timely health facility referrals to pregnant women they found with these signs during their home visits. The danger signs job card supplied to each VHT by ASSIST for identification of dangers signs during community visits 29

34 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE Pregnant women displaying their birth plans during an SMGL dialogue meeting in Gulu district EVERY PREGNANT WOMAN HAS A BIRTH PLAN AND SAVES FOR EMERGENCY BIRTH EXPENSES AND DELIVERY AT A HEALTH FACILITY During ASSIST-supported community dialogue meetings with pregnant women, their partners and local leaders, involved midwives and VHTs sharing with women the list of essential items for labor and delivery, the cost of emergency transport and linking these women to existing village loans and savings associations (VSLAs) for birth-related savings. On average pregnant women are saving $20-$30 for birth expenses and during each ANC visit, midwives check the progress of birth items acquisition with community follow up conducted by the VHTs. 30

35 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE EVERY PREGNANT WOMAN HAS A BIRTH PLAN AND SAVES FOR EMERGENCY BIRTH EXPENSES AND DELIVERY AT A HEALTH FACILITY Ayaa Judith, an enrolled midwife from Pader HCIII leading a session on savings for birth expenses at Acoro Parish, Pader district To enhance emergency transportation of pregnant mothers in labor, contacts of reliable Boda Boda riders (Motorbike Taxi) as well as district ambulance drivers were shared during SMGL supported community meetings. 31

36 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE An ASSIST-supported TBA meeting in Owiny village, Nambieso sub county, Apac district EVERY PREGNANT WOMAN HAS A BIRTH PLAN AND SAVES FOR EMERGENCY BIRTH EXPENSES AND DELIVERY AT A HEALTH FACILITY Transforming the Role of the Traditional Birth Attendant Across the 6 SMGL districts, ASSIST engaged TBAs together with local leaders in meetings where midwives illustrated the risks of home deliveries for both mother, newborn and to themselves. TBAs were mapped according to villages and each linked to a VHT in their catchment for follow up. In front of their leaders, they made commitments to stop delivering women and instead escort them to hospital for delivery. They now also refer suspected pregnant women to the health facility for early ANC. 32

37 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE A TRADITIONAL BIRTH ATTENDANT S (TBA) PERSPECTIVE I have been conducting deliveries in the community since 2000 while living in a military barracks in Kumi district. In 2003, I moved to Olanyoti village where I have conducted over 20 deliveries in the past 12 years. Women in this village call for my help during emergencies and also fear going to Daktari (health worker) because they cannot afford to pay for the fees and things they ask for. They come to me because I don t ask for money or when the woman is in a lot of pain. The women give me soap, farm products or a small amount of money for appreciation. While I have not lost any mother or baby in my 12 years serving this community, the district authorities and VHTs told me that it is dangerous to deliver a woman in the community because it is not clean, unsafe for me and I m not trained to help women with complication including over bleeding. I have now changed this and want to support the VHTs in my village to register and refer pregnant women to Daktari. I will visit homes of pregnant women and tell them to stop waiting until late, support them to prepare for delivery, educate women about antenatal care and child immunization. I will continue with my farming activities as a source of money. In my new role, I have so far identified 9 pregnant women who are all attending antenatal care at health facilities with two having delivered at a facility. I have also referred four mothers with danger signs for treatment and 3 of these went to the health facility for treatment. I will be very happy if no mother or baby dies in this community. I also will support the VHTs to reach out to other TBAs in this community and request them to change so that our mothers do not die. Jacinta Obol, 48 year old TBA from Olanyoti village, Aduku, Apac district 33

38 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE EARLY COMMUNITY LEVEL POSTNATAL FOLLOW UP VISITS TO CHECK FOR MOTHER AND NEWBORN WELLNESS USAID ASSIST conducted community based mentorship to VHTs on the provision for home based postnatal care for both mother and newborn including; proper cord care, warmth for the baby and danger signs in newborns. Senior nursing officer-midwifery Margaret Lajara, maternity in charge- Lalogi HCIV, Omoro district (former Gulu district) demonstrating newborn cord care to VHTs 34

39 INCREASING HEALTH FACILITY DELIVERIES & COMMUNITY POSTNATAL CARE (L-R) Lily Grace Ayamo, Adong Grace holding her daughter Brenda Alanyo, and Charles Onen the senior linkage facilitator GIVING PRETERM BRENDA ALANYO A CHANCE AT LIFE Charles Onen, a senior linkage facilitator supporting KochGoma HCIII was one of those trained under SMGL, During one of his recent routine home visits he met Adong Grace, a resident of Agonga A parish and mother of 2 who had previously had a preterm delivery to a baby girl weighing 1.9kgs, Following this home birth which was assisted by a relative, she had not sought any health care which risked both hers and newborn s life as Charles narrates: I found the mother and child in a bad state, guided by my job aid I assessed and inquired for any symptoms from Grace, she informed me that she was weak, experiencing severe abdominal pain, had a terrible cough and chest pain while her newborn was not feeding well and was really small. Worse still her husband had run off following the preterm birth leaving her to fend for the newborn with no resources. Grace and her premature baby exhibited all the danger signs in my manual and I immediately issued her a referral note to Kochgoma HCIII for specialized preterm care and post-partum complication management. At Kochgoma HCIII, Ayamo Lilly Grace a clinical officer and facility in charge received the mother and newborn conducted clinical assessments which included positive HIV & TB results. Grace was severely malnourished and had not fully recovered from the delivery while her baby was underweight and weak. I immediately admitted her on the post-natal ward where she was enrolled in PMTCT mother baby pair services, given nutrition support, post-partum care services and supported to provide Kangaroo mother care to her preterm baby. We monitored her for a number of days and once her and her baby were stable, I discharged her to return home and be followed up by Charles. In the community, Charles continued to support the mother and her newborn on proper management of the pre-term as trained, this included support on proper feeding techniques, skin to skin warmth provision and safe cleaning practices as Grace shares: Charles taught me and my caregiver, my brother, how to take care of the baby using KMC, initially he shied away from it but through continuous counselling and demonstration by Charles a fellow man, he embraced it. My baby was naked except for a diaper and a piece of cloth covering her back, we placed her in an upright position against mine or my brother s chest and she was warm. I noticed with this practice she grew better and faster, begun feeding well and I got more confident that her life was no longer in danger; I also recovered quickly and I remain so grateful to Charles and the health workers for saving us. 35

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41 SMGL VOICES From the evidence, it s absolutely clear that SMGL saves lives and contributes significantly to strengthening the health system in six districts in Northern Uganda. Health workers supported by the SMGL project feel competent and confident in not only providing care for mothers and their newborn babies; but also in sharing their learnings with their peers. The next step is to take the SMGL learning to a larger scale so that it will benefit thousands more patients. Dr. Claudia Morrissey Conlon, US Government Lead SMGL (second right) being taken through the emergency preparedness processes during a visit to Anaka Hospital, Nwoya district; Dr. Mirwais Rahimzai (second left ) East African Director ASSIST-then Chief of Party ASSIST Uganda looks on. Dr. Mirwais Rahimzai, Regional Director East Africa, USAID ASSIST Project 37

42 The SMGL phase II chapter in Northern Uganda used a diverse range of quality improvement methods to create and sustain a platform for voices of leaders, health workers, community members, mothers, fathers, and babies to come together to solve problems leading to maternal and perinatal deaths. In the North, the SMGL team showed that you can reduce maternal and perinatal mortality significantly with minimum resources. The critical components responsible for the good results attained were the structured role played by the district and facility leaders, strengthening the health system by enabling local human resource to use best practices learnt from the phase 1 work, and systematic registration and engagement of pregnant women at the community level. This work will inform the WHO MNCH Quality of Care initiative to be launched this year in Uganda. Dr. Esther Karamagi, Chief of Party Uganda, USAID ASSIST Project The SMGL Phase II Project in Northern Uganda has clearly shown that once you use a health systems strengthening approach with a focus on quality improvement, you can reduce maternal and perinatal morbidity and mortality even with the minimal existing resources. In the community interventions, SMGL focused on early identification and referral of pregnant women. Through this community model, VHTs in targeted poor performing villages were empowered to identify, register and refer pregnant women for care. This model was successful and it provides a platform for many other health interventions targeting pregnant women and newborns such as emtct, IPT among others. These best practices need to be spread further for improving quality of care for mothers and newborns. Dr. Dinah Amongin, Senior Quality Improvement Advisor MNCH/FP, USAID ASSIST Project It s been a long time since we had a post-partum hemorrhage case as SMGL continuously mentored the team on active management of the third stage of labor, we were exposed to specialists like obstetricians who upped our skills. Today our mothers are receiving an improved quality of care. Sr. Tino Beatrice, In-charge maternity, Aduku HCIV, Apac district Most critical to maternal and newborn mortality reduction, the SMGL program revived the midwives knowledge on partograph use which they d left at school, similarly newborn resuscitation has improved and birth asphyxia is under control at all our health facilities. Sr. Margaret Okot, Assistant DHO Omoro 38

43 Implementation of phase II of Saving Mothers Giving Life in Northern Uganda focused on strengthening the district health system in each of the six SMGL districts. The district and facility leaders were mobilized to allocate resources that supported renovation of operating theatres at HCIVs (Ogur HCIV & Lalogi HCIV), supported training of local critical human resource to provide emergency obstetric care (anesthetic assistant trained in Pader district-pajule HCIV), allocation of resources to support emergency referral of mothers, coordinated the ambulance system through developing local ambulance guidelines in the districts (Dokolo district),district MPDR committees were formed to follow up facility level MPDR recommendations and identification of district-based mentors who owned the coaching in the respective districts supported by regional mentors. USAID-ASSIST through applying a quality improvement approach facilitated rapid improvement in staff skills. It was this team approach that contributed to a reduction in institutional maternal mortality ratio of 12.9% and institutional perinatal mortality rate reduction of 37.5% between February 2015 and December Dr. Paul Isabirye, Quality Improvement Advisor MNCH, USAID ASSIST Project The SMGL project was one with a passion for mothers and newborns of northern Uganda. Dr. Okello Ambrose, In-charge, Dokolo HCIV From August 2015 December 2016, the SMGL community component focused on addressing the first two delays which occur in the home or community. My role involved generation and rolling out effective community strategies that improve access to maternal and newborn health services in the SMGL districts. With a team of dedicated MOH staff, district staff, ASSIST staff, health workers, Village Health Teams and other community owned resource persons we achieved a two-fold increase in first trimester ANC visits and institutional deliveries. Bridging the gap between communities and formal health systems as well as strengthening networks at all levels were our winning points! As we spread this work to other districts in the region, we hope to accelerate further reduction in the death of mothers and newborns. Mabel Namwabira Kamoga, Senior Quality Improvement Advisor, USAID ASSIST Project This is my third baby delivered at this health facility, the services right from antenatal care to delivery here have really improved, the midwives are kind, they take their time to find out your problem and address it, the improved services are encouraging more mothers to deliver at this health facility. Adong Vicky, Beneficiary Mother, Purongo HCIII, Nwoya district 39

44 Through SMGL we operationalized our operating theater for timely caesarean sections, we used to refer pregnant women to Gulu regional referral hospital (120 kms away) being able to offer CeMONC has definitely improved our capacity to reduce maternal and newborn mortality. Dr. Amoko Robert, In-charge Lalogi HCIV, Omoro district Walking this 22 month journey with USAID ASSIST committed staff, strong political-technical district leadership and an energized community health workforce to realize infrastructure improvements and upgrading of facilities to provide emergency obstetric and neonatal care, through the SMGL project has not only been fulfilling but inspirational, I m proud of many things in life; and Saving Mothers and Giving Life counts. Dr. Judith Aloyo, Programme Coordinator, USAID ASSIST Project Efforts together, we can eliminate preventable Neonatal deaths! Reducing preventable neonatal deaths became a reality through enhancing the knowledge and skills of the health workers on the MOH recommended low cost evidencebased interventions like Helping Babies Breathe, Kangaroo Method of Care, prevention and management of Neonatal infections. A quality improvement approach to achieve and maintain the recommended standards of care was key. Dr. Hellen Kyokutamba, QI technical officer, USAID ASSIST Project The Quality Improvement Approach introduced under SMGL program was important in improving the quality of care for mothers and newborns, engaging all cadres improved skills across the board and motivated staff, as an SMGL coach it was amazing to see management of PPH and ENBC being achieved at HCIIIs. Dr. James Okello, Medical Officer, Lira RRH Through SMGL, our knowledge on utilizing partographs to monitor progress of labor was revised, we now identify obstructed labor cases in time and notify the medical officer for timely lifesaving C-sections in our recently functionalized operating theater. Sr. Sophia Akello, Enrolled Midwife, Ogur HCIV With ASSIST technical mentorship and donated equipment from Project CURE, we set up a neonatal intensive care unit, we no longer refer premature newborns and sick babies. Innocent Okello, Enrolled Midwife, Apac Hospital, Apac district 40

45 Through the SMGL program, engaging the Facility and district MPDR committees on monthly and quarterly basis helped the teams understand Facility and community gaps that could have contributed to mothers and their babies die. In reviewing these gaps, avoidable factors were identified and addressed, setting and following up recommendations to ensure that they are worked on and also reporting to district Health office and Ministry of health was done. This constant engagement to review all death improved the Maternal and new born outcomes across all the SMGL districts. The interventions to improve MPDR processes started with Nwoya district and we used the lessons learnt to scale up to the rest of the SMGL districts. Dr. Damasco Wamboya, Technical Officer MNCH, USAID ASSIST Project From capacity building of our health workers to using the resources available optimally, the SMGL program generated a lot of knowledge and evidence to us as the district leadership that it is possible to save mothers and newborns with minimal resources. During the project time, we witnessed a big reduction in maternal and newborn deaths in the district s very high volume health facilities and the number of referrals from lower units equally reduced as a result of improved skills, together with ASSIST we also worked in ensuring that Lalogi HCIV starts offering lifesaving C-sections. Richard Amoko, DHO Omoro district/former DHO Gulu district The project was highly successful in reduction of perinatal deaths by 37% and maternal mortality by 12.9% after a short time. Scale up to other districts will significantly improve our health indices as a country. Dr. Placid Mihayo, Senior Consultant OB/Gyn, Reproductive Health Division, MOH The SMGL community arm created demand for facility deliveries, mothers come to the facility in time and we are no longer losing newborns. Obonye Robert, Enrolled Midwife, Kwera HCIII, Dokolo district A healthy community is able to learn, demonstrate learning and are more likely to escape poverty. Saving mothers giving life project was an exciting possibility to improve the lives of mothers and children in Northern Uganda. Ronald Tibita, Quality Improvement Officer, USAID ASSIST Project SMGL refined the relationships and roles of the VHTs and health care workers, this restored confidence in pregnant mothers in VHTs and altogether bridged the gap between the community and health facility. Okwera Peter Julius, VHT, Purongo HCIII, Nwoya district 41

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