Conference Outcomes and Issues For consideration by the Ministry of Community Development, Maternal and Child Health, The Ministry of Health, Cooperating and Implementing Partners Recorded by Mercy M. Mbewe, Dr. David Percy, Miss Vanessa Halipi and Louise Smith Maternal and Newborn Health Conference, Intercontinental Hotel, 1st November 2012
Key outcomes of the conference: setting priorities for action After a day of presentations and discussion regarding interventions in maternal and newborn health from key stakeholders working in Zambia (see the attached programme), the final session of the conference asked the conference delegates through round table discussions to consider key priorities or issues for ongoing discussion, between the Ministries, Cooperating and Implementing partners, to rapidly accelerate the reduction of maternal and newborn mortality in Zambia. The following is a summary of the outcomes of the discussions and the issues and priorities presented by each table leader on behalf of his/her table during the plenary discussion. Issues for further consideration are in bold and numbered in each relevant section. Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA) The current health strategy in Zambia is to have a health system where all mothers and newborns should be looked after by a Skilled Birth Attendant. However, it will take time to train and deploy Skilled Birth Attendants. Conference delegates discussed whether, in the short term, Traditional Birth Attendants should be trained in some of the relevant competences to make them safe practitioners. Traditional Birth Attendants It is estimated that Traditional Birth Attendants are engaged in the delivery of 23% [31% in rural areas and 5% in urban areas] of babies in Zambia; meaning that some babies are being delivered at home by TBAs, who may not be able to recognize or manage potential complications. A further 25% of babies are delivered by a family member and 5% of women are alone during delivery. Delegates discussed the fact that the involvement of TBAs in deliveries will not change in the short term. It was recommended by a majority of participants that, in the short term, TBAs should be trained to recognize danger signs in pre, intra and post-partum care, to help them to refer mothers in a timely fashion to the next levels of care. Further it was proposed by some delegates that in the short term, when an SBA is unavailable, TBAs should be trained to have the competences to deal with some basic and emergency care of both mother and baby. Some disagreed with this recommendation stating that TBAs should not be trained but more effort should be made to increase skilled health workers. Below are issues for further consideration as presented by table leaders related to TBAs; 1) Provide TBAs with training and mentoring to equip them with the competences to provide safe and comprehensive care from family planning through to postnatal care, as well as basic lifesaving skills. For example, being able to administer Misoprostol to manage postpartum hemorrhage and equipping them with the competences to help babies breathe. 2) Develop a transition strategy for the redeployment of TBAs once SBAs are available. 1
Skilled Birth Attendants Delegates noted that no country has turned around its MMR and NMR without skilled birth attendants. Below are issues for further consideration as presented by table leaders related to SBAs; 3) They endorsed the current plans to increase the capacity of training institutions to increase the output of nurse/midwives. It was suggested that the ministries and international donors continue to work together to plan and resource a rapid increase in training capacity. 4) They encouraged the ministries to review the policy framework for staff establishment to ensure the employment, deployment, retention, supervision and continued training of SBAs in all health settings including 24 hour coverage of health facilities. 5) Encourage the ministries to review the curriculum to develop health professionals with the required competences in maternal and newborn health, including lifesaving skills. Some delegates suggested that graduates should be both a nurse and a midwife through shortened courses. Increased involvement of Safe Motherhood Action Groups Delegates noted that the government of Zambia responded to the challenge of providing a continuum of care by supporting pilot programmes to establish Safe Motherhood Action Groups (SMAGs) at community level. A framework has been established for the national scale-up of SMAGs, through a standardized training package. During the conference evidence was presented on the effectiveness of SMAGs and it is anticipated that when further evidence is available this will guide future SMAG interventions. Below are the issues to be considered further as presented by each table leader in relation to SMAGs 6) Increase the number of SMAGs to cover all districts. 7) Expand the role of SMAGS to include antenatal, intra-natal and post-natal care and family planning. 8) Strengthen SMAGs competences so that they can further develop their community interventions. Volunteers and Community Health Assistants It was noted by delegates that Community Volunteers and Community Health Assistants are offering services that address maternal and newborn care and they also noted that accountability of volunteers to the health system is weak. 2
Below are the issues to be considered further as presented by table leaders related to Volunteers and Community Health Assistants. 9) Developing a volunteer management and coordinating system needs to be considered, to include equitable remuneration, supervision and accountability mechanisms. 10) Reconsider the term Volunteer as it does not carry authority, and define accountability or remuneration. 11) That Community Health Workers/Assistants should complement the role of nurse/ midwives and there should be a degree of task sharing or task shifting. 12) They supported the training of Community Health Assistants and that they take on key roles [especially with the introduction of an expanded curriculum] in reproductive, maternal and newborn health. Community involvement The potential positive impact of community leaders on best practice in maternal and newborn health was highlighted in discussion. Below is the issue to be considered further as presented by table leaders related to community leaders 13) Engage with Chiefs, Traditional Leaders, Head Men and Church Leaders in all districts to encourage them to be advocates for safe maternal and newborn health practices. NGOs and Coordinated Leadership The conference survey and other evidence confirmed that there are a large number of organizations (INGOs, NGOs, FBOs etc.) working in maternal and newborn health in Zambia. There is currently no clear strategy, coordination or rationalization of the many organizations involved. The survey showed that best practices informing activities in MNH are numerous and diverse. Table leaders issues for the Ministries to consider further are: 14) Ministries taking the lead in the coordination and geographical distribution of organizations working in MNH through an MOU and rules of engagement which include the use of human and financial resources. 15) Developing best practice guidelines which organizations should use to guide activities in MNH. 3
Strengthening access to care It was noted that Zambians have difficulties in access to care in rural areas due to the distances to health facilities and poor road infrastructure, particularly in the wet season. Table leaders presented the following issue for further consideration: 16) The ministries should consider providing patient transport to each health facility and make resources available to maintain them. These could be community managed (including bicycles, motorbikes or boats) and delegates further recommended that the service should be free to expectant mothers. Emergency care It was discussed that health posts were not fully developed in all districts and that health centers were not always fully staffed and do not always have the equipment or infrastructure to provide emergency obstetric and neonatal care [EmONC] nationwide. Table leaders presented the following priorities for further consideration: 17) All mothers should be delivered where there are accessible EmONC services including basic equipment, infrastructure and where there is access to emergency surgery by a trained health worker. 18) Deliveries should be done in a health facility. Access to EmONC services should be available at facility including referral system in place if it is not an EmONC site. Finalization of the MNCP Roadmap It was discussed that the MNCP Roadmap had not been fully adopted into policy and that its implementation requires a consistent approach to monitoring and evaluation. The issues that table leaders presented for further consideration are: 19) Zambia s health management information system needs to be enhanced and implemented to guide the allocation of resources, including the use of standardized maternal and newborn indicators. 20) The Ministries should consider taking the lead in ensuring that organizations involved in maternal and newborn health use a monitoring and evaluation framework that is aligned to that of the Ministries. 4
Family planning It was highlighted in discussions that birth spacing reduces MMR and NMR and that family planning coverage across Zambia is only at 33%. The following are issues for further consideration as presented by table leaders: 21) The ministries should consider rapidly accelerating family planning coverage using a range of providers working to government strategy and standards. 22) The availability of injectable contraceptives should be increased, potentially using community health assistants and workers as a method of administration. Delegates also highlighted that the quality of this service could be ensured through the Health Professions Council of Zambia issuing good practice guidelines. 5