Maternal and Newborn Heath Assessment - Mozambique Key Findings and Recommendations 1a Mary Ellen Stanton, USAID/W Nahed Matta, USAID/W Koki Agarwal, MCHIP December 10, 2009

Objective of the visit Brief background on key MNH indicators USAID/Moz and the Global Health Initiative (GHI) MCHIP objectives Observations – Opportunities and Challenges Recommendations We will cover

Objective of the visit Review and learn about MCHIP/Mozambique program Learn about the Maternal and Newborn Health Situation and Programs Make recommendations to USAID/Moz for MCHIP future work

Maternal and Newborn Health 4 Mozambique Source: KAgarwel-Mozambigue 09

Maternal Mortality 4,000 Maternal deaths Over 90% preventable About 40,000 newborns die each year from mostly preventable causes Source: KAgarwel-Mozambique 09

Trends in MMR and MDG 5

Causes of Maternal Mortality

8 DHS 2003 and MICS 2008 Newborn Interventions needed to continue progress

Causes of Neonatal Mortality in Mozambique Child mortality study 2009

Timing of Neonatal Deaths Maternal and Neonatal Facility Assessment 2009

Health facilities in Mozambique Health FacilityNumbers Central Hospitals3 General Hospital6 Provincial Hospitals7 Rural Hospitals26 District Hospitals7 Urban Health Centers98 Rural Health Centers820 Health Posts271 Total1,238 Source: MoH, National Integrated Plan to Achieve MDGs 4 and 5

Health infrastructure shortfall ParticularsPercentage Population living within 30 min of a health facility 36% Health facilities that have electricity50% Health facilities that have running water 48% Health facilities that have means of communication for referral 43% Health facilities providing EmOC based on WHO recommendations 38%

Coverage of high-impact interventions ParticularsPercentage AMTSLNot reported Not practiced PartogramNot filled C-section rate in facilities providing CEmOC 2% ENCNot reported Exclusive breastfeeding up to 6 months 30%

USAID/Mozambique program and GHI Strategic approach: ACCELERATING THE REDUCTION OF MATERNAL, NEWBORN, AND CHILD MORTALITY THROUGH THE THREE DIMENSIONAL APPROACH to assist the MOH is achieving MDG goals

DEVELOP and Strengthen Health Systems DELIVERY: Phased Expansion of Interventions Social and Behavioral DETERMINANTS Home and community Sub-health center Health center District hospital Immediate: Rapid scale-up of high impact interventions through existing system capacity Medium-term: Additional interventions & systems strengthening Long-term: Full package with expanded systems Three-Dimensional (3-D) Approach Deliver High-Impact Interventions, Develop & Strengthen Systems, Address Social & Behavioral Determinants

All home/community interventions provided by community health workers, outreach workers, and skilled birth attendants All sub-health center interventions plus the following: 7 signal BEmONC functions: Intravenous antibiotics, oxytocics, MgSO4 Manual removal of placenta Assisted vaginal delivery Removal of retained products Basic newborn resuscitation Referral to CEmONC facility Home/CommunityDistrict HospitalHealth Center Tetanus Toxoid, Iron Folate Intermittent preventive tx (IPT) for malaria Deworming Misoprostol, clean delivery Newborn drying & wrapping, breastfeeding Clean cord care, hand-washing Newborn stimulation for resuscitation Kangaroo mother care as part of facility-to- community chain for low birth weight newborns Antibiotics for newborn (poor access settings) Postnatal visit within 2-3 days Birth spacing, family planning PMTCT With Skilled Birth Attendants (if available) All above plus the following: AMTSL, partograph, MgSo4 loading dose, basic newborn resuscitation (bag and mask) Skilled birth attendants (incl. community midwives) 2 to 4 Basic Emergency Obstetric & Newborn Care Facilities per 500,000 population, Skilled Birth Attendants, Doctors Sub-Health Center Long term: full package with expanded systems Dimension 1: Delivery Phased Expansion of Maternal and Newborn Health Revised, October 17, 2009 Medium term: additional Interventions & systems strengthening Immediate: rapid scale up of high- impact interventions through existing system capacity 7 signal functions (see below) 4 BEmONC per 500,000 population 3 additional signal functions: C-section Blood transfusion Advanced newborn resuscitation 1 CEmONC per 500,000 population Community Health Workers & Outreach Workers Filling in gaps for Comprehensive Emergency Obstetric Care if feasible and if partial CEmONC already in place (see above)

GHI Guiding Principles Women-Centered Approach Strategic Integration and Coordination Country Ownership Sustainability and Health System Strengthening Improved Metrics, Monitoring, Evaluation and Research

MCHIP Objectives 10/1/08-12/1/2010 Strengthen BEONC and CEONC including Family Planning in an integrated manner in selected healthcare facilities in all Provinces. Strengthen BEONC and CEONC in an integrated manner in pre- service institutions for MCH mid-level nurses. Assist in the development and implementation preventive FP/RH services, including cervical cancer (CxCa) screening and treatment in selected healthcare facilities in selected provinces and plan for roll up

MCHIP Objective for the 5-Year Associate Award Act as the technical US lead partner in MNH working at the national level to provide technical assistance to USG partners to support MOH achieve MDG goals 4 &5 Support the expansion and national level coverage of at least 4 high-impact MNH interventions with MOH and US partners Assist MOH in scaling-up of the Model Maternities in collaboration with USG partners at all provinces as appropriate Support the expansion of Cervical Cancer (CxCa) activities using the single visit approach (SVA) and assist in the roll-out plan (PEPFAR) Develop partnerships to strengthen and promote nation-wide integrated, quality, community and facility-based delivery of high impact MNH interventions through an integrated (MNH/FP/Malaria/PMTCT, STI and CxCa) approach with MOH and all USG partners.

MCHIP Approach Play a catalytic and supportive role related MNH activities at a national level Provide capacity building through TA to partners and MOH Coordinate closely with USG and other partners Assist MOH in strategic integration of services at all levels Lead national efforts to focus on high impact interventions Build on a health system strengthening and improvement models Ensure a humanized, women centered and equitable delivery of services

Observations- Opportunities 1 MCHIP has a strong team providing technical leadership in MNH to support MOHP national goals and initiatives. USG is supporting several MOH initiative targeting maternal and newborn mortality which is aliened well with USG and GHI approaches and guiding principles such; scale –up high impact intervention, women centered approaches, strong emphases on integration within health and beyond, and country ownership of programs. USG programs designed with strong integration objectives; diverse expertise and approach, building on MCH/FP and PEFPFAR platforms

Observations- Opportunities 2 The MOH has strong commitment (apparent) for achieving MGD goals 4 & 5; several good policy documents, strategies, tools and training materials were developed and approved. The Central –level MOH is in full control and thus all provinces will use same materials. Training Institutes in various provinces use the same curricula. Usually easier for partners collaboration and standardization of practice. Initiatives such as the model maternities and humanization approach, with high political commitment, can contribute to improved services, if efforts and emphasis are sustained and monitored. The MOH is addressing quality of care across the health sector as a top priority and requested scale-up of MCHIP standard based management- response (SBM-R) tool to achieve and monitor quality of care.

Observations - Opportunities 3 Task –shifting opportunities initiated by MOH allowing medical technicians to perform surgical procedures and C-Sections and allowing nurse to insert IUD are great -more is needed More women are seeking skilled care; 58% of pregnant women deliver with skilled birth attendants (SBA) at a health facility (urban 81% and rural 49%). In the MOH facilities are conducting on average deliveries per day (urban H center and central hospitals respectively); great opportunity and huge challenge. In general, the visited facilities were clean, infection prevention observed (gloves, syringe dispenser box, staff wearing uniform and gowns), key medication such as Oxytocin, Magnesium Sulfate, Folic acid tablets were available in all visited facilities, though stock-out was reported. Women are observed for 24 hours after delivery (better than other countries where women are discharged after 2 hours).

Challanges The human resource shortage is serious, in all the facilities visited, the number of nurses were less than half of the desired coverage (staff reporting); not considering WHO recommendations. In all visited facilities in Maputo and Nampula, women and newborns were left alone immediately after delivery as providers had to attend to other emergencies or this is a cultural practice? Serious complications can occur during this period In the Model Maternities the visiting team observed that staff did not follow guidance on performing high- impact interventions such as use of partogram and use of oxytocin for PPH prevention, though these are key components of training. Reasons mentioned include: new program, changes not instigated, doctors not allowing partogram use by nurses, available oxytocin will not cover all deliveries or staff too busy to assist with AMTSL. All this need programmatic and policy decisions. Harmful traditional practices at the community most likely contributing to maternal and newborn death

Recommendations 1 The USG and UN partner’s support to address HR crises is critical and contribute to the national plan for HR Development. The plan to fund enrollment of students in the training institutes will have a long term positive impact. However it is critical to address the absorptive capacity of those institutes to ensure quality of graduates. Nampula Training Institute reported that when the MOH pushed for higher numbers in 2007, the quality of training was affected negatively. Related to student recruitment, it is recommended to design a district/province- based selection of candidates, consideration of geographic needs, with commitment to work in those districts. Community engagement in this process can ensure compliance. Consider supporting the Health Science Institute of Higher Education (ISCISA) which graduates clinical technicians.

Recommendations 2 In the short and long term, it is recommended that USAID support the strengthening of the quality of pre-service training through revisions/updates of MCH and the integrated curricula and improving teaching skills of tutors. MCHIP is assisting in this task and more is needed; experience exists within Jhpiego in many countries. Based on recent “situation analysis of nursing career in Mozambique) funded by CDC, it is recommended that USG engage in policy dialogue with MOH and partners to support recommendation to merge the two cadres of basic and mid -level training for general and MCH nurses to one level (mid) for 24 months; thought this will have workforce financial implications, but will streamline training and can contribute to better quality and higher recruitment rates. It is critical to address key other factors impacting on service delivery such as provision of essential drugs and key supplies and equipment. UNFPA and other USG partners are addressing this area; collaboration is needed to address stock outs..

Recommendations 3 USAID/Moz and MCHIP to collaborate with UNFPA, MOH and AMDD to analyze UNFPA-funded MNH facility level assessment to inform policy and program implementation. Develop provincial level briefs to highlight challenges, gaps and barriers Community activities related to MNH and the integrated program is critical. The team learned about several harmful traditional practices for abortion or induction of labor which could be contributing to the high rupture uterus rate and mortality. Recommend some facts finding and address in community educational messages. MCHIP to support the establishment of maternal mortality committees at national and provide support at the provincial level with USG partners. Develop action plans with key MOH officials and partners at each level to analyze causes and contributing factors to maternal mortality and monitor progress at all levels.

Recommendations 4 MCHIP, MOH and USG partners to select few key indicators from the SBM-R tool and monitor on regular basis from all model maternity or upgraded facilities and eventually nation wide- Target for 80% coverage in current and future model maternity over 5 years period. MCHIP and partners to develop a postnatal care model with a special emphasis on PMTCT follow-up with a strong PPFP component.

Recommendations 5 MCHIP to develop on-the job training package for MNH and integrated package and supportive supervision tools to be used by all partners addressing this area. MCHIP to conduct TOT courses to train more provincial teams to upgrade training capacity on BEONC and CEONC and the integrated package. MCHIP to promote regular analysis of service statistics of current 34 + model maternities for coverage of outcomes, case- fatality rates, and maternal and newborn facility deaths MCHIP to build capacity of Godfathers/Mothers to act as lead trainers and clinical supervisors in each province. Plan for periodic events (workshops) for technical updates and look for opportunities for supporting attendance

Thank You - Obrigado 30 Source: NMatta- Mozambique 09