1. 1 Experience of Task Shifting in Mozambique: A Response to Limited Human Health Resources Nafissa Bique Osman Department of Obstetric and Gynecology, Eduardo Mondlane University, Central Hospital, Maputo. XIX FIGO World Congress, 4-9 October 2009, Cape Town Safe Motherhood and Newborn Health

2. 2 Mozambique Population: 20 million Growth rate: 2.4% Pop in rural area: 70% P density: 20 inh/km² Among the 10 poorest countries in the world Poverty line: 69.4% below Life expectancy at birth: 45 years Source: 2007census, DHS 2003

3. 3 Mozambique Children< 5yr: 17% pop 10-24 yrs: 33% pop 15-49 yrs: 49% pop Women 15-49yrs: 25% pop = 5 million >50 yrs: 9.4% pop Birth rate: 35.2/ 1000 Death rate: 21.3/ 1000 Source: 2007census, DHS 2003

4. 4 Maternal and neonatal Health Worldwide, more than one woman dies every minute, 585.000 women die every year. Ninety nine percent of these deaths occur in developing countries, demonstrating that they could be avoided if resources and services were available Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in Mozambique

5. 5 Maternal Health ANC ANC - 84% pregnant women -1 visit Institutional deliveries: Institutional deliveries: 46% (urban- 71%, rural- 29%) Maternal mortality : 1997- 975/ 100,000 2003- 408/ 100,000 1/3 of Maternal death are < 19 years old Main causes of MM: 75% direct causes hemorrhage, sepsis, eclampsia, uterine rupture 75% direct causes: hemorrhage, sepsis, eclampsia, uterine rupture 25% HIV, malaria 25% indirect causes: HIV, malaria Source: DHS 1997 & 2003, Revision of MM study, MOH 1998

6. 6 Neonatal and Infant mortality Neonatal mortality: 1997: 59/1000 live births 2003: 48/ 1000 live births Main causes: Main causes: preterm delivery, LBW, infections, asphyxia Infant mortality: 1997: 147/ 1000 live births 2003:125/ 1000 live births Source: DHS 1997 & 2003

7. 7 Challenges in Safe Motherhood Adolescent pregnancy: 40% Adolescent pregnancy: 40% Unwanted pregnancies, early marriage Unwanted pregnancies, early marriage Unsafe abortion: 11% of MM Unsafe abortion: 11% of MM Contraceptive rate: 1997: 6% Contraceptive rate: 1997: 6% 2003: 17% 2003: 17% Modern contraceptive rate: 2003: 12% Women knowledge of contraceptives: 90% Women knowledge of contraceptives: 90% Syphilis in pregnancy: 7% Syphilis in pregnancy: 7% HIV prevalence: 16% HIV prevalence: 16% Source: DHS 1997 & 2003, Epidemiological Surveillance, 2007

8. 8 National Health System Primary level: Primary level: Health post (514) Health post (514) Rural and urban health centers (775) Rural and urban health centers (775) Secondary level : Secondary level : Rural and district hospital (31), general hospitals (4). Rural and district hospital (31), general hospitals (4). First referral level First referral level Tertiary level: Tertiary level: Provincial hospital (7) Provincial hospital (7) Quaternary level: Central hospital (3) Central hospital (3) 1 health unit/ 15,000 inhabitants 1 health unit/ 15,000 inhabitants 1 hospital/ 434,368 inhabitants 1 hospital/ 434,368 inhabitants Source: MoH, NDH, 2006

9. 9 Strategies to decrease MM 1975 Independence. Universal access to primary health care was a goal but, human resources crisis, 80 Moz doctors/14 million; Independence. Universal access to primary health care was a goal but, human resources crisis, 80 Moz doctors/14 million; Intensive training of nurses, midwives, medical officers to replace the doctor; Intensive training of nurses, midwives, medical officers to replace the doctor; Elementary (1yr training) and basic (20 month training) mother/child nurse- midwives to work at primary care level and also at 2 nd and 3 rd level Elementary (1yr training) and basic (20 month training) mother/child nurse- midwives to work at primary care level and also at 2 nd and 3 rd level

10. 10 Task Shifting and Delegation of responsibilities 1980 Civil war, increased casualties, unmet need for emergency life saving skills in war casualties and obstetrics; No surgeons, obstetricians and orthopedics in rural, district hospitals; Long distance and deficient transport network1984 técnico de cirurgia (TC); Training of assistant medical officers with skills in surgery técnico de cirurgia (TC); 3 year training to perform all emergency operations in obstetric, trauma and surgery. Training of técnico of anesthesiology Training of técnico of anesthesiology

11. 11 Evaluation of TC skills in Obstetrics Controversy of delegation of major operations to a non medical doctor; Controversy of delegation of major operations to a non medical doctor; Evaluation after 4 yr of the 1 st group Evaluation after 4 yr of the 1 st group1992 Evaluation of 958 cesarean deliveries performed by TC & 1113 by obstetricians at Central Hospital in Maputo– found no clinically significant difference in postoperative outcomes. Superficial wound separation more frequent in CS by TC Source: C Pereira, A Bugalho, S Bergstrom, F Vaz, M Cotiro. A comparative study of cesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J obstet Gynaecol 1996; 103:508-12

12. 12 Task Shifting and Delegation of responsibilities 1990 Medium level mother/child nurse-midwife 30 months training with skills for EmOC (basic) Medium level mother/child nurse-midwife 30 months training with skills for EmOC (basic)2004 High level nurse-midwife with university degree: 3 year training- bachelor High level nurse-midwife with university degree: 3 year training- bachelor 4 year training- licentiate. With training in EmOC (comprehensive) including cesarean section 4 year training- licentiate. With training in EmOC (comprehensive) including cesarean section 2008 29 were graduated. Now, 1 class of 37 student, in 7 th semester and 1 class of 35 student in 3 rd semester 29 were graduated. Now, 1 class of 37 student, in 7 th semester and 1 class of 35 student in 3 rd semester Source: Instituto Superior de Ciências de Saúde

13. 13 Task Shifting and Delegation of responsibilities 2004 Revue of TC curricula Revue of TC curricula 3 yrs training- bacharel 3 yrs training- bacharel 4 yrs training- licentiate 4 yrs training- licentiate So far 61 TC graduated as bachelor and licentiate degree. So far 61 TC graduated as bachelor and licentiate degree. Retired and died: 11 Retired and died: 11 Now, 1 class with 18 students in the 4 th year training and 1 class with 16 student in the 1 st year. Now, 1 class with 18 students in the 4 th year training and 1 class with 16 student in the 1 st year. Source: Instituto Superior de Saúde

14. 14 Evaluation of TC skills in Obstetrics 2002 Analyses of 12,178 obstetric operations in all 34 public hospitals; Analyses of 12,178 obstetric operations in all 34 public hospitals; TCs performed 92% of major obstetric surgery at district/rural hospital; TCs performed 92% of major obstetric surgery at district/rural hospital; TCs compared with physicians, stay longer in rural areas. After 7 years 90% of TCs were still in district hospitals while no physician remained TCs compared with physicians, stay longer in rural areas. After 7 years 90% of TCs were still in district hospitals while no physician remained Source: C Pereira, A Cumbi, R Malalane, F Vaz, C McCord, A Bacci, S Bergstrom. Meeting the need for emergency obstetric care in Mozambique: work performed and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; DOI:10.1111/j.1471-0528.2007.01489.

15. 15 Human Resources Elementary level health worker- 63% Elementary level health worker- 63% Basic level health worker- 20% Basic level health worker- 20% Medium level health worker- 13% Medium level health worker- 13% High level health worker- 4% High level health worker- 4% 1 doctor & 7 nurses/ 33,000 inhabitants 1 doctor & 7 nurses/ 33,000 inhabitants Obstetricians- 42 in provincial & central hospital, being 12 in Maputo city Obstetricians- 42 in provincial & central hospital, being 12 in Maputo city Source: MoH DNRH, 2006

16. 16 Challenges Conflict between doctor (GP), TC and midwife Midwife performing CS, less interested in routine midwifery work at normal delivery Importance of Team Work: Obstetrician, GP doctor, Midwife and TC

17. 17Conclusions After 20 yr experience of delegation of surgical interventions to técnico de cirurgia and 1 yr to midwives, we can say that this strategy is very important to increase access to Comprehensive EmOC at first referral level. After 20 yr experience of delegation of surgical interventions to técnico de cirurgia and 1 yr to midwives, we can say that this strategy is very important to increase access to Comprehensive EmOC at first referral level. It can contribute to reduction of maternal and neonatal mortality in poor countries with shortage of human resources It can contribute to reduction of maternal and neonatal mortality in poor countries with shortage of human resources

18. 18 Thank You