1. Humanization of Childbirth: A Worthwhile Investment for Health Care Services, Professionals, Clients and Communities Veronica Reis, MD, MPH – MCHIP Mozambique Elvira Xavier, MD – MoH Mozambique Abstract to be presented at 18th International Congress on Women’s Health “CITIES AND WOMEN’S HEALTH: GLOBAL PERSPECTIVES” University of Pennsylvania, Philadelphia, USA, April 7- 10, 2010

2. OBJECTIVE OF THE SESSION  To share the results of efforts undertaken in Mozambique to promote the quality and humanization of healthcare, particularly in the area of childbirth.

3. Humanization of Childbirth DEFINITION  “Humanization of childbirth” is an approach that:  centers on the individual,  emphasizes the fundamental rights of the mother, newborn and families  promotes birthing practices that recognize women’s preferences and needs.

4. Symbols of the “Technocratic Model”:  The body as a machine  Separation between the body and the mind FROM Technocratic TO Humanistic Model

5. Symbols of the “Technocratic Model”  Centered on the professional  Disempowerment of the woman

6. Symbols of the “Technocratic Model” Use of no evidence based practices

7. Symbols of the “Technocratic Model” Woman “solitary”

8. Separation Between Father - Mother - Newborn - Family

9. Humanization of Childbirth Includes:  Respecting beliefs traditions and culture  The right to information and privacy  Choice of a companion during childbirth  Liberty of movement during the labor

10. MNH Humanistic Model Includes:  Choice of position for childbirth  Newborn on “Skin-to- skin” care  Use of evidence based practices  Guarantee of Emergency Obstetric and Neonatal Care, if necessary

11. Humanization of Childbirth in Mozambique

12. MOZAMBIQUE CONTEXT Population: 20 million Life expectancy at birth: 45 years HIV prevalence: 16.2% Maternal mortality: 408/100,000 live births Neonatal mortality: 48/1,000 live births Major cause of death (all ages): Malaria HIV prevalence rate: 16.2% Source: 2007 Census, DHS 2003 Photo: Ismael Miquidade

13. Main problems on the Health System identified by Mozambique MoH  Shortfalls in Infrastructure, lack of supplies and limited human resources  Poor management of health services  Long waiting times in health facilities  Lack of a welcoming reception  Lack of privacy and limited information provided to the client  Minimal satisfaction of clients and health workers. Source: MoH Moz, 2007.

14. Investing in quality improvement and humanization of health care  In 2006, Mozambique Ministry of Health, with support from Jhpiego and others partners, developed a National Plan to Improve the Quality and Humanization of Maternal and Child Health (MCH) Services that adopted Standards-Based Management and Recognition (SBM-R) methodology. Photo: MCHIP Mozambique

15. Standards-Based Management and Recognition (SBM-R)  It is a practical approach that follows four main steps: 1. Setting performance standards based on national norms and international references 2. Implementing standards through a systematic methodology 3. Measuring progress to guide improvement toward standards 4. Recognizing achievement of the standards

16. 2007-2008: Quality improvement process in 6 Provinces / 18 HC Results:  By the end of 2008 Facilities doubled or tripled their performance, were operating at a higher quality level, adhering to established evidence-based standards.

17. Rural Hospital of Manjacaze An example of this movement!  At Manjacaze Hospital, located in the south of Mozambique in Gaza Province, staff has been working with the local community to guide the transformation of the hospital into a welcoming environment for clients. Humanization principles have been successfully incorporated into services.  These efforts have resulted in increased health worker and client satisfaction and increased demand for services.

18. At Manjacaze Hospital Humanization efforts included…  Trainning staff on the implementation of the MNH standards;  Disseminating information about humanization and quality of care, and client rights;  Ensuring the implementation of humanized childbirth and MNH high impact intervention practices. Manjacaze Hospital

19.  Considering the results achieved, the MOH expanded the quality and humanization improvement process in 2009 to the 34 largest hospitals throughout the country. Training of Trainers – August 2009 2009-2010 - Model Maternities Initiative MCHIP Mozambique

20. Model Maternities Initiative  MMI is a an initiative led by the Minister of Health to create facilities that are models not only for quality patient care but also that serve as top of the line clinical training sites for improving health care worker education. 20

21. 1 TOT and 3 Regional MNH trainings: Total of 29 trainers and 90 health professionals trained Each of the 34 maternities has at least 2 people trained 11 nurse training institutes has at least 1 preceptor trained 20 of the 34 maternities have carried out base line assessments and developed work plan to improve the quality of MNH services 21 Progress achieved from August 2009 to Feb 2010

22. 2009-2010 - Model Maternities Initiative A work in progress… Training 22 Photos: MCHIP Mozambique

23. 2009 - Model Maternities Initiative Baselines and Action Plans 23 Photos: MCHIP Mozambique

24. Promoting Humanistic Care and High-impact Interventions 24 Companion during childbirth, Birth in vertical position, Skin-to-skin care, Early breastfeeding... Photos: MCHIP Mozambique

25. Client satisfaction  One mother allowed to accompany her daughter during childbirth at a health center said: “This is what I can call true independence!”.  One young Mozambican woman that gave birth to her first child under humanized conditions, in a squatting position and accompanied by her partner, is now sharing her experiences with other women and communities in Mozambique, affirming, “We women must speak up to fight for our rights”. And the father of the baby said: “It was the most incredible experience of my life”!

26. Conclusion  Humanizing healthcare can improve quality of care, increase service utilization and client satisfaction.  While more research is needed to measure the benefits of humanizing healthcare, current analysis of experiences in Mozambique demonstrate humanizing healthcare is a worthwhile investment.

27. References  ACCESS. Module 4: Women-friendly Care. In: Best Practices in Maternal and Newborn Care: Learning Resource Package. Jhpiego-Johns Hopkins University. Baltimore-MD, USA. 2008.  Davis-Floyd R., St.Jonh G. From Doctor to Healer: The transformative Journey. New Brunswick NJ: Rutgers University Press. 1998.  Gupta and Nikodem. Maternal posture in labour. Eur J Obstet Gynecol Reprod Biol 2000 Oct;92(2): 273-277.  Jones R. O Homem de Vidro: Memórias de um obstetra humanista. Porto Alegre-BR: Idéias a Granel, 2004.  Maadi et al. Effects of female relative support in labor: A randomized controlled trial. Birth. 1999 Mar; 26(1): 4-8. Erratum in: Birth 1999 Jun; 26(2): 137.  MISAU. Atenção humanizada a mulher e ao recém-nascido durante o parto e o nascimento. Ministério da Saúde. Moçambique, 2007a.  MISAU. Plano Estratégico do Sector Saúde 2007-2012. Ministério da Saúde. Moçambique, 2007b.  MoH. National Integrated Plan To Achieve MDGs 4 & 5. Mozambique, 2009.

28. THANK YOU!