1. Improving Quality and Access to Essential Obstetric Care: The Latin American Maternal Mortality Reduction Initiative (LAMM) Stephane Legros, MD, MPH, MBA QAP/URC-CHS SOTA meeting Miami, FL March 15, 2001

2. Description of LAMM 3 countries: Bolivia, Ecuador, and Honduras Activities began mid-98 Project area: average of 200,000 inhabitants per country Community and facility interventions Three levels of care: primary, district, and regional MMRs range from 390 to 108/100,000

3. Components of LAMM initiative 2. Process (Re)design Process 3. Improvement Problem solving 4. Provider performance improvement 5. EOC Standards communication guidelines, job aids 6. Monitoring system EOC indicators, rapid surveys Clinical audit, Maternal death audit Leadership in EOC Local steering committees, community governance 7. Linkages informal/formal providers 1. Community mobilization Presentation Road Map QA interventions within LAMM

4. Pathway to Maternal Survival From the Community to the Facility: Access and Quality of Care Processes from Mother Care project, M.Koblinski

5. 1. Community Mobilization Key Components Training programs IEC Referral system Monitoring system Emergency access plans Community revolving funds

6. Impact of Community Mobilization in Ecuador

7. Training Modules  Human body  Pregnancy  Delivery  Neonate  In preparation  Post partum

8. IEC IEC  Posters  Flyers  Radio spots  Soap operas

9. IEC IEC  Plastic disc to estimate date of delivery

10. Referral System Specific form used for: Prenatal care Delivery Postpartum Neonate and FP

11. Monitoring System Specific form developed for mother and neonate Complications Location of delivery Health outcomes

12. Emergency Access Plan Developed by community Negotiated with drivers Displayed in grocery store

13. Results at Community Level in Ecuador

14. Percent of Communities with Emergency Access Plans and Community Revolving Funds for Obstetrical Complications Cotopaxi, Ecuador, 2000

15. Complicated Deliveries Attended at Home and in Health Facilities Cotopaxi, Ecuador, 2000

16. 2. Quality Design of a New Process Team work, mix of providers and patients Focus on user needs Stepwise methodology Identification, design, and implementation of key elements

17. Three Waves of Process (Re)design in All LAMM Countries 1st: Achieving access, mid ‘98- to-mid ‘99 community transportation, referral, reception/triage, 2nd: Receiving care -- EOC, mid-to-end ‘99 EOC complications, labor monitoring, normal delivery, prenatal care 3rd: Receiving care -- EOC, Year 2000 maternal waiting home, postpartum care, neonatal care

18. Impact of Quality Design on Prenatal Care in Ecuador and Honduras

19. Pathway to Maternal Survival

20. Improvements in Prenatal Care at Health Center Level, Ecuador and Honduras  Patient exam larger room with privacy  New appointment system  Integrated dental care and vaccination status

21. Results of New Prenatal Care Design at Health Center Level in Honduras + 49% +36% +11% Number of Visits (Design was implemented in 1999)

22. Impact of Quality Design on Reception/Triage in Ecuador

23. 2- Improvements in Reception/ Triage at Salcedo Hospital, Ecuador  24-hour guard system  Training of personel on IPC  Personnel dedicated for triage with specific room  New work schedule  New outpatient rooms  New transportation beds

24. 2- Improvements of Reception/ Triage at Salcedo Hospital, Ecuador  Repaired delivery table  Repaired anaesthesia and sterilization equipment

25. Results: Number of Deliveries in Salcedo District Hospital, Ecuador Design was implemented in 1999. 180%

26. Impact of Quality Design on Normal Delivery Care in Honduras

27. First New Maternal Clinic Jose Maria Ochoa, Honduras Problem: Over-utilization of referral hospital Solution: Opening of a satellite maternal clinic to reduce burden

28. New Maternal Clinic, Jose Maria Ochoa, Honduras

29. Results: Number of Deliveries at Jose Maria Ochoa Maternal Clinic, Honduras, 2000 (Clinic opened in July 2000)

30. 3. Process Improvement, Topics Selected by the Teams EOC drugs availability Medical supplies and equipment availability Waiting time reduction Patient satisfaction improvement

31. 4. Provider Performance Improvement Competency Based Training (8 days duration) in on-site training centers Knowledge of EOC standards and guidelines Clinical skills training with mannequins –prenatal care, normal delivery, prolonged labor, hemorrhages, neonatal care Problem solving methodology Interpersonal Communication

32. Knowledge Improvement in EOC Clinical Skills, Bolivia, 2000 (N= 75) 42% 65%

33. 5. EOC Standards and Guidelines: Communication  Training  Problem-based learning through case management  Job aids: pocket EOC standards manual, use of partographs  Clinical audits

34. Example from Honduras: Pocket Guide of EOC Standards  Handy  User Friendly  New format

35. 6. Project Monitoring Monitoring system, uses existing facility resources –Baseline assessment, pre/post intervention –Rapid facility survey, annual (24-hour care, drug availability, skilled attendants) –Facility level indicators, quarterly met need, c-section rate, referral rate –Community level indicators, quarterly

36. Results: Percentage of Met Need for Obstetrical Complications in Cotopaxi Referral Hospital, Ecuador

37. Other Activities Linkages informal/formal providers –workshops, matrices & action plans –community delivery homes with TBA Maternal death audit –pilot with PAHO in Honduras EOC leadership –local steering committees –community governance

38. 7- Linkages Informal/Formal Providers Casa Comunitaria de Parto in Honduras

39. Casa Comunitaria de Parto 2, Honduras

40. Ongoing Challenges Maintain team commitment & energy Shorten time to (re)design Increase physician involvement Data collection for monitoring system Leadership at central level Project work load

41. Lessons Learned and Future Directions Mix of QI & QD with more rapid results Focus on EOC standards and compliance Foster data management EOC skills training from the beginning Simple monitoring systems linked with EOC standards Benchmark the successful activities