1. Model Maternities Initiative: Model Maternities Initiative: Providing Humanistic Maternal and Newborn Care in Mozambique Veronica Reis, MD, MPH – MCHIP Mozambique Lidia Chongo, MD – MoH Mozambique USA, April 6, 2010

2. Purpose of the session  Share the development of a new initiative in Maternal and Child Health in Mozambique  Discuss challenges and lessons learned of implementing interventions in a poor resource context

3. Topics Background The concept and rationale behind Model Maternities Initiative Overview of the interventions Progress achieved and challenges Successful approaches and lessons learned Moving forward 3 Photo: Ismael Miquidade

4. Total population: 20.53 million (2007) Life expectancy at birth: 42 years Maternal Mortality ratio: 408/100,000 lb Neonatal mortality rate: 48/1,000 live births Major cause of death (all ages): malaria HIV prevalence rate: 16.2% Background: general health situation in Mozambique Source: 2007 Census, DHS 2003

5. Trends in MMR and MDG 5

6. Trends in Neonatal / Infant / Under five Mortality 6 Neonatal Mortality represent 40% of Infant Mortality.

7. Causes of Maternal Mortality Source: National Needs Assessment 2007

8. Causes of Neonatal Mortality in Mozambique, % Source: Child Mortality Study, 2009

9. Background: situation of SRH and MHC in Mozambique Indicator200720082009 Percentage of deliveries by a skilled birth attendant 54%55% Intra-hospital maternal mortality ratio 473/100,000 LB* 196/100,000 LB 149/100,000 LB Health facilities that provide basic emergency obstetric care, per 500, 000 inhabitants 1.131.445.9 Percentage of pregnant women who had at least two doses of IPT in an ANC visit 27%77%51.1% Percentage of HIV+ pregnant women who had ARV drugs in the last 12 months (as PMTCT) 17.1%32%45.7% Contraceptive prevalence rate (17% 2003 – DHS) Source: Joint Evaluation of Health Sector performance, 2010 *Needs assessment in SRH, 2008

10. Health infrastructure shortfall ParticularsPercentage Population living within 30 min of a health facility 36% Health facilities that have electricity 49% 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% Source: MoH, National Integrated Plan to Achieve MDGs 4 and 5 / Needs Assessment??

11. Coverage of high-impact interventions ParticularsPercentage AMTSLNot practiced in general PartogramNot filled systematically C-section rate in facilities providing CEmOC 2% Exclusive breastfeeding up to 6 months 30% ENCNot reported

12. MCHIP Mozambique Objectives 2009-2010 12  Strengthen EMNC and BEmONC services, including PPFP, in selected healthcare facilities in all provinces, as well as key integrated RH/MCH services in selected healthcare facilities in selected provinces.  Strengthen BEONC and CEONC in an integrated manner in pre-service institutions for MCH mid-level nurses.  Assist the MOH on the development of modular, integrated in-service training package for RH/MCH.

13. Model Maternities Initiative: concept and rationale Model Maternities Initiative are built on the principles of “humanization and quality of Maternal and Neonatal Health (MNH) care”. Humanization of MNH care 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.

14. FROM Technocratic model TO Humanistic model Model Maternities Initiative: concept and rationale

15. Symbols of the “technocratic Model”  The body as a machine  Separation between the body and the mind

16. Symbols of the “technocratic Model”  Centered on the professional  Disempowerment of the woman

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

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

19. Separation between father - mother - newborn - family

20. MNH Humanistic Model includes:  Respecting beliefs traditions and culture  The right to information and privacy  Choice of a companion during childbirth  Liberty of movement during the labor

21. 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

22. MMI: Foccus on humanistic care and scale-up high-impact interventions Antenatal care: Tetanus Toxoid, Iron Folate, Intermittent preventive tx (IPT) for malaria PMTCT Normal deliver: Use of partograph; clean delivery; newborn care, include skin-to-skin care; AMTSL and mother/newborn monitoring on the immediate post-partum Post-natal care: Visit within 2-3 days for mother and newborn Post-partum family planning / Birth spacing BEmONC: Intravenous antibiotics, oxytocics, MgSO4, manual removal of placenta, assisted vaginal delivery, removal of retained products, newborn resuscitation, Kangaroo Mother care and antibiotics for newborn Referral to CEmONC facility 22

23. MMI Implementation Methodology  Standards-Based Management and Recognition (SBM-R) 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 4. Recognizing achievement of the standards

24. Model Maternities Initiative: Selected Facilities (Pre-service training sites) Health Facility that provide delivery care TotalModel Maternities Central Hospitals33 Provincial Hospitals77 General Hospital44 Rural Hospitals2611 District Hospitals7 Urban Health Centers989 Rural Health Centers820 Total96634

25. MMI Standards by Area and M&E Selected indicators ÁREASCONTENTS STANDARDS 1.Managment 09 2.Information, Monitoring and Evaluation 05 3.Human and Material Resources 04 4.Health work conditions 06 5.Health Education and Community envolvment 04 6.Antenatal and Post-natal Care 11 7.Labor, Delivery and Neonatal Care 25 8.BEmONC 09 9. Training 04 TOTAL OF STANDARDS 79 Selected Indicators 32

26. Key indicators for M&E of MMI IndicatorBaseline (2009)MCHIP Target (2010) % of pregnant women who received at least 2 doses of IPT 51%70% % of HIV+ pregnant women who received prophylaxis (PMTCT) 45%60% Number of births by SBA113,70410% above natural growth* % of deliveries with partogram completely filled 050% % of newborns with skin-to-skin care and early breastfeeding 060% % of birth with AMTSL060% % of severe pre-eclampsia and eclampsia treated with MgSO 4 <10%60% Source for baselines: NHIS, 2010 *Natural population growth:2.4%

27. Policy and strategy development: National Plan for Humanization of Healthcare; Guidelines for Maternal and Neonatal Death Audit Committees; Evidence-based training packages for EMNC and basic EmONC developed/translated/adapted Quality EMNC and BEmONC standards (SBM- R) developed and refined after trainings 1 TOT and 3 Regional MNH trainings on EMNC, basic EmONC and SBM-R approach: total of 29 trainers and 90 health professionals trained 27 Progress achieved on 8 months August 2009 – March 2010

28. 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 Provincial Godfathers/Godmothers for SRH and MCH involved in all trainings 28 Progress achieved Training of Trainers – August 2009

29. Model Maternities Initiative National and Regional training 29 Photos: MCHIP Mozambique

30. Model Maternities Initiative Baselines and Action Plans 30 Photos: MCHIP Mozambique

31. Model Maternities Initiative 31 Promoting birth in vertical position, skin-to-skin care, early breastfeeding... Photos: MCHIP Mozambique

32. Successful approaches Working together with preservice training institutes and inservice trainers Create a pool of trainers that also act as supervisors Leave room for the provinces to organize most aspects of cascade training will help them grow Identify champions at central and provincial level Be attentive and clarify critical managerial and technical issues along the way (eg, how to better organize labor and delivery rooms; how to conserve oxytocin; how to ensure sistematic use of partogram; how to introduce new practices like birth on the vertical position, skin to skin care, AMTSL…)

33. Some Lessons learned  Involvement of heads of wards/services is a critical determinant of adoption/ implementation of MMI in Moz facilities.  Ensure retention of clinical skills by sustained training/supervision is critical for the humanization and quality improvement process.  Never take for granted that existing SRH/MCH supervisors have the required skills for do the supervision. They often need additional training on such skills.

34. Increase the number of health professionals trained Ensure retention of clinical skills by sustained training/supervision Support Maternities on the humanization and quality improvement workplan implementation and on the sistematic measure of progress Improve recording of data (general M&E, SBM-R, etc) Support the MoH on the recognution process Improve documentation of lessons learned and best practices from MMI implementation, at facility level Support MoH to implement national scale-up of MMI Moving forward and overcoming challenges

35. THANK YOU! Where there is a Wish... there is a Way Mozambique MOH