A Systems Approach to Lifesaving Maternal and Newborn Care

Kate Cassidy, SMGL USAID Initiative ManagerMona Mehta Steffen, SMGL USAID M&E Advisor

Mini-U Presentation - March 4, 2016

Maternal & Newborn Mortality

Globally, in 2014, over 300,000 women and 3 million newborns died

from complications of pregnancy and childbirth

Nearly all of these deaths are preventable with skilled care before, during, and after

childbirth

62% of maternal deaths and 39% of newborn deaths occur in sub-Saharan Africa

• Hemorrhage

• Eclampsia

• Infection

• Obstructed Labor

• Sequelae of unsafe abortion

• Indirect causes

Why do Women Die?

“Women are not dying because of diseases we cannot treat…

They are dying because societies have yet to make the decision that

their lives are worth saving”

Mahmoud Fathalla, MD

Father of the Safe Motherhood Movement

USG Response: Partnership for MH

Saving Mothers, Giving Life is a five-year initiative –launched in 2012 – that

strengthens health services at the district level by

combining the capabilities & resources of diverse

partners to accelerate the reduction of maternal &

newborn mortality

Saving Mothers, Giving Life Goal:

Decrease Maternal Mortality in SMGL areas by 50%

Founding Partners

Founding Partners

US Government

SMGL Countries and Phases

ZAMBIA

Phase 11/12-9/13

Refined model scaled-up in:

10 Ugandan districts

18 Zambian districts

Cross River State, Nigeria

Phase 210/13-9/15

UGANDA

Phase 310/15-9/17

National (and State) Scale-up & institutionalization

MMR & NMR in SMGL CountriesUN figures (2015)

Maternal Mortality Newborn Mortality

Maternal Mortality Ratio (deaths per 100,000 live births)

Number of deaths per year

Newborn Mortality Rate (deaths per 1,000 births)

Number of deaths per year

Uganda 343 5,700 22 34,602

Zambia 224 1,400 29 17,783

Nigeria 814 58,000 39 260,000

Using a Systems Approach

We are taking an integrated health systems approach to

addressing the three delays…

1. Delays in the decision to seek care

2. Delays in accessing appropriate care in a timely manner

3. Delays in receiving high-quality respectful care at a health facility

Using a Systems Approach

Build on existing national/State/local

platforms

Work with both public and private

sectors

Focus on labor,

delivery & first 48 hrs

post-partum

Integrate HIV/AIDS, maternal,

and newborn

health services

Using a Systems Approach

Determine the ecology of safe delivery services in a given area by assessing public and private service delivery points

Ensure access to comprehensive emergency care within 2 hours should a complication arise

Rationalize financial and technical inputs to maximize coverage and quality of services

Count, analyze, and report all maternal and newborn deaths

Key Interventions

DEMAND

• Training Community Health Workers & mobilizing community leaders• Communicating & promoting services, birth planning and healthy

behaviors

ACCESS

• Renovating facilities (BEmONC and CEmONC), maternity wards, surgical theaters and waiting homes

• Providing transportation vehicles &/or vouchers

Key Interventions

QUALITY

• Hiring physicians, nurses & midwives with government uptake• Training & mentoring providers on AMTSL, EmONC, ENC, HBB, QI• On-the-job practice and drilling• QI Teams/respectful care

HEALTH SYSTEMS SUPPORT

• Improving supply chain management, equipment & supplies• Training in data collection & reporting• Building staff housing, where appropriate

The results after the first year were striking

Results: Proof of Concept

Uganda

Zambia

Perinatal mortality rate17% Case fatality rate 18%

Perinatal mortality rate14%

Case fatality rate 35%

Other Health Outcomes

Uganda

Key Highlights

the number of facilities practicing the active management of third

stage labor (AMTSL)

Doubled

4,076 trained as part of village health teams to educate women & their families about the risks associated with giving birth at home

In SMGL districts, 72% of women now live within 2 hours of an EmONC facility

Mama Kits were distributed15,655

to enable clean childbirth

Zambia

Key Highlights

Trained 199 providers and 302 mentors

13.5% increase in scores on knowledge tests

Hired 19 healthcare workers

Every SMGL-supported facility in the pilot districts now conducts regular

maternal death reviews

100%

98% of SMGL-supported facilities did not experience stockouts of oxytocin in the last 12 months87% of SMGL-supported facilities did not experience stockouts of magnesium sulfate in 12 months

Strengthening HIV services

Managing Mother-to-Child Transmission of HIV

+18%In Zambia

+28%In Uganda

ART for PMTCT

+29%In Zambia

+27%In Uganda

ARV prophylaxis for infants

What Did We Learn?

Build all political, public health, and community commitments and actions on foundation of zero

tolerance for preventable maternal and newborn deaths

Saving the lives of pregnant women requires a functioning health system:

• There is no ‘magic bullet’

• Coordination of both public and private inputs and outputs makes for a stronger ‘whole’

• System strengthening is not cheap but it is an investment and a public health good

• Country ownership must be realized from the national to the district levels of the MOH

• Integrating HIV- and MNH-related services can result in better health outcomes than when provision is soloed

• Robust M&E provides powerful proof of effect:

– Capture health outcomes

– Tally expenditures

Results: Mid-Initiative

264

462

2014

2012

146

311

2014

2012

53% Reduction in MMR*

(facilities only)

41% Reduction in MMR*

(district wide)

*Maternal deaths per 100,000 live births *Maternal deaths per 100,000 live births

37.9

30.5

7.7

27.0

19.4

7.8

Perinatal Mortality Rate(per 1,000 births)

Total Stillbirth Rate(per 1,000 births)

Institutional Pre-discharge Neonatal

Mortality Rate(per 1,000 live births)

Progress in improving newborn health

+2%-37%-29%39.3

31.2

8.4

37.3

29.6

7.9

Perinatal Mortality Rate(per 1,000 live births)

Total Stillbirth Rate(per 1,000 births)

Institutional NeonatalMortality Rate

(per 1,000 live births)*includes low birth weight

neonates

Progress in improving newborn health

-5% -5% -6%

17% 26%

28%

37%

0%

20%

40%

60%

80%

100%

2012 2014

38% increase in facility delivery

Percent deliveries in EmONC facilities

Percent deliveries in lower-level

37%

62%

26%

28%

0%

20%

40%

60%

80%

100%

2012 2014

43% increase in facility delivery

Percent deliveries in EmONC facilities

Percent deliveries in lower-level facilities

Select Mid-term Outcomes

20

-29% Facility Perinatal

Mortality Rate

-53%Maternal

Mortality Ratio in SMGL facilities

+32% C-Section

Rate

+81%Women

receiving ART for PMTCT

-45% Case Fatality

Rate

ZAMBIA

Select Mid-term Outcomes

21

-6% Facility Newborn

Mortality Rate

-45%Maternal Mortality

Ratio in SMGL facilities

-41% MMRIn SMGL Districts

+31% C-Section

Rate

+417%Deliveries

supported by transport vouchers

-47% Case Fatality

Rate

UGANDA

• Health facility assessments completed in all facilities providing delivery services in Cross River State

• Results shared and implementation plans crafted with key stakeholders

• Intervention “clusters” identified based on access and availability of services

• GIS mapping of all facilities and travel time in progress

• Work plan to implement SMGL in select private facilities through Merck for Mothers

Progress In Nigeria

SMGL - Nigeria CrossRiver State Facilities

• Inconsistent and slow flow of funding

• Turnover of implementing partners

• Slower progress in achieving impact on newborn mortality

• Sustainability

SMGL Challenges Encountered

A Call to Action: together we can save mothers and newborns!

www.savingmothersgivinglife.org

Thank you!