Dr Sisana Majeke (PhD) and ESMOE Board Inspiring Greatness
Slide 2
Key findings: 1500 maternal deaths per year 4867 maternal
deaths were reported in 2008-2010 3959 maternal deaths were
reported in 2005-2007 3296 maternal deaths were reported in
2002-2004 (NCCEMD Saving Mothers report, 2008 2010).
Slide 3
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MMR 310 /100000 live births (2008) MMR 330/100000 live births
(2009) The institutional MMR has increased across all levels of
care when compared with 2005-2007 (Saving mothers report,
2008-2010).
Slide 5
Major causes of maternal deaths Top 3 preventable causes of
maternal deaths, accounted for almost 70% of Maternal deaths:
Non-pregnancy related infections (HIV&AIDS) ( 40.5%) Obstetric
haemorrhage (14%) Hypertension (14 % ) Prioritization of the
prevention of these conditions is essential The biggest impact can
be made on preventing maternal deaths-MDG 5
Slide 6
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Patient related Accessing health care services Unsafe
miscarriages Administrative Transport between facilities Access to
ICU Access to blood Inadequate staff Health care providers Not
assess patients properly Delay in referral Not follow standard
protocols
Slide 8
32000 perinatal deaths per year PNMR 34/1000 births Primary
obstetric causes Intrapartum asphyxia and birth trauma Spontaneous
preterm birth Hypertension Major neonatal death causes Hypoxia
Immaturity o 8 234 Early Neonatal Deaths Neonates with LBWT (Saving
Babies report 2008-2009 written by NaPeMMCO)
Slide 9
Reduce deaths due to HIV/AIDS Reduce deaths due to Haemorrhage
Reduce deaths due to Hypertension Improve Health worker training
Strengthen Health System Each stresses prevention and emergency
care
Slide 10
Train all health care workers involved in maternity care in the
ESMOE-EOST programme and obstetric anaesthetic module, with
emphasis on the following: Standardised observation and monitoring
practices which stipulate the frequency of observations and aid
interpretation of severity e.g. early warning monitoring charts.
These would enable earlier detection of haemorrhagic shock
following delivery and after CS; and also enable earlier
interventions for complicated pre-eclampsia. The skills of safe
labour practices; use of and interpretation of the partogram,
AMTSL, use of uterotonic agents, safe CS, and additional surgical
procedures for complicated CS. To achieve competence in the
management of obstetric emergencies e.g. PPH, eclampsia, acute
collapse. Train all health care workers who deal with pregnant
women in HIV advice, counselling, testing and support (ACTS),
initiation of HAART, monitoring of HAART and the recognition,
assessment, diagnosis and treatment of severe respiratory
infections.
Slide 11
Essential steps in the management of common conditions
associated with maternal and neonatal mortality guideline
Guidelines for Maternity Care in South Africa second edition 2007.
Life Saving Skills manual (RCOG) Facilitators guide (Adapted RCOG
guide) Mannequins Posters CD/DVDs Emergency Obstetric Simulation
Training (EOST) Scenarios Scoring sheets
Slide 12
Use principles of adult learning Lecture Skills demonstration /
DVD/ video Skills practice Scenarios 12 modules (90 minutes each)
Training 3 day workshops 2 day workshops 12 weekly in-service
training meetings
Slide 13
1. Resuscitation Maternal7. Obstructed labour 2. Resuscitation
Neonatal8. Interpreting CTGs 3. Sepsis and Shock9. Obstetric
complications 4. Eclampsia and pre-eclampsia10. Surgical skills 5.
Haemorrahge11. Complications of abortion 6. Assisted delivery12.
HIV in pregnancy
Slide 14
Pre-test and post test May & August 2008 Significantly
increases knowledge and skills
Slide 15
2005-2007: 80% of anaesthetic related maternal deaths clearly
avoidable 2008-2010: 90% of anaesthetic maternal deaths possibly or
probably avoidable Most in district hospitals Problems
Complications of spinal anaesthesia Failed intubation Obstetric
Anaesthetic module developed in 2010, tested 2011
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ESMOE Board Master Trainer Training Certification Quality
assurance (monitoring) Updating/ Editing Master trainers At
hospitals with interns Intern training Certified Registered by
HPCSA EOST at hospital: Midwives & doctors Documented Part of
CEO KRAs EOST at hospital: Midwives & doctors Documented Part
of CEO KRAs EOST at hospital: Midwives & doctors Documented
Part of CEO KRAs COSMOs skilled Province: Supply personnel for
training Coordinate training workshops Medical officers Ad.
midwives
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To significantly reduce maternal and neonatal deaths in SA by
improving obstetric and neonatal emergency care
Slide 20
Target initially the Districts which are most in need for
emergency obstetric and neonatal care training as targeting these
will have the most immediate effect on reducing MMR and NNDR
Training of 80%+ of maternity health care providers leads a
significant reduction in maternal deaths (MI decreased by 50%),
significant reduction in SBR (15%) Kenya, India, Sierra Leone,
Zimbabwe, Bangladesh
Slide 21
Data DHIS births for each district NCCEMD maternal deaths per
district DHIS Stillbirths and neonatal deaths Criteria for
selection Scoring system according to MMR SBR Number maternal
deaths Priority in province
Slide 22
Top 25 districts according to Ins MMR Score MMR1=180-230;
2=230-280; 3=280+ Score SBR1=25-27; 2=27+ Score MD1=100-150;
2=150-200; 3=200+ Score Province2=highest MMR; 1=second highest
MMR
9 Districts with district regional hospitals 3 Districts with
tertiary hospitals (3 Districts with medical schools) 12 Districts
give 50% of maternal deaths in districts without medical schools
remaining 32 Districts give the rest
Lack of master trainers Funding Staff shortages in the
different districts and hospitals
Slide 30
NDOH and PDOH will facilitate cooperation by province and
district respectively Master trainers will be available and will be
trained on ESMOE-EOST 600 master training slots in 30 months
Doctors and midwives will be trained mostly together in teams
Anaesthetic module will be included in the scale-up, but not
necessarily at the same time as ESMOE-EOST Funding available
(DFID)
Slide 31
Ordered 25 districts to have ESMOE-EOST and anaesthetic module
scale-up DOH to fund the 10 new sites
Slide 32
Step 1 Baseline assessment and standard ESMOE-EOST Training
Step 2 Saturation training (80%+ all HCW in MNH trained) 1 district
in 2 months (5 districts/year) 6x3-day workshops (30 master
trainers) 4x2-day workshops (20 master trainers) 50 master training
slots per district
Slide 33
Facilities and functionality audit Basic Emergency obstetric
care Anticonvulsants, oxytocics, antibiotics, Manual removal of
placenta, perform MVA, assisted delivery Bag and mask ventilate a
neonate Comprehensive Emergency Obstetric Care Perform C/S and give
blood transfusion Ensure all sites have a doctor and midwife
trained in ESMOE-EOST and are doing EOST exercises Trained in
monitoring tools PPIP, MaMMAS and maternal near miss audits
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Stepped wedge design Used where know intervention is effective
but cannot implement it everywhere at once Random allocation of
order of sites is fairest way to provide roster for intervention
All sites have had Standard ESMOE-EOST training at baseline Random
allocation to saturation training All sites end up with saturation
training
Slide 36
1212 1 1010 9 8 7 6 5 4 3 2 1 Base 12345678910111213 - 18 Time
Epochs (2-3 months) Phase 1 Districts Stepped wedge design Perform
EOST exercises Saturatio n Trained, EOST exercises
Slide 37
Baseline data collection complete at all core districts Fezile
Dabe District completed saturation training
Slide 38
The CHC health providers are also been trained now from August
2012. Midwives are encouraged to attend these trainings for 2 days
in their districts. Thank you !!!