Posts filed under ‘MCHIP’
By Nasir Bashir, Samaila Yusuf and Ann LoLordo
With each pregnancy, Malam Abubakar Maikudi worried about the health of his wife, Hadiza. The father of three children, Maikudi feared that another baby, born too soon, would further weaken her and make it harder for her to care for the children. But what could he do? A visit by a community health counselor helped this Nigerian father attend to the needs of his family.
Ali Ibrahim, a male counselor who is part of a U.S. Agency for International Development (USAID)-supported program to enhance reproductive health services in northern Nigeria, explained to Maikudi the benefits of properly spacing future pregnancies. He discussed several family planning methods for the couple and referred them to the Kiru Comprehensive Health Centre.
“Your visit to my house has taken a big burden out of my life,” Maikudi told the counselor. “I am very much satisfied with the information you have given me on how to plan my family and where to get services.”
After meeting with a health provider at the center, Hadiza and Maikudi decided that an intrauterine contraceptive device (IUD) was their preferred method of family planning.
The couple is just one of thousands of families who have been helped through a comprehensive program supported by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), managed by Jhpiego and partners to strengthen reproductive, maternal and family planning services in three states in northern Nigeria. An estimated 30,000 women die annually from complications of childbirth in Nigeria. The program began under the ACCESS Program and is being continued by MCHIP.
Through its cooperation with the Nigerian Ministry of Health over the past four years, MCHIP in Kano, Katsina and Zamfara States has achieved steady and significant gains in women’s visits to antenatal care clinics, skilled birth attendance, active management of third stage of labor, essential newborn care and use of long-term family planning. Through this initiative, 164,040 women have received family planning and reproductive health counseling.
“We are partners in progress because from the time when they came and started the activities in this state, we have made a tremendous progress,” said Dr. Bello Buzu, the chairman of the Health Services Management Board in Zamfara State.
The goal of the program has been to strengthen health systems and improve the quality of care in the community and health facilities to reduce the deaths of women and newborns. In northern Nigeria, women have an average of five to seven children. Program partners launched a multi-tiered approach that targeted 57 health facilities in more than two dozen local government areas, and relied on community health counselors and mobilizers to reach women in their homes and villages. The program focused on strengthening emergency obstetric and newborn care and family planning services.
Key accomplishments of the program have included:
- Health facilities using active management of third stage of labor increased from about 30 percent to more than 60 percent in the three states in northwest Nigeria;
- The number of facilities performing newborn resuscitation nearly doubled;
- Use of family planning among postpartum women in the areas served by the program increased from one percent to 15 percent of households; and
- More than 8,000 women chose injectables as the preferred form of contraceptive during a one-year period, an increase over the estimated 6,000 women seen at the start of the program.
As part of the project, health care providers were educated in emergency obstetric and newborn care skills, and family planning methods and e-learning opportunities were strengthened to build capacity in these areas. Beyond community education and facility improvement, a key strategy was to integrate health screenings with immunizations, newborn care and well-baby visits so as not to miss an opportunity to address women’s health and family planning needs.
“We have a reason for being in northern Nigeria. If you look at the demographic characteristics, many indicators are very poor in northern Nigeria compared to southern Nigeria,’’ said Prof. Emmanuel Otolorin, Jhpiego’s Country Director. “Our household-to-hospital continuum of care approach aimed to eliminate the delays to accessing health care delivery such as ignorance of the danger signs in pregnancy and childbirth and/or inappropriate customs. It also aimed to address delays in reaching the point of care due to lack of appropriate transport or poor roads and geographic terrain, as well as delays in receiving care after arriving at the health facility because of weak health systems—including a shortage of skilled birth attendants or lack of equipment and supplies.”
A network of community health volunteers taught pregnant women and mothers basic health care skills to prepare for childbirth and encouraged them to access health care services before and after delivery. Men were recruited to participate in outreach efforts to discuss the importance of pregnancy spacing and family planning with husbands, fathers and other male relatives. Savings clubs were organized for women, giving them the financial means to contribute to their families and develop leadership skills.
A Jhpiego-pioneered quality assurance approach, Standards-Based Management and Recognition, was shared with health care providers and administrators in an effort to improve services at facilities; measurable progress was made. In addition, health facilities were renovated and equipment upgraded.
“In terms of capacity building, systems strengthening and physical infrastructure, ACCESS, followed by MCHIP, has really supported Kano State government,” added Dr. Ashiru Rajab, Deputy Director of Primary Health at the Ministry of Health in Kano State.
But there’s more work that can be done.
“While there is an increase trend in the uptake of family planning services in Kano, a large number of women still have an unmet need for family planning,” said Dr. Yusuf Munkaila, Medical Director of the Sir Muhammad Sanusi Specialist Hospital. “There is a need to step up engagement of the religious and traditional leaders to understand the health benefits of family planning so that they can actively participate in advocacy efforts and disseminating messages that promote family planning as a means to improve maternal and newborn health.”
By Ann LoLordo
Women’s accounts of giving birth in community health centers and local hospitals in three districts in Indonesia revealed a series of problems with the care and service they received. The women’s stories, told to a team of visiting health professionals, detailed improper assessments, lack of monitoring, questionable management of labor and birth, difficult emergency transport, poor attitudes among providers and numerous out-of-pocket expenses.
The interviews with 45 women offer a unique perspective on conditions that may discourage pregnant women from choosing to give birth in a health facility with skilled attendants, a key contributor to reducing the deaths of mothers and newborns. These first-person accounts provide an opportunity for Indonesian health care providers—with the support of the U.S. Agency for International Development’s Maternal and Child Health Integrated Program (MCHIP)—to strengthen hospital referral services through a Jhpiego-pioneered quality assurance program that has been successfully implemented in Indonesia and 30 other countries with demonstrable results.
For more than 25 years, Jhpiego has worked collaboratively with the Indonesian government and other partners to help improve health care access and delivery in this nation of islands. This work has included building capacity among midwives, developing a model program for cervical cancer screening and prevention, and preparing health workers in prevention and treatment of avian influenza.
In two recent Jhpiego-supported programs, efforts to improve quality of care at health centers and clinics attended by midwives delivered substantive results. Health providers increased their competency in nine areas, ranging from antenatal care to infection prevention, and women received a higher quality of maternal and newborn services.
For example, when Jhpiego received support from British Petroleum and Rio Tinto in 2007 to improve maternal and newborn health care services in the district of Kutai Timur (pop. 250,000), many small, local health facilities were below standard, village midwives lacked basic emergency and newborn care skills, and poor infrastructure impeded women’s efforts to reach health centers to give birth.
Jhpiego’s pioneering Standards-Based Management and Recognition (SBM-R) approach helped administrators and staff at two community health centers identify problems and gaps in service, propose solutions and assess outcomes. The SBM-R approach gives health providers the means to develop and implement their own self-improvement program. It builds capacity by both motivating and rewarding employees who participate and encourages a sense of ownership in maintaining compliance with performance standards.
In Kutai Timur, to address gaps in knowledge and skills, an on-the-job mentoring program was devised for village and hospital midwives in basic and emergency obstetric care, infection prevention, and family planning counseling and services. Subsequent assessments showed steady improvement in antenatal care, labor and birth, newborn care, postpartum care, family planning, child immunization and infection prevention over the two years of the program, improving from an average of 69.4 percent to 87.9 percent in normal delivery care and from an average of 76 percent to 91 percent in infection prevention. Through the SBM-R approach, the midwives working in health clinics improved their level of care, meeting 90 percent of evidence-based standards, up from 50 percent.
MCHIP, which is led by Jhpiego, is presently working with six hospitals and 17 community health centers in the districts of Kutai Timur, Bireuen and Serang. SBM-R has been introduced in these facilities to identify problem areas and improve care and services. In just six months, the facilities have shown improvement, with some increasing their performance from 22 percent to 61 percent of the standards achieved.
A report from a midwife working in a small village health clinic in Teluk Pandan illustrates the impact of the program in helping to save lives. In May of 2010, the staff had their first complicated delivery since participating in the Jhpiego-supported training. A woman with prolonged labor had a breech birth and the umbilical cord was wrapped around the baby’s neck.
“We managed to deliver the baby, but it did not breathe,” wrote one midwife. “BEONC (basic emergency obstetric and newborn care) team consisted of me and two new midwives. After two minutes of using a resuscitation bag and mask, the baby finally breathes… . If there was no knowledge update from Jhpiego we might have failed to keep the baby alive.”
By Jorge Anez
Maputo, Mozambique—When newborns at Mavalane General Hospital in Maputo developed skin rashes, the suspected culprit was a new policy of encouraging skin-to-skin contact between mother and child. But the maternity ward’s health review team saw it differently. They decided to implement some new infection prevention measures to help control the outbreak while identifying its cause. For instance, they banned the traditional practice of wrapping a newborn in a mother’s dress and offered pregnant women the chance to take a bath after admission to the maternity ward. Within days of taking those simple steps, the rashes subsided.
The health team’s approach to resolving the problem is a prime example of the operational changes evident in Mozambique’s main obstetric hospitals, which grew out of the government’s commitment to improve health care delivery at these facilities. Through the use of a Jhpiego-pioneered quality assurance program, hospital staff are actively engaged in setting standards for service, identifying gaps in care, recommending solutions and assessing outcomes. The Standards-Based Management and Recognition (SBM-R) approach puts a priority on employee input and compliance and recognizes achievement.
This approach was introduced as part of the nationwide Model Maternities Initiative begun in the country’s largest emergency obstetric and newborn care facilities. The project grew out of a Ministry of Health (MOH) call for a comprehensive review of maternal, newborn and child health policies, guidelines and programs in October 2009. This work was done with funding from the U.S. Agency for International Development’s flagship Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego.
A year later, MCHIP-assisted programs, in partnership with the MOH, have shown measurable improvements in health care policy and service delivery that include:
• Development of 15 separate national maternal, newborn and child health strategies, standards and guidelines;
• Establishment of the Model Maternities Initiative in 34 of the busiest hospitals with emergency obstetric services, which account for 21 percent of all births in health care facilities nationwide; and
• Integration of reproductive health and family planning services with the country’s first ever national cervical cancer prevention program.
The goal of the Model Maternities Initiative is to provide a humane, caring environment in which women give birth and improve maternal and newborn health care services. The program encourages women to have a companion join them in the birth process and choose their birth position, and practice skin-to-skin contact between mother and child and immediate breastfeeding. During labor and delivery, birth attendants are urged to use the partograph to monitor labor and assist in decision-making and actively manage the third stage of labor.
“Mozambique, as in other African countries, is a place where many women have their babies outside of a health facility. Sometimes access to health services is not easy for them. Other times, they are afraid of not being well treated at the health facility and they feel more comfortable at home,” said Dr. Veronica Reis, MCHIP’s technical advisor on the program. “The biggest problem is that when complications occur at home with the mother or baby, the possibility of solving the problem or reaching a health facility in time to ensure the appropriate care is very limited.
“In this context, the MMI is a very important effort by the Mozambique government and partners because this initiative is focused on improving the quality of care and creating a good environment where the woman can feel respected, well treated and safe.
“The preliminary results from the implementation of MMI show an increase in mothers’ and families’ satisfaction,” said Dr. Reis. “It’s expected that, as the program continues, use of maternal and neonatal health services will consequently impact the health of Mozambican mothers and babies.”
Since the October 2009 launch of MMI, improved quality of care for women is becoming more routine in the maternity ward at Mavalane General Hospital. For example, in March 2010, hospital staff used active management of third stage of labor during the majority of the 820 births (520 or 63.4 percent). The same number of new moms also immediately put their babies on their chests as part of the skin-to-skin contact initiative. And lessons have been learned. As the skin rash outbreak showed, “it is extremely important to put in place simple measures for hygiene to prevent skin infections among newborns,” said Dr. Bernadina Gonzalves, the pediatrician in charge of the maternity ward at Mavalane General Hospital.
A key achievement resulting from the improved maternal health services under the Model Maternities Initiative has been an increase in the number of Mozambican women who choose to give birth in a health facility with a skilled birth attendant present, a critical factor in safeguarding the lives of mother and child. Through the Model Maternities Initiative, 318 skilled birth attendants have been taught emergency obstetric and newborn care skills and family planning.
As a result of this capacity building, health care services have been strengthened dramatically according to key indicators charted by participating hospitals:
• 44 percent of births have a completed partograph;
• 65 percent of births included active management of third stage of labor;
• 89 percent of women with pre-eclampsia/eclampsia were treated with magnesium sulfate;
• 59 percent of newborns have skin-to-skin contact with mother; and
• 57 percent of infants are breastfed within one hour of birth.
Targets were achieved in every area but complete use of the partograph, which helps health care providers monitor the progress of labor and make decisions about when further interventions are needed.
As a result of the integration of services, cervical cancer screening units have been established in nine rural and six referral health facilities. The women are screened in a single visit approach, a method championed by Jhpiego that uses the application of acetic acid (the main component in household vinegar) to detect pre-cancerous lesions of the cervix.
If such lesions are found, a health provider will immediately treat the cervix with a freezing agent that eradicates the cells. Women with a more serious condition will be referred for further treatment. Through this new national protocol, at least 4,791 women have been screened for cervical cancer. Of those, 341 were positive for pre-cancerous cells and 60 percent of these women received treatment for the pre-cancerous lesions on the same day.
Integrating cervical cancer screening with maternal health services is important because cervical cancer—the leading cancer killer of women in the developing world—is preventable. If symptoms are detected early, women can be treated successfully. Women who are HIV-positive are more at risk for cervical cancer and, in Mozambique where over 11% of adults are HIV-positive and a third of the population doesn’t know their HIV status, early screening is critical to saving lives.
By Abrar Muhibbul and Charlene Reynolds
Since her marriage nine years ago, Munni Manjari has given birth to six children. All but one has survived. She is just 25 years old and lives in the Sylhet area of northeast Bangladesh. When receiving maternal and newborn health care services from her local community health worker, Munni begged for some family planning options. But the health worker was neither trained nor equipped to provide such options to her. Munni’s repeated pregnancies have left her anemic, suffering from chest pains and generally weak. Her recurrent fatigue keeps her from working several days a week. With limited means, she and her husband, Kripa, can barely provide for their children, who range in age from four months to nine years old.
Like Munni, the women of Sylhet face an uncertain future because health services are scarce and poorly equipped. A group of Bangladeshi and U.S. health care professionals, Baltimore researchers and local community health workers are coming together to change that. They have joined together to educate women, men and families on the benefits of healthy birth spacing and to provide information on family planning options.
More than 2,200 mothers are participating in the Healthy Fertility Study, a collaboration of the Bangladesh Ministry of Health and Family Welfare, Jhpiego, two local nongovernmental organizations (NGOs)—Shimantik and the Center for Data Processing and Analysis—and the Johns Hopkins Bloomberg School of Public Health.
Previously supported by the ACCESS-FP Program, with funding through the U.S. Agency for International Development (USAID) from 2007 to 2010, the study is now supported by USAID’s Maternal and Child Health Integrated Program (MCHIP), which is led by Jhpiego, and Johns Hopkins public health researchers.
The study is already making a difference in the lives of the women participants.
The area of Sylhet has the highest fertility rate in the country—women there have about four children, compared to an average of about three in the five other divisions in the country. The maternal mortality ratio (MMR) is highest in Sylhet (471 per 100,000 live births, compared to the national average of 322), and the infant mortality rate is twice what it is elsewhere in the country, according to country health data.
But results from the Healthy Fertility Study so far show that women and their families are getting the message that pregnancies spaced too closely after a live birth or miscarriage carry very high risks for the mother and her newborn. Three years into the project, the use of family planning in the area is up—36 percent of women reported using contraception as compared to 18 percent in the comparison area at six months postpartum.
A key aspect of the project is providing community-based postpartum family planning along with maternal and newborn health services to women. This integration of services maximizes the benefits of the contact between the community health worker and the woman.
Community health workers—who are typically young, unmarried women with a tenth grade education—are trained to visit homes in their communities to identify pregnant women and educate women enrolled in the study about maternal and newborn health. They also provide information about postpartum family planning, supply oral contraceptive pills and condoms based upon the women’s fertility intentions, and make referrals to government and NGO health facilities for other contraceptive methods.
One effective method that new mothers can use is the Lactational Amenorrhea Method, in which breastfeeding women follow specific criteria in order to avoid pregnancy during the initial six months after a birth. After that period, women need to use other modern contraceptive methods to avoid unplanned pregnancies.
The recent results from the Healthy Fertility Study found exclusive breastfeeding rates were higher, at 38 percent as compared to 28 percent at three months postpartum. In addition, 94 to 95 percent of women in Sylhet said they had seen communications materials developed for the project and 87 percent said they attended a community meeting related to it.
“The Healthy Fertility Study is important because it is using innovative strategies that are helping Bangladeshi women avoid unplanned pregnancies,” said Catharine McKaig, a family planning specialist with MCHIP. “The study is helping women, men, families and communities understand that modern contraceptive methods can be used to ensure that pregnancies occur at healthy times, and avoided at unhealthy times.
“Findings from this study will influence how family planning is integrated in community-based maternal and newborn health care programming elsewhere in the world,” McKaig said.