Maternal and Newborn Health Conference for Zambias Mothers and Babies

Transcription

1 Maternal and Newborn Health Conference for Zambias Mothers and Babies Conference Summary Report 1st November 2012 The Intercontinental Hotel, Lusaka, Zambia Recorded by Eleonah Kapapa Written by Mercy M. Mbewe With support from Louise Smith, Vanessa Halipi and David Percy

2 Acknowledgements The conference organisers wish to thank DFID for providing funding to allow delegates from the provinces to attend and for funding the review paper, THET for the management of the survey and the Conference Advisory Group for their guidance. We would also like to thank colleagues at the Ministry of Health and the Ministry of Community Development, Mother and Child Health for their support and collaboration with this initiative. We also thank all presenters for their contributions and all those who submitted abstracts and displayed projects on the day. Finally we thank Zambian and international participants for attending and contributing their knowledge and experience to the discussions. 1

3 Contents Acknowledgements... 1 Contents... 2 Abbreviations Introduction Background to the conference Methodology of the conference Workshop participants Welcome remarks Keynote Address Key thematic outcomes Panel 1: Maternal, Neonatal and Child health Strategy in the MNCH Road map Survey of Maternal and Newborn health services in Zambia Overview of Community Health Workers Programme Midwifery Association of Zambia Panel 2: Safe Motherhood Action Groups Introduction and update on the implementation of Safe Motherhood Action Groups (SMAGs) Safe Motherhood Action Groups training in Mwinilunga District Africare Communication support for Health Mothers Alive Campaign Panel 3: Access to Care and Community Interventions CHAZ Community leadership: PMTCT Programme to improve health outcomes of HIV exposed babies Mobilizing Access to Maternal Health Services in Zambia (MAMAZ) Riders for Health Panel 4: Maternal Healthcare interventions Saving Mothers, Giving Life Endeavour (SMGL) Emergency Obstetric and Newborn Care (EmONC) signal functions and health facility capacity Role of Intensive Mentorship in Emergency, Obstetric and Neonatal care: the MCHIP approach Safer Anesthesia from Education (SAFE) Obstetrics: Improving maternal outcomes through training

4 2.4.5 Use of Misoprostol for Post-Partum Heamorrhage prevention in Home deliveries Panel 5: Newborn Health Care Interventions Newborn Health Scale Up Framework for Zambia: an Overview of the Newborn Strategy Newborn Care Training in Developing countries: the First Breath Clinical Trial Zambia Chlorhexidine Application Trial (ZamCAT) Lufwanyama Neonatal Survival Project (LUNESP) Key outcomes of the conference: setting priorities for action Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA) Traditional Birth Attendants Skilled Birth Attendants Increased involvement of Safe Motherhood Action Groups Volunteers and Community Health Assistants Community involvement NGOs and Coordinated Leadership Strengthening access to care Emergency care Finalization of the MNCP Roadmap Family planning Conclusion of the conference Appendices: Conference Programme List of participants Question and answer sessions Panel 1 - Maternal, Neonatal and Child health Panel 2 - Safe Motherhood Action Groups Panel 3 - Access to Care and Community Interventions Panel 4 - Maternal Healthcare Interventions Panel 5 - Newborn Healthcare Interventions

5 Abbreviations AIDS Acquired Immune Deficiency Syndrome ART - Antiretroviral Therapy ANC Antenatal Care CHW Community Health Workers DALY Disability Adjusted Life Year DHMT District Health Management Team ENC Essential Newborn Care EmONC Emergency Obstetric and Neonatal Care FBO Faith Based Organisation FP Family Planning GRZ Government of the Republic of Zambia HIV Human Immunodeficiency Virus INGO International Non- Governmental Organisation MCDMCH Ministry of Community Development, Mother and Child Health MCHIP Maternal and Child Health Integrated Programme MDG Millennium Development Goal MMR Maternal Mortality Ratio MNCH Maternal Newborn and Child Health MNH Maternal and Newborn Health MoH Ministry of Health MOU Memorandum of Understanding MTCT Mother to Child Transmission NGO - Non- Governmental Organisation NRP- Neonatal Resuscitation Programme NMR Neonatal Mortality Rate PPH Post Partum Hemorrhage PMTCT Prevention of Mother to Child Transmission SBA Skilled Birth Attendants SMAGs Safe Motherhood Action Groups SMGL Saving Mothers Giving Life ST Sample Transport TAT Turnaround times TBA Traditional Birth Attendant VCT Volunteer Counseling and Testing WHO World Health Organisation 4

6 1. Introduction 1.1 Background to the conference The Zambia UK Health Workforce Alliance (ZUKHWA) is a network of seventy UK and Zambian organizations who work together to promote and improve the coordination and impact of Zambia- UK joint work in health. ZUKHWA s main objective is to support the Government of the Republic of Zambia through the Ministry of Health and the Ministry of Community Development, Mother and Child Health, to achieve its national strategic plan and global health goals. This current initiative is to support the Zambian government to achieve the Millennium Development Goals 4 and 5 around maternal and child health. The conference was held to bring together Zambian and international stakeholders, partners and NGOs to critically evaluate what is happening now, and the next steps to improve maternal and newborn morbidity and mortality Methodology of the conference A highly interactive approach was used; the plenary and discussion group sessions were aimed at setting priorities for further action, in order to accelerate the attainment of improved maternal and child health services. The questions and answers after each set of presentations were collated into issues for the Ministries and cooperating partners to consider further. These issues were presented by discussion table leaders and then further discussed in a plenary session. The outcomes of the discussion sessions have been included in appendix Workshop participants Participants were drawn from both governmental and non-governmental organizations, cooperating partners, and other individuals working or involved in providing support and conducting research towards accelerating the improvement of maternal and child health. 1.2 Welcome remarks Session Chairperson: Dr P. Mwaba, Permanent Secretary, Ministry of Health Dr Mwaba welcomed participants and said how pleased he was that the conference was finally in session. A special welcome was extended to Prof E. Chomba, Permanent Secretary at the Ministry of Community Development, Mother and Child Health and Lord Nigel Crisp from the UK. Apologies were given from the Minister of Community Development, Maternal and Child Health Development, who was unable to attend the meeting due other commitments. Welcome remarks by Prof E. Chomba, Permanent Secretary, Ministry of Community Development, Mother and Child Health Whilst the health sector has made progress in improving maternal and child health indicators, more effort needed to reach the MDGs targets on maternal and child health; 70% of childhood illnesses are preventable and require community involvement. Targets for improving Maternal (MDG 5) and Child 5

7 health (MDG 4) have to be addressed in combination with reducing poverty (MDG 1), improving water and sanitation (MDG 7) and reducing HIV (MDG 6). Good policies have been developed, but interventions are not yet implemented with the full participation of those in the community. The Ministry of Community Development, Mother and Child Health aims to empower every household to live a productive, healthy and useful life. This will be achieved through interventions which: Promote, prevent and treat disease in women and children; Address the challenges surrounding delays in decision making, delays in accessing health services and delays at health facilities; Address the lack of holistic care in the health facilities, where symptoms not the disease are treated and where the influences of poverty, high fertility rates, inadequate access to safe water and sanitation and poor nutrition are ignored; Provide a social cash transfer of funds to vulnerable and poor people in the community and community self-help programmes; Provide health promotion, growth monitoring, and family planning; Provide skills and training for youths, which incorporate prevention programmes targeting adolescents; Provide food security packs targeting malnourished clients in the health facilities; Integrate services to ensure good health and poverty alleviation Welcome remarks and Objectives of the Conference: Lord Nigel Crisp. Lord Crisp welcomed everyone to the conference and expressed his pleasure at working with both Permanent Secretaries. He stated that the conference was being held to specifically support Zambia s plans on maternal and newborn health. He also expressed his thanks to over 100 organisations who had shared their experiences through a survey which reviewed and mapped initiatives in maternal and newborn health in Zambia, to the 30 organisations who presented abstracts for the conference, and finally to those who put up project displays in the conference hall. Lord Crisp then outlined the following conference objectives: a) To share local experiences and identify evidence based interventions that will accelerate attainment of improved maternal and child health services; b) To present current activity in maternal and newborn health services in Zambia and consider this in relation to international best practices; c) To develop recommendations to rapidly improve maternal and newborn mortality and morbidity. 6

8 1.3 Keynote Address The Honorable Minister of Community Development, Mother and Child Health, Dr. J. Katema Delivered By Prof E. Chomba The Keynote address highlighted some of the major issues in maternal health in Zambia, and called for resolutions to move forward. Maternal mortality presents a great challenge to Zambia and it is unacceptable that pregnancy in Zambia still results in 591 maternal deaths per 100,000 live births, where the global average is 210 per 100,000 live births. Zambia faces challenges in the shortage of skilled workers and material resources, poor health infrastructure and difficulties of access to healthcare provision due to long distances and poor road conditions. These challenges are also aggravated by poor water and sanitation as well as a high HIV prevalence. The poor and most remote communities bear the heaviest burden, due to a lack of access to skilled birth attendant s which increase the rates of maternal mortality. The ministry recognise their responsibility in improving the lives of women and children, especially of those in poorer communities. The ministry will do this by providing more comprehensive and targeted delivery of services to accelerate the reduction of maternal and neonatal mortality. A team effort is required, involving all levels of society, from communities to traditional leaders and other influential networks right up to the policy makers. We should all leave this conference with plans and resolutions and the momentum to move forward and achieve our goals of MDG 4 and 5. 7

9 2. Key thematic outcomes Five thematic sessions were presented which led onto questions and discussions. The presentations and subsequent discussions were carried forward to priority setting in table discussions later in the conference. 2.1 Panel 1: Maternal, Neonatal and Child health Strategy in the MNCH Road map The MNCH road map is a strategic document that highlights the need to address the problems of high maternal, neonatal, infant and under-5 mortality rates in Zambia over the next 10 years. The goal of the MNCH road map is an accelerated reduction of maternal, newborn and childhood morbidity and mortality to attain MDG targets by To reduce maternal mortality from 591 to 162 per 100,000 live births To reduce neonatal mortality from 34 to 20 per 1,000 live births To reduce Under-5 mortality rate from 119 to 64 per 1000 live births There are a number of issues surrounding the high Maternal Mortality Ratio (MMR) and Neonatal Mortality Ratio (NMR) in Zambia. For example, to train or not to train TBAs, the three delay model; reduced funding affecting outreach services, reduced human resources and rural versus urban disparities. Key strategies to be implemented were outlined as follows: 1. Five critical phases in the lifecycle of women and children were recognised in the continuum of care approach; 2. Using a three dimensional approach in coming up with strategies and interventions to ensure engagement and synergy between the health system, communities, other line ministries and the private sector; 3. Strengthening partnerships with the donor community and the private sector for sustainable long-term predictable financing to achieve universal coverage; 4. Advocacy and resource mobilization to increase the budget allocation for MNCH interventions from internal and external resources; 5. Revising laws and policies hindering the effective provision of MNCH services; 6. Improving the production, employment, deployment and retention of a skilled health workforce at all levels; 7. Institutionalising maternal death reviews; 8. Health system strengthening and capacity building for MNCH; 9. Community mobilization by educating and sensitising communities on community-based MNCH interventions and behaviour change communication approaches for quality MNCH; 10. Fostering partnerships and accountability and effective implementation of this MNCH strategic plan; 8

10 11. A monitoring and evaluation framework addressing one set of agreed indicators for maternal, newborn and child health interventions. The implementation of this roadmap will include a multi-sector approach to increase access to health services. This will involve the MCDMCH and Ministry of Health, other ministries, the Disaster Management and Mitigation Unit and cooperating partners such as NGOs and the private sector Survey of Maternal and Newborn health services in Zambia This survey to map maternal and newborn initiatives across Zambia was requested by the Ministry of Health and the Ministry of Community Development Mother and Child Health. The survey covered faith based, community based and non-governmental organizations. It was revealed that, whilst health organizations are present in every district, there is an uneven geographical spread. There is a higher concentration of initiatives in the health centres of more densely populated areas and not enough initiatives in the health centres in rural areas; this was particularly evident in the Western and North Western Provinces. The pattern was similar to the number of health staff vacancies and it was noted that many rural health centres are being run by unskilled workers. This uneven geographical distribution is affecting rural access to care and thus the maternal and neonatal mortality rates. The survey revealed that projects were using a wide variety of best practice models. Whilst many of these come from reputable international sources, it would be beneficial to have a more coordinated and harmonized approach to best practice in Zambia. The types of interventions showed an understanding of the importance of a continuum of care. There was a strong emphasis on promoting facility based births with a Skilled Birth Attendant, early antenatal care, engaging traditional leaders, promoting birth planning, malaria prevention, spreading knowledge of danger signs in pregnancy as well as infant and child nutrition. However, clinical interventions such as EmONC were less frequently addressed. Sixty percent of programmes applied community engagement processes in implementing their interventions. The results indicated that: A more strategic distribution of interventions is required; Community engagement is an important component of the continuum of care; Community Health Workers (CHWs) and Safe Motherhood Action Groups (SMAGs) are able to increase the demand for and uptake of health services; Distance and poor road infrastructure remains an obstacle for many women Overview of Community Health Workers Programme It has been observed that Zambia s health sector has a serious human resources shortage and that this is a key obstacle to reducing disease burden and achieving MDGs by A situational analysis revealed that CHW training was not standardized, the duration of study was varied and not aligned to the diverse community health needs and that 23,500 CHWs are needed in Zambia. In addition, incentive structures varied and the MoH had no policy to guide the management of CHWs; this lead to the development of the National CHW Strategy within the Human Resources for Health Strategic 9

11 Plan. The plan includes a pilot, a phased expansion, and recruitment and selection criteria along with a monitoring framework of integration into the national healthcare system. The one year training programme for Community Health Workers/Assistants offers 11 modules using an integrated and skills-based learning model with a focus on primary health care. The graduates are then registered with the Zambian Health Professions Council. A total of 307 Community Health Assistants have graduated and have since been deployed at selected health posts and 2500 posts have been established. Following a curriculum review, changes to the CHWs scope of work have been proposed; Family planning, HIV testing and couple counseling; Provision of antenatal care (ANC) and life-saving skills during delivery; Skills to conduct emergency delivery procedures and referring mothers to deliver at a health facilities; Administration of Misoprostol in emergency situations; Providing postpartum care at household level; Male reproductive health issues such as promotion of voluntary male circumcision for infant and adult males at community level; Nutrition using an integrated approach in all modules; Provide an integrated Voluntary Counseling and Testing services for adults, children and pregnant mothers; A disease prevention and control package Midwifery Association of Zambia In Zambia, the number of midwives deployed to provide sexual and reproductive health services, especially maternal health services, has remained very low for a long time. According to the MoH Training Operational Plan (2008) there were 2,273 midwives in the country for all maternal, neonatal and child health (MNCH) services. Midwives play a primary role in healthcare delivery; therefore the improvement of pre-service and in-service midwifery education can contribute to improved performance of the entire health care system. MAZ intend on expanding the number of midwives through providing collaborative education with several national and international partners. MAZ also have plans to ensure that all women in Zambia have access to skilled birth attendants. These plans include; a. Providing the women and their partners education and counseling on the importance of facility delivery; b. MAZ will be engaged in capacity enhancement programmes for Midwives and advocating for the improvement of the health of women and families; c. Increasing the availability and utilization of quality ANC services including PMTCT; d. Improving access to skilled attendance at delivery including emergency obstetrical and neonatal care; e. Increase availability and utilization of youth friendly FP and HIV and AIDS prevention services. 10

12 2.2 Panel 2: Safe Motherhood Action Groups Introduction and update on the implementation of Safe Motherhood Action Groups (SMAGs) The Maternal Mortality Ratio in Zambia is one of the highest in the world, standing at 591/ live births. The Safe Motherhood Action Groups (SMAGs) were established at community level in 44 districts to address challenges in safe motherhood, which include the 3Ds (decision making at community level, delay in accessing a health facility because of lack of transport and delay in receiving care at health facility). The objectives of SMAGs are as follows: Strengthening community participation in maternal, newborn, and child health; Improving community knowledge on safe motherhood issues through health education; Enhancing the community s utilization of reproductive health services; Increasing male involvement in safe motherhood activities; Strengthening partnerships between the community and health system. For SMAGs to significantly improve maternal and newborn health, they are involved in health education, maternal and child nutrition, income generating activities, outreach activities and involvement in the management of patients with obstetric fistula. They are motivated groups, whose activities are supported through materials such as ID cards, SMAGs Bags, SMAGs T-shirts, flip charts for training and sensitizing communities, and bicycle ambulances for transferring patients with complications. Where SMAGs are fully involved there have been notable improvements in health seeking behavior, reduction in maternal and child mortality and increased first ANC visits. Nonetheless there are problems, including the maintenance of the bicycle ambulances, despite communities having agreed to maintain them through contributions from Neighborhood Health Committees and user fees Safe Motherhood Action Groups training in Mwinilunga District Mwinilunga district trained SMAGs with support from the Zambia Integrated Systems Strengthening Programme (ZISSP) and American College of Nurse Midwives (ACNM). The aim of the training was to institutionalise SMAGs to improve mothers and newborn lives. In order to ensure effective training, various teaching methods were utilized, such as the use of storytelling and picture cards during teaching. This was particularly beneficial to participants who were unable to read. A total 82 SMAGs were trained. It was observed that, whilst mobilising communities can be very expensive, empowering communities with skills and knowledge can reduce MMR. The methodology used also made learning a lifelong experience. 11

13 2.2.3 Africare Mobilizing communities to reduce maternal mortality This project focused on the critical need to generate informed community demand for high quality maternal and child health services, in order to reduce maternal and neonatal deaths. SMAGs were trained using a Lead SMAG and Health Post SMAG and were able to reach 53,000 households with health education messages to improve care seeking behaviors, as well as providing access to a variety maternal and child health services (family planning, access to prenatal care and skilled birth attendants). Six hundred and twenty five community leaders were orientated to promote the best cultural practices to protect the interests of women and children. Antenatal visits increased from 21% to 69%; Institutional deliveries increased 64% from to 92% and postnatal attendance at 6 days increased from 33% to 82%. In addition there was significant reduction in obstetric fistula through sensitization by the SMAGs and community volunteers and increased access to surgery for women with fistula was provided Communication support for Health Mothers Alive Campaign This campaign is a strategy to contribute to the reduction in maternal mortality from 591 to 162 per 100,000 live births. This was to achieve an increased demand for the use of contraception; early initiation of ANC, attending at least 4 ANC visits, facility-based delivery and post-partum follow up care. In order to achieve the objectives of the campaign, mass media and community strategies were applied through partners and also by introducing Change Champions. These Change Champions are described as: Traditional and political leaders trained to use their influence to motivate families in the utilization of maternal services. These champions then work with sub-leaders, the health centers, SMAGs and community groups to discuss issues with communities. The leaders from different communities then share successes, challenges and possible solutions. The Change Champions are shown a documentary featuring the work of other leaders who, without external support, have reduced or eliminated preventable maternal deaths in their area. Leaders are given a guide book as well as a set of communication tools; this approach has resulted in leaders reporting feeling better equipped, enabled and motivated to save mothers lives. The key messages from this project included; Community development or intervention must involve the key leaders rather than subordinates, Distribution channels for materials must be well defined, Change Champions must ensure that they are connected to or a part of the health system. 12

14 2.3 Panel 3: Access to Care and Community Interventions CHAZ Community leadership: PMTCT Programme to improve health outcomes of HIV exposed babies. This study was conducted at a hospital with an antiretroviral therapy (ART) programme where there are high HIV prevalence rates among pregnant women. MTCT was at 9.5% among hospitalized patients and at 50% among home deliveries in This was due to long distances to the health facilities, traditional beliefs and few PMTCT interventions happening. In order to improve PMTCT outcomes, an HIV prevention strategy that embraces all community members was developed; this involved sensitizing the local Chief to gain support. Mothers were encouraged to join support groups that enabled networking and fighting against discrimination. Adherence support workers were then recruited to help client (mother and their infant) defaulter tracing. Men were also involved through the community leaders and hospital staff in attending antenatal clinic visits with their wives. HIV+ women in their third trimester of pregnancy were encouraged to stay at the maternity waiting home if they lived a long way from the health facility and all ANC clients were encouraged to undergo VCT as a couple. This PMTCT intervention at community level has had a positive impact. The community leadership embraced the initiative and decreed that all women should deliver at a health facility. If a woman failed to do so, she would be fined one goat. 72 HIV positive women who delivered at the health facility benefited from the programme which resulted in 93% babies testing negative for HIV Mobilizing Access to Maternal Health Services in Zambia (MAMAZ) An Innovative and Scalable Community Engagement Approach for Increasing Access to Maternal and Newborn Health Services One of the main objectives of MAMaZ is to improve access to, and utilization of, routine and emergency maternal and newborn care through community-based interventions. The intervention was carried out in six districts to test how communities can be effectively mobilized around a maternal and newborn agenda. It also tested how to establish and sustain community systems to address key barriers preventing the timely utilization of services. The community engagement strategy for increasing access to maternal and newborn health services has four main components: (1) community mobilization processes; (2) the establishment of community response systems; (3) community monitoring systems and (4) a mentoring and coaching support system. Five districts also have a fifth component: a facility-based emergency transport system. Using a holistic community approach, generating approval for behavior and capacity building has been essential to sustaining the changes. Communities have also established a number of community emergency systems, comprising community savings schemes, community emergency transport schemes (ETS). A social fund, part of the community savings schemes, has served as an incentive for communities to save and apply for grants as well as using the money to support or extend community emergency systems. This fund created high level of interest and exceeded targets for the number of beneficiary communities. 13

15 Facility based emergency transport systems, particularly the use of motorbike ambulances, have been used within a ten kilometre radius of the health facility and used by staff with lifesaving skills. Emergency treatment can be given en route to stabilize critical cases and patients with complications can be transported to meet district ambulances. The results of the intervention show that the Community ETS contributed to the provision of affordable and reliable transport. The utilization of this has been beneficial and more pregnant women want it as a safety-net. Deliveries by a skilled birth attendant increased over time and, by the end of the programme, targets for Skilled Birth Attendants (SBA) had been exceeded in three out of six districts (Choma, Chama and Mkushi). Four out of six districts reported an increase in deliveries including post-natal care. Other changes included an increase in support for mothers and their babies and a change of attitudes towards gender based violence Médecins Sans Frontières The Bicycle Ambulance: the experience of MSF in Luwingu District In Luwingu district, 92% of the population live in remote rural areas. 67% of births take place at home attended by TBAs and only 33% take place at a health facility. In this programme, the objectives were to increase facility based delivery and improve community awareness of the importance of referral in the presence of pregnancy danger signs. In order to achieve the objectives, a community based transport system was introduced in the district using the modified bicycles known as Zambikes. Eight zones participated and training was conducted among leaders, SMAGs and community health workers. The implementation of this emergency transport required the utilisation of existing community support networks. The bikes were used for the referral of women with pregnancy danger signs and those in need of postnatal or neonatal care. The Zambikes were considered to be a feasible, cost effective and scalable way of increasing facility based deliveries Riders for Health Transport reducing delays in accessing laboratory based testing. This programme focused on providing reliable, scalable, cost-efficient and appropriate transport solutions for laboratory based testing of medical samples, with an emphasis on rural access and difficult terrain. Partnering with the District Health Office, the sample transport (ST) system was piloted for effectiveness by examining testing volumes and turnaround times (TATs) from sample collection to the return a result to health facilities in Chadiza district. The outcomes of the pilot revealed that the average TAT decreased by three days, from 11 days before to 8 days after introducing the ST. Each ST courier transported samples per month in 2010, in 2011, and between Jan and May As a result, this contributed to early initiation of ART and an increase in access to laboratory based testing for women and children. 14

16 2.4 Panel 4: Maternal Healthcare interventions Saving Mothers, Giving Life Endeavour (SMGL) The Saving Mothers, Giving Life initiative is being run under the US Government, as part of President Obama s Global Health Initiative. It is committed to supporting the acceleration of improvement in maternal health in four pilot districts. The initiative is a collaboration of USAID, CDC, Peace Corps and The Department of Defence, as well as other implementing partners committed to reducing maternal mortality by 50% in the four districts. The aim is to achieve this through increasing the availability and use of high impact maternal health services particularly in labour, delivery and the immediate postpartum period. This is achieved through the 121 health facilities and multi-level interventions such as Community Sensitization, SMAGs, empowerment of the DHMT, facility upgrades, training, education and mentoring. Activities included: Establishing district and community leadership or empowerment taskforces to develop SMGL implementation or action plans; Rolling-out the Essential Medicines Logistics Improvement Programme (EMLIP); Hiring 20 contract nurses for health centres with no SBAs; Reinforcing GRZ leadership at central and district level through chairing monthly partner meetings in Lusaka; Creating functioning maternal death review committees. There is a multifaceted plan to evaluate the impact of SMGL through a detailed survey of all health care facilities at baseline and endline, to document the services available. In addition there is a rollout of Smart Care to capture all pregnancies as well as ANC. Baseline household surveys with verbal autopsies were also conducted to determine the true baseline MMR. Finally the plan supported robust maternal mortality reviews and monitored the implementation process. Challenges were encountered with poor electricity supply, staff monitoring, data for quality improvement, improving electronic health records and linking maternal and child health services Emergency Obstetric and Newborn Care (EmONC) signal functions and health facility capacity Baseline evaluations of the Saving Mothers, Giving Life in pilot districts in Zambia The causes of MMR are preventable. Every 60 minutes a woman dies from pregnancy related complications yet the rate to reducing MMR is slow, with less than half of the pregnant women delivering at health facilities attended by skilled birth attendants. Effective EmONC can contribute to the reduction of MMR. The evaluation for Saving Mothers, Giving Life (SMGL) was conducted in 120 facilities in 4 districts of Zambia. The survey revealed that one Skilled Birth Attendant per health facility may not provide the services required and gaps also existed in the availability of electricity, water, radio communication and transport. It was also revealed that there was substantial unmet need for life saving obstetric 15

17 and neonatal care services, in particular basic EmONC facilities. In order to significantly reduce the maternal and neonatal morbidity and mortality a comprehensive and sustainable increase in human resources, clinical skills, physical infrastructure and essential supplies and equipment is required Role of Intensive Mentorship in Emergency, Obstetric and Neonatal care: the MCHIP approach The design of this initiative involved training a team of 16 Mansa District mentors in mentoring skills, using Institute of Rural Health Supervisory Tools and EmONC skill checklists as well as the use of anatomic models to guide on-site clinical simulations, data collection, support and reporting. A trained team of 2-3 mentors visited each delivery facility on a monthly basis and also held quarterly recognition or clinical update meetings with staff representatives from all facilities. The outcomes of this approach have been successful. Staff acquired immediate and sustainable skills, improved health provider confidence and improved morale. The health centres were also able to manage complications in pregnancy and delivery; for example they were able to carry out the manual removal of a placenta, which improved the outcomes for the pregnant women. They also reduced the pressure on emergency transport systems and referral facilities. An increase in mentoring has been observed (0.06% to 15%) and there has been improved documentation in service delivery registers. What was learnt from this district was the positive impact of strong leadership including ownership by Mansa District Health Office, the involvement and collaboration with other partners and the use of anatomical models for on-site clinical simulations Safer Anesthesia from Education (SAFE) Obstetrics: Improving maternal outcomes through training Worldwide 360,000 childbirth related deaths occur each year, mostly in most in low and middle income countries. The most common causes of death are bleeding, infection, unsafe abortions, eclampsia and obstructed labour. The SAFE Obstetrics programme is aimed at improving the clinical management of life-threatening emergencies by anaesthetic practitioners. This is a three day course focusing on the leading causes of death and resuscitation of the mother and child. It is run by an overseas faculty with identification of potential local teachers. On the fourth day a Train the Trainer course is conducted among local delegates identified as potential trainers. The course is handed over once the local trainers were self-sufficient and can cascade the training to the provinces. The course has been piloted and run in Uganda, Liberia and Ghana since 2011 and is due to start in Zambia in

18 2.4.5 Use of Misoprostol for Post-Partum Heamorrhage prevention in Home deliveries In this pilot project Misoprostol was distributed in ten districts with high home deliveries. Following this, an in-depth interview was conducted among twenty eight women in three districts (Chongwe, Mumbwa and Mwense) who had been given the Misoprostol tablets during antenatal visits. The outcomes of this pilot study demonstrated that women showed an understanding of the purpose of Misoprostol, when to take the drug (i.e. after the delivery of the baby), precautions (ensuring that the woman is checked for a second baby before she swallows misoprostol) and the common side effects. After collecting Misoprostol during ANC some women discussed the drug with spouses, friends, and relatives. However some women did not discuss the drug with anyone. The women showed an understanding of the need for good, appropriate storage. In terms of community myths there was a general appreciation of Misoprostol although, some felt it may negatively affect fertility and the fetal development in future pregnancies. Being in possession of the Misoprostol tablets did not influence womens birth plans and decision to deliver at home, this was usually due to other, extenuating, circumstances. In view of these findings, future Post-Partum Hemorrhage (PPH) prevention programmes in similar rural settings should consider antenatal distribution of Misoprostol in areas with high rates of home deliveries or limited access to skilled providers and supplies. Secondly, community level myths and misconceptions need to be addressed. Finally additional guidance regarding the timing and sequence for correct use of Misoprostol to prevent PPH should be provided. 2.5 Panel 5: Newborn Health Care Interventions Newborn Health Scale Up Framework for Zambia: an Overview of the Newborn Strategy The goal of the scale up is to accelerate the reduction of neonatal morbidity and mortality. The rationale behind this is that two thirds of newborn deaths could be prevented with a higher coverage of essential maternal, newborn and child health service packages. It is also important to consider the critical time periods of pre-pregnancy, pregnancy, labour, delivery and the first 1-2 hours of life up to late the neonatal period (weeks 2-4 ). The scale up therefore focuses on three strategic objectives which will guide programming and selection of interventions. These include strengthening capacity to improve newborn health care at all levels of the health care system, increasing the availability, access and utilization of high quality newborn health care services and empowering communities to improve community maternal and newborn health care practices, across the continuum of care. The opportunities for this scale up cover the following: policy and planning, national pre-service and in-service training, expanding promising national interventions and pilot programmes, community and facility based strategies. 17

19 2.5.2 Newborn Care Training in Developing countries: the First Breath Clinical Trial Ninety eight percent of stillbirths and neonatal deaths occur in the developing countries. This includes Zambia, where an intervention was demanded to reduce the NMR. The First Breath Clinical Trial was used to train the trainers who in turn train midwives who conduct deliveries in 18 low risk health birth centres in Lusaka and Ndola. The training of midwives consisted of data collection; WHO Essential Newborn Care and the American Academy of Paediatrics Neonatal Resuscitation Programme (NRP). 71,689 pregnant women were enrolled in the study. The results showed that the 7 day neonatal mortality rates reduced from 36.5 deaths to 25.1 per 1,000 live births after the Emergency Neonatal Care (ENC) training this was due to decreases in death rates attributed to birth asphyxia and infection. There was a further decrease in deaths in the 7 day neonatal mortality rates to 15.9 per 1,000 live births after the Neonatal Resuscitation Programme training. A cost effectiveness analysis was carried on the ENC training packages. A study in the first level delivery clinics in Lusaka and Ndola showed it was very cost-effective in first level facilities ($5 per DALY) Zambia Chlorhexidine Application Trial (ZamCAT) Umbilical cord infections and sepsis are leading causes of neonatal morbidity in low resource countries. In Zambia, neonatal mortality accounts for 29% of under-five mortality, with infection responsible for 30% or more of neonatal deaths. The objective of the study was to determine whether Chlorhexidine cord cleansing is more effective than dry cord care for prevention of neonatal mortality in the Southern province of Zambia. This was a cluster randomized effectiveness trial of 4% daily Chlorhexidine umbilical cord cleaning compared to dry cord care. In order to carry this out, pregnant women were enrolled in the study in the second and third semester and were asked where they intended to deliver. The results from the analysis of delivery plans for 9,816 pregnant women showed that of 93% who indicated plans to deliver at health facility, only 63% actually carried out this plan. Women who delivered at home tended to be older. The reasons for home delivery included distance, finances, family pressures, short duration of labour, and lack of transport. Once recruitment and follow up of pregnant women and their newborns have been completed, the data will contribute evidence on the effectiveness of Chlorhexidine for reducing neonatal mortality Lufwanyama Neonatal Survival Project (LUNESP) This project sought to establish whether, in communities with limited access to health care, it was possible to reduce neonatal mortality by training TBAs in skills that address some of the most important causes of neonatal mortality; notably birth asphyxia, neonatal hypothermia, and neonatal sepsis. 18

20 This was a randomized intervention with two study groups. In one group training was given in Neonatal Resuscitation Protocol including providing a single dose of amoxicillin coupled with facilitated referral of infants to a health centre. In the second group, the control TBAs continued their existing standard of care. The results of this trial indicated that the intervention was highly effective in reducing neonatal mortality, with 45% reduction in all-cause mortality by day 28 (primary endpoint); the neonatal mortality rate decreased by 18 per 1000 live births. Secondly, the largest impact was in the earliest days of life; on the day of birth a 60% reduction in NMR was seen and during week one a 44% reduction in NMR was achieved. Finally NRP appeared to be the most effective component of interventions, as birth asphyxia deaths reduced by 70-80%. 19

21 3. Key outcomes of the conference: setting priorities for action After a day of presentations and discussion regarding interventions in maternal and newborn health from key stakeholders working in Zambia (see the attached programme), the final session of the conference asked the conference delegates through round table discussions to consider key priorities or issues for ongoing discussion, between the Ministries, Cooperating and Implementing Partners, to rapidly accelerate the reduction of maternal and newborn mortality in Zambia. The following is a summary of the outcomes of the discussions and the issues and priorities presented by each table leader on behalf of his/her table during the plenary discussion. Issues for further consideration are in bold and numbered in each relevant section. 3.1 Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA) The current health strategy in Zambia is to have a health system where all mothers and newborns should be looked after by a Skilled Birth Attendant. However, it will take time to train and deploy Skilled Birth Attendants. Conference delegates discussed whether, in the short term, Traditional Birth Attendants should be trained in some of the relevant competences to make them safe practitioners Traditional Birth Attendants It is estimated that Traditional Birth Attendants are engaged in the delivery of 23% [31% in rural areas and 5% in urban areas] of babies in Zambia; meaning that some babies are being delivered at home by TBAs, who may not be able to recognize or manage potential complications. A further 25% of babies are delivered by a family member and 5% of women are alone during delivery. Delegates discussed the fact that the involvement of TBAs in deliveries will not change in the short term. It was recommended by a majority of participants that, in the short term, TBAs should be trained to recognize danger signs in pre, intra and post-partum care, to help them to refer mothers in a timely fashion to the next levels of care. Further it was proposed by some delegates that in the short term, when an SBA is unavailable, TBAs should be trained to have the competences to deal with some basic and emergency care of both mother and baby. Some disagreed with this recommendation stating that TBAs should not be trained but more effort should be made to increase skilled health workers. Below are issues for further consideration as presented by table leaders related to TBAs; 1) Provide TBAs with training and mentoring to equip them with the competences to provide safe and comprehensive care from family planning through to postnatal care, as well as basic lifesaving skills. For example, being able to administer Misoprostol to manage postpartum hemorrhage and equipping them with the competences to help babies breathe. 2) Develop a transition strategy for the redeployment of TBAs once SBAs are available. 20

22 3.1.2 Skilled Birth Attendants Delegates noted that no country has turned around its MMR and NMR without skilled birth attendants. Below are issues for further consideration as presented by table leaders related to SBAs; 3) They endorsed the current plans to increase the capacity of training institutions to increase the output of nurse/midwives. It was suggested that the ministries and international donors continue to work together to plan and resource a rapid increase in training capacity. 4) They encouraged the ministries to review the policy framework for staff establishment to ensure the employment, deployment, retention, supervision and continued training of SBAs in all health settings including 24 hour coverage of health facilities. 5) Encourage the ministries to review the curriculum to develop health professionals with the required competences in maternal and newborn health, including lifesaving skills. Some delegates suggested that graduates should be both a nurse and a midwife through shortened courses. 3.2 Increased involvement of Safe Motherhood Action Groups Delegates noted that the government of Zambia responded to the challenge of providing a continuum of care by supporting pilot programmes to establish Safe Motherhood Action Groups (SMAGs) at community level. A framework has been established for the national scale-up of SMAGs, through a standardized training package. During the conference evidence was presented on the effectiveness of SMAGs and it is anticipated that when further evidence is available this will guide future SMAG interventions. Below are the issues to be considered further as presented by each table leader in relation to SMAGs 6) Increase the number of SMAGs to cover all districts. 7) Expand the role of SMAGS to include antenatal, intra-natal and post-natal care and family planning. 8) Strengthen SMAGs competences so that they can further develop their community interventions. 3.3 Volunteers and Community Health Assistants It was noted by delegates that Community Volunteers and Community Health Assistants are offering services that address maternal and newborn care and they also noted that accountability of volunteers to the health system is weak. Below are the issues to be considered further as presented by table leaders related to Volunteers and Community Health Assistants. 9) Developing a volunteer management and coordinating system needs to be considered, to include equitable remuneration, supervision and accountability mechanisms. 21

23 10) Reconsider the term Volunteer as it does not carry authority, and define accountability or remuneration. 11) That Community Health Workers/Assistants should complement the role of nurse/ midwives and there should be a degree of task sharing or task shifting. 12) They supported the training of Community Health Assistants and that they take on key roles [especially with the introduction of an expanded curriculum] in reproductive, maternal and newborn health. 3.4 Community involvement The potential positive impact of community leaders on best practice in maternal and newborn health was highlighted in discussion. Below is the issue to be considered further as presented by table leaders related to community leaders 13) Engage with Chiefs, Traditional Leaders, Head Men and Church Leaders in all districts to encourage them to be advocates for safe maternal and newborn health practices. 3.5 NGOs and Coordinated Leadership The conference survey and other evidence confirmed that there are a large number of organizations (INGOs, NGOs, FBOs etc.) working in maternal and newborn health in Zambia. There is currently no clear strategy, coordination or rationalization of the many organizations involved. The survey showed that best practices informing activities in MNH are numerous and diverse. Table leaders issues for the Ministries to consider further are: 14) Ministries taking the lead in the coordination and geographical distribution of organizations working in MNH through an MOU and rules of engagement which include the use of human and financial resources. 15) Developing best practice guidelines which organizations should use to guide activities in MNH. 3.6 Strengthening access to care It was noted that Zambians have difficulties in access to care in rural areas due to the distances to health facilities and poor road infrastructure, particularly in the wet season. Table leaders presented the following issue for further consideration: 16) The ministries should consider providing patient transport to each health facility and make resources available to maintain them. These could be community managed (including bicycles, motorbikes or boats) and delegates further recommended that the service should be free to expectant mothers. 22