FIGO World Congress, Rome 7th12th October 2012

HUMANIZING CHILDBIRTH IN MOZAMBIQUE

Panel - Respectful care: A dimension of quality maternal care Presenter: Dr. Veronica Reis, MCHIP Technical Advisor Wednesday, 10 October, in Room Aurelia (A) Hall 10. 13h45

Session Objective
To share the results of efforts undertaken in Mozambique to promote the quality and humanization of health care, particularly in the area of childbirth.
Mozambique: Popula tion: 20 million Life expecta ncy a t birth: 45 yea rs Ma terna l morta lity: 408/ 100,000 lb Neona ta l morta lity: 48/ 1,000 lb
Source: 2007 Census, DHS 2003.

General Concepts and Considerations

Humanization of Maternity Care is an approach that:
Centers on the individual Emphasizes the fundamental

rights of the mother, newborn and families Promotes evidence-based practices that recognize womens preferences and needs
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Background, 20062008
Initiated implementation of a Quality and Humanization improvement process in MCH services, in 6 provinces/ 18 HF (primary and secondary level), using the Jhpiego Standards-Based Management and Recognition (SBM-R ) approach. Results: By the end of 2008, selected health facilities doubled or tripled their performance and were operating at a higher quality level, adhering to established evidencebased standards.
Manjacaze HospitalGaza

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SBM-R: Standards-Based Management and Recognition

It is a practical approach that follows four main steps:
1.

2. 3. 4.

Setting performance standards based on national norms and international references Implementing standards through a systematic methodology Measuring progress to guide improvement toward standards Recognizing achievement of the standards

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Model Maternities Initiative (MMI): A Work in Progress

Q ua lity a nd Huma niza tion improvement process expa nded in 2009 to the 34 la rgest hospita ls throughout the country (MMI) MMI a ims to crea te fa cilities tha t a re models for ma ternity ca re a nd tha t serve a s model clinica l tra ining sites Na tiona l Pla n for the Huma niza tion of Hea lthca re la unched by the MO H in 2010
Results from 20072008 100 80 60 40 20 0

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MMI Promotes Practices that Recognize Womens Preferences and Needs

Photos: MCHIP Mozambique

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Scaling-Up of High-Impact Interventions

Implementation of the MMI Process

(Measurement of Performance and Elaboration of Action Plan)

Photos: MCHIP Mozambique

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MMI Adopted Standards by Area

AREAS CO NTENTS
STANDARDS

1. 2. 3. 4. 5. 6. 7. 8. 9.

Managment Information, monitoring and evaluation Human and material resources Health work conditions Health education and community involvment Antenatal and postnatal care Labor, delivery and neonatal care BEmONC T raining TOTAL OF STANDARDS
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8 5 4 9 4 14 23 9 4 80

Key M&E Result Indicators Selected for MMI

INDICATORS

% of pregna nt women who received a t lea st 2 doses of IPT % of HIV+ pregna nt women who received prophyla xis (PMTCT) Number of births by SBA in the selected Model Ma ternities % of women with compa nion during la bor a nd birth % of deliveries with pa rtogra ph completely filled %of women giving birth in a semi-vertica l or vertica l position % of newborns with skin-to-skin ca re % of newborns with ea rly brea stfeeding % of birth with AMTSL % of severe pre-ecla mpsia a nd ecla mpsia trea ted with MgSO 4
Source for ba selines: NHIS, 2010 *Na tura l popula tion growth:2.4%

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Some Results from MMI

(Average of all 34 HF, Oct 2009Dec 2012)
100 Humanization of care: Birth position; companion during labor and birth 80
Weighted avg. attainment of all quality standards, baseline and follow-up

60

40
50% 32%

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Baseline 1st Quarter (Jan (Oct. - Dec. 09) - Mar 10) % women with companion during labor 0.0 21.7 % women with companion during birth 0.0 19.4 % women giving birth in semi-vertical / 0 18.1 vertical position

2nd Quarter (Apr - Jun 10) 26.0 23.2 21.7

3rd Quarter (Jul 4th Quarter (Oct - Sep 10) - Dec 10) 28.8 34.2 25.5 26.8 23.3 29.5

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Some Results from MMI

(Average of all 34 HF, Oct 2009Dec 2012)
Maternity care high impact interventions: partograph use; AMTSL; use of magnesium sulfate
100

80

60

40

20

Baseline (Oct. - Dec. 09) 0.0 0.0 20.0

1st Quarter (Jan - 2nd Quarter (Apr 3rd Quarter (Jul Mar 10) - Jun 10) Sep 10) 22.6 86.1 87.2 29.1 86.1 74.1 33.1 73.9 76.4

4th Quarter (Oct - Dec 10) 37.9 78.4 70.0

% births with partograph completely filled out % births with AMTSL % cases severe PE / E treated with Mg. sulfate

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Some Results from MMI

(Average of all 34 HF, Oct 2009Dec 2012)
Newborn high-impact interventions: Skin-to-skin contact; immediate breastfeeding
100 90 80 70 60 50 40 30 20 10 0 Baseline (Oct. - Dec. 09) 0.0 0.0 1st Quarter (Jan - 2nd Quarter (Apr 3rd Quarter (Jul - 4th Quarter (Oct Mar 10) - Jun 10) Sep 10) - Dec 10) 77.0 77.3 81.0 77.3 72.4 72.2 76.8 77.3

% newborns with skin-to-skin contact % newborns with immediate breastfeeding

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Correlation between Humanization and Quality Improvement and Maternal Death

100 90 80 70 60 50 40 30 20 10 0
91 (0.51%) 80 (0.52%) 80 (0.45%) 71 (0.40%) 59 (0.33%) 49 (0.31%)

Jul-Sep09

Oct-Dec09 Jan-Mar10 Apr-Jun10

Jul-Sep10

Oct-Dec10

% of SBMR related to PPH % of AMTSL use 41

% of SBMR related to SPE/ E # maternal deaths

Correlation between Humanization and Quality Improvement and Fresh Stillbirths

120 100 80 60 40 20 0 Jul-Sep09 Oct-Dec09 Jan-Mar10 Apr-Jun10 Jul-Sep10 Oct-Dec10 % of SBMR related to labor care % of use of partograph for labor # of cases of fresh stillbirth (+ FHR at admission with 5 minute APGAR of 0) 42

110 (0.61%) 95 (0.53%) 89 (0.50%) 86 (0.48%)

36 (0.23%)

49 (0.31%)

Client Satisfaction
One Mozambican mother allowed to accompany her daughter during childbirth at a health center said: This is what I can call true independence, 2010! One young Mozambican woman, who gave birth to her first daughter in a squatting position and was accompanied by her partner, is now sharing her experiences with other women and communities in Mozambique, affirming, We women must speak up to fight for our rights. And the father of the baby said: It was the most incredible experience of my life, 2010.

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Main Lessons Learned and Successful Approaches from Mozambique

Working together with pre-service/ in-service training institutes and professional organizations creates a more sustainable training process. Developing a pool of trainers and supervisors is an important approach. Identifying champions is crucial for the smooth implementation of interventions. Being supportive and clarifying critical managerial and technical issues along the way is important for success.
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Lessons Learned and Successful Approaches from Mozambique

Political will" is critical for quality improvement and humanization of health services. Community and media involvement is very important in this process. Its necessary to mobilize resources to support the process implementation.
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Conclusion
Humanizing health care can improve quality of care and increase service utilization and client satisfaction!

THANK YOU!