Joint Initiative Ended with Success
The International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM) and the International Pediatric Association (IPA) jointly implemented the PMNCH funded project on Essential Interventions between July 2013 and September 2014, in Uganda and Nepal. The project aimed to improve maternal and newborn health resulting from the accelerated implementation of the 17 Essesential Interventions (EI) relating to Childbirth and Postnatal Care through the joint action by the Health Care Professional Associations (HCPA). Essential Interventions are those health care interventions that have been defined by the World Health Organization (WHO) as having the biggest potential to reduce maternal and newborn deaths. Successful implementation was achieved in Uganda and active engagement of the national HCPAs has been secured in Nepal (which replaced the first selected Indonesia).
In Uganda, the HCPAs worked in two health facilities and collaborated with the Ministry of Health, academic institutions, civil society and private partners. The initiative was comprised of a package of activities, jointly developed by obstetricians, midwives and pediatricians, built on an evidence-based conceptual framework and supported by a communication strategy. It was cascaded to about 60% of the total 157 health providers working in childbirth and newborn care in the two Ugandan hospitals and included six activities: dissemination workshops, development of reminders, birth simulation sessions, team building, case reviews and academic visits in the wards. A booklet for dissemination of 8 EIs was produced as well as a checklist and monitoring cards for the other activities.
Data collection was completed for 4750 deliveries, 1731 corresponding to St. Rafael of St. Francis Nsambya Hospital in Kampala and 3019 to Mbarara Regional Referral Hospital in Mbarara, reflecting about 70% of total deliveries in those health facilities.
The results of this study revealed that 4 Essential Interventions (EI) already had high levels of coverage in both health facilities and maintained throughout the study (social support during childbirth, prophylactic uterotonics, thermal care and CPAP above 75% most of the study points in time). In contrast, more coverage variability was observed for the other 4 EIs (prophylactic antibiotics, induction of labour for prolonged pregnancy and Kangaroo mother care (KMC)), which are specific EIs, and for immediate breastfeeding. Geographic and institutional differences in the two settings (Nsambya/private not for profit/urban vs. Mbarara/public/rural) must be considered to explain that variability. In Nsambya, data helped to identify deficiencies in the procedural and management of storage, administration and recording of antibiotics. In this urban setting immediate breastfeeding rates were low, remaining below 15% during most points in time and only in the last point increased to 55%. In contrast, Mbarara benefited from synergies with another project on PMTCT and showed rates close to 100%.
Each hospital had differing coverages rates for induction of labour, Mbarara highest coverage rate was only 8% and Nsambya highest rate was 47.4%. Health providers alluded to women in the rural communities not attending or accessing facilities for induction of labour and, even in the urban setting they do not always return for the appointment for induction. Kangaroo Mother Care (KMC) remained below 70% in Mbarara, which could be due to lack of space, and Nsambya experienced variations between 57% and 100%, which could be attributed to the difficulty in separating the numbers of babies requiring intensive care, for example CPAP and therefore not suitable for Kangaroo mother care.
Additionally, a Health Provider survey was conducted and the results show that there were significant improvements in relationships between midwives and pediatricians, pediatricians’ involvement in hospital activities and in the respectful attitude of obstetrician trainers. The vast majority of respondents rated their knowledge as good or excellent on each EIs before and after the project and evidence reveals that, after the project, there was a significant increase in the knowledge and confidence in relation to antibiotics for C-section, social support and CPAP. For KMC and breastfeeding there was a significant increase only in knowledge.
This survey along with the qualitative evidence demonstrate the positive effect of the project to improve joint work, EIs compliance and documentation. It is clear that this first collaborative joint initiative has gone the extra mile to establish structures, systems and secure commitment of the three HCPAs to take ownership and contribute to the activities. Nevertheless it is apparent that midwives continue to lag behind in taking a lead in activities; therefore, it is of utmost importance to keep strengthening midwives association and invest in developing midwives leadership skills and visibility at national and local initiatives.
Many lessons have been learnt by the international and national HCPAS. They have strongly collaborated to understand each other, respect each other and most importantly to jointly develop a package of activities to improve quality of care for mothers and newborn. After the end of this phase 1, it is strongly recommended that the project is continued to build on the momentum gained in Uganda and consolidate the experience in Nepal.
Report prepared by Sue Jacob, project coordinator for ICM