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Part I: Safe Motherhood. Kristen Cotter, MSIV. Africa: % of all Maternal Death: 48% Lifetime risk: 1 in 20 MMR: 830. Developed Countries: % of all Maternal Death: 0.5% Lifetime risk: 1 in 2500 MMR: 20 (per 100,000 live births). WHO/UNICEF/UNFPA, 2000. Why care (and act)?.

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Part i safe motherhood

Part I: Safe Motherhood

Kristen Cotter, MSIV


Part i safe motherhood

Africa:

% of all Maternal Death: 48%

Lifetime risk: 1 in 20

MMR: 830

Developed Countries:

% of all Maternal Death: 0.5%

Lifetime risk: 1 in 2500

MMR: 20 (per 100,000 live births)

WHO/UNICEF/UNFPA, 2000


Why care and act

Why care (and act)?

  • 529,000 maternal deaths in 2000

  • Often leading cause of adult female death

  • Great disparity

    • MMR 50x higher in developing countries

  • Infant health & survival affected

  • Maternal deaths are avoidable


Causes of maternal death worldwide

Causes of Maternal Death Worldwide

Note: #1 cause of Maternal Death in USA doesn’t even make the top 5.


The making pregnancy safer initiative safe motherhood initiative

The Making Pregnancy Safer Initiative(Safe Motherhood Initiative)

  • Vision: All women go safely through pregnancy and childbirth, and that their infants are born alive and healthy.

  • Goal: To reduce maternal mortality by 75% from 1990 levels by the year 2015.

www.WHO.org


The old hope 1987 nairobi s m conference

The old hope (1987 Nairobi S.M. Conference). . .

  • The key to reducing maternal mortality was in the community

    • Risk assessment by trained non-doctor

      • Low risk delivery with TBA

      • High risk referred to skilled attendant

    • Antenatal care by TBAs


New realizations 1997 columbo technical consultation

New realizations (1997 Columbo Technical Consultation). . .

  • Every pregnancy faces risk

  • No data to show that training TBAs lower MM

  • Key to lowering MM: Health Infrastructure

Clean, Safe Delivery

with Skilled Attendance

for all women


Key components of safe motherhood

Key Components of Safe Motherhood

  • Skilled attendance (now 62%)

  • Health systems

    • Policies

    • Essential supplies of medicines and equipment

    • Infrastructure

    • Referral system

    • Monitoring & evaluation

    • Supervision & training of staff

    • Records

  • Involving communities


Part ii safe motherhood needs assessment

Part II: Safe Motherhood Needs Assessment

Kikoneni and Dzombo Locations

Kwale District,

Coast Province,

Kenya

Kristen Cotter

March – May 2003


Part i safe motherhood

Mombasa

Mombasa

Mombasa


Icrh background

ICRH Background

  • Branch of Univ. of Ghent SOM,

    Dept. of OB/Gyn

  • Kenya programs include:

    • HIV prevention (sex workers, workplace, youth)

    • Voluntary Counseling & Testing (VCT)

    • Prevention of Mother-to-Child Transmission of HIV

    • Safe Motherhood


Kikoneni and dzombo locations background

Kikoneni and Dzombo LocationsBackground

  • Pop. 44,647

  • 2 hours outside of Mombasa

  • Estimated HIV seroprevalence: 9%

  • 49% ♀, 29% ♂ never attended school

  • 8% ♀, 17% ♂ educated past primary school

  • Home building materials:

    • Grass/palm roofs74%

    • Mud and wood walls64%

    • Earth floors75%


Kenya background

Kenya Background

  • MMR: 1000 per 100,000 live births

  • Lifetime risk of OB death: 1 in 19

  • Fertility rate: 4.7

    • Rural: 5.2

    • No education: 5.8

  • ♀ using modern contraception: 32%

  • Births in health facility: 42%

(WHO/UNICEF/UNFPA 2000, DHS 1998)


Design and methodology

Design and Methodology

  • Survey tools developed and used in similar settings

    • MEASURE Evaluation

    • WHO Safe Motherhood Needs Assessment

  • Adapted by ICRH staff

  • Professionally translated & back-translated into Swahili

  • Locations

    • Kikoneni Health Centre (KHC)

    • 3 Dispensaries

    • Mobile Clinic

  • Interviewer: Diana Ngombo (clinical & PH nurse, ICRH staff)


Overview of assessment

Overview of Assessment

  • Retrospective Review of KHC clinical records

    • ANC Register

    • FP Register

    • Maternity Admissions Register

  • Cross-Sectional Surveys

    • Facilities Assessment (drugs, equip., supplies)

    • Human Resources (provider knowledge, training)

    • ANC Client Exit Interviews

    • TBA Interviews


Limitations

Limitations

  • Sample sizes small

  • Multiple translations

  • Non-random sampling

    • ANC clients in register, but only 12-22% had lab results recorded

    • Women who come to clinics for ANC or delivery are different from general community

      Descriptive only. Cannot be generalized.

  • Without community-wide survey, prevalence cannot be determined (though we tried)

  • Observation bias & social desirability bias

  • Population Council tool problematic


Who pillars of safe motherhood

WHO Pillars of Safe Motherhood

  • Pillar #1ANC

  • Pillar #2Clean, safe delivery

  • Pillar #3Emergency Obstet. Care

  • Pillar #4Family Planning


Pillar 1 antenatal care review of anc register

Pillar #1: Antenatal CareReview of ANC Register

  • New ANC clients at KHC44 pt/mo

  • Age22.4 yrs

  • Parity2.0 children

  • Age of nulliparous pts18.6 yrs

  • Adolescent pts33%

  • Gestational age at presentation26 wks

    • 3rd trimester45%

  • Previous children dead12%


Pillar 1 antenatal care review of anc register1

Pillar #1: Antenatal CareReview of ANC Register

Lab results

  • Anemia (Hb<10.0)92%

    • Mild (Hb 8.1-9.9) 32%

    • Moderate (Hb 5.1-8.0)57%

    • Severe (Hb <5.0)2%

  • Syphilis2%

  • Malaria9%

  • Helminths 38%

  • Schistosomiasis 5%

  • Negative Rhesus 3%


Pillar 1 antenatal care hc provider management

Pillar #1: Antenatal CareHC Provider Management

  • Iron  “all”

    • Non-Anemic: 200 mg tid for 1 week

    • Anemic: 200 mg tid for 1 or 2 weeks

    • Referral at Hb ≤5.0

    • Barriers: stock shortages, cost

  • Folate  “all”

    • 5 mg tab for 1 week

    • Stock shortages, cost


Pillar 1 antenatal care hc provider management1

Pillar #1: Antenatal CareHC Provider Management

  • Multi-Vitamins  “some”

    • 1 tab bid or tid for 1 week

  • SP (Sulphadozine Pyrimethamine) “all”

    • 3 tab stat, twice during pregnancy

  • Deworming  “all,” “some”


Pillar 1 antenatal care cost of 1 st anc visit

Pillar #1: Antenatal CareCost of 1st ANC visit

Service/SuppliesKSh

Consultation + labs160

ANC card20

Iron x 2 weeks20

Folate x 2 weeks20

Vitamins x 2 weeks20

Ketrex20

SPFree

Tetanus toxoidFree

Tetanus (syringe)10__________

TotalKSh 270 (= US$3.50)

(26% of Kenyans live below $1 per day)


Pillar 1 antenatal care anc exit interview khc

Pillar #1: Antenatal CareANC Exit Interview, KHC

KHCMobile

Transportation  

Walked80%83%

Time 66 min.66 min.

Client-Provider   

Meeting time 14 min.7 min.

Advised to return94%100%


Pillar 1 antenatal care anc exit interview khc1

Pillar #1: Antenatal CareANC Exit Interview, KHC

KHCMobile

Physical Exam  

Abdominal exam100%100%

Fetal heart beat100%100%

BP check97%100%

Medical Hx100%100%

Medications  

SP97%50%

Iron91%42%

Investigations  

Blood69%13%

Urine69%13%


Pillar 1 antenatal care anc exit interview khc2

Pillar #1: Antenatal CareANC Exit Interview, KHC

Counseling TopicKHCMobile

Birth plan (place)17%0

Benefits of delivering in

a health facility9%0

Nutrition Counseling6%8%

FP or child-spacing3%13%

STIs, HIV, AIDS3%33%

Transportation in event

of emergency3%0

Action if bleeding or seizures00

Infant care08%


Pillar 2 clean safe delivery

Pillar #2: Clean safe delivery

Safe Attendance =

Trained attendant

+

Enabling environment

(Equipment, Drugs, Facilities)


Pillar 2 clean safe delivery basic ob equipment

Pillar #2: Clean safe deliveryBasic OB Equipment

All 4All 43/4

Sphygmo-Delivery set Scrub basin

manometerIV fluid setsSuture set

StethoscopeSponge forcepsSuturing tray

GlovesForceps bowl Containers

Needles & receiver Stretchers

& syringesVaginal speculum

Adult scalesSuture needles & materials

Baby scalesThermometer

Fetal stethoscopePadded tongue blade

Examination table


Pillar 2 clean safe delivery basic ob equipment1

Pillar #2: Clean safe deliveryBasic OB Equipment

2/41/40/4

IV catheter setsTourniquetsAmnihook

Stopwatch/WatchStraight CatheterFoley catheter

SterilizerPartographs Nitrazine paper

Antenatal formsCentrifuge or Sterile packing Tape measure hemoglobinometer material Urine testing Towels or cloth

equipmentOxygen tank

Sterile 4x4 gauze

MVA

Vacuum extractor

Protective gown

Bulb syringe


Pillar 2 clean safe delivery basic ob equipment2

Pillar #2: Clean safe deliveryBasic OB Equipment

KHC equipment scores

  • Absolute Minimal for Delivery 1.00

  • Basic Equipment0.67

  • Partographs 1.00

  • ANC 1.00

  • APH 1.00

  • Eclampsia 1.00

  • Infection1.00


Pillar 2 clean safe delivery basic ob equipment3

Pillar #2: Clean safe deliveryBasic OB Equipment

KHC equipment scores (con’t)

  • Complicated Deliveries

    & Lacerations 0.73

  • Dysfunctional Labor 0.60

  • PPH 0.50

  • Normal L&D 0.44

  • Storage0.00


Pillar 2 clean safe delivery medication

Pillar #2: Clean safe deliveryMedication

  • Normal L&D1.00

  • ANC0.50

  • Dysfunctional Labor0.50

  • Complicated Deliveries & Lacerations0.33

  • PPH0.33

  • Infection0.33

  • APH0.00

  • Eclampsia0.00


Pillar 2 clean safe delivery facilities

Pillar #2: Clean safe deliveryFacilities

  • Water

    • KHC: rainwater & borehole pump

    • Dry sinks & showers & toilets

  • Electricity

    • generator house, but no generator


Pillar 2 clean safe delivery attendant knowledge

Pillar #2: Clean safe deliveryAttendant knowledge


Pillar 2 clean safe delivery coverage

Kenya (DHS 1998)42%

31 KHC births ÷

659 expected births (K’neni Loc)= 5%

74 KHC births ÷ 994 ANC clients (KHC)= 7%

ANC clients reporting last birth in health facility

Mobile Clinic (1 of 14)7%

KHC (12 of 29)41%

Limitations!

Other birthing facilities?

ANC clients are not a random sample!

Pillar #2: Clean safe deliveryCoverage


Pillar 2 clean safe delivery preference demand

Pillar #2: Clean safe deliveryPreference & Demand

  • Final decision-maker if referral needed

    • Husband100%

  • Why women choose TBAs instead of health facility (according to TBAs)

    • Can deliver at home85%

    • Cheaper/free31%

    • Natural to them8%


Pillar 2 clean safe delivery traditional birth attendants

Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • Married women with >4 children

  • 60% never went to school

  • 3.2 deliveries per month (0.9 last month)

  • Most have other primary occupations

  • Learn by apprenticeship (“gift from God” or goats)

  • 4 of 13 had attended training

  • Herbal medicines & spiritual practices included

    • Also provided for men and non-pregnant women


Pillar 2 clean safe delivery traditional birth attendants1

Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • Equipment: 54% razors

    46% gloves

    39% soap

  • ANC PE: 82% assess baby’s position

  • Delivery prep: 62% sterilize equipment

    54% wash hands

  • Eating/drinking encouraged during labor


Pillar 2 clean safe delivery traditional birth attendants2

Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • When bear down?

    • Woman feels urge to push85%

    • Excessive pain/screaming54%

    • Water breaks46%

    • Urge to defecate39%

    • Crowning23%


Pillar 2 clean safe delivery traditional birth attendants3

Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • Sometimes insert hand into vagina39%

  • Episiotomies0

  • Perineal tears31%

    • Tx: warm saline baths/compresses

  • Manual version for malpresentation54%

  • Razors to cut cord100%

    • Boil70%

    • Wash31%


Pillar 2 clean safe delivery traditional birth attendants4

Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • How to make placenta come out

    • Press on abdomen69%

    • Wait31%

    • Beaded necklace15%


Pillar 3 emergency obstetric care

Pillar #3: Emergency Obstetric Care

  • Attendant knowledge

    • Clinical case scenarios

      • “ANC pt at 32 wks gestation, c/o swollen hands & feet and increased HAs”

      • “Pt c/o malaise 48 hrs after delivery”

    • History-taking

    • Physical Exam

    • Action


Pillar 3 emergency ob care attendant knowledge

Pillar #3: Emergency OB CareAttendant knowledge


Pillar 3 emergency ob care referral system

Pillar #3: Emergency OB CareReferral System

  • Transportation

    • No formal system

    • Family arranges matatu or car

      • KSh 2000

    • 2+ hrs from referral to hospital

    • Dispensaries refer directly to Msambweni


Pillar 4 family planning fp register khc

Pillar #4: Family PlanningFP Register, KHC

  • Fertility

    • Kenya TFR (DHS 1998) 4.7

    • Mean parity of ANC pts (Register) 2.0

    • Mean gravida of ANC pts (Exit) 3.7 & 3.4

    • TBAs 5.7 children

  • Counseling opportunities

    • 3% of ANC pts at KHC (Exit)

    • 13% of ANC pts at MC (Exit)

    • 15% of PNC pts for TBAs (TBA)


Pillar 4 family planning fp register khc1

Pillar #4: Family PlanningFP Register, KHC

Attendance: 96.7 visits/month


Pillar 4 family planning fp register khc2

Pillar #4: Family PlanningFP Register, KHC

Couple Years of Protection: with Norplant

Last birth in health facility: 41.4%


Pillar 4 family planning fp register khc3

Pillar #4: Family PlanningFP Register, KHC

Distribution Events: Depo Condoms


Pillar 4 family planning fp register khc4

Pillar #4: Family PlanningFP Register, KHC

Coverage

  • Female pop. of Kikoneni Location: 7533

  • Females of Reproductive Age: ~5,251

  • FP visits: 2321 for 2001-2002

  • 0.22 visits per Female of Repro Age

  • Ratio of 1 visit per 4.55 women

  • Limitation: Not a community-wide survey


Conclusions pillar 1 antenatal care

Conclusions: Pillar #1 Antenatal Care

  • Med Hx, PE, ANC cards, & adequate time with provider offered to nearly all ANC clients

  • Lab coverage is low: 69% KHC, 12.5% MC

  • Coverage of SP for IPT: 97% KHC, 50% MC

  • Anemia: 92%

  • Helminths: 38%

  • Minimal counseling, including STIs/HIV

  • Late gestational age at presentation for ANC

  • HIV testing & PMTCT not yet available


Conclusions pillar 2 clean safe delivery

Conclusions: Pillar #2 Clean Safe Delivery

  • 67 women have delivered at KHC since 2001

    = 7.4% of ANC clients at KHC

    = 5.3% of expected births for Kikoneni Location

    Kenya MOH goal for 2010: 80% births with skilled attendance

  • KHC is well equipped and staff well trained to provide normal delivery services.

  • No water & electricity at KHC, though infrastructure in place

  • Few deliveries at dispensaries


Summary of pillar 3 emergency obstetric care

Summary of Pillar #3Emergency Obstetric Care

  • KHC referred 9.5% of maternity pts

  • Referrals from dispensaries are rare. Few/no complications seen in last year.

  • Pre-referral management of complications score poorly

  • If KHC is to provide “basic OB care,” more equipment & drugs are needed

  • Transportation: 1.5 to 3.0 hours from referral to arrival at hospital


Summary of pillar 4 family planning

Summary of Pillar #4:Family Planning

  • 97 visits per month at KHC

  • Norplant’s addition to MM raised CYP substantially

  • Condom distribution is low

  • ANC clients counseled on FP during pregnancy: 3% KHC, 13% MC

  • 15% of TBAs provide FP advice during PNC


Recommendations

Recommendations

  • Policy considerations

    • Iron dosing, transportation, Rh- referrals, PNC. . .

  • Quality of Female Reproductive Health Care

    • Labs, delivery, ed., condoms. . .

  • Staff Training and Development

  • Community-based Opportunities

    • Gender, empowerment, men, delayed marriage. .


Questions responses

Questions? Responses?

[email protected]


Part iii parting thoughts on inhl

Part III: Parting thoughts on INHL


How i squeezed inhl into med school

How I squeezed INHL into med school

  • Summer between 1st and 2nd year

    • Spanish language school

  • IHMEC conference in Honduras

  • CAMC Family Medicine in Honduras

  • MPH (“year off”), with internship in Kenya

  • 4th year elective in Paraguay


Opportunities resources

Opportunities & Resources

  • www.ihmec.org

    • International Health Medical Education Consortium

    • Links to hundreds of INHL organizations, rotations, volunteer-seeking groups, etc.

    • Join!

  • http://nhsc.bhpr.hrsa.gov/ambassadors/training-abroad.cfm

    • Spanish language learning and serving opportunities

  • http://www.aamc.org/students/medstudents/overseasfellowship/

    • Fellowship for 1 year of mentored clinical research in developing countries, for graduate students in health sciences


Mph programs

MPH Programs

  • Strong INHL programs

    • Harvard

    • Johns Hopkins

    • UNC Chapel Hill

    • Tulane University

  • Usually 1 year with MD


Things to read

Things to Read

  • Mountains beyond Mountains, The Quest of Dr. Paul Farmer, a man who would cure the world, 2003, by Tracy Kidder

  • Alma Ata Declaration, 1978


Thank you

Thank you!

  • [email protected]


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