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Experience of Task Shifting in Mozambique: A Response to Limited Human Health Resources

Experience of Task Shifting in Mozambique: A Response to Limited Human Health Resources Nafissa Bique Osman Department of Obstetric and Gynecology, Eduardo Mondlane University, Central Hospital, Maputo. XIX FIGO World Congress, 4-9 October 2009, Cape Town. Safe Motherhood and Newborn Health.

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Experience of Task Shifting in Mozambique: A Response to Limited Human Health Resources

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  1. Experience of Task Shifting in Mozambique: A Response to Limited Human Health Resources Nafissa Bique Osman Department of Obstetric and Gynecology, Eduardo Mondlane University, Central Hospital, Maputo. XIX FIGO World Congress, 4-9 October 2009, Cape Town Safe Motherhood and Newborn Health

  2. Mozambique • Population: 20 million • Growth rate: 2.4% • Pop in rural area: 70% • P density: 20 inh/km² • Among the 10 poorest countries in the world • Poverty line: 69.4% below • Life expectancy at birth: 45 years • Source: 2007census, DHS 2003

  3. Mozambique • Children< 5yr: 17% pop • 10-24 yrs: 33% pop • 15-49 yrs: 49% pop • Women 15-49yrs: 25% pop • = 5 million • >50 yrs: 9.4% pop • Birth rate: 35.2/ 1000 • Death rate: 21.3/ 1000 • Source: 2007census, DHS 2003 • Source: 2007census, DHS 2003

  4. Maternal and neonatal Health • Worldwide, more than one woman dies every minute, 585.000 women die every year. • Ninety nine percent of these deaths occur in developing countries, demonstrating that they could be avoided if resources and services were available • Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in Mozambique

  5. Maternal Health ANC-84% pregnant women -1 visit Institutional deliveries:46% (urban- 71%, rural- 29%) Maternal mortality:1997- 975/ 100,000 2003- 408/ 100,000 1/3 of Maternal death are < 19 years old Main causes of MM: 75% direct causes: hemorrhage, sepsis, eclampsia, uterine rupture 25% indirect causes: HIV, malaria Source:DHS 1997 & 2003, Revision of MM study, MOH 1998

  6. Neonatal and Infant mortality Neonatal mortality: 1997: 59/1000 live births 2003: 48/ 1000 live births Main causes:preterm delivery, LBW, infections, asphyxia Infant mortality: 1997: 147/ 1000 live births 2003:125/ 1000 live births Source: DHS 1997 & 2003

  7. Challenges in Safe Motherhood Adolescent pregnancy: 40% Unwanted pregnancies, early marriage Unsafe abortion: 11% of MM Contraceptive rate: 1997: 6% 2003: 17% Modern contraceptive rate: 2003: 12% Women knowledge of contraceptives: 90% Syphilis in pregnancy: 7% HIV prevalence: 16% Source: DHS 1997 & 2003, Epidemiological Surveillance, 2007

  8. National Health System Primary level: Health post (514) Rural and urban health centers (775) Secondary level: Rural and district hospital (31), general hospitals (4). First referral level Tertiary level: Provincial hospital (7) Quaternary level: Central hospital (3) 1 health unit/ 15,000 inhabitants 1 hospital/ 434,368 inhabitants Source: MoH, NDH, 2006

  9. Strategies to decrease MM 1975 Independence. Universal access to primary health care was a goal but, human resources crisis, 80 Moz doctors/14 million; Intensive training of nurses, midwives, medical officers to replace the doctor; Elementary (1yr training) and basic (20 month training) mother/child nurse-midwives to work at primary care level and also at 2nd and 3rd level

  10. Task Shifting and Delegation of responsibilities 1980 Civil war, increased casualties, unmet need for emergency life saving skills in war casualties and obstetrics; No surgeons, obstetricians and orthopedics in rural, district hospitals; Long distance and deficient transport network 1984 Training of assistant medical officers with skills in surgery “técnico de cirurgia” (TC); 3 year training to perform all emergency operations in obstetric, trauma and surgery. Training of “técnico” of anesthesiology

  11. Evaluation of TC skills in Obstetrics Controversy of delegation of major operations to a non medical doctor; Evaluation after 4 yr of the 1st group 1992 Evaluation of 958 cesarean deliveries performed by TC & 1113 by obstetricians at Central Hospital in Maputo– found no clinically significant difference in postoperative outcomes. Superficial wound separation more frequent in CS by TC Source: C Pereira, A Bugalho, S Bergstrom, F Vaz, M Cotiro. A comparative study of cesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J obstet Gynaecol 1996; 103:508-12

  12. Task Shifting and Delegation of responsibilities 1990 Medium level mother/child nurse-midwife 30 months training with skills for EmOC (basic) 2004 High level nurse-midwife with university degree: 3 year training- bachelor 4 year training- licentiate. With training in EmOC (comprehensive) including cesarean section 2008 29 were graduated. Now, 1 class of 37 student, in 7th semester and 1 class of 35 student in 3rd semester Source: Instituto Superior de Ciências de Saúde

  13. Task Shifting and Delegation of responsibilities 2004 Revue of TC curricula 3 yrs training- bacharel 4 yrs training- licentiate So far 61 TC graduated as bachelor and licentiate degree. Retired and died: 11 Now, 1 class with 18 students in the 4th year training and 1 class with 16 student in the 1st year. Source: Instituto Superior de Saúde

  14. Evaluation of TC skills in Obstetrics 2002 Analyses of 12,178 obstetric operations in all 34 public hospitals; TCs performed 92% of major obstetric surgery at district/rural hospital; TCs compared with physicians, stay longer in rural areas. After 7 years 90% of TCs were still in district hospitals while no physician remained Source: C Pereira, A Cumbi, R Malalane, F Vaz, C McCord, A Bacci, S Bergstrom. Meeting the need for emergency obstetric care in Mozambique: work performed and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; DOI:10.1111/j.1471-0528.2007.01489.

  15. Human Resources Elementary level health worker- 63% Basic level health worker- 20% Medium level health worker- 13% High level health worker- 4% 1 doctor & 7 nurses/ 33,000 inhabitants Obstetricians- 42 in provincial & central hospital, being 12 in Maputo city Source:MoH DNRH, 2006

  16. Challenges Conflict between doctor (GP), TC and midwife Midwife performing CS, less interested in routine midwifery work at normal delivery Importance of Team Work: Obstetrician, GP doctor, Midwife and TC

  17. Conclusions After 20 yr experience of delegation of surgical interventions to “técnico de cirurgia” and 1 yr to midwives, we can say that this strategy is very important to increase access to Comprehensive EmOC at first referral level. It can contribute to reduction of maternal and neonatal mortality in poor countries with shortage of human resources

  18. Thank You

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