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Decentralising Maternal Care In Fiji

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  1. Decentralising Maternal Care In Fiji Dr James Fong Chairperson Obstetrics and Gynaecology CSN

  2. District Hospital Health Care Pyramid Subdivisional Hospital Quality Mentorship/Supervision Quality Referral MIDWIFERY SKILLS MIDWIFERY SKILLS Health Centres, Nursing stations Family/Community

  3. Challenges to Safe Motherhood Decentralisation • Obstetric Complications occurs in 15% of pregnant women and can neither be predicted nor prevented • Care for women with Obstetric Complications is an inpatient activity and requires a functioning health service

  4. Challenges to Safe Motherhood Decentralisation • AMDD requires timely access to Basic and/or Comprehensive EmOC • Functioning referral system • Quality of Care • Trained Staff in Post • 24 hour Coverage • Essential Drugs and Supplies

  5. Challenges to Safe Motherhood Decentralisation • Inappropriate Deployment and rapid turn over of staff • Poor maintenance of Equipment • Interruptions in essential drug supplies • Poor Management and Morale • Lack of Sustainability especially with external donor support • Lack of integration and co-ordination between district hospital and primary care services

  6. CSP Service Delivery Roles • Divisional Hospital (Mother Safe and Comprehensive EmONC compliant) • Low and High Risk ANC • Low and High Risk Intra-partum Care • Low and High Risk Postpartum Care • Subdivisional Hospitals (Mother Safe and Basic EmONC Compliant) • Low Risk ANC • Low Risk Planned Intra-partum Care • MCH Clinics • Health Centres And Nursing Stations (Mother Friendly Facilities) • Low Risk ANC • Low Risk Unplanned Intra-partum Care • MCH clinics

  7. Limitations to Decentralising Services Workload In Fiji • Impact of Urbanization • Divisional Hospitals will always have a large catchment population thus require high levels of resourcing to ensure safe services • Peripheral faciities need a critical level of workload and ongoing mentorship and support to ensure safe services

  8. BIRTH BY FACILITIES BEFORE AND AFTER CSP 9/25/2014

  9. Emergency Obstetric Care Health Facility Survey • Defined gaps in service resourcing and provision • None of the SDH were basic EmONC compliant • Since then • 5 SDH equiped by UNFPA • 11 SDH will be equiped via FHSSP and MOH • Health Centres – delivery Kits

  10. Obstetric Operations Centre Concept In All Divisional Hospital • Evolving The Divisional Hospital Morning Rounds • Midwifery driven • Midwifery networking to foster midwifery skills • Communication Stretagies • Agenda • Track all pregnancy related admissions • Facilitate and promote timely review plans • Premptively stabilize referral logistics and ensure timely referral

  11. Outreach Support Visits • At intra-divisional and inter-divisional level • 3 core components • Practice Support • Audit • CME • Models based Drills

  12. CWM Hospital Deliveries 2013 • January 640 • Feb 645 • March 899 • April 861 • May 875 • June 800+

  13. EmONC Workshops • Fiji EmONC Course • Evolving since 2006 and has incoporated ALSO principles • Models based training • Accreditation structures • FNU/MOH initiatives • west and north

  14. Proportion of targeted sub-divisions that have adequate number of staff trained in obstetric care, reproductive health and family planning. Proportion of targeted facilities adhering to the Obstetric Emergency Protocols Manual Indicators 9/25/2014

  15. Proportion of sub-divisional hospitals that meet “Mother Safe Hospital Initiative” accreditation standard Proportion of targeted facilities audited each year against “Mother Safe” standards Proportion of deliveries carried out in sub-divisional hospital or higher level institutions, disaggregated by level (Divisional Hospital vs. Sub-Divisional Hospital). Indicators 9/25/2014

  16. >90% of women will attend > 4 ANCs deliver in a facility that can be easily made mother safe >80% maternal and perinatal morbidities and mortalities will occur in a hospital – do most sick patients will reach an appropriate point of care? STATUS SO FAR IN FIJI 9/25/2014

  17. District Hospital Health Care Pyramid Subdivisional Hospital Quality Mentorship/Supervision Quality Referral MIDWIFERY SKILLS MIDWIFERY SKILLS Health Centres, Nursing stations Family/Community

  18. Prud’homme (1994) “decentralisation measures are like some potent medicines; they must be taken at the right time in the right dose, and for the right illness to have the desired salutary effect. Taken improperly, they can harm rather than heal” Take Home Message 9/25/2014