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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 roofs 74%

    • Mud and wood walls 64%

    • Earth floors 75%


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 #1 ANC

  • Pillar #2 Clean, safe delivery

  • Pillar #3 Emergency Obstet. Care

  • Pillar #4 Family Planning


Pillar 1 antenatal care review of anc register
Pillar #1: Antenatal CareReview of ANC Register

  • New ANC clients at KHC 44 pt/mo

  • Age 22.4 yrs

  • Parity 2.0 children

  • Age of nulliparous pts 18.6 yrs

  • Adolescent pts 33%

  • Gestational age at presentation 26 wks

    • 3rd trimester 45%

  • Previous children dead 12%


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%

  • Syphilis 2%

  • Malaria 9%

  • 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 + labs 160

ANC card 20

Iron x 2 weeks 20

Folate x 2 weeks 20

Vitamins x 2 weeks 20

Ketrex 20

SP Free

Tetanus toxoid Free

Tetanus (syringe)10__________

Total KSh 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    

Walked 80% 83%

Time 66 min. 66 min.

Client-Provider    

Meeting time 14 min. 7 min.

Advised to return 94% 100%


Pillar 1 antenatal care anc exit interview khc1
Pillar #1: Antenatal CareANC Exit Interview, KHC

KHCMobile

Physical Exam    

Abdominal exam 100% 100%

Fetal heart beat 100% 100%

BP check 97% 100%

Medical Hx 100% 100%

Medications    

SP 97% 50%

Iron 91% 42%

Investigations    

Blood 69% 13%

Urine 69% 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 facility 9% 0

Nutrition Counseling 6% 8%

FP or child-spacing 3% 13%

STIs, HIV, AIDS 3% 33%

Transportation in event

of emergency 3% 0

Action if bleeding or seizures 0 0

Infant care 0 8%


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 4 All 43/4

Sphygmo- Delivery set Scrub basin

manometer IV fluid sets Suture set

Stethoscope Sponge forceps Suturing tray

Gloves Forceps 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

2/4 1/4 0/4

IV catheter sets Tourniquets Amnihook

Stopwatch/Watch Straight Catheter Foley catheter

Sterilizer Partographs Nitrazine paper

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

equipment Oxygen 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 Equipment 0.67

  • Partographs 1.00

  • ANC 1.00

  • APH 1.00

  • Eclampsia 1.00

  • Infection 1.00


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

  • Storage 0.00


Pillar 2 clean safe delivery medication
Pillar #2: Clean safe deliveryMedication

  • Normal L&D 1.00

  • ANC 0.50

  • Dysfunctional Labor 0.50

  • Complicated Deliveries & Lacerations 0.33

  • PPH 0.33

  • Infection 0.33

  • APH 0.00

  • 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

    • Husband 100%

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

    • Can deliver at home 85%

    • Cheaper/free 31%

    • Natural to them 8%


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 push 85%

    • Excessive pain/screaming 54%

    • Water breaks 46%

    • Urge to defecate 39%

    • Crowning 23%


Pillar 2 clean safe delivery traditional birth attendants3
Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • Sometimes insert hand into vagina 39%

  • Episiotomies 0

  • Perineal tears 31%

    • Tx: warm saline baths/compresses

  • Manual version for malpresentation 54%

  • Razors to cut cord 100%

    • Boil 70%

    • Wash 31%


Pillar 2 clean safe delivery traditional birth attendants4
Pillar #2: Clean safe deliveryTraditional Birth Attendants

  • How to make placenta come out

    • Press on abdomen 69%

    • Wait 31%

    • Beaded necklace 15%


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?

cotter_kristen@hotmail.com



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!

  • cotter_kristen@hotmail.com