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Improving Quality and Access to Essential Obstetric Care: The Latin American Maternal Mortality Reduction Initiative (LAMM). Stephane Legros, MD, MPH, MBA QAP/URC-CHS SOTA meeting Miami, FL March 15, 2001 . Description of LAMM. 3 countries: Bolivia, Ecuador, and Honduras

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slide1

Improving Quality and Access to Essential Obstetric Care:The Latin American Maternal Mortality Reduction Initiative (LAMM)

Stephane Legros, MD, MPH, MBA

QAP/URC-CHS

SOTA meeting

Miami, FL

March 15, 2001

description of lamm
Description of LAMM
  • 3 countries: Bolivia, Ecuador, and Honduras
  • Activities began mid-98
  • Project area: average of 200,000 inhabitants per country
  • Community and facility interventions
  • Three levels of care: primary, district, and regional
  • MMRs range from 390 to 108/100,000
slide3

Presentation Road Map QA interventions within LAMM

Leadership in EOC

Local steering

committees,

community governance

1. Community

mobilization

7. Linkages

informal/formal

providers

2. Process (Re)design

Process

3. Improvement

Problem solving

Components of

LAMM initiative

6. Monitoring system

EOC indicators,

rapid surveys

Clinical audit,

Maternal death audit

4. Provider

performance

improvement

5. EOC Standards

communication

guidelines, job aids

slide4

From the Community to the Facility:

Access and Quality of Care

Pathway to Maternal Survival

Processes

from Mother Care project, M.Koblinski

1 community mobilization key components
1. Community MobilizationKey Components
  • Training programs
  • IEC
  • Referral system
  • Monitoring system
  • Emergency access plans
  • Community revolving funds
training modules
Training Modules
  • Human body
  • Pregnancy
  • Delivery
  • Neonate
  • In preparation
  • Post partum
slide8
IEC
  • Posters
  • Flyers
  • Radio spots
  • Soap operas
slide9
IEC
  • Plastic disc to estimate date of delivery
referral system
Referral System
  • Specific form used for:
  • Prenatal care
  • Delivery
  • Postpartum
  • Neonate and FP
monitoring system
Monitoring System
  • Specific form developed for mother and neonate
  • Complications
  • Location of delivery
  • Health outcomes
emergency access plan
Emergency Access Plan
  • Developed by community
  • Negotiated with drivers
  • Displayed in grocery store
slide14
Percent of Communities with Emergency Access Plans and Community Revolving Funds for Obstetrical Complications Cotopaxi, Ecuador, 2000
2 quality design of a new process
2. Quality Design of a New Process
  • Team work, mix of providers and patients
  • Focus on user needs
  • Stepwise methodology
  • Identification, design, and implementation of key elements
three waves of process re design in all lamm countries
Three Waves of Process (Re)design in All LAMM Countries
  • 1st: Achieving access, mid ‘98- to-mid ‘99
      • community transportation, referral, reception/triage,
  • 2nd: Receiving care -- EOC, mid-to-end ‘99
      • EOC complications, labor monitoring, normal delivery, prenatal care
  • 3rd: Receiving care -- EOC, Year 2000
      • maternal waiting home, postpartum care, neonatal care
improvements in prenatal care at health center level ecuador and honduras
Improvements in Prenatal Care at Health Center Level, Ecuador and Honduras
  • Patient exam larger room with privacy
  • New appointment system
  • Integrated dental care and vaccination status
results of new prenatal care design at health center level in honduras
Results of New Prenatal Care Design at Health Center Level in Honduras

Number of Visits

+36%

+ 49%

+11%

(Design was implemented in1999)

2 improvements in reception triage at salcedo hospital ecuador
2- Improvements in Reception/ Triage at Salcedo Hospital, Ecuador
  • 24-hour guard system
  • Training of personel on IPC
  • Personnel dedicated for triage with specific room
  • New work schedule
  • New outpatient rooms
  • New transportation beds
2 improvements of reception triage at salcedo hospital ecuador
2- Improvements of Reception/ Triage at Salcedo Hospital, Ecuador
  • Repaired delivery table
  • Repaired anaesthesia and sterilization equipment
results number of deliveries in salcedo district hospital ecuador
Results: Number of Deliveries in Salcedo District Hospital, Ecuador

180%

Design was implemented in 1999.

first new maternal clinic jose maria ochoa honduras
First New Maternal Clinic Jose Maria Ochoa, Honduras

Problem:

Over-utilization of referral hospital

Solution:

Opening of a satellite maternal clinic to reduce burden

results number of deliveries at jose maria ochoa maternal clinic honduras 2000
Results: Number of Deliveries at Jose Maria Ochoa Maternal Clinic, Honduras, 2000

(Clinic opened in July 2000)

3 process improvement topics selected by the teams
3. Process Improvement, Topics Selected by the Teams
  • EOC drugs availability
  • Medical supplies and equipment availability
  • Waiting time reduction
  • Patient satisfaction improvement
4 provider performance improvement
4. Provider Performance Improvement

Competency Based Training (8 days duration) in on-site training centers

  • Knowledge of EOC standards and guidelines
  • Clinical skills training with mannequins
    • prenatal care, normal delivery, prolonged labor, hemorrhages, neonatal care
  • Problem solving methodology
  • Interpersonal Communication
5 eoc standards and guidelines communication
5. EOC Standards and Guidelines: Communication
  • Training
  • Problem-based learning through case management
  • Job aids: pocket EOC standards manual, use of partographs
  • Clinical audits
6 project monitoring
6. ProjectMonitoring
  • Monitoring system, uses existing facility resources
    • Baseline assessment, pre/post intervention
    • Rapid facility survey, annual

(24-hour care, drug availability, skilled attendants)

    • Facility level indicators, quarterly

met need, c-section rate, referral rate

    • Community level indicators, quarterly
results percentage of met need for obstetrical complications in cotopaxi referral hospital ecuador
Results: Percentage of Met Need for Obstetrical Complications in Cotopaxi Referral Hospital, Ecuador
other activities
Other Activities
  • Linkages informal/formal providers
    • workshops, matrices & action plans
    • community delivery homes with TBA
  • Maternal death audit
    • pilot with PAHO in Honduras
  • EOC leadership
    • local steering committees
    • community governance
slide38

7- Linkages Informal/Formal Providers

Casa Comunitaria de Parto in Honduras

ongoing challenges
Ongoing Challenges
  • Maintain team commitment & energy
  • Shorten time to (re)design
  • Increase physician involvement
  • Data collection for monitoring system
  • Leadership at central level
  • Project work load
lessons learned and future directions
Lessons Learned and Future Directions
  • Mix of QI & QD with more rapid results
  • Focus on EOC standards and compliance
  • Foster data management
  • EOC skills training from the beginning
  • Simple monitoring systems linked with EOC standards
  • Benchmark the successful activities