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Part I: Safe Motherhood

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

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  1. Part I: Safe Motherhood Kristen Cotter, MSIV

  2. 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

  3. 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

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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Part II: Safe Motherhood Needs Assessment Kikoneni and Dzombo Locations Kwale District, Coast Province, Kenya Kristen Cotter March – May 2003

  10. Mombasa Mombasa Mombasa

  11. 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

  12. 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%

  13. 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)

  14. 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)

  15. 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

  16. 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

  17. WHO Pillars of Safe Motherhood • Pillar #1 ANC • Pillar #2 Clean, safe delivery • Pillar #3 Emergency Obstet. Care • Pillar #4 Family Planning

  18. 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%

  19. 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%

  20. 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

  21. 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”

  22. 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)

  23. 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%

  24. 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%

  25. 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%

  26. Pillar #2: Clean safe delivery Safe Attendance = Trained attendant + Enabling environment (Equipment, Drugs, Facilities)

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Pillar #2: Clean safe deliveryFacilities • Water • KHC: rainwater & borehole pump • Dry sinks & showers & toilets • Electricity • generator house, but no generator

  33. Pillar #2: Clean safe deliveryAttendant knowledge

  34. 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

  35. 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%

  36. 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

  37. 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

  38. 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%

  39. 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%

  40. Pillar #2: Clean safe deliveryTraditional Birth Attendants • How to make placenta come out • Press on abdomen 69% • Wait 31% • Beaded necklace 15%

  41. 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

  42. Pillar #3: Emergency OB CareAttendant knowledge

  43. 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

  44. 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)

  45. Pillar #4: Family PlanningFP Register, KHC Attendance: 96.7 visits/month

  46. Pillar #4: Family PlanningFP Register, KHC Couple Years of Protection: with Norplant Last birth in health facility: 41.4%

  47. Pillar #4: Family PlanningFP Register, KHC Distribution Events: Depo Condoms

  48. 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

  49. 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

  50. 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

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