Sada Group 7 Rh

SADA (SAFE DELIVERY APPROACH) A 3 years Project to Reduce MMR In District Noshki Balochistan Group VII Dr Afzaal, Dr Ali Raja, Dr Majeed, Dr Muhabbat, Dr Waseem

Demographic Data • • • • • •

Population 152785 Area 5792 Sq.Km Population Density # of Tehsils 1 # of U/Cs 10 Literacy Rate33.59% – Male 48% 19.5% – Female

20person/km2

RH Indicators of Noshki • • • • •

MMR 714/100000 live births CPR 31% C/Sections 5-7/month Antenatal visit 100 /month Hospital Based deliveries 35-40/months

Health Facilities • • • • • •

# of DHQ Hospital # of THQ Hospital # of RHCs # of BHUs # of CDs # of MCH centers

1 0 2 10 25 3

The New Paradigm • All pregnancies are at risk: Most obstetrical complications are neither predictable, nor avoidable, but can be treated if assisted by a SBA • Shift of focus from pregnancy to delivery • Therefore, from the viewpoint of providers, readiness becomes the key word, accompanied by quality of obstetric care • Provided parturients can access and use these ready and quality institutions

Maternal Mortality • Each year, more than 500,000 women die from complications in pregnancy and childbirth, even though the means exist to save the vast majority of these lives • Millions more women are disabled (Near Miss)

• « during childbirth »: because evidence shows that most complications, and deaths, occur during childbirth (25%), or immediately thereafter (60%); [the rest before labour]

Attendance at Birth According to Community-based Surveys 6%

6%

26%

40%

22%

Doctor Other SkAt TBA Relative No-one

Maternal Mortality • The main reasons for the high rates of maternal mortality are: • (1) lack of perinatal care • (2) Lack of properly trained birth attendants or medical facilities • (3) Lack of transport to the nearest properly equipped hospital • While almost 80 percent of births in the country occur at home.

The UNFPA Strategy for the Reduction of Maternal Mortality and Morbidity

is based on 3 pillars:

• Family Planning • Skilled attendance at (all) births • Emergency Obstetric Care

Five Assumptions 1. 2. 3. 4. 5.

Lack of Health seeking behavior of people towards SBA or facility based delivery Lack of awareness among the TBAs/LHWs and other family members regarding the identification of danger signs Non-availability and geographic distribution of facilities – non-availability of equipments and supplies – nonavailability of means of communication – 24/7 Lack of positive supervision and effective monitoring Poor resources Management – planning and budgeting, Posting and retention – low quality of life

Possible Curative Interventions • • • • •

Skilled Birth Attendants at all Births Intrapartum Care based in Health center Antenatal and Post natal care Emergency Obstetric care Quality Care of Reproductive health services • Post Abortion care

Possible Preventive Interventions • • • • • • • • • •

Awareness Family Planning Capacity Building (Trainings) Women empowerment Nutrition and micronutrients Exclusive Breast feeding up to 6 months Female literacy Poverty Reduction Discouraging early age marriages Couple counseling (Male involvement)

Identified Curative/Preventive intervention • Curative Intervention – Skilled Birth Attendants at all Births

• Preventive Intervention – Awareness regarding the utilization of maternal health services

Due to Clustering of mortality around delivery and dominance of Hemorrhage, infection and hypertension; and keeping in view the geographical and cultural barriers of the District We focus to intervene the three DELAYS.

3 Ds approach • First: Delay in deciding to seek care for a perceived obstetrical complication (community) • Second: Delay in reaching the appropriate facility (transport) • Third: Delay in receiving appropriate care at the facility (skilled care) • Put emphasis on the third delay, which should come first. Useless to address the other two if quality care is not ensured in health facilities.

BCC

Transport, telecom

Dai

H

Upgrade and make fully operational

MNH Training

o

m

LHW Village Village Cluster

RHC/ BHU

e

A SB

Basic EmOC

Obstetric emergencies (bypass Basic EmOC)

Framework-SADA Project

DHQH Comp. EmOC

SADA Project (SAFE DELIVERY APPROACH)

District Noshki

Aims and Objective •

Aim – Improved health status of women by reducing maternal deaths in District Noshki

•

Objective – To reduce maternal deaths by 75% in District Noshki in 3 years. – To raise awareness among 100% general population of District Noshki regarding RH services utilization in 3 three years

Organogram of SADA Project EDO (H) (Chairman)

District Coordinator (SMO)

WMOs

LHVs/CMWs

Coordination of District Support Team (Multisectoral Approach) • • • • • •

Health Department People’s Primary Health Care Initiative LHWs Program Population Welfare Department Education Department NGOs and Line Departments

District Maternal Health Committee (DMHC) • A committee will be formulated for regular monitoring and on job supervision of SADA Project • The committee meeting will be conducted on quarterly basis • Members will be – – – – – – –

Distt. Nazim/DCO EDO (H) Distt. Coordinator SADA Project MS DHQ (H) All LMOs Anesthetist LHVs of Basic EmOC facilities

Chairman Secretary Member Member Member Member Member

Spot Map AFGHANISTAN

Kishingi

n osta B m Ana

Dak

Mengal

C

Jamaldini

Noshki city

H A G A

Ahmed Wal Mal

I KHARAN

• • •

DHQ CEmOC BEmOC

M A S T U N G

Target Population • • • • • •

All Women of Reproductive Age Group All adult males Elderly women of the community All influential leaders of the community Ulemas and Masjid Imams Male and Female councilors

Strategies for first delay • Awareness regarding Girls Primary Education • Skill Development of LHSs and LHWs in Inter Personal Communication and Counseling. • All LHWs will be trained in to identify danger signs and improve appropriate referral. • Seminars on RH/youth/gender issues. • Health Education Sessions at Girls and Boys High Schools & Colleges. • Documentaries/ RH messages & gender issues in local cable network. • Celebration of International Days (population, mothers, midwives, women's days)

Strategies for Second delay • Provision of 6 fully equipped ambulances (one for each Basic EmOC facility) • Repair of existing ambulances. • Reactivation of Village Health Committees for Community Transport System • Wire Less Loop/ Land line phone for selected LHWs/ LHS/ Health Facilities and Ambulances on ownership

Strategies for Third delay • • • •

Establishment of Comprehensive EmOC at DHQH 24/7. Establishment of Basic EmOC at 02 RHCs & 04 BHUs. Labour rooms at these health facilities. Repair/renovation of Health Facilities & Residences for Female Staff. • Posting of Anesthetist at DHQ • Posting of LHVs/CMW at all Basic EmOC facilities. • Financial and other incentives for the health care providers • Capacity building of Lady Medical Officers / LHVs / Paramedics in Safe Delivery practices, Infection prevention, HMIS, RH, FP, STI, etc.

Strategies for Third delay • Provision of medicines, minor equipment, and consumables • Maternal Mortality Conference at District level on Quarterly basis. • Refresher Management Courses at AKU Karachi for District Health Managers. • Laboratory support

Strategies for Third delay • Three Months Training of 03 LMO in Cesarean Section at AKU Karachi. • Two Months Training of Anesthetic & OT Assistant in Operation theater at BMCH Quetta • Three month training of one LMO in Ultrasound at SPH Quetta • HMIS orientation workshop for HCPs in two batches • Verbal autopsy on maternal & Neonatal death

But the main argument for institutional delivery remains Quality of care Good experience with providers encourages use of care – cost is not a major concern in such situations Women’s perspectives about quality of care  Respect by health service providers- not to be abused or scolded- talk and smile…particularly at night…  Sensitivity to needs, including respect for dignity  Care and support, explanations, choices  Costs

MADAD Cards (Medicine availability for diseases after delivery)

• 15% of deaths occur due to puerperal infections • MADAD Cards are introduced to decrease the deaths due to puerperal infections • MADAD Cards will be issued by LMO to the near misses • Each MADAD Card will help these women to get prescribed medicines with in range of Rs.3000/=

Indicators of Monitoring and Evaluation • Process Indicators – # of Deliveries by SBA – # of Deliveries At Health centers – # of C/Section – # of Referrals to CEmOC

• Out come Indicators – %age of Deaths due to maternal cause – %age of mothers with complications – %age of Normal Births

Future Plans • Monthly IUDs camps at RHCs • PG Rotation • Establishment of Midwifery school at Noshki

Activity Plan

Work Plan WEEK 1: • Introductory meeting with DHMT. • Meeting with DHMT about training of HCP’s and awareness campaigns. • Decision about schedule will be finalized. • Willing HCP’s will be sent for training. • Surety bond will be taken from them that they will serve in the District for at least five years.

Work Plan- Week 2 • Purchase committees about purchase of medicines, ambulances and vehicle, equipment and furniture and printing material. • Meeting about improvement of infrastructure with DHMT. • Meeting about budget allocation. • Tender will be given in newspapers about purchase of medicines, ambulances, equipment and furniture and renovation of infrastructure accordingly.

Onward Activity • Monthly meetings about the progress and efficacy of the project will be conducted at EDO(H) office NOSHKI. • All in charges of health facilities will make sure their presence in the meetings along with monthly progress reports. • Monthly meeting will be conducted in first week of every month. • Process and Outcome indicators of the project will be analyzed in the meeting

TRAINING PLAN PHASE 1: • Training of two LMOs from Agha Khan Hospital, Karachi for three month. • Training of Anesthetist from Bolan Medical Complex Hospital ,Quetta for two month. PHASE 2: • Training of nurses, mid wives and LHV’s in three batches for a period of one month by trained LMO’s at DHQ hospital NOSHKI. • Training of CMWs and LHW’s by two trained nurses for a period of one month in different batches at DHQ hospital NOSHKI. PHASE 3: • One week refresher courses for all health care providers after every six months.

BUDGET

Allocation of budget for the first year (2009-10) of Project (SADA) 1.

AWARENESS CAMPAIGNS a) b) c) d) e)

2.

Seminars Health education sessions Documentary movies /Puppet shows IEC /Posters /Wall chalking Radio / TV (local cable)

TRAINING a) b) c)

3.

RS 5.0 millions

LMOs/LHW’s/CHW SBA’s TOT’s

PURCHASE OF VEHICLES a) b)

RS 4.0 millions

RS 14.0 millions

Ambulances (6) Toyota Hilux double cabin (1)

4.

IMPROVEMENT OF INFRASTRUCTURE

RS 7.5 millions

5.

EQUIPEMENTS AND FURNITURE

RS 4.0 millions

2009-10 (cont’d…) 6.

ESTABLISHMENT OF EmOC SERVICES a) Basic EmOC services (6) b) Com EmoC service (1)

RS 3.7 millions

7.

MEDICINES

RS 8.0 millions

8.

LOCAL PURCHASE

RS 2.5 millions

9.

POL

RS 5.5 millions

10.

REPAIR AND MAINTANANCE

RS 3.0 millions

11.

INCENTIVES FOR HCP’s

RS 2.0 millions

12.

MADAD CARDS FOR WOMEN having post partal COMPLICATIONS

RS 3000 per card(300 cards) Total RS 0.9 millions

TOTAL

RS 60.1 millions

BUDGET FOR YEAR 2010-11 1.

MEDICINES

RS 7.5 millions

2.

MAINTANANCE AND REPAIR

RS 2.5 millions

3.

LOCAL PURCHASE

RS 2.0 millions

4.

INCENTIVES

RS 2.0 millions

5.

POL

RS 5.5 millions TOTAL

RS 19.5 millions

BUDGET FOR YEAR 2011-12 1.

MEDICINES

RS 8.0 millions

2.

MAINTANANCE AND REPAIR

RS 2.9 millions

3.

LOCAL PURCHASE

RS 2.0 millions

4.

INCENTIVES

RS 2.0 millions

5.

POL

RS 5.5 millions TOTAL

GRAND TOTAL FOR THREE YEARS(2009-12)

RS 20.4 millions 100 MILLION RUPEES

HAR MAAN KI DUA

SADA RAHE

SADA

THANKS