Slide 1

Dr Sisana Majeke (PhD) and ESMOE Board Inspiring Greatness

Slide 2

Key findings: 1500 maternal deaths per year 4867 maternal deaths were reported in 2008-2010 3959 maternal deaths were reported in 2005-2007 3296 maternal deaths were reported in 2002-2004 (NCCEMD Saving Mothers report, 2008 2010).

Slide 3

Slide 4

MMR 310 /100000 live births (2008) MMR 330/100000 live births (2009) The institutional MMR has increased across all levels of care when compared with 2005-2007 (Saving mothers report, 2008-2010).

Slide 5

Major causes of maternal deaths Top 3 preventable causes of maternal deaths, accounted for almost 70% of Maternal deaths: Non-pregnancy related infections (HIV&AIDS) ( 40.5%) Obstetric haemorrhage (14%) Hypertension (14 % ) Prioritization of the prevention of these conditions is essential The biggest impact can be made on preventing maternal deaths-MDG 5

Slide 6

Slide 7

Patient related Accessing health care services Unsafe miscarriages Administrative Transport between facilities Access to ICU Access to blood Inadequate staff Health care providers Not assess patients properly Delay in referral Not follow standard protocols

Slide 8

32000 perinatal deaths per year PNMR 34/1000 births Primary obstetric causes Intrapartum asphyxia and birth trauma Spontaneous preterm birth Hypertension Major neonatal death causes Hypoxia Immaturity o 8 234 Early Neonatal Deaths Neonates with LBWT (Saving Babies report 2008-2009 written by NaPeMMCO)

Slide 9

Reduce deaths due to HIV/AIDS Reduce deaths due to Haemorrhage Reduce deaths due to Hypertension Improve Health worker training Strengthen Health System Each stresses prevention and emergency care

Slide 10

Train all health care workers involved in maternity care in the ESMOE-EOST programme and obstetric anaesthetic module, with emphasis on the following: Standardised observation and monitoring practices which stipulate the frequency of observations and aid interpretation of severity e.g. early warning monitoring charts. These would enable earlier detection of haemorrhagic shock following delivery and after CS; and also enable earlier interventions for complicated pre-eclampsia. The skills of safe labour practices; use of and interpretation of the partogram, AMTSL, use of uterotonic agents, safe CS, and additional surgical procedures for complicated CS. To achieve competence in the management of obstetric emergencies e.g. PPH, eclampsia, acute collapse. Train all health care workers who deal with pregnant women in HIV advice, counselling, testing and support (ACTS), initiation of HAART, monitoring of HAART and the recognition, assessment, diagnosis and treatment of severe respiratory infections.

Slide 11

Essential steps in the management of common conditions associated with maternal and neonatal mortality guideline Guidelines for Maternity Care in South Africa second edition 2007. Life Saving Skills manual (RCOG) Facilitators guide (Adapted RCOG guide) Mannequins Posters CD/DVDs Emergency Obstetric Simulation Training (EOST) Scenarios Scoring sheets

Slide 12

Use principles of adult learning Lecture Skills demonstration / DVD/ video Skills practice Scenarios 12 modules (90 minutes each) Training 3 day workshops 2 day workshops 12 weekly in-service training meetings

Slide 13

1. Resuscitation Maternal7. Obstructed labour 2. Resuscitation Neonatal8. Interpreting CTGs 3. Sepsis and Shock9. Obstetric complications 4. Eclampsia and pre-eclampsia10. Surgical skills 5. Haemorrahge11. Complications of abortion 6. Assisted delivery12. HIV in pregnancy

Slide 14

Pre-test and post test May & August 2008 Significantly increases knowledge and skills

Slide 15

2005-2007: 80% of anaesthetic related maternal deaths clearly avoidable 2008-2010: 90% of anaesthetic maternal deaths possibly or probably avoidable Most in district hospitals Problems Complications of spinal anaesthesia Failed intubation Obstetric Anaesthetic module developed in 2010, tested 2011

Slide 16

Slide 17

ESMOE Board Master Trainer Training Certification Quality assurance (monitoring) Updating/ Editing Master trainers At hospitals with interns Intern training Certified Registered by HPCSA EOST at hospital: Midwives & doctors Documented Part of CEO KRAs EOST at hospital: Midwives & doctors Documented Part of CEO KRAs EOST at hospital: Midwives & doctors Documented Part of CEO KRAs COSMOs skilled Province: Supply personnel for training Coordinate training workshops Medical officers Ad. midwives

Slide 18

Slide 19

To significantly reduce maternal and neonatal deaths in SA by improving obstetric and neonatal emergency care

Slide 20

Target initially the Districts which are most in need for emergency obstetric and neonatal care training as targeting these will have the most immediate effect on reducing MMR and NNDR Training of 80%+ of maternity health care providers leads a significant reduction in maternal deaths (MI decreased by 50%), significant reduction in SBR (15%) Kenya, India, Sierra Leone, Zimbabwe, Bangladesh

Slide 21

Data DHIS births for each district NCCEMD maternal deaths per district DHIS Stillbirths and neonatal deaths Criteria for selection Scoring system according to MMR SBR Number maternal deaths Priority in province

Slide 22

Top 25 districts according to Ins MMR Score MMR1=180-230; 2=230-280; 3=280+ Score SBR1=25-27; 2=27+ Score MD1=100-150; 2=150-200; 3=200+ Score Province2=highest MMR; 1=second highest MMR

Slide 23

ProvinceDistrictsTotal FSLejweleputswa DM8 ECO Tambo DM8 NWBojanala Platinum DM7 FST Mofutsanyane DM7 LIMCapricorn DM7 NCFrances Baard DM6 KZNUgu DM6 KZNUthungulu DM6 GPEkurhuleni MM6 FSFezile Dabi DM5 FSMotheo DM5 MPUG Sibande DM5

Slide 24

ProvinceDistrictsMaternal deaths FSLejweleputswa DM 102 ECO Tambo DM 281 NWBojanala Platinum DM 188 FST Mofutsanyane DM 122 LIMCapricorn DM 222 NCFrances Baard DM 80 KZNUgu DM 126 KZNUthungulu DM 154 GPEkurhuleni MM 319 FSFezile Dabi DM 72 FSMotheo DM 124 MPUG Sibande DM 112 Total 1902 (38% all MD)

Slide 25

ProvinceDistrictsTotal KZNuMgungundlovu DM4 KZNeThekwini MM4 WCCentral Karoo DM4 FSXhariep DM3 NCJ T Gaetsewe DM3 NCPixley ka Seme DM3 ECAmathole DM3 NWDr K Kaunda DM3 KZNUthukela DM2 ECA Nzo DM2 NWNgaka Modiri Molema DM2 NCSiyanda DM1 LIMWaterberg DM1

Slide 26

ProvinceDistrictsMaternal deaths KZNuMgungundlovu DM 117 KZNeThekwini MM 391 WCCentral Karoo DM 6 FSXhariep DM 11 NCJ T Gaetsewe DM 35 NCPixley ka Seme DM 24 ECAmathole DM 191 NWDr K Kaunda DM 65 KZNUthukela DM 86 ECA Nzo DM 48 NWNgaka Modiri Molema DM 93 NCSiyanda DM 22 LIMWaterberg DM 78

Slide 27

9 Districts with district regional hospitals 3 Districts with tertiary hospitals (3 Districts with medical schools) 12 Districts give 50% of maternal deaths in districts without medical schools remaining 32 Districts give the rest

Slide 28

ProvinceCore Districts ECAmathole DM FSLejweleputswa DM FST Mofutsanyane DM FSFezile Dabi DM KZNUgu DM KZNUthungulu DM KZNuMgungundlovu DM GPEkurhuleni MM LIMWaterberg DM MPUG Sibande DM NCFrances Baard DM NWBojanala Platinum DM Districts with Medical Schools ECO Tambo DM LIMCapricorn DM FSMotheo DM

Slide 29

Lack of master trainers Funding Staff shortages in the different districts and hospitals

Slide 30

NDOH and PDOH will facilitate cooperation by province and district respectively Master trainers will be available and will be trained on ESMOE-EOST 600 master training slots in 30 months Doctors and midwives will be trained mostly together in teams Anaesthetic module will be included in the scale-up, but not necessarily at the same time as ESMOE-EOST Funding available (DFID)

Slide 31

Ordered 25 districts to have ESMOE-EOST and anaesthetic module scale-up DOH to fund the 10 new sites

Slide 32

Step 1 Baseline assessment and standard ESMOE-EOST Training Step 2 Saturation training (80%+ all HCW in MNH trained) 1 district in 2 months (5 districts/year) 6x3-day workshops (30 master trainers) 4x2-day workshops (20 master trainers) 50 master training slots per district

Slide 33

Facilities and functionality audit Basic Emergency obstetric care Anticonvulsants, oxytocics, antibiotics, Manual removal of placenta, perform MVA, assisted delivery Bag and mask ventilate a neonate Comprehensive Emergency Obstetric Care Perform C/S and give blood transfusion Ensure all sites have a doctor and midwife trained in ESMOE-EOST and are doing EOST exercises Trained in monitoring tools PPIP, MaMMAS and maternal near miss audits

Slide 34

Slide 35

Stepped wedge design Used where know intervention is effective but cannot implement it everywhere at once Random allocation of order of sites is fairest way to provide roster for intervention All sites have had Standard ESMOE-EOST training at baseline Random allocation to saturation training All sites end up with saturation training

Slide 36

1212 1 1010 9 8 7 6 5 4 3 2 1 Base 12345678910111213 - 18 Time Epochs (2-3 months) Phase 1 Districts Stepped wedge design Perform EOST exercises Saturatio n Trained, EOST exercises

Slide 37

Baseline data collection complete at all core districts Fezile Dabe District completed saturation training

Slide 38

The CHC health providers are also been trained now from August 2012. Midwives are encouraged to attend these trainings for 2 days in their districts. Thank you !!!