putting the basic back into basic emergency obstetric...
TRANSCRIPT
Dilys Walker, MD, Associate Professor Depts of Global Health and Ob/Gyn
University of Washington School of Medicine Mini-Med School, February 14, 2012
Putting the BASIC Back into Basic Emergency Obstetric Care
Millennium Development Project Global Maternal Health Millennium Summit (September 2000)
A new global partnership to reduce extreme poverty by 2015
Between 1990 and 2015: MDG 4: Reduce under-5 mortality rate by 2/3 MDG 5: Reduce maternal mortality ratio by 3/4
Country 1990 2008 Change Globally 320 251 -78% Bolivia 439 180 -41% China 87 40 -46% Vietnam 158 64 -40% Morocco 384 124 -32% Afghanistan 1,261 1,575 +25% Zimbabwe 232 624 +169% Ivory Coast 580 944 +63% United States 12 17 +42%
Maternal Mortality Ratio/100,000 live births. Lancet 2010; 375(9726):1609–1623..
B E S T
WO R S T
Maternal Mortality The World’s Best and Worst
Major Causes Maternal Death What can be done?
http://www.usaid.gov/our_work/global_health/mch/images/MaternalMortality.gif
Oxytocin Maternal compression
Tetanus toxoid Immunization Clean delivery Antibiotics Magnesium
sulfate Partogram
Family Planning Postabortion care
Iron supplements Malaria—intermittent treatment Antiretroviral for HIV
http://www.usaid.gov/our_work/global_health/mch/images/MaternalMortality.gif
Major Causes Infant Death What can be done?
Access to contraceptives, to avoid unintended
pregnancies
Access to skilled care at the time of birth
Timely access to emergency obstetric care in the event of
complications
Reducing Maternal Mortality Key Strategies
What new technologies are available for babies?
Low tech resuscitation simulation
baby
Resusci-tation
materials
Windup fetal
monitor
Solar energy kit
Alterna-tive to forceps
Low-tech ultra-sound
What new technologies are available for mothers?
Non-Pneumatic anti-shock garment
Uniject Bakri-Balloon
tamponade
Cell phone apps
PartoPants
Most effective intervention?
Skilled attendants at childbirth
Saving Mothers and Babies Skilled Attendants at Birth
What is happening in Mexico?
Move towards institution-based birth Births with skilled birth attendant
Mexican Perspective Over last 3 decades, proportion of births attended by MDs dramatically:
Cuadernos de Salud Reproductiva. República Mexicana, México, pp. 73-91.Suárez, Leticia, 2010. Salud Materno Infantil en Chávez A. y Menkes C (eds.), Procesos y tendencias poblacionales en el México contemporáneo.
Una mirada desde la ENADID 2006, Secretaría de Salud (en prensa)
Majority of maternal deaths occur in metropolitan area hospitals: • 60% among women 20–34 • 90% had prenatal care • From preventable causes—hemorrhage, preeclampsia
1974 2006 1997
89.5% 84.3%
54.7%
Associated with Quality of Care
What’s been happening in Mexico?
Fuentes: OMS: 1955-1978, INEGI/SSA: 1979-2202, CONAPO: NV 1955-2002
Between 1940 and 1990, maternal mortality dropped 71%. Since 1993, curve has flattened out.
ROSA MARIA NUÑEZ URQUIZA. Propuesta “Transción Epidemiológica Materna-perinatal” a la Fundación CARSO. .
Delays/Omissions/Failures in delivery of appropriate care
What happens? Where?
Family Planning
Prenatal Care Referral 2nd
Referral Delivery Postpartum
RN
Maternal Deaths in Mexico Characteristics
• In institutions • During delivery • Cared for by physicians QUALITY OF CARE
A health professional with the competencies for care during normal birth and the capacity to recognize, manage and refer complications in the woman and newborn.
Skilled Birth Attendant Definition
How can you be sure that a SBA will use the right technology
for the right problem at the right time? ?
Basic Emergency Obstetric Care Standards
Basic EmOC IV/IM: antibiotics
oxytoxics anticonvulsants
Manual removal of placenta Assisted vaginal delivery Removal of retained products
Maine D, Lancet 2007; 370: 1380–82
How to train providers to assimilate evidence-based practices?
Adult Learning Theory
Strategies: Disseminate written materials Didactic sessions
Repetitive reminders On-site facility visits
Clinical audits Interactive sessions/
Simulation-based learning
2004
More Effective
Ineffective
SIMULATION
System adapted from aviation for use in health system
Increase Knowledge
OBJECTIVES for medical
environment
Halamek LP et al. Time for a New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment PEDIATRICS Oct 2000. 106(4): e45.
Improve technical
skills
Improve coordination of care between
providers
Assure efficient
mobilization of resources
Limitations of Simulation Cost Centralization Transportation
How can we bring simulation to where it is most needed?
Programa de Rescate Obstetrico y Neonatal Tratamiento Optimo y Oportuno
• In-situ simulation-based training • High fidelity (environmental
and psychological) • Low-tech (Parto-PantsTM)
Concept
• Team training (Team STEPPS) • Evidence-based practices
(AMTSL, MgSO4 for preeclampsia, delayed cord clamping, algorithms)
• Humanized birth
Module I • PPH—mild atony, • Delayed PPH— retained placenta • PPH—severe atony & meconium aspiration • Incomplete AB/IPV • Placenta previa
Module II • Shoulder dystocia • Eclampsia
PRONTO Simulations
Simulation Debrief • What did we see? • How was the treatment of baby?
— Contact with mom — Delayed cord clamping — Early lactation — Immediate care of newborn
• How was the treatment of mom? — AMTSL — Episiotomy — Limpieza — Contact
• How was identification and treatment of hemorrhage?
• How did they work as a team?
PRONTO
Where are we now? Implementation Research • Matched cluster, randomized, controlled trial in Mexico
(12 matched pairs) • Aim to measure impact on perinatal mortality
and serious obstetric complications (index) — Chiapas, Guerrero, Mexico — Maternal/neonatal indicators — Follow-up 1 yr post-training
PRONTO
Guatemala • Matched pair, cluster-randomized,
implementation study to — perinatal mortality — institution-based obstetric care among indigenous populations in Guatemala
• Implement in 4 districts in Guatamala with highest rates of MM (60 small clinics)
• 3 elements in package — PRONTO — Social marketing to institution-based delivery — Obstetric nurse liaison with traditional midwives
www.prontointernational.org [email protected]
Results Common Recurrent Weaknesses/Errors in Practice
Hemorrhage • AMTSL/ delayed cord clamping • Timely diagnosis/differential diagnosis • Coordinated care • Medications
(Oxytocin, Carbetocin, Ergonovine, Misoprostol) — Storage — Administration (pre vs post) — Maximum
Preeclampsia • Diagnosis • Loading and maintaining MgSO4 • MgSO4 and/or antihypertensive • Dosing antihypertensive, choice • Valium, Dilantin, phenobarbitol
Results Common Recurrent Weaknesses/Errors in Practice
General • Calling for help • Fundal pressure • Uterine limpiezas • Episiotomy • Position for birth • Domestic violence • Hierarchy • D&C vs MVA
Results Common Recurrent Weaknesses/Errors in Practice
Results Strategic Planning Achievements
• Alarm system • Medication availability • Medication refrigeration • Ambulance functionality • Disseminate algorithms • Ultrasound access/training • Neonatal resuscitation training • Team work dissemination • Implement AMTSL
PRONTO