Country experiences in delivering integrated maternal and newborn care

Dr. Jorge Hermida Regional Director, LAC programs The USAID ASSIST Project, University Research Co., LLC

Global Newborn Health Conference JOHANNESBURG, SOUTH AFRICA. April 2013

The situation before 2009

Maternal and child care managed from separate offices in the Ministry of Health Norms developed or updated separately Initiative for Quality of Maternal Care but not for Child or Newborn Care No coordination in delivery of care at facilities between obstetric and pediatric care and personnel System for maternal mortality surveillance but not for Newborn mortality

Changes in 2009
Maternal and Child Care programs were unified and are now managed from one single office at the MOH Norms were updated and were issued jointly A newborn care component was included within the Maternal Quality Improvement Initiative, including training on evidence-based interventions both theoretical and practical, quality standards, indicators, a monitoring system, and local QI teams implementing PDSAs and continuously improving care. Joint QI teams for maternal and newborn care were mandated at every facility where births occur. A Newborn mortality surveillance system was developed and issued.

ESSENTIAL OBSTETRIC AND NEWBORN CARE NETWORK, COTOPAXI

PROVINCIAL HOSPITALS (2)

COMPLETE EONC
24 hours/7days

COUNTY HOSPITALS (5)

BASIC EONC
REFERRAL
24 hours/7days

HEALTH CENTERS

Parish micronetwork: TBAs, health centers and social organizations working together

COMMUNITY EONC
TBAs

Field test in one of 24 provinces of Ecuador:

Expanding Access to both maternal and newborn care through a three-tiered EONC Network: Community, Basic and Comprehensive ONC. TBAS, community organizations and health centers work together to identify pregnant women, conduct home visits and refer women and babies to nearby county hospitals. County hospitals provide integrated Basic EONC; provincial hospitals provide integrated Comprehensive EONC. Essential newborn care, HBB and Kangaroo Mother Care were introduced, standardized management of preterm deliveries dexamethasone for fetal lung maturation, standardized management of PROM, complications such as infection, prematurity/LBW and respiratory distress. Integration happens horizontally between provider institutions including the MOH, the Social Security facilities and provider NGOs . Access to and quality of Maternal/Newborn Care are monitored monthly and quarterly at facility and provincial aggregated levels. After 2 years of testing , results show model is feasible to implement and low-cost. Access in terms of skilled attendance at birth, maternal-newborn complications identification and referral, quality of care was improved. Newborn mortality was reduced in intervention areas The MOH decided in late 2012 to scale up the integrated model to the entire country, mostly using its own resources. Scale-up is currently underway.

Key Challenges
Sense of property of programs at the MOH. Hospital specialists who prefer to have their own reign Deficiencies in training on NB knowledge and skills of doctors and nurses Legal and institutional difficulties to integrate MOH, Social Security and NGOs Resistance to effectively integrate the TBA as a link between the communities and the health system and as a direct community provider of services when reach is not possible.

Obstacles and failures

To integrate more strongly the civil society organizations into an oversight and support for improvement role. To effectively introduce NB mortality (and near misses) surveillance as a regular task of district management teams To strengthen pre-service training on knowledge and skills for integrated maternal and newborn evidence-based interventions.