MATERNAL, NEWBORN,

AND CHILD HEALTH IN EAST AFRICA

Discussion Topics

• Current State of MNCH in East Africa.

• Kissito Healthcare Interventions.

• Why Global Health Matters.

“The probability that a woman will die from a maternal cause is 1 in 31 in sub-Saharan Africa compared with 1 in 4,300 in developed regions. The risk of stillbirth during labour for an African woman is 24 times higher than for a woman in a high-income country.”

The State of the World’s Midwifery 2011, Delivering Health, Saving Lives,

UNFPA

“Every year approximately 350,000 women die while pregnant or giving birth – almost 1,000 a day. Of these women, 99 percent die in developing countries. An estimated 8 million more suffer serious illnesses and lifelong disabilities as a result of complications at the time of childbirth.”

The State of the World’s Midwifery 2011, Delivering Health, Saving Lives,

UNFPA

“Every year up to 2 million newborns die within the first 24 hours of life. In addition, there are 2.6 million stillbirths, of which approximately 45 percent occur during labour and birth. Millions more newborns suffer birth traumas that impair their development and future productivity.”

The State of the World’s Midwifery 2011, Delivering Health, Saving Lives,

UNFPA

The Challenge

• The United Nations committed to 8 specific goals for improving the quality of life of those living in developing countries.

• Maternal, Newborn, and Child Health figures prominently in the Millennium Development Goals which are to be achieved between 2000 and 2015.

Millennium Development Goals

MNCH Specific Goals

Goal 4: Reduce child mortality rates• Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

Under-five mortality rate Infant (under 1) mortality rate Proportion of 1-year-old children immunized against measles

Goal 5: Improve maternal health• Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal

mortality ratio Maternal mortality ratio Proportion of births attended by skilled health personnel

• Target 5B: Achieve, by 2015, universal access to reproductive health Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage Unmet need for family planning

Infant Mortality Rate Trends

IMR 1990 (A) 2009 (A) 2015 (T)

Ethiopia 124 67 41

Sudan 78 69 26

Uganda 111 79 37

USA 9 7 N/A

Source: UNICEF 2010

Uganda, Ethiopia, Sudan, and USA 1990, 2009, 2015 Target

A = ActualT = Target

Maternal Mortality Ratio

MMR 1990 (A) 2000 (A) 2009 (A) 2015 (T)

Ethiopia 990 750 470 248

Sudan 830 770 750 208

Uganda 670 640 430 168

Uganda, Ethiopia, and Sudan 1990, 2009, 2010, 2015 Target

A = ActualT = Target

Source: UNICEF 2010

Mortality of Children Under Five

1990 (A) 2000 (A) 2009 (A) 2015 (T)

Ethiopia 210 148 104 70

Sudan 124 115 108 41

Uganda 184 154 128 61

USA 11 8 8 N/ASource: UNICEF 2010

Uganda, Ethiopia, Sudan, and USA 1990, 2009, 2010, 2015 Target

A = ActualT = Target

Causes of Maternal Death

Severe Bleeding (haemorrhage)InfectionsEclampsiaObstructed labourUnsafe abortionOther direct causesIndirect causes

The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.intwhr/2005/en, accessed 14 August 2008).

Root Causes of East African Maternal/ Newborn Death and Disability

• Access to at least one antenatal visit (Ethiopia 28% / Uganda 94%).

• Births Attended by Skilled Health Professional (Ethiopia 6% / Uganda 42%).

• Lack of basic EmONC systems and referral interventions.• Availability of human resources, essential drugs, supplies,

and equipment throughout the health system.The State of the World’s Midwifery 2011,

Delivering Health, Saving Lives, UNFPA

The Role of Human Behavior in Maternal Death

• A sense of fatalism…it was meant to be.

• Acceptance…this is the way it has always been.

• Greed…a lack of regard for the value of human

life.

• Transference of responsibility…she should have gotten here sooner.

Maternal Death in Mbale, Uganda

September 20, 2011

New York Times July 29, 2011

Global Health’s Unintended Consequences

• Each donor dollar has resulted in a $0.43 to $1.14 decline in developing nation funding.

• Physician migration to non-patient services/private hospitals/out of country.

• Donor funding is transitory (the 3 year grant project) resulting in a continual regression to the mean.

• Capacity building is silo based…new hospitals without staff or supplies.

• Quality is forgotten in a frenzy to spend donor dollars on capacity building.

• Little attention is focused on behavior change.

• Getting what you asked for…the India Hospital Birthing experience.

• Incentives to misreport Health Statistics.

• Donor reporting and site visit burden.

Wall Street Journal

July 29, 2011

Kissito on the Map

HospitalAnnual

Deliveries

Annual

OPDVisits

Comments

Sipara (owned)Addis Ababa, Ethiopia

2,200 42,000 Deliveries expected to increase to 6,000+ after Fall of 2011 relocation and new teaching affiliations.

Mbale (PPP)Mbale, Uganda

7,300 UNK New PPP to operate all OB/GYN and Newborn programs. Regional Referral Hospital for over 2.0 million people.

Bugobero (PPP)Bugobero, Uganda

700 73,000 Highest Level of Care for a population of 330,000+.

Kamashi (owned)Kamashi, BGRS, Ethiopia

N/A N/A Regional Referral Hospital under construction. Referral population exceeds 1.0 million people.

Ottoro (owned)Ottoro, SNNPR, Ethiopia

N/A N/A New construction expected to open in January of 2012. Highest Level of Care for a population of 144,000+.

Busiu (PPP)Busiu, Uganda

700 UNK New PPP established to share resources with Bugobero.

Hosanna (PPP)Hosanna, SNNPREthiopia

2,500 UNK New PPP to operate all OB/GYN and Newborn programs. Regional Referral Hospital.

Kissito Engagement Areas

• Maternal, Newborn, and Child Health/EmONC (B and C)

• Malaria Intervention and Treatment

• Pediatric Diarrhea Intervention and Treatment

• Community Based Health and Referral Interventions

• Health Sector-Human Resource Development

• Nutrition and Acute Malnutrition Management

• FP and VCT/PMTCT/ART Integration

Kissito Differences

• Sustainable Public Private Partnerships.

• Comprehensive solutions/processes…versus one time events.

• Always seeking a better understanding of community needs/problems. Engaging all stakeholders.

• Long term partnerships versus short-term projects.

• Clinical Skills/Professional Management development of National staff.

• Limited resource solutions.

• Community Based Interventions (fixing the problem not just treating the symptoms).

Current Activity

• Ensuring our hospitals always have the staff, equipment, supplies, and essential drugs to meet our patients’ needs.

• Training, practicing, and testing ourselves. When this is accomplished, we will train, practice, and test ourselves again…it will never end!

• Integrating our hospitals into community health systems: sharing resources, managing referrals, measuring and improving patient outcomes.

Clinical Competencies

• We utilize Evidence Based Best Practices in Global Health, designed by experts from organizations such as the WHO, JHPIEGO, AMDD, FIGO, AAP, and USAID.

• Our Academic and Clinical partners from around the world have generously supported our efforts with talented physicians, midwives, nurses, public health leaders, medical educators, and clinical training.

Boston University –Kissito Global Health Alliance

• To be launched on January 1, 2012.

• Matching the resources of the School of Medicine, School of Public Health, Boston University Medical Center Residency Programs, and partner academic institutions and teaching hospitals.

• Providing for ongoing and permanently staffed academic, research, and clinical relationships.

• Catalyst for the development of fully integrated sustainable interventions, processes, and systems for the improvement of patient outcomes.

Massachusetts General Hospital Maternal, Newborn, and Child Survival “Tool Kit”

Massachusetts General HospitalMaternal, Newborn , Child Survival

Massachusetts General HospitalMaternal, Newborn, Child Survival

Massachusetts General HospitalMaternal, Newborn, Child Survival

Massachusetts General HospitalMaternal, Newborn, Child Survival

Massachusetts General Hospital

“With regard to FHW practices in the 2-3 months since training, participants reported an average of 3.0 referrals (range 0-20) to a higher level of care. Furthermore, 78.3% of FHWs were more likely to refer patients as a result of the training they received.”

Maternal, Newborn, Child Survival (MNCS) InitiativeInterim Evaluation: Executive Summary

DRAFT, September 2011

Measuring Performance

Everything we undertake must be measured! Kissito has adopted five universally recognized and benchmarked indicators

by which we expect to be judged.

•Infant Mortality Rate•Maternal Mortality Ratio•Child Mortality Rate•Malaria Mortality Rate•Diarrhea Mortality Rate

Maternal Death was inevitable…until Kissito opened a shuttered Operating Theater.

Rural Ottoro Hospital is expected to open in January of 2012, in an area where obstetrical complications

frequently result in death or disability.

Supporting neighboring facilities with EmONC physicians and supplies.

Kissito is fully committed to treating acutely malnourished children, like 4 year old Mane.

Volunteers Carlos and Carolina Tovar at the Bugobero Malnutrition Center.

Building capacity one brick at a time…Kamashi, Ethiopia.

Kissito has eliminated essential drug shortages in Bugobero while treating over 200 patients a day.

Public Private Partnerships…the only path to sustainable outcomes!

Dr. Kiprono introduces Doppler and Portable Ultrasound to the L&D of Mbale.

Why Global Health Matters• Contributing to the betterment and care of all life is at the core of our

humanity. The happiness, meaning, and higher calling we experience in the care of our patients often leaves us wondering who is benefitting more.

• When you have one physician for over 330,000 people…then one more physician will have a meaningful impact. When patients are dying from the lack of sutures…then saving the sterile but discarded sutures at your hospital will have a meaningful impact. When basic skills are lacking…taking the time to share your knowledge will save lives.

• When Global Health does not matter to us: We are really saying…human life…at least in certain places…is no longer important. As individuals we can make a difference…collectively, we can transform the world!