Improving Quality and Access to Improving Quality and Access to Essential Obstetric Care:Essential Obstetric Care:The Latin American The Latin American Maternal Mortality Reduction Maternal Mortality Reduction Initiative (LAMM)Initiative (LAMM)

Stephane Legros, MD, MPH, MBAQAP/URC-CHSSOTA meeting

Miami, FLMarch 15, 2001

Description of LAMMDescription of LAMM

3 countries: Bolivia, Ecuador, and Honduras Activities began mid-98 Project area: average of 200,000 inhabitants

per country Community and facility interventions Three levels of care: primary, district, and

regional MMRs range from 390 to 108/100,000

Components of LAMM initiative

2. Process (Re)designProcess

3. ImprovementProblem solving

4. Providerperformanceimprovement

5. EOC Standards communication

guidelines, job aids

6. Monitoring systemEOC indicators,

rapid surveysClinical audit,

Maternal death audit

Leadership in EOCLocal steering

committees, community governance

7. Linkages informal/formal

providers

1. Community

mobilization

Presentation Road Map Presentation Road Map QA interventions within LAMMQA interventions within LAMM

Recognitionof problem

and Decisionto

seek care

AchievingAccess to

Care

ReceivingQuality Care

Essential Obstetric Care system

I.E.CCommunityMobilizationTraining

Transportation

Referral/Counter-referral

Reception/Triage

Prenatal CareManagement of labor and deliveries

Management of ComplicationsPost-partum care

Commodities and SuppliesSupervision

TrainingMonitoring of system performance

Medical Records

Pathway to Maternal Survival

From the Community to the Facility: From the Community to the Facility: Access and Quality of CareAccess and Quality of Care

Processes

from Mother Care project, M.Koblinski

1. Community Mobilization1. Community MobilizationKey ComponentsKey Components

Training programsIEC Referral systemMonitoring systemEmergency access plansCommunity revolving funds

Impact of Community Impact of Community Mobilization in EcuadorMobilization in Ecuador

Training ModulesTraining Modules

Human body

Pregnancy

Delivery

Neonate

In preparation

Post partum

IECIEC

Posters

Flyers

Radio spots

Soap operas

IECIEC

Plastic disc to estimate date of delivery

Referral SystemReferral System

Specific form used for:

• Prenatal care

• Delivery

• Postpartum

• Neonate and FP

Monitoring SystemMonitoring System

Specific form developed for mother and neonate

• Complications

• Location of delivery

• Health outcomes

Emergency Access PlanEmergency Access Plan

• Developed by community

• Negotiated with drivers

• Displayed in grocery store

Results at Community Level Results at Community Level in Ecuadorin Ecuador

Percent of Communities with Emergency Access Percent of Communities with Emergency Access Plans and Community Revolving Funds for Plans and Community Revolving Funds for

Obstetrical Complications Cotopaxi, Ecuador, 2000Obstetrical Complications Cotopaxi, Ecuador, 2000

1022 20

88

20.4

91.8

28.5

93.8

0

20

40

60

80

100

Percentages

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Revolving Funds Emergency Access Plan

Complicated Deliveries Attended at Home and in Complicated Deliveries Attended at Home and in Health FacilitiesHealth Facilities

Cotopaxi, Ecuador, 2000Cotopaxi, Ecuador, 2000

57.1

42.8

27.7

72.2

14.8

85.1

26.6

73.3

0

20

40

60

80

100Percentages

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Complicated Deliveries at Health Facility

Complicated Deliveries at Home

2. Quality Design of a New 2. Quality Design of a New ProcessProcess

Team work, mix of providers and patients

Focus on user needsStepwise methodology Identification, design, and

implementation of key elements

Three Waves of Process (Re)design Three Waves of Process (Re)design in All LAMM Countriesin All LAMM Countries

1st: Achieving access, mid ‘98- to-mid ‘99• community transportation, referral,

reception/triage,

2nd: Receiving care -- EOC, mid-to-end ‘99• EOC complications, labor monitoring, normal

delivery, prenatal care

3rd: Receiving care -- EOC, Year 2000• maternal waiting home, postpartum care,

neonatal care

Impact of Quality Design on Impact of Quality Design on Prenatal CarePrenatal Carein Ecuador and Hondurasin Ecuador and Honduras

Recognitionof problem

and Decisionto

seek care

AchievingAccess to

Care

ReceivingQuality Care

Essential Obstetric Care system

I.E.CCommunity MobilizationTraining

Transportation

Referral/Counter-referral

Reception/Triage

Prenatal CareMonitoring of labor and deliveries

Procedures to treat ComplicationsPost-partum care

Commodities and SuppliesSupervision

TrainingMonitoring of system performance

Pathway to Maternal SurvivalPathway to Maternal Survival

Improvements in Prenatal Care Improvements in Prenatal Care at Health Center Level, Ecuador and at Health Center Level, Ecuador and

HondurasHonduras

Patient exam larger room with privacy

New appointment system

Integrated dental care and vaccination status

Results of New Prenatal Care Design at Results of New Prenatal Care Design at Health Center Level in HondurasHealth Center Level in Honduras

0

500

1000

1500

2000

2500

1999 2000

Number oftotal visitsNumber offollow up visitsNumber of firstvisits

+ 49%

+36%

+11%

Number of Visits

(Design was implemented in 1999)

Impact of Quality Design on Impact of Quality Design on Reception/Triage in EcuadorReception/Triage in Ecuador

2- 2- Improvements in Reception/ Improvements in Reception/ Triage at Salcedo Hospital, EcuadorTriage at Salcedo Hospital, Ecuador

24-hour guard system Training of personel on IPC Personnel dedicated for triage with

specific room New work schedule New outpatient rooms New transportation beds

2- Improvements of Reception/ 2- Improvements of Reception/ Triage at Salcedo Hospital, EcuadorTriage at Salcedo Hospital, Ecuador

Repaired delivery table

Repaired anaesthesia and sterilization equipment

Results: Number of Deliveries in Results: Number of Deliveries in Salcedo District Hospital, EcuadorSalcedo District Hospital, Ecuador

197

264

356

0

100

200

300

400

1998 1999 2000

Nu

mb

er o

f D

eli

verie

s

Design was implemented in 1999.

180%

Impact of Quality Design on Impact of Quality Design on Normal Delivery Care in Normal Delivery Care in HondurasHonduras

First New Maternal Clinic First New Maternal Clinic Jose Maria Ochoa, HondurasJose Maria Ochoa, Honduras

Problem:

Over-utilization of referral hospital

Solution:

Opening of a satellite maternal clinic to reduce burden

New Maternal Clinic, New Maternal Clinic, Jose Maria Ochoa, HondurasJose Maria Ochoa, Honduras

Results: Number of Deliveries at Results: Number of Deliveries at Jose Maria Ochoa Maternal Clinic, Jose Maria Ochoa Maternal Clinic,

Honduras, 2000Honduras, 2000

8

27

23

17

2325

0

5

10

15

20

25

30

No. ofdeliveries

(Clinic opened in July 2000)

3. 3. Process Improvement, Topics Process Improvement, Topics Selected by the TeamsSelected by the Teams

EOC drugs availability Medical supplies and equipment

availabilityWaiting time reductionPatient satisfaction improvement

4. 4. Provider Performance Provider Performance ImprovementImprovement

Competency Based Training (8 days duration) in on-site training centers

• Knowledge of EOC standards and guidelines• Clinical skills training with mannequins

– prenatal care, normal delivery, prolonged labor, hemorrhages, neonatal care

• Problem solving methodology• Interpersonal Communication

Knowledge Improvement in EOC Knowledge Improvement in EOC Clinical Skills, BoliviaClinical Skills, Bolivia, 2000, 2000

0

20

40

60

80

100

Pre Test Post Test(N= 75)(N=75)

42%

65%

5. 5. EOC Standards and Guidelines: EOC Standards and Guidelines: CommunicationCommunication

Training

Problem-based learning through case management

Job aids: pocket EOC standards manual, use of partographs

Clinical audits

Example from Honduras: Example from Honduras: Pocket Guide of EOC StandardsPocket Guide of EOC Standards

Handy

User Friendly

New format

6. 6. ProjectProject MonitoringMonitoring

Monitoring system, uses existing facility resources

– Baseline assessment, pre/post intervention

– Rapid facility survey, annual

(24-hour care, drug availability, skilled attendants)

– Facility level indicators, quarterly

met need, c-section rate, referral rate

– Community level indicators, quarterly

Results: Percentage of Met Need for Results: Percentage of Met Need for Obstetrical Complications in Cotopaxi Obstetrical Complications in Cotopaxi

Referral Hospital, EcuadorReferral Hospital, Ecuador

2530

55

0

10

20

30

40

50

60

1998 1999 2000

Percentage ofMet Need

Other ActivitiesOther Activities

Linkages informal/formal providers– workshops, matrices & action plans– community delivery homes with TBA

Maternal death audit– pilot with PAHO in Honduras

EOC leadership– local steering committees – community governance

7- Linkages Informal/Formal 7- Linkages Informal/Formal ProvidersProviders

Casa Comunitaria de Parto in Honduras

Casa Comunitaria de Parto 2,Casa Comunitaria de Parto 2,HondurasHonduras

Ongoing ChallengesOngoing Challenges

Maintain team commitment & energy

Shorten time to (re)design

Increase physician involvement

Data collection for monitoring system

Leadership at central level

Project work load

Lessons Learned and Future Lessons Learned and Future DirectionsDirections

Mix of QI & QD with more rapid results

Focus on EOC standards and compliance

Foster data management

EOC skills training from the beginning

Simple monitoring systems linked with EOC standards

Benchmark the successful activities