Part I: Safe Motherhood
Kristen Cotter, MSIV
Developed Countries:
 % of all Maternal
Death: 0.5%
 Lifetime risk: 1 in 2500
 MMR: 20 (per 100,000 live births)
Africa:
 % of all Maternal
Death: 48%
 Lifetime risk: 1 in 20
 MMR: 830
WHO/UNICEF/UNFPA, 2000
Why care (and act)?



529,000 maternal deaths in 2000
Often leading cause of adult female death
Great disparity
–


MMR 50x higher in developing countries
Infant health & survival affected
Maternal deaths are avoidable
Causes of Maternal Death Worldwide
Hemorrhage
25%
15%
Sepsis
Eclampsia
13%
Unsafe abortion
13%
Obstructed labor
Other direct
Indirect
7%
8%
20%
Note: #1 cause of Maternal Death in USA doesn’t even make the top 5.
The Making Pregnancy Safer Initiative
(Safe Motherhood Initiative)


Vision: All women go safely through pregnancy
and childbirth, and that their infants are born alive
and healthy.
Goal: To reduce maternal mortality by 75% from
1990 levels by the year 2015.
www.WHO.org
The old hope (1987 Nairobi S.M. Conference). . .

The key to reducing maternal mortality was
in the community
–
Risk assessment by trained non-doctor


–
Low risk delivery with TBA
High risk referred to skilled attendant
Antenatal care by TBAs
New realizations (1997 Columbo Technical Consultation). . .



Every pregnancy faces risk
No data to show that training TBAs lower MM
Key to lowering MM: Health Infrastructure
Clean, Safe Delivery
with Skilled Attendance
for all women
Key Components of Safe Motherhood


Skilled attendance (now 62%)
Health systems
–
–
–
–
–
–
–

Policies
Essential supplies of medicines and equipment
Infrastructure
Referral system
Monitoring & evaluation
Supervision & training of staff
Records
Involving communities
Part II: Safe Motherhood
Needs Assessment
Kikoneni and Dzombo
Locations
Kwale District,
Coast Province,
Kenya
Kristen Cotter
March – May 2003
ICRH Background


Branch of Univ. of Ghent SOM,
Dept. of OB/Gyn
Kenya programs include:
–
–
–
–
HIV prevention (sex workers, workplace, youth)
Voluntary Counseling & Testing (VCT)
Prevention of Mother-to-Child Transmission of
HIV
Safe Motherhood
Kikoneni and Dzombo Locations
Background






Pop. 44,647
2 hours outside of Mombasa
Estimated HIV seroprevalence: 9%
49% ♀, 29% ♂ never attended school
8% ♀, 17% ♂ educated past primary school
Home building materials:
–
–
–
Grass/palm roofs
Mud and wood walls
Earth floors
74%
64%
75%
Kenya Background



MMR: 1000 per 100,000 live births
Lifetime risk of OB death:
1 in 19
Fertility rate:
4.7
–
–


Rural:
No education:
5.2
5.8
♀ using modern contraception: 32%
Births in health facility:
42%
(WHO/UNICEF/UNFPA 2000, DHS 1998)
Design and Methodology

Survey tools developed and used in similar settings
–
–



Adapted by ICRH staff
Professionally translated & back-translated into Swahili
Locations
–
–
–

MEASURE Evaluation
WHO Safe Motherhood Needs Assessment
Kikoneni Health Centre (KHC)
3 Dispensaries
Mobile Clinic
Interviewer: Diana Ngombo (clinical & PH nurse, ICRH staff)
Overview of Assessment

Retrospective Review of KHC clinical records
–
–
–

ANC Register
FP Register
Maternity Admissions Register
Cross-Sectional Surveys
–
–
–
–
Facilities Assessment (drugs, equip., supplies)
Human Resources (provider knowledge, training)
ANC Client Exit Interviews
TBA Interviews
Limitations



Sample sizes small
Multiple translations
Non-random sampling
–
–



ANC clients in register, but only 12-22% had lab results recorded
Women who come to clinics for ANC or delivery are different from
general community
Descriptive only. Cannot be generalized.
Without community-wide survey, prevalence cannot be
determined (though we tried)
Observation bias & social desirability bias
Population Council tool problematic
WHO Pillars of Safe Motherhood




Pillar #1
Pillar #2
Pillar #3
Pillar #4
ANC
Clean, safe delivery
Emergency Obstet. Care
Family Planning
Pillar #1: Antenatal Care
Review of ANC Register






New ANC clients at KHC
Age
Parity
Age of nulliparous pts
Adolescent pts
Gestational age at presentation
–

3rd trimester
Previous children dead
44 pt/mo
22.4 yrs
2.0 children
18.6 yrs
33%
26 wks
45%
12%
Pillar #1: Antenatal Care
Review of ANC Register
Lab results
 Anemia (Hb<10.0)
–
–
–





Mild (Hb 8.1-9.9)
Moderate (Hb 5.1-8.0)
Severe (Hb <5.0)
Syphilis
Malaria
Helminths
Schistosomiasis
Negative Rhesus
92%
32%
57%
2%
2%
9%
38%
5%
3%
Pillar #1: Antenatal Care
HC Provider Management

Iron  “all”
–
–
–
–

Non-Anemic: 200 mg tid for 1 week
Anemic: 200 mg tid for 1 or 2 weeks
Referral at Hb ≤5.0
Barriers: stock shortages, cost
Folate  “all”
–
–
5 mg tab for 1 week
Stock shortages, cost
Pillar #1: Antenatal Care
HC Provider Management

Multi-Vitamins  “some”
–

SP (Sulphadozine Pyrimethamine)  “all”
–

1 tab bid or tid for 1 week
3 tab stat, twice during pregnancy
Deworming  “all,” “some”
Pillar #1: Antenatal Care
Cost of 1st ANC visit
Service/Supplies
Consultation + labs
ANC card
Iron x 2 weeks
Folate x 2 weeks
Vitamins x 2 weeks
Ketrex
SP
Tetanus toxoid
Tetanus (syringe)
Total
KSh
160
20
20
20
20
20
Free
Free
10__________
KSh 270 (= US$3.50)
(26% of Kenyans live below $1 per day)
Pillar #1: Antenatal Care
ANC Exit Interview, KHC
Transportation
Walked
Time
Client-Provider
Meeting time
Advised to return
KHC
Mobile
80%
66 min.
83%
66 min.
14 min.
94%
7 min.
100%
Pillar #1: Antenatal Care
ANC Exit Interview, KHC
Physical Exam
Abdominal exam
Fetal heart beat
BP check
Medical Hx
Medications
SP
Iron
Investigations
Blood
Urine
KHC
Mobile
100%
100%
97%
100%
100%
100%
100%
100%
97%
91%
50%
42%
69%
69%
13%
13%
Pillar #1: Antenatal Care
ANC Exit Interview, KHC
Counseling Topic
Birth plan (place)
Benefits of delivering in
a health facility
Nutrition Counseling
FP or child-spacing
STIs, HIV, AIDS
Transportation in event
of emergency
Action if bleeding or seizures
Infant care
KHC Mobile
17% 0
9%
6%
3%
3%
0
8%
13%
33%
3%
0
0
0
0
8%
Pillar #2:
Clean safe delivery
Safe Attendance =
Trained attendant
+
Enabling environment
(Equipment, Drugs, Facilities)
Pillar #2: Clean safe delivery
Basic OB Equipment
All 4
Sphygmomanometer
Stethoscope
Gloves
Needles
& syringes
Adult scales
Baby scales
Fetal stethoscope
Examination table
All 4
3/4
Delivery set
Scrub basin
IV fluid sets
Suture set
Sponge forceps
Suturing tray
Forceps bowl
Containers
& receiver Stretchers
Vaginal speculum
Suture needles & materials
Thermometer
Padded tongue blade
Pillar #2: Clean safe delivery
Basic OB Equipment
2/4
IV catheter sets
Stopwatch/Watch
Sterilizer
Antenatal forms
measure
1/4
Tourniquets
Straight Catheter
Partographs
Centrifuge or
hemoglobinometer
Urine testing
equipment
0/4
Amnihook
Foley catheter
Nitrazine paper
Sterile packing Tape
material
Towels or cloth
Oxygen tank
Sterile 4x4 gauze
MVA
Vacuum extractor
Protective gown
Bulb syringe
Pillar #2: Clean safe delivery
Basic OB Equipment
KHC equipment scores
 Absolute Minimal for Delivery
 Basic Equipment
 Partographs
 ANC
 APH
 Eclampsia
 Infection
1.00
0.67
1.00
1.00
1.00
1.00
1.00
Pillar #2: Clean safe delivery
Basic OB Equipment
KHC equipment scores (con’t)
 Complicated Deliveries
& Lacerations
 Dysfunctional Labor
 PPH
 Normal L&D
 Storage
0.73
0.60
0.50
0.44
0.00
Pillar #2: Clean safe delivery
Medication








Normal L&D
ANC
Dysfunctional Labor
Complicated Deliveries & Lacerations
PPH
Infection
APH
Eclampsia
1.00
0.50
0.50
0.33
0.33
0.33
0.00
0.00
Pillar #2: Clean safe delivery
Facilities

Water
–
–

KHC: rainwater & borehole pump
Dry sinks & showers & toilets
Electricity
–
generator house, but no generator
Pillar #2: Clean safe delivery
Attendant knowledge
perf orm bimanual examinations
perf orm speculum examinations
suture (repair) vaginal lacerations
suture (repair) episiotomies
start IV inf usions
manually remove placentas
f irst assist at C/Section
use partographs to manage labor
Skill
bimanually compress the uterus (external)
perf orm vacuum extractions
perf orm external versions
perf orm ref lex testing
suture (repair) 3rd/4th degree lacerations
bimanually compress the uterus (internal)
perf orm prenatal risk screening
perf orm internal versions
suture (repair) cervical lacerations
check hemoglobin
perf orm menstrual extractions
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
Percent
60.0%
70.0%
80.0%
90.0%
100.0%
Pillar #2: Clean safe delivery
Coverage




Kenya (DHS 1998)
31 KHC births ÷
659 expected births (K’neni Loc)=
74 KHC births ÷ 994 ANC clients (KHC)=
ANC clients reporting last birth in health facility
–
Mobile Clinic (1 of 14)
–
KHC (12 of 29)
Limitations!

–
–
Other birthing facilities?
ANC clients are not a random sample!
42%
5%
7%
7%
41%
Pillar #2: Clean safe delivery
Preference & Demand

Final decision-maker if referral needed
–

Husband
100%
Why women choose TBAs instead of health
facility (according to TBAs)
–
–
–
Can deliver at home 85%
Cheaper/free
31%
Natural to them
8%
Pillar #2: Clean safe delivery
Traditional Birth Attendants







Married women with >4 children
60% never went to school
3.2 deliveries per month (0.9 last month)
Most have other primary occupations
Learn by apprenticeship (“gift from God” or goats)
4 of 13 had attended training
Herbal medicines & spiritual practices included
–
Also provided for men and non-pregnant women
Pillar #2: Clean safe delivery
Traditional Birth Attendants

Equipment:
54% razors
46% gloves
39% soap


ANC PE: 82% assess baby’s position
Delivery prep: 62% sterilize equipment
54% wash hands

Eating/drinking encouraged during labor
Pillar #2: Clean safe delivery
Traditional Birth Attendants

When bear down?
–
–
–
–
–
Woman feels urge to push
Excessive pain/screaming
Water breaks
Urge to defecate
Crowning
85%
54%
46%
39%
23%
Pillar #2: Clean safe delivery
Traditional Birth Attendants



Sometimes insert hand into vagina
Episiotomies
Perineal tears
–


Tx: warm saline baths/compresses
Manual version for malpresentation
Razors to cut cord
–
–
39%
0
31%
Boil
Wash
54%
100%
70%
31%
Pillar #2: Clean safe delivery
Traditional Birth Attendants

How to make placenta come out
–
–
–
Press on abdomen
Wait
Beaded necklace
69%
31%
15%
Pillar #3:
Emergency Obstetric Care

Attendant knowledge
–
Clinical case scenarios


–
–
–
“ANC pt at 32 wks gestation, c/o swollen hands & feet
and increased HAs”
“Pt c/o malaise 48 hrs after delivery”
History-taking
Physical Exam
Action
Pillar #3: Emergency OB Care
Attendant knowledge
PPH Urgent Action
PIH Action
Infection Follow Up
Knowledge category
APH Identification
Infection Ask
Eclampsia Action
Dysfunctional Labor Identification
PPH Identification
PPH Action
Infection Action
APH Action
0.00
0.10
0.20
0.30
0.40
0.50
Calculated score
0.60
0.70
0.80
0.90
1.00
Pillar #3: Emergency OB Care
Referral System

Transportation
–
–
No formal system
Family arranges matatu or car

–
–
KSh 2000
2+ hrs from referral to hospital
Dispensaries refer directly to Msambweni
Pillar #4: Family Planning
FP Register, KHC

Fertility
–
–
–
–

Kenya TFR (DHS 1998)
Mean parity of ANC pts (Register)
Mean gravida of ANC pts (Exit)
TBAs
Counseling opportunities
–
–
–
3% of ANC pts at KHC (Exit)
13% of ANC pts at MC (Exit)
15% of PNC pts for TBAs (TBA)
4.7
2.0
3.7 & 3.4
5.7 children
Pillar #4: Family Planning
FP Register, KHC
400
Attendance: 96.7 visits/month
350
300
number of clients
250
Unspecified
200
Return
New
150
100
50
0
2001-Q1
2001-Q2
2001-Q3
2001-Q4
2002-Q1
2002-Q2
2002-Q3
2002-Q4
Pillar #4: Family Planning
FP Register, KHC
120.00
Couple Years of Protection:
100.00
with Norplant
Last birth in health facility: 41.4%
CYP provided
80.00
Norplant
Condom
60.00
OCP
Depo
40.00
20.00
0.00
Q1 2001
Q2 2001
Q3 2001
Q4 2001
Q1 2002
Quarter
Q2 2002
Q3 2002
Q4 2002
Pillar #4: Family Planning
FP Register, KHC
120.00%
Distribution Events: Depo
Condoms
Percentage of distribution events
100.00%
80.00%
Norplant
Condom
60.00%
OCP
Depo
40.00%
20.00%
0.00%
Q1 2001
Q2 2001
Q3 2001
Q4 2001
Q1 2002
Quarter
Q2 2002
Q3 2002
Q4 2002
Pillar #4: Family Planning
FP Register, KHC
Coverage
 Female pop. of Kikoneni Location: 7533
 Females of Reproductive Age: ~5,251
 FP visits: 2321 for 2001-2002
 0.22 visits per Female of Repro Age
 Ratio of 1 visit per 4.55 women

Limitation: Not a community-wide survey
Conclusions: Pillar #1
Antenatal Care








Med Hx, PE, ANC cards, & adequate time with
provider offered to nearly all ANC clients
Lab coverage is low: 69% KHC, 12.5% MC
Coverage of SP for IPT: 97% KHC, 50% MC
Anemia: 92%
Helminths: 38%
Minimal counseling, including STIs/HIV
Late gestational age at presentation for ANC
HIV testing & PMTCT not yet available
Conclusions: Pillar #2
Clean Safe Delivery

67 women have delivered at KHC since 2001
= 7.4% of ANC clients at KHC
= 5.3% of expected births for Kikoneni Location
Kenya MOH goal for 2010: 80% births with skilled attendance



KHC is well equipped and staff well trained to
provide normal delivery services.
No water & electricity at KHC, though infrastructure
in place
Few deliveries at dispensaries
Summary of Pillar #3
Emergency Obstetric Care





KHC referred 9.5% of maternity pts
Referrals from dispensaries are rare. Few/no
complications seen in last year.
Pre-referral management of complications score
poorly
If KHC is to provide “basic OB care,” more
equipment & drugs are needed
Transportation: 1.5 to 3.0 hours from referral to
arrival at hospital
Summary of Pillar #4:
Family Planning





97 visits per month at KHC
Norplant’s addition to MM raised CYP
substantially
Condom distribution is low
ANC clients counseled on FP during
pregnancy: 3% KHC, 13% MC
15% of TBAs provide FP advice during PNC
Recommendations

Policy considerations
–

Quality of Female Reproductive Health Care
–


Iron dosing, transportation, Rh- referrals, PNC. . .
Labs, delivery, ed., condoms. . .
Staff Training and Development
Community-based Opportunities
–
Gender, empowerment, men, delayed marriage. .
Questions? Responses?
cotter_kristen@hotmail.com
Part III: Parting thoughts on INHL
How I squeezed INHL into med school

Summer between 1st and 2nd year
–




Spanish language school
IHMEC conference in Honduras
CAMC Family Medicine in Honduras
MPH (“year off”), with internship in Kenya
4th year elective in Paraguay
Opportunities & Resources

www.ihmec.org
–
–
–

http://nhsc.bhpr.hrsa.gov/ambassadors/trainingabroad.cfm
–

International Health Medical Education Consortium
Links to hundreds of INHL organizations, rotations,
volunteer-seeking groups, etc.
Join!
Spanish language learning and serving opportunities
http://www.aamc.org/students/medstudents/overseas
fellowship/
–
Fellowship for 1 year of mentored clinical research in
developing countries, for graduate students in health
sciences
MPH Programs

Strong INHL programs
–
–
–
–

Harvard
Johns Hopkins
UNC Chapel Hill
Tulane University
Usually 1 year with MD
Things to Read


Mountains beyond Mountains, The Quest of
Dr. Paul Farmer, a man who would cure the
world, 2003, by Tracy Kidder
Alma Ata Declaration, 1978
Thank you!

cotter_kristen@hotmail.com