Title: Support to a Safe Motherhood Project in Maputo City Hospital Geral Jose Macamo
1Support to a Safe Motherhood Project in Maputo
CityHospital Geral Jose Macamo
- Ministry of Health / UNFPA / NORAD, MOZAMBIQUE
- Sundby, Johanne, Univ. of Oslo, Norway
- Ustá, Momade Bay, HGJM, Maputo
- Rwamushaija, Emmanuel, HGJM/UNFPA, Maputo
2Hospital Geral Jose MacamoOutline of
presentation.
- Introducing 24 hours comprehensive obstetric
services - Experiences from the first 2 years and challenges
ahead - Support and Sustainability in Maputo City and
Maputo Province Context
3Baseline before we started
- Before April 2000 - Maputo Central Hospital
Maternity (HCM) was the only 24-hr Obstetric
Gynaecological - referral facility for over 1.2 million people in
Maputo City and also serving part of Maputo
Province. - Because of too many patients, it was suffering
from severe work overload and deterioration of
quality of services and training
4There was therefore an urgent need for another
functiong referral hospital. Objectives were
- To improve the quality coverage of CEOC in
Maputo City as a whole. - To improve services in HGJM so that it could give
CEOC 24 hours a day every day of the week. - To reduce the burden of work and improve quality
of care at the Central Hospital Maternity - WHO estimates that there should be at least one
Hospital providing CEOC services for each 500
000 people.
5To provide good quality service through training
- In order to be a good health worker, and know
what good quality service is, you need to have
been exposed to work in a well functioning health
unit! - The project has created another training site at
Jose Macamo (HGJM) for MCH Nurses Surgical
Technicians Doctors - The project trains personnel from Maputo City,
Province and other areas
6Actvities scheduled and carried out in the
hospital
- Limited Rehabilitation of the existing
infrastructure HGJM and periph. maternities,
theatre, etc. - Acquisition of medical equipment supplies
- Recruitment of personnel nurses, technicians,
doctors - Improved administration, in-service routines,
training and supervision - Improvment of the patients referral system
7A before - and - after design for review of
project
- At baseline, an operational research plan was
developed, to follow changes in patient flow,
care quality and technical skills - After project launch - April 2000 - 24-h. CEOC
services were firmly established, and changes
assessed
8Components of assessing the project progress
- Patient satisfaction study at baseline
- Staff satisfaction survey and quality of care
observations - Review of service statistics and patient transfer
patterns from HGJM, CHM, city and province
maternity. - Review of types services provided, complications
handled and outcomes - A new patient / staff satisfaction survey in HGJM
and maternities, and reasons for utilization
patterns - Cost recovery study
- Formal project evaluation
9Rapid changes
- After 1 April 2000, the number of admissions to
HGJM increased from ca. 400/month to ca.
1000/month. - Caseload at the Central hospital went down. These
figures are now (2001) fairly stable - The Caesarian section rate in HGJM increased from
less than 1 to an average of 12-13
10A great change 1rst April 2000
- In 2000, HGJM admitted 12153 patients
- Ref. to HGJM Jan-March 0 patients
- REFERRALS to HGJM AFTER APRIL
- from home 9723 patients
- from Bagamoio 692 patients
- from Chamanculo 610 patients
- from Machava 449 patients
- from Matola 403 patients
- and others 286 patients
11HGJM current workload
- HGJM has 1000 or more admissions per month
- The caesarian section rate is 12-13The hospital
treats more than 600 gynecological patients every
month, ca. 300 of them being abortion related. - More than 10 of admissions have a reported
complication.
12Total DeliveriesHCM versus HGJMJanuary -
December 2000
13Referral patterns 2001
- 70 of admitted patients come from their homes.
At least 10 those are high risk patients, but
most are normal deliveries. - 50 of patients come from and live in Maputo
Province - 2/3 of the referrals are from maternities outside
the catchment area, in Maputo City and Province.
14Where do HGJM patients come from in 2001?
Proportion of referrals transferred from
- Chamanculo 25.4
- Bagamoio 20.7
- Matola 17.5
- Machava 15.0
- Catembe 2.2
- Others 18.7
- ( catchment area)
15Obstetrics Referrals to HCM January - December
2000
16Where do HGJM c/s. Patients come from (2001)?
- Of the total number of c/s, we have found that
- 48.4 from Maputo Province
- 29.4 from JM area
- 18 from Chamanculo
- 4.2 are from from Mavalane area
- HGJM functions as a referral hospital for Maputo
City and Province
17Caesarian SectionsHCM versus HGJM January -
December 2000
18Is there enough capacity for caesarian sections
in Maputo?
- The joint c.s. rate for (2000) Maputo Province
and Maputo City is around 5, which is considered
the lowest acceptable rate. - Maputo Province perform a small proportion of the
needed c.s. in the province (2000 79 c.s. /
39297 deliveries 0.2). - The rate in the city is calculated an adequate 9
, but the denominator also includes an unknown
number of patients from the Province.
19 .
Percentage () of Caesarean Sections HCM versus
HGJM 2000
20Why do uncomplicated patients not seek care in
primary level maternities?
- Some complain that the facilities are not good,
lack equipment or the quality of services is
inappropriate - Even if these maternities provide more space and
have more time, it is difficult to get FAST
transfer or treatment if something happens.
21Why do the patients come to HGJM?
- It is near, convenient, easy to reach
- It provides good services 24 h, has doctors and
equipment - They do not have to pay
- They are advised to go by ANC services
- They are referred from a maternity
22Maternal and perinatal deaths at HGJM in 2001
- Before 2000, all complications were transferred
to HCM. - In 2001 so far, there has been 8 maternal deaths
Institutional MMR 121/100 000 - Perinatal mortality rate is 44/1000 (only incl.
early neonatal deaths) - Stillbirths ca 80 of perinatal deaths.
23Morbidity and intrapartum fetal deaths
- Malaria in pregnancy is a frequent complication
(30-55/month) - Maternal Case Fatality for major complications is
1.3 -1.5 - (accepted rate1!)
- Intrapartum deaths In Jan-Jun 2001, for 12
caesarian sections the outcome was a dead baby.
In addition, another 39 vaginal delivery
intrapartum deaths occurred.
24Morbidity, continued
- 75 of all patients have had a syphilis (VRDL)
test performed during ANC - Syphilis prevalence is 5.1
- Of those positive for VRDL, 50 to 90 have
received treatment according to prenatal records - Anemia 14 have hemoglobin 9 g or less
25Reasons for being transferred to HGJM 2001
- Hypertensive/eclamptic compl. 386 cases
- Arrested labor/slow progress 140 cases
- Fetal distress 112 cases
- Ruptured Membranes 104 cases
- Others are breech, malaria, prev.section,
haemorrhage, large uterus, uncertain term etc. - (20.8 of admissions to maternity are for noted
problems or complications)
26Major maternal complications treated in HGJM
Jan-Jun 2001 (excl. abortions) is 12
- Hypertens./Preeclamp. 285 cases
- Malaria 266 cases
- Obstructed labor 141 cases
- Haemorrhage 81 cases
- Ectopic pregnancy 22 cases
- Post partum sepsis 14 cases
- Ruptured Uterus 4 cases
- (minimum estimate)
27Project expenditures covered by UNFPA
- Total investments and infrastructure 1,028,817.00
USD - Recurrent expenses (consumables, salaries,
overtime) 10-12 000.00 USD/month in addition to
core gvmt. funds - Estimated extra costs per delivery 16 USD.
- IS THIS THE REAL PRIZE OF SAFE MOTHERHOOD?
28Staffing structure, at present
- Nurses (incl. midwives) Total 28
- MISAU employed nurses 13
- Project /UNFPA nurses 15
- Doctors Total 7
- National OB/Gyn (Hosp. Direc) 3
- Expat. OB/Gyn (Proj. TA) 3
- Expat. Anesth. 1
29Hired personnel (overtime)
- To cover some night shifts, senior OB/GYN
postgraduate doctors are paid by the project. - Anaest. technicians, theatre nurses and some
midwives are also hired in on a part time basis.
- Surg. tech. are paid on weekends, by the HCM
30Conclusions
- It has been possible to establish good quality
Emergency Obstetric Services, and women use them.
Women in this urban/semiurban environment know
and would like to have safe delivery services - HCM has got a better capacity to take care of
complicated deliveries and training/teaching
31More conclusions
- Referrals do not follow administrative - but
rather practical - patterns - There is still a need to change patient streams.
More uncomplicated pregnancies could be managed
at the peripheral level - A lot of training now takes place at HGJM
- Staffing structure is marginal
32Challenges ahead
- It is difficult to sustain such a high work
burden in HGJM with the current staffing and
supply patterns of this hospital - There is still considerable scope for quality
assurance and improvement - Case management protocols for maternal
complications are urgently needed.
33More challenges
- The project is not sustainable without continued
extra funding, external support, or some cost
recovery mechanisms - The total health systems and referral patterns
for maternities in Maputo Province and City need
revision - Rapid communication referral (ambulance and
radio) is important
34Making peripheral maternities attractive to women
- Better staff skills in handling basic emergencies
- clear guidelines - Upgrade infrastructure and equipment
- More streamlined referrals at all times
- Better communication with patients
- Improved staff supervision
35Lower work burden would allow better integration
of RH services
- More health information and education material
should be available in the maternities and HGJM
(for staff and for patients) - Integration of FP and STD services in MCH must be
implemented - A birth is an opportunity point for FP and HIV /
AIDS health messages - but this is compromised
within the current workload