Support to a Safe Motherhood Project in Maputo City Hospital Geral Jose Macamo - PowerPoint PPT Presentation

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Support to a Safe Motherhood Project in Maputo City Hospital Geral Jose Macamo

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Introducing 24 hours comprehensive obstetric services. Experiences from the first 2 years and ... Obstetrics Referrals to HCM. January - December 2000. 16 ... – PowerPoint PPT presentation

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Title: Support to a Safe Motherhood Project in Maputo City Hospital Geral Jose Macamo


1
Support 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

2
Hospital 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

3
Baseline 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

4
There 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.

5
To 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

6
Actvities 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

7
A 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

8
Components 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

9
Rapid 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

10
A 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

11
HGJM 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.

12
Total DeliveriesHCM versus HGJMJanuary -
December 2000
13
Referral 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.

14
Where 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)

15
Obstetrics Referrals to HCM January - December
2000
16
Where 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

17
Caesarian SectionsHCM versus HGJM January -
December 2000
18
Is 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
20
Why 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.

21
Why 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

22
Maternal 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.

23
Morbidity 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.

24
Morbidity, 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

25
Reasons 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)

26
Major 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)

27
Project 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?

28
Staffing 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

29
Hired 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

30
Conclusions
  • 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

31
More 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

32
Challenges 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.

33
More 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

34
Making 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

35
Lower 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
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