Maputo, Mozambique—When newborns at Mavalane General Hospital in Maputo developed skin rashes, the suspected culprit was a new policy of encouraging skin-to-skin contact between mother and child. But the maternity ward’s health review team saw it differently. They decided to implement some new infection prevention measures to help control the outbreak while identifying its cause. For instance, they banned the traditional practice of wrapping a newborn in a mother’s dress and offered pregnant women the chance to take a bath after admission to the maternity ward. Within days of taking those simple steps, the rashes subsided.
The health team’s approach to resolving the problem is a prime example of the operational changes evident in Mozambique’s main obstetric hospitals, which grew out of the government’s commitment to improve health care delivery at these facilities. Through the use of a Jhpiego-pioneered quality assurance program, hospital staff are actively engaged in setting standards for service, identifying gaps in care, recommending solutions and assessing outcomes. The Standards-Based Management and Recognition (SBM-R) approach puts a priority on employee input and compliance and recognizes achievement.
This approach was introduced as part of the nationwide Model Maternities Initiative begun in the country’s largest emergency obstetric and newborn care facilities. The project grew out of a Ministry of Health (MOH) call for a comprehensive review of maternal, newborn and child health policies, guidelines and programs in October 2009. This work was done with funding from the U.S. Agency for International Development’s flagship Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego.
A year later, MCHIP-assisted programs, in partnership with the MOH, have shown measurable improvements in health care policy and service delivery that include:
- Development of 15 separate national maternal, newborn and child health strategies, standards and guidelines;
- Establishment of the Model Maternities Initiative in 34 of the busiest hospitals with emergency obstetric services, which account for 21 percent of all births in health care facilities nationwide; and
- Integration of reproductive health and family planning services with the country’s first ever national cervical cancer prevention program.
The goal of the Model Maternities Initiative is to provide a humane, caring environment in which women give birth and improve maternal and newborn health care services. The program encourages women to have a companion join them in the birth process and choose their birth position, and practice skin-to-skin contact between mother and child and immediate breastfeeding. During labor and delivery, birth attendants are urged to use the partograph to monitor labor and assist in decision-making and actively manage the third stage of labor.
“Mozambique, as in other African countries, is a place where many women have their babies outside of a health facility. Sometimes access to health services is not easy for them. Other times, they are afraid of not being well treated at the health facility and they feel more comfortable at home,” said Dr. Veronica Reis, MCHIP’s technical advisor on the program. “The biggest problem is that when complications occur at home with the mother or baby, the possibility of solving the problem or reaching a health facility in time to ensure the appropriate care is very limited.
“In this context, the MMI is a very important effort by the Mozambique government and partners because this initiative is focused on improving the quality of care and creating a good environment where the woman can feel respected, well treated and safe.
“The preliminary results from the implementation of MMI show an increase in mothers’ and families’ satisfaction,” said Dr. Reis. “It’s expected that, as the program continues, use of maternal and neonatal health services will consequently impact the health of Mozambican mothers and babies.”
Since the October 2009 launch of MMI, improved quality of care for women is becoming more routine in the maternity ward at Mavalane General Hospital. For example, in March 2010, hospital staff used active management of third stage of labor during the majority of the 820 births (520 or 63.4 percent). The same number of new moms also immediately put their babies on their chests as part of the skin-to-skin contact initiative. And lessons have been learned. As the skin rash outbreak showed, “it is extremely important to put in place simple measures for hygiene to prevent skin infections among newborns,” said Dr. Bernadina Gonzalves, the pediatrician in charge of the maternity ward at Mavalane General Hospital.
A key achievement resulting from the improved maternal health services under the Model Maternities Initiative has been an increase in the number of Mozambican women who choose to give birth in a health facility with a skilled birth attendant present, a critical factor in safeguarding the lives of mother and child. Through the Model Maternities Initiative, 318 skilled birth attendants have been taught emergency obstetric and newborn care skills and family planning.
As a result of this capacity building, health care services have been strengthened dramatically according to key indicators charted by participating hospitals:
- 44 percent of births have a completed partograph;
- 65 percent of births included active management of third stage of labor;
- 89 percent of women with pre-eclampsia/eclampsia were treated with magnesium sulfate;
- 59 percent of newborns have skin-to-skin contact with mother; and
- 57 percent of infants are breastfed within one hour of birth.
Targets were achieved in every area but complete use of the partograph, which helps health care providers monitor the progress of labor and make decisions about when further interventions are needed.
As a result of the integration of services, cervical cancer screening units have been established in nine rural and six referral health facilities. The women are screened in a single visit approach, a method championed by Jhpiego that uses the application of acetic acid (the main component in household vinegar) to detect pre-cancerous lesions of the cervix.
If such lesions are found, a health provider will immediately treat the cervix with a freezing agent that eradicates the cells. Women with a more serious condition will be referred for further treatment. Through this new national protocol, at least 4,791 women have been screened for cervical cancer. Of those, 341 were positive for pre-cancerous cells and 60 percent of these women received treatment for the pre-cancerous lesions on the same day.
Integrating cervical cancer screening with maternal health services is important because cervical cancer—the leading cancer killer of women in the developing world—is preventable. If symptoms are detected early, women can be treated successfully. Women who are HIV-positive are more at risk for cervical cancer and, in Mozambique where over 11% of adults are HIV-positive and a third of the population doesn’t know their HIV status, early screening is critical to saving lives.