Leadership and Learning

Global Leadership
Through its success as an implementer of high-quality maternal health programs, MCHIP has played a key role in the development of global policies and recommendations. As the go-to technical assistance organization for high-level global standards meetings convened by WHO and others, MCHIP has contributed to the development and dissemination of essential WHO guidelines on high-quality, high-impact interventions aimed at reducing maternal mortality on important topics such as PE/E, PPH and task shifting, all of which are designed to strengthen national health systems in addressing these issues. MCHIP has developed numerous key derivatives from each of these guidelines, which have been endorsed and used by WHO and translated into numerous languages. MCHIP’s own regional meetings in Addis Ababa and Dhaka, where many of these guidelines and polices were disseminated, have encouraged many programs in countries across Africa, Asia and the Near East to adopt evidence-based maternal health programs that achieve impact at scale.

In Pakistan, following the Asia Regional Meeting on Intervention for Impact in Essential Obstetric and Newborn Care, representatives of provincial departments of health, professional bodies, academic institutions, civil society organizations, and development partners met and, as a direct result, adopted the inclusion of misoprostol on the Essential Medicines List for KP-FATA, Punjab and Baluchistan. Additionally, MCHIP staff serve on key technical advisory committees for maternal/newborn health programs of other donors, including the Pre-EMPT program, the maternal sepsis component of the ANISA study, and the Care Group of the Born Too Soon Steering Committee.

Program Learning Achievements
Using the results from the 2012 multi-country analysis and the QoC studies to determine whether all the necessary components are in place to scale up best practices for prevention and management of PPH and PE/E, MCHIP has achieved the following:

  • South Sudan: AMTSL is now part of the basic midwifery training at the midwifery schools for all levels.
  • Malawi: Supported the Ministry of Health to revise obstetric protocols, including management of severe PE/E, which were then distributed to all maternity units country-wide and are posted in all maternity wards for easy reference.
  • Ethiopia: Training on use of MgSO4 is included in BeMONC training and currently 50% of SBAs have received this training (up from 20% at the time of the QoC survey).
  • Kenya: Supported the Ministry to develop guidelines, such as the National Guidelines for Quality Obstetrics and Perinatal are, job aids and posters on Kangaroo Mother Care, AMTSL, use of MgSO4, learning resource packages, and various newborn job aids based on standard protocols. In addition, MCHIP has worked the Ministry to develop national MNH standards which are in the process of being piloted and approved.

How does MCHIP Maternal Health address equity and community?
In many of the countries where MCHIP works, a majority of births are home-based and women have little or no access to care. To address the issue of PPH, MCHIP has introduced community-based distribution of misoprostol in South Sudan, Rwanda, Liberia and Madagascar with a focus on reaching women with limited access to health care and expanding coverage of PPH prevention programming. These programs1 also provide training for facility-based health workers on AMTSL and site strengthening in order to perform safe deliveries. While women are counseled and encouraged to develop a birth preparedness plan in order to deliver in a facility, they are also empowered with the ability to take misoprostol to prevent PPH if they are unable to do so. The May 2013 dissemination meeting in South Sudan received positive feedback with MOH, USAID and NGO partners present and the findings will be submitted for publication in the second half of 2013. A key result of these introductory programs is that plans are underway to scale up this living saving intervention in South Sudan and several other countries—with oversight from MCHIP—which will help to dramatically increase uterotonic coverage for countless women. This program ensures that the most vulnerable are reached while maintaining and improving services for those with access to facilities.

How does MCHIP Maternal Health address scale?
The goal of MCHIP’s maternal health team is to take evidence-based interventions to scale and to work with MoHs (where possible) to ensure that these interventions are institutionalized at the national level. In Zimbabwe, MCHIP has developed a competency-based Basic Emergency Obstetric and Newborn Care (BEmONC) training curriculum, which is currently being scaled up nationally through the Maternal, Newborn and Child Health Transition Fund (HTF), the multi donor MNCH funding mechanism.

MCHIP has developed post training follow up and routine supportive supervision guidelines, which have been adopted nationally. MCHIP also trained supervisors to conduct these follow up and routine supportive supervision in MCHIP learning sites. Based on MCHIP data collected at the end of 2012, the number of early neonatal and intrapartum deaths has steadily decreased at MCHIP’s Standards-based Management and Recognition (quality improvement) supported sites. In all facilities nationwide, maternal deaths have decreased from a high of 291 to 149 as of December 2012.

Improved maternal, newborn and child health (MNCH) donor funding (such as HTF, Global Fund and USAID) has facilitated the national scale up of all MNCH trainings, including nutrition, prevention of mother-to-child transmission of HIV, and malaria. On the job training, post-training follow-up, and supportive supervision have become institutionalized with MCHIP technical support. MCHIP’s contribution to this effort has been the development of post-training follow up and supportive supervision guidelines, which have been adopted nationally to ensure a continuous quality improvement process. In the past, one-off trainings were standard. Thanks to MCHIP, training is now competency based and linked to post training follow up and on-going supportive supervision to ensure that providers are able to transfer skills and knowledge to the workplace.

How does MCHIP Maternal Health address quality?
In addition to the Multi-Country Analysis Survey, MCHIP has been able to present and disseminate the results of the QoC Surveys and use this advocacy tool to raise QoC issues related to facility readiness. Conducted in seven countries—Mozambique, Madagascar, Rwanda, Tanzania, Zimbabwe, Kenya and Ethiopia—these studies have resulted in country-level programmatic changes in several areas, such as prevention of PPH, prevention and treatment of PE/E, and newborn care. For example, in Ethiopia, MCHIP assisted the MoH to implement QoC study recommendations to update the midwifery curriculum, which is now competency based and covers all basic EmONC signal functions and other MNH services such as AMTSL, partograph use, and immediate newborn care. MCHIP is also using data analysis from the QoC study to develop a validated subset of about 20 quality indicators which will be piloted in Tanzania. The goal is to develop a simpler and more rapid on going assessment of quality that can be applied elsewhere to effectively measure both the access to and quality of care.

Similarly, MCHIP is addressing quality by strengthening reporting of results and improvements in health provision (Standards Based Management and Recognition, or SBM-R, processes) and achievement of maternal and newborn health outcomes. More specifically, MCHIP has nearly finalized the development of a guidance document which will help programs demonstrate a link between performance on SBM-R or other quality improvement programs and improved health outcomes.

Finally, in addition to supporting the development of the White Ribbon Alliance Charter, which affirms a woman’s right to respectful maternity care (RMC), MCHIP has recently launched an RMC toolkit. This toolkit provides evidence-based content for use by clinicians, trainers, educators and supervisors as well as by policy makers interested in promoting RMC. Technical staff also include RMC content in training courses and when providing field support to pre-service and in-service programs.

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1 The Madagascar program does not train facility-based workers due to a restriction on working with the government