TECHNICAL REPORT Botswana Maternal Mortality Reduction Initiative
DECEMBER 2015
This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Dr. Morrison Sinvula and Dr. Maria Insua of URC under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. The work of the USAID ASSIST Project is made possible by the generous support of the American people through USAID.
FINAL REPORT Botswana Maternal Mortality Reduction Initiative
DECEMBER 2015
Morrison Sinvula, University Research Co., LLC Maria Insua, University Research Co., LLC
DISCLAIMER The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Acknowledgements This technical report was prepared by Dr. Morrison Sinvula and Dr. Maria Insua from the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, managed by University Research Co., LLC (URC), for the Ministry of Health (MOH) in Botswana. It reflects USAID ASSIST technical report for the Ministry’s Maternal Mortality Reduction Initiative (MMRI). The MMRI quality improvement activities supported by USAID ASSIST could not have been possible without the dedication of the MOH district midwife coordinators (Eva Lephirimile, Kebonye Tangane, Dolly Oitsile, Tlhabologo Autilia Johannes, Margaret Buzwane, Chiani Thomas, Keolebogile Keolebale, Thapelo Gaselesego, Kefilwe Matlhare, Kefilwe Kgopana, Veronica Hange, Susan Pono, Emma Lucky and Ms. Hiri) and numerous individuals who formed the quality improvement teams within the various hospitals and districts. The initiative was managed by both ASSIST and the Ministry of Health in Botswana. Dr. Kolaatamo Malefho and Dr. Khumo Seipone have shown a tireless dedication towards the elimination of all avoidable deaths of mothers and their children. Boitumelo Thipe provided the leadership at the Sexual & Reproductive Health Division, and through her we were able to link the initiative with maternal mortality audits. Jessica Mafa-Setswalo ran our office at the Ministry of Health (MOH), and she has been the link between the MOH and the districts. Special thanks to the leadership and guidance in quality improvement provided by Catherine Green during the length of the project. We are grateful for the financial and managerial support provided by Anjali Chowfla, and the overall guidance and strategic leadership provided by M. Rashad Massoud from USAID ASSIST. USAID ASSIST support for the MMRI was funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The USAID ASSIST Project is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected]. Recommended citation Sinvula M, Insua M. 2015. Botswana Maternal Mortality Reduction Initiative. Final Report. Published by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. Bethesda, MD: University Research Co., LLC (URC).
TABLE OF CONTENTS List of Tables and Figures ...... i Acronyms ...... iii I. INTRODUCTION ...... 1 II. MATERNAL MORTALITY REDUCTION INITIATIVE ...... 1 Improvement Strategy ...... 2 Key Continuous Quality Improvement (CQI) Activities Conducted by the MMRI ...... 2 MMRI Monitoring and Evaluation ...... 3 Anemia during Pregnancy ...... 9 Best Practices during Labor ...... 11 Post-partum Hemorrhage ...... 12 Pre-eclampsia and eclampsia ...... 15 HIV ...... 18 Post-abortion Care ...... 20 Caesarean Sections ...... 23 Maternal Mortality ...... 24 Progress towards Achieving Millennium Development Goal 5 ...... 28 III. SUSTAINABILITY AND INSTITUTIONALIZATION ...... 29 IV. CONCLUSIONS AND RECOMMENDATIONS ...... 30 Lessons Learned ...... 31 APPENDICES ...... 33 Appendix 1: MMRI Improvement Framework ...... 33 Appendix 2: Change Package ...... 35
List of Tables and Figures Table 1. Facilities included in the MMRI ...... 2 Table 2. MMRI data collection and electronic reporting tools ...... 4 Table 3. District distribution of facilities providing maternity services included in the MMRI ...... 6 Table 4. QI Teams established per type of facility ...... 8 Table 5. Improvement aims selected by QI Teams ...... 8 Table 6. Distribution of maternal deaths per district and type of facility, 2014 ...... 26
Figure 1. Number of facilities reporting MMRI data per month in each district (Feb 2014 – July 2015) ...... 8 Figure 2. Percentage of pregnant women in labor that were screened for anemia during ANC visits disaggregated by gestational trimester and reporting month (Feb 2014 – July 2015), n= 47,696 ANC visits ...... 9
Botswana Maternal Mortality Reduction Initiative i Figure 3. Anemia rate during pregnancy and labor disaggregated by month (Feb 2014 – July 2015), n= 49,481 ...... 10 Figure 4. Percentage of pregnant women with ANC managed per protocol (Feb 2014 – July 2015), n= 8,694 ...... 11 Figure 5. Percentage of pregnant women diagnosed with anemia during ANC visits, per district (Feb 2014 – July 2015). n=47,696 ANC visits ...... 11 Figure 6. Compliance with best practices during delivery (Feb 2014 – July 2015). n=49,481 deliveries ... 12 Figure 7. PPH rate (Feb 2014 – July 2015), n= 49,481 deliveries ...... 1 3 Figure 8. PPH due to uterine atony (Feb 2014 – July 2015), n= 905 PPH ...... 13 Figure 9. Provision of AMTSL vs PPH due to uterine atony (Feb 2014 – July 2015), n=49,481 deliveries ...... 14 Figure 10. Management of PPH due to uterine atony per protocol (Feb 2014 – July 2015), n= 296 PPH due to atonic uterus ...... 15 Figure 11. Percentage of pregnant women screened for hypertensive disorders of pregnancy (PE/E) during the antenatal period (Feb 2014 – July 2015). n= 47,696 ANC visits ...... 16 Figure 12. Compliance with management of PE/E during ANC (blue) compared to during labor (red) (Feb 2014 – July 2015) ...... 17 Figure 13. HIV prevalence during pregnancy (2001-2015) ...... 18 Figure 14. Distribution of HIV prevalence during pregnancy in Botswana (2014 – 2015) ...... 19 Figure 15. Abortion ratio per 100,00 live births (Feb 2014 – July 2015). n=10,048 abortions ...... 20 Figure 16. Botswana: Distribution of burden of abortion complications (Feb 2014 – July 2015) ...... 21 Figure 17. Type of abortion (Feb 2014 – July 2015). n=10,048 abortions ...... 21 Figure 18. Percentage of incomplete abortions managed within two hours (Feb 2014 – July 2015) ...... 22 Figure 19. Compliance with management of septic abortion with three antibiotics IV (Feb 2014 – July 2015) ...... 22 Figure 20. Percentage of post-abortion patients receiving counselling and family planning supplies (Feb 2014 – May 2015) ...... 23 Figure 21. Distribution of C-section rate per facility type (Feb 2014 – July 2015) ...... 24 Figure 22. C-section rates per district (Feb 2014 – July 2015) ...... 24 Figure 23. Number of maternal deaths per month, nationwide (Jan 2013 – June 2015) ...... 25 Figure 24. Maternal mortality peaks (Jan 2012 – June 2015) ...... 25 Figure 25. Causes of maternal deaths (2014) ...... 27 Figure 26. Patient factors contributing to maternal death ...... 27 Figure 27. Health system contributory factors to maternal deaths (2014) (51 maternal deaths audited (74%)) ...... 28 Figure 28. Botswana HIV incidence rate and maternal mortality rate (1990-2014) ...... 29
ii Botswana Maternal Mortality Reduction Initiative Acronyms AIDS Acquired immunodeficiency syndrome AMTSL Active management of the third stage of labor ANC Antenatal care ART Antiretroviral therapy ASSIST USAID Applying Science to Strengthen and Improve Systems Project BBA Born before arrival CQI Continuous quality improvement EmONC Emergency obstetric and newborn care FP Family planning HAART Highly active antiretroviral therapy HCI USAID Health Care Improvement Project HIV Human immunodeficiency virus IT Information technology LB Live births M&E Monitoring and evaluation MDG Millennium Development Goals MMR Maternal mortality ratio MMRI Maternal Mortality Reduction Initiative MOH Ministry of Health OB-GYN Obstetrics & Gynecology PDSA Plan-Do-Study-Act cycles PE/E Pre-eclampsia/eclampsia PEPFAR U.S. President’s Emergency Plan for AIDS Relief PMTCT Prevention of mother-to-child transmission of HIV PPH Post-partum hemorrhage QI Quality improvement SRH Sexual and reproductive health URC University Research Co., LLC USAID United States Agency for International Development VMMC Voluntary Medical Male Circumcision
Botswana Maternal Mortality Reduction Initiative iii
I. INTRODUCTION Botswana is facing the challenge of meeting the Millennium Development Goal (MDG) 5 by the end of 2015. The country has made tremendous progress in the reduction of maternal mortality since 1990 when the agreement to meet the MDG was made. At that point, the maternal mortality ratio (MMR) in the country was 360 per 100,000 live births (LB). This rate remained high for the following 10 years, in part due to the concomitant HIV epidemic that hit the country with devastating force. After the effective introduction and widespread provision of antiretrovirals (ARVs) to pregnant women the maternal mortality rate was brought down by 50% to a MMR of 196 per 100,000 Live Births (LB) in 2008. Since then, progress in the reduction in maternal mortality has stagnated, threatening the ability of Botswana to reach or exceed the MDG 5 goal of 80 maternal deaths per 100,000 live births by 2015. In 2013, the Ministry of Health (MOH) in Botswana designed and implemented a new initiative to accelerate the reduction of maternal mortality in Botswana: the Maternal Mortality Reduction Initiative (MMRI). Technical assistance for this initiative was provided by the USAID Health Care Improvement Project (HCI) and its successor, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. USAID support of the MMRI initiative ended in September 2015. The aim of the MMRI is to develop a system-level strategy to achieve the MDG target of reducing maternal deaths by identifying gaps in the health system and implementing improvements in a timely and efficient way. The initiative uses quality improvement methods implemented by teams in facilities providing obstetric care countrywide. Topic areas for improvement were informed initially by the MOH’s 2007-2011 Maternal Mortality Audit Report that identified 73% of all maternal deaths were due to direct obstetric and mainly avoidable causes. The 2007-2011 report listed the most frequent causes of death as hemorrhage (38%), hypertensive disorders in pregnancy (24%), and abortion complications (22%). Contraceptive prevalence was estimated at 52.8%. Access to obstetric health services was high with 98% of deliveries occurring in health facilities and 94.6% of births countrywide attended by skilled personnel.1 This technical report gives the accomplishments and results of the MMRI through July 2015.
II. MATERNAL MORTALITY REDUCTION INITIATIVE
The project operated in all 26 districts in Botswana, establishBox 1: ingScale quality of MMRI improvement work in (QI)Botswana teams in 72% of the 122 facilities providing inpatient maternity services. The MOH appointed 11 midwife district coordinators and a health officer to support QI activities. A national coordinator, supported by USAID ASSIST, was appointed to provide support and direction to the initiative in the country. ASSIST also provided technical support and guidance through a senior technical advisor who supported the initiative with technical guidance and monitoring and evaluation (M&E) in Botswana as well as from URC headquarters, a QI specialist consultant who provided QI coaching support to the district coordinators, and ongoing high-level technical assistance from other personnel from ASSIST headquarters.
1 Millennium Development Goals. Status Report. BOTSWANA 2010
Botswana Maternal Mortality Reduction Initiative 1 The implementation of QI activities in maternal health reached 80% (41,600 out of an estimated 52,000) of deliveries that occurred in the country in 2014 (Box 1) . Facilities included in the MMRI and number of QI teams formed are presented in Table 1. Table 1. Facilities included in the MMRI Facility type MOH master MMRI % maternity QI Teams % MMRI facility list 2006 facilities facilities participating w QI in MMRI Team Maternity 102 92 90% 63 68% Clinic District and 30 (9 district+16 28 90% (No 22 79% Primary primary+ 5 private Hospitals private hospitals) hospitals) Referral 2 (+1 psychiatric) 2 100% 2 100% Hospital Total 136 122 90% 88 72%
Improvement Strategy The focus of the MMRI-related QI activities relies on the implementation of evidence-based, high-impact interventions. The top three causes of maternal death identified by the MOH in Botswana2 were post- partum hemorrhage (PPH), severe pre-eclampsia/eclampsia (PE/E), and post-abortion complications. By targeting these three major causes of mortality, we expected to see a measurable reduction in the maternal mortality in the country. High impact interventions are included in the MMRI Improvement Framework in the Appendix. Improvement Goal: Reduce maternal mortality and morbidity through improved quality of care for obstetric complications in hospitals and clinics. Improvement Aim 1: Decrease PPH incidence and case fatality rate through improved PPH prevention [Active management of third stage of labor (AMTSL)], detection, and case- management in targeted hospitals and clinics Improvement Aim 2: Decrease eclampsia incidence and case fatality through improved intra- and post-partum early detection and case management of severe pre-eclampsia and eclampsia Improvement Aim 3: Decrease mortality and morbidity due to post-abortion complications through improved prevention, early detection, and management of abortion complications
Key Continuous Quality Improvement (CQI) Activities Conducted by the MMRI Conducted trainings on quality improvement. Trainings for district coordinators appointed by the MOH to support the MMRI were conducted in January and February 2014 and again in December 2014 on quality improvement methodology and practical application. Provided support for the development and functioning of QI teams. On-going coaching to district coordinators and QI teams was provided by the National MMRI Coordinator, ASSIST’s QI consultant, and from staff from the Sexual and Reproductive Health (SRH) Department of the MOH. Developed job aids for prevention and management of frequent obstetric complications. Posters covering prevention, early detection, and management of PPH, pre-
2 Botswana Ministry of Health Maternal Mortality Report 2007-2011
2 Botswana Maternal Mortality Reduction Initiative eclampsia/eclampsia, and post abortion complications were developed to be placed in the facilities to support compliance with protocols. Supported MOH training in Emergency Obstetric and Neonatal Care (EmONC). One hundred and twenty (120) midwives and doctors participated in a two-week training during the first quarter 2014, designed to improve identification and management of obstetric and neonatal emergencies and to improve providers’ clinical skills. Supported national maternal mortality audits. The National MMRI Coordinator and some district coordinators are active participants of the Maternal Mortality Audit Committee. Provided ongoing support to the QI strategy being implemented in the facilities (Oct 2014 – Sept 2015) o District coordinators conducted QI coaching visits to the QI teams twice a month. MMRI district coordinators still continue to provide regular and ongoing support to QI teams at the facility level. These visits included a review of the data collected by the teams, coaching in problem identification and analysis, and support with running Plan-Do-Study-Act (PDSA) cycles to test changes in their chosen areas of improvement.
o Coaching support was provided by an external QI specialist. Between October 2014 and March 2015, an ASSIST consultant made two visits to Botswana to provide a total of seven days of intensive coaching support to three of the district coordinators in the districts of Ngami, Palapye and Tutume.
Conducted QI learning/sharing workshops. Workshops were held in May 2014, September 2014, and February 2015. The workshops provided a forum for QI coordinators to share progress of their improvement teams and discuss improvement strategies and barriers to implementation. Coordinators shared change ideas that had been tested and found to secure improvements within the facilities. In addition, time was taken to review more recent maternal mortality audits to ensure interventions were appropriately targeted around gaps in provision of care and processes. Daily participation in the morning clinical rounds at the National Referral Hospital Princess Marina. The MMRI National Coordinator attended the daily morning rounds of the OB- GYN department at Princess Marina Hospital in Gaborone, the country’s main referral hospital. System issues such as overcrowding in the ward were discussed during the morning rounds. The hospital often reported up to 20+ patients waiting in a single day to have an elective C- section and occupying beds usually held for emergencies. The national coordinator worked with hospital managers and coordinated with other referral hospitals to absorb the backlog in elective C-sections at Princess Marina Hospital. This was expected not only to improve the overcrowding of patients in the hallways but also to improve infection control, postoperative monitoring, and bring about a reduction in postoperative sepsis. Weekly monitoring and reporting on the availability of essential drugs and commodities in the facilities. As a result of improved monitoring and reporting of stock-outs, the MOH and Central Medical Stores took immediate action to address the availability of essential drugs and commodities. MMRI has been working directly with facilities to develop a contingency plan to make drugs available in facilities, coordinate with the facilities’ pharmacies to improve procurement, and in some cases arrange for drugs from one facility to be sent immediately to another facility that is experiencing a stock-out.
MMRI Monitoring and Evaluation The M&E system was designed to inform policy and programming decisions by providing accurate morbidity and mortality data and timely analysis and reporting of results.
Botswana Maternal Mortality Reduction Initiative 3 Monitoring and Evaluation Framework The national technical team with support from ASSIST developed an M&E framework with indicators to monitor leading causes of maternal mortality and their predisposing factors. The MMRI framework includes indicators to monitor performance in implementing proven or high impact interventions to reduce obstetric complications and maternal mortality. The indicators used are included in the quality improvement framework Tables 1, 2 and 3 in the Appendix. Data collection tools and reporting mechanism The initiative designed four paper-based data collection tools and one electronic data collection tool to support the collection and reporting of MMRI data: MMRI-1 ANC Individual Patient Data Collection Tool; MMRI-2 ANC Monthly Data Aggregation Tool; MMRI-3 Maternal/Post Abortion Individual Patient Data Collection Tool; MMRI-4 Maternal/Post Abortion Monthly Data Aggregation Tool; and the e-MMRI District Reporting Tool. The computer-based e-MMRI District reporting tool captures and consolidates data at the district level and provides automatic calculation of indicators and time series charts at both the facility and district levels. Each coordinator received a laptop loaded with the e-MMRI tool for their specific area of coverage. Facilities participating in the MMRI collected patient level data in the paper based tools which was then aggregated monthly by the midwife coordinators in the electronic tool for each facility and district. The monthly report was submitted electronically (email) to the central level for aggregation and analysis. Table 2. MMRI data collection and electronic reporting tools
4 Botswana Maternal Mortality Reduction Initiative 1. Key M&E Activities Capacity building on data collection and reporting. In early January 2014, district coordinators were trained on the use of both the paper-based and electronic tools for data collection Capacity building at the central level for data management and analysis. The MMRI, through the support of ASSIST, has provided training and coaching to the MOH to consolidate, analyze, and report data. Monitoring availability of drugs essential to the provision of maternal services. To assess the magnitude of the stock-out of drugs essential to the provision of high-quality maternity services, the project developed a simple tool to assess the presence/absence of key drugs needed to prevent and treat obstetric complications in clinics and hospitals. Elaboration of quarterly and annual progress reports for the MOH and donors. Developed an electronic tool for surveillance and analysis of obstetric complications (Form MH 3123). The MOH requested technical advice from ASSIST (Dr. Maria Insua) to support the Sexual and Reproductive Health Monitoring and Evaluation System by adapting their paper-based perinatal surveillance reporting tool (MH 3123) to an electronic format. At the time, the paper form of the MH 3123 was used to collect data on obstetric and neonatal complications in health facilities and was sent by fax or mail to the central level for analysis. Reporting Figure 2: Example of dashboard of obstetric complications was inconsistent, with some for one hospital facilities reporting only quarterly or annually instead of monthly, and other facilities not reporting at all. Central-level data analysis often caused a significant delay (often years) in producing results. In February 2015, ASSIST adapted the existing MOH paper tool MH 3123 to an Excel format that will allow for timelier reporting via email and will facilitate timely analysis by removing the data entry step at the central level. To promote the use of the data at the facility and district levels, the new electronic form contains an embedded a dashboard of indicators and graphs that are automatically generated based on the data entered into the data sheet. The indicators dashboard was provided to each hospital in slide format to facilitate reporting by hospital superintendents in national quarterly reporting meetings (see Figure 2). Conducted capacity-building sessions in the use of the new electronic MH 3123 form for district M&E officers and district MMRI coordinators. Sessions took place in Gaborone (May 25-26, 2015) for the southern districts and in Francistown (May 28-29) for the central and northern districts. The trainings were organized and funded by the MOH. Approximately 20-25 district M&E, information technology, and medical data officers, as well as the 11 MMRI district coordinators were updated on the use of the MMRI tools and the new perinatal surveillance tool. The tool was presented to the Prime Secretary and relevant MOH officers and it was recommended that it needed to be pilot tested and included in the Integrated Patient
Botswana Maternal Mortality Reduction Initiative 5 Management System (IPMS) system.
ASSIST conducted weekly monitoring of near misses and immediate audit of near misses (Oct 2014-August 2015). Through this process as well as the review of the national maternal mortality audits, the project has developed a more nuanced understanding of the causes of near misses and maternal deaths, allowing for more targeted follow-up of potential complications and the development of strategies to address ongoing process failures. For example, a review of the maternal mortality audits in 2014 revealed that the majority of cases of PPH in Botswana are not due to uterine atony as previously thought but to poor clinical practices during and after C- sections. As a result, district coordinators were asked to report all incidences of PPH to the National Coordinator on a weekly basis with specific details on the causes of bleeding, the estimated quantity of bleeding, how the patient was managed, and the fate of the patient. The National Coordinator has subsequently been responding to reports of inadequate management of PPH by paying targeted visits to specific facilities for immediate follow-up of clinical and process issues. In addition, a surgical checklist was developed to improve compliance with best practices and better management of surgical patients.
2. Facilities Reporting MMRI Data A sample of 122 facilities providing maternal services were assigned to monitor MMRI indicators. Of those, 92 were maternity clinics, 21 primary hospitals, 5 district hospitals, 2 private hospitals and 2 referral hospitals. The two private hospitals included in the sample failed to report any data (Table 3). Table 3. District distribution of facilities providing maternity services included in the MMRI Districts Maternity Primary District Private Referral Total Clinic Hospital Hospital Hospital Hospital BOBIRWA 4 2 6 BOTETI 2 2 4 CHOBE 2 1 3 FRANCISTOWN 7 1 8 GABORONE 3 (1) 1 5 GHANTSI 3 1 4 GOODHOPE 1 1 GUMARE 6 1 7 JWANENG 2 1 3 KGALAGADI North 2 1 3 KGALAGADI South 7 1 8 KGATLENG 5 1 6 KWENENG East 2 1 1 (1) 5 KWENENG West 3 3 LOBATSE 3 1 4 MAHALAPYE 5 2 7 MOSHUPA 4 4 NGAMI 4 1 5 NORTH East 4 1 5
6 Botswana Maternal Mortality Reduction Initiative PALAPYE 2 1 3 SELIBE PHIKWE 3 1 4 SEROWE 4 1 5 SOUTH 4 4 SOUTH East 2 1 3 SOUTHERN 1 1 2 TLOKWENG 2 2 TUTUME 6 2 8 Grand Total 92 21 5 (2) 2 122
QI team performance was affected in several districts due to challenges faced by some of the district coordinators that significantly reduced the frequency of facility visiting. Extra support was provided and two coordinators were replaced towards the end of 2014 with improvement in QI support to the teams in the affected districts. During January-February 2015, the number of facilities reporting data decreased from 95 in December 2014 to 54 in February 2015 (Figure 1). This was as a result of the massive transfer of 759 midwives throughout the country that disrupted QI teams and their M&E activities. District coordinators have been working on reforming QI teams in the facilities since March 2015 and have trained new personnel as focal points for data collection. As a result, data reports in March included data collection for the missing months of January-March 2015. The retroactive number of facilities reporting data is presented in Figure 1 in blue.
Botswana Maternal Mortality Reduction Initiative 7 Figure 1. Number of facilities reporting MMRI data per month in each district (Feb 2014 – July 2015)
Health facilities reporting MMRI data Feb 2014‐July 2015
108 110 108 108 103 104 104 102 102 100 100 97 100 99 95 92 85 72 65 54
FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL
3. QI Teams
A total of 88 QI teams were formed in the Table 4. QI Teams established per type of facility facilities, accounting for 72% of the 122 facilities included in the initiative. QI teams Type of facility QI teams QI teams were not implemented in private hospitals or established functional in some remote maternity clinics. QI teams Maternity clinic 63 55 were considered to be functional if they met regularly (weekly/by weekly) and used QI District hospital 6 6 methodology to identify gaps and proposed Primary hospital 17 15 solutions or changes that were tested Private hospital 0 0 (following PDSA). The team had to use Referral hospital 2 2 performance data to evaluate if the changes tested were successful in obtaining the Total 88 78 targets established. 89% (78 out of 88) of QI teams formed were functional. Table 4 presents the distribution per facility of QI teams.
Improvement aims focus of the QI teams. Each QI team selected one or more areas of improvement based on baseline data and audits of patient files. Of the 78 QI teams that actively worked on improvement, 68% worked on improving monitoring of 4th stage of labor, 55% on adherence to AMTSL, 6% on PE/E management during labor, 16% on management of incomplete abortions, 6% on management of septic abortions, and 14% on other topics [improving partogram use, promoting hospital delivery, checking for cervical tears, family planning (FP) counselling and supply] (see Table 5). Table 5. Improvement aims selected by QI Teams Area of Maternity Primary District Referral Total improvement Clinic Hospital Hospital Hospital QI Teams QI Teams QI Teams QI Teams QI Teams # % # % # % # % # % Postpartum monitoring 40 63% 13 76% 5 100% 1 50% 59 68% (4 stage labor) AMSTL 35 56% 9 53% 3 60% 1 50% 48 55%
8 Botswana Maternal Mortality Reduction Initiative PE/E ANC 0% 3 18% 0% 0% 3 3% PE/E Labor 1 2% 1 6% 2 40% 1 50% 5 6% Incomplete abortion N/A 0% 7 41% 5 100% 1 50% 14 16% Septic abortion N/A 0% 2 12% 3 60% 0% 5 6% Other 11 17% 0% 1 20% 0% 12 14% Total QI teams 63 100% 17 100% 5 100% 2 100% 87 100%
Anemia during Pregnancy Data was collected to monitor the burden of anemia and management of the condition during the antenatal period as documented in the obstetric record (patient obstetric booklet) that each women caries to her delivery in the facility. The presence of anemia is a risk factor for both severe morbidity such as hypovolemic shock, postpartum hemorrhage, and maternal death. Hypovolemic shock could manifest even before a woman has lost 500 mL of blood.
1. Anemia screening during ANC The MMRI chose the following indicators for ANC screening of anemia Percentage pregnant women screened for anemia during the first trimester Percentage pregnant women screened for anemia during the second trimester Percentage pregnant women screened for anemia during the third trimester According to the MMRI data from our sample, 97% pregnant women (of the 49,481 who had facility deliveries) went to at least one ANC visit from February 2014-July 2015. Of those women who had a facility delivery and attended ANC in their first trimester (<14 weeks gestation), 32% were screened for anemia. Of those attending in the second trimester (14-26 weeks), 63% were screened. That number rose to 66% for women attending ANC in the third trimester (>26 weeks) (Figure 2). This clearly shows increased screening for anemia during ANC visits with advancing gestational age, indicating that there are missed opportunities in early detection and management of anemia during the early trimesters of pregnancy. Figure 2. Percentage of pregnant women in labor that were screened for anemia during ANC visits disaggregated by gestational trimester and reporting month (Feb 2014 – July 2015), n= 47,696 ANC visits
Botswana Maternal Mortality Reduction Initiative 9 2. Anemia rate during pregnancy We found that 19% of pregnant women who attended ANC visits and were screened for anemia were subsequently diagnosed with anemia. On admission during labor, women were again tested for hemoglobin levels and 7% of women still presented anemia. This analysis does not include women that became anemic or had anemia worsen as a result of hemorrhage during delivery. Figure 3 shows the anemia rates during pregnancy from February 2014 to July 2015, which were disaggregated by diagnosis during antenatal period and during labor. Figure 3. Anemia rate during pregnancy and labor disaggregated by month (Feb 2014 – July 2015), n= 49,481
3. Management of anemia during ANC Management of anemia during the antenatal period data was collected retrospectively from the obstetric record (patient obstetric booklet) once the women accessed the facility for delivery. Indicator: Percentage pregnant women who were in active labor at the facilities that MMRI was monitoring who received treatment for anemia during the ANC visits Women with hemoglobin levels <10gr/dl were considered anemic. Most women received prophylactic management of anemia that only included one dose of hematinics daily. If the woman is diagnosed with anemia (microcytic hypochromic anemia and does not require immediate transfusion) the appropriate management will be prescription of 200mg of ferrous sulphate three times a day. Only 56% of pregnant women identified as having anemia during the ANC period received appropriate treatment for their condition and at the time of delivery 7% of women were still presenting anemia. Management of anemia during ANC reduced by 12% the prevalence of anemia during labor (Figure 4). Management of anemia during the ANC period improved from 60% in February 2014 to 70% in July 2015. The initiative was instrumental in conducting weekly advocacy meetings with the MOH to correct anemia drugs stock outs. Since October 2014, there were no reports of ferrous sulfate stock outs.
10 Botswana Maternal Mortality Reduction Initiative Figure 4. Percentage of pregnant women with ANC managed per protocol (Feb 2014 – July 2015), n= 8,694
700 80%
600 70% 60% 500 50% 400 40% 300 30% 200 20%
Number of ANC anemias 100 10% % Anemia receiving treatment 0 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July
ANC‐Total anaemia ANC‐Total anemia treated % Severe anemia receiving ANC treatment
4. Distribution of anemia in pregnancy Districts that presented the highest prevalence of anemia during pregnancy were North East and Chobe with 27% each, Tutume and Bobirwa 25% each, Boteti 24%, Goodhope 23%, and Francistown, Selibe Phikwe and Gaborone 21% each (Figure 5). Figure 5. Percentage of pregnant women diagnosed with anemia during ANC visits, per district (Feb 2014 – July 2015). n=47,696 ANC visits
30%
25%
20%
15%
10%
5%
0% CHOBE SOUTH BOTETI NGAMI TUTUME LOBATSE GHANTSI GUMARE SEROWE PALAPYE BOBIRWA JWANENG MOSHUPA SOUTHERN KGATLENG GABORONE GOODHOPE TLOKWENG SOUTH EAST MAHALAPYE NORTH EAST Kweneng East Kweneng West FRANCISTOWN SELIBE PHIKWE KGALAGADI SOUTH KGALAGADI NORTH
Best Practices during Labor The MMRI monitored compliance with four best practices as per national protocol that should be observed in every delivery:
Botswana Maternal Mortality Reduction Initiative 11 1. Correct use of the partograph to monitor labor. 76% of deliveries (vaginal deliveries and emergency C-sections) were monitored with a partogram. Indicator: Percentage of deliveries where partogram was used to monitor labor progress. 2. Examination of cervix and perineum to identify tears and lacerations. 85% of deliveries had the cervix and perineum inspected after delivery to identify tears and lacerations. Indicator: Percentage deliveries inspected for lacerations documented after delivery. 3. Documentation of the status of the placenta after delivery. 82% of deliveries had the placenta status documented in the patient’s record. Indicator: Percentage of deliveries that were inspected and documented for the status of placenta and membranes. 4. Monitoring postpartum vitals during the two hours following delivery (4th stage of labor). Indicator: Percentage of women monitored during the postpartum period (4th stage labor). Women should be monitored for vital signs, vaginal bleeding, uterine consistency, height of the uterine fundus and urine output every 15 minutes for the first hour following delivery and every 30 minutes for the next hour. This is a complex indicator to comply with, time-consuming, and requires consistent health worker availability to perform measurement of vitals and physical assessments six times in the first two hours postpartum. Monitoring postpartum vitals was a main focus of improvement for 68% of QI teams. As a result, compliance with this indicator increased from a baseline of 46% in February 2014 to 84% in July 2015 (Figure 6).
Figure 6. Compliance with best practices during delivery (Feb 2014 – July 2015). n=49,481 deliveries
Post-partum Hemorrhage Post-partum hemorrhage (PPH) is defined as bleeding more than 500 ml after vaginal delivery, more than 1000ml after a C-section, or any blood volume loss that causes hemodynamic instability in a patient. There are several possible reasons for severe bleeding during and after the third stage of labor: uterine atony (failure of the uterus to contract properly after delivery), trauma (cervical, vaginal, or perineal lacerations), retained or adherent placental tissue, clotting disorders, and inverted or ruptured uterus.
1. PPH rate Indicator: Percentage of women diagnosed with PPH during or following delivery (vaginal deliveries and C-section deliveries)
12 Botswana Maternal Mortality Reduction Initiative From February 2014-July 2015 a total of 905 cases of PPH were documented in 49,481 deliveries resulting in a PPH rate of 1.8%. It seems that there is a general trend downwards for the PPH rate (Figure 7). Figure 7. PPH rate (Feb 2014 – July 2015), n= 49,481 deliveries
In the literature3, uterine atony is reported as the leading cause (75–90%) of immediate PPH . Project data found that in Botswana, uterine atony was responsible of 35% of the PPH cases. There appears to be a decreasing trend over the period February 2014 – July 2015 (Figure 8). Figure 8. PPH due to uterine atony (Feb 2014 – July 2015), n= 905 PPH
70 100% 90% 60 80% 50 70% 60% 40 50% 30 40%
20 30% 20% 10 10% 0 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July
Total PPH Total PPH due to uterine atony % PPH due to atonic uterus
Analysis of maternal mortality data in 2014 found that most causes (60%) of PPH that lead to death occurred post-C-section due to procedural (iatrogenic) complications and/or poor monitoring after the intervention. Stock outs of blood products also contributed to the poor outcome of PPH cases. Starting in
3 Koh E, Devendra K, Tan L K. B-Lynch suture for the treatment of uterine atony. Singapore Med J 2009; 50(7): 693-697
Botswana Maternal Mortality Reduction Initiative 13 May 2015, we introduced a new indicator to monitor cases of PPH that occurred after a C-section to further monitor and evaluate the causes leading to hemorrhage after delivery.
2. Prevention of PPH due to uterine atony: AMTSL Indicator: Percentage of women administered oxytocin in the first minute after delivery (AMTSL) PPH cannot be predicted, thus it is recommended that all women receive prophylactic management for uterine atony with oxytocin 10 units IM or misoprostol or ergometrine if there are no contraindications for its administration during the third stage of labor. We observed a decline in the percentage of women with PPH due to uterine atony from 58% reported in May 2014 to 21% in May 2015 (Figure 9) that could be explained by the changes in practice introduced by the QI teams such as improvement in timely provision of AMTSL. Nevertheless, the proportion of women who benefitted from active management of the third stage of labor has remained steady around 78% since February 2014. From Feb 2014-July 2015, there were 905 cases of PPH documented of which 296 (33%) were due to uterine atony, 294 (32%) to retained placenta and 315 (35%) due to other causes (cervical tears, uterine laceration, uterine rupture, coagulopathy, post procedural C-section complications) (see Figure 9). Figure 9. Provision of AMTSL vs PPH due to uterine atony (Feb 2014 – July 2015), n=49,481 deliveries
3. PPH management Indicator: Proportion of women diagnosed with PPH due to uterine atony managed as per protocol. Most (94%) PPH cases due to uterine atony were reported to be in compliance with protocol management (Figure 10). On the other hand, data from maternal mortality audits during the same year found mismanagement and delay in the management of PPH cases that lead to maternal deaths, being the main cause related to post C-section complication (See Section K. Maternal Mortality).
14 Botswana Maternal Mortality Reduction Initiative Figure 10. Management of PPH due to uterine atony per protocol (Feb 2014 – July 2015), n= 296 PPH due to atonic uterus
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Denominator PPH due to uterine atony 40 20 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
Pre-eclampsia and eclampsia Literature reports that globally 10% pregnant women will suffer from high blood pressure during pregnancy, and preeclampsia will complicate 2% to 8% of pregnancies.4 Preeclampsia can lead to problems in the liver, kidneys, brain and the clotting system as well as risks for the baby including poor growth and prematurity. Eclampsia occurs when women with preeclampsia develop seizures. Magnesium sulfate is a low cost effective treatment that can prevent and control eclamptic seizures and halve the risk of eclampsia in pre-eclamptic women. Every pregnant women should have blood pressure and presence of protein in urine monitored at each antenatal visit to identify early onset of pre-eclampsia. This is a severe condition that requires immediate treatment to avoid severe maternal and fetal complications and/or death. Pre-eclampsia and eclampsia (PE/E) were the second cause of maternal mortality in Botswana during 2014.
1. Screening for Pre-eclampsia/eclampsia during ANC Indicators: Percentage of pregnant women who later delivered in a health facility recording data screened for blood pressure in every ANC visit
4 Leila, D. The Global Impact of Pre-eclampsia and Eclampsia. Seminars in Perinatology.Volume 33, Issue 3, June 2009, Pages 130–137. Available at http://www.sciencedirect.com/science/article/pii/S0146000509000214
Botswana Maternal Mortality Reduction Initiative 15 Percentage of pregnant women who later delivered in a health facility recording data screened for proteinuria in every ANC visit Data indicates that while 97% of pregnant women had their blood pressure measured during at least one ANC visit, only 23% were screened for the presence of protein in their urine. Measurement of protein is a simple method that consists of dipping the uristick in the woman’s urine, with the result of proteinuria ready in minutes. The percentage of women screened for proteinuria increased slightly from 20% at baseline in February 2014 to 32% in July 2015 as a result of the improvement in the supply and distribution chain of dipsticks for urinalysis to the facilities. However, uristicks are for the most widely in short supply (Figure 11). Figure 11. Percentage of pregnant women screened for hypertensive disorders of pregnancy (PE/E) during the antenatal period (Feb 2014 – July 2015). n= 47,696 ANC visits
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%ANC screened for BP % ANC screened for proteinuria
2. PE/E rates during ANC and labor Indicators: Number of pregnant women diagnosed with severe pre-eclampsia during ANC visits Number of pregnant women diagnosed with eclampsia during ANC visits Number of pregnant women in labor diagnosed with severe pre-eclampsia Number of pregnant women in labor diagnosed with eclampsia As a result of the screening gap, we feel pre-eclampsia is for the most underdiagnosed in Botswana. The number of preeclampsia cases decreased from 95 (4.8% incidence) cases in February 2014 to 15 (<1% incidence) in July 2015. This incidence falls below what will be expected as per International studies5 that found a 2% to 8% global incidence of preeclampsia in pregnancies.
5 The Global Impact of Pre-eclampsia and Eclampsia. Lelia Duley, MD, Seminars in Perinatology.Volume 33, Issue 3, June 2009, Pages 130–137. Available at http://www.sciencedirect.com/science/article/pii/S014600050900021
16 Botswana Maternal Mortality Reduction Initiative 3. Management of severe PE (ANC and labor) Indicators: Percentage of pregnant women with severe pre-eclampsia during ANC visits that are managed with Mg SO4 and immediately referred to a higher facility for further management Percentage of pregnant women with severe pre-eclampsia during labor managed as per protocol (MGSO4+delivery) This indicator is measured at two levels: Severe pre-eclampsia diagnosed during ANC visits should be treated with a loading dose of MgSO4 and promptly referred to a higher-level facility; PE diagnosed during labor should receive MgSO4 and be evaluated for immediate delivery. Compliance with antenatal management of pre-eclampsia as per protocol was very low at the beginning of the project with only 6% of cases demonstrating adequate management of PE identified during ANC and 17% of PE cases managed per protocol when diagnosed in the facility during labor. Despite a low number (only 3%) of QI teams working on improving the management of PE/E during ANC and 6% during labor, compliance with PE management increased for both antenatal and during labor) (Figure 12). The improvement observed in management of PE/E needs to be taken with caution since we also observed a dramatic reduction in the number of cases of severe PE/E reported since August 2014. The cause of this reduction is unknown and will require further investigation. Figure 12. Compliance with management of PE/E during ANC (blue) compared to during labor (red) (Feb 2014 – July 2015)
(N1=701 PE/E ANC, N2=824 PE/E Labor) 100% 90% 80% PE/E LABOUR 70% 60% 50% 40% 30% 20% 10% PE/E ANC 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July
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Botswana Maternal Mortality Reduction Initiative 17 HIV The initiative did not focus on improving the quality of PMCT services as this was being done by a number of programs in the country working on HIV prevention, diagnosis, and management. Since HIV is a main contributor to the poor outcomes and complications during pregnancy, the initiative monitored outcomes and performance in provision of treatment. Data from the MMRI can be triangulated with data obtained by other projects to obtain a more accurate assessment of the HIV burden and management in pregnancy. Indicators: Number of HIV+ women identified during ANC visits Number of HIV+ newly identified during labor Percentage of HIV+ that were receiving ARV when presented for labor Percentage of HIV + among pregnant women
1. Prevalence of HIV during pregnancy From Feb 2014 to July 2015, we found 13,014 pregnant women identified as HIV+ during ANC visits and 406 (0.8%) newly diagnosed during labor. This translates into a prevalence of HIV among pregnant women of 28% in 2014 and 26% from January to July 2015. Prevalence of HIV among pregnant women is higher than the 18.5% HIV prevalence found in general population (aged 18 weeks and over), with females at 19.2% and males 14.1% documented by the Botswana AIDS Impact Survey IV Report 6. Figure 13 presents the evolution of HIV prevalence in Botswana from data reported by the 2011 Botswana Sentinel Surveillance (grey color) and data reported by the MMRI on 49,481 deliveries from February 2014 to July 2015 (orange color). We observed a decreasing trend in the prevalence of HIV among pregnant women in Botswana from 36.2% in 2006 to 26% in July 2015. Figure 13. HIV prevalence during pregnancy (2001-2015)
6 Botswana AIDS Impact Survey IV (BAIS IV, 2013). http://1govportal.imexsystems.net/en- gb/Documents/Ministry%20of%20State%20President/NACA/Botswana%20AIDS%20Impact%20Survey% 20IV%20Report.pdf
18 Botswana Maternal Mortality Reduction Initiative 2. ART coverage of HIV-positive pregnant women Data from Feb 2014 to July 2015 found that 95% of women diagnosed with HIV during ANC visits received antiretroviral treatment during the antenatal period and this coverage was maintained constant over the time of the analysis. This represents an improvement from data reported in 2013 by the MOH (National Eligibility Guidelines) where only 67% of the total HIV-infected pregnant women were reported to have received ART. We assume that the improvement in coverage is due in part to the more inclusive eligibility criteria set by the MOH at the beginning of 2014 to receive ART. Now every HIV-positive pregnant woman qualifies for ART, treatment while in 2013, national guidelines established a cutting point of a CD4 count lower than 350 cells/µl to qualify for ART. Districts that showed ARV coverage rates below 94% average were: Tlokweng (88%), Lobatse (89%), South (90%), and Gaborone (90%).
3. District distribution of HIV prevalence in pregnancy The map in Figure 14 shows the distribution of HIV prevalence in pregnancy in the country. Districts with an HIV prevalence above the national 27% median (2014-2015) are colored in orange and those districts with an HIV prevalence below national average are colored in green. We observe highest HIV pregnancy prevalence in the North Easter districts (Figure 14). The highest HIV prevalence during pregnancy was reported in the districts: Bobirwa (35%), Palapye (34%), North East (33%), Francistown (33%), Chobe (33%), Tutume (32%), Selibe Phikwe (31%), and Boteti (31%, South (31%), Mahalapye (30%), Serowe (27%) and Gaborone (27%). Figure 14. Distribution of HIV prevalence during pregnancy in Botswana (2014 – 2015)
Our data differ somehow from those provided by the Sentinel Surveillance Study (2011) that reported a 30.3 % HIV prevalence rate among pregnant women (2011). The surveillance study found that districts with the highest prevalence were Bobirwa (41.1%), S- Phikwe (39.6%), North East (37.9%), Serowe-
Botswana Maternal Mortality Reduction Initiative 19 Palapye (35.2%), Kgatleng (33.9), Mahalapye (32.6), Chobe (30.8), Boteti (30.5) Francistown (32.7%) and Kweneng West (30.6%).
Post-abortion Care Indicators: Number of abortions Number of incomplete abortions Number of septic abortions Maternity clinics refer post abortion complications to be managed at hospitals. During February to July 2014 a lower number of abortions was reported with an average of 403 abortions per month compared to an average of 598 abortions per month in subsequent months. We assume that this was probably due to an increase in facilities reporting from June 2014 onwards (21 between February and May 2014 and increasing to 30 in July 2015).
1. Abortion ratio The abortion ratio (Feb 2014-Jul 2015) was 209 per 1,000 live births. Figure 15 presents the monthly variations of the abortion ratio. This ratio exceeds the international abortion ratio of 148 per 1000 live births estimated in the World Health Report 2005.7 In addition, the incidence of abortion is underreported since the MMRI only captures data of complicated abortions that needed medical attention, leaving out abortions that occur in the community or those that do not require emergency management. Figure 15. Abortion ratio per 100,00 live births (Feb 2014 – July 2015). n=10,048 abortions
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2. District distribution of abortions The average abortion ratio in all districts was 209 abortion complications (abortions that require emergency management) per 1000 live births. Figure 16 shows that Francistown and Gaborone have the highest burden, with an abortion ratio of 555 and 361 per 1,000 live births respectively, followed closely by Chobe District with a ratio of 353/1,000 live births, Selibe Phikwe with 325/1,000 live births, Ngami 264/1,000 live births and Palapye 207/1,000 live births.
7 World Health Report (2005). Makie every mother and child count. Accessed at: http://www.who.int/whr/2005/en/
20 Botswana Maternal Mortality Reduction Initiative Figure 16. Botswana: Distribution of burden of abortion complications (Feb 2014 – July 2015)
Figure 17. Type of abortion (Feb 2014 – July 2015). 3. Abortion complication type n=10,048 abortions Seventy one percent (71%) of abortion complications reported were incomplete abortions and 10% were septic abortions. Other The total number of abortions and type of 20% abortions disaggregated by month is Septic presented in Figure 17. abortion 10% 4. Post abortion management Indicators: Percentage incomplete abortions managed within 2 hours of diagnosis Incomplete abortion Percentage of septic abortions receiving 3 drug antibiotherapy IV 70% Percentage of abortions receiving counselling and family planning supplies before leaving the facility Management of incomplete abortions. QI teams worked on improving the timely management of incomplete abortions as it was found that there were constant delays in evacuation of retained products. It was proposed that evacuations should be performed immediately within two hours of diagnosis to prevent secondary infection of retained products. In the 26 facilities reporting management of abortions (data on this indicator is only collected in hospitals, as clinics in Botswana do not perform uterine evacuation of retained products of conception). At baseline, in February 2014, 50% of incomplete abortions diagnosed were evacuated within the prescribed two-hour time frame. Performance with compliance with this indicator improved to 64% in July 2015. Figure 18 presents aggregated data of all facilities performing evacuation of incomplete abortions From February 2014 to July 2015. The figure shows a positive increase in compliance with prompt uterine evacuation with five performance points above the median since November 2014.
Botswana Maternal Mortality Reduction Initiative 21 Figure 18. Percentage of incomplete abortions managed within two hours (Feb 2014 – July 2015)
Management of septic abortions. Performance in management of septic abortions with triple intravenous antibiotherapy was initially high at 85% compliance at the baseline in February 2014. Performance increased after September 2014 to reach 100% in May 2015 showing five consecutive data points above the 88% median (Figure 19). Figure 19. Compliance with management of septic abortion with three antibiotics IV (Feb 2014 – July 2015)
Median: 88%, N=964 septic abortions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July
% septic abortion treated with 3 antibiotics median
Provision of FP counselling and FP method. Sixty three percent (63%) of post-abortion patients received counselling and family planning supplies before leaving the facility at baseline in February 2014. Compliance with this indicator has remained steady (normal variation) through May 2015 (Figure 20).
22 Botswana Maternal Mortality Reduction Initiative Figure 20. Percentage of post-abortion patients receiving counselling and family planning supplies (Feb 2014 – May 2015)
Median: 62.5%. N=10,048 abortions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
% abortions receiving counselling and FP median
Caesarean Sections A caesarean section may be necessary to perform when delivery complications arise such as prolonged labor, fetal distress, or because the baby is presenting in an abnormal position. However, C-sections can cause significant complications, disability, or death, particularly in settings that lack the means to conduct safe surgeries or treat potential complications. The international healthcare community has considered the “ideal rate” for C-section to be between 10% and 15%8 of deliveries. Indicators: Percentage of vaginal deliveries Percentage of C-sections C-section rate. The C-section rate among 49,481 deliveries (Feb 2014-July 2015) was 15%. The C- section rate was highest in the two referral hospitals (25%) followed by district hospitals (12%) and primary hospitals (11%). No C-sections were performed in maternity clinics (Figure 21). Planned or elective C-sections accounted for 20% of total C-sections. The initiative began collecting disaggregated data on elective C-sections in June 2014. Distribution C-section rate. Gaborone and Francistown districts presented the highest C-section rates with 25% and 24% respectively, driven by the presence of referral hospitals. Other districts with a rate above the median were: Kgatleng 21%, Selibe Phikwe 19%, South East 18% and Mahalapye 17%, and Serowe 15%. No C-sections were reported in Kweneng West, Moshupa, and South districts (Figure 22).
8 World Health Organization (2015). News release: Caesarian sections should only be performed when medically necessary. Accessed at: http://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/
Botswana Maternal Mortality Reduction Initiative 23 Figure 21. Distribution of C-section rate per facility type (Feb 2014 – July 2015)
30% 25% 25%
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Figure 22. C-section rates per district (Feb 2014 – July 2015)
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Maternal Mortality Maternal death refers to the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.9 In 2012, there were 70 maternal deaths in Botswana, 90 deaths in 2013, and 69 in 2014, which accounts for a 23% reduction in maternal mortality in 2014. As shown in Figure 23, the median maternal deaths per month in 2013 was eight. In 2014, the median was reduced to 5.5 deaths. We observed a shift in maternal deaths in 2014 with six consecutive points below the 2013 baseline median, indicating an improvement in Botswana’s maternal mortality in 2014 over its previous year’s performance.
9 World Health Organization (1992). International Classification of Disease or ICD-10. Accessed at: http://www.who.int/classifications/icd/en/
24 Botswana Maternal Mortality Reduction Initiative Figure 23. Number of maternal deaths per month, nationwide (Jan 2013 – June 2015)
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1. Seasonal distribution of maternal deaths The median of maternal deaths per months during January 2013 to June 2015 was seven deaths per month. Figure 24 presents the occurrence of mortality “peaks” defined as an increase in mortality of at least 20% over the median. Mortality peaks were observed at the end of the year coinciding with family vacations including “Christmas Holidays” in years 2011-2012, 2012-2013, and 2013-2014. During 2014 we observed a peak during the month of April. The anticipated peak over the holiday season 2014-2015 did not manifest, in part due to advocacy conducted with facility managers to ensure a more rational leaving schedule, maintaining a minimum “key” personnel and gynecologists. An unexpected nationwide transfer of midwives and doctors was scheduled to occur during December 2014 to March 2015 that resulted in disruption of personnel schedules and delay in services. A different peak pattern occurred during 2015 that can be explained, at least in part, by the two events described previously. Figure 24. Maternal mortality peaks (Jan 2012 – June 2015)
Maternal mortality peaks (>20% increase over monthly median)
14 +30% +30,30,42,22% 12 +22% +22% +22% 10 8 6 4 2 0 JFMAMJJASONDJFMAMJJASONDJFMAMJJASONDJFMAMJ 2012 2013 2014 2015
Botswana Maternal Mortality Reduction Initiative 25 Distribution of maternal deaths. Table 6 presents the distribution of maternal deaths that occurred in 2014 in the districts, disaggregated by the facility type where they occurred. In 2014, most of the deaths were reported in hospitals, with the exception of one death that occurred at home (Table 6). Table 6. Distribution of maternal deaths per district and type of facility, 2014 Districts Home Maternity Primary Private District Referral Total Clinic Hospital Hospital Hospital Hospital Bobirwa 1 2 3 Chobe 2 2 Francistown 15 15 Gaborone 17 17 Ghantsi 1 1 2 Goodhope 1 1 Gumare 1 1 Kgatleng 5 5 Kweneng East 41 5 Lobatse 1 1 Mahalapye 3 3 Ngami 7 7 Selibe Phikwe 1 1 Serowe 4 5 Southern 1 1 Grand Total 1(1%) 3(4%) 19(28%) 1(1%) 12(17%) 32(46%) 69
Almost all maternal deaths (99%) occurred in facilities. Hospitals were responsible for the 96% of deaths reported and almost half of hospital deaths (46%) occurred in the two referral hospitals followed by 28% in primary hospitals and 17% district hospitals. Maternal mortality audits. The National Maternal Mortality Audit Committee audited 51 (74%) of the 69 maternal deaths that occurred in 2014. Major findings of the audits conducted were: Death avoidable. Eighty one percent (81%) of maternal deaths in 2014 were considered avoidable. HIV status. HIV-positive status was reported in (35 out of 69) 51% of the deaths, HIV-negative in 36%, and unknown in 13% of deaths. HIV-related complications (AIDS) were responsible for 13% of all maternal deaths.
1. Causes of maternal deaths Direct vs. indirect obstetric causes. Seventy-one percent (71%) of the causes of maternal death in 2014 were due to direct obstetric causes, 25% to indirect causes and 4% were unknown Figure 25 shows the main clinical causes of maternal deaths: - Abortion complication : 22% (15 deaths) - PPH : 14% (10 deaths) - PE/E: 14% 10 deaths) - HIV related :13% (9 deaths) - Other obstetric complications (embolism, post procedural/surgical, ectopic pregnancy): 12% (8 deaths) - Sepsis:9% (6 deaths) - Cardiac failure: 6% (4 deaths) - Other clinical conditions: 6% (4 deaths)
26 Botswana Maternal Mortality Reduction Initiative - Not known: 4% (3 deaths) Figure 25. Causes of maternal deaths (2014)
Cardiac Clinical failure Obstetric Sepsis condition 6% condition 9% 6% (embolism, blank ectopic, post 4% procedural) abortion 12% 22% PPH PE/E AIDS. HIV 14% 14% 13%
Source: Maternal Death Audits, 2014 Factors contributing to maternal deaths 1. Patient factors Patient factors contributed to 53% of the maternal deaths. As seen in Figure 26, of those 35% were due to delay in seeking care. Default in taking highly active anti-retroviral (HAART) treatment was documented in 6% of cases. Delay in booking ANC visits was identified in 20% of deaths and 14% did not have any ANC visit. Even though the audits consider this factor as contributory to the maternal death it is uncertain the contribution that delay/lack of attendance to ANC visits may have had in each death. More than one type of patient factor was found to contribute to maternal deaths. Figure 26. Patient factors contributing to maternal death
2. Health system factors were identified in 92% of maternal deaths. The most frequent of these factors related to lack of provider knowledge and skills to diagnose and manage conditions as per quality standards. Figure 27 shows that: - Lack of provider skills were identified in 92% of maternal deaths. Areas of deficient provider skills included providing the wrong medication for the condition or wrong dosage (including overdose), poor diagnostic skills, and failure to recognize the clinical condition and/or reach a correct clinical diagnosis. - Poor patient profiling (triage) and failure to recognize a patient with a clinical emergency was identified in 76% of maternal deaths. - Delay in providing service was identified in 69% of maternal deaths. Delay in provision of care includes: delay in seeing the patient once in the facility, delay in the provision of
Botswana Maternal Mortality Reduction Initiative 27 treatment (magnesium sulfate), delay in taking the patient to theatre to conduct a C-section or uterine evacuation, delay in prescribing lab test, and delays retrieving the test results. - Poor monitoring was reported in 69% of maternal deaths. Poor monitoring includes poor or lack of monitoring a patient’s vitals and urine output, no monitoring for adverse events to medications, poor post-operative monitoring, and poor postpartum monitoring. - Referral issues were reported in 59% of maternal deaths. These included delay in transferring a patient to the hospital, lack of transport, attempting to transport an unstable patient, poor coordination of referral, and poor communication on the status of the patient from the referring doctor to the receiving doctor. - Poor documentation was reported in 49% of cases. - Stock-outs and lack of availability/disrepair of lab machines were reported in 24% of maternal death cases. Figure 27. Health system contributory factors to maternal deaths (2014) (51 maternal deaths audited (74%))
92% 76% 69% 69% 59% 53% 49% 24%
Source: Maternal Death Audits, 2014
Progress towards Achieving Millennium Development Goal 5 The Trends in Maternal Mortality 1990-2010 Report 10 considers Botswana a country with a moderate MMR of 160/100,000 live births (2010). The MMR in Botswana increased from 1990 to 2000 as a result of the HIV epidemic. In order to achieve the MDG, countries are expected to reduce MMR by 5.5% annually. If the annual decline in the MMR is between 2-5.5%, the country is considered to be “making progress”.
Year 1990 1991 1995 2000 2005 2008 2009 2010 2011 2012 2013 2014 MDG Target MMR (per 360 326 370 390 340 196 190 163 189 150 182 134 82 100,000 live births)
The HIV and AIDS epidemic has had a significant impact on maternal mortality in Botswana. In Figure 28, the peak of HIV incidence occurred in the country in 1995, causing the maternal mortality rate to rise during the following 10 years. The reduction in the incidence of HIV and the increased access to ARV treatment have contributed to the reduction of maternal mortality levels. Despite achievement in the
10 World Health Organization (2012). Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank estimates. Accessed at: http://apps.who.int/iris/bitstream/10665/44874/1/9789241503631_eng.pdf
28 Botswana Maternal Mortality Reduction Initiative reduction of maternal death, more needs to be done in order to meet the MDG 5. There are other system factors contributing to the stagnation of the maternal mortality rate in the country such as poor prevention and management of obstetric emergencies, poor referral system, and stock outs of essential drugs and supplies. Figure 28. Botswana HIV incidence rate and maternal mortality rate (1990 -2014)
Note: The scale for 1990-2005 correspond to 5 year interval data Data sources for graph. MMR 1990-2008: UNDP data MMR 2008-2013: Statistics Botswana MMR 2014: Data from ASSIST/MMRI HIV incidence estimates. HIV and AIDS in Botswana, Estimated Trends (2008). http://data.unaids.org/pub/Report/2008/20080701_botswana_nationalestimate2007_en.pdf
III. SUSTAINABILITY AND INSTITUTIONALIZATION Since the inception of its quality improvement support, ASSIST’s role in supporting Botswana’s national MMRI was designed to be managed by the Ministry of Health. Through ASSIST, the initiative received technical assistance from a National Coordinator, an outside consultant with extensive QI experience who provided coaching and capacity building through monthly visits to different districts in the country, and a senior technical advisor based at URC headquarters. In turn, and critical to the institutionalization of the improvement work under MMRI, the Ministry appointed a total of 11 midwife coordinators to oversee quality improvement activities throughout Botswana’s 26 health districts and provide logistical support for the implementation of MMRI activities. ASSIST’s support to the Ministry of Health and the MMRI ended in August 2015, when technical activities and related tools were handed over to the Ministry of Health. During the duration of ASSIST’s support to the MMRI, the project was involved in a range of activities meant to directly support the institutionalization, sustainability, and gradual scale-up of improvement activities directed at maternal care. These included: Capacity building at the central level of the Ministry to continue the monitoring and evaluation of MMRI-related activities. ASSIST developed a manual for MMRI data collection and data analysis to facilitate further knowledge transfer to the MOH. ASSIST also provided ongoing capacity building in data management and analysis with designated MOH personnel from the beginning of the project. Tool development to facilitate data reporting and analysis of maternal complications, including the electronic adaptation of an existing paper-based MOH perinatal surveillance tool (MH 3123). The tool was developed in Excel to facilitate timely electronic reporting and reduce data entry errors, facilitating better analysis of routine data by linking to a master database that pulls from other data sources.
Botswana Maternal Mortality Reduction Initiative 29 Capacity building to M&E district officers and MMRI district coordinators in the use of the electronic perinatal surveillance tool and the MMRI QI performance tool to support the integration of both reporting systems. Support to MMRI district coordinators in the development of work plans to guide the implementation of QI activities at the facility level and monitor progress towards activities planned. Development of a data extraction tool for maternal mortality audit qualitative data, including capacity building within the Maternal Mortality Unit to analyze maternal mortality audits in a timely way. Development of a change package of successfully proven changes that lead to improvement, to facilitate scaling up improvement in facilities throughout the country. Challenges for sustainability As in many focused projects receiving external technical assistance, there were a range of challenges related to achieving sustainability of the intense and important work under the Maternal Mortality Reduction Initiative. The most significant challenges included: The need for a critical mass of QI-trained coordinators. Under the MMRI, the implementation structure was very lean due to budget constraints, relying to a large degree on the National Coordinator and eleven regional coordinators. Each coordinator had very specific functions that in theory should continue in order to ensure sustainability. During the one and a half years of ASSIST support to the MMRI, implementation efforts were mostly focused on the training and mentoring of the selected QI coordinators as well as direct support to activities. In order to ensure sustainability, a larger pool of MOH staff and professionals should have been trained in QI methods to achieve a critical mass and broader foundation. The existence of a broader quality improvement framework would help in integrating improvement efforts conducted by several programs in the country and to ensure coordination of methods and reporting activities. One immediate priority for extending the impact of QI activities beyond maternal mortality reduction should have been around efforts to decrease neonatal mortality. Other initiatives to introduce QI methods in HIV prevention and other relevant areas could have further contributed to a broader emergence of an organizational improvement culture in the health system. The presence of an operational QI/QA department in the Ministry of Health at the central level would help to support QI activities across different health areas. Coordination with other areas of care and departments (clinical services, pharmacy and procurement, pre-service training, and continuous medical education) would have contributed to broader sustainability of QI activities. The lack of a multi-year commitment, budget, and work plan for the MMRI work and its expansion poses a major challenge to its sustainability.
Need for a Skills Lab and an on-going specialist training program at the University of Botswana or similar program. There are currently only four practicing Batswana Obstetricians & Gynecologists in Botswana.
IV. CONCLUSIONS AND RECOMMENDATIONS Project data found that 35% of PPH cases were due to uterine atony, 22% to retained placenta, and the remaining percentage due to other causes. Data from maternal audits (2014) found that 60% of deaths due to PPH were secondary to complications of a previous C-section and 30% due to uterine atony. This unexpected finding will require further investigation to elucidate root causes of this problem. Immediate audits conducted on near misses during 2014 found that providers’ poor skills to perform C-sections as one of the main contributors to PPH post C-section. It will therefore be very important to improve knowledge and skills of health workers performing C-sections to avoid ominous outcomes of an intervention performed to save lives. Pre- eclampsia/ eclampsia. Management of pre-eclampsia and eclampsia as per protocol was only provided in 23% of PE cases diagnosed during antenatal care and 42% of PE cases diagnosed during labor. PE/E was responsible of 14% maternal deaths in 2014. Efforts need to be conducted to ensure a prompt diagnosis and adequate management of preeclampsia including referral of stabilized patients to
30 Botswana Maternal Mortality Reduction Initiative higher facilities for management of this obstetric emergency. In addition, we observed a downward trend in PE/E incidence reported below expected international levels11 for which we do not have an explanation. Further investigation of factors leading to underreport should be conducted. MMRI data found a HIV prevalence rate in pregnant women of 28% in 2014 and 25.2% in 2015 (January-May). This shows a 3% decrease from 29% HIV pregnancy prevalence reported by the NACA sentinel surveillance 2009.12 Our research showed higher HIV prevalence among pregnant women in the country’s North-Eastern districts. Further studies should be conducted to identify drivers of a higher prevalence of HIV in pregnancy in those districts to support targeted recommendations for reduction of HIV prevalence. ART coverage has been improving, reaching 94% coverage in pregnant women in 2014. This coverage is expected to continue to increase after the recent MOH decision to implement the Option B+ that will provide free ARV medication for pregnant women indefinitely after their pregnancy. MMRI project data reported an abortion ratio of 209 abortions/miscarriage per 1,000 live births from Feb 2014-July 2015. This ratio exceeds the international abortion ratio of 148 per 1000 live births estimated in the World Health Report 2005.13 In addition, the incidence of abortion is underreported since the MMRI only captures data of complicated abortions that needed medical attention, leaving out abortions that occur in the community or those that do not require emergency management. A community approach to improve awareness of dangers associated with unsafe abortions practiced in the community will be necessary to educate women and the population in general on safe abortions and pregnancy prevention through reinforcing family planning at the community level. Also only 63% of women with post abortion complications receive family planning counselling and supplies before they leave the facility. There is much room for improvement in compliance with this indicator in hospitals. Maternal mortality was reduced from 90 deaths in 2013 to 69 deaths in 2014, which accounts for a reduction of 23% in one year. Maternal death audits identified as the mayor contributor to maternal death the lack of providers skills in 94% of death audits conducted. Poor clinical competence of health personnel and inconsistent compliance with protocols are playing a major role in the outcome of maternal complications in Botswana. Trainings to improve provider’s knowledge in the management of obstetric emergencies and practical training to improve provider’s skills to manage complications should be considered as well as programs to support continuous medical education of providers. A dysfunctional referral system was found in 59% of maternal deaths. Uncoordinated referrals between facilities, delays and failure to stabilizing patients before referral caused patients to die in transit, and patients referred to two or three facilities before being admitted for emergency treatment. In order to improve the referral system the MOH will need to design clear referral protocols for obstetric and neonatal emergencies. A coordination mechanism such as a call center (24/7) should be implemented to coordinate emergency referrals to facilities with the capacity to manage the emergency.
Lessons Learned The MMRI has been successful in piloting the implementation of a QI model to reduce maternal mortality during its almost two years of implementation. The lessons learned in the process should inform and advance the implementation of other QI activities in the country: Supportive supervision: Consistently scheduled supporting supervisory visits to each facility by the regional coordinator (twice a month) was a key factor to ensure that improvement activities were followed up in the facilities. We observed that in districts where coordinators did not maintain the visiting schedule due to various reasons including personal leave, health conditions or poor performance of the coordinator, the facilities in that catchment area lagged behind others
11 World Health Organization (2005). World Health Report. Making every mother and child count. Accessed at http://www.who.int/whr/2005/en/ 12 Country HIV and AIDS Facts at Glance. Botswana. Second Generation Sentinel Surveillance 2009. Accessed at www.naca.gov.bw/.../The%20National%20Response%20to%20HIV%20 13 World Health Organization (2005). World Health Report. Making every mother and child count.
Botswana Maternal Mortality Reduction Initiative 31 in implementing QI activities, as well as in merely reporting routine data. On the other hand, whenever there was a strong coordinator at the district level, not only did the implementation of activities advance in facilities; they also reached out to the community to promote the utilization of antenatal services and delivery in a facility by trained personnel. Strong leadership: The presence of a national coordinator who is well connected and respected by peers was key for: maintaining programmatic focus; reaching out to the medical community with technical advice; and coordinating with higher levels in the MOH by sharing information on system issues and supporting decision making (the leadership of the national coordinator even extended to providing immediate technical advice and coordination of care in cases of clinical obstetric emergencies). The continuous requests for support from the national coordinator prompted the MOH to consider the creation of a technical call-in center for emergencies, manned 24/7 by several gynecologists to provide clinical advice and facilitate the coordination of emergency referrals. Importance of real-time data: Data collection and reporting tools designed for the MMRI provided timely data for analysis at the central level. Since they included automatically calculated run charts for key indicators, they proved to be a successful tool to facilitate the use of data at the facility level to support QI activities and to inform local decision-making. Data collection tools gathered data from hospital and maternity clinic activities. A new set of data collection tools was designed to support the implementation of antenatal and postnatal activities – but these were not implemented by end of the Project. Overall, the MMRI data generated through the M&E activities should be integrated within the Health Information Management System to ensure sustainability of obstetric M&E activities. Evidence for improvement: A change package was developed to summarize change ideas that had been tested by participating QI teams with demonstrated contributions to performance in specific areas (Appendix). The change package included specific changes and sequences of changes tested in multiple facilities throughout the country and is expected to facilitate the scaling up of QI efforts to reduce maternal mortality in facilities. Lessons learned from teams that successfully implemented changes in specific areas will further guide other teams that have not worked in these areas of improvement, thereby speeding up the improvement process. Possible expansion of QI experience: Lessons learned from the implementation of QI activities to reduce maternal mortality are highly relevant for achieving other health improvements and policy objectives, e.g. the reduction of neonatal and child mortality, by reaching out to neonatal and pediatric wards in the facilities, as well as ambulatory family health services. Furthermore, there are opportunities to introduce QI activities in the provision of integrated sexual and reproductive health services with HIV prevention and management. These include: - HIV testing and counselling at the ANC level, linked to PMTCT (new set of QI activities); - Family planning and community education, to reduce abortions as the primary cause of maternal death in 2014; - Introduction of other SRH activities: Cervical cancer screening, sexually transmitted diseases, HIV prevention (VMMC, PMTCT, ART default reduction…), etc.
32 Botswana Maternal Mortality Reduction Initiative APPENDICES
Appendix 1: MMRI Improvement Framework Table A1-1. Indicators for Improvement Aim 1: Improving Prevention, Early Detection, and Case Management of PPH Indicator Numerator Denominator Improvement Aim 1: Decrease PPH incidence and case fatality rate through improved PPH prevention, case detection and management Percent of women who Number women who receive a uterotonic Total number women benefitted from active within first minute of delivery of fetus who delivered in the management of third stage of (oxytocin 10 units IM or misoprostol or last month labor (AMTSL) for prevention of ergomertrine--if BP normal-- if oxytocin PPH unavailable) Percent of deliveries with Number of deliveries with Total # deliveries in documentation of placenta documentation of placenta status the last month status for PPH prevention (complete/incomplete /retained ) Percent deliveries with Number of deliveries with documentation Total number documentation of absence or of absence or presence of deliveries in last presence of vaginal/cervical vaginal/cervical lacerations. month lacerations for PPH prevention. Percent of women monitored Number of women in last month Total women for complications per standard monitored post-partum every 15 minutes delivered in the last in the post-partum period (4th for the first hour and every 30 minutes in month stage of labor) the 2nd and 3rd hour with documentation of vital signs, vaginal bleeding, uterine consistency , urine output, fundal height) Number of deliveries in last month with Total number Estimated PPH rate EBL > 500 cc if SVD, 1,000 cc if deliveries in last cesarean or any amount of bleeding with month hemodynamic instability (Tachycardia >100 bpm or DBP<50) Percent PPH recorded as due Number of PPH recorded as due to Total # estimated to uterine atony managed per atony documenting appropriate PPH cases recorded standard management: as due to uterine PPH due to Uterine atonyOxytocin 40 atony. IU, massage, IV fluids, misoprostol 600- 1000 mcg (oral or rectal) Percent vaginal deliveries Number vaginal deliveries in last month Total number vaginal documenting incomplete or documenting incomplete or retained deliveries retained placenta and manual placenta and manual removal of documenting retained removal of placenta placenta or incomplete placenta in last month,
Table A1-2. Indicators for Improvement Aim 2: Improving Early Detection and Case Management of Pre-eclampsia (PE) and Eclampsia (E) Indicator Numerator Denominator Improvement Aim: Improving Early Detection & Case Management of Pre-eclampsia (PE) and Eclampsia (E) Percentage of pregnant women Number of pregnant women documented Total number diagnosed with PE/E managed with severe PE/E diagnosis documented pregnant women per protocol in chart or meeting diagnostic criteria per diagnosed with PE/E chart documentation managed according in the previous month to protocol:
Botswana Maternal Mortality Reduction Initiative 33 Magnesium sulphate, And deliver if >34 w or steroids 24 h if <34 w GA antihypertensive treatment monitored for danger signs or every 4 hours if in labor
Table A1-3: Indicators for Improvement Aim 3: Improving Prevention, Early Detection, and Case Management of Post-abortion Complications Indicator Numerator Denominator Improvement Aim 3: Improving Prevention, Early Detection & Case Management of post-abortion complications % women septic abortion in # of women seen for septic abortion in last Total # women last month treated according month treated per guideline: treated for septic to guidelines -Hospital: oral misoprostol 600-1000 or abortion in last MVA or surgical curettage & Triple month antibiotic IV regimen: IV ampicillin (2gm) & IV gentamycin (240 mg) and discharge on oral doxycycline 100 mg po bid (or amoxicillin 500mg tds) and metronidazole 400 mg po tds x 7 days. % women in last month # of women treated for Total # women treated for post abortion miscarriage/abortion in treated for complications who received last month who received FP counseling miscarriage counseling and FP before and modern FP method /abortion in last discharge month Proportion of women treated Number of women with clinical Total # women for incomplete abortion complication due to incomplete abortion diagnosed with managed per evidence-based with initiation of following interventions incomplete abortion standards within 2 hours of diagnosis in facility: in the previous month IV line and emergency evacuation of the uterus: Single dose of Misoprostol 400 μg sublingual or 600 μg oral /rectal in a health-care facility, or Dilatation and evacuation (D&E) with manual/electrical vacuum aspiration or Dilatation and curettage (D&C) with general or regional anesthesia -Broad spectrum antibiotic and analgesics.
34 Botswana Maternal Mortality Reduction Initiative Appendix 2: Change Package ASSIST PROJECT SUPPORT TO THE BOTSWANA NATIONAL MATERNAL MORTALITY REDUCTION INITIATIVE 2013-2015 Change Package This document summarizes the changes developed and implemented under the national initiative to reduce maternal mortality with support from the ASSIST project between early 2013 and August 2015. Change packages are completed at the end of a quality improvement intervention and summarize the changes that have been introduced by participating teams as they were found to have made a demonstrable contribution to improving performance. The purpose of developing a change package is to compile the evidence-based learning from an improvement effort in a format that can readily inform broader discussions, including on the potential geographic and programmatic scale up. The package can also be shared with other stakeholders for the purpose of stimulating similar changes and trigger comparable improvement efforts.
ASSIST aims in support of the National Maternal Mortality Reduction Initiative (MMRI)
Reduce maternal mortality through Districts: All 26 health districts implementation of evidence-based, high-impact interventions 122 facilities (90%) providing obstetric services: 2 referral hospitals, 28 district Contribute to improving maternal outcomes of and primary hospitals, and 92 clinics with HIV-positive women through improving maternity maternity services. care and prevention of mother-to-child transmission of HIV for HIV-positive women and QI teams formed in 88 facilities with their newborns maternity services (72% of total)
Review of change ideas under ASSIST For this particular change package, focused on changes teams tested in specific maternal care processes that would contribute to the Botswana Maternal Mortality Reduction Initiative’s overall goal of reducing maternal mortality, the criteria used to establish if changes led to improvement were rigorously applied (see “Methodology” section below). Time series charts for all facilities visited by the 6 (of 11) midwife coordinators supporting the Maternal Mortality Reduction Initiative that participated in the change package development were analyzed and commented upon, ranging from 54 facility-specific time series charts for monitoring the mother during the 4th stage of labor to 2 facility-specific time series charts for administration of magnesium sulfate to treat severe pre-eclampsia during labor. Several examples of these site-specific time series charts are included in the USAID ASSIST Botswana Country Report FY15 (see Figures 7, 13, and 15). For each change idea, a value was assigned indicating the “strength of evidence” of the idea’s efficacy in helping secure improvement based on applying time series chart interpretation rules. The value was determined by analyzing the relevant time series charts and using the following six-point scale: 0 – No evidence 1 – Anecdotal/possible evidence of improvement 2 – Signs of improvement (≥3 consecutive data points above or below the median OR 4 consecutive data points ascending or descending but not sustained or insufficient data to meet time series chart rules)
Botswana Maternal Mortality Reduction Initiative 35 3 – Time series chart rules met – (in 1-4 facilities) 4 – Time series chart rules met – (in ≥5 facilities) 5 – Time series chart rules met – (in ≥10 facilities) Improvement topics In the following tables, change ideas for each of eight improvement topics addressed by facility improvement teams in Botswana are listed in order of the strength of evidence and the number of facilities demonstrating improvement using that idea. The eight topics covered in the change package are:
1 Practicing active 2 Monitoring the 3 Giving Oxytocin IV 4 Puerperal checks management of mother during the to all women of all women the third stage of fourth stage of during the fourth before discharge labor labor stage of labor
to prevent post-
partum hemorrhage
5 Evacuation of the 6 Treating septic 7 Treating severe 8 Monitor all women uterus in patients abortions with pre-eclampsia with in active labor with incomplete triple antibiotics IV Magnesium using a abortion Sulfate partograph
Change ideas that showed no evidence of improvement are listed but are assigned a zero. They have been included because lack of evidence does not necessarily mean they did not work. Sometimes performance prior to the introduction of the change was already excellent so it was not possible to detect an improvement if it had occurred. On other occasions, several ideas were introduced around the same time so it was impossible to determine which was contributing what to any improvement seen. In addition to providing information about the strength of evidence in support for a given change idea (including the number of facilities with strong evidence of improvement as a result of the change idea), the change package describes any modifications made by individual teams. Methodology for the development of the Change Package Telephone interviews were conducted with six of the 11 midwife coordinators. For each of their facilities and for each improvement topic their QI teams had worked on, coordinators were asked to describe the changes each team had introduced and when. They were also asked if the changes had been tested on a small scale before they were implemented. For the majority of change idea, there had not been testing on a small scale before implementation. For each facility, performance across a range of maternity-related indicators for the period February/March 2014 to May 2015 was sourced from the national MMRI comprehensive database. Performance data from individual facilities that introduced changes for the process area in question were analyzed in the form of time series charts. Charts were annotated to show what changes were made and when using the information provided by the coordinators. These charts were then fed back to the coordinators to verify their correctness. For each time series chart, the median performance of the facility prior to the introduction of the change idea was calculated and plotted on the chart; this median became the reference point for determining whether a “shift” had occurred. Two run chart rules were then applied: the shift and the run. A shift is six or more consecutive data points falling either above or below the median line. A run is five or more consecutive points ascending or descending irrespective of the position of the median. When these rules are observed in a time series chart, there is clear evidence that the process producing this section of the data has changed. If this change is in a positive direction, improvement has occurred. Once improvement has been demonstrated, it is then necessary to note whether it coincided with the
36 Botswana Maternal Mortality Reduction Initiative introduction of a new change idea. If improvement starts before or a period of time after the introduction of the change, it is not possible to argue that the change led to the improvement. Strictly speaking, baselines should comprise 10 or more data points. This was never achieved, and the fewer the number of data points included in the baseline, the less confidence that the median truly reflected the usual performance of the process prior to the introduction of the change. Where one or less data points had been recorded before testing/implementing the change idea, a median was calculated across all data points. This is a legitimate way to assess whether improvements are evident in any part of the graph but it makes them harder to detect. Five coordinators’ facilities and data were not included in the change package. The reasons for excluding these data were two-fold: a) Either they were considered potentially unreliable due to changes in the facility improvement team and/or periods of sickness, or b) Because of delays in the quality improvement teams being formed. For improvement to be demonstrated using time series chart rules, at least five data points are needed after establishing baseline performance. Where teams formed late in 2014, there was insufficient data to be able to determine if changes were leading to improvement.
Botswana Maternal Mortality Reduction Initiative 37 Topic-specific Change Packages Change Topic 1: 10 IU Oxytocin Given Intramuscular Injection within 1 Minute of Birth (Active Management of the Third Stage of Labor) Related outcome measure: Percentage of women in active labor who were given 10 iu oxytocin IM within 1 minute of delivery
No. of facilities Change idea Comment introducing the Strength of evidence
Rank Rank change idea
1 Write the time patient received Prior to the introduction of this change idea most 27 Strength: 2 – Baseline oxytocin on their record midwives were writing on the records that oxytocin had performance was close to been given, noting the dosage but not stating the 100% in many facilities; in
actual time. After the change, the measurement such cases it is difficult to became more stringent; unless the time had been demonstrate written and it was within one minute of the delivery, improvement. Also,
most facilities did not count it. Consequently, a several changes were deterioration in performance immediately after the introduced at the same introduction of this change could be attributed to more time as this one. rigorous measurement 2 Pre-fill syringe with oxytocin and Some facilities had already introduced this change 24 Strength: 1 – Baselines keep cool to maintain the cold before getting involved in the MMRI. However, six often 100% and several chain facilities were not maintaining the cold chain so they changes introduced at the implemented this element of the change idea. This same time
change would only contribute to the efficacy of the drug, not time delivered. 3 Ask a nursing auxiliary or non- Sometimes the refrigerator in which the oxytocin is 2 Strength: 0 – Baselines midwife to fetch the oxytocin stored is some distance away from the labor ward. often 100% and several from the refrigerator if the changes introduced at the The cold chain was maintained either by keeping the patient arrives in the second same time syringe on an ice pack or by leaving it in a cooler box. stage of labor Usually the syringe is drawn by the delivering midwife but sometimes another midwife or nurse assisted. 4 Keeping the oxytocin in a cooler 2 Strength: 0 – Baselines box in the labor ward often 100% and several
38 Botswana Maternal Mortality Reduction Initiative No. of facilities Change idea Comment introducing the Strength of evidence
Rank Rank change idea
changes introduced at the same time 5 Focal lead for MMRI checks In-charge checks records and gives feedback. 2 Strength: 0 – Introduced randomly selected files to ensure at the same time as other the time oxytocin was given is change ideas written; feedback given to midwives on their performance 6 On-coming shift checks whether 1 Strength: 0 – Change the time oxytocin was written idea introduced at the has been documented in the same time as others patients’ files 7 MMRI focal lead emphasizes 1 Strength: 0 – Early importance of doing all three evidence of a shift but no elements of AMTSL baseline
Change Topic 2: Monitoring the Mother During the Fourth Stage of Labor Related outcome measure: Percentage of women who are monitored in 4th stage of labor: 8 prescribed checks done 6 times over a period of hours (4 in first hour, 2 in the second)
No. of facilities Change Idea Comment introducing the Strength of evidence
Rank change idea
1 Non-midwives assigned to take Non-midwives included hospital orderlies, auxiliary 36 Strength: 4 – Eight vital signs nurses, and registered nurses. Midwives often need facilities support while they are suturing the women who
delivered.
Botswana Maternal Mortality Reduction Initiative 39 No. of facilities Change Idea Comment introducing the Strength of evidence
Rank Rank change idea
2 Duty manager checks patient 8 Strength: 4– Five files to see if monitoring has facilities been done; feeds back to matron who feeds back to staff. Other senior personnel, including focal lead for MMRI, also provided feedback on performance. This is sometimes done at the morning report. 3 Midwives pair up for a delivery Midwives often need support while they are suturing 18 Strength: 3 – Four and support each other in doing the women who delivered. Some facilities just facilities all the essential elements, advocated that all midwives needed to contribute to 4th
including 4th stage of labor stage of labor monitoring without formally assigning monitoring. Sometimes pairing them in pairs. Sometime support staff were requested only continued for an hour until to help in addition. suturing was complete.
4 On-coming shift checks if 17 Strength: 3 – Two monitoring of previous shift has facilities been done during shift handover. Patient records are brought to the shift handover for review. Sometimes the checking takes place during the morning report. For small teams, the non- delivering midwife may do the checking. In a hospital, the post- natal staff checked on receiving the patient.
40 Botswana Maternal Mortality Reduction Initiative No. of facilities Change Idea Comment introducing the Strength of evidence
Rank Rank change idea
5 Additional midwives assigned to This change was only feasible in district or regional 1 Strength: 2 work in labor ward hospitals. 6 More midwives assigned to night 1 Strength: 1 duty without reduction in numbers during the day 7 Location of night watchman This change idea was bundled with the midwives 3 Not applicable; bundled changed so that he can hear the and/or nurses assisting each other. At night and when with another change idea midwife calling for additional other staff were not in the facility, the night watchman help. was needed to alert them to the delivering midwife’s request for assistance. 8 Involve all midwives and nurses 1 Strength: 0 in checking files to see if 4th stage of labor monitoring has been performed during the shift handover and in preparing data for monthly MMRI report. 9 Document why monitoring of 4th 1 Strength: 0 stage is not done
Change Topic 3: 20/40 IU Oxytocin Given IV in Fourth Stage of Labor Related outcome measure: Incidence of post-partum hemorrhage No. of facilities who introduced Change Idea Comment Strength of evidence the change Rank Rank idea 1 Staff informed they should be 1 Strength: 1 giving 20 iu IV oxytocin in ringers lactate or normal saline
Botswana Maternal Mortality Reduction Initiative 41 No. of facilities who introduced Change Idea Comment Strength of evidence the change Rank Rank idea to all women during the 4th stage of labor. Women at high risk of post-partum hemorrhage to receive 40 iu IV oxytocin. 2 Lecture given to doctors, 1 Strength: 1 midwives, and ward managers on importance of giving 40 iu oxytocin IV to women gravida 5 or at risk of uterine atony.
Change Topic 4: Puerperal Checks Related outcome measure: Percentage of women who have puerperal checks completed before discharge
No. of facilities Change Idea Comment introducing the Strength of evidence
Rank change idea 1 Focal lead for project reviews This topic was only championed by one of the 5 Strength: 3 – One patients’ files after discharge to see midwife coordinators. facility Strength: 2 – if puerperal checks were done. Three facilities Feeds back to team and delivering midwife. Feedback given in morning report or shift handover. In a small facility, the midwife not performing the delivery checks her colleagues’ work.
42 Botswana Maternal Mortality Reduction Initiative Change Topic 5: Evacuation of Uterus within Two Hours for Patients with Incomplete Abortion to Prevent Septic Abortion Related outcome measure: % of women with incomplete abortion who have management/uterine evacuation within 2 hours of diagnosis No. of facilities Change Idea Comment introducing the Strength of evidence
Rank Rank change idea 1 Evacuate the patient diagnosed with Most patients present via Accident & Emergency 10 Strength: 3 – One incomplete abortion prior to (A&E) but some present in Outpatient Department facility; often no baseline admitting her onto the Gynecology (OPD). Some hospitals explored using different has been recorded or ward. theatres to avoid congestion. performance was at 100% prior to the Many facilities were not recording the time the introduction of the patient was diagnosed or when the procedure was change idea performed before working on this topic, so there was rarely a baseline from which to establish evidence of improvement. 2 Senior doctors teach others how to 2 Strength: 3 – One clinically diagnosis incomplete facility abortion rather than waiting for an ultrasound to confirm. Directions were given to doctors that they did not need to confirm diagnosis with ultrasound. 3 The ward doctor or hospital 1 Strength: 3 – One superintendent makes other doctors facility aware of the policy of evacuation of incomplete abortions within 2 hours 4 Produce a recording tool in which Doctors did not always use the tool for 3 Strength: 0 the time of diagnosis and time of documentation but it did help improve evacuation are recorded documentation in the patient record. 5 Feed back to the doctors how well In one facility this was primarily to encourage the 2 Strength: 0 they are doing in evacuating doctors to record the time they diagnosed the incomplete abortions within 2 hours. patient and when they performed the procedure.
Botswana Maternal Mortality Reduction Initiative 43 No. of facilities Change Idea Comment introducing the Strength of evidence
Rank Rank change idea
In one facility, doctors were invited to join the QI team so that they would routinely have feedback on performance. 6 During the morning report, notifying 1 Strength: 0 OB/GYN staff of the admission of a patient with an incomplete abortion and whether an evacuation has been completed. 7 Increase the number of A&E doctors 1 Strength: 0 to two
Change Topic 6: Treat Septic Abortions with Triple Antibiotics IV Related outcome measure: % of women with septic abortion who are treated with triple antibiotics IV No. of facilities
Change Idea Comment introducing the Strength of evidence
Rank change idea 1 Performance in treating septic Health facilities with maternity beds would be 2 Strength: 3 – One abortion is shared during shift expected to initiate treatment and then refer a case facility handover. Feedback given to of septic abortion. OB/GYN staff during morning report. 2 Management and staff are made 2 Strength: 1 – Septic aware of protocol for treating septic abortion is a rare event abortion. so it is difficult to detect an improvement.
44 Botswana Maternal Mortality Reduction Initiative No. of facilities
Change Idea Comment introducing the Strength of evidence
Rank change idea 3 Produce a recording tool on which 2 Strength: 1 the treatment of septic abortion with triple antibiotics is recorded. 4 Doctors who do not follow protocol 1 Strength: 1 are given feedback on their performance.
Change Topic 7: Treat Severe Pre-eclampsia on Diagnosis with Magnesium Sulfate to Prevent Eclampsia Related outcome measure: Percentage of women diagnosed with severe pre-eclampsia during labor who are managed with Mg SO4
No. of facilities who introduced Change Idea Comment Strength of evidence the change Rank Rank idea 1 All patients with severe pre- 1 Strength: 1 – Evidence eclampsia to be seen by a specialist of improvement but two within one hour of admission and ideas introduced at the started on MgSO4 same time 2 All severe pre-eclampsia cases 1 Strength: 1 – Evidence discussed in the morning report for of improvement but two team handover, peer review, and ideas introduced at the learning same time 3 Midwife not admitting patient checks Patients presenting with severe pre-eclampsia in 1 Strength: 1 – Baseline that admitting midwife gave MgSO4 labor should already have been identified as “at performance already on diagnosis of severe pre- risk” and referred to the care of a primary/district or 100% eclampsia. regional hospital. However, if they do present at a health center with maternity beds, the protocol to treat with MgS04 should be followed.
Botswana Maternal Mortality Reduction Initiative 45 Change Topic 8: Women in Active Labor Monitored Using a Partograph Related outcome measure: Percentage of women in active labor who were monitored with a partograph
k No. of facilities Change Idea Comment introducing the Strength of evidence
Ran change idea 1 In-charge checks partographs for 2 Strength: 2 – One facility; early evidence of completeness and provides feedback. improvement but tested with other change ideas 2 All nurses review partographs for MMRI 1 Strength: 2 – One facility; early evidence of reporting. improvement but tested with another change idea 3 Patients’ records are brought to shift 1 Strength: 2 – One facility; early evidence of handovers. improvement but tested with other change ideas 4 The two midwives delivering the 4 Strength: 1 – Two facilities; early evidence of woman check each other’s improvement but tested with other change documentation on the partograph and ideas sign off their own section. Assistant
nurse and other staff check delivering nurses’ partograph. 5 The focal lead for MMRI checks records 2 Strength: 0 to see if they have been signed off. 6 Midwives check their own partographs 2 Strength: 0 for completeness and to identify gaps.
Strength of evidence 0 – No evidence 1 – Anecdotal/possible evidence of improvement 2 – Signs of improvement (≥3 consecutive data points above the median OR 4 consecutive data points ascending or descending but not sustained or insufficient data to meet time series chart rules) 3 – Time series chart rules met – (1-4 facilities) 4 – Time series chart rules met – (≥5 facilities) 5 – Time series chart rules met – (≥10 facilities)
46 Botswana Maternal Mortality Reduction Initiative
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