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