Obstetric Fistula Technical Meeting Convened by Maternal Health Task Force and Engender Health

By Mary Nell Wegner, Executive Director, MHTF 

On July 8-11, the MHTF had the privilege of co-hosting two meetings with the Fistula Care Plus project, led by EngenderHealth. It was a terrific opportunity to learn about the current state of fistula research, discuss gaps in surveillance and measurement, as well as consider our shared goal of how best to support providers in high burden countries to tackle this persistent problem.

These providers of obstetric care and women with fistula offer important insight into the existence of fistula, but the reality is that we have no idea how many women in the world are currently living with fistula or are at risk for getting a fistula. Because obstetric fistula is a relatively rare event and women with fistula are often stigmatized, appropriate measurement mechanisms are elusive. Although household and mixed method surveys, key informant interviews, health management information systems, and modeling all offer insight, none of these alone adequately captures the scope of the problem. Consequently, measuring incidence and prevalence of this maternal morbidity is difficult. Additionally, fistula often affects the poorest, most vulnerable, and powerless women and, because they are frequently so marginalized, they can be hard for a “system” to find.

Still, that is no reason to give up.

As the global community comes together to work towards ending preventable maternal mortality and morbidity and address the needs of newborns, fistula is a critical issue. Obstetric fistula, often a sequela of unskilled or absent emergency obstetric care, provides an important lens on how health systems are failing women and newborns when they are at their most vulnerable.

While arguably the vast majority of obstetric fistula is caused by lack of emergency obstetric care during obstructed labor, it is becoming increasingly apparent that there is also some proportion caused within facilities by providers with inadequate skills. In the process of providing cesarean sections, some providers may actually cause a fistula. A forthcoming retrospective review by Dr. Thomas Raassen and others will provide data on this topic covering 18 years and 11 countries.[i]

While the maternal health community is to be commended for all of the work conducted in the last decades to increase access to emergency obstetric care, in our haste we may have made a critical error in failing to ensure the provider has the skills and resources needed to operate effectively. It’s time to take a closer look at the training providers receive and what can improve their competence.

Not all women who arrive at a facility with obstructed labor are guaranteed to receive the care they need for the prevention of fistula. Some women arrive too late after a fistula has begun to form. For those who arrive promptly, a skilled provider can make a critical difference in a woman’s life when the provision of a c-section to relieve obstructed labor will safeguard the health of the mother and newborn. Let’s pause to recognize this need for prompt, skilled emergency obstetric care and plan accordingly.

Let’s also pause to congratulate the Fistula Care project and the incredible surgical teams and facilities staff in the Global South who have provided more than 29,000 fistula repairs to women in more than ten countries, as well as published 22 journal articles, in the last five years. With this kind of track record, further substantial progress in preventing both obstetric and iatrogenic fistula certainly seems within reach.

[i] Raassen TJIP, Ngongo CJ, Mahendeka MM, Iatrogenic genitourinary fistulas: An 18-year old retrospective review of 801 iatrogenic injuries. International Journal of Urogynecology, in press

AIDS conference Exclusive: HIV diagnosis and forced sterilization in Mesoamerica

By Katie Millar, Technical Writer, MHTF

A quarter of HIV-positive women surveyed in Mesoamerica reported health care workers pressured them into sterilization, recent research shows. This rate was consistent across the four countries (Mexico, Nicaragua, El Salvador, and Honduras), all races, and education and socioeconomic levels in the study, showing distinct, consistent discrimination against women with HIV. This is a serious violation of reproductive rights, especially in light of advances in treatment and prevention of HIV.

“It’s really unthinkable that women living with HIV are being pressured and forced into sterilization when treatment almost eliminates the possibility of mother-to-child transmission… and also provides options for safer conception and pregnancy,” says Dr. Tamil Kendall (Reuters), lead research for this project and a Canadian Institutes of Health Research postdoctoral researcher with the Women and Health Initiative and a Takemi Fellow at the Harvard School of Public Health. But, Kendall relays, “We found that only slightly more than half of the women who participated in the study were told that there exists an intervention—a regimen of AIDS-fighting antiretroviral drugs—that can reduce the probability of HIV mother-to-child transmission by 98%–99%.” Even without any intervention, an HIV-positive woman has only a 15-45% chance of transmitting the virus to her newborn. So why are health workers pressuring women to be sterilized?

Stigma.

Kendall said, “Even though our knowledge is growing about how safe conception and pregnancy can be with current HIV treatments; about the possibility of dramatically reducing transmission of HIV to a partner; and about interventions to help people with HIV conceive safely, this knowledge is still often ignored as a routine part of HIV care—even in the U.S. Reproduction among people with HIV continues to be very stigmatized.”

The lengths to which health workers go to pressure or coerce women to sterilize are drastic. “Women are told that if they have another pregnancy that either they will die or their children will almost surely acquire HIV and die,”  Kendall said (Reuters). Some women are even denied medical care if they do not consent to sterilization. One 19-year old woman from El Salvador said, “The nurses forced me to sign. They asked me more than three times and threatened not to perform the cesarean. Because of the pressure, I had no option but to sign.” Even more extreme, some are sterilized without any consent or knowledge of the procedure.

These findings have significant implications for policy advocates, makers, and enforcers. “There’s also a great need to evaluate how health care providers are held accountable—in the courts, for example—for violating the reproductive rights of women with HIV. And it’s important to work with policy makers, because they are the ones who ultimately need to hold institutions accountable,” Kendall states. Continued research and policy advocacy is needed to produce change and respect for HIV-positive women’s reproductive rights.

The unique aspect of this research was it was community-based and broadly collaborative. Led by Dr. Kendall, the research was initiated by Balance, a Mexican NGO, and the International Community of Women Living with HIV and AIDS. More than 60 peer researchers, most of whom are women leaders living with HIV, collected data. In addition, research and policy advocacy are routinely integrated through in-country presentations to participating organizations and national decision-makers, the formation of a regional manifesto, and advocacy with the Commission on the Status of Women and other UN bodies.

Kendall would like to recognize and thank all the organizations that participated in this research.

Want to learn more about Dr. Kendall’s Research? Read interviews with her by the Harvard School of Public Health and Reuters. Want to learn more about HIV/AIDS and maternal health? See our topic page.

Penda Health: 3 Lessons on Motivating Health Providers

By Paige Sholar, Writing and Communications Intern, Penda Health

This post is part of our “Supporting the Human in Human Resources” blog series co-hosted by the Maternal Health Task Force and Jacaranda Health.

Penda Health has built a chain of quality primary care clinics serving Kenya’s poor. Within three years of establishing these clinics, Penda has overcome the challenge of poor provider performance through the use of non-financial incentives.

In Kenya, some clinics give their providers a revenue target every month, forcing the providers to act more like salespeople and sell unnecessary services. This method may allow the clinic to remain profitable but creates distrust between patients and providers and an environment that distracts providers from quality care.

Over the years, Penda has created a profitable new model that creates a trustful provider-patient relationship. Penda also focuses on creating a friendly work environment with motivating non-financial incentives where providers enjoy coming to work every day. During the development of this model, Penda has learned 3 lessons about how to motivate providers.

#1: Providers Will Work Hard to Improve Quantitative Quality Scores

Example of Quality Metrics:  Percent of properly documented quality metrics for tonsillitis by Penda's clinical officers

Example of Quality Metrics: Percent of properly documented quality metrics for tonsillitis by Penda’s clinical officers

Penda Health implements quality metrics as a form of standardization that improve consistency of care, provide quantifiable data, and allow providers to utilize their training and knowledge for diagnosis. The best of both worlds, this method measures and promotes quality care.

The resulting data allow Penda to track the progress of each provider and highlight areas for improvement. When our data highlights a need for improvement, Penda provides topic-specific training until the providers consistently score well. After some resistance, our providers realized this data drove improvement and was not a punishment.

The results of each provider are made accessible to everyone and can be tracked month-to-month. We expected our providers to be competitive with each other, but we are still continually impressed with their desire to improve their own scores. Consistently communicating these quality metrics provides open communication within the clinic and constant feedback to each provider. Also, the transparency of these scores encourages our providers to train their peers.

#2: Providers Love Continuing Medical Education

Penda began offering continuing medical education courses to our providers to support evidence-based medicine while encouraging them to constantly learn and improve, which shows our commitment to the clinics and community. At these trainings providers receive additional information, interact with their colleagues, and leave empowered to treat patients with quality care. The providers receive a certificate after completing the course, which incentivizes completion of the entire course successfully.

After we established training of our own providers, we started inviting providers from other organizations and clinics to our trainings, which increases the medical abilities of the entire community. With outside providers attending the trainings, we encourage our providers to lead sections of the course. Our providers value this opportunity and love teaching their peers!

#3: Positive Feedback from Patient to Provider is Pure Gold!

We have invented ways to collect more patient feedback throughout each provider’s day.

    1. Patient Follow-up Calls: A new protocol requires our providers to call each patient after the clinic visit. The majority of patients is thrilled with this phone call. It is not uncommon for our providers to hear thank you, a blessing, or even joyful tears during these phone calls.

If the patient is not feeling well, the provider invites the patient back to the clinic for a free check-up. In both scenarios, the provider receives daily feedback directly from their patients, which increases provider morale as it demonstrates to each provider that patients value the quality of their care. Penda has created an intimate connection between patient, provider, and data where the provider feels empowered to affect the patient’s experience as well as outcomes.

  1. Patient Feedback: Each patient seen at our clinic completes a feedback form. The positive reviews are read aloud in our weekly team meeting with the name of the staff member who treated them! This is motivating since providers want to continue delivering high quality care so their name is associated with the positive reviews each week.
    1. Compliment Cards: Every six months each one of our staff members receives positive feedback through a “Compliment Card.” Each card includes 5-10 good comments from patients or staff. At our all-company meeting someone reads all of the compliments out loud. The public recognition of each provider is a morale booster and allows each provider to feel appreciated among their peers.

Penda Health has developed a model that uses non-financial incentives to leverage providers’ innate motivation to help people and to create a positive atmosphere where the providers continually strive to deliver the quality medical care.

Innovative Methods of Delivering Antenatal Care: A Policy Dialogue

By Katie Millar, Technical Writer, MHTF

WWCAntenatal care has long been viewed as a critical component of comprehensive maternal and newborn health care, together with care at the time of delivery and during the postnatal period. Yet, in low-income countries, only 38% of pregnant women attended the recommended four or more ANC visits during 2006-2013. Since numerous life-saving interventions can be delivered in the weeks and months leading up to birth, what is holding the global maternal health community back from successfully delivering high quality ANC to all pregnant women around the world? Further, what does high quality ANC actually entail? What innovative models for delivering ANC exist, and might be scaled up to reach more women in more settings?

To begin to answer these questions—and their policy implications—the MHTF recently worked together with the Wilson Center, as part of the Advancing dialogue on maternal health, series to facilitate the policy dialogue, “Delivering Quality Antenatal Care in Low Resource Settings: Examining Innovative Models and Planning For Scale up.”

The panel for this policy dialogue consisted of Dr. A. Metin Gülmezolgu of the World Health Organization (WHO), Carrie Klima, PhD of the University of Illinois at Chicago, and Faith Muigai of Jacaranda Health. The three experts on this panel offered insight into both gaps and solutions to the current ANC environment. Their expertise focused around three main topics: continued rigorous research, creating more effective and efficient models of care, and delivering quality care through investing in the health workforce.

Research

Global standards for ANC have experienced numerous iterations, and the World Health Organization (WHO) continues to examine the best schedule and content for ANC. The second iteration of WHO’s ANC model, Focused Antenatal Care (FANC), was released in 2001 and outlines key interventions to be delivered in four visits that are critically timed. But a WHO trial in Zimbabwe showed an increase in perinatal death, specifically fetal deaths, in those who had only four ANC visits.This model is currently under reevaluation by the WHO and we can look forward to new guidelines in the coming year.

Dr. Gülmezolgu emphasized the continual need of rigorous research like randomized control trials (RCTs) to evaluate two questions—what should be delivered and how. This is being accomplished partially through the joint WHO and MHTF project, Adding Content to Contact, which systematically assesses the obstacles that prevent and the factors that enable the adoption and implementation of cost-effective interventions for antenatal and postnatal care along the care continuum. Research and interventions for ensuring a healthy pregnancy and delivery should occur on several levels: individual interventions, barriers and facilitators to access to and provision of care, large-scale program evaluation to address policy issues, and health systems interventions. The outcomes of these interventions and research are not only maternal, but should also be evaluated on the fetal and neonatal level and women-centered—creating a space where women can learn about pregnancy and not just preventing complications.

Innovative Models of Care

Public facilities in low-income countries are often overcrowded with poor provider-to-patient ratios, straining health workers and providing a barrier to sufficient ANC. Carrie Klima offers insight to a model of care that could improve the efficiency and effectiveness of health workers in low-resource settings. CenteringPregnancy is a group care model that has been implemented in the Unites States since the 1990s. In CenteringPregnancy, eight to 12 pregnant women with similar due dates receive their prenatal care, education, and support in a group setting. This model has shown an increase in weight and gestational age for mothers who deliver prematurely. But could this model, primarily used in a developed country, also work in the developing world?

Recently Klima traveled to Tanzania and Malawi to conduct a feasibility and acceptability study of this model of care. The current CenteringPregnancy model of ten visits and was pared down to four to reflect the FANC guidelines for this study. What did the results show? Both health workers and expecting mothers were accepting of this model and qualitatively reported an increase in the quality of ANC. Midwives reported that they finally felt like they were able to practice their profession as they were taught to do in midwifery school. Women were also taught how to perform self-assessments and reported feeling more empowered by better understanding the metrics of their care and options for treatment.

Invest in the Health Workforce

Jacaranda Health in Kenya provides a novel model of care not often seen in low-resource settings—quality over quantity, a valued health workforce versus one that is overworked. This health model has six areas of focus: patient-centered design, human resources, quality improvement, technology, measuring impact, and business innovation. Faith Muigai, Director of Clinical Operations, stressed the importance of supply-side incentives for ANC as she highlighted patient-centered interventions. During their stay at the facility women receive three meals, two snacks, medications, maternity pads, and other goods that the woman or her family normally must supply. At Jacaranda facilities, patients keep coming back because the quality is much better. Jacaranda also works with women to create a savings plan for delivery fees. Since some women can’t afford these fees, Jacaranda is working with the Government of Kenya to subsidize care and lower prices.

Jacaranda not only creates a quality place to receive care, but also a quality place to provide care. Jacaranda is passionate about their health workforce and has developed a career ladder for their staff to help create a sustainable health system. This allows task-shifting, which maximizes time with clients so education can be provided. Muigai concluded by emphasizing that the model of care Jacaranda implements is “a means of proving concepts that impact the delivery of cost-effective, patient-centered, quality care in low-resource settings.”

Interested in learning more about what our speakers had to say? Follow the links below:

Interested in learning more about the MHTF’s ongoing work relating to antenatal care? Contact Annie Kearns, project manager of Adding Content to Contact (ACC).

Resource Tool: Human Resources for Health

By Katie Millar, Technical Writer, MHTF

This post is part of our “Supporting the Human in Human Resources” blog series co-hosted by the Maternal Health Task Force and Jacaranda Health.

To enrich the “Supporting the Human in Human Resources” blog series, a round-up of recent literature on the subject is here aggregated as a useful tool for public health practitioners. Let us know how these articles are helpful and about other human resource topics that interest you.

Landmark articles:

  1. Systematic Review on Human Resources for Health Interventions to Improve Maternal Health Outcomes: Evidence from Developing Countries
  2. HUMAN RESOURCES FOR HEALTH: foundation for Universal Health Coverage and the post-2015 development agenda
  3. Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes
  4. Human resources for maternal health: multi-purpose or specialists?

Recent Publications:

  1. Time to address gender discrimination and inequality in the health workforce
  2. Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya
  3. Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi
  4. HRM and its effect on employee, organizational and financial outcomes in health care organizations
  5. Hope and despair: community health assistants’ experiences of working in a rural district in Zambia
  6. Reaching Mothers and Babies with Early Postnatal Home Visits: The Implementation Realities of Achieving High Coverage in Large-Scale Programs
  7. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness
  8. Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review
  9. Expansion in the private sector provision of institutional delivery services and horizontal equity: evidence from Nepal and Bangladesh
  10. Performance-based incentives to improve health status of mothers and newborns: what does the evidence show?
  11. Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries
  12. Retention of female volunteer community health workers in Dhaka urban slums: a prospective cohort study