How to Create Well-Coordinated Change to Save Women’s Lives

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By: Katie Millar, Senior Project Manager, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Monthly Review Meetings diagramThis post is the third of four, which discuss three interventions that worked synergistically to strengthen a health system and improve obstetric emergency management in Addis Ababa, Ethiopia.

When clinicians from all levels of a health system gather together once a month, not only are communication and interpersonal relations strengthened, but program implementation and health outcomes also improve.

The Addis Ababa Regional Health Bureau and the Ethiopian Federal Ministry of Health conceived the idea for monthly review meetings for referral networks throughout Addis Ababa. The MHTF provided support to St. Paul’s Millennium Medical College, which scheduled and carried out these meetings for the St. Paul’s Referral Network, then made up of one tertiary hospital and eight health centers.

St. Paul's Hospital in Addis Ababa, Ethipia (Photo: Katie Millar/MHTF)
St. Paul’s Hospital in Addis Ababa, Ethiopia (Photo: Katie Millar/MHTF)

In Addis Ababa, Ethiopia, hospital-health center referral networks were organized with the knowledge that the majority of deliveries are low-risk and should take place in health centers, while pregnant women who are high-risk and develop complications should be referred to and deliver in tertiary hospitals. Government health officials hoped this organization would create an efficient use of health services, unburdening the highly accessed tertiary hospitals and increasing the utilization of health centers.

But, despite the reorganization, women in the St. Paul’s Hospital Referral Network were still turned away from the overcrowded hospital and not efficiently referred to or by the health centers. Very often, women simply ended up delivering outside of a facility. Why was this? Collaboration between facilities was poor and inexperienced health center midwives referred many uncomplicated patients to St. Paul’s without communicating first. Often, St. Paul’s Hospital did not have a bed for the referred woman when she arrived and had to refer the woman to another hospital across town, hoping she wouldn’t deliver before she arrived. This left both health center and St. Paul’s staff frustrated.

What was the solution for this frustration? Monthly review and coordination meetings: an opportunity for providers from all facilities to discuss the challenges they were facing in their practice, create solutions and collaborate to implement those solutions. Overall, these meetings facilitated coordination, trust and communication between facilities.

Dr. Delayehu Bekele, Assistant Professor of Obstetrics & Gynecology at St. Paul's Millennium Medical College (Photo: Katie Millar/MHTF)
Delayehu Bekele, Assistant Professor of Obstetrics & Gynecology at St. Paul’s Millennium Medical College (Photo: Katie Millar/MHTF)

“The hot agenda used to be that mothers which are referred from those health centers are not being accepted by our hospital.  So that was the most common complaint.  And every time in the meeting we were hammered by our health centers,” said Delayehu Bekele, then the Chair, and currently Assistant Professor of Obstetrics & Gynecology, St. Paul’s Hospital Millennium Medical College.

These complaints came from health center staff when they did not realize how busy the hospital was and that the number of beds available for women was scarce. St. Paul’s staff came to the meetings frustrated by the unnecessary referrals coming from insufficiently trained health center midwives.

What was discussed at the meetings?

The meetings gave each facility an opportunity to review the number of women who received antenatal care, the number of deliveries, the number of referrals and why each woman had been referred in the past month, explained Lia Tadesse, then the Vice Provost for Academic Programs and Research at St. Paul’s Millennium Medical College and currently the Project Director of the Maternal and Child Survival Program in Ethiopia.

“It is an amazing experience and the meetings are very good, because we use them to assess the performance of each health center and the hospital.  And we see the trends, the improvements, the gaps, how the referrals work and we hear the many complaints.  These meetings are the only opportunity to hear the complaints from the health centers. So, it is a very good approach,” said Bekele.

Clinicians collaborate, change happens

The presentation of clinical performance measures allowed clinicians to problem solve collaboratively. At these meetings, interventions to improve skills and strengthen the health system—like the midwife exchange, Basic Emergency Obstetric and Newborn Care (BEmONC) training, obstetric emergency drills and back referrals of low-risk women from St. Paul’s Hospital to the health centers—were conceptualized, planned and implemented.

“If there’s a new intervention, we use the meetings to train staff. For example, the midwife exchange didn’t start immediately. When we were about to start the midwife exchange, we discussed in these forums to get the buy-in from clinicians,” said Tadesse.

The meetings also created a strong connection between clinicians and the Ethiopian Ministry of Health. “Even if we cannot solve their challenge, we can discuss with the Regional Health Bureau or the Ministry to solve those problems,” said Tadesse.

Successes of the monthly review meetings

Lia Tadesse, former Vice Provost for Academic Programs and Research at St. Paul’s Millennium Medical College (Photo: Katie Millar/MHTF)
Lia Tadesse, former Vice Provost for Academic Programs and Research at St. Paul’s Millennium Medical College (Photo: Katie Millar/MHTF)

“The health centers are commended during the meetings these past three months. That is a dramatic change because for more than a year it was only complaints, and the shortcomings seemed beyond our capacity to solve. But since the main problems have been solved, the whole air of the meetings has changed.  It is very positive…   And the other thing is the back referral has also contributed to alleviate some of the problems with overcrowding,” said Bekele.

“The back referral was really one of the key achievements of the project,” said Tadesse.

During the same period that the monthly review meetings were implemented, BEmONC training and the midwife exchange program took place to improve the skills of the health center midwives. With improved skills, health center midwives were ready to better manage pregnant women through their delivery.

At the monthly review meetings, clinicians decided that low-risk patients who arrived at St. Paul’s Hospital for delivery could be back-referred to health centers to deliver there. “When St. Paul’s has no space and a mother is low-risk, she can deliver at the health center. We will send the mother, with appropriate information, to the health center and they should be receiving her. So that was the consensus,” said Tadesse.

The monthly review meetings improved communication, allowed interventions to become institutionalized and created a sense of social accountability between the facilities in the referral network, said Tadesse. This has improved the morale of health center providers, strengthened the referral system and contributed to decreased crowding at St. Paul’s Hospital.