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Nicaragua | Prevention and Management of Obstetric and Neonatal Complications (CONE) Collaborative
Sponsors/partners:
USAID Health Care Improvement Project (HCI), Ministry of Health of Nicaragua (MINSA)
Topics: Active management of the third stage of labor, Antenatal care, Essential newborn care, Essential obstetric care, Infection prevention in delivery care, Maternal sepsis/infection, Maternal, Newborn and Child Health, Neonatal sepsis/infection, Post-partum care, Post-partum hemorrhage, Pre-eclampsia/eclampsia
Region and Country: Central America and the Caribbean, Nicaragua
Date improvement activities began:
March, 2009
Date of end of collaborative:
September, 2010
Aims/objectives:
The aim of the collaborative was to achieve the following objectives in maternal health during the 18 months of the collaborative:
1. Reduce the maternal mortality rate rate due to post-partum hemorrhage, pre-eclampsia/eclampsia, and sepsis by 10%.
2. Reduce cases of post-partum hemorrhage and sepsis by 10%.
3. Reduce the fatality rate for post-partum hemorrhage, pre-eclampsia/eclampsia and sepsis by 10%.
The collaborative also aimed to achieve the following objectives in neonatal and child health in 18 months:
1. Reduce the fatality rate for neonatal asphyxia by 10%.
2. Reduce the fatality rate for neonatal sepsis by 10%.
3. Reduce the fatality rate for pneumonia by 5%.
4. Reduce the fatality rate for diarrhea by 5%.
5. Reduce the incidence of neonatal respiratory distress syndrome by 10%.
Implementation package/interventions:
The primary goal of the collaborative was to make sure that all providers were familiar with and properly followed national protocols in maternal-neonatal care, including for PPH, pre-eclampsia/eclampsia, maternal and neonatal sepsis, pre-term birth, asphyxia, and respiratory distress syndrome.
To improve the quality of maternal health indicators, facilities were encouraged to enact the following changes:
- For women 26 to 35, identify and address risk factors for pre-term labor, pre-eclampsia/eclampsia, post-partum hemorrhage, and membrane rupture. Providers worked to determine whether any of the previous risk factors necessitated an elective caesarian.
- Conduct staff reviews of cases involving asphyxia, maternal and neonatal sepsis, pre-eclampsia/eclampsia and post-partum hemorrhage morbidity.
- All diagnoses should conform to the CIE-10; admission, discharge, and registration forms should be completed properly.
- Improve monitoring of women in the post-partum period; women remained in the labor room for two hours after giving birth before going to the maternity ward for post-partum care.
- Emphasize active management of the third stage of labor (AMTSL) for both vaginal births and caesarians; a stamp reminding providers of the steps is put on each partograph.
To address newborn health needs, the facilities participating in the collaborative:
- Focused on compliance with resuscitation care protocols;
- Received training on neonatal resuscitation and integrated management of childhood illnesses;
- Encouraged early initiation of breastfeeding;
- Identified maternal risk factors for asphyxia;
There was an effort to promote better integration and coordination of care between obstetric, pediatric, and laboratory services. The collaborative also worked to ensure that all providers were familiar with evidenced-based interventions to reduce neonatal mortality, as well as the importance of identifying risk factors and how to properly address them. In terms of the quality improvement process, each facility completed the following activities:
- Monthly monitoring and analysis of indicators to assess performance and determine gaps in quality.
- Conduct performance evaluations of providers.
- Ensure sufficient supplies to ensure compliance with protocols and prevent stock outs.
- Documentation of changes to determine whether or not they were successful.
- With HCI’s supervision, designing and placing posters in the labor and delivery wards to remind staff of risk factors and proper steps during birth. Each facility designed its own poster based on specific deficiencies identified during their data analysis and coaching visits.
Measurement:
During the collaborative, teams measured the following key indicators in maternal health:
- Percent of users with severe pre-eclampsia or eclampsia that received treatment according to protocol.
- Percent of births for which a partograph was completed and correctly interpreted.
- Percent of women who were monitored according to protocol during the post-partum period (post-partum or post-caesarian).
- Percent of women with obstetric hemorrhage (post-partum or post-caesarian) that received treatment according to protocol.
- Percent of women with post-partum sepsis that received treatment according to protocol.
The following key indicators were used to monitor newborn health outcomes:
- Percent of newborns that were treated according to the immediate newborn care protocol.
- Percent of newborns with severe asphyxia that were treated according to protocol.
- Percent of newborns diagnosed with sepsis that were treated according to protocol.
- Percent of basic medical supplies available for immediate newborn care.
A full list of indicators is available in the attached document titled “Nicaragua CONE Collaborative Indicators.”
Spread strategy:
Personnel from the SILAIS were included in learning sessions, and a SILAIS representative attended each coaching visit to increase knowledge at the SILAIS level. This also empowered the SILAIS to provide assistance to facilities not participating in the collaborative.
Number of sites/coverage:
9 hospitals and 30 health centers across 9 SILAIS participated in the collaborative.
Coaching:
HCI quality improvement (QI) advisors conducted coaching visits at all sites participating in the collaborative each month. During the visits, coaches focused on improving the weakest standards as identified by the facilities’ continuous monitoring of collaborative indicators. The facilities were encouraged to complete PDSA (plan-do-study-act) forms during rapid improvement cycles to address areas where improvement was needed. Teams documented these changes using PDSA cycle forms distributed by HCI and were able to determine how successful each change was. Interventions that were determined to be successful were deemed best practices and shared with other facilities during coaching visits and learning sessions. Strategies that were shown to be unsuccessful were also shared so that facilities would not waste time or efforts trying to implement a change that would not be effective.
Learning sessions & communication among teams:
Facilities were divided into two geographic groups and participated in two learning sessions each. Each facility also participated in smaller learning sessions with other facilities in their SILAIS. At these sessions, teams shared the best practices they identified during the improvement cycles and coaching visits. The sessions provided an opportunity to share results and served to motivate and encourage teams. A forum between the hospital teams was also organized so that these facilities working on similar interventions could share and learn from each other. Unfortunately, teams from two remote SILAIS, RAAN and RAAS, had difficulties traveling to the learning sessions and were not able to participate.
The teams from Nueva Segovia and Juigalpa participated in an exchange visit with Jinotega, which was identified as having successfully implemented best practices in approaches related to newborn sepsis. These visits were very successful; the visiting teams were able to make improvements after visiting Jinotega.
Results:
In maternal health, teams were able to achieve significant reductions in the fatality rates for post-partum hemorrhage, pre-eclampsia/eclampsia, and sepsis. There was a 56.7% reduction in cases of post-partum hemorrhage, with a reduction to 232 cases in 2010 from 536 cases in 2009. The percentage of post-partum hemorrhage was reduced by 46%, from a case fatality rate of 1.3 per 1,000 in 2009 to 0.7 per 1,000 in 2010. AMTSL, improved classification of cases, timely identification of PPH risk factors, and better monitoring of women in labor contributed to these decreases. The fatality rate for pre-eclampsia/eclampsia decreased by 29.4%, with a decrease from 5.1 per 1,000 cases in 2009 to 3.6 per 1,000 cases in 2010. Active identification of risk factors and the promotion of calcium and aspirin use contributed to the decrease, as did the development of better diagnostic criteria spread to all facilities. There were no reported sepsis deaths during the collaborative. The hospitalization rate for PPH, pre-eclampsia/eclampsia, and sepsis cases requiring hospitalization decreased by 17.3%.
Teams also made significant improvements in neonatal health. The incidence of neonatal asphyxia decreased by 26%, from 0.69% in 2009 to 0.51% in 2010. The fatality rate for asphyxia was reduced by 17.2%. These reductions were possible because staff improved their identification of risk factors and achieved better integration of care between obstetric and pediatric services. Facilities had a 61.4% decrease in deaths attributed to neonatal sepsis, reducing 70 deaths in 2009 to 27 in 2010 through September, the end of the collaborative. Through participation in the collaborative, staff were better able to identify risk factors, achieved higher compliance with hygiene, disinfection and anti-sepsis protocols, improved treatment of UTIs in pregnant women. The introduction of a laboratory testing package has improved the precision of diagnosis in many facilities. Finally, there was an 18.4% decrease in the fatality rate of respiratory distress syndrome due to the promotion of antenatal corticosteroid use.
Best practices/conclusions:
The field visits to Jinotega, a successful facility, were an excellent way for the visiting facilities to understand and achieve improvements.
Improved screening may lead to finding an increased incidence of a disease, while decreasing the fatality rate, which is an important achievement. For example, although better screening in the participating facilities detected 7.2% more cases of pre-eclampsia/eclampsia, but the case fatality rate fell by 29.4%. The identification of good indicators is important so that facilities can see these improvements.
In Nicaragua, neonatal sepsis surveillance is based on laboratory tests. By better integrating and organizing the obstetric, pediatric, and laboratory services, facilities were able to reduce the sepsis fatality rate. Especially for neonatal health, integration across these services is key to achieving improved quality of care.
A collaborative should work with a specific, defined set of topics to best address improvement and achieve better quality of care. There can be compromise in the facilities if the content addressed is too broad, and it can also interfere with Ministry of Health priorities.