Niger Essential Obstetric and Newborn Care Collaborative

Sponsors/partners:

Ministry of Health Department of Reproductive Health, USAID HCI Project, UNICEF, and WHO

Date improvement activities began:

January, 2006

Date of end of collaborative:

December, 2008

Aims/objectives:

To scale up high-impact quality maternal newborn child health services for leading causes of mortality

Implementation package/interventions:

The Niger EONC Collaborative has been implemented in phases. In phase 1 (completed in December 2007), the collaborative introduced basic infection prevention; Active Management of the Third Stage of Labor (AMTSL) (including administration of Oxytocing, controlled cord traction, and uterine massage after delivery of the placenta; and Essential Newborn Care (ENC) to sites. In phase 2 (beginning in 2008), the collaborative introduced systematic anti-malarial Intermittent Preventive Therapy (IPTp) during antenatal care and a phased complications care improvement intervention targeting pre-eclampsia/eclampsia and maternal and newborn sepsis. Because AMTSL and ENC were not part of Ministry of Health practice prior to the collaborative, training reinforced by on-site supervision has been an important part of the collaborative's intervention. Training is conducted on-site as part of a "whole-site model" in which all maternal health providers are trained in unison by regional trainers using standard provider job aids and a training manual developed in consultation with the collaborative's expert group.

Measurement:

The EONC collaborative started with a minimal set of indicators that were developed and approved at the same time as the EONC norms. The indicators were field-tested to ensure that data required were available. The indicators include 5 indicators for AMTSL, 5 for newborn care, and one for infection prevention. The key indicators for the collaborative were:

% births in which all 3 elements of AMTSL were applied
% births with immediate breastfeeding occurred
% compliance with AMTSL standards (composite)
Post-partum hemorrhage rate (PPH) (# PPH/ # births / month)
% newborns for whom ENC standards were met

Spread strategy:

The collaborative was started at national scale in 7 of Niger’s 8 regions. The collaborative expanded in February 2007 to an additional 11 primary care maternities in the same regions. Beginning in August 2008, UNICEF will fund the MOH to scale up the Phase 1 EONC Collaborative interventions to all remaining district, regional, and national hospitals in the country.

Number of sites/coverage:

Phase 1 of the collaborative was originally launched in 28 reference maternities (representing 77% of national/regional and 62% of district hospitals in 7 of Niger's 8 regions). In February 2007, the collaborative expanded to include an additional 11 primary care maternities, covering 39 total maternity care facilities in 64% of Niger's districts. These facilities accounted for 32% of public facility births (45,760 births) in 2007. Phase 2 of the collaborative was launched in 37 health facilities (primary and reference) in January 2008, including analysis of baseline assessment and on-site training of over 300 providers.

Coaching:

Local teams receive regular on-site training that integrates technical and QI skills so that participants learn to problem-solve to reduce obstacles to implementing new standards in their local settings. Bimonthly supervision visits by regional MOH "external coaches" with technical support from HCI staff provide ongoing reinforcement to individual site teams.

Learning sessions & communication among teams:

Best practices and results are shared during quarterly "Learning Sessions" and disseminated to all participants country-wide. During quarterly regional Learning Sessions, local midwives and doctors from different sites share best changes for rapidly integrating AMTSL, ENC, and improved infection prevention practices into routine delivery care. A written summary of most effective changes identified at the regional level is shared among all collaborative participants so that individual sites can adopt successful innovations that have been tested by other sites. A national learning session was held in August 2007 with national and regional health officials and coaches to synthesize results and best practices from all the teams participating in phase 1 of the collaborative.

Results:

In its first two years of implementation (phase 1), compliance with AMTSL and ENC standards has improved from 0% and 17% at baseline, respectively, to 98% and 96% in targeted facilities as of December 2007. The proportion of births given immediate breastfeeding has increased from 23% at baseline to 98% in the same period. Most importantly, the incidence of post-partum hemorrhage in participating facilities was reduced from 2.1% of births to 0.4%, a dramatic drop in this life-threatening condition. The reduction in post-partum hemorrhage rates has been a powerful local motivator for sustaining systematic AMTSL practice in the face of the huge challenges posed for health care workers by sudden post-partum hemorrhage.

Best practices/conclusions:

Service reorganization:
In all sites, maternity patient flow had been re-organized by the site QI team to promote more efficient circulation for pregnant women who arrive for evaluation and care (designated labeled rooms for initial evaluation, labor, delivery, and post-partum monitoring), including designated staff for each point of care.
In most sites, a 24-hour call schedule has been instituted to ensure the presence of a skilled birth attendant in the maternity facility at all hours. Prior to launch of the EONC collaborative, matrones had performed a substantial proportion of births even in the larger district hospitals (especially after routine work hours), with the result that the skilled provider had to be "called in" for an emergency.
In most sites, facility maternity rooms have been reorganized to include a separate labor and delivery room, including introduction of "privacy partitions" to promote increased privacy. Prior to the collaborative, women had often labored and delivered in a single room without privacy barriers in many sites.
In many sites, midwives and matrones have been reorganized into 2-person teams (especially in the larger hospitals with more adequate staffing) to promote improved immediate post-partum integrated maternal and newborn care.
In most sites, a designated staff person had been assigned to track and manage stock of essential inputs and medications (e.g., sterile delivery kits, Oxytocin, infection prevention materials (color-coded buckets for instrument decontamination, eau de Clavel), eye ointment, etc.

Note: As in many countries, lack of human resources and staff mobility presents an ongoing major challenge for the Niger EONC collaborative, interfering with optimal QI team functioning and site-level achievement of EONC phase 1 standards. Inputs:
In many regions, the regional MOH gestionnaire has assumed responsibility for ensuring continuous stock of Oxytocin through central MOH and partner supplies.
In most sites, a large cooler had been placed in delivery rooms to ensure maintenance of a cold chain for Oxytocin in a setting of frequent power outages.

Monitoring
The current national partogram record does not include many elements of ENC or any elements of AMTSL. The EONC collaborative Expert Group elected early on to introduce a 'rubber stamp' into all collaborative site partograms to monitor new AMTSL and ENC interventions while awaiting the pending revision of the national partogram by the MOH.

Region and Country: Niger