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Integrated Family Planning and Emergency Obstetric and Neonatal Care in Uganda Dr.

Salwa Bitar, E2A, STRIDES (MSH) and ASSIST (URC)


Global Technical Meeting Throughout the Reproductive Health Course, April 2-3, Washington, DC

E2A-STRIDES-ASSIST Partnership
- STRIDES: led by Management Sciences for Health (MSH) in Uganda to build capacity in MCH, FP-RH, nutrition, and malaria interventions in 15 districts. - Evidence to Action (E2A): USAIDs global flagship for strengthening FP and RH service delivery and scaling up best practices. - E2A-STRIDES partnership is based on applying global approaches within a local context. E2A offers short-term TA to support STRIDES to introduce, implement, synthesize, and document Improvement Collaborative results. - ASSIST is URCs quality improvement (QI) project, which collaborates with STRIDES in two saving mothers giving life districts.

Objectives of Presentation
Emphasize the importance of using the Improvement Collaborative (IC), a systematic approach for scaling up a FP/maternal and newborn health (MNH) package. Share field experience and process of integrating FP services into Essential Obstetric and Neonatal Health (EONH) services. Share QI changes, results, challenges and lessons learned from using the IC to integrate FP in immediate postpartum MNH services in Uganda.

Significance/Background for Intervention in Uganda


Maternal mortality: 438/100,000 Neonatal mortality: 27/1000 Contraceptive use: 30% High unmet need for FP: 34% Missed opportunity to offer PPFP: 57% of deliveries are facility based (UDHS 2011) DHS data from 27 countries: 65% of women 012 months postpartum have an unmet need for FP.

The Improvement Collaborative


Improvement Collaborative (IC): An organized network of a large number of sites that work together for a specified period of time to achieve significant improvements in a focused topic through shared learning and intentional spread methods.
Essential features
Improvement objectives Organizational structure Initial implementation package Spread strategy QI teams Monitoring system Coaching system Shared learning Tested implementation package

Process: Introducing the IC to Integrate FP in Immediate Postpartum Care


In March 2012, QI teams from 10 facilities in two districts developed a QI workplan using the IC methodology. In June 2012, the process was expanded to an additional 36 facilities in 8 new districts. QI teams agreed on the improvement objectives, the implementation package and data collection (baseline and monthly progress data). Existing standards, job aids, checklists, clinical tools, and indicators utilized to build capacity in clinical aspects. Coaches trained in facilitative supervision, tools, indicators, data.

Uganda QI Teams Develop Action Plans (March 2012)

Patient Flow and Infrastructure

Package of Best Practices Introduced through the IC


Essential Obstetric Care: measured through Partograph use and active management of third stage of labor (AMSTL) Essential Newborn Care (ENC): measured through 7 ENC elements (immediate breastfeeding, keeping baby warm, cord care, etc.) Immediate Postpartum FP Counseling and Services

Illustrative QI Changes by QI teams


Implementation and adherence to MCH evidence-based standards Improved registers and data collection Internal reallocations of drugs to address stock outs QI teams made photocopies of Partograph tool to address shortage. Skilled providers offered on-the-job training on long-term FP methods to their peers in other sites. Documentation journals and flow charts used to measure changes and improvements . Experience sharing between QI teams on quarterly basis, accelerated problem-solving

Partograph Use
PARTOGRAPH USE PHASE I AND PHASE II Facilities
80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2 months prior to implementation 6 months after implementation 12 months after implementation Phase I Facilities (9) Phase II Facilities (35)

Essential Newborn Care


APPLICATION OF ENC PHASE I AND PHASE II FACILITIES
100.0%
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2 months prior to implementation 6 months after implementation 12 months after implementation Phase I Facilities (10) Phase II Facilities (35)

Immediate Postpartum FP Counseling


PPFP COUNSELING PHASE I AND PHASE II Facilities
70.0% 60.0%

50.0%

40.0% Phase I Facilities (9) 30.0% Phase II Facilities (31)

20.0%

10.0%

0.0% 2 months prior to implementation 6 months after implementation 12 months after implementation

Immediate Postpartum FP Uptake


PPFP UPTAKE PHASE I AND PHASE II FACILITIES
7.0% 6.0%

5.0%

4.0%

3.0%

Phase I Facilities (10)


Phase II Facilities (31)

2.0%

1.0%

0.0% 2 months prior to implementation 6 months after implementation 12 months after implementation

Challenges/Solutions: FP counseling & uptake


Provider bias and low competency in PPIUD Womens lack of awareness about immediate PPFP Solutions: On-the-job training to providers QI teams encouraged to link with community and ANC STRIDES has introduced PPIUD insertions and emphasized documenting LAM acceptance and referral to outpatient services

Lessons Learned
The IC empowers teams to explore simple and locally generated solutions rather than relying on the central level. Systematic approaches for scaling up best practices accelerate the scale-up of high-quality services. The IC can be introduced at any time during program implementation.

Programs can use the IC to accelerate local capacity building, empowerment, and institutionalization.

Thank you!
For copies of this presentation or for additional information, please contact: Salwa Bitar sbitar@e2aproject.org

1201 Connecticut Avenue NW, Suite 700 Washington, DC 20036, USA WWW.E2APROJECT.ORG

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