1. “Scaling Up Best Practices in Jordan” Low Cost, Underutilized Technologies to Reduce Maternal Mortality in Jordan By Sabry Hamza MD, Dr Ob/Gyn Chief of Party Health System Strengthening Project Amman - Jordan

2. 2 Highlights on Jordan

3. 3 Highlights on Jordan “DHS 2007” Total Area (sq. km) 89,287 Total Population 5.7 million Total Fertility Rate 3.6 Less Than 15 Years Old 37.3% CPR (Modern) 57% (42%) MMR 41/100,000 live births IMR 19 per 1000 live births Illiteracy Rate (=>15) 9% Life Expectation (M, F) 71.7 (70.8, 72.5)

4. 4 Selected Best Practice Use Magnesium Sulfate for all patients with pregnancy induced hypertension in all public hospitals in Jordan. Magnesium Sulfate is the anticonvulsant of choice for treating eclampsia; more effective than diazepam, phenytoin, or lytic cocktail. Although it is a low cost effective treatment, Magnesium Sulfate was not available in MOH hospitals in Jordan.

5. 5 Global Burden of Pre-eclampsia / Eclampsia Recent estimates developed by WHO indicate that the incidence of pre-eclampsia is estimated at 3.2% of live births, giving a total number of over 4 million cases each year, of which over 72,000 were fatal.

6. 6 Problem in Jordan The Jordanian National Maternal Mortality Study 1995/1996 highlighted that “hypertensive disorders with pregnancy” is the first most common direct obstetric cause of maternal mortality representing 27.8% of direct obstetric deaths and 20% of all maternal deaths.

7. 7 Gaps Magnesium Sulfate was not available in MOH hospitals. Service providers were not trained on the use of Magnesium Sulfate. Scaling up its use for eclampsia and severe pre-eclampsia will contribute to reduction of related maternal deaths.

8. 8 Interventions to Address Gaps Interventions to Address Lack of MgSO4: Correct immediate shortage: Correct immediate shortage:  Advocated to the Minister of Health.  Emergency purchase procedure adopted. Economies of scale through purchasing needed quantities for 5 years: Economies of scale through purchasing needed quantities for 5 years:  Established a committee to project the need.  Developed feasible alternatives to current purchasing process. Interventions to Address Capacity Building:

9. 9 Interventions to Address Gaps (cont.) Evidence Based Clinical Guidelines Developed:

10. 10 Competency Based Training for Service Providers (Classroom & OJT): Interventions to Address Gaps (cont.)

11. 11 Clinical Performance Monitoring Checklist for Pre-eclampsia / Eclampsia: Interventions to Address Gaps (cont.)

12. 12 Progress to Date

13. 13 Lessons Learned Didactic training alone does not change providers’ attitudes and behaviors. Most providers adopt clinical protocols and master skills after on-the-job training with expert. Application: Application: Continue to use the CBT methodology with a special focus on OJT through a highly qualified and extensively experienced team of local trainers.

14. 14 Lessons Learned (cont.) Training of service providers following the classic teaching approach sometimes faces challenges and resistance from their side to apply what they have learned. Application: Application: Build the capacity of service providers to review the literature and look for the valid reliable technical knowledge and integrate that knowledge into their clinical practice through adopting evidence based medicine.

15. 15 Lessons Learned (cont.) Establishing safe motherhood committees at MOH hospitals proved effective to ensure availability of Magnesium Sulfate and oversee its utilization, but lacks sustainability and central level support. Application: Application: link the committees with the quality directorate at central MOH and advocate for the formulation of a central safe motherhood committee to provide necessary formal support and institutionalize the use of Magnesium Sulfate nationwide.

16. 16 Conclusion “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving”. Prof. Mahmoud Fathalla – from Egypt FIGO Past President

17. 17 New 7 Wonders of the World Chichenitza, MexicoColosseum, Italy Taj Mahal, IndiaGreat Wall of China Christ Redeemer, BrazilMachu Picchu, PeruPetra, Jordan

18. 18 Thank You