1. Formação/Actualização de Formadores em COEB e CERN Maputo, 10-21 de Agosto, 2009 Defrief August 24,2009 Gloria Metcalfe - JHPIEGO consultant

2. OBJECTIVES Describe and demonstrate the importance of the implementation of HUMANIZED PRACTICES in the Maternal and Neonatal Health Units. Update the participants to bring a humanized care during ANC, labor, birth assistance, post partum and family planning and MN. complications to improve the care and reduce maternal and neonatal morbidity and mortality. Reinforce clinical training skills of participants to replicate the training in their regions. Prepare participants to implement the “Iniciativa Maternidade Modelo” using SBMR approach.

3. Participants and Facilitators 1st TOT Place: Centro de Formação das Telecomunicações de Moçambique 29 health providers (2 Ob/gyn, 2GP, 25 trainer and assistencial nurses) from CH,GH,IT* Nampula (7), Sofala (7), Maputo (15) city/province Facilitators: 7 MOH and Jhpiego/MCHIP staff and consultant (GM), WHO Practice: HCM, HJM,HCh, CS 1 o de Maio ** *Central Hospital, General Hospital, Institute of Training ** Central Hospital of Maputo, Hospiatal Jose Macamo, Hospital Chamanculo, Health Canter

4. TOT team

5. Methodology and Technical references Participative and competency based (use of anatomic models and checklists) Case study for solving problem Pre and post tests Participants evaluation of the training Clinical practice MOH: Norms/Manuals - Tool of Standards for Maternidade Modelo Jhpiego: TOT and MNC best practices manuals WHO: MNH and RH references

6. Contents MNH situation in Mozambique Basic training skills Rationale of the Humanization of Care Evidence based best practices: - Focused ANC (BPCR * ). - Labor (partograph and emotional support), assistance of birth (squatting/vertical position, AMSTL**, NB care), pp (monitoring) - FP post partum and post abortion - MN complications (PIH, PPH, *** fever, prolonged labor, asphyxia neonatal, premature NB, abortion-VA ) Standard-based management and recognition process *Birth preparedness and complication readiness ** active management of third stage of labor *** pregnancy induced hypertension, post partum hemorrhage

7. Findings MOH was involved all the time Logistic was very good, technical material was available for all participants MOH norms are not updated (i.e.IPH, PPH) Participants were participative and punctual Level of knowledge of participants was good Participants prepared and presented action plans for the implementation of the Iniciativa Maternidade Modelo in their facilities and, to replicate the training at regional level Problem solving, use of scientific evidence and BPCR were unknown topics for participants Competency based approach was also new for most of them Contents of the training were too many; time for practice in models and clients was insufficient Checklists and standards are too long and too many

8. Findings in practice sites Open attitude of the staff for allowing participants to perform the best practices (except one shift in HCM) All participants were able to perform VA,ANC, and PPC * Some participants assist births in the labor room, in different position, using AMSTL and without transfer women to the birth room. Babies were put skin to skin with their mother immediately after born. Some maternal and neonatal complication were successfully identify and managed (PPH, PE ** severe, prolonged expulsive and asphyxia neonatal) *Vacuum aspiration, antenatal care, post partum care ** pre eclampsia

9. Findings in practice sites 2 Too many beds in each maternity room with limited space in between (1mt). There are unused or under used spaces. Illumination and ventilation are inadequate (light can’t be lower and window can’t be closed). Clinical records are incompletely filled in. Monitoring and emotional support of women during labor and post partum progress are insufficient. Poor communication with women in labor. Missed opportunity for provide FP post partum and post abortum

10. Findings in practice sites 3 None of the best practices were properly implemented in the practice sites before training i.e BPCR, IP, use of partograph, birth in different position, NB skin to skin, accompanies, AMSTL, etc) Equipment was insufficient and/or not working i.e B/P cuff, Pinard stethoscope, vacuum, kit for assistance of birth. Lines were insufficient, particularly for drying the NB and to protect the abdomen of the mother. There are not setting emergency trays for women and NBs

11. Conclusions Training gave to participants information and diverse methodology to improve and implement the MNH best recommended practices in a humanized way, following the standards Most of the participants still need coaching to improve their clinical and teaching skills. The implementation of the “Iniciativa Maternidade Modelo” using the SBMR seems to be a very timely intervention to improve all the weaknesses observed in the providers skills as well as in the health system.

12. RECOMENDATIONS 1.Participants needs to be supported in their facilities for the implementation of their action plans. Coaching at the field by primary facilitators team is highly recommended 2. Practice needs to be the main focus during next trainings. It’s highly recommended to assure skills competency and confidence in every trainee. For accomplish that: – Start first with the implementation of the best and humanized practices at their facilities, using the performed standards, and then, plan and conduct the regional trainings – Assure having all the basic necessary equipment and supplies on place, including emergency trays for mothers and babies, before starting the trainings

13. RECOMMENDATIONS 2 – Assure that IP practices are implemented and followed – Reinforce the monitoring of clients and properly filling in the clinical records – Start to reinforce/improve first the main basic skills for prevention and management of more frequent complications: focused ANC, use of partograph, AMSTL, NB/pp care, HIE, HPP and asphyxia neonatal. Then focus in Vacuum, VA, other MN complications – Reinforce communication skills with women

14. RECOMMENDATIONS 3 3.Theoretical contents need to be conducting mainly using cases study and group discussion with emphasis in solving problem, scientific evidence and short presentations with the key points. 4.Simplify and assure coherence between checklists and performance standards 5.Support MOH in updating the EOC norms 6.Regularly follow up, monitoring and evaluation of the performance improvement process (standards)

15. Others Recommendations Test of proteinuria must be available for ANC and in maternities Oxitocyn must be refrigerated 2 – 8° C Kit of birth separated from Kit of episiotomy/repair Linens package for assistance of births need to be prepare Redesign the unused and/or under used spaces of the facilities to improve the women and NB care (ANC and maternity). Organize places that allow pregnant women having labor, birth, NB care and pp at the same place, assuring privacy, space for walking and having accompanies