MCHIP/ZIMBABWE LDHF and Intensive Mentorship: Improving Practice and Patient Outcomes in Zambia Presenter: Samantha Holcombe March 2, 2015

Background  Commenced 1 st October 2011  End date 30 th June 2014  In-country partners:  Jhpiego – Maternal Health  Save the Children – Newborn Health  Context: Key clinical implementing partner of USG-led Saving Mothers, Giving Life endeavor (end date September 2017) 2

Saving Mothers, Giving Life  Conceived as 1-year, USG-led endeavor to reduce maternal mortality by 50% in 4 districts in Zambia → Now, 5-years, 8+ districts  Interventions focus on labor/delivery and immediate post partum period  Service delivery (EmONC)  Facility infrastructure (labor wards, MWHs)  Emergency transport  Demand creation (facility deliveries) 3

Target Districts  Luapula Province (MCHIP)  Mansa  Samfya  Eastern Province  Chipata  Lundazi  Nyimba  Southern Province  Choma  Kalomo  Central Province  Kabwe Phase I Pilot Districts

1)Increase the quality of labor/delivery and postpartum/postnatal care services in MOH facilities in SMGL Districts 2)Build capacity of MOH facilities in Mansa District to increase uterotonic coverage through use of AMTSL in facilities and through distribution of misoprostol for home birth 3)Expand the availability of quality post-partum family planning services in MOH facilities in Mansa District 5 MCHIP/Country Objectives

Key Interventions  Scale-up of EmONC services  Scale-up newborn resuscitation w/HBB approach  Roll-out of misoprostol for postpartum hemorrhage (PPH) prevention  Strengthening of long-acting reversible contraception (LARC) and postpartum family planning (PPFP) services  Development of district clinical mentorship program

Purpose  To build the capacity of MOH and partner staff in SMGL districts to conduct targeted, clinical, on-site mentorship in EmONC, reinforcing practical knowledge and skills, to ensure that clients receive high-quality, improved services which will help reduce both maternal and child mortality

District Clinical Mentorship Program Strategy:  Reinforce skills using “low dose/high frequency” approach  Build capacity of district MCDMCH & partner staff to provide quality mentorship

Mentorship Approach Establishing Mentors  1 week clinical mentorship training, including skills update and on-site clinical practicum  16–20 mentor trainees recruited, including the DMO, DNO, SMGL Coordinator, staff from hospitals and large UHCs, and MCHIP and other maternal health implementing partner staff

Facility Visits  Mentors divided into teams of 2-3 persons with diverse clinical expertise  All facilities visited monthly by mentorship team for at least one full day  Mentor teams arrive in morning and help service clients, taking the opportunity for mentorship with any maternity/newborn clients and freeing health care providers’ time for mentorship in the afternoon

Facility Visits  Review files and registers  Targeted technical assistance  Identify any challenges encountered with EmONC service delivery  Refer to previous month’s action plan  Mentor on focus EmONC function  Assess providers’ skill competency on anatomic models or with clients using skills checklists  Mentors fill out report form for DCMO and MCHIP, develop an action plan to be completed before next month’s mentorship visit

Benefits of Mentorship  Low-cost intervention  Can maximize benefits of complementary, higher-cost interventions  Opportunity for building more sustainable, local capacity  Provides clinical support and long-term morale  Addresses site-specific unique challenges faced by health staff

Outcomes  Immediate and sustained application of skills learned during EmONC training;  Improved provider confidence and morale;  Management of complications at rural health center level that previously were referred to other facilities  Reduced pressure on emergency transport systems and referral facilities  Improved outcomes for pregnant women

Key Achievements  In Mansa Y6 Q2, 100% of pre-eclampsia cases and 95% of PPH cases were treated according to clinical guidelines  From baseline to Y6 Q2, use of the partograph increased from 6 to 45 percent

Care Meeting National Standards— Pre-Eclampsia, Mansa District

Care Meeting National Standards— Eclampsia, Mansa District

Keys to Success  Strong ownership by the local DCMO  Diverse partner involvement and collaboration  Proper training in mentorship skills  Use of anatomic models for on-site clinical simulations  Ongoing assessment of providers’ EmONC skills even in the absence of live client cases

Lessons Learned  Mentors’ clinical skills should be routinely assessed  Simple, user-friendly tools help to ensure program success  Monthly targeting of specific EmONC skills with anatomic models ensures skills remain sharp  Peer mentorship through facility exchange visits is critical and can significantly improve service delivery

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