Decentralising Maternal Care In Fiji Dr James Fong Chairperson Obstetrics and Gynaecology CSN

Health Care Pyramid District Hospital Subdivision al Hospital Health Centres, Nursing stations Family/Community Quality Referral Quality Mentorship/Supervision MIDWIFERY SKILLS

Challenges to Safe Motherhood Decentralisation Obstetric Complications occurs in 15% of pregnant women and can neither be predicted nor prevented Care for women with Obstetric Complications is an inpatient activity and requires a functioning health service

Challenges to Safe Motherhood Decentralisation AMDD requires timely access to Basic and/or Comprehensive EmOC – Functioning referral system – Quality of Care Trained Staff in Post 24 hour Coverage Essential Drugs and Supplies

Challenges to Safe Motherhood Decentralisation Inappropriate Deployment and rapid turn over of staff Poor maintenance of Equipment Interruptions in essential drug supplies Poor Management and Morale Lack of Sustainability especially with external donor support Lack of integration and co-ordination between district hospital and primary care services

CSP Service Delivery Roles Divisional Hospital (Mother Safe and Comprehensive EmONC compliant) – Low and High Risk ANC – Low and High Risk Intra-partum Care – Low and High Risk Postpartum Care Subdivisional Hospitals (Mother Safe and Basic EmONC Compliant) – Low Risk ANC – Low Risk Planned Intra-partum Care – MCH Clinics Health Centres And Nursing Stations (Mother Friendly Facilities) – Low Risk ANC – Low Risk Unplanned Intra-partum Care – MCH clinics

Limitations to Decentralising Services Workload In Fiji Impact of Urbanization – Divisional Hospitals will always have a large catchment population thus require high levels of resourcing to ensure safe services – Peripheral faciities need a critical level of workload and ongoing mentorship and support to ensure safe services

10/12/2015 BIRTH BY FACILITIES BEFORE AND AFTER CSP FACILITY DIVISIONAL HOSPITALS 62.9%72.7% SUBDIVISIONAL HOSPITALS 33.6%25.0% HEALTH CENTRES AND NURSING STATIONS 2.3%2.1% TBA1.0%0.1%

Emergency Obstetric Care Health Facility Survey Defined gaps in service resourcing and provision None of the SDH were basic EmONC compliant Since then – 5 SDH equiped by UNFPA – 11 SDH will be equiped via FHSSP and MOH – Health Centres – delivery Kits

Obstetric Operations Centre Concept In All Divisional Hospital Evolving The Divisional Hospital Morning Rounds – Midwifery driven – Midwifery networking to foster midwifery skills Communication Stretagies Agenda – Track all pregnancy related admissions – Facilitate and promote timely review plans – Premptively stabilize referral logistics and ensure timely referral

Outreach Support Visits At intra-divisional and inter-divisional level 3 core components – Practice Support – Audit – CME Models based Drills

CWM Hospital Deliveries 2013 January 640 Feb645 March899 April861 May875 June800+

EmONC Workshops Fiji EmONC Course – Evolving since 2006 and has incoporated ALSO principles – Models based training – Accreditation structures FNU/MOH initiatives – west and north

10/12/2015 Indicators Proportion of targeted sub-divisions that have adequate number of staff trained in obstetric care, reproductive health and family planning. Proportion of targeted facilities adhering to the Obstetric Emergency Protocols Manual

10/12/2015 Indicators Proportion of sub-divisional hospitals that meet “Mother Safe Hospital Initiative” accreditation standard Proportion of targeted facilities audited each year against “Mother Safe” standards Proportion of deliveries carried out in sub- divisional hospital or higher level institutions, disaggregated by level (Divisional Hospital vs. Sub-Divisional Hospital).

10/12/2015 STATUS SO FAR IN FIJI >90% of women will – attend > 4 ANCs – deliver in a facility that can be easily made mother safe >80% maternal and perinatal morbidities and mortalities will occur in a hospital – do most sick patients will reach an appropriate point of care?

Health Care Pyramid District Hospital Subdivision al Hospital Health Centres, Nursing stations Family/Community Quality Referral Quality Mentorship/Supervision MIDWIFERY SKILLS

10/12/2015 Take Home Message Prud’homme (1994) “decentralisation measures are like some potent medicines; they must be taken at the right time in the right dose, and for the right illness to have the desired salutary effect. Taken improperly, they can harm rather than heal”