A Community Based Surveillance System for Maternal and Early Neonatal Complications: The Intibucรก Case Study
Rosales A. Catholic Relief Services, Program Quality and Support Departments, Baltimore, Maryland USA Galindo J. Catholic Relief Services/Honduras Flores A. Secretary of Health, Honduras
Abstract:
One determinant for the prevailing health inequalities in the developing world is the inappropriate or lack of health information, especially in rural areas. New and innovative methods for collection of information in developing countries have recently been developed and implemented by countries such as China, Tanzania, and India. Notwithstanding these efforts, maternal generated data remains one of the most neglected areas. This paper describes the development of a population-based health information system designed and implemented by CRS in the rural areas of Intibucรก, Honduras. The main objectives of this system were: first, to estimate the magnitude of maternal and early neonatal health problems in the population of pregnant women and newborn children; second, to document its distribution and spread at a population level; and third, to evaluate the impact on maternal and neonatal mortality of an intervention utilizing traditional birth attendants for risk assessment, first aids in obstetric emergencies, and management of an emergency transport system. The collection, analysis, and dissemination of health data and information were designed to support the decision making at the community level and the entire system was sustained by community structures. Additionally, the paper describes the various steps taken by the program in the design phase of the system; its training methodology, its implementation and information flow within the system, and it provides an in-depth description of the supervision methodology and used approach, as well as an innovative approach to promote the utilization of information at all levels of the system. The case study, also presents an example of maternal-related indicators with potential use in the management of the program at local and national levels. The authors of the paper concluded that maternal information to prioritize, plan, implement, and sustain effective intervention strategies can be produced and sustained by community structures at a low cost, that this information is useful for health planning and policy development at district and national level, and that the information produced
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complies with WHO standards. The implementation of information systems at population level could be a factor in decreasing health inequalities in developing countries.
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A Community Based Surveillance System for Maternal and Early Neonatal Complications: The Intibucá Case Study.
Introduction:
In developing countries inequalities in health are overwhelmingly prevalent. Health care between rich and poor, urban and rural, adults and children, female and male, is just not the same. It is better for some, and worse for others. Determinants for these differences are many, but one of them, especially in rural areas, is without a doubt: lack of information.
One important limitation in
addressing global and developing country health status is the limitation of available measures of global-country health status. In this 21st century, less than 90 countries contributed age and sex death statistics and cause specific death statistics to the latest WHO data bank.1
Less than one third of the world’s
population is adequately covered by national vital registration systems and there is a wide regional variation ranging from 80% population coverage in the European region to less than 5% population coverage in the Eastern Mediterranean and African regions of WHO. Hence, many public health experts have questioned the process by which countries and international agencies are producing relevant and responsive health policies at national and global level. Given this picture, some developing countries are resorting to new and innovative methods to collect this type of data. Since 1992, Tanzania initiated a demographic surveillance system2 to monitor health and poverty status at national level. This “sentinel” system generates a wide range of indicators from a sample of 500,000 persons, with a cost of only US $ 0.20 per person. In China, provincial authorities have provided death data on a routine basis for the past decade from a nationally representative system of 145 disease surveillance centers covering 1% of the total Chinese population.3 Similar attempts have World Health Report 2003: Making the future. WHO: Geneva 2003 Mswia R et al. and the AMMP Team. Dar es Saalam demographic surveillance system . In: The INDEPTH Network. Population and Health in Developing countries. Vol. 1: Population, Health and Survival at INDEPTH sites. Ottawa, International Development Research Centre, 2002:143-150 3 Lopez AD. Counting the death in China: measuring tobaccos impact in the developing world. BMJ 1998; 317: 1399-400 1 2
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been made in India where, through multiple channels (Sample Registration System and retrospective half-yearly population surveys), a high coverage of all deaths (estimated at 95%) has been achieved.
Honduras, where this case study took place, according to reports in the last decade is estimated to have at least a 40% under-reporting of mortality data. The under reporting is especially severe for maternal-related deaths and acutely tilted towards rural areas. It has been very well documented through many reports the acute inequalities in health that takes place in the American continent. Health inequalities between urban and rural communities in Honduras are abysmal. In an effort to bring this inequality to a halt, Catholic Relief Services (CRS) started implementing during 1999, in conjunction with a local agency (COCEPRADII), a child survival program funded by the United States Agency for International Development (USAID) in the rural areas of IntibucĂĄ, Honduras.
The four-year program spends 35% percent of program effort on “safe motherhood and newborn care� interventions, the objectives of this component were to improve the ability of women, families and traditional birth attendants (TBAs) to recognize/prevent, and respond to obstetric complications; and to improve the ability of women, families, and TBAs to access first-level referral facilities in the event of obstetric complication. In this area of Honduras, where UNICEF estimated a maternal mortality rate of 534 per 100,000 live births, and where 83.5% of deliveries occur in the home, a community based health information system (CB-HIS) was the first step in the process of improving access to, and adequate maternal care.
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Purpose of the Health Information System:
The main objectives of the health information system were to estimate the magnitude of maternal and early neonatal health problems in the population of pregnant women and newborn children, to document its distribution and spread at a population level, and to evaluate the impact on maternal and neonatal mortality of an intervention utilizing traditional birth attendants for risk assessment, first aids in obstetric emergencies, and management of an emergency transport system. The program considered this model a communitybased HIS since the collection, analysis, and dissemination of health data and information were designed to support the decision making at the community level.
Development of the System:
Design: the surveillance system was designed by CRS health technical officer at headquarters in collaboration with the Honduras field office. Health staff from the Ministry of Health and community resources started to take part in the system design after the second step was finalized.
First step: The first step taken was to define
Steps in the Design Phase
specific information needs; specifically, what do we want to know? One principle applied in this step was to carefully include information that would have implicit action, information with a purpose. Thus, the system does not become overwhelmingly filled with “nice” but useless information that eventually causes
• • • • • •
Establish objectives Develop indicators Develop or adapt datacollection instruments Field-test instruments Develop dissemination mechanisms Assure use of analysis and interpretation
the entire system to become unmanageable.
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Second step: Once information needs, based on the objectives of the system, were defined, the program’s team worked on developing health indicators that would comply with program information needs. Numerators and denominators were also defined, and their collection feasibility assured. In this case in particular, many of maternal indicators were already being defined during the program development phase, but even these were subject to revision given local reality and program needs.
Third step: once indicators were defined, the field team started gathering information regarding locally designed data collection tools. The program was basically looking for a tool with two characteristics, simplicity and sustainability. After considering various models, the program adopted a data collection tool developed by University Research Corporation/Quality Assurance Program for the Hondurans’ Ministry of Health. The tool had been designed to collect maternal information at the community level, and to be used by individuals with limited educational skills. Thus, the tool was of simple use and integrated into the ministry of health information system. After its selection, the tool then went under a process of adaptation, in which program staff and stakeholders from the communities revised the tool to satisfy program requirements. The tool (Listado Comunitario de la Salud Materna) collects 16 pregnancy-related variables and it has drawings incorporated to aid those community resources with limited literacy skills.
Fourth step: The team proceeded to probe the effectiveness of the tool in supplying the information needed by the program and its user- friendliness, thus a small group of TBAs was trained to use the tool on a small scale and report back to the team. The tool was adapted based upon recommendations from users during the probing period.
Fifth step: During the next phase, program staff with support from an adult educator expert proceeded to design the training content and methodology for
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trainers of trainers and community resources. Likewise, during this period the staff determined the flow of information within the system. During an evaluation after one year of implementation, it was noted that information collected was not been used by all levels in the system for program management purposes, therefore a sixth step in the system design was added.
Sixth step: Assure use of analysis and interpretation. With support from the health STA at headquarters, the program identified criteria for decision-making at each operational level, from the household to headquarters level for interpretation and use of information. The process utilized in this step is discussed in the section “programmatic use of information�.
Training methodology: The training on the HIS for this program was done in two phases. During the first phase, all program personnel (field supervisors and health educators) received a 4-day training. The training used an adult education approach, based on experiential reflection and group discussions. The content of the training included a general concept of a health information system, programmatic
needs
of
information,
information
utilization
in
program
management, strengths and weaknesses of a health information system, and differences between monitoring and evaluation. In the first topic concepts related to goals and objectives, indicators, and monitoring and evaluation were reviewed and discussed. During the programmatic needs of information, participants discussed the need of information for management purposes, assessment of program activities and readjustment in response to program information. Also in this section other topics for discussion were program benefit distribution, financial assessment, and program limitation and responsiveness to local needs.
An
exercise to analyze potential users of program information was done, followed by a presentation on the qualities of an information system in terms of credibility, precision and opportunity, result attribution, relevancy, and representativeness. Technical and operational limitations of an information system were also examined with the participants. The last part of the training content dealt with
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monitoring and evaluation information needs vis-Ă -vis the various phases in program implementation.
A second part of the training included working groups to determine specific program information needs based upon program indicators, and identification of local information sources at community and health facility level. Based on this process, the last day of the training the group adapted HIS tools and standard format reports.
During the second phase, program staff (health educators) trained the TBAs on the utilization of HIS tools. During an initial stage a 3-day training was implemented for the TBAs; followed by weekly home-visits to review use of datacollection forms and limitations in its utilization by TBAs.
The training was focused on proper utilization of the data collection tool and information for decision-making. A very important part of the training methodology was the field visits to localities where the TBAs were collecting data and accompaniment on this process. This accompaniment was intense during the first month after the training, once the appropriate use of the data collection instrument was assured program personnel relaxed individual accompaniment of TBAs. In those cases in which serious limitations in the use of the instrument were identified, a peer-to-peer approach was utilized, in which more experienced TBAs visited less experienced ones until capacities were improved. There were few cases in which due to serious literacy limitations the TBAs were found to have serious limitations in the use of the instrument. In these cases, program staff identified and selected a literacy-able person in the community to assist the TBA in data collection activities (in many occasions the TBA would select this person, which in many cases ended up being a relative of the TBA with literacy skills).
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Each Month, health officials and program personnel with the TBA held a meeting in the health facility during which the information collected was reviewed. The meetings emphasized a process of analysis and reflection on real situations experienced by the TBAS during that period of time, how situations were addressed, what limitations were encountered, and possible solutions were discussed.
How the system works:
The system is initiated by the identification of a pregnant woman. The local traditional birth attendant does this identification. Once the woman is identified, the data collection tool is applied. This tool collects the number of pregnant women in the village; status of prenatal care; age of the pregnant woman, presence of complication, its period of occurrence (prenatal, delivery, postpartum), and type of complication; referral and its causes; place of delivery and by whom; outcome of pregnancy (dead or alive) for both mother and newborn, as well as cause of death (see annex 1). The tool collects enough data to produce 6 out the 17 indicators for monitoring progress in achieving reproductive health goals4 recommended by the World Health Organization, UNICEF and UNFPA. See box 1.
Box 1. Indicators for monitoring maternal health collected by the Intibucรก maternal surveillance system 1. 2. 3. 4. 5. 6.
Maternal Mortality ratio Percentage of women attended, at least once during pregnancy, by skilled health personnel for reasons related to pregnancy Percentage of births attended by skilled health personnel Number of facilities with functioning basic essential obstetric care per 500,000 population Number of facilities with comprehensive obstetric care per 500,000 population Early Perinatal Mortality rate
4
July 2000 inter-agency revision added two new indicators to the list of 15 defined during the 1996 inter-agency consultation, involving WHO, UNICEF, and UNFPA. 10
Information system flow: the second step in the development of the system was to determine how the information would flow between the different levels as well as how this information would be utilized at these various levels. As observed in figure one, the traditional birth attendant collects the information from a pregnant woman in the community. On a monthly basis, the TBA reports this information to the next level, the health educator. At this level the information from various TBAs is tabulated using a formatted report. The report is subsequently delivered to the next level, the field supervisor, and a copy is shared with the local health facility. The supervisor tabulates information from various health educators to produce a report of his/her area of supervision. The program manager then collects this report, and shares a copy with the health region officer from the ministry of health. The CRS’ program manager aggregates monthly data to produce a quarterly report, which is submitted to CRS’ program quality and support department in headquarters (Baltimore). The health officer in headquarters uses these quarterly reports to develop an annual report, which examines variables associations and trends.
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Figure 1. Community reproductive health information system flow, Intibucรก, Honduras.
Case report source
Traditional Birth attendant
Program Health Educator
First level HF-MoH
Program Field Supervisor
CRS-Program Manager
Health District-MoH
CRSHeadquarters
Supervision: the supervisory approach in the program was conceived and applied as a support activity. Every effort was taken in the program to avoid police-approach supervision. The system supervision had various levels, with each level having a clear set of supervisory activities and responsibilities. At all levels the supervisory methods applied were observation with checklists, field visits, work plans reviews, and report analysis. Supervisory activities counted at
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each level with skill specific-checklists to aid in the implementation of supervisory activities.
In the first level of supervision, the health educator supervised the local level of data collection (TBA). This supervision was done on a monthly basis, and it had three main objectives: a) To review the information system b) To analyze maternal health status in the locality based upon the information collected, and c) To provide skill-related continued education to the TBA. The health educator reviewed each data collection form submitted by the TBA and corroborated that the form had been adequately filled. When a form was identified with errors, the health educator contacted the responsible TBA and supported him/her in correcting the mistake. Also, during each supervisory visit the health educator applied a skill-specific checklist to assess through observation how the TBA was implementing an obstetric-specific skill.
Those TBAs identified with major
technical or administrative needs during supervision were visited more frequently. Each health educator had 6 or 7 TBAS under their supervision. Based on information collected during supervisory visits a technical support agenda was developed to be implemented on a monthly basis at the health facility monthly meetings. Each month, a meeting with community health resources (TBAs) was held at the health facility. During these meetings, the TBAs would use their health registry (listado comunitario) collected during that month and submit it as a report to the local health facility. Health facility personnel would use this registry to update their official health information system. Also during these meetings a maternal mortality cause analysis was done in those communities in which a maternal death had occurred during the previous month. Communities with identified maternal deaths would receive a joined CRS-MoH field visit, which would provide information on how to prevent maternal deaths in the community.
In the second level of supervision, the field coordinator accompanied the health educator in field visits. Each field coordinator supervised 5 or 6 health educators. During this visits the field coordinator reviewed a sample of data collection forms
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from each health educator to assure data quality. Also a supervisory checklist was applied in each visit with individual support supplied. Common challenges identified during these visits were addressed during monthly group meetings.
In the third level of supervision, the health coordinator in collaboration with the program manager supervised three field coordinators utilizing the same methodology, but mostly focused on improving supervisory skills. On a monthly basis, meetings with technical personnel were done for activity planning and performance analysis. Data analysis and Interpretation: the main purpose of a MIS is to have information for the management of a program5. Analysis of collected data is an intrinsic piece, and the first step in information usage; it is an essential prerequisite for programmatic management decisions. In the case of Intibucรก, the information system systematically collected, analyzed, and interpreted ongoing information about maternal and neonatal health status at the population level for use in the planning, implementation, and evaluation of community maternal interventions.
In its more simplistic way, data analysis refers to the aggregation of information collected, whereas interpretation conveys the action of assessing the emergence of patterns in the information collected. The aggregation phase of data collected took place at field level (health educator/field coordinator/program manager). Data interpretation in the system took place progressively from simple to complex interpretation at program manager and headquarters level. The Intibucรก information system was descriptive in its nature, providing the What, Who, When, and Where of maternal health related events in the rural communities of Intibucรก. Data was organized and summarized according to time, place and person.
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Guide for Program Managers in Developing Simple, Participatory Systems to Enhance Use of Data for Decision Making. Catholic Relief Services 1999 14
The Intibucรก program managers (CRS/COCEPRADII) carried out on a monthly and quarterly basis a descriptive analysis of data collected at the community level. Additionally, an assessment of achievement of field personnel monthly objectives was done. The Intibucรก health team in collaboration with CRS headquarters created a database on EPI-INFO 2000 and Microsoft Excel with information collected on the maternal-neonatal component. Using this database CRS Honduras produced and submitted a quarterly report to CRS headquarters. This report included the computation of frequencies and percentages on variables such as prenatal care, pregnancy by age group, deliveries by locus, maternal and neonatal death rates etc. CRS headquarters used these quarterly data to further its analysis in finding trends and associations amongst variables. Based on these analyses a two- years report was produced and used in an impact evaluation of the program6.
At the local level, program managers held a monthly meeting with program staff to present descriptive analysis and monthly objectives achievement per municipality. Likewise, every four months, a community meeting was held to present data on maternal and neonatal status in the respective communities. This meting was held during a weekend and attended by the entire community, municipal leaders, local ministry of health staff and health program personnel (CRS-COCEPRADII). The information was communicated verbally and with support from visual aids to encourage participation from illiterate community members. During these community meetings, participants were expected to participate in problem-analysis and discuss and propose feasible solutions to the problems analyzed.
Programmatic Use of Information: one of the main objectives of CRS health programs worldwide is to empower communities to manage their health as part of the development process. As such, building capacity at community level to use
6
Anderson et al. Final Evaluation Report Community Based Child Survival Program CRS Intibucรก Honduras. December 2003. 15
relevant health information to make decisions is a fundamental aspect in the empowerment process. A review of the Intibucá CB-HIS highlighted the fact that the system
was operational and producing
the
expected
information,
nonetheless, use of this information by the various programmatic levels involved in the program was limited 7. The recommendation by this review was to identify the criteria for decision-making at each operational level: TBAS followed by health educators, field supervisors, and finally, CRS managers. During that time it was stipulated that community members and staff from the ministry of health would be involved in this process of setting criteria for decision-making as well as in the regular assessment of decision-making that would follow. Hence, criteria for decision-making and related information needs were defined for each level of the system, starting with decisions at household, followed by decisions at the TBA level, health educator, field supervisors and managers. See figure 2.
The program followed the traditional steps in the decision making process8: •
Define the problem or decision to be made: at each level, starting with the household, the program staff defined in accordance with information collected vis-à-vis program objectives, what type of decisions were expected to be taken at each level.
•
Determine who will use the data/information gathered: from the beginning of system design the different levels of information use were determined. Use of information even at the client level (pregnant woman) was incorporated into the design.
7 8
Rosales A, Report on Intibucá HIS evaluation. CRS June 2001 Debay M et al. On the Design of Community-Based Health Information Systems. CSTS February 2003 16
•
Define the information needed and gathered the relevant data: this step was done during the design of the information system in this particular case. It is important to note that the process can occur in
Steps in the Decision-making Process
any order, and is iterative. As mentioned before, the definition of information needs in
•
this program was done in several moments of
•
program
• • • •
implementation,
starting
at
the
proposal design phase. •
Define the criteria to select the best solution: based on information gathered and local
•
feasibility of action, a criterion for its selection
•
was established. The most important fact in
Define the problem or decision to be made Determine who will use the information Define the information needs Establish criteria Generate alternative solutions Predict the consequences of alternative solutions Compare solutions and select the best alternative Implement and monitor the best alternative
this selection was the feasibility for action given local conditions and community consensus. •
Generate solutions and select the best alternative: the best solutions to potential problems were identified at each level.
•
Compare solutions and select the best alternative: this step was implemented simultaneously with the previous one, and executed in a participatory way to assure commitment from the decision maker.
•
Implement and monitor the best alternative: monitoring of decision-making implementation was done through monthly staff meetings and quarterly community meetings.
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Figure 2: Criteria for Decision-Making defined in the Intibucรก program by oprational level
Community/Household/pregnant woman Decisions: adopting key behaviors, seeking outside care, emergency transport
Traditional Birth Attendant/Community Decisions: case management, referral, follow-up with support; supportive actions
Program Health Educator Decisions: collective education-information, quality of TBA Data, technical assistance for TBA, inter-sectoral coordination
Program Field Supervisor Decisions: program management, operational supervision
Program Manager Decisions: program management, technical supervision, needs assessments
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Household and pregnant woman: in the community and household members as well as the pregnant woman decisions were related to which key behaviors to adopt, and when and where to seek care outside the home. The program emphasized information on danger signs related to pregnancy as well as exclusive breastfeeding for neonatal health. The program improved substantially referral of pregnant women with complications to health centers with essential obstetric care through decisions at the household level to seek care outside and through decisions at the community to support evacuation of complicated cases via a community emergency transportation system. Community and household members receive feedback information from collected data during community meetings held every four months. During these meetings program and ministry of health staff reported back to the community on status of its maternal and newborn population. Emphasis was done on information about key behaviors and emergency transport activities.
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Example of desicions taken by communities during quaterly Community meetings Community
Problem addressed
Community analysis
El Gabriel Colomoncagu a
During AugustNovember period FY 02, CHWs attrition increased, 10% of children weighted with inadequate weight-gain tendency.
Economic situation in the area is promoting external migration, especially to El Salvador. In the community there is only one CHW in place. Some members of health committees have also emigrated.
Callejón Colomoncagu a
During AugustNovember period FY 02, 32% of children weighted with inadequate tendency, and 7% of these have done so in two consecutive periods.
Children in communities experienced an increased in diarrheal and ARI diseases.
Las Aradas, Ojos de agua, La montaña – Santa Lucía
Lack of access to Obstetric emergencies in the 3 communities
There are no community plans for evacuation during emergencies.
Decision take/commitment • Continue with weight monitoring of children in the community • One more CHW is assigned and began training • New community members for the health committee are incorporated. • Chlorination of water for adult consumption and boiled water for children. • Referral of children with danger signs to health facility • Training of 5 more community resources on nutrition. • Referral of children with nutritional deficits to nutritional center. Emphasis on: * Surveillance to pregnant women, prenatal care promotion, continuation of TBAs health promotion on danger signs during pregnancy, delivery and puerperium. *TBAs will identify those women with danger signs, and the transportation committee will provide the means to evacuate those cases with obstetric emergencies.
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Traditional Birth Attendants: at the TBA operational level decisions were taken on daily organization of work activities, prioritization of home-visits, selection of education activities, as well as detection and referral of complicated cases, investigation of maternal and neonatal deaths. TBAs received from program staff and secretary of health staff specific guidelines on information utilization during supervisory visits and during their monthly meetings.
Health Educators: at this operational level, information was utilized to identify training needs of TBAs, prioritization of geographical sectors for technical support, and monitoring of work activities. Programmatic and management decisions were taken systematically during monthly meetings.
Field Supervisors and program managers: at this level most of the information was used to make programmatic decisions. Also maternal and neonatal health priorities were identified through data analysis, as well as development of action plans to address these priorities. Also information was used to assess staff performance on a monthly basis.
Links with SOH health information system: the Intibucå HIS was linked to the official (MOH) health information system through monthly reports shared at two levels of the system (see figure 1). The first link was established through the systematic submission of the health educator’s report to the local health facility; also the program’s manager report was shared systematically with the regional or district level. These linkages in addition to provide valuable information for program planning at the local and district level, it also galvanized a sense of program ownership as well in the government sector.
Overall results of the HIS: some of the results documented by the information system were the following: postpartum visits within a 48 hours period were increased in 75 percent points, 100% of maternal complications were referred to a health center with resolution capacity, 100% of these referrals were
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accompanied by a TBA, 98% of communities produced an emergency plan for evacuation of maternal complications, exclusive breastfeeding increased in 31 percent points, the population of women in reproductive age showed an increased of 70 percent points in knowledge of danger signs associated with pregnancy, likewise this population improve their knowledge on the lacto amenorrheic method by 78 percent points.
In the following section, we present an example of descriptive and analytical epidemiological
data
produced
by
the
system
during
two
years
of
implementation.
The system identified a total of 2123 pregnancies for the period of September 2001 through September 2003 in 95 villages. The estimated total population of women of reproductive age (12-49 years) in this location is 11,310. It was estimated based on fertility rates an annual number of pregnancies of approximately 600 live births per year for this locality (810 LB FY02). Therefore we can infer that the HIS is probably detecting 100% of pregnancies in the area. 96% of these pregnancies are receiving prenatal care.
N u m b e r a n d P ro p o rtio n o f P re g n a n c ie s in P re n a ta l C a re . In tib u c a , H o n d u ra s . S e p te m b e r 0 1 - S e p te m b e r 0 3
V a r ia b le
N um ber
P r o p o r tio n
# to ta l o f p re g n a n c ie s
2123
100%
P re n a ta l c a re
2030
96%
93
4%
W ith o u t P C
22
Additionally, the system allows to identified number and proportion of pregnancies by age group.
N u m b e r a n d p r o p o r t io n o f p r e g n a n c i e s b y a g e g r o u p . In tib u c a , H o n d u ra s . S e p t 0 1 - 0 3 A g e G ro u p
# p r e g n a n c ie s
p r o p o r tio n
1 2 -1 8
254
12%
1 9 -3 5
1594
75%
>35
275
13%
In relationship with pregnancy-related health problems, the system showed an overall complication rate in the area of 14%. The majority of these complications occurred during the prenatal period. The main causes of prenatal complications were headache, abnormal presentations, edema, hemorrhage, and fever. During delivery and postpartum hemorrhage was the main complication identified.
C o m p lic a tio n ra te d u rin g p re g n a n c y , d e liv e r y , a n d p u e rp e riu m . In tib u c a , H o n d u ra s . S e p t0 1 /S e p t.0 3 C o m p lic a tio n s
N um ber
p r o p o r tio n
T o ta l
300
14%
P re n a ta l
185
62%
D e liv e ry
94
31%
P o s t-p a rtu m
21
7%
Health outcomes in the system were defined as referral, status of mother: dead or alive; and status of the newborn: dead or alive
23
The HIS identified maternal deaths. The cases in this indicator (Maternal Mortality Ratio [MMR]) are defined according to the definition of pregnancyrelated death proposed in ICD-10. In the computation of this indicator, two types of aggregates can be used as denominators: the number of live births or the number of total births. WHO recommends the second one. This indicator provides the program and health area with information about the magnitude of the problem.9
M a te r n a l M o r ta lit y R a tio b y m u n ic ip a lit y a n d t o ta l c o v e r e d a r e a . In tib u c a , H o n d u r a s . S e p t 0 1 - 0 3
P la c e
N um ber m a te r n a l d e a th s
MMR /1 0 0 ,0 0 0 lb
# of liv e - b ir th s
T o ta l b ir th s
C o lo m o n c a g u a 2
2 5 3 /2 4 6
789
813
C am asca
1
2 2 3 /2 2 1
448
452
S a n ta L u c ia
1
2 6 1 /2 5 3
383
394
T o ta l
4
2 4 7 /2 4 1
1620
1659
Proportion of women attended at least once during pregnancy by skilled health personnel for reasons related to pregnancy: This indicator is aimed at maternal health (not maternal mortality). This is a process indicator that provides information on the level of utilization of care by pregnant women for reasons related to pregnancy. “Skilled health personnel� is defined as doctors (specialist or non-specialist) and/or persons with midwifery skills who can diagnose and manage obstetric complications as well as normal deliveries. The term excludes TBAs trained or not trained (WHO definition). The most common used 9
In terms of measuring impact at the moment, given the short period of data collection (24 months), trends are not advisable to examine, we are proposing to analyze these trends at a 3-5 year period. Nonetheless, during 1,999 UNICEF reported a MMR for the area of 534/100,000, which if correct, the current MMR reported for the area of influence would represent a magnitude 47.2% less in maternal mortality.
24
denominator for this indicator is the number of live births, which acts as a proxy for the number of pregnant women. This however underestimates the total number of pregnancies. In our program we use the actual number of pregnant women as denominator to have a more accurate indicator. The proportion reported
in
the
baseline
(89%)
was
collected
through
a
cross-
sectional/retrospective study using a cluster sampling methodology (30-cluster). The proportion reported by the project area is a product of a prospective type of study and not a sample. Therefore, we do not think these two proportions can be comparable, and we even infer that if comparable there would not be a statistical significant.
P r o p o r t io n o f w o m e n a t te n d e d a t le a s t o n c e d u r in g p r e g n a n c y b y s k ille d h e a lt h p e r s o n n e l f o r r e a s o n s r e la t e d t o t h e p r e g n a n c y . I n t ib u c a , H o n d u r a s . S e p t 0 3 P la c e B a s e lin e
# wom en a tte n d e d 268
# p re g n a n t wom en
p r o p o r tio n
P r o je c t a r e a
2030
2123
96%
C o lo m o n c a g u a
1016
1062
96%
C am asca
534
551
97%
S . L u c ia
474
510
93%
89%
Proportion of births attended by skilled health personnel: This indicator is aimed both at maternal health and, to a limited extent, at maternal mortality. A skilled health personnel is defined as doctors (specialist or non-specialist) and/or persons with midwifery skills who can diagnose and treat obstetric complications as well as normal deliveries. The term excludes TBAs. The numerator includes the number of deliveries at clinic/hospital; and the denominator the total number of deliveries reported at the communities. If our figures are correct since the start of implementing activities there has been in 20 months an increment of 11 percent points in institutional deliveries; from 14% to 25%. The municipality of
25
Camasca has experienced the highest increment at 38% of total deliveries being attended at clinic or hospital.
P r o p o r t i o n o f b i r t h s a t t e n d e d b y s k ille d h e a lt h p e r s o n n e l. I n t i b u c a , H o n d u r a s S e p t . 0 3 P la c e B a s e li n e
# to ta l b irth s 300
# d e liv e r ie s c lin ic /h o s p it a l 43
p r o p o r t io n 14%
P r o je c t a r e a
1620
410
25%
C o lo m o n c a g u a 7 8 9
148
19%
C am asca
448
170
38%
S . L u c ia
383
90
23%
Comparison of proportion of births attended by skilled health personnel at baseline and final survey: the present graph, just to evidence the impact on institutional deliveries in two years of program implementation in the area.
P ro p o rtio n o f b irth s a tte n d e d b y s k ille d h e a lth p e rs o n n e l a t b a s e lin e a n d fin a l s u rv e y . In tib u c a , H o n d u ra s , S e p t. 2 0 0 3 30% 25% 20% 15% 10%
B a se lin e F in a l
5% 0%
Early perinatal mortality rate (EPMR): Perinatal mortality (number of stillbirths and deaths within one week of birth by the total number of births) is suggested for utilization as a proxy indicator for maternal mortality and maternal health 26
outcomes. In addition it provides useful insight on the quality of intrapartum care. One of its major advantages is that there are approximately 15 times more perinatal deaths than maternal deaths. Its ability to register changes is therefore probably superior to the maternal mortality ratio. Early perinatal mortality (stillbirths plus one day deaths) is even a stronger indicator for maternal mortality according to WHO (World Health Organization). In this table we observe that early perinatal mortality in the program area is 30 per 1000. The national rate of perinatal mortality for Honduras reported by ENESF (Encuesta Nacional de Epidemiologia y Salud Familiar) in 2001 was of 29 per 1000. Since EPMR indicator only includes those children dead after 24 hours and ENESF includes those children dead after one week, we can infer that health status for pregnant women and neonates in the program area is worst than at the national level. Additionally, when we compare early perinatal mortality rate by municipality we found that there is a statistical significant difference among them, additionally we found that children born in Colomoncagua are 4 times more likely to die than children born in Camasca, likewise children born in Santa Lucia are three times more likely to die that children born in Camasca.
E a rly p e rin a ta l m o rta lity ra te (s tillb irth s p lu s o n e -d a y o f a g e d e a th s ) b y lo c a lity . In tib u c a , H o n d u ra s . M a y o 0 3 P la c e
# p e rin a ta l d e a th s
# to ta l b irth s
EPM R x 1000
P ro je c t a re a
48
1620
30x1000
C o lo m o n c a g u a
32
789
41x1000 (O R = 3 .6 ; P = 0 .0 0 4 )
C am asca
5
448
11x1000 (O R = 1 )
S . L u c ia
11
383
29x1000 (O R = 2 .5 ; P = 0 .0 7 )
But the most interesting finding is what we found in the association among MMR/Obstetric access and EPMR
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Association between maternal health monitoring indicators at community: in this graph, the association between increased access for prenatal care/institutional delivery and decreased MMR and EPMR is evident. Likewise, the relative advantage of institutional delivery over prenatal care in affecting EPMR is obvious. Another interesting fact deduced from this graph is the higher sensitivity to identify change of EPMR over MMR.
A sso ciatio n be tw e e n m atern a l h ea lth m on itorin g in dic a to rs a t th e com m un ity le vel. In tib uc a, H o n d u ras. M a yo 2 00 3 350 300
A ll m u n icip a lities C o lo m o n ca gu a C a m a sca S . L u cia
250 200 150 100 50 0 MMR
% p ren atal
% d eliver
EPMR
Percentage of population within 1-hour travel time to health center offering essential obstetric care: this newly proposed indicator is aimed at measuring progress towards the reduction of maternal mortality. This indicator measures the extent of the availability of emergency obstetric facilities. It answers issues of proximity rather than accessibility. This indicator measures the “delay� from the moment a care-seeking decision is being made to actual arrival to health care location where essential obstetric care (EOC [parenteral antibiotics/parenteral sedatives/parenteral oxitocics/manual extraction of placenta/D&C]) can be provided. In our covered area there is only one institution that provides EOC; and only 3% of pregnant women in Camasca reach that center within one hour.
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P e rc e n ta g e o f p o p u la tio n w ith in 1 h o u r tra v e l tim e to h e a lth c e n te r o ff e r in g e s s e n tia l o b s te tric c a re . In tib u c a , H o n d u r a s . M a y o 2 0 0 3 P la c e
# to ta l p r e g n a n c ie s
P r o p o r tio n w ith in th e h o u r - E O C
P r o p o r tio n w ith in th e h o u r - H F
P r o je c t a r e a
2123
0 .7 % ( 1 4 /2 1 2 3 )
5 6 % ( 1 1 9 8 /2 1 2 3 )
C o lo m o n c a g u a
1062
0 % ( 0 /1 0 6 2 )
4 7 % ( 4 9 8 /1 0 6 2 )
C am asca
551
3 % (1 4 /5 5 1 )
6 6 % ( 3 6 5 /5 5 1 )
S . L u c ia
510
0 % ( 0 /5 1 0 )
5 7 % ( 2 9 0 /5 1 0 )
The association that exist between access to EOC and institutional delivery with maternal health is demonstrated in this graph, where the municipality with the lowest EPMR is the one with the highest percentage of institutional delivery and the only one with access to EOC.
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A s s o c ia tio n b e tw e e n in d ic a to rs o f a c c e s s to m a te rn a l c a re a t th e c o m m u n ity le v e l a n d e a r ly p e r in a ta l m o rta lity ra te . In tib u c a , H o n d u ra s . M a y o 2 0 0 3
40 35
A l l m u n ic ip a litie s C o lo m o n c a g u a C a m a sc a S . L u c ia
30 25 20 15 10 5 0 % I d e liv
EPM
A cces s
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Lessons Learned:
In developing a community based HIS, CRS Honduras identified several important lessons:
1. The development process of a CB-HIS must take into account the availability of local and simple tools for collecting information. Two important characteristics that should never be relegated are local idiosyncrasy and educational level of personnel using the system.
2. Information collected must be specific for project management purposes. Information needs to be related to action, thus avoiding overburdening the system with useless information.
3. Feasible and useful flow of information, and use at different management level. The design of the system needs to take into account efficiency in the information flow and information use specific for each level in the system.
4. Training methodology simple and acceptable. Adult training methods and supervision ideology are important issues in the development of a useful and efficient information system.
5. Supervisory approach must be oriented to a culture that values information-based
decision-making.
In
developing
countries,
and
especially at community levels one known barrier to using information is a lack of interpretation skills. Thus, supervision activities need to include this factor into the equation.
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Conclusions:
In conclusion, information to fulfill the core functions of public health can be collected effectively and efficiently at community level, using community structures. This fact we think has been overlooked by international and national initiatives.
The quality of information produced at population level, as demonstrated by this case-study, fulfills international standards, is real information and not estimates, and represents more accurately what is actually happening in poor and neglected settings. Thus, this type of information better guides political and technical decisions.
Maternal information to prioritize, plan, implement, and sustain effective intervention strategies can be produced and sustained by “community-based” structures. The information produced by a CB-HIS complies with WHO’s standards, and it is useful for health planning and policy development at district and national level.
Current literature and health policy discourages the inclusion of community resources, such as TBAs, as part of the solution for the maternal health problems as evidenced by the Colombo’s resolution. Our experience is showing that this is not a matter of “either-or”; the participation of community resources such as TBAs is a necessary complement to government initiatives in the solution of maternal health problems. Impact and sustainability of the impact depends upon this alliance.
The cost of these types of initiatives is extremely low when applied to a population level.
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