Post on 06-Apr-2018
Maternal and Newborn Health Conference for
Zambias Mothers and Babies Conference Summary Report
1st November 2012
The Intercontinental Hotel,
Lusaka, Zambia
Recorded by Eleonah Kapapa
Written by Mercy M. Mbewe
With support from Louise Smith, Vanessa Halipi and David Percy
1
Acknowledgements
The conference organisers wish to thank DFID for providing funding to allow delegates from
the provinces to attend and for funding the review paper, THET for the management of the
survey and the Conference Advisory Group for their guidance.
We would also like to thank colleagues at the Ministry of Health and the Ministry of
Community Development, Mother and Child Health for their support and collaboration with
this initiative.
We also thank all presenters for their contributions and all those who submitted abstracts
and displayed projects on the day.
Finally we thank Zambian and international participants for attending and contributing their
knowledge and experience to the discussions.
2
Contents Acknowledgements ................................................................................................................................. 1
Contents .................................................................................................................................................. 2
Abbreviations .......................................................................................................................................... 4
1. Introduction ..................................................................................................................................... 5
1.1 Background to the conference ............................................................................................ 5
1.1.1 Methodology of the conference ..................................................................................... 5
1.1.2 Workshop participants .................................................................................................... 5
1.2 Welcome remarks ............................................................................................................... 5
1.3 Keynote Address .................................................................................................................. 7
2. Key thematic outcomes ................................................................................................................... 8
2.1 Panel 1: Maternal, Neonatal and Child health .................................................................... 8
2.1.1 Strategy in the MNCH Road map .................................................................................... 8
2.1.2 Survey of Maternal and Newborn health services in Zambia ......................................... 9
2.1.3 Overview of Community Health Workers Programme ................................................... 9
2.1.4 Midwifery Association of Zambia .................................................................................. 10
2.2 Panel 2: Safe Motherhood Action Groups ......................................................................... 11
2.2.1 Introduction and update on the implementation of Safe Motherhood Action Groups
(SMAGs) ....................................................................................................................................... 11
2.2.2 Safe Motherhood Action Groups training in Mwinilunga District ................................. 11
2.2.3 Africare .......................................................................................................................... 12
2.2.4 Communication support for Health ‘Mothers Alive” Campaign ................................... 12
2.3 Panel 3: Access to Care and Community Interventions .................................................... 13
2.3.1 CHAZ Community leadership: PMTCT Programme to improve health outcomes of HIV
exposed babies. ............................................................................................................................. 13
2.3.2 Mobilizing Access to Maternal Health Services in Zambia (MAMAZ) ........................... 13
2.3.4 Riders for Health ............................................................................................................ 14
2.4 Panel 4: Maternal Healthcare interventions ..................................................................... 15
2.4.1 Saving Mothers, Giving Life Endeavour (SMGL) ............................................................ 15
2.4.2 Emergency Obstetric and Newborn Care (EmONC) signal functions and health facility
capacity ....................................................................................................................................... 15
2.4.3 Role of Intensive Mentorship in Emergency, Obstetric and Neonatal care: the MCHIP
approach ....................................................................................................................................... 16
2.4.4 Safer Anesthesia from Education (SAFE) Obstetrics: Improving maternal outcomes
through training ............................................................................................................................ 16
3
2.4.5 Use of Misoprostol for Post-Partum Heamorrhage prevention in Home deliveries ..... 17
2.5 Panel 5: Newborn Health Care Interventions.................................................................... 17
2.5.1 Newborn Health Scale Up Framework for Zambia: an Overview of the Newborn
Strategy ....................................................................................................................................... 17
2.5.2 Newborn Care Training in Developing countries: the First Breath Clinical Trial ........... 18
2.5.3 Zambia Chlorhexidine Application Trial (ZamCAT) ........................................................ 18
2.5.4 Lufwanyama Neonatal Survival Project (LUNESP) ......................................................... 18
3. Key outcomes of the conference: setting priorities for action ...................................................... 20
3.1 Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA) ............................ 20
3.1.1 Traditional Birth Attendants .............................................................................................. 20
3.1.2 Skilled Birth Attendants ..................................................................................................... 21
3.2 Increased involvement of Safe Motherhood Action Groups ............................................ 21
3.3 Volunteers and Community Health Assistants .................................................................. 21
3.4 Community involvement ................................................................................................... 22
3.5 NGOs and Coordinated Leadership ................................................................................... 22
3.6 Strengthening access to care ............................................................................................. 22
3.7 Emergency care ................................................................................................................. 23
3.8 Finalization of the MNCP Roadmap .................................................................................. 23
3.9 Family planning.................................................................................................................. 23
4. Conclusion of the conference ........................................................................................................ 24
Appendices: ........................................................................................................................................... 25
1. Conference Programme .................................................................................................... 25
2. List of participants ............................................................................................................. 28
3. Question and answer sessions .......................................................................................... 32
Panel 1 - Maternal, Neonatal and Child health ............................................................................. 32
Panel 2 - Safe Motherhood Action Groups ................................................................................... 33
Panel 3 - Access to Care and Community Interventions ............................................................... 33
Panel 4 - Maternal Healthcare Interventions ................................................................................ 34
Panel 5 - Newborn Healthcare Interventions ................................................................................ 34
4
Abbreviations
AIDS – Acquired Immune Deficiency Syndrome
ART - Antiretroviral Therapy
ANC – Antenatal Care
CHW – Community Health Workers
DALY – Disability Adjusted Life Year
DHMT – District Health Management Team
ENC – Essential Newborn Care
EmONC – Emergency Obstetric and Neonatal Care
FBO – Faith Based Organisation
FP – Family Planning
GRZ – Government of the Republic of Zambia
HIV – Human Immunodeficiency Virus
INGO – International Non- Governmental Organisation
MCDMCH – Ministry of Community Development, Mother and Child Health
MCHIP – Maternal and Child Health Integrated Programme
MDG – Millennium Development Goal
MMR – Maternal Mortality Ratio
MNCH – Maternal Newborn and Child Health
MNH – Maternal and Newborn Health
MoH – Ministry of Health
MOU – Memorandum of Understanding
MTCT – Mother to Child Transmission
NGO - Non- Governmental Organisation
NRP- Neonatal Resuscitation Programme
NMR – Neonatal Mortality Rate
PPH – Post Partum Hemorrhage
PMTCT – Prevention of Mother to Child Transmission
SBA – Skilled Birth Attendants
SMAGs – Safe Motherhood Action Groups
SMGL – Saving Mothers Giving Life
ST – Sample Transport
TAT – Turnaround times
TBA –Traditional Birth Attendant
VCT – Volunteer Counseling and Testing
WHO – World Health Organisation
5
1. Introduction
1.1 Background to the conference
The Zambia UK Health Workforce Alliance (ZUKHWA) is a network of seventy UK and Zambian
organizations who work together to promote and improve the coordination and impact of Zambia-
UK joint work in health. ZUKHWA’s main objective is to support the Government of the Republic of
Zambia through the Ministry of Health and the Ministry of Community Development, Mother and
Child Health, to achieve its national strategic plan and global health goals. This current initiative is to
support the Zambian government to achieve the Millennium Development Goals 4 and 5 around
maternal and child health. The conference was held to bring together Zambian and international
stakeholders, partners and NGOs to critically evaluate what is happening now, and the next steps to
improve maternal and newborn morbidity and mortality.
1.1.1 Methodology of the conference
A highly interactive approach was used; the plenary and discussion group sessions were aimed at
setting priorities for further action, in order to accelerate the attainment of improved maternal and
child health services.
The questions and answers after each set of presentations were collated into issues for the Ministries
and cooperating partners to consider further. These issues were presented by discussion table
leaders and then further discussed in a plenary session. The outcomes of the discussion sessions
have been included in appendix 3.
1.1.2 Workshop participants
Participants were drawn from both governmental and non-governmental organizations, cooperating
partners, and other individuals working or involved in providing support and conducting research
towards accelerating the improvement of maternal and child health.
1.2 Welcome remarks
Session Chairperson: Dr P. Mwaba, Permanent Secretary, Ministry of Health
Dr Mwaba welcomed participants and said how pleased he was that the conference was finally in
session. A special welcome was extended to Prof E. Chomba, Permanent Secretary at the Ministry of
Community Development, Mother and Child Health and Lord Nigel Crisp from the UK. Apologies were
given from the Minister of Community Development, Maternal and Child Health Development, who
was unable to attend the meeting due other commitments.
Welcome remarks by Prof E. Chomba, Permanent Secretary, Ministry of Community
Development, Mother and Child Health
Whilst the health sector has made progress in improving maternal and child health indicators, more
effort needed to reach the MDGs targets on maternal and child health; 70% of childhood illnesses are
preventable and require community involvement. Targets for improving Maternal (MDG 5) and Child
6
health (MDG 4) have to be addressed in combination with reducing poverty (MDG 1), improving
water and sanitation (MDG 7) and reducing HIV (MDG 6). Good policies have been developed, but
interventions are not yet implemented with the full participation of those in the community.
The Ministry of Community Development, Mother and Child Health aims to empower every
household to live a productive, healthy and useful life. This will be achieved through interventions
which:
• Promote, prevent and treat disease in women and children;
• Address the challenges surrounding delays in decision making, delays in accessing health
services and delays at health facilities;
• Address the lack of holistic care in the health facilities, where symptoms not the disease are
treated and where the influences of poverty, high fertility rates, inadequate access to safe
water and sanitation and poor nutrition are ignored;
• Provide a social cash transfer of funds to vulnerable and poor people in the community and
community self-help programmes;
• Provide health promotion, growth monitoring, and family planning;
• Provide skills and training for youths, which incorporate prevention programmes targeting
adolescents;
• Provide food security packs targeting malnourished clients in the health facilities;
• Integrate services to ensure good health and poverty alleviation
Welcome remarks and Objectives of the Conference: Lord Nigel Crisp.
Lord Crisp welcomed everyone to the conference and expressed his pleasure at working with both
Permanent Secretaries. He stated that the conference was being held to specifically support Zambia’s
plans on maternal and newborn health. He also expressed his thanks to over 100 organisations who
had shared their experiences through a survey which reviewed and mapped initiatives in maternal
and newborn health in Zambia, to the 30 organisations who presented abstracts for the conference,
and finally to those who put up project displays in the conference hall. Lord Crisp then outlined the
following conference objectives:
a) To share local experiences and identify evidence based interventions that will accelerate
attainment of improved maternal and child health services;
b) To present current activity in maternal and newborn health services in Zambia and consider
this in relation to international best practices;
c) To develop recommendations to rapidly improve maternal and newborn mortality and
morbidity.
7
1.3 Keynote Address
The Honorable Minister of Community Development, Mother and Child Health,
Dr. J. Katema
Delivered By Prof E. Chomba
The Keynote address highlighted some of the major issues in maternal health in Zambia, and called
for resolutions to move forward.
Maternal mortality presents a great challenge to Zambia and it is unacceptable that pregnancy in
Zambia still results in 591 maternal deaths per 100,000 live births, where the global average is 210
per 100,000 live births. Zambia faces challenges in the shortage of skilled workers and material
resources, poor health infrastructure and difficulties of access to healthcare provision due to long
distances and poor road conditions. These challenges are also aggravated by poor water and
sanitation as well as a high HIV prevalence. The poor and most remote communities bear the
heaviest burden, due to a lack of access to skilled birth attendant’s which increase the rates of
maternal mortality.
The ministry recognise their responsibility in improving the lives of women and children, especially of
those in poorer communities. The ministry will do this by providing more comprehensive and
targeted delivery of services to accelerate the reduction of maternal and neonatal mortality. A team
effort is required, involving all levels of society, from communities to traditional leaders and other
influential networks right up to the policy makers. We should all leave this conference with plans and
resolutions and the momentum to move forward and achieve our goals of MDG 4 and 5.
8
2. Key thematic outcomes
Five thematic sessions were presented which led onto questions and discussions. The presentations
and subsequent discussions were carried forward to priority setting in table discussions later in the
conference.
2.1 Panel 1: Maternal, Neonatal and Child health
2.1.1 Strategy in the MNCH Road map
The MNCH road map is a strategic document that highlights the need to address the problems of
high maternal, neonatal, infant and under-5 mortality rates in Zambia over the next 10 years.
The goal of the MNCH road map is an accelerated reduction of maternal, newborn and childhood
morbidity and mortality to attain MDG targets by 2015.
To reduce maternal mortality from 591 to 162 per 100,000 live births
To reduce neonatal mortality from 34 to 20 per 1,000 live births
To reduce Under-5 mortality rate from 119 to 64 per 1000 live births
There are a number of issues surrounding the high Maternal Mortality Ratio (MMR) and Neonatal
Mortality Ratio (NMR) in Zambia. For example, to train or not to train TBAs, the three delay model;
reduced funding affecting outreach services, reduced human resources and rural versus urban
disparities.
Key strategies to be implemented were outlined as follows:
1. Five critical phases in the lifecycle of women and children were recognised in “the continuum
of care” approach;
2. Using a three dimensional approach in coming up with strategies and interventions to ensure
engagement and synergy between the health system, communities, other line ministries and
the private sector;
3. Strengthening partnerships with the donor community and the private sector for sustainable
long-term predictable financing to achieve universal coverage;
4. Advocacy and resource mobilization to increase the budget allocation for MNCH
interventions from internal and external resources;
5. Revising laws and policies hindering the effective provision of MNCH services;
6. Improving the production, employment, deployment and retention of a skilled health
workforce at all levels;
7. Institutionalising maternal death reviews;
8. Health system strengthening and capacity building for MNCH;
9. Community mobilization by educating and sensitising communities on community-based
MNCH interventions and behaviour change communication approaches for quality MNCH;
10. Fostering partnerships and accountability and effective implementation of this MNCH
strategic plan;
9
11. A monitoring and evaluation framework addressing one set of agreed indicators for
maternal, newborn and child health interventions.
The implementation of this roadmap will include a multi-sector approach to increase access to health
services. This will involve the MCDMCH and Ministry of Health, other ministries, the Disaster
Management and Mitigation Unit and cooperating partners such as NGOs and the private sector.
2.1.2 Survey of Maternal and Newborn health services in Zambia This survey to map maternal and newborn initiatives across Zambia was requested by the Ministry of
Health and the Ministry of Community Development Mother and Child Health. The survey covered
faith based, community based and non-governmental organizations.
It was revealed that, whilst health organizations are present in every district, there is an uneven
geographical spread. There is a higher concentration of initiatives in the health centres of more
densely populated areas and not enough initiatives in the health centres in rural areas; this was
particularly evident in the Western and North Western Provinces. The pattern was similar to the
number of health staff vacancies and it was noted that many rural health centres are being run by
unskilled workers. This uneven geographical distribution is affecting rural access to care and thus the
maternal and neonatal mortality rates.
The survey revealed that projects were using a wide variety of best practice models. Whilst many of
these come from reputable international sources, it would be beneficial to have a more coordinated
and harmonized approach to best practice in Zambia.
The types of interventions showed an understanding of the importance of a continuum of care.
There was a strong emphasis on promoting facility based births with a Skilled Birth Attendant, early
antenatal care, engaging traditional leaders, promoting birth planning, malaria prevention, spreading
knowledge of danger signs in pregnancy as well as infant and child nutrition. However, clinical
interventions such as EmONC were less frequently addressed. Sixty percent of programmes applied
community engagement processes in implementing their interventions.
The results indicated that:
• A more strategic distribution of interventions is required;
• Community engagement is an important component of the continuum of care;
• Community Health Workers (CHWs) and Safe Motherhood Action Groups (SMAGs) are able
to increase the demand for and uptake of health services;
• Distance and poor road infrastructure remains an obstacle for many women.
2.1.3 Overview of Community Health Workers Programme
It has been observed that Zambia’s health sector has a serious human resources shortage and that
this is a key obstacle to reducing disease burden and achieving MDGs by 2015. A situational analysis
revealed that CHW training was not standardized, the duration of study was varied and not aligned
to the diverse community health needs and that 23,500 CHWs are needed in Zambia. In addition,
incentive structures varied and the MoH had no policy to guide the management of CHWs; this lead
to the development of the National CHW Strategy within the Human Resources for Health Strategic
10
Plan. The plan includes a pilot, a phased expansion, and recruitment and selection criteria along with
a monitoring framework of integration into the national healthcare system.
The one year training programme for Community Health Workers/Assistants offers 11 modules using
an integrated and skills-based learning model with a focus on primary health care. The graduates are
then registered with the Zambian Health Professions Council. A total of 307 Community Health
Assistants have graduated and have since been deployed at selected health posts and 2500 posts
have been established.
Following a curriculum review, changes to the CHWs scope of work have been proposed;
Family planning, HIV testing and couple counseling;
Provision of antenatal care (ANC) and life-saving skills during delivery;
Skills to conduct emergency delivery procedures and referring mothers to deliver at a
health facilities;
Administration of Misoprostol in emergency situations;
Providing postpartum care at household level;
Male reproductive health issues such as promotion of voluntary male circumcision for
infant and adult males at community level;
Nutrition using an integrated approach in all modules;
Provide an integrated Voluntary Counseling and Testing services for adults, children and
pregnant mothers;
A disease prevention and control package.
2.1.4 Midwifery Association of Zambia
In Zambia, the number of midwives deployed to provide sexual and reproductive health services,
especially maternal health services, has remained very low for a long time. According to the MoH
Training Operational Plan (2008) there were 2,273 midwives in the country for all maternal, neonatal
and child health (MNCH) services. Midwives play a primary role in healthcare delivery; therefore the
improvement of pre-service and in-service midwifery education can contribute to improved
performance of the entire health care system.
MAZ intend on expanding the number of midwives through providing collaborative education with several national and international partners. MAZ also have plans to ensure that all women in Zambia have access to skilled birth attendants. These plans include;
a. Providing the women and their partners education and counseling on the importance of facility delivery;
b. MAZ will be engaged in capacity enhancement programmes for Midwives and advocating for the improvement of the health of women and families;
c. Increasing the availability and utilization of quality ANC services including PMTCT;
d. Improving access to skilled attendance at delivery including emergency obstetrical and
neonatal care;
e. Increase availability and utilization of youth friendly FP and HIV and AIDS prevention services.
11
2.2 Panel 2: Safe Motherhood Action Groups
2.2.1 Introduction and update on the implementation of Safe Motherhood
Action Groups (SMAGs)
The Maternal Mortality Ratio in Zambia is one of the highest in the world, standing at 591/100 000
live births. The Safe Motherhood Action Groups (SMAGs) were established at community level in 44
districts to address challenges in safe motherhood, which include the 3Ds (decision making at
community level, delay in accessing a health facility because of lack of transport and delay in
receiving care at health facility).
The objectives of SMAGs are as follows:
• Strengthening community participation in maternal, newborn, and child health;
• Improving community knowledge on safe motherhood issues through health education;
• Enhancing the community’s utilization of reproductive health services;
• Increasing male involvement in safe motherhood activities;
• Strengthening partnerships between the community and health system.
For SMAGs to significantly improve maternal and newborn health, they are involved in health
education, maternal and child nutrition, income generating activities, outreach activities and
involvement in the management of patients with obstetric fistula. They are motivated groups, whose
activities are supported through materials such as ID cards, SMAGs Bags, SMAGs T-shirts, flip charts
for training and sensitizing communities, and bicycle ambulances for transferring patients with
complications. Where SMAGs are fully involved there have been notable improvements in health
seeking behavior, reduction in maternal and child mortality and increased first ANC visits.
Nonetheless there are problems, including the maintenance of the bicycle ambulances, despite
communities having agreed to maintain them through contributions from Neighborhood Health
Committees and user fees.
2.2.2 Safe Motherhood Action Groups training in Mwinilunga District
Mwinilunga district trained SMAGs with support from the Zambia Integrated Systems Strengthening
Programme (ZISSP) and American College of Nurse Midwives (ACNM). The aim of the training was to
institutionalise SMAGs to improve mothers’ and newborn lives.
In order to ensure effective training, various teaching methods were utilized, such as the use of
storytelling and picture cards during teaching. This was particularly beneficial to participants who
were unable to read. A total 82 SMAGs were trained.
It was observed that, whilst mobilising communities can be very expensive, empowering
communities with skills and knowledge can reduce MMR. The methodology used also made learning
a lifelong experience.
12
2.2.3 Africare
Mobilizing communities to reduce maternal mortality
This project focused on the critical need to generate informed community demand for high quality
maternal and child health services, in order to reduce maternal and neonatal deaths. SMAGs were
trained using a “Lead SMAG” and “Health Post SMAG” and were able to reach 53,000 households
with health education messages to improve care seeking behaviors, as well as providing access to a
variety maternal and child health services (family planning, access to prenatal care and skilled birth
attendants).
Six hundred and twenty five community leaders were orientated to promote the best cultural
practices to protect the interests of women and children. Antenatal visits increased from 21% to
69%; Institutional deliveries increased 64% from to 92% and postnatal attendance at 6 days
increased from 33% to 82%. In addition there was significant reduction in obstetric fistula through
sensitization by the SMAGs and community volunteers and increased access to surgery for women
with fistula was provided.
2.2.4 Communication support for Health ‘Mothers Alive” Campaign
This campaign is a strategy to contribute to the reduction in maternal mortality from 591 to 162 per
100,000 live births. This was to achieve an increased demand for the use of contraception; early
initiation of ANC, attending at least 4 ANC visits, facility-based delivery and post-partum follow up
care.
In order to achieve the objectives of the campaign, mass media and community strategies were
applied through partners and also by introducing ‘Change Champions’. These ‘Change Champions’
are described as:
“Traditional and political leaders trained to use their influence to motivate families in the
utilization of maternal services. These champions then work with sub-leaders, the health
centers, SMAGs and community groups to discuss issues with communities. The leaders from
different communities then share successes, challenges and possible solutions”.
The Change Champions are shown a documentary featuring the work of other leaders who, without
external support, have reduced or eliminated preventable maternal deaths in their area. Leaders are
given a guide book as well as a set of communication tools; this approach has resulted in leaders
reporting feeling better equipped, enabled and motivated to save mothers’ lives.
The key messages from this project included;
• Community development or intervention must involve the key leaders rather than
subordinates,
• Distribution channels for materials must be well defined,
• Change Champions must ensure that they are connected to or a part of the health system.
13
2.3 Panel 3: Access to Care and Community Interventions
2.3.1 CHAZ Community leadership: PMTCT Programme to improve health
outcomes of HIV exposed babies.
This study was conducted at a hospital with an antiretroviral therapy (ART) programme where there
are high HIV prevalence rates among pregnant women. MTCT was at 9.5% among hospitalized
patients and at 50% among home deliveries in 2010. This was due to long distances to the health
facilities, traditional beliefs and few PMTCT interventions happening. In order to improve PMTCT
outcomes, an HIV prevention strategy that embraces all community members was developed; this
involved sensitizing the local Chief to gain support.
Mothers were encouraged to join support groups that enabled networking and fighting against
discrimination. Adherence support workers were then recruited to help client (mother and their
infant) defaulter tracing. Men were also involved through the community leaders and hospital staff in
attending antenatal clinic visits with their wives. HIV+ women in their third trimester of pregnancy
were encouraged to stay at the maternity waiting home if they lived a long way from the health
facility and all ANC clients were encouraged to undergo VCT as a couple.
This PMTCT intervention at community level has had a positive impact. The community leadership
embraced the initiative and decreed that all women should deliver at a health facility. If a woman
failed to do so, she would be fined one goat. 72 HIV positive women who delivered at the health
facility benefited from the programme which resulted in 93% babies testing negative for HIV.
2.3.2 Mobilizing Access to Maternal Health Services in Zambia (MAMAZ)
An Innovative and Scalable Community Engagement Approach for Increasing Access to
Maternal and Newborn Health Services
One of the main objectives of MAMaZ is to improve access to, and utilization of, routine and
emergency maternal and newborn care through community-based interventions. The intervention
was carried out in six districts to test how communities can be effectively mobilized around a
maternal and newborn agenda. It also tested how to establish and sustain community systems to
address key barriers preventing the timely utilization of services.
The community engagement strategy for increasing access to maternal and newborn health services
has four main components: (1) community mobilization processes; (2) the establishment of
community response systems; (3) community monitoring systems and (4) a mentoring and coaching
support system. Five districts also have a fifth component: a facility-based emergency transport
system. Using a holistic community approach, generating approval for behavior and capacity building
has been essential to sustaining the changes.
Communities have also established a number of community emergency systems, comprising
community savings schemes, community emergency transport schemes (ETS). A social fund, part of
the community savings schemes, has served as an incentive for communities to save and apply for
grants as well as using the money to support or extend community emergency systems. This fund
created high level of interest and exceeded targets for the number of beneficiary communities.
14
Facility based emergency transport systems, particularly the use of motorbike ambulances, have
been used within a ten kilometre radius of the health facility and used by staff with lifesaving skills.
Emergency treatment can be given en route to stabilize critical cases and patients with complications
can be transported to meet district ambulances. The results of the intervention show that the
Community ETS contributed to the provision of affordable and reliable transport. The utilization of
this has been beneficial and more pregnant women want it as a safety-net.
Deliveries by a skilled birth attendant increased over time and, by the end of the programme, targets
for Skilled Birth Attendants (SBA) had been exceeded in three out of six districts (Choma, Chama and
Mkushi). Four out of six districts reported an increase in deliveries including post-natal care. Other
changes included an increase in support for mothers and their babies and a change of attitudes
towards gender based violence.
2.3.3 Médecins Sans Frontières
The Bicycle Ambulance: the experience of MSF in Luwingu District
In Luwingu district, 92% of the population live in remote rural areas. 67% of births take place at home
attended by TBAs and only 33% take place at a health facility. In this programme, the objectives were
to increase facility based delivery and improve community awareness of the importance of referral in
the presence of pregnancy danger signs.
In order to achieve the objectives, a community based transport system was introduced in the
district using the modified bicycles known as “Zambikes”. Eight zones participated and training was
conducted among leaders, SMAGs and community health workers. The implementation of this
emergency transport required the utilisation of existing community support networks. The bikes
were used for the referral of women with pregnancy danger signs and those in need of postnatal or
neonatal care.
The Zambikes were considered to be a feasible, cost effective and scalable way of increasing facility
based deliveries.
2.3.4 Riders for Health
Transport reducing delays in accessing laboratory based testing.
This programme focused on providing reliable, scalable, cost-efficient and appropriate transport
solutions for laboratory based testing of medical samples, with an emphasis on rural access and
difficult terrain. Partnering with the District Health Office, the sample transport (ST) system was
piloted for effectiveness by examining testing volumes and turnaround times (TATs) from sample
collection to the return a result to health facilities in Chadiza district.
The outcomes of the pilot revealed that the average TAT decreased by three days, from 11 days
before to 8 days after introducing the ST. Each ST courier transported 442.8 samples per month in
2010, 355.6 in 2011, and 423.6 between Jan and May 2012.
As a result, this contributed to early initiation of ART and an increase in access to laboratory based
testing for women and children.
15
2.4 Panel 4: Maternal Healthcare interventions
2.4.1 Saving Mothers, Giving Life Endeavour (SMGL)
The Saving Mothers, Giving Life initiative is being run under the US Government, as part of President
Obama’s Global Health Initiative. It is committed to supporting the acceleration of improvement in
maternal health in four pilot districts. The initiative is a collaboration of USAID, CDC, Peace Corps and
The Department of Defence, as well as other implementing partners committed to reducing maternal
mortality by 50% in the four districts. The aim is to achieve this through increasing the availability
and use of high impact maternal health services particularly in labour, delivery and the immediate
postpartum period. This is achieved through the 121 health facilities and multi-level interventions
such as Community Sensitization, SMAGs, empowerment of the DHMT, facility upgrades, training,
education and mentoring.
Activities included:
• Establishing district and community leadership or empowerment taskforces to develop SMGL
implementation or action plans;
• Rolling-out the Essential Medicines Logistics Improvement Programme (EMLIP);
• Hiring 20 contract nurses for health centres with no SBAs;
• Reinforcing GRZ leadership at central and district level through chairing monthly partner
meetings in Lusaka;
• Creating functioning maternal death review committees.
There is a multifaceted plan to evaluate the impact of SMGL through a detailed survey of all health
care facilities at baseline and endline, to document the services available. In addition there is a roll-
out of Smart Care to capture all pregnancies as well as ANC. Baseline household surveys with verbal
autopsies were also conducted to determine the true baseline MMR. Finally the plan supported
robust maternal mortality reviews and monitored the implementation process.
Challenges were encountered with poor electricity supply, staff monitoring, data for quality
improvement, improving electronic health records and linking maternal and child health services.
2.4.2 Emergency Obstetric and Newborn Care (EmONC) signal functions and
health facility capacity
Baseline evaluations of the Saving Mothers, Giving Life in pilot districts in Zambia
The causes of MMR are preventable. Every 60 minutes a woman dies from pregnancy related
complications yet the rate to reducing MMR is slow, with less than half of the pregnant women
delivering at health facilities attended by skilled birth attendants. Effective EmONC can contribute to
the reduction of MMR.
The evaluation for Saving Mothers, Giving Life (SMGL) was conducted in 120 facilities in 4 districts of
Zambia. The survey revealed that one Skilled Birth Attendant per health facility may not provide the
services required and gaps also existed in the availability of electricity, water, radio communication
and transport. It was also revealed that there was substantial unmet need for life saving obstetric
16
and neonatal care services, in particular basic EmONC facilities. In order to significantly reduce the
maternal and neonatal morbidity and mortality a comprehensive and sustainable increase in human
resources, clinical skills, physical infrastructure and essential supplies and equipment is required.
2.4.3 Role of Intensive Mentorship in Emergency, Obstetric and Neonatal
care: the MCHIP approach
The design of this initiative involved training a team of 16 Mansa District mentors in mentoring skills,
using Institute of Rural Health Supervisory Tools and EmONC skill checklists as well as the use of
anatomic models to guide on-site clinical simulations, data collection, support and reporting.
A trained team of 2-3 mentors visited each delivery facility on a monthly basis and also held quarterly
recognition or clinical update meetings with staff representatives from all facilities. The outcomes of
this approach have been successful. Staff acquired immediate and sustainable skills, improved health
provider confidence and improved morale. The health centres were also able to manage
complications in pregnancy and delivery; for example they were able to carry out the manual
removal of a placenta, which improved the outcomes for the pregnant women. They also reduced
the pressure on emergency transport systems and referral facilities. An increase in mentoring has
been observed (0.06% to 15%) and there has been improved documentation in service delivery
registers.
What was learnt from this district was the positive impact of strong leadership including ownership
by Mansa District Health Office, the involvement and collaboration with other partners and the use
of anatomical models for on-site clinical simulations.
2.4.4 Safer Anesthesia from Education (SAFE) Obstetrics: Improving maternal
outcomes through training
Worldwide 360,000 childbirth related deaths occur each year, mostly in most in low and middle
income countries. The most common causes of death are bleeding, infection, unsafe abortions,
eclampsia and obstructed labour. The SAFE Obstetrics programme is aimed at improving the clinical
management of life-threatening emergencies by anaesthetic practitioners.
This is a three day course focusing on the leading causes of death and resuscitation of the mother
and child. It is run by an overseas faculty with identification of potential local teachers. On the fourth
day a ‘Train the Trainer’ course is conducted among local delegates identified as potential trainers.
The course is handed over once the local trainers were self-sufficient and can cascade the training to
the provinces.
The course has been piloted and run in Uganda, Liberia and Ghana since 2011 and is due to start in
Zambia in 2013.
17
2.4.5 Use of Misoprostol for Post-Partum Heamorrhage prevention in Home
deliveries
In this pilot project Misoprostol was distributed in ten districts with high home deliveries. Following
this, an in-depth interview was conducted among twenty eight women in three districts (Chongwe,
Mumbwa and Mwense) who had been given the Misoprostol tablets during antenatal visits.
The outcomes of this pilot study demonstrated that women showed an understanding of the purpose
of Misoprostol, when to take the drug (i.e. after the delivery of the baby), precautions (ensuring that
the woman is checked for a second baby before she swallows misoprostol) and the common side
effects. After collecting Misoprostol during ANC some women discussed the drug with spouses,
friends, and relatives. However some women did not discuss the drug with anyone. The women
showed an understanding of the need for good, appropriate storage. In terms of community myths
there was a general appreciation of Misoprostol although, some felt it may negatively affect fertility
and the fetal development in future pregnancies. Being in possession of the Misoprostol tablets did
not influence womens’ birth plans and decision to deliver at home, this was usually due to other,
extenuating, circumstances.
In view of these findings, future Post-Partum Hemorrhage (PPH) prevention programmes in similar
rural settings should consider antenatal distribution of Misoprostol in areas with high rates of home
deliveries or limited access to skilled providers and supplies. Secondly, community level myths and
misconceptions need to be addressed. Finally additional guidance regarding the timing and sequence
for correct use of Misoprostol to prevent PPH should be provided.
2.5 Panel 5: Newborn Health Care Interventions
2.5.1 Newborn Health Scale Up Framework for Zambia: an Overview of the
Newborn Strategy
The goal of the scale up is to accelerate the reduction of neonatal morbidity and mortality. The
rationale behind this is that two thirds of newborn deaths could be prevented with a higher coverage
of essential maternal, newborn and child health service packages. It is also important to consider the
critical time periods of pre-pregnancy, pregnancy, labour, delivery and the first 1-2 hours of life up to
late the neonatal period (weeks 2-4 ).
The scale up therefore focuses on three strategic objectives which will guide programming and
selection of interventions. These include strengthening capacity to improve newborn health care at
all levels of the health care system, increasing the availability, access and utilization of high quality
newborn health care services and empowering communities to improve community maternal and
newborn health care practices, across the continuum of care.
The opportunities for this scale up cover the following: policy and planning, national pre-service and
in-service training, expanding promising national interventions and pilot programmes, community
and facility based strategies.
18
2.5.2 Newborn Care Training in Developing countries: the First Breath Clinical
Trial
Ninety eight percent of stillbirths and neonatal deaths occur in the developing countries. This
includes Zambia, where an intervention was demanded to reduce the NMR. The First Breath Clinical
Trial was used to train the trainers who in turn train midwives who conduct deliveries in 18 low risk
health birth centres in Lusaka and Ndola.
The training of midwives consisted of data collection; WHO Essential Newborn Care and the
American Academy of Paediatrics Neonatal Resuscitation Programme (NRP). 71,689 pregnant
women were enrolled in the study.
The results showed that the 7 day neonatal mortality rates reduced from 36.5 deaths to 25.1 per
1,000 live births after the Emergency Neonatal Care (ENC) training this was due to decreases in death
rates attributed to birth asphyxia and infection. There was a further decrease in deaths in the 7 day
neonatal mortality rates to 15.9 per 1,000 live births after the Neonatal Resuscitation Programme
training.
A cost effectiveness analysis was carried on the ENC training packages. A study in the first level
delivery clinics in Lusaka and Ndola showed it was very cost-effective in first level facilities ($5 per
DALY).
2.5.3 Zambia Chlorhexidine Application Trial (ZamCAT)
Umbilical cord infections and sepsis are leading causes of neonatal morbidity in low resource
countries. In Zambia, neonatal mortality accounts for 29% of under-five mortality, with infection
responsible for 30% or more of neonatal deaths.
The objective of the study was to determine whether Chlorhexidine cord cleansing is more effective
than dry cord care for prevention of neonatal mortality in the Southern province of Zambia.
This was a cluster randomized effectiveness trial of 4% daily Chlorhexidine umbilical cord cleaning
compared to dry cord care. In order to carry this out, pregnant women were enrolled in the study in
the second and third semester and were asked where they intended to deliver.
The results from the analysis of delivery plans for 9,816 pregnant women showed that of 93% who
indicated plans to deliver at health facility, only 63% actually carried out this plan. Women who
delivered at home tended to be older. The reasons for home delivery included distance, finances,
family pressures, short duration of labour, and lack of transport.
Once recruitment and follow up of pregnant women and their newborns have been completed, the
data will contribute evidence on the effectiveness of Chlorhexidine for reducing neonatal mortality.
2.5.4 Lufwanyama Neonatal Survival Project (LUNESP)
This project sought to establish whether, in communities with limited access to health care, it was
possible to reduce neonatal mortality by training TBAs in skills that address some of the most
important causes of neonatal mortality; notably birth asphyxia, neonatal hypothermia, and neonatal
sepsis.
19
This was a randomized intervention with two study groups. In one group training was given in
Neonatal Resuscitation Protocol including providing a single dose of amoxicillin coupled with
facilitated referral of infants to a health centre. In the second group, the control TBAs continued their
existing standard of care.
The results of this trial indicated that the intervention was highly effective in reducing neonatal
mortality, with 45% reduction in all-cause mortality by day 28 (primary endpoint); the neonatal
mortality rate decreased by 18 per 1000 live births. Secondly, the largest impact was in the earliest
days of life; on the day of birth a 60% reduction in NMR was seen and during week one a 44%
reduction in NMR was achieved. Finally NRP appeared to be the most effective component of
interventions, as birth asphyxia deaths reduced by 70-80%.
20
3. Key outcomes of the conference: setting priorities for action
After a day of presentations and discussion regarding interventions in maternal and newborn health
from key stakeholders working in Zambia (see the attached programme), the final session of the
conference asked the conference delegates through round table discussions to consider key priorities
or issues for ongoing discussion, between the Ministries, Cooperating and Implementing Partners, to
rapidly accelerate the reduction of maternal and newborn mortality in Zambia.
The following is a summary of the outcomes of the discussions and the issues and priorities
presented by each table leader on behalf of his/her table during the plenary discussion. Issues for
further consideration are in bold and numbered in each relevant section.
3.1 Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA)
The current health strategy in Zambia is to have a health system where all mothers and newborns
should be looked after by a Skilled Birth Attendant. However, it will take time to train and deploy
Skilled Birth Attendants. Conference delegates discussed whether, in the short term, Traditional Birth
Attendants should be trained in some of the relevant competences to make them safe practitioners.
3.1.1 Traditional Birth Attendants
It is estimated that Traditional Birth Attendants are engaged in the delivery of 23% [31% in rural
areas and 5% in urban areas] of babies in Zambia; meaning that some babies are being delivered at
home by TBAs, who may not be able to recognize or manage potential complications. A further 25%
of babies are delivered by a family member and 5% of women are alone during delivery. Delegates
discussed the fact that the involvement of TBAs in deliveries will not change in the short term. It was
recommended by a majority of participants that, in the short term, TBAs should be trained to
recognize danger signs in pre, intra and post-partum care, to help them to refer mothers in a timely
fashion to the next levels of care.
Further it was proposed by some delegates that in the short term, when an SBA is unavailable, TBAs
should be trained to have the competences to deal with some basic and emergency care of both
mother and baby. Some disagreed with this recommendation stating that TBAs should not be trained
but more effort should be made to increase skilled health workers.
Below are issues for further consideration as presented by table leaders related to TBAs;
1) Provide TBAs with training and mentoring to equip them with the competences to provide
safe and comprehensive care from family planning through to postnatal care, as well as
basic lifesaving skills. For example, being able to administer Misoprostol to manage post-
partum hemorrhage and equipping them with the competences to help babies breathe.
2) Develop a transition strategy for the redeployment of TBAs once SBAs are available.
21
3.1.2 Skilled Birth Attendants
Delegates noted that no country has turned around its MMR and NMR without skilled birth
attendants.
Below are issues for further consideration as presented by table leaders related to SBAs;
3) They endorsed the current plans to increase the capacity of training institutions to increase
the output of nurse/midwives. It was suggested that the ministries and international donors
continue to work together to plan and resource a rapid increase in training capacity.
4) They encouraged the ministries to review the policy framework for staff establishment to
ensure the employment, deployment, retention, supervision and continued training of SBAs
in all health settings including 24 hour coverage of health facilities.
5) Encourage the ministries to review the curriculum to develop health professionals with the
required competences in maternal and newborn health, including lifesaving skills. Some
delegates suggested that graduates should be both a nurse and a midwife through
shortened courses.
3.2 Increased involvement of Safe Motherhood Action Groups
Delegates noted that the government of Zambia responded to the challenge of providing a
continuum of care by supporting pilot programmes to establish Safe Motherhood Action Groups
(SMAGs) at community level. A framework has been established for the national scale-up of SMAGs,
through a standardized training package. During the conference evidence was presented on the
effectiveness of SMAGs and it is anticipated that when further evidence is available this will guide
future SMAG interventions.
Below are the issues to be considered further as presented by each table leader in relation to SMAGs
6) Increase the number of SMAGs to cover all districts.
7) Expand the role of SMAGS to include antenatal, intra-natal and post-natal care and family
planning.
8) Strengthen SMAGs competences so that they can further develop their community
interventions.
3.3 Volunteers and Community Health Assistants
It was noted by delegates that Community Volunteers and Community Health Assistants are offering
services that address maternal and newborn care and they also noted that accountability of
volunteers to the health system is weak.
Below are the issues to be considered further as presented by table leaders related to Volunteers
and Community Health Assistants.
9) Developing a volunteer management and coordinating system needs to be considered, to
include equitable remuneration, supervision and accountability mechanisms.
22
10) Reconsider the term ‘Volunteer’ as it does not carry authority, and define accountability or
remuneration.
11) That Community Health Workers/Assistants should complement the role of nurse/
midwives and there should be a degree of task sharing or task shifting.
12) They supported the training of Community Health Assistants and that they take on key roles
[especially with the introduction of an expanded curriculum] in reproductive, maternal and
newborn health.
3.4 Community involvement
The potential positive impact of community leaders on best practice in maternal and newborn health
was highlighted in discussion.
Below is the issue to be considered further as presented by table leaders related to community
leaders
13) Engage with Chiefs, Traditional Leaders, Head Men and Church Leaders in all districts to
encourage them to be advocates for safe maternal and newborn health practices.
3.5 NGOs and Coordinated Leadership
The conference survey and other evidence confirmed that there are a large number of organizations
(INGOs, NGOs, FBOs etc.) working in maternal and newborn health in Zambia. There is currently no
clear strategy, coordination or rationalization of the many organizations involved. The survey showed
that best practices informing activities in MNH are numerous and diverse.
Table leaders’ issues for the Ministries to consider further are:
14) Ministries taking the lead in the coordination and geographical distribution of organizations
working in MNH through an MOU and rules of engagement which include the use of human
and financial resources.
15) Developing best practice guidelines which organizations should use to guide activities in
MNH.
3.6 Strengthening access to care
It was noted that Zambians have difficulties in access to care in rural areas due to the distances to
health facilities and poor road infrastructure, particularly in the wet season.
Table leaders presented the following issue for further consideration:
16) The ministries should consider providing patient transport to each health facility and make
resources available to maintain them. These could be community managed (including
bicycles, motorbikes or boats) and delegates further recommended that the service should
be free to expectant mothers.
23
3.7 Emergency care
It was discussed that health posts were not fully developed in all districts and that health centers
were not always fully staffed and do not always have the equipment or infrastructure to provide
emergency obstetric and neonatal care [EmONC] nationwide.
Table leaders presented the following priorities for further consideration:
17) All mothers should be delivered where there are accessible EmONC services including basic
equipment, infrastructure and where there is access to emergency surgery by a trained
health worker.
18) Deliveries should be done in a health facility. Access to EmONC services should be available
at facility including referral systems in place if it is not an EmONC site.
3.8 Finalization of the MNCP Roadmap
It was discussed that the MNCP Roadmap had not been fully adopted into policy and that its
implementation requires a consistent approach to monitoring and evaluation.
The issues that table leaders presented for further consideration are:
19) Zambia’s health management information system needs to be enhanced to guide the
allocation of resources, including the use of standardized maternal and newborn indicators.
20) The Ministries should consider taking the lead in ensuring that organizations involved in
maternal and newborn health use a monitoring and evaluation framework that is aligned to
that of the Ministries.
3.9 Family planning
It was highlighted in discussions that birth spacing reduces MMR and NMR and that family planning
coverage across Zambia is only at 33%.
The following are issues for further consideration as presented by table leaders:
21) The ministries should consider rapidly accelerating family planning coverage using a range
of providers working to government strategy and standards.
22) The availability of injectable contraceptives should be increased, potentially using
community health assistants and workers as a method of administration. Delegates also
highlighted that the quality of this service could be ensured through the Health Professions
Council of Zambia issuing good practice guidelines.
24
4. Conclusion of the conference
Dr. Mwaba closed the conference by thanking the Zambia UK Health Workforce Alliance, Prof
Chomba and the local and international partners. He reiterated that the challenge of high MMR and
NMR in Zambia is one that can be overcome. The challenges of infrastructure, staffing and NGO
coordination need to be examined in order to improve the health of mothers and babies in this
country.
25
Appendices:
1. Conference Programme
08:30 – 09.30 REGISTRATION
09:30 – 10.05 Chaired by Dr. Peter Mwaba Greetings and welcome Objectives and why we are here Keynote speech
Prof. Elwyn Chomba, PS (MCDMCH) Lord Crisp, Chair of Zambia UK Health Work Force Alliance (ZUKHWA) Dr Joseph Katema, Minister of Community Development, Mother and Child Health (MCDMCH)
10.05 – 10.25
Presentation of and strategy in the MNCP Roadmap.
Dr. Caroline Phiri, (MCDMCH)
10.25 – 10.55
Presentation of Review paper: Survey of Maternal and Newborn Health Initiatives in Zambia.
Meredith Budge, Consultant, Tribal Strategies
10.55 – 11.03 11.03 – 11.10
Ministry of Health Overview of the Community Health Workers Programme. Midwives Association of Zambia (MAZ)
Jenny-Meya Nyirenda (MoH) Mr David Mbewe, Vice President
11.10 – 11.20 Collect refreshments and return to tables promptly
11.20 – 11.45 Q&A chaired by Lord Crisp
11.45 – 12.20 Safe Motherhood Action Groups Presentation Panel Introductions and Update on the implementation of Safe Motherhood Action Groups in Zambia Safe Motherhood Action Groups (SMAGs) training in Mwinilunga district AFRICARE: Mobilizing communities to reduce maternal mortality Communications Support for Health “Mother’s Alive” Campaign Questions to Panel
Chaired by Dr. Elizabeth Chizema Monde Imasiku, Principle Nursing Officer (PMO) Mr Ernest Kakoma, (MoH), Solwezi
Elizabeth Simwawa Maggie Sinkamba
26
12.20 – 12.50
Access to Care and Community Interventions Church’s Health Association of Zambia (CHAZ) Community Leadership: PMTCT Programme to improve health outcomes of HIV exposed babies MAMAZ Mobilising Access to Maternal Health Services in Zambia: Interventions Medecins Sans Frontieres: “The Bicycle Ambulance” Riders for Health: Transport Reducing delays to accessing laboratory-based testing Questions to Panel
Chaired by Dr. Peggy Chibuye Dr. Dhally M. Menda, Director of Health Programmes Mr Abdul Razak Badru Hemmend Lukongs Ms. Constance Chibiliti
12.50 - 14.00 LUNCH (Visit Project and Poster Displays)
14.00 - 14.45 14.45 – 15.10
Maternal Health Care Interventions Saving Mothers, Giving Life Endeavour (Summary of 4 Abstracts) Emergency Obstetric and Newborn Care The Role of Intensive Mentorship in Emergency, Obstetric and Neonatal Care SAFE Obstetrics Society for Family Health: Use of Misoprostol for PPH prevention Questions to Panel Newborn Health Care Interventions Outline of Newborn Strategy Center for Infectious Disease in Zambia (CIDZR): Newborn Care Training in Developing Countries: The First Breath Clinic trial Zambia Center for Applied Health Research and Development (ZCHARD): ZAMCAT Trial and TBA Training Questions
Chaired by Dr. Sebastian Chinkoyo U.S. Government Agencies and Implementing Partners USG Representative Dr. Carla Chibwesha, CIDRZ Martha Ndhlovu, MCHIP Prof. John Kinnear Ms Jully Chilambwe Chaired by Dr Penelope Kalesha-Masumbu, Ministry of Health Dr. Albert Manasyan Dr. Godfrey Biemba
27
15:10 – 15.25 Collect refreshments and return to tables promptly
15.25 – 15.30 Introducing Discussion Groups, Lord Crisp
15.30 - 16.15
Discussions and Action Points 12 tables of participants will propose key priorities and action points to move forward
Chaired by Lord Crisp
16.15 – 17.00 Presentations of Recommendations by each table
Chaired by Lord Crisp Rapporteurs: Dr. David Percy (ZUKHWA) and Mercy Mbewe (Nurse and Midwife Educator)
17.00 – 17.30 Plenary discussion of recommendations Setting Priorities and Action to move forward
Chaired by Lord Crisp
17.30 – 17.45 Closing Remarks / Follow up: What next? Prof. Chomba, and Dr. Mwaba.
28
2. List of participants
Zambia UK Health Work Force Alliance Chairman Lord Crisp
Zambia UK Health Work Force Alliance Director Dr. David Percy
Zambia UK Health Work Force Alliance Coordinator Vanessa Halipi
Zambia UK Health Work Force Alliance Assistant Coordinator Louise Smith
THET Country Representative Emily Measures
Ministry of Health Permanent Secretary Dr. Peter Mwaba PS
Ministry of Health Director Public Health and Research
Dr. Elizabeth Chizema
Ministry of Health Deputy Dir Public Health and Research
Dr. Max Bweupe
Ministry of Health Principal Surveillance and Research Officer
Dr Pascalina Chanda-Kapata
Ministry of Health Senior M&E Officer Brivine Sikapande
Ministry of Health The Acting Chief Nursing Officer Mrs Sarah Shankwaya Siyunda
Ministry of Health National community Health Specialist
Jenny-Meya Nyirenda
Ministry of Health
Roy Chisihinga
Ministry of Community Development, Mother and Child Health
Permanent Secretary Prof Elwyn Chomba
Ministry of Community Development, Mother and Child Health
Acting Director, MCH Dr. Caroline Phiri
Ministry of Community Development, Mother and Child Health
Acting Deputy Director, Child Health
Dr Penelope Kalesha-Masumbu
Ministry of Community Development, Mother and Child Health
Health Promotion officer Ms. Beatrice Mwape
Ministry of Community Development, Mother and Child Health
Friday Nkhoma
DFID Health Advisor Meena Gandhi
DFID Programme Officer Chibesa Chibesakunda
DFID Health Advisor Sile Seko-Grutz
Midwives Association of Zambia Vice-President Mr David Mbewe
AfriCare Programme Manager Gertrude Musonda
AfriCare Country Representative Paul Pascal Chimedza
AfriCare Provincial Facilitator Elizabeth Simwawa
Afyamzuri Director of Programmes Moses Sinkala
Boston University/ZCAHRD Country Director Dr Godfrey Biemba
Brighton-Lusaka Healthlink Trustee Cassandra Blowers
CARE Programme Manager John Kabongo
Catholic Medical Mission Board Country Director Dr Moses Sinkala
Centre for Infectious Deseases Research Project Coordinator Melody Kunda Chiwila.
CHAI (Clinton Health Access Initiative) Lead for maternal health Kathryn Bradford Vosburg
29
CHAI (Clinton Health Access Initiative) Country Director Jan Willem van den Broek
CHAI (Clinton Health Access Initiative) Programme Manager Dr. Rachel Thomas
CHAI (Clinton Health Access Initiative)
Nalwndu Muthumbwa
CHAZ (Churches Health Assocation of Zambia)
Executive Director Mrs. Karen Sichinga
CHAZ (Churches Health Assocation of Zambia)
Director of Health Programmes Dr.Dhally Menda
CHAZ (Churches Health Assocation of Zambia)
Deputy Chief of Party Dr. Modester Bwalya
CHAZ (Churches Health Assocation of Zambia)
Manager Health Programmes Rosemary Kabwe
Chemonics, Communications Support for Health Project
Deputy Chief Of Party Linda Nonde
Childfund Partnership Development Director
Godfrey Mwelwa
Childfund Technical Advisor - Health Lydia Jumbe
Childfund
Priscilla Chama
Children in Need Network Executive Director Theresa Katempa Kabeka-Mwansa
CIDA (Canadian International Development Agency)
Development Officer Mr Gregory Saili
CIDA (Canadian International Development Agency)
Development Officer Mrs Pezo Mateo-Phiri
CIDRZ Assistant Professor of Obstetrics and Gynecology
Dr. Carla Chibwesha
Concern Project Manager Subrata Chakrabarty
CSH Zambia Deputy Chief of Party Anne Fiedler
CSH Zambia SMGL Coordinator Margaret Sinkamba
CSH Zambia
Christina Wakefield
CSH Zambia
Ethel Kupelende
Dalhousie University
Adrian Mackenzie
Dalhousie University Director; WHO/PAHO Gail Tomblin Murphy
Dalhousie University
Amy Gough
EGPAF Country Director Susan Strasser
EGPAF
Lauren Smith
Faith's Orphans Foundation Director Faith Liyena
Family Fountain of Hope Coordinating Secretary Monde Imasiku
FHI360 Country Director Dr. Prisca Kasonde
FHI360 / LPCB Family Planning and HIV Olivian Chizyuka Namangolwa
Freelance Consultant
Dr. Peggy Chibuye
Gates Foundation Consultant Felice Apter
GlaxoSmithKline Country Manager Suzgo Kaira
Global Network for Women’s and Children’s Health Research
Programme Director Dr. Albert Manasyan
Happy Children (HAPCHI) Community Executive director Peter Dimas Mfwaya
30
Development Project
Health Professions Council Zambia Registration Officer Nandipa E Kalenje
International Association for Digital Publications
Director Angus Scrimgeour
IPAS
Dr. Chibesa Chibesakunda
ITOCA Programme officer Blessing Chataira
JICA HIV/TB Programme Co-ordinator Naomi Hamada
JICA Child Health Specialist Dr Aya Kayebeta
JICA In House Consultant - Health Priscilla Likwasi
JPHIEGO MCHIP Coordinator Michelle Wallon
JPHIEGO MCHIP MNH Technical Advisor Martha Ndhlovu
Katete School of Midwifery Nurse Tutor Mr Alidon Banda
Livingstone General Hospital Obs/Gynae Specialist EmONC trainer
Dr Isaiah Hansingo
MAMAZ Country Director Abdul Razak Badru
MAMAZ Programme Assistant Dynes Kaluba
Marie Stoppes Country Director Adrienne Quitana
MCHIP
Martha Ndhlovu
Medecins Sans Frontieres Luwingu project Medical Team Leader
Hemmed Lukonge
Médecins Sans Frontières Regional Medical coordinator based in Harare
Dr Jean François Saint-Sauveur
Médecins Sans Frontières Luwingu District Mother and Child Health Coordinator
Mr. Munkombwe Davey
Medical Aid Films Nurse Tutor at Chitambo Mission Hosp
Levison Chifwaila
Mercy Flyers UK Anaesthetist Dr. Andrew Wood
Nchanga DEM School, Chingola Principal Tutor Ms Gladys Kapembwa
Ndola Central Hospital Consultant obstetrician and clinical lead for Guys Link
Dr Sebastian Chinkoyo
NIPA Nurse Midwife Educator Mercy M. Mbewe
OUT TO AFRICA PROJECT Anaesthetist Dr. Niven Akotia
OUT TO AFRICA PROJECT ICU Sister Sr Julie Windass
PATH Country Director Joan Littlefield
Riders for Health NGO Health Transport Constance Chibiliti
Riders for Health
Charles Situmbeko
Roan DEM school, Luanshya Principal Tutor Mr Ronald Katongo
Save the Children Advocacy Coordinator Kotuto Chimuka
School of Midwifery Principal Tutor Mrs Beatrice Zulu
School of Nursing Acting Principal Tutor Eric Chisupa
School of Nursing Nurse Tutor Betty Mwinga
SIDA (Swedish International Development Agency)
First Secretary; Health, HIV and AIDS
Veronica Perzanowska
SIDA (Swedish International Development Agency)
National Programmeme Officer Audrey Mwendapole
31
Sightsavers Country Director Glenda Mulenga
SMAG: Mwinilunga District Trainer Mr Ernest Kakoma
Society for Family Health Reproductive Health Programme Manager
Jully Chilambwe
THET Partnership Development Director
Andrew Jones
THET Communications Maggie Jones
THET Eleonah Kapapa
THET Safe Obstetrics Training Course Prof. John Kinnear
THET UTH NHS Manager Lisa Kelly
Tribal Stretegies Consultant Meredith Budge
UNAIDS (Joint United Nations Programme on HIV/AIDS)
Investment and Efficiency Advisor Mrs Robin Ridley
UNICEF Country Coordinator Dr Nilda Lambo
UNICEF Health Specialist-Maternal Newborn and Child Health
Mrs. Christine Mutungwa-Lemba
UNZA NASG Representative Rhoda Amafumba
UNZA NASG Representative Dr.G. Mkumba
UNZA Medical School Dean Dr. Fastone Goma
US AID FP/MNCH Advisor Dr. Masuka Musumali
US AID Deputy Team Leader Dr. Jorge Velasco
US AID Senior Health Advisor Dr Kanweka, William
USAID HPN: Health Population and Nutrition Officer
Sangita Patel
USG, CDC
Dr. Lawrence Marum
UTH
Dr. Mkienechansa Masuku
VSO Country Director Phil Thomas
WORLD VISION Child Health Now Coordinator Miss Chitimbwa Chifunda
ZAGO Zambian Association of Obs and Gynae
Obstetrician and Gynaecologist Dr Getrude Gundumere Tshuma
ZAGO Zambian Association of Obs and Gynae
Senior Registrar on the Neonatal unit
Dr M Kapasa
School of Medicine, Uni. of Zambia Assistant Dean Dr. Margaret. C Maimbolwa
ZUNO (Zambia Union of Nurses Organizations)
Director Programs and Professional Affairs
Mrs. Jennifer Munsaka
ZUNO (Zambia Union of NursesOrganizations)
Agnes Sitanzye
32
3. Question and answer sessions
Panel 1 - Maternal, Neonatal and Child health Questions/comments Responses
Can you give us an insight to why there
are few maternal health interventions
in the Northern Province?
The reason that remote areas are poorly covered is to do
with coordination and strategic planning. There is a lot
happening in very concentrated areas and it is very difficult
to get staff to go to rural areas. The MCDMCH is developing
a register where NGOs should indicate where they are
working.
How many Community Health Workers
have been trained, how have they
been deployed and which communities
are to be covered?
We have 307 of Community Health Workers as of July this
year. Some have been deployed to a population of 3300
people.
Do we know where the trained
midwives are? Is there a register?
At the moment it is difficult to establish where trained
midwives are currently working/ deployed. Midwives have
choice of where to go and remote areas are not the most
preferred. Many choose the private sector or go abroad.
What is the way forward for TBAs since
you said they cannot do deliveries?
The TBA will refer cases to health centers. It is not fair to
give them a task they cannot cope with, their role is to
guide women to health centres. Offering intrapartum care
by TBAs would be difficult without intensive supervision
and scaling up their competencies.
In view of revising the CHW
curriculum, what will happen to those
who have been trained on the old
curriculum?
Those trained on an old curriculum have been attached to
someone trained on the new curriculum for mentoring.
Comment: Best practices involve the communities but incentives are not harmonized. There is need
for a volunteer management system because the same people are being used repeatedly and are
being over burdened.
Do we train the TBAs or not train
them? Lets be honest. We have to
reduce other factors too, like distance.
We need to find a solution to this.
TBAs are still doing deliveries, what I said was that their
role should not include carrying out deliveries. But if we do
not train more midwives then we will not address this
problem.
The Health Professionals Council is still
deciding on community based
distributors; how far are you from
arriving the decision?
Regarding distributors and family planning; there is a team
at the MoH who are looking into this issue.
33
How are we going to ensure that the
Community Health Assistants being
introduced are not a short cut to fully
skilled staffing by the MoH?
MoH has a plan for different cadres. People have a choice
but community health workers/assisatants are still
needed. The MoH is paying a salary to CHAs.
Panel 2 - Safe Motherhood Action Groups Questions/comments Responses
Has the SMAGs training been standardized? The SMAGS training manual has been reviewed and
is now standardized to incorporate the use of
pictures for training and to make training more
practical.
There are concerns about the distances to
health facilities which need to be addressed,
these measures should be sustainable.
This requires further discussion but the MoH has a
budget for infrastructure.
Comment: bicycle ambulances are in rural
areas where people cannot afford to pay.
Bicycle ambulances should be free.
Concerning obsetric fistulahow is it
addressed? Can a mother wait in the
mother’s shelter until they are taken?
There should be a commitment to reducing the
occurrence of obstetric fistulae through promoting
and encouraging maternal waiting shelters and
identifying fistula patients for referral.
Africare have facilitated transport, sanitation and
detegents while the women await surgery.
Panel 3 - Access to Care and Community Interventions Questions/comments Responses
Are there any gaps? Are all the districts
are covered, and if they are, how can
they can be sustained?
If the SMAGs are motivated then it can sustained.
Could you say more about the use of
bicycles and motorbikes?
In the Eastern province, a motorbike is used where roads
are difficult to pass. In unaccessible areas, costs vary from
district to district due to the number of facilities, however
a charge per kilometer can be worked out.
The maintenance of the bicycle ambulance was a problem
as most communities cannot afford their upkeep. The
government should take on this responsibility by supplying
and maintaining the bicycle ambulances.
34
Panel 4 - Maternal Healthcare Interventions Questions/comments Responses
When will the SAFE Obstetrics course start in
Zambia?
The course was due to start next Monday but it
will now start in February 2013. It will start with
30 anaesthetic practitioners.
Misoprostol for family planning; if let loose it
may be abused for abortion. What measures are
there to prevent that?
Misoprostol is a controlled drug therefore its use
and administration is strictly regulated.
There is a management chain where
accountability is demanded for all tablets
dispensed.
Antenatal women are given three tablets. They
are instructed to surrender the drugs if they are
not used and there have been no problem so far.
Comment: “Women may visit the health facility many times, but still die from pregnancy
complications if there are no skilled birth attendants present”.
Panel 5 - Newborn Healthcare Interventions Questions/comments Responses
How much it will cost to train TBAs? It is a highly cost effective intervention.
You have been talking about training TBAs for
delivery, but this needs to be discussed -
especially regarding issues of distance and access
to health care.
We do have a follow up study on TBAs. It is a
controversial issue, especially regarding taking
care of the mother and the baby.
It is biased to see the outcomes of the delivery
only considering the baby. What about the
mother and the TBA?
Cost effectiveness was only done on deliveries in
health clinics but effects on TBAs I cannot
comment
There are a lot of TBAs in Zambia and we need to
evaluate this. In Eastern province they are doing
a good job.
The question should be: “do we train TBAs?”.