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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

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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.

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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

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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

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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

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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

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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.

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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.

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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;

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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


Acting Director, MCH Dr. Caroline Phiri


Acting Deputy Director, Child Health

Dr Penelope Kalesha-Masumbu


Health Promotion officer Ms. Beatrice Mwape


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


Director of Health Programmes Dr.Dhally Menda


Deputy Chief of Party Dr. Modester Bwalya


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.

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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.

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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?”.

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