Saving Mothers’ Lives W h a t W o r k s Field Guide for Implementing Best Practices in Safe Motherhood The White Ribbon Alliance for Safe Motherhood/India Best Practices Sub-committee September 2002 WRA Global Secretariat: WRA Global Secretariat: 1050 17th St., NW, STE. 1000 Washington, DC 20036 USA email: Copyright © 2002, The White Ribbon Alliance for Safe Motherhood/India (WRAI). All rights reserved. Designed by Cecilia Snyder Photographs courtesy of the White Ribbon Alliance This publication was made possible through support provided by: ICICI Social Initiative Group, Mumbai, India The ENABLE Project/The Centre for Development and Population Activities (CEDPA) and the United States Agency for International Development, Office of Health, Infectious Diseases, and Nutrition under the terms of Cooperative Agreement No.: HRN-A-00-98-00009-00 The MacArthur Foundation The opinions expressed herein are those of the authors and do not necessarily reflect the views of ICICI, USAID, and The MacArthur Foundation. The reprinting of this publication was made possible through support of USAID, Office of Health, Infectious Diseases, and Nutrition/CATALYST Consortium The reprinting of this publication was initiated by The Child Survival Collaborations and Resources Group (CORE). CORE represents a consortium of 35 PVOs implementing child survival projects which have 18 years of experience in designing, implementing, and evaluation community-based Child Survival projects that seek to reduce childhood and maternal mortality and morbidity. ACKNOWLEDGEMENTS In 2001, the White Ribbon Alliance for Safe Motherhood, India (WRAI) as part of one of our three goals - To Act As A Catalyst For Action To Address The Tragedy Of Maternal Deaths - felt the need to share the most recent evidenced based knowledge and practices from India, the region and around the world about what works (and what does not) to reduce maternal mortality. The WRAI decided to form a committee to produce a Field Guide on Safe Motherhood Best Practices. We would like to acknowledge our committee members for their vision, guidance, and fund-raising efforts to make this Field Guide possible: Marta Levitt-Dayal, CEDPA Shilpa Deshpande, ICICI Social Initiatives Group Anisha Arur, ICICI Social Initiatives Group Janet Chawla, Matrika Lovelyn Johri, CARE, India Ragini Pasricha, PRIME/INTRAH, India Criteria for the Field Guide was get by the committee – we wanted evidence of impact but also the how to’s of best practices. Often case studies tell about the best practices, but in few cases do we learn about the steps in how these were achieved or get the tools used to allow us to replicate these best practices. We wanted to put together a sort of “cookbook of safe motherhood best practices.” A call for best practices was sent out globally to the White Ribbon Alliance for the collection of current evidence-based best practices that included the how to’s of implementation. In addition, a thorough search was done for information, publications, presentations and other documents on evidence-based safe motherhood and best practices. This initial process which was far more challenging than expected as though many of us do good work, we tend to not document the how to’s of what we do. Thus, the recipes for our best practices “cookbook” will need to continue to be collected. We would like to thank those who responded and ask our readers to write us and send additional best practices with the how to’s that will enable us to publish a series of issues on best practices. We are thankful to Dr. Aparajita Gogoi, WRAI coordinator, CEDPA for spearheading the entire process, to Renuka Motihar for leading the search for and collection of information and published material on and examples of best practices and assisting us in defining a best practice, and to Deepika Ganju for helping us conceptualize the format of the field guide and for writing the initial drafts of the sections on Facts About Maternal Mortality, ANC and Postpartum Care. The WRAI is most grateful to the group of WRAI members who took it upon themselves to complete this Field Guide – writing the remaining sections and finalizing drafted sections - in time for launching at the International Conference on Safe Motherhood: Saving Mothers Lives: What Works held in Delhi, Oct. 3-6 2002: Janet Chawla, Matrika, wrote the section on Building Bridges Between Indigenous And Biomedical Practices And Practitioners Sara Chhetry wrote the final draft of the section on Postpartum Care and fist draft of the section on Obstetric First Aid Jean Patrick DuConge, MD, MPH, Medical Advisor, European Commission Health and Family Welfare Programme, India wrote the section of Effective Referrals Marta Levitt-Dayal, PhD, MPH, Chief of Party, CEDPA/India wrote the Introduction, Training of Traditional Birth Attendants, Skilled Attendance, and Birth Preparedness; finalized the sections on Community-Based Obstetric First Aid And Home-Based Life Saving with Rajni Ved and on Postpartum Best Practices. Dr. Levitt-Dayal also completed the final technical editing of the Field Guide. Inga Inga Lucyna Oleksy, MPH, wrote the section on Verbal Autopsy Shereen Penny wrote the section on Management of Labor and Delivery with Sara Chhetry. With Anuradha Marwah, Marta Levitt-Dayal collated and organized the material and edited the entire document to make it as user-friendly as possible. We would like to acknowledge the following publications in particular that this Field Guide has heavily drawn from: 1. De Brouwere, V & Van Lerberghe (Eds) (2001) Safe Motherhood Strategies: A Review of the Evidence, Studies in Health Services Organisation and Policy 17, Antwerp, Belgium, ITG Press. 2. MAQ Exchange (2002). CD Powerpoint Presentations on ANC and Intrapartum Care. USAID. 3. Ross, Susan Rae (1998) Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers. CARE. 4. White Ribbon Alliance for Safe Motherhood (2002). Community Works: A Technical Resource Packet 5. WHO presentation on Skilled Attendance, 2002. Finally, we would like to give our sincere appreciation to the organizations that have provided financial support for this publication: ICICI Social Initiative Group, USAID through CEDPA’s ENABLE project and The MacArthur Foundation. We hope that our colleagues in the field and those who are designing programs and policies will find this publication useful in steering us towards adopting evidence-based practices. White Ribbon Alliance, India, 2002 TABLE OF CONTENTS Introduction to Best Practices ........................................ 1 The Facts About Maternal Mortality .................................... 11 Making Antenatal Care Effective ....................................... 21 Birth Preparedness and Complication Readiness ......................... 32 Skilled Attendance at Delivery ........................................ 45 Training of Traditional Birth Attendants .............................. 56 Management of Labor and Delivery ...................................... 69 Postpartum Care Best Practices ........................................ 83 Effective Referrals for Obstetric Emergencies ......................... 95 Community-Based Obstetric First Aid and Home-Based Life Saving ........ 115 Verbal Autopsies ...................................................... 133 Building Bridges Between Indigenous and Biomedical Practices and Practitioners ........................................ 147 ABOUT THE WHITE RIBBON ALLIANCE The White Ribbon Alliance for Safe Motherhood was set up in May 1999 in the US by several international organizations to increase awareness of the need for safe pregnancy and childbirth. The Alliance aims to foster grassroots efforts that complement the work of the Safe Motherhood Initiative, and to build alliances and act as a catalyst for action. Alliance members believe that a broad-based coalition can make safe motherhood a priority issue for governments, NGOs, donors and international organizations. Alliance partners collaborate to reduce maternal mortality through shared resources and experiences. These efforts have gone a long way in increasing awareness of the issue with policy makers, legislators, NGOs, health service providers families and communities. The WRA now works in 20 countries across the world. The White Ribbon is dedicated to the memory of all women who have died in pregnancy and childbirth—to all those whose lives could have been saved. The White Ribbon Alliance in India Unlike general mortality and infant mortality in India, maternal mortality has not declined significantly. In India over 100,000 women die due to pregnancy-related causes every year. The recently released NFHS-2 data shows that the maternal mortality ratio (the number of pregnancy related deaths per 100,000 births) is 540, indicating no reduction in the rate of maternal deaths in the last six years. Moreover, maternal mortality is far greater in rural areas (619, according to NFHS 2) than in urban areas. The White Ribbon Alliance Movement was launched in India in November 1999 to raise awareness among citizens, international NGOs, national NGOs and governments of the need to ensure safe pregnancy and childbirth; build alliances through wide-ranging, intersectoral partnerships; and act as a catalyst for action to reduce maternal deaths and sustain the current safe motherhood effort. Today, the alliance in India has 58 member organizations and five state level chapters, with diverse membership from international and Indian NGOs, donors, researchers, activists and health professionals. A range of perspectives are represented, from biomedical to ethnomedical. This provides an opportunity for dialogue, exchange, and convergence of ideas. The Alliance has been actively involved in a number of areas. Partners: • Share existing material and best practices • Mobilize involvement and endorsement from political figures and policy makers • Implement innovative projects and campaigns through local partners and networks • Disseminate messages and information through the mass media • Decentralize coalition activities to the States and expand grassroots action • Collaborate with different organizations and sectors to decrease maternal mortality through shared resources and experiences. • Increase awareness of safe motherhood and related issues among policy makers, legislators, NGOs, health service providers, families and communities. • Help local NGOs integrate safe motherhood activities within their existing programs • Advocate through members, media, government, the private sector etc. to turn the alliance activities into a movement • Build alliances at the grassroots level and at the state/regional level • Build the capacity of NGOs/CBOs/service providers • Mobilize/facilitate resources to enable grassroots NGOs to efficiently concentrate and plan activities relating to safe motherhood. • Mobilize celebrities to talk about the issue. INTRODUCTION TO BEST PRACTICES This section will help the reader to make a shift from continuing to implement safe motherhood activities as has always been done to exploring and using the evidence to make programmatic strategy decisions. Implementers will learn: z Why we are writing this field guide z What do we mean by best practices z Lessons learned from history and evidence z Facilitating change in light of the evidence z Social mobilization, societal change and safe motherhood 1