GUIDELINE ON MATERNITY WAITING HOME - Ministry of Health

Acknowledgement
The Ministry of Health wishes to acknowledge the contributions made by:
-Professor Koum Kanal, Director of the National Maternal and Child Health Center
-Dr Tung Rathavy, Deputy Director of the National Maternal and Child Health Center
-Dr Narimah Arwin, WHO WPRO Regional Advisor
-Dr Cheang Kannitha, WHO Cambodia
-Dr Mary Mohan, MCH Freeland Consultant
-Dr Heng Nhoeur, Director of Provincial Health Department Stung Treng
-Ms Sann Channy, Stung Treng Provincial MCH Chief
-Dr Khoy Bun Thanny, Director of Provincial Health Department Preah Vihear
-Dr Kuong Lo, Director of Provincial Referral Hospital, Preah Vihear
-Mrs Marcia Harmond, Care and Relief for Child, United Kingdom (CRY-UK)
-All officers from National Reproductive Health Program.
The Ministry of Health would like also to thank all those who participated in the workshop
held on 24 December 2009 and provided invaluable input to finalize this document.
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Content
Background……………………………………………………………………………………... 4
Purpose of Maternity Waiting Home…………………………………………………………… 4
What are the crucial elements of a Maternity Waiting Home…………………………………... 4
History of Maternity Waiting Homes around the world………………………………………... 5
Experiences in Cambodia……………………………………………………………………….. 5
Establishing of a Maternity Waiting Home…………………………………………………….. 7
Identification and referral of women……………………………………………………………. 10
Monitoring, Evaluation and Indicators………………………………………………………….. 10
Annexes………………………………………………………………………………………….. 12
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NATIONAL GUIDELINE ON MATERNITY WAITING HOME
1. BACKGROUND
Somewhere in the world a woman dies during or as a result of pregnancy or childbirth, every
minute of every day. Of the 580,000 maternal deaths which occur each year, 99% occur in the
developing world. Currently, most of maternal deaths result from the direct obstetrical
complications of hemorrhage, sepsis, obstructed labor, hypertensive disorders of pregnancy and
septic abortion.
What is lacking in many areas of the world is the ability to bring the necessary technical
skills – economic, geographical, and operational – to the women in need of help. Access to a
continuum of care, including appropriate management of pregnancy, delivery, post partum care and
access to life-saving obstetric care when complications arise are crucial to Safe Motherhood.
There are three possible ways to improve access to obstetrical services when complications
arise:
1. Bringing medical services to women in need – e.g. flying squads
2. Bringing women who need them to medical services - emergency transport
3. Decentralization of care so that women have easy access to skilled obstetric care
2. PURPOSE OF MATERNITY WAITING HOME
The purpose of Maternity Waiting Home (MWH) is to provide a setting where high-risk
women can be accommodated during the final weeks of pregnancy near a hospital with
Comprehensive Emergency Obstetric and Newborn care facilities. Some MWHs have expanded
their purpose to include not only decreased maternal mortality but also improved maternal and
neonatal outcomes.
Many consider MWH to be the key element to ‘bridge the geographical gap’ in obstetric
care between rural areas, with poor access to facilities and urban areas where the services are
available. In these maternal waiting homes additional emphasis is put on education and counseling
regarding pregnancy, delivery and care of the newborn infant and family.
While anecdotal evidence indicates that MWH is successful in reducing maternal mortality,
little quantitative research has been done to substantiate or prove their efficacy. Utilization rates and
user satisfaction are insufficiently documented.
3. WHAT ARE THE CRUCIAL ELEMENTS OF A MATERNITY WAITING HOME
Maternity Waiting Homes (MWH) are residential facilities, located near a health facility,
where women defined as ‘high risk’, including those expecting their first delivery, women with
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many previous births, very young women, older women and those identified as having problems
such as high blood pressure during pregnancy, can await their delivery and be transferred promptly
to a tertiary medical facility, should complications arise.
MWHs are places where women can be accommodated for the last weeks of pregnancy, near
a hospital with Emergency Obstetric Care.
• They do not require high technology
• They rely instead on human resources already present in many communities
• They can serve in a practical way to meet the needs of the pregnant woman
• They are the link in a larger chain of comprehensive maternity care, all components of
which must be available and of sufficient quality to be linked with the home
• The concept of MWHs has been based on the premise that it is possible to identify
pregnancies likely to develop complications and need skilled obstetric care.
4. HISTORY OF MATERNITY WAITING HOMES AROUND THE WORLD
Several countries have developed ‘Maternity Waiting Homes’ as an alternative to
decentralization of essential obstetric services. Some were launched as a result of government
initiatives (e.g. Mongolia, Cuba), others were created by medical, academic and community groups
(e.g. Columbia, Indonesia).
Since the beginning of the 20 th century these homes have existed in Northern Europe,
Canada and the US. In Africa one of the early experiments with MWHs was in Eastern Nigeria in
the 1950s known as ‘Maternity Villages’. These maternity waiting areas developed in small
buildings adjacent to the district hospital where women were housed for at least two weeks of their
pregnancy. Such houses helped to reduce maternal mortality. Cuba built the first home in 1962,
followed by 85 more in the country; MMR fell from 118 to 31 per 100,000 live births. Ethiopia,
Nicaragua, Mozambique, Papua New Guinea and Bangladesh and some of the other countries have
tried this initiative. Today various forms of waiting homes have been documented in 18 more
countries.
5. EXPERIENCES IN CAMBODIA
Maternity Waiting Homes are still in its infancy in Cambodia. Currently there are no
specific guidelines regarding the development of such homes. A couple of NGOs, however, have
piloted, MWHs in remote provinces in the country, Stung Treng, Koh Kong and Preah Vihear.
With this document, the National Maternal and Child Health Centre (NMCHC) of the
Ministry of Health in Cambodia, is developing a guideline that will help in the establishment of
Maternal Waiting Homes in the more remote and inaccessible parts of the country as part of their
continuing effort to address and reduce Maternal Mortality in the country.
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5.1 Koh Kong
In December 2002, with support from CARE, 2 Mother-Houses were built in Srae Ambil
and Beung Preav HCs in Koh Kong, then followed by 2 more in Takavet and Andong Teuk HCs
in 2004, to solve problems of low delivery rate in health centers, women are living far away
from the health centers and no place for women to wait during pre and post-delivery. The
objectives of building Mother-houses are:
• Increase percentage of women delivered a baby with a trained providers at health
facility
• Increase percentage of infants less than 6 months who were put to the breast
immediately after birth.
• Increase percentage of postpartum women who receive a postpartum check up within
2 days.
• Increase percentage of postpartum women who received a vitamin A capsule and 42
iron tables from midwives
As results, the number of delivery at health center increased from 4 in 2001 to 239 in
2004. And referring coverage by TBAs to health facilities increased from 0 (in 2001) to 3% (in
2004).
5.2 Stung Treng
In 2004, a MWH was established in the remote district in order to:
• Increase the utilization of the hospital by women for delivery and care
• Enable poor women at risk from pregnancy and child birth living in remote areas
greater access to medical care.
A house with 2 rooms, a kitchen and bathroom located next to the hospital was rented. The
single most important issue highlighted by women was food. If food was provided they were
happy to use the MWH. Women were referred to the house by TBAs, midwives and doctors.
Those women who came were assessed by the RH or the HC and a plan made and eligibility
justified. On the other hand several of the women referred to the home were those with post
natal complications, so that they were able to complete their treatment. Midwives from the RH
visited the MWH twice a week to provide care and health education. The data showed an
increasing number of women with ANC2 from 2077 (62%) in 2006 to 2856 (81%) in 2009; and
an increasing in percentage of women who give births with trained midwives from 14.3% in
2006 to 31.4% in 2009.
5.3 Preah Vihear
With supporting budget from Cry-UK, the MWH was started constructing in the ground of
16 Makara Referral Hospital, Preah Vihear province on 20 March, 2008. The building will be
served for public sector in October same year, with the aim of reduction maternal and child
mortality and morbidity rate in the whole province. The MWH will be a place for pregnant
women with complications to stay for the safe delivery. The vision of MWH is that all pregnant
women with high risk, of whatever, age, race, living status, and place of residence to have equal
access to high quality of care. The report from Preah Vihear showed that there is an increasing
of utilization of referral hospital for delivery from 348 (delivery by skilled staffs) in 2008 to 480
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in 2009. Pregnant women from remote areas were gradually known about MWH and stayed in
this facility for safe delivery. In late 2008, 2 women stayed and delivered in referral hospital, 39
women were in 2009 and there were 28 women from January to May 2010.
The MWH has proved to be popular in remote provinces. The willingness for women to
return to the house sometime after birth might suggest satisfaction. Over half the women using
the waiting house are very poor, are at risk and have 100% exemption from hospital fees.
6. ESTABLISHING OF A MATERNITY WAITING HOME
Maternity Waiting Homes are the solution to a specific problem – geographic inaccessibility
to skilled obstetric care. Only very remote communities with this particular problem should
consider establishing these homes.
6.1 Needs Assessment
Before setting up a Maternity Waiting Home in any remote location, the Provincial Health
Department must conduct a ‘Needs Assessment’. The assessment should focus on the
availability and accessibility to quality Obstetric care especially Basic and Comprehensive
Emergency Obstetric and New born Care within the province, means of transportation, referral
system, financial and human resources, availability and sustainability (utilization rate) of the
venue selected for the MWH.
6.2 Selection of a location
Following the assessment, the PHD should be involved in the selection of the location for
the set up of a MWH. The following points should be kept in mind:
• MWH should be located ONLY in rural remote areas where poor women have difficulty
in accessing Basic or Comprehensive Emergency Obstetric Care
• It should be located within the compound of a Referral Hospital (CEmONC) or health center
(BEmONC) with at least 2 secondary midwives and services available 24 hours/day all 7
days/week.
• It can be used also for providing information on VCCT and PMTCT
• Skilled staff should be present to facilitate timely referrals
6.3 Management of MWHs
The management of MWHs is dependent on the specific objectives established and the
availability of local resources. The primary factors that need to be considered for effective
management are:
• Services to be offered
• Liaison with community and the health system (primary level and referral)
• Administration and Staffing
• Facility Brief and supplies
• Operational Costs
6.3.1 Services to be offered
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The services range from antenatal and obstetric services plus health education and
recreational activities, to being a secure shelter for women in close proximity to a hospital. It
should ideally include:
• Health services
o Pre and Post natal care
o 24hr on-call maternity services
o Physical examinations where necessary
• Health Education
o On childbirth and post-natal care
o Birth spacing and family planning
o Newborn care
o Kangaroo mother care for preterm or low birth weight babies
o Early and exclusive breast feeding
o Vaccination
o Nutrition
o VCCT and PMTCT
• Other related services
• Food and laundry facilities
• Income generation (if possible)
• Child care
• Ambulance service
6.3.2 Liaison with community and the health system
Community members need to be informed by the PHD, of the importance of MWHs.
Community health volunteers such as VHSG members and commune council focal persons
for women and children should be encouraged to work closely with health personnel in
identifying and helping women to utilize the maternity waiting homes well before the
expected date of delivery.
Orientation meetings and regular quarterly meetings should be conducted in order to provide
correct information to pregnant women and other people in the community. Involvement
of key community members such as secondary school students, teachers, TBAs, policemen
and others of some stature in the community using posters, leaflets, newspaper articles,
simple notices etc will help in promoting the benefits of MWHs, especially for women from
very far locations.
To be successful MWHs should be planned and implemented with community involvement
and support. Decision makers in the community (husbands, religious leaders, teachers,
politicians and women) should be involved in both the establishment and daily operations of
the MWHs.
6.3.3 Administration and Staffing
Each maternity waiting home is to be managed and administered by the Health Center with
Basic Emergency Obstetric and Neonatal Care (BEmONC) facilities or by the Referral
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Hospital (with CEmONC facilities) administrator; both of the above will be under the
supervision of PMCH/PHD with support from the communities’ Health Centre Management
Committee and Local Authority.
Pregnant women should be encouraged to come to the maternity waiting home 1-2 weeks
prior to the expected date of delivery. During their stay in maternity waiting home, they
should go daily for antenatal care to the health center (BEmONC) or referral hospital
(CEmONC) to ensure regular checkups by a skilled birth attendant. They are admitted to the
delivery room at the onset of labor or if a complication occurs during their stay.
Following delivery they may stay in maternity waiting home for a further three days (up to 5
days) for post-natal and newborn care. Women are allowed to have one person (husband,
mother or another relative) accompany them to the maternity waiting home to assist her
during her stay and act as a watchman.
Every maternity waiting home should have one full-time house keeper, a skilled birth
attendant on-call for referral of complications or emergencies and visiting skilled birth
attendants from health centers or referral hospitals for health education sessions. Records
and reports should be filled and prepared according to the regulation of health facility and
kept in safe place for monitoring and evaluation purposes. MWHs should have also Internal
regulation, Job description for MWH staff and other supported documents (please see
annexes).
6.3.4 Facility Brief and Supplies
The MWH should be a building with two or three bedrooms, a verandah, kitchen and toilet.
There should also be 2-3 beds in a room; a sharing dining table and chairs. The house is
fully connected to main services of water, electricity and waste disposal.
To provide quality services, a sphygmomanometer and stethoscope would be handy in case
the woman requires a check up at the home.
6.3.5 Operational Costs
The MWH could be an entirely new building or an existing building which can be
refurbished. If it is a new building or refurbished building, it needs to follow MoH/MoEF
regulation for construction. The operational cost must follow the rate that already exists and
implement in Second Health Sector Support Program (Reference letter dated 29 July 2009):
N0 Description Rate
1 House keeper (one) 40 USD per month
2 Water Will be paid according to the actual bills
3 Electricity Will be paid according to the actual bills
4 Food allowance for one patient 2 USD per day
including one care taker
5 Fee for midwife providing health Will be the same as trainer fees
education and check up at MWH
7 Others (cleaning tool, soap, detergent, 3 USD per month
wood charcoal)
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7. IDENTIFICATION AND REFERRAL OF WOMEN
The effectiveness of the MWHs depends on the ability to recognize and refer women at risk
and the utilization of the homes by such women. This again depends on an effective system of
health services at the community staffed by providers who have been specifically trained in the
identification and referral of high risk pregnancies.
Antenatal risk factors include:
• Parity 0 or ≥ 5
• History of perinatal death
• History of operative or complicated delivery
• Height ≤ 145 cm
• Hypertension
• Diabetes
• Anaemia
• Hydramnios
• Pre-eclampsia
• Non-cephalic presentation
• Multiple pregnancy
• Heart disease or other related diseases (Malaria in Pregnancy, HIV/AIDS, Fever without any
reasons ect.)
8. MONITORING, EVALUATION AND INDICATORS
Monitoring of MWHs should be conducted regularly by the PHD and OD staff with checklists that
address the activities and functioning of the MWH. The monitoring should include the following:
o Monitor daily activities in the MWH
o Reason for admission to MWH and referral of pregnant women/mothers to highlevel
health facility
o Monitor pregnancy outcomes
Evaluation should be conducted:
• Before and after the establishment of the MWH - so that indicators are measured before and
after the interventions are carried out
• Cross comparison – where maternal health indicators are measured in an OD with a MWH
and compared to a similar OD without a MWH
• Health Status Indicators – where survival or health status of those using MWHs is compared
with those with similar needs who do not use a MWH
When women leave the MWH they should be viewed as a potential ‘ambassador’ of the
MWH. Word of mouth is still one of the most compelling means of communication. Women who
are satisfied with the care and services will encourage their families and friends to use the service.
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The power of women to determine their own needs and seek their own solutions should not
be under estimated. For this reason their support and involvement and participation must be
considered in the planning stages of this important initiative.
Indicators:
• Outcome indicators:
o Maternal Mortality Ratio
o Neonatal Mortality Rate
• Process indicators:
o Percentage of delivery by skilled birth attendant at health facility with
maternity waiting home
o No of women using maternity waiting home
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9. ANNEXES
Annex 1: Sample of Attendance list at MWH
Provincial Health Department
Provincial Referral Hospital
Maternity Waiting House
KINGDOM OF CAMBODIA
NATION RELIGION KING
Attendance List
N Name Age Name Address Refer
of care from
taker
Reason
for
referral
Admission
date
Gestational
age
No of
pregnancy
No of
living
children
Date of
delivery
Date of
discharge
No of
day
stayed
Date:
Signature:
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Annex 2: Sample of Daily Activity Checklist
Provincial Health Department
Provincial Referral Hospital
Maternity Waiting House
KINGDOM OF CAMBODIA
NATION RELIGION KING
Daily Activity Checklist
N Name Age Address Admission
date
Date of
discharge
ANC Food Sanitation Reason for
referral
1 2 Not enough Enough Poor Good Wrong Right
Approved by:
Director PRH
Date:
Signature:
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Annex 3: Sample of Referral slip
KINGDOM OF CAMBODIA
NATION RELIGION KING
Provincial Health Department……
……………………………………
Referral Form
Name of pregnant woman:……………………….Age:………..Weight:…………Height:…………
Address:……………………Village:…………….Commune:………………..District:…………….
Date of referral:…………….Time:……………….
Date of arrival:……………...Time:……………….
Number of pregnancy:……………………………Gestational age:…………………………………
Number of living children:……………………......
Reason for referral:…………………………………………………………………………………...
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
Vital signs: Temperature……Pulse rate:…….Respiratory Rate:………Blood pressure:……………
Treatment provided before referral:………………………………………………………………......
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
Current Medication:…………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
Refer to and reason for referral:………………………………………………………………………
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
Date:
Signature of referrer:
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Annex 4: Sample of MWH internal regulation
Provincial Health Department
Provincial Referral Hospital
Maternity Waiting Home
Internal regulation
KINGDOM OF CAMBODIA
NATION RELIGION KING
In order to protect environment, keep facility clean and peacefully rest in Maternity Waiting
Home, everyone should know and respect that:
o Allow one accompanying person and one child (under 3 years old) to stay in if
necessary.
o Admission time starts from 7:30 to 11:30 am and from 13:30 to 17:30 pm
o All women stay in the MWH get health education from trained midwives
o Keep clean and silence in MWH
o Food will be provided to woman and one accompanying person.
o There is no gambling, smoking, drinking alcohol in the MWH
Director of Provincial Referral Hospital
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Annex 5: Sample of Job Description for midwife at MWH
Provincial Health Department
Provincial Referral Hospital
Maternity Waiting Home
KINGDOM OF CAMBODIA
NATION RELIGION KING
Job Description for Midwife supporting Maternity Waiting Home
Title:
Midwife
Responsible to: Director of Provincial Referral Hospital
Tasks:
o Admission pregnant women and discharge
o Provide regular health education to pregnant women and accompanying
persons
o Provide medical check up and care on-call
o Monitor daily activities
o Refer women on time to appropriate health facility
o Provide monthly, quarterly reports
o Perform other duties as required
Requirements:
o Midwife working at maternity ward of CEmONC or at BEmONC facility
o Ability to work and having good relationship with pregnant women, house
keeper, colleagues and other staffs.
Director of Provincial Referral Hospital
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Annex 6: Sample of Cleaner Job Description
Provincial Health Department
Provincial Referral Hospital
Maternity Waiting Home
KINGDOM OF CAMBODIA
NATION RELIGION KING
Job Description for House Keeper
Title:
House keeper
Duty station: Maternity Waiting Home
Responsible to: (Director of Provincial Referral Hospital)
Date to be at work: January 1 st , 2010 to December 31 st , 2010
Tasks:
o Clean in and outside the MWH
o Shop and cook food
o Take responsible for materials and furniture in MWH
o Accompany the pregnant woman to labour room (maternity ward) or to
other facilities if necessary
o Able to arrange work schedule
o Perform other duties as required
Requirements:
o Strong ability to read, write and speak Khmer
o Ability to work with pregnant women and poor people
Director of Provincial Referral Hospital
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Annex 7: Sample of Purchase Request
Ministry of Health
Second Health Sector Support Program
Discrete Fund (UNFPA)
Provincial Health Department PREAHVIHEAR
KINGDOM OF CAMBODIA
NATION RELIGION KING
Date: 27/07/09
Part1- Purchase Request/Contract Request
Items requested and purpose:
sMeNIsuMTijsMPar³
GMe)asesμA 2 x $ 1.00 $ 2.00
GMe)asFagdUg 2 x $ 0.50 $ 1.00
cRgáan 1 x $ 2.00 $ 2.00
sab‘UemSA 1kg x $ 1.30 $ 1.30
$ 6.30
Category number 3
Account Code
Estimated cost $ 6.30
Approved by:
Director PHD
Verified by: Prepared by: Request by:
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Annex 8: Sample of Petty Cash Payment Voucher
Ministry of Health
Second Health Sector Support Program
Discrete Fund
Provincial Health Department PREAHVIHEAR
KINGDOM OF CAMBODIA
NATION RELIGION KING
Petty Cash Payment Voucher
Vendor Name & Address/Pay to: Mrs MY staff of 16 Makara r/h
Support document: Budget request form PCR09-031 dated 17/08/09
Activity:
Date Source Account name/Description GL A/c
entered No Date
Code
Amount
Debit Credit
1 2 3 4 5 6 7
17/08/09 PCPV09-031 17/08/09
TUTat;éføTijsMPar
$ 6.00
³
Petty cash $ 6.00
TUTat;éføTijsMPar³sMrab;pÞHrg;caM
$ 6.00 $ 6.00
Approved by:
Verified by:
Prepared by:
Director PHD Chief of Account
Accountant
Received by:
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