SADA

(SAFE DELIVERY APPROACH)

A 3 years Project to Reduce MMR

In District Noshki
Balochistan

Group VII
Dr Afzaal, Dr Ali Raja, Dr Majeed,
Dr Muhabbat, Dr Waseem
 Demographic Data
• Population 152785
• Area 5792 Sq.Km
• Population Density 20person/km2
• # of Tehsils 1
• # of U/Cs 10
• Literacy Rate33.59%
– Male 48%
– Female 19.5%
 RH Indicators of Noshki

• MMR 714/100000 live births

• CPR 31%
• C/Sections 5-7/month
• Antenatal visit 100 /month
• Hospital Based deliveries 35-40/months
 Health Facilities
• # of DHQ Hospital 1
• # of THQ Hospital 0
• # of RHCs 2
• # of BHUs 10
• # of CDs 25
• # of MCH centers 3
 The New Paradigm
• All pregnancies are at risk: Most obstetrical
complications are neither predictable, nor
avoidable, but can be treated if assisted by a SBA
• Shift of focus from pregnancy to delivery
• Therefore, from the viewpoint of providers,
readiness becomes the key word, accompanied
by quality of obstetric care
• Provided parturients can access and use these
ready and quality institutions
 Maternal Mortality
• Each year, more than 500,000 women die
from complications in pregnancy and
childbirth, even though the means exist to
save the vast majority of these lives

• Millions more women are disabled

(Near Miss)
• « during childbirth »: because evidence
shows that most complications, and
deaths, occur during childbirth (25%),
or immediately thereafter (60%);
[the rest before labour]
 Attendance at Birth According to
Community-based Surveys
6% 6%

Doctor
26%
Other SkAt
TBA
Relative
No-one
40%

22%
 Maternal Mortality
• The main reasons for the high rates of maternal
mortality are:

• (1) lack of perinatal care

• (2) Lack of properly trained birth attendants or

medical facilities

• (3) Lack of transport to the nearest properly

equipped hospital

• While almost 80 percent of births in the country

occur at home.
 The UNFPA Strategy
for the Reduction of Maternal Mortality
and Morbidity

is based on 3 pillars:

• Family Planning
• Skilled attendance at (all) births
• Emergency Obstetric Care
 Five Assumptions
1. Lack of Health seeking behavior of people towards
SBA or facility based delivery
2. Lack of awareness among the TBAs/LHWs and other
family members regarding the identification of danger
signs
3. Non-availability and geographic distribution of facilities
– non-availability of equipments and supplies – non-
availability of means of communication – 24/7
4. Lack of positive supervision and effective monitoring
5. Poor resources Management – planning and
budgeting, Posting and retention – low quality of life
 Possible Curative Interventions
• Skilled Birth Attendants at all Births
• Intrapartum Care based in Health center
• Antenatal and Post natal care
• Emergency Obstetric care
• Quality Care of Reproductive health
services
• Post Abortion care
 Possible Preventive
Interventions
• Awareness
• Family Planning
• Capacity Building (Trainings)
• Women empowerment
• Nutrition and micronutrients
• Exclusive Breast feeding up to 6 months
• Female literacy
• Poverty Reduction
• Discouraging early age marriages
• Couple counseling (Male involvement)
 Identified Curative/Preventive
intervention
• Curative Intervention
– Skilled Birth Attendants at all Births

• Preventive Intervention
– Awareness regarding the utilization of
maternal health services
 Due to Clustering of mortality around
delivery and dominance of Hemorrhage,
infection and hypertension;
and keeping in view the geographical and
cultural barriers of the District We focus to
intervene the three DELAYS.
 3 Ds approach
• First: Delay in deciding to seek care for a
perceived obstetrical complication (community)
• Second: Delay in reaching the appropriate
facility (transport)
• Third: Delay in receiving appropriate care at the
facility (skilled care)
• Put emphasis on the third delay, which should
come first. Useless to address the other two if
quality care is not ensured in health facilities.
 MNH Upgrade and
Training make fully
BCC operational
Transport,
Dai telecom

RHC/
DHQH
H o m e BHU
Comp.
Basic
A EmOC
SB
LHW EmOC

Village

Village Obstetric emergencies

Cluster
(bypass Basic EmOC)

Framework-SADA Project
SADA Project
(SAFE DELIVERY APPROACH)

District Noshki
 Aims and Objective
• Aim
– Improved health status of women by
reducing maternal deaths in District Noshki
• Objective
– To reduce maternal deaths by 75% in
District Noshki in 3 years.
– To raise awareness among 100% general
population of District Noshki regarding RH
services utilization in 3 three years
Organogram of SADA Project
EDO (H)
(Chairman)

District Coordinator
(SMO)

WMOs LHVs/CMWs
 Coordination of District Support
Team (Multisectoral Approach)
• Health Department
• People’s Primary Health Care Initiative
• LHWs Program
• Population Welfare Department
• Education Department
• NGOs and Line Departments
 District Maternal Health
Committee (DMHC)
• A committee will be formulated for regular monitoring
and on job supervision of SADA Project
• The committee meeting will be conducted on quarterly
basis
• Members will be
– Distt. Nazim/DCO Chairman
– EDO (H) Secretary
– Distt. Coordinator SADA Project Member
– MS DHQ (H) Member
– All LMOs Member
– Anesthetist Member
– LHVs of Basic EmOC facilities Member
 Spot Map
AFGHANISTAN Kishingi
osta
n M
m B
Ana A
S
T
Dak Mengal U
C Jamaldini Noshki city N
H G

A
G Ahmed Wal
Mal
A
• DHQ
I • CEmOC
KHARAN • BEmOC
 Target Population
• All Women of Reproductive Age Group
• All adult males
• Elderly women of the community
• All influential leaders of the community
• Ulemas and Masjid Imams
• Male and Female councilors
 Strategies for first delay
• Awareness regarding Girls Primary Education
• Skill Development of LHSs and LHWs in Inter
Personal Communication and Counseling.
• All LHWs will be trained in to identify danger signs
and improve appropriate referral.
• Seminars on RH/youth/gender issues.
• Health Education Sessions at Girls and Boys High
Schools & Colleges.
• Documentaries/ RH messages & gender issues in
local cable network.
• Celebration of International Days (population,
mothers, midwives, women's days)
 Strategies for Second delay
• Provision of 6 fully equipped ambulances
(one for each Basic EmOC facility)
• Repair of existing ambulances.
• Reactivation of Village Health
Committees for Community Transport
System
• Wire Less Loop/ Land line phone for
selected LHWs/ LHS/ Health Facilities
and Ambulances on ownership
 Strategies for Third delay
• Establishment of Comprehensive EmOC at DHQH 24/7.
• Establishment of Basic EmOC at 02 RHCs & 04 BHUs.
• Labour rooms at these health facilities.
• Repair/renovation of Health Facilities & Residences for
Female Staff.
• Posting of Anesthetist at DHQ
• Posting of LHVs/CMW at all Basic EmOC facilities.
• Financial and other incentives for the health care
providers
• Capacity building of Lady Medical Officers / LHVs /
Paramedics in Safe Delivery practices, Infection
prevention, HMIS, RH, FP, STI, etc.
 Strategies for Third delay
• Provision of medicines, minor equipment,
and consumables
• Maternal Mortality Conference at District
level on Quarterly basis.
• Refresher Management Courses at AKU
Karachi for District Health Managers.
• Laboratory support
 Strategies for Third delay
• Three Months Training of 03 LMO in Cesarean
Section at AKU Karachi.
• Two Months Training of Anesthetic & OT
Assistant in Operation theater at BMCH Quetta
• Three month training of one LMO in Ultrasound at
SPH Quetta
• HMIS orientation workshop for HCPs in two
batches
• Verbal autopsy on maternal & Neonatal death
But the main argument for
institutional delivery remains Quality
of care
Good experience with providers encourages use of
care – cost is not a major concern in such situations
Women’s perspectives about quality of care
 Respect by health service providers- not to be abused
or scolded- talk and smile…particularly at night…
 Sensitivity to needs, including respect for dignity
 Care and support, explanations, choices
 Costs
 MADAD Cards
(Medicine availability for diseases after delivery)
• 15% of deaths occur due to puerperal
infections
• MADAD Cards are introduced to decrease
the deaths due to puerperal infections
• MADAD Cards will be issued by LMO to
the near misses
• Each MADAD Card will help these women
to get prescribed medicines with in range
of Rs.3000/=
 Indicators of Monitoring and
Evaluation
• Process Indicators
– # of Deliveries by SBA
– # of Deliveries At Health centers
– # of C/Section
– # of Referrals to CEmOC
• Out come Indicators
– %age of Deaths due to maternal cause
– %age of mothers with complications
– %age of Normal Births
 Future Plans
• Monthly IUDs camps at RHCs
• PG Rotation
• Establishment of Midwifery school at
Noshki
Activity Plan
 Work Plan WEEK 1:

• Introductory meeting with DHMT.

• Meeting with DHMT about training of
HCP’s and awareness campaigns.
• Decision about schedule will be finalized.
• Willing HCP’s will be sent for training.
• Surety bond will be taken from them that
they will serve in the District for at least
five years.
 Work Plan- Week 2

• Purchase committees about purchase of

medicines, ambulances and vehicle, equipment
and furniture and printing material.
• Meeting about improvement of infrastructure
with DHMT.
• Meeting about budget allocation.
• Tender will be given in newspapers about
purchase of medicines, ambulances, equipment
and furniture and renovation of infrastructure
accordingly.
 Onward Activity
• Monthly meetings about the progress and
efficacy of the project will be conducted at
EDO(H) office NOSHKI.
• All in charges of health facilities will make sure
their presence in the meetings along with
monthly progress reports.
• Monthly meeting will be conducted in first week
of every month.
• Process and Outcome indicators of the project
will be analyzed in the meeting
 TRAINING PLAN
PHASE 1:
• Training of two LMOs from Agha Khan Hospital, Karachi for three
month.
• Training of Anesthetist from Bolan Medical Complex Hospital
,Quetta for two month.
PHASE 2:
• Training of nurses, mid wives and LHV’s in three batches for a
period of one month by trained LMO’s at DHQ hospital NOSHKI.
• Training of CMWs and LHW’s by two trained nurses for a period of
one month in different batches at DHQ hospital NOSHKI.
PHASE 3:
• One week refresher courses for all health care providers after every
six months.
BUDGET
 Allocation of budget for the
first year (2009-10) of Project (SADA)
1. AWARENESS CAMPAIGNS RS 4.0 millions
a) Seminars
b) Health education sessions
c) Documentary movies /Puppet shows
d) IEC /Posters /Wall chalking
e) Radio / TV (local cable)

2. TRAINING RS 5.0 millions

a) LMOs/LHW’s/CHW
b) SBA’s
c) TOT’s
3. PURCHASE OF VEHICLES RS 14.0 millions
a) Ambulances (6)
b) Toyota Hilux double cabin (1)

4. IMPROVEMENT OF INFRASTRUCTURE RS 7.5 millions

5. EQUIPEMENTS AND FURNITURE RS 4.0 millions

 2009-10 (cont’d…)
6. ESTABLISHMENT OF EmOC SERVICES RS 3.7 millions
a) Basic EmOC services (6)
b) Com EmoC service (1)

7. MEDICINES RS 8.0 millions

8. LOCAL PURCHASE RS 2.5 millions
9. POL RS 5.5 millions
10. REPAIR AND MAINTANANCE RS 3.0 millions
11. INCENTIVES FOR HCP’s RS 2.0 millions
12. MADAD CARDS FOR WOMEN having post partal RS 3000 per
COMPLICATIONS card(300 cards)
Total
RS 0.9 millions
TOTAL RS 60.1 millions
 BUDGET FOR YEAR 2010-11
1. MEDICINES RS 7.5 millions

2. MAINTANANCE AND REPAIR RS 2.5 millions

3. LOCAL PURCHASE RS 2.0 millions

4. INCENTIVES RS 2.0 millions

5. POL RS 5.5 millions

TOTAL RS 19.5 millions

 BUDGET FOR YEAR 2011-12
1. MEDICINES RS 8.0 millions

2. MAINTANANCE AND REPAIR RS 2.9 millions

3. LOCAL PURCHASE RS 2.0 millions

4. INCENTIVES RS 2.0 millions

5. POL RS 5.5 millions

TOTAL RS 20.4 millions

GRAND TOTAL FOR THREE YEARS(2009-12) 100 MILLION RUPEES

HAR MAAN KI DUA

SADA
RAHE
SADA

THANKS