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Mobilizing Communities for Obstetric and Neonatal Emergencies

"If it is a birth I cannot attend alone, I look for help. When there is no emergency vehicle, I find the person on call to help me take the patient."

Dedicated to the women of her community in rural Nicaragua, traditional birth attendant Felipa Arteta has learned new skills for assessing a complicated birth. Artera's training in emergency obstetric and neonatal care is part of a program designed by the PRIME II Project and local partners to strengthen community responses to obstetric and neonatal emergencies in the mountainous Jinotega region.

The maternal mortality ratio in Jinotega, estimated at 150 per 100,000 live births in 2002, is the highest in Nicaragua and one of the highest in Latin America. PRIME II's initiative for safer motherhood and improved newborn care in the region is part of the Project's global effort, funded by USAID, to strengthen the performance of primary-care providers as they strive to improve family planning and reproductive health services in their communities.

Encouraged by her trainers to "learn and evolve," Arteta enjoys her expanded role as a coordinator of birth plans for pregnant women and emergency complications readiness efforts in Venecia, her small community. She found the training sessions practical and easy to apply in the real-life situations she faces. Along with standards for the birthing process and postpartum care, her training addressed danger signs in pregnancy and caring for a mother and baby during a birth with complications.

"When we were in the training, we talked about what we would do in these cases," Arteta emphasizes. "What to do when a birth becomes abnormal, when there are problems with bleeding, or if it is a birth we cannot assist." Community-based life-saving skills modules developed by PRIME supporting institution, the American College of Nurse-Midwives, are the basis for preparing the traditional birth attendants and clinical providers to deal with emergencies at the local level.

Training sessions on responding to emergencies are tailored to the providers' qualifications. Community health promoters and traditional birth attendants learn immediate first-aid requiring little or no medical equipment and supplies, while facility-based providers are taught basic emergency skills including administration of drugs and intravenous fluids. At Jinotega Hospital and health centers in the communities of Wiwili and Pantasma, the program has trained 51 traditional birth attendants and 109 physicians, nurses and auxiliary nurses, 85 from the Ministry of Health and 24 from private and voluntary organizations.

Building and reinforcing linkages among community members, community-based providers, health facilities and facility-based providers is a key goal in the program's strategy for raising awareness of the danger signs of complicated pregnancies, the consequences of delays in seeking care, and the importance of a prompt response to postpartum bleeding. Community mobilization activities include setting up emergency obstetric and neonatal care committees, pooling emergency funds, and establishing transportation plans to ensure women and newborns can reach referral facilities in the event of an emergency. To complement these community organizing efforts, PRIME has facilitated an ongoing census of pregnant women in the region.

PRIME staff also participated in a national commission to develop emergency obstetric and neonatal care protocols, which are undergoing evidence-based validation from the national referral hospital, regional and departmental hospitals, and health centers. A practical document to enable health personnel to apply and follow the protocols should be ready by the end of 2003.

In addition to the Ministry of Health, PRIME II project partners in Nicaragua include NGO Networks, NicaSalud, Project Hope, Project Concern International, Wisconsin-Partners of the Americas, Catholic Relief Services, Management Sciences for Health and the Quality Assurance Project.

Results from a mid-term evaluation of the program demonstrate significant improvement in provider performance. As defined by a quality index score, care of immediate postpartum women by traditional birth attendants has improved 87 percent. Management of postpartum hemorrhage by physicians, nurses and auxiliary nurses has risen 20 percent. These positive results for providers have been matched by community efforts. In the 32 project areas, 78 percent of planned emergency obstetric and neonatal care community committees have been organized. Emergency transportation systems have been established in 56 percent of communities and emergency funds set aside in 25 percent. A census of pregnant women is available in 81 percent of the communities, and 47 percent have implemented birth and complications readiness plans.

In Venecia, emergency funds are being administered by a community committee and someone with a vehicle is now on call at all hours to transport women to the nearest hospital in cases of emergency. In addition to assisting with deliveries, Felipa Arteta visits pregnant women at their homes to provide prenatal care and help them create birth and emergency complications readiness plans. As Arteta sums up, the knowledge and skills she acquired through training have enhanced her ability to "do a little bit to help in this world."

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