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GO MOMS Guatemala Nov. 2016 Report


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GO MOMS Guatemala Nov. 2016 Report

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GO MOMS Guatemala Nov. 2016 Report

  1. 1. GO MOMS: Simulation based education for the management of postpartum hemorrhage Guatemala City, Guatemala November 2016
  2. 2. PART I:INTRODUCTION Maternal Healthcare Worldwide Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy. An estimated 576,000 maternal deaths occurredworldwide in 1990 with over 99% of deaths in developing nations. In 2005, women in Western and Central Africahad a 1 in 17 lifetime risk of maternal death (maternal mortality rate (MMR) 1,100 maternal deaths per 100,000 livebirths) compared to a risk of 1 in 8,000 for women industrialized. (MMR 8 maternal deaths per 100,000 live births).1 In 2000, the United Nations signed the Millennium Development Goals (MDG) identifying eight goals toaddress poverty,hunger, disease, education and gender equality. Improving maternal health was the target of Goal 5. Goal 5A was to reduce by 75% the maternal mortality ratio between 1990 to 2015. Goal 5B was to achieve, by 2015, universal access to reproductive health, including antenatal care.2 Toreduce the MMR by 75% over25 years there wouldneed to be a 5.5% annual decline.1 Between 1990 and 2005, there was a <1% annual decline in MMR worldwide, however, this value is influenced by sub-Saharan Africa, where the annual decline was only 0.1% despite accounting for 66% of all maternal deaths. Between 2005 and 2015 there were improvements in the MMR, with an annual decline of 2.3% .3 Only 9 countries achieved MDG 5. Southern Africa whichhas the lowest MMR in Africa, actually had an increase in their mortality rate since 1990.3 In keeping with the momentum of the MDG, the United Nations has adopted the Sustainable Development Goals (SDGs).SDG 3.1 is to reduce the global MMR to less than 70 per 100,000 live births by 2030. Achieving the SDG target of a global MMR below 70 will require reducing global MMR by an average of 7.5% each year between 2016 and 2030. To increase healthcare equity, the World Health Organization (WHO) established a supplementary national target that no country should have an MMR greater than 140 per 100,000 live births. Methods to achieve these goals include: addressing inequities in access to and quality of reproductive, maternal, and newborn health care services, ensuring universal health coverage,addressing all causes of maternal mortality, strengthening health systems to respond to the needs and priorities of women and girls and ensuring accountability.4
  3. 3. Maternal Healthcare in Guatemala Guatemala has the highest fertility rate in Central America, with 3.6 children per woman in 2009. Howeverit also has a higher maternal mortality rate compared to the rest of Latin America. In 1990, Latin America had an MMR of 124 maternal deaths per 100,000 births compared to Guatemala, which had an MMR of 205 maternal deaths per 100,000 births. 3 In 2005, Guatemala still had a 1 in 71 lifetime risk of maternal death.1 Guatemala was one of only 17 countries outside of Africawhere maternal morbidity is at least 15 per cent of the disease burden in reproductive aged women.5 Of the maternal deaths, 70% were indigenous women,and 46% died giving birth at home.6 In 41% of maternal deaths, the health services did not have the necessary preparations tohandle the emergency. Forty-seven percent of patients had significant barriers to access of healthcare including lack of transportation or money to pay for it.7 The highest mortality rates area in the Guatemalan Highlands, called the “corridorof death,” which is predominantly Mayan.8 Figures: Maternal mortality rates are highest in the rural indigenous regions.
  4. 4. To achievethe Millennium Development Goals, Guatemala created several officesand programs that address the needs of women and indigenous peoples.9 The National Study of Maternal mortality identified four delays for patients receiving perinatal care; lack of awareness of medical emergencies, lack of empowerment for patients to seek help, lack of transportation to facilities and inability of healthcare facilities to treat medical emergencies.10 Complicating the issue is that in the indigenous regions of the country obstetric care is provided by traditional Mayan birth attendants (comadronas or iyoma). Mayans face language and cultural barriers, as well as a distrust of non-indigenous (Ladinos) from a history of colonization.In 2010, Guatemala passed the Ley para la Maternidad Saludable (Law forsafe motherhood) whichaddresses accessibility, equity, gratuity and respect for multiculturalism in maternal health. Included in the law are a right for “respect forcultural identity, values and customs of the indigenous communities” and “a transition program forthe training of iyomatrained and certified at a technical level”.11 When Mayans do choose to seek Western medicine they typically only have access to health posts that are run by auxiliary nurses or medical students. These government health posts are more accessible and significantly cheaper than hospitals.12 Only 7% of Mayans report consulting a doctoror hospital. In an effortto improve Mayan healthcare utilization, efforts have been made to make healthcare more culturally sensitive. One example of this is Casa Materna, a free program for high-risk pregnancies that partners with the local Mayan community. At Casa Materna an auxiliary nurse performs most deliveries. The auxiliary nurse is Mayan, from the local municipality, and speaks the local Mayan dialect and is trained in the activemanagement of the third stage of labor, withan obstetrician available as backup.13 Casa Materna has noticeably increased prenatal and postpartum in the Mayan community. Seventy-six percent of Mayan people live in extreme poverty and health care expenditures is less than 2.5 % of the gross domestic product.11 Lackof healthcare spending is a major contributor to the high maternal mortality rate, as healthcare is not affordableor accessible. In 2009, Guatemala adopted the Mi Familia Progresa program to help achieve MDG 5. The program provides conditional cash transfers of up to 300 quetzales (US$40) per month to pregnant mothers in fiveof the highest risk municipos provided the pregnant women agree to preventive maternal-child health care services.14 The program saw increases in prenatal coverage but the impact of payments on maternal mortality has not yet been evaluated.
  5. 5. Additionally, governmental health posts, while often poorly staffedand stocked, are available free of charge. While Guatemala did not achieve MD5 it is classified as “Making Progress” having a 3.4% annual decrease in maternal mortality since 1990, compared to Latin America as a whole whichonly had a 2.9% change.3 Guatemala is now on trackto achieve MDG 5 between 2026-2030, while the rest of Central America willnot achieve MDG 5 until after 2040.15 Postpartum Hemorrhage Postpartum hemorrhage (PPH)isthe leading cause of maternal mortality in low-income countries and the primary cause of nearly one quarter of all maternal deaths globally.16 PPHis the cause of almost half of maternal deaths in Guatemala. The majority of PPH cases can be avoided by activemanagement of the third stage of labor including the use of prophylactic uterotonics at the time of delivery. Of the 452 maternal deaths that occurredin Guatemala in 2013, 90 percent were preventable.17 Studies have shown only 50% of providers perform an activemanagement of the third stage of labor.18 The WHO developed a list of 32 recommendations for the prevention of postpartum hemorrhage including recommendations on uterotonics, uterine balloon tamponade and surgical management of PPH.Recommendation 31 was that “the use of simulations of PPH treatment is recommended forpre-service and in-service training programmes.” The guideline developers place a high value on simulation-based education, including both hi- tech and low-techprograms.16
  6. 6. Healthcare in Guatemala Healthcare in Guatemala is divided into multiple sectors: public, private non-profitand private for-profit. The public sector is Minesterio de Salud Publicay Asistencia Social (MSPAS).Only 25% of Guatemalans have some form of health insurance and MSPAS is expected to provide coveragefor the remaining 75% of the population free of charge. MSPAS only receives a budget of 1% of the GDP and is subject to shortages. In reality only 3 out of 10 people below the poverty line seek any care 40% of the population has no access to care. There are multiple private non-profit sectors. IGSS (Guatemalan Social Security Institute) insures government employees that pay into the system. Approximately 17% of the population is covered by IGSS. Healthcare expenditure forIGSS is 5 times higher per capita than forMSPAS. The Sistema Integrado de Atención a la Salud (SIAS) contracts withprivate providers to provide healthcare in remote rural areas that have no access to health facilities. Members of the armed forcesare covered through Sanidad Militar. Only 5% of the population is covered by private for-profitinsurance. The majority of these patients (83%) pay out of pocketfor their care.
  7. 7. Medical Workforcein Guatemala Undergraduate medical education in Guatemala is a total of 7 years. There is one public university and fourprivate universities offeringa medical degree, which are all located in Guatemala City, Guatemala. There are several recently created satellite programs; three are in Alta Verapaz, twoare in Quetzaltenango, and one is in Chiquimula. Cuba’s Latin American Schoolof Medicine also trains students from Guatemala.7 The public university Facultad de Ciencias Médicas de a Universidad de San Carlos de Guatemala is the oldest and largest medical school. In the sixth year of medical education, medical students are required to perform their EjercicioProfesionalSupervisado (EPS),whichhas a six-month long rural program in whichstudents are stationed at 18 health posts throughout Guatemala, encompassing 50,000 inhabitants.19 At private medical schoolssuch as the Universidad Francisco Marroquin, the students also rotate at rural health centers. At the student-run Barbara Health center in San Juan Sacatepéquez, students have a program to reduce maternal and child morbidity and mortality rates. The students are supported by an ancillary staff of midwives and community advocates and develop training plans forthe staff. Health indicators such as maternal mortality, infant mortality and others have been improved as a result of the presence of this program.20 The obstetrics and gynecology residency is four years total. The first year is internship year. Years two and three are spent at the residency teaching hospital. The final year of residency is spent workingin the community. The majority of resident physicians are trained in Guatemala City, Guatemala, with 824 out of 1525 MSPAS residents workingat just two hospitals within the city. In Guatemala in 2010, there were 16,043 licensed physicians, 9,447 of whom were working in the profession. There is 11 physicians per 10,000 population overallin Guatemala, but they are not evenly distributed geographically. In Guatemala city there are 36.1 physicians per 10,000 population, whereas smaller departments such as Quiche´, has 1.4 physicians per 10,000 population. Roughly 70% of all physicians are concentratedin Guatemala City. The Ministry of Public Health has struggled to fill temporary positions in rural areas, particularly in departments such as Quiche´ and Solola´. Given the difficulties in finding doctors to provide ambulatory services in the Extension of Coverage Program, the Ministry began to contract nurses forthese positions.
  8. 8. PART 2: GO MOMS SIMULATION Background GO MOMS is a simulation based educational program on postpartum hemorrhage developed by Kay Daniels, MDand colleagues. A major goal of the program is to demonstrate fertility- sparing methods to control postpartum hemorrhage, in order to limit the number of hysterectomies. Of the residents surveyed, almost half said they perform postpartum hysterectomies occasionally or more frequently.The GO MOMS program consists of twolectures on postpartum hemorrhage and misoprostol. Then the participants are divided into groups and perform simulations of B-Lynchsutures and uterine balloon tamponade. Finally, the participants have a practical simulation on PPHusing the wearable MamaNatalie birthing simulator, shown at the right. Dr. Daniels presented the program to an ACOG affiliatein Central America (CAFA) and was approached by Dr. Edgar Herrarte whoworkswith obstetrics and gynecology resident education at the IGSS hospital in Guatemala City, Guatemala. The primary goal of the GO MOMS program was to perform the PPHsimulation to faculty and residents, to shadow physicians at the local hospital, and to make introductions with the faculty for future site visits. Secondary goals were to understand the Guatemalan healthcare system, obtain basic information on how obstetrics and gynecology is practiced at the hospital, and identify potential education gaps for future site visits. Four attending obstetrician gynecologists, one resident and one Spanish translator traveled to Guatemala City in November 2016 to teach the GOMOMS simulation to approximately 50 IGSS attending and resident physicians over three days. Additionally, the GO MOMS teams performed a needs assessment questionnaire forthe site and were allowed to shadow at the IGSS hospital Labor and Delivery unit.
  9. 9. PART 3: NEEDSASSESSMENT: The GO MOMS simulation was one of many possible simulations that can be easily performed. One of the goals of the program was to perform a needs assessment for future simulation based education at IGSS. Below are results from a questionnaire given to all GO MOMS participants Activemanagement of third stage of labor Most residents are very comfortablewith activemanagement of the third stage of labor. Residents have oxytocin, methylergonovine and misoprostol available, similar to the United States. The IGSS pharamacy does not carry prostoglandin F2 alpha, which is the only uterotonic that can be redosed during the management of postpartum hemorrhage in the United States. At IGSS, methylergonovine can be given 0.125 mg IV every 5 minutes for up to 5 doses. Guatemala also has carbetocin that is a longer acting analogue of oxytocin. Misoprostol, a cheap, readily available, and effectiveuterotonic withminimal side effects, is not readily available in Guatemala due to concerns it will be used as an abortifacent. B-Lynch One third of residents (16 of 43 residents) stated that they had never practiced or observed a B-Lynchsuture. The remaining residents said that they only used it very rarely. To simulate a B-Lynchcompression suture we used models made of neoprene sewn together to make a pouch.The teaching points of the B-Lynchstation were to have tactical muscle memory in performing a B-Lynchsuture as well discuss the indications forB-Lynch and correctsuture material.
  10. 10. Uterine Balloon Tamponade The Bakri balloon system is commonly used in the United States to perform uterine balloon tamponade. The costof a Bakri balloon is US $250 and is unavailable in developing countries. As such, a majority of residents at IGSS had never used or even seen a Bakri balloon. A cheaper alternative to the Bakri balloon is the condom balloon, proposed by Akhter and colleagues in 2003.21 The purpose of this simulation was to demonstrate the condom uterine balloon as a cheap, safe and easy alternative management to postpartum hemorrhage. The condom balloon tamponade is made from a condom, a foley catheter, a piece of string or spare suture and sterile water or saline. The total cost of the device is less than US $5. Using the neoprene vaginal models we had residents practice making and filling condom tamponade balloons. Uterine Artery Ligation Uterine artery ligation, or an “O’Leary stitch” requires a laparotomy and is most frequently used in cesarean section to prevent PPH.The IGSS residents were comfortably withO’Leary stitches and practiced on the model uterus.
  11. 11. Operative Vaginal Delivery The average cesarean section rate at IGSS in 2013 was 46%, with some providers having up to 79% rate of cesarean section. Operative vaginal delivery is limited to the private sector. Obstetric vacuums are not available at IGSS and two-thirdsof residents have never seen a vacuum delivery.Obstetric forceps are available at IGSS but rarely used and are limited to the private sector. One half of residents stated they had never practiced forceps deliveries.
  12. 12. Vaginal Hysterectomy and Urogynecology GO MOMS TEAMhas developed a simulation based training course of vaginal hysterectomy called GO GYN. Vaginal hysterectomy is the preferred minimally invasive method in appropriately selected candidates. The course also simulates pessary fitting for pelvic organ prolapse. Vaginal hysterectomy is taught to all residents at IGSS but resident experience varies based on year of training. Most residents have not offered pessary to their patients. Urinary incontinence is treated with Kegel exercises, oxybutynin or transobturator tape (TOT).Vaginal prolapse is treated with hysterectomy or anterior and/or posterior colporrhaphy. Cervical Dysplasia Most residents at IGSS are comfortable withcervicaldysplasia and colposcopy by the end of their residency training. All residents report regularly performing Pap smears.
  13. 13. PART 4: SHADOWING On the final day of the GO MOMS simulation program the faculty and housestaff at IGSS invited a member of the GO MOMS team to observe the Labor and Delivery Unit overnight. That night was a reportedly slow night with 14 vaginal deliveries and 11 cesarean sections in 12 hours. Additionally multiple postpartum tubal ligations were performed. Anecdotally, IGSS is the largest birthing hospital in Central America and this high volume significantly influences their healthcare practices. A laboring woman delivering at IGSS first presents to a triage area. Approximately 100-150 triages are seen per day.Once it is determined that a patient is in active labor (>4cm dilation) she is then transferred to the laboring room where there is a line of 16 beds with women in various stages of labor. Given the high volume and limited space, patients are expected to follow along a normal labor curveand progressing normally on oxytocin. Oxytocindose is limited to 10 mu/min. Fetal monitoring is intermittent. The only induction agents available are vaginal dinoprostone and foley balloons. Patients are allowed 12 hours
  14. 14. of induction time to achieve activelabor. Once the patient reaches the second stage and labors downshe is transferred across the hall to the delivery rooms. Again, the patient is expected to follow a normal labor curve and if labor is protracted she is recommended for cesarean delivery.Vacuum is unavailable and forceps are not practical because adequate anesthesia is not available. Fundal pressure is used in the second stage. Mediolateral episiotomy is standard for nulliparous women.
  15. 15. There were up to fiveoperating rooms being used overnight. Cesarean sections are performed via Pfannenstiel incision. All gowns and drapes are made of reusable cloth. The uterus is not exteriorized. All layers (including peritoneum and rectus muscles) are closed. Nylon suture is used for the skin. Postpartum is a shared space with up to 10 beds per room. Vaginal deliveries are discharged postpartum day 1. Cesarean sections are discharged post-operative day 2. PART 5: CONCLUSIONS The staff and housestaff at IGSS were extremely welcomingand receptive to the GO MOMS simulation based training. Obstetrics and gynecology education and training has many similarities to training in the United States. The staff and housestaff provide evidence-based health care favoringthe same resources (e.g. used in the United States. Differencesin practice are mainly due to cost ( Bakri, vacuum) or cultural preference (concernsabout misoprostol). On the needs assessment questionnaire, many residents commented on their desire to learn B-Lynchand uterine tamponade balloon. After shadowing Labor and Delivery,howeverthe usefulness of the GO MOMS intervention at IGSS may be limited. Due to the high patient volume and limited facilities, patients withany signs of labor dystocia are recommended to
  16. 16. have a cesarean section. This reduces the risk factors forpostpartum hemorrhage including prolonged first and second stages, use of multiple induction agents, operative vaginal delivery and chorioamnionitis. The high rate of cesarean section, however,is concerning for developing morbidly adherent placenta whichis a cause of massive, life threatening PPH. The IGSS hospital has a blood bank in case of emergency. The goals of the GO MOMS trip were to perform a simulation based educational program, collecta needs assessment, and establish a collaborative relationship forfuture site visits. Based on the needs assessment, there is a role for future simulation based training at IGSS in operative vaginal delivery and vaginal hysterectomy/urogynecology. At future IGSS visits there is also a plan to review which PPHmanagement options are being implemented and whichneed further simulation. Future GO MOMS simulations should target residents at the public hospitals or medical students starting their EPSrural rotation—as these trainees may likely manage postpartum hemorrhage in a nonhospital setting.
  17. 17. REFERENCES 1. Maternalmortality in 2005: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization, 2007.Available at 2. 3. WHO, UNICEF, UNFPA and The World Bank, Trends in MaternalMortality: 1990 to2015,WHO, Geneva, 2015. 4. Strategies toward ending preventable maternalmortality (EPMM). 5. United Nations Population Facts. 6. Tercer informe de avances en elcumplimiento de los Objetivos de desarrollo del milenio. Objetivo 5: Mejorar la salud maternalGuatemala: Serviprensa,2010. 7. Guatemala. 2012/index.php?option=com_docman&task=doc_view&gid=132&Itemid=270 8. Walton, A et al. “Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala” Int J Gynaecol Obstet. 2016 Mar; 132(3): 359–364. 9. Gender Equality and Empowerment of Women in the Context of the Implementation of the Millennium Development Goals. 50143_(e)_(desa)dialogues_ecosoc_achieving_gender_equality_women_empowerment.pdf.pp22-23 10.Ministry of Public Health and Social Assistance Action Plan for the Reduction of Maternaland Neonatal Mortality and Improvement in Reproductive Health 2010–2015 [in Spanish] Published 2010. 11.Giralt, A. “Guatemala’s Indigenous Maternal Health Care: A System In Need Of Decolonization” Ed: Raudem, Revista de Estudios de las Mujeres. Vol. 2,2014 12.Bhatt S. Health Care Issues Facing the Maya People of the Guatemalan Highlands: The Current State of Care and Recommendations for Improvement.Journalof Global Health Perspectives. 2012 Aug 1 [last modified: 2012 Aug 1]. Edition 1. 13.Ira Stollaka, Mario Valdezb, Karin Rivasc, Henry Perry.Casas Maternas in the RuralHighlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population. Glob Health Sci Pract March 21,2016 vol. 4 no. 1 p. 114-131 14.Guatemala Human CapitalInvestment Program (GU-L1017) Loan Proposal. 15.Lozano et al. Progress towards Millennium Development Goals 4 and 5 on maternaland child mortality: an updated systematic analysis. The Lancet. 2011 vol:378 iss:9797 pg:1139 -1165 16.World Health Organization WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Published 2012. 17.Avila, Carlos, Rhea Bright, Jose Gutierrez, Kenneth Hoadley,Coite Manuel, Natalia Romero, and MichaelP. Rodriguez. Guatemala Health System Assessment, August 2015.Bethesda,MD: Health Finance & Governance Project, Abt Associates Inc. 18.Walton A, Kestler E, Dettinger JC,Zelek S, Holme F, Walker D. Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala. International Journalof Gynaecology and Obstetrics. 2016;132(3):359-364.doi:10.1016/j.ijgo.2015.08.009. 19. 20. 21.Sayeba Akhter, Mosammat Rashida Begum, Zakia Kabir, et al. Use of a condom to control massive postpartum hemorrhage.Posted:September 11,2003.Medscape GeneralMedicine. 2003;5(3)