Plan of Action to Improve O&G Services at District Hospital Level to Achieve Millennium Development Goal 5.

1. PLAN OF ACTION TO IMPROVE O&G
SERVICES AT DISTRICT HOSPITAL
LEVEL:
TO
ACHIEVE MDG 5
By
Dr. Harris N. Suharjono
20.02.2012

2. Statistics for Sarawak:
The state MMR for 2011 is 19.9/100,000 Live Births

3. National MMR
National MMR in 2009 – 30/100,000 LB

4. Sarawak State MMR
• National MMR have reached a plateau between 28-
30/100,000 LB for the last 10 years
• MDG 5 target for state by 2015 –
11.08/100,000 LB
• State MMR showing a decreasing trend the
last 4 years but…..
• MMR for 2010 (21.3) & 2011 (19.9) –
are we reaching a plateau?

5. Achieving MDG 5: Can we do it?
• Ensure every component of the
healthcare services in the state plays
it’s role, implement and monitor
policies and strive to improve
• Leadership at every level is of critical
importance!
• DHOs & Hospital Directors plays a very
important role

6. SARAWAK DATA:
• Approx. 40,000+ deliveries per year
• 60% delivered in specialist hospitals
• 25% delivered in non specialist hospitals
• 5% delivered in health clinics
• 1.5% home deliveries
• 8.5% delivered in private health centers

7. No. of Maternal death per classification
2009 2010 2011
Direct 8 5 5
Indirect 4 4 4
Fortuitous 15 15 11
Unknown 2 4 4
The estimated live births:
2010 = 42,292
2011 = 45,118

8. No. of direct & indirect deaths by
venue:
Places of death 2009 2010
Gov. Specialist Hosp. 6 7
District Hospital 5 0
Private Health Center 0 1
Health clinic 0 0
Homes 1 0
BID 0 1
Total: 12 9

9. TOP 4 CAUSES OF MATERNAL DEATH
• PPH
• HEART DISEASE IN PREGNANCY
• ECLAMPSIA/HELLP SYNDROME
• OBSTETRIC EMBOLISM

10. State CEMD 2009 -2011
• 30-40% of cases were preventable
• Failure to appreciate severity
• Inappropriate, inadequate and delayed
therapy
• Delay in transfer!

11. DEFICIENCIES NOTED FROM STATE CEMD
• Directives & guidelines not followed
• Lack of blood & blood products in DH
• Substandard management of PPH at DH
• Delays in transferring ill patients to specialist hospitals
• Obstetric patients only seen by MA in A&E or OPD
• Unsafe clinical practices in LW
• Inadequate post natal care
• Failure to offer TOP in early pregnancy by physicians and
cardiologists
• More specialists & specialist hospitals!

12. Lessons from National CEMD
• More than 60% of maternal deaths
occurred during the postnatal period
• The risk of maternal deaths higher in
women over 40 yrs and in mothers who
already had 6 or more children
• Deaths due to obstetric embolism is
rising
• Non booked cases have higher risk of
mortality
• Home deliveries is unsafe

13. POA: Manpower & Equipment Needs
• Hospital Directors should address hospital
needs in terms of manpower and O&G
medical equipment including ambulance
services
• To list out needs and forward to JKNS by End of
March 2012
• JKNS to compile and forward at the appropriate time
• Buddy specialist could assist if required
• Kindly cc a copy to me at harris@suharjono.com

14. POA: Ensure all O&G directives are implemented
• All previous and future directives from JKNS
and O&G guidelines MUST be implemented and
practiced
• By Whom: Hospital Director / LW nursing sister
• Activities:
1. MO, A&E and LW Staff should be briefed
2. All directives should be displayed on notice board (Target –
100%)
3. Directives and guidelines should easily accessible in a file in
LW- (Target 100%)
• Time Frame: Immediate

15. POA: Improve A&E/OPD services
• All antenatal and postnatal mothers should be
considered as HIGH RISK when attending
A&E/OPD
• By Whom: Hospital Director
• Activities: Brief all MO and A&E/OPD staff
• Target:
1. Antenatal & postnatal cases must be reviewed by MO (95%)
2. Repeat A&E visits for the same complaints should be
admitted for further monitoring and management (95%)
3. Low tolerance for admission
• Time Frame: Immediate

16. POA: Ensuring Optimal Blood & FFP Level
• By Whom: Hospital Director
• Activities:
1. Assign a lab assistant to be responsible (Target)
2. Daily stock level check
• Targets:
1. Ensure optimal level achieved at most times
2. Yellow alert should be at 70% optimum stock
3. Red alert should be at 50% optimum stock, response
time to replenish stock within 24 hours
4. Increase FFP stock by 20% if possible
• Time Frame: Immediate

17. POA: Improving PPH Management in DH
• By Whom: Hospital Director/LW Nursing Sister
• Activities:
1. Compulsory regular obstetric drills (Target 3x/year)
2. ‘Red Alert’ system to be implemented (TARGET)
3. PPH box to be made available and regularly checked
4. Carboprost at least 4 ampoules must be made
available in LW at all times
5. BAKRI balloons once used have to be indented
6. ‘PPH management flowchart’ have to be on the
notice board in LW
7. Ambulance driver should be called once Red Alert is
activated
• Time Frame: Immediate

18. POA: Reduce Delays in Transfer of ill Patients
• By Whom: Hospital Director
• Activities:
1. Refer to specialist early!
2. All hospital directors/MO must be well versed with SOP on
using medevac services
3. Brainstorm and decide best way to reduce transit time
4. Reduce time taken to prepare patient for transfer
5. Ensure ambulance services is adequate to meet demands and
have contingency plans!
• Target:
1. Audit time taken to transfer ill obstetric cases to specialist
hospital from decision to arrival.
2. Then try to reduce transfer time from decision to arrival at
specialist hospital by 20% (without driving faster!)

19. POA: Improve O&G Clinical Services in Hospitals
• By Whom: Hospital Directors/O&G specialists
• Activities & Targets:
1. Identify weaknesses by doing regular clinical audit
of near misses and bad outcome (6 in 6 months)
2. Improve clinical work processes to reduce errors
3. Improve skills & knowledge of MO and LW staff
through CME / workshops ( Organize 6 in 6 months)
4. ‘Buddy Specialist’ to do supervisory visits in DH
(2x/year)
5. Short attachments for medical officers
• Time Frame: To start immediately

20. POA: Improve Postnatal Care
• By Whom: Hospital Directors/Maternity NS
• Activities:
1. E-notifications should be implemented by all
2. Write postnatal management plan in high risk patients on
e-notification so that clinic staff can prioritize home visits
3. Unwell postnatal patients attending A&E/OPD should be
managed as high risk and are at risk of DVT/PE – admit
and manage accordingly
• Target:
1. e-notifications for all deliveries (100%)
2. All unwell postnatal mothers (within 42 days)
attending A&E/OPD should be admitted
• Time Frame: Immediate

21. POA: Reduce Risk of Obstetric Embolism
• By Whom: Hospital Directors
• Activities:
1. All caesarean sections require thromboprophylaxis
(LMWH or SC heparin) follow guidelines
2. High risk patients require 7 days of thromboprophylaxis
(continue after discharge)
3. All postnatal mothers should be advised to drink
adequate water and to mobilize
4. All postnatal mothers must be counseled to go to the
nearest clinic if they are feeling unwell
• Time Frame: Practice immediately

22. POA: Improving FP Services in DH
• By Whom: Hospital Director/obstetric counselor
• Activities:
1. Obstetric counselors to organize activities & set targets
2. All antenatal & postnatal mothers should be counseled
3. Make IUCD, Depo-provera and OCP available
4. Send obstetric counselor for training to insert IUCD
5. Advocate postnatal BTL for high risk patients in remote areas
6. Promote family planning in hospital (leaflets, videos)
• Target:
1. All antenatal & postnatal mothers must be given
family planning counseling – April 2012 onwards
2. Obstetric counselor to be sent for training for
IUCD insertion by July 2012 (credentialing &
privileging)

23. POA: Promoting Pre-Pregnancy Clinic
• By Whom: Hospital Director/Obstetric Counselor
• Activities:
1. Identify women in the reproductive age group with
medical diseases or high risk postnatal patients who
would benefit or require pre-pregnancy assessment
before embarking on another pregnancy to the
nearest ‘Pre-Pregnancy Clinic’
• Aim of FP and Pre-pregnancy clinic is to reduce
unplanned pregnancies, grand multi parity and
optimization before pregnancy to reduce maternal
morbidity & mortality
• Time Frame: Immediate

24. Monitoring & Feedback
• JKNS needs to obtain feedback from all
hospitals for the various targets set
• All the components of the ‘Plan of Action’ and
the targets set for 2012 are achievable

25. sgh-og.tumblr.com
• Website by the O&G Department, SGH
• Bookmark website in maternity & LW
desktops
• Videos (O&G procedures)
• Guidelines
• Lectures
• Downloads – forms, patient information
leaflets, LW manual etc