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The USAID Maternal Health Technical Series

by Cynthia F. Young, Senior Staff Writer

Dr. Oscar Nunez and Dr. Luis Urbina of the Quality Assurance Project (QAP), Nicaragua, presented a session on Maternal Health in Nicaragua on February 22, 2001 at the Ronald Reagan Building.

Waiting Room, Nicaragua

In 1998, maternal mortality in the departments of Jinotega and Matagalpa, Nicaragua, averaged 321 deaths per 100,000 live births, 16 times the rate in neighboring Costa Rica in the same year. The QAP with USAID assistance, is introducing modern quality assurance techniques, adapted from the US health system, to make better use of limited resources. Less than a year after the program began, the number of maternal deaths in El Cua and Bocay, the two districts in Jinotega where the QA Project is active fell from ten in 1999 to three in the first ten months of 2000. This represents a drop in the maternal mortality rate from 202 to 73 (per 100,000). It is too soon to be sure if this drop will be sustained, but improvements in care are well established.

Initially, providers were largely unaware of national standards for obstetrical care. Drs. Nuñez and Urbina, two Nicaraguan physicians, initiated and led a program of quality improvement which focuses on issues of client satisfaction and improving compliance with national standards for prenatal and delivery care. Service processes were redesigned (for example, there is a special line for pregnant women which has resulted in a total waiting and visit time of less than ½ hour compared to 2 hours before the program began), health workers were re-trained in the care of obstetric complications, and PAHO perinatal technologies such as the partogram were introduced to follow the women's labor and to identify danger signals.

Mother with newborn

The health center team monitors its own performance and compliance with standards by reviewing a sample of records each month and posts the results on a bulletin board outside the centers for both staff and clients to see. In only 10 months health center teams have increased compliance with obstetric standards from under 3% initially to between 70% and 90%. Patient satisfaction has increased from 58% to 87%.

These changes were illustrated recently when a USAID team was visiting a clinic when an obstetrical emergency happened to be brought in. The woman had delivered a healthy baby at home, but experienced a retained placenta (the leading cause of maternal mortality in Nicaragua) and was in danger of a fatal hemorrhage. A number of steps were carried out effectively to save this woman's life: the traditional birth attendant in the village was trained to recognize the problem promptly, the mother was brought directly to the clinic, and at the clinic, each step in the national standards for her care were followed. By the time that the USAID team left the clinic, she was resting comfortably, breast-feeding her new baby.

Mother nursing newborn

Dr. Oscar Nuñez: Dr. Nuñez is a pediatrician who was Deputy Director of the National Children's Hospital in Managua prior to joining the QA Project. He has received training at the CDC in Atlanta in Quality Management and had a long commitment to its implementation at the Children's Hospital. He has also been the President of the Nicaragua Society of Pediatrics. He acts as the QA Project Country coordinator as well as being involved daily in implementing the QA program in the field. 

Dr. Luis Urbina: Dr. Urbina is an obstetrician with extensive experience in the practice and teaching of obstetrics. He received a Fulbright scholarship to study reproductive Health at Tulane University and was Director of Profamilia's Regional Center in Managua. He is dedicated to improving maternal care in rural Nicaragua and has been involved in training TBA's in Nicaragua for UNFPA. As the full-time Maternal Health Coordinator for the QA Project he has organized the technical approach to assure the management of maternal care and complications according to evidence based standards of care and by assuring the implementation of the PAHO Perinatal Technologies in the five project districts in Matagalpa and Jinotega.

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.