Monitoring and Supervision of Health Workers’ Competencies and the Application of the Neonatal IMCI Strategy in Bolivia and Nicaragua

In Bolivia an interviewer verifies a professional’s immediate newborn care and neonatal resuscitation competencies through a simulation.“This methodology is very practical and allows us to know whether what we have taught in the IMCI workshops is being applied” said one participant from the validation team in Bolivia.

In the Americas, around 3% of newborns suffer asphyxiation at birth and it is estimated that 39,102 neonates died from this cause (29%) in 2006. An equal number of survivors suffer some neurological disorder and brain damage. A majority of these neonatal deaths (during the first 28 days of life) can be prevented with simple measures such as clean delivery, effective management of complications (such as asphyxiation and infections), and early breast feeding. Human resources constitute a factor of critical importance in the implementation of interventions, which means that plans to develop the health workforce so that it meets the needs of the community, as well as systems of supervision, logistics, reference and follow-up and monitoring are essential measures.

It is crucial that health care workers have an understanding of and can carry out basic essential newborn care interventions including recognition of warning signs during pregnancy, delivery, and immediate care after birth. Health workers must also be able to perform prompt and timely resuscitation to prevent neonatal deaths by asphyxia and neurological sequelae, in addition to assisting mothers to provide early breastfeeding to newborns.

Initiative
Traditionally the supervision and monitoring process consisted of a set of questionnaires for health workers, in addition to instruments for the verification of the availability of supplies, drugs, and basic equipment in a health facility. However, this modality of monitoring demonstrated little effectiveness since it did not permit the assessment of health workers’ competencies. In this context, the national team in Bolivia prepared a new Neonatal IMCI instrument for monitoring and supervision, this time aimed at measuring the competencies of trained health workers. Validation of the instrument, which was made possible through the PAHO-USAID project and conducted in Santa Cruz de la Sierra, Bolivia, demonstrated through a series of methodologies the usefulness of confirming the essential competencies of health workers. These competencies focus on specific critical moments of care for pregnant woman (e.g. labor), immediate care for the newborn and neonatal resuscitation. In May 2008, PAHO convened a new workshop in which participants from 6 countries further adapted the instrument to a Regional version and initiated its adaptation for Nicaragua.

The Follow-up and Monitoring of Neonatal Clinical IMCI instrument was well received in Bolivia and Nicaragua. It permits verification, documentation and strengthening of the competencies of health workers trained in neonatal IMCI and therefore has great potential for future adaptation. Currently more than 10 countries of the Region, including the Dominican Republic, Guatemala, and Honduras, are interested in this methodology and are setting up workshops for national adaptation and use at local health facilities.

Success Stories in the implementation of IMCI in Nicaragua

Candida Rodriguez Ortiz, who was treated for preeclampsia and high blood pressure during her pregnancy, is checked by Dr. Ileana Arias Hernandez at La Concepción Health Center in Nicaragua. - Photo: PAHO/Francisco Martinez

The Minister of Health in Nicaragua, Dr. Guillermo Gonzalez, along with more than 100 health personnel from the PAHO regional program; major public and private medical schools; obstetric and gynecological, pediatric and perinatal medical societies; and other agencies and NGOs, launched the National Plan for the Reduction of Neonatal Mortality on September 3, 2008.

One of the main instruments that the country will utilize to achieve Millennium Development Goal 4 is the application of Neonatal Integrated Management of Childhood Illnesses (IMCI) with cost-effective interventions based on evidence that have already started to give positive results.

The two success stories that follow demonstrate the application of Neonatal IMCI by trained medical staff for two mothers who suffered from two of the three most common causes of neonatal mortality: preeclampsia/chronic arterial hypertension and vaginal bleeding. The health professionals at both health centers and Masaya Hospital where the mothers sought service were trained in Clinical Neonatal IMCI with an emphasis on evidence-based interventions, thanks to the support of PAHO and USAID in the region.

Doctor detects life-threatening condition in pregnant woman
IMCI-trained doctor’s smart decision to refer an ill pregnant woman saves her and her child

Dr. Ileana Arias Hernandez examines the daughter of Candida Rodriguez Ortiz, a Nicaraguan woman who was diagnosed with preeclampsia at the end of her pregnancy. “By applying Neonatal IMCI, we have been able to provide better care to pregnant mothers and children, improve timely references to the hospital and overall lower maternal and infant mortality.” Photo: PAHO/Francisco Martinez

After Dr. Ileana Arias Hernandez diagnosed Candida Rodriguez Ortiz, a 35-year-old pregnant woman in Nicaragua, with preeclampsia and chronic hypertension, she knew she had to act quickly. Preeclampsia is one of the leading causes of complications in pregnancy; if left untreated, it can kill the mother and her baby. Dr. Arias recognized that an emergency C-section would be needed to safely deliver Candida’s child before her condition worsened. However, the La Concepción Health Center where Candida was being treated was not properly equipped for this procedure. For this reason, Dr. Arias referred Candida to the Masaya Hospital, where doctors delivered a healthy baby girl, who Candida named Ashley Nahomi Guevara Rodriguez.

Dr. Arias was quickly able to identify Candida as a high-risk labor by following the steps of the Integrated Management of Childhood Illnesses (IMCI) strategy. With financial, logistical and human resource support from PAHO and USAID, this strategy is implemented to help health care providers determine the steps that need to be taken when evaluating a pregnant mother, newborn or child under the age of 5 years. Part of the IMCI strategy indicates when a patient should be referred to a larger, more specialized health facility.

“We are very happy with the IMCI strategy,” Dr. Arias said. “By applying Neonatal IMCI, we have been able to provide better care to pregnant mothers and children, improve timely references to the hospital and overall lower maternal and infant mortality.”

At a follow-up visit at the La Concepción Health Center when Ashley was a month old, she was diagnosed with a respiratory infection. Again using the Neonatal IMCI strategy, the medical staff provided the proper care and treatment, and she made a full recovery.

“I’m very grateful to the La Concepción Health Center and Masaya Hospital,” Candida said. “They provided excellent care to me and my daughter when we were sick.”