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Sharing What Works: International Collaboration Helps Belize Reduce Its Maternal Mortality Rate by 62%
Good news from Belize
In Belize, the country's maternal mortality rate fell from 88 in 100,000 live births in 2004–2008 to 33 in 2009–2013. The Ministry of Health [MOH] attributes the drop to the quality improvement technical assistance that USAID's Health Care Improvement (HCI) project provided. "Those monthly audits, first implemented in 2009 to identify areas for improvement, have been carried out faithfully ever since," the Maternal and Child Health Technical Advisor for the project in Belize told URC.
How has the MOH made such great strides in reducing maternal mortality? Their story is a model of innovation and economy, knowledge sharing and best practices, with great implications for development projects all over the world.
A challenge revealed leads to a search for solutions
In 2009, the Belize Ministry of Health (MOH) approved a policy that allowed patients to register complaints or service areas in need of strengthening. Investigating these claims, the MOH discovered something more serious than simple customer dissatisfaction: the policy revealed gaps in health services documentation and in compliance with monitoring the implementation of protocols.
As in many countries, maternal mortality in Belize during the period 2004–2008 was mainly related to direct obstetric causes, e.g., eclampsia or severe pre-eclampsia and postpartum hemorrhage. Since so many deaths are linked to these conditions, the MOH believed that implementing a system of quality improvement (QI) and best practices to prevent them could have a profound impact on health outcomes.
Seeking the technical assistance (TA) it would need to address these gaps, the MOH examined what neighboring countries had experienced under the guidance of USAID's Health Care Improvement (HCI) Project, which was assisting the MOH in those countries to embed effective monitoring and improvement systems for similar areas of health care. Belize reached out for assistance from its neighbors in the subregion to develop its own QI system. Using its own funds and with support from the United Nations Population Fund (UNFPA), the Belize MOH committed to implementing strategic improvement strategies, first in a demonstration and then countrywide.
As in many countries, maternal mortality in Belize is often related to pre-eclampsia, eclampsia and post-partum hemorrhage (PPH). Since so many deaths are linked to these two conditions, the MOH believed that implementing a system of quality improvement (QI) and best practices to prevent them could have a profound impact on health outcomes.
Team-based, collaborative QI approach
In Belize, improving maternal health and reducing child mortality is a priority. While its basic resources, including personnel, equipment and supplies, were adequate, the MOH and its staff really needed "know how." The MOH was not asking for someone to come in and fix it but rather, the training and technical assistance to develop, execute and institutionalize its own improvement processes.
A team of dedicated professionals in Belize worked together using virtual collaboration and in-person meetings and transformed the quality improvement process for maternal and neonatal care in just 15 months.
Patients' complaints—combined with health statistics—pointed the collaborators toward a starting point: Punta Gorda Community Hospital and Polyclinic in Toledo District and Southern Regional Hospital and Dangriga Polyclinic in Stann Creek District. Their first objective was to reduce maternal (and newborn) mortality in these facilities through the rapid improvement in the quality of care provided to women during pregnancy and childbirth.
Seeking the technical assistance (TA) it would need to address these gaps, the MOH examined neighboring countries' experiences under the guidance of USAID's Health Care Improvement (HCI) Project, which was assisting other MOH to embed effective monitoring and improvement systems for similar areas of health care. Belize reached out for assistance from its neighbors in the subregion to develop its own QI system. Using its own funds and with support from the United Nations Population Fund (UNFPA), the Belize MOH committed to implementing strategic improvement strategies, first in a demonstration and then countrywide.
From August 2009 to September 2011, Belize worked to transform the two districts' quality of care, using the technical assistance and training provided by the HCI Project. Drs. Oscar Nuñez, URC Country Director in Nicaragua, and Luis Urbina, URC's Technical Advisor for Maternal Health, applied a collaborative improvement model to rapidly improve the quality of care. The model incorporates the use of evidence-based interventions that have been recommended by international literature after having shown good results in similar situations. In addition to including lessons learned from the HCI Project, the Belizean QI teams drew on their own knowledge and experience to develop solutions. Technical assistance from HCI supported simultaneous testing; refinement based on ongoing monitoring and evaluation and on the use of rapid improvement cycles (also known as Plan, Do, Study, Act cycles) enabled health care workers to identify gaps and implement effective changes quickly.
At the end of the demonstration phase in November 2010, MOH staff compared baseline data with monthly project assessments and cumulative data. The numbers left no doubt that a teams-based, collaborative approach had provided rapid quality improvement for specific aspects of maternal and neonatal health care. The achievements did not go unnoticed: In October 2010, CIFAL Atlanta, a UN-sponsored institution, awarded the government of Belize with the Americas Award 2010 Laureate in the category of Improving Maternal Health.
By the end of 2010, the Ministry's achievements inspired the scale-up the QI approach to the rest of the country (a summary of those first 15 months, "Improving Maternal Care in Belize: Results of the Ministry of Health's Quality Initiative," can be found in the Resources section of the URC website).
Belize and the Millennium Development Goals
In September 2000, Belize committed itself to achieving the United Nations Millennium Development Goals (MDGs) to (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria and other diseases; (7) ensure environmental sustainability; and (8) develop a global partnership for development.
While Belize had made great progress toward these goals, its 2010 report (see references below) noted that further reductions would have to be made to achieve its 2015 maternal mortality goal of 29.7 maternal deaths per 100,000 live births.
The future of maternal and newborn health in Belize
A recent review of the project (A Report on the Maternal and Neonatal Health Care Collaborative Improvement, Including Lessons Learned and Recommendations, August 2009–December 2013) indicated that the QI processes introduced through local initiatives had a positive impact on the sustainability of best practices in maternal and neonatal care. For example, compliance with AMTSL, a protocol that requires careful monitoring of a woman immediately after childbirth, contributed to the prevention of PPH.
Belize is taking on the challenges that remain, including the need for strengthening reproductive health services, with a focus on adolescents, and providing integrated management of childhood illnesses, with a focus on growth promotion and development. Dr. Jorge Hermida, URC's Regional Director for Programs in Latin America and the Caribbean, is supporting the MOH in reducing the gaps while health care personnel continue to employ the rapid improvement cycles process introduced four years ago. In Belize during the last three years, maternal deaths due to direct obstetric causes are rare—in 2011 and 2013, no maternal deaths were registered. Belize continues to work with its neighbors, receiving advice on how to develop quality standards and indicators, create a database for monitoring the indicators and use of a single sheet of paper to plan and evaluate a rapid improvement cycle. The sharing is mutual, with best practices and knowledge crossing the borders between them while also spreading among the districts in each country.
With its highly motivated staff and its successful regional collaboration efforts, Belize has the support, tools and knowledge to continue to improve the quality of care for mothers and their newborns.
Belize National MDG Team with Vanus James. 2010. Belize MDG Scorecard and Outlook Report: Final Report Accessed 6/5/2014 and available at http://www.eclac.cl/portofspain/noticias/paginas/3/37323/Belize_Scorecard_and_Outlook_Final_Report_January_30-1.pdf
UNICEF. 2012. Country Profile Belize: Maternal, Newborn & Child Survival. Accessed 6/5/2014 and available at http://www.childinfo.org/files/maternal/DI%20Profile%20-%20Belize.pdf
June 13, 2014