APS et qualité des soins. Luc de Bernis Conseiller principal en Santé maternelle et néonatale UNFPA

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1 APS et qualité des soins Luc de Bernis Conseiller principal en Santé maternelle et néonatale UNFPA

2 Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving. Prof. Mahmoud Fathalla 1997 Former President of FIGO Professor of Obstetrics and Gynaecology, Assiut University, Egypt.

3 Faits et solutions Stagnation de la MM/MN; consensus mondial sur stratégies Besoins non couverts en SONU Pratiques révolues persistantes Pratiques prouvées efficaces et coût efficaces non mises en œuvre Nouveau partage des tâches Formation et formation des formateurs, supervision Mécanismes d assurance qualité Audit des décès et échappée-belles Attitudes des professionnels Accès financier aux soins obstétricaux et SONU Recherche Les professionnels montrent la voie

4 MMR Ghana, Congo, Gabon, AS, Namibie, Botswana < 550 Stagnation depuis 20 ans malgré des progrès très localisés Chaque année: ½ m de décès maternels m mort-nés + 3 m décès neo-natals = 6.8 m

5 Nous savons ce qui marche (1) Les services: Planification Familiale Soins qualifiés à l accouchement Soins obstétricaux et néonatals d urgence (SONU) et (2) la mobilisation communautaire

6 Evidence historique : différents modèles USA Median Poor Countries ' E&W SW

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8 Besoins non couverts en SONU SONU de base: 6-35% SONU complets: % % besoins couverts: 8-23%

9 Pratiques révolues persistantes (source: JHPIEGO, interviews in 16 countries Afrique, Asie, AL, 2006) Dilatation-curetage plutôt que AMIU 84% Utilisation de l approche à risque 48% Usage du Diazepam pour Eclampsie 48% Pas d utilisation de partogramme 88% AMTS seulement pour patientes «à risque» 42% Episiotomie systématique chez primipares 32% Traitement systématique par AB pour CS 59% Pas de lavage des mains entre 2 TV 72% CS en général sous AG 65% Pas d assistance à l accouchement par voie basse 57%

10 Pratiques prouvées efficaces non mises en œuvre (Superviseurs SONU) source: JHPIEGO, 2006 Préparation pour la naissance / complications 53% Prise en charge Eclampsie, pré-éclampsie sévère 47% Prise en charge du Paludisme pdt grossesse 33% Partogramme 40% Prise en charge du choc 53% Compression bi-manuelle 47% Délivrance artificielle 33% Réparation déchirures du col 47% Ventouse obstétricale 40%

11 Nouvelles répartition des tâches Formation de cliniciens non médecins à la chirurgie essentielle, incluant la chirurgie obstétricale Chirurgie vs SONU complets Formation de MG Formation de S-F Formation d infirmiers (anesthésie, bloc opératoire)

12 Table 1. Care in pregnancy, childbirth and postpartum period for mother and newborn infant MOTHER Pregnancy care - 4 visits Essential Routine care (offered to all women and babies) Confirmation of pregnancy Monitoring of progress of pregnancy and assessment of maternal and fetal well-being Detection of problems complicating pregnancy (e.g., anaemia, hypertensive disorders, bleeding, malpresentations, multiple pregnancy Respond to other reported complaints. Tetanus immunization, anaemia prevention and control (iron and folic acid supplementation). Information and counselling on self care at home, nutrition, safer sex, breastfeeding, family planning, healthy lifestyle. Birth and emergency planning, advice on danger signs and emergency preparedness. Recording and reporting Syphilis testing Additional care (for women and babies with moderately severe diseases and complications) Treatment of mild to moderate pregnancy complications: -mild to moderate anaemia, -urinary tract infection, -vaginal infection. Post abortion care and family planning. Pre-referral treatment of severe complications: -pre-eclampsia, -eclampsia, -bleeding, -infection, -complicated abortion Support for women with special needs e.g. adolescents, women living with violence Treatment of syphilis (woman and her partner) Specialized -- Obstetrical, neonatal and surgery (for women and babies with severe diseases and complications) Treatment of severe pregnancy complications:: -anaemia -severe pre-eclampsia, -eclampsia, -bleeding, -infection, -other medical complications. Treatment of abortion complications Situational HIV testing and counselling Antimalarial Intermittent preventive treatment (IPT) and promotion of insecticide treated nets (ITN) Deworming Assessment of FGM Treatment of HIV by ART and prevention of mother to child transmission, (PMTCT),by ARV, infant feeding counselling, mode of delivery advice Treatment of mild to moderate opportunistic infections Treatment of uncomplicated malaria Treatment of severe HIV infection Treatment of complicated malaria. Childbirth Care (labour, delivery, and immediate postpartum) Essential Care during labour and delivery -Diagnosis of labour. -Monitoring progress of labour, maternal and fetal well-being with partograph -Providing supportive care and pain relief. -Detection of problems and complications (e.g. malpresentations, prolonged and/or obstructed labour, hypertension, bleeding, and infection). -Delivery and immediate care of the newborn baby, initiation of breastfeeding. -Newborn resuscitation. -Active management of third stage of labour. Immediate postpartum care of mother -Monitoring and assessment of maternal well being, prevention and detection of complications (e.g. hypertension, infections, bleeding, anaemia) -Treatment of moderate post-haemorrhagic anaemia. -Information and counselling on home self care, nutrition, safe sex, breast care and family planning -Advice on danger signs, emergency Treatment of abnormalities and complications (e.g. prolonged labour, vacuum extraction; breech presentation, episiotomy, repair of genital tears, manual removal of placenta). Pre-referral management of serious complications (e.g. obstructed labour, fetal distress, preterm labour, severe peri- and postpartum haemorrhage). Emergency management of complications if birth imminent. Support for the family if maternal death Treatment of severe complications in childbirth and in the immediate postpartum period, including caesarean section, blood transfusion and hysterectomy): -obstructed labour, -malpresentations, -eclampsia, -severe infection, bleeding. Induction and augmentation of labour

13 Audit des décès et échappéesbelles Amélioration de la qualité des soins, si suivi d action et de suivi-évaluation Amélioration de la collecte des données Travail d équipe nouvelle philosophie. Auto-évaluation, «no name, no blame» Diffusion depuis Travail avec APS Résultats? Institutionalisation? Enquête régionale Réunion UA / NEPAD, Johannesburg, Avril 2008

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15 Attitudes Lancet 1996 Niamey Y. Jaffré, P. Olivier de Sardan, Une médecine inhospitalière, Khartalla 2005 Droit des femmes Respect, écoute, confidentialité, intimité, soutien psychologique Pratiques de pouvoir Corruption (effets des politiques de gratuité)

16 Les professionnels montrent la voie Guediawaye, Sénégal Commune 30 et Bobo-Dioulasso, B-F Zinder, Niger

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