MABDUS: Mother and Baby Delivery of Unified Services

 

Quarterly Maternal-Perinatal Statistics: the Vicente Sotto Memorial Medical Center Model for Service Delivery Network for Maternal Health (MABDUS)

In 2015, the overwhelming problem was the high maternal and perinatal mortality.  The VSMMC Department of Obstetrics and Gynecology, together with the Department of Pediatrics jointly organized monthly Perinatal Statistics since 2015 to identify areas for improvement.  The aim was to identify the different causes of mortalities and morbidities, assess as to whether these causes were preventable or non-preventable, to improve the coordination between the stakeholders within VSMMC so as to have better patient outcomes.  It soon became apparent, however, that being an apex hospital, VSMMC needed to coordinate with hospitals within the service delivery network.  Like other government hospitals, VSMMC was inundated with patients - as many as 10 patients sharing one bed.  Most of the patients were referrals from district and provincial hospitals from all over Cebu Province. 

 

An assessment of referrals revealed that the main reason for patient transfer was the unavailability of expert assessment (obstetrician, anesthesiologist, pediatrician) and services required were beyond the capability of the referring institution (no operating rooms, medical equipment and maternal and/or neonatal intensive care units). The department annual statistics show that there were 16,375 obstetric admissions in 2017.  The turnaround time for cesarean section was as long as 2 days with an average of 12 hours. The long turnaround time was often identified as one of the key factors which contributed to poor maternal and neonatal outcomes.  Up to 40% of patient admissions in 2015 to 2017 were low risk obstetric admissions, which could have been managed adequately in lying-in clinics, birthing homes and primary hospitals. 

In order to spearhead regular meetings of the chiefs of hospitals within the service delivery network to identify the problems that can be solved, the VSMMC Department of Obstetrics and Gynecology set well in advance the schedule for the QUARTERLY MATERNAL-PERINATAL STATISTICS (QMPS), which initially started as a whole day event at a hotel function room.  Later on, the meeting was scheduled as three half-day virtual conferences during the COVID19 pandemic.  The main goal for the Maternal-Perinatal Statistics is to assess and develop strategies to strengthen the referral system in order to reduce maternal and perinatal mortality.   Initially, the goals were simple, such as:  the provision of the initial dose of antenatal corticosteroid for patients with preterm labor, and magnesium sulfate for patients with preeclampsia or eclampsia, prior to transfer to VSMMC, until it ballooned to all sorts of problems with corresponding suggested solutions.  The QMPS began a platform where healthcare workers from different hospitals, lying in clinics and birthing centers, could express issues and concerns and expect acceptable solutions.

 

With the promotion of the Service Delivery Network (SDN) by the Department of Health Central Visayas Center for Health Development (DOH CVCHD), the aim was to ensure that the right patient is at the right facility at the right time, which means that patients admitted to the apex tertiary government hospital are (1) patients needing emergency care; (2) patients referred from other hospitals and (3) patients with high-risk conditions like preterm pregnancies <35 weeks age of gestation, and (4) those patients needing intensive care. This is made possible through the electronic referral system developed as a real-time inter-hospital communication platform.  In recent years, the buy in for hospitals to use this system was the refusal of VSMMC to accept walk-in patients, and those not documented through the electronic referral system.

 

To facilitate this, the technical working group was created, members of which  committed to meet quarterly to review statistics, accomplishment reports and selected patient cases to recommend policies and guidelines for maternal healthcare service delivery.  The functionality of peripheral hospitals were improved with funding from the DOH Health Facility Development Bureau.  Continuity of these conferences to maintain transparency and accountability for hospital mandates will ensure implementation of the universal healthcare within the Central Visayas healthcare provider network.

The COVID-19 pandemic reflected the weakness in our healthcare system, but it also revealed our strengths.  Under the supervision of the DOH CVCHRD, the QMPS is actively and consistently participated by ten (10) government hospitals in the island of Cebu.  There are four (4) DOH-mandated hospitals, namely the Vicente Sotto Memorial Medical Center (VSMMC), Eversley Childs Sanitarium and General Hospital (ECSGH), Saint Anthony Mother and Child Hospital (SAMCH) and the Cebu South Medical Center (CSMC).  There are four (4) Cebu Provincial Hospitals (CPH): CPH-Bogo, CPH-Danao, CPH-Balamban and CPH-Carcar.  There are two (2) city hospitals, the Lapu-Lapu City Hospital and the Cebu City Medical Center.   While VSMMC presents the maternal mortalities, perinatal statistics and census of referrals, the other hospitals present their quarterly accomplishment reports for accountability.

Utilizing the electronic referral system as a real-time tool to facilitate coordinated patient transfers between health facilities to ensure people safety, the system allows for monitoring and evaluation of the quality of referrals as well.  During meetings, there is a no-blame policy where the discussion is considered safe space, where we could openly discuss and identify areas for improvement in the cases of maternal mortalities presented, to learn from our mistakes.  This allows for everyone to be on board and commit to the process of identifying problems and proposing solutions. 

 

The decreasing trend in obstetric admissions and deliveries at the end-referral apex hospital is a function of low-risk pregnancies effectively managed at the grassroots level and more high risk pregnancies referred to VSMMC.  Direct communication between healthcare providers through text messaging and chat groups augments the electronic referral system for coordinated patient transfers to ensure patient safety.  To address infection control issues, a coordinated schedule of general cleaning of the obstetric complex, neonatal ICU and wards of each government hospital is made possible without interrupting patient access to health service delivery.  Continuing professional education is provided free of charge for healthcare workers within the network to boost confidence and improve their capacity to serve.  Bottomline, the impact of the quarterly maternal-perinatal statistics is the dramatic reduction of annual maternal mortalities from 132 maternal mortalities in 2015 to 33 maternal mortalities in 2021.

Universal healthcare advocates financial risk protection and VSMMC believes in shared identity and shared responsibility.  The QMPS is a low cost, high impact intervention that is highly recognized by the Department of Health during the regional field implementation coordination team meetings with the electronic referral system as a best practice unique to Central Visayas. 

Moving forward, the members of the technical working group is in the process of editing the second version of the Central Visayas Health Referral System Manual and developing collaborative research for documentation of evaluation and impact analysis of these interventions toward improved maternal and perinatal health, because at Vicente Sotto Memorial Medical Center, quality service is our pride!