How Georgia revolutionized maternity care and reduced maternal mortality by 40%.
Despite the Soviet Union’s claim to have outstanding health care, reality was very different. At the fall of the Soviet Union, and for many years after, Georgia had a surprisingly high maternal mortality ratio. Maternity care was inhumane and, at times, even harmful for mothers and their babies.
Georgian women delivered in large, damp, often freezing maternity rooms, four to six to a room, without family support, and with staff generally insensitive to their suffering or cries for help. Pregnant and delivering women were given many useless or harmful medications, unnecessary induced labor, or unnecessary Cesarean sections.
Newborns were taken from mothers immediately after birth, weighed on cold examination tables; newborn hypothermia was common. Breastfeeding was delayed by several days and newborns were kept in nurseries separate from their mothers.
The birth rate plummeted. Again and again, women describe the psychological and physical trauma of giving birth under these conditions. Husbands, grandmothers, and families were not allowed inside maternity hospitals; they were relegated to standing outside, in the freezing cold or burning heat, waiting to catch a fleeting glimpse of their newborn through the maternity hospital window.
In 2003, recognizing that things could be better for Georgian women and their newborns, USAID awarded John Snow, Inc. (JSI) a project to modernize maternal and newborn care. JSI analyzed key areas needing change, and introduced “effective perinatal care” to Georgia. With an emphasis on evidence-based medicine, effective perinatal care encourages health care providers to question and discard routine practices that were previously considered appropriate or essential.
Looking back, Georgian neonatologist Marika Petriashvili (below) remembers,
“It was a very bad picture before 2003: We were separating mothers and babies, we were prioritizing infant formula over breastfeeding. We over-prescribed hormones, diuretics, antibiotics, vitamins, and anti-vomiting medicine to treat sick newborns and mothers. And neonatology was completely separated from the obstetrical unit.”
At first, ob/gyns, neonatologists, and hospital administrators were reluctant to admit anything was wrong with their practice, or that there were gaps and poor quality of care. Convincing hospitals to implement the system-wide and attitudinal changes needed was also difficult.
Starting with a small group of influential and forward-thinking professionals in a few hospitals, the first (of many) effective perinatal care course for doctors took place in Kutaisi (Georgia’s second largest city) in 2005.
Reforms seem simple in retrospect, but in practice it took time. JSI introduced active management of third stage labor, using partograms to track labor progress, reducing medications, and improving newborn care (skin-to-skin and warm chain, a system of keeping the newborn warm immediately after delivery). JSI also introduced single, comfortable, and cozy delivery rooms, allowing women to choose their position for labor, and encouraging family members to be present in the labor and delivery room.
Initial results from the first round of hospitals were encouraging. Studies showed a win-win-win scenario: improved medical outcomes for delivering mothers and infants (reduction of morbidity and mortality), greatly reduced costs for budget restricted maternity centers, and overwhelmingly positive client satisfaction.
Dads got involved, too! No one thought in the beginning that Georgian men would participate in their children’s births, but all this has changed. Men now even provide skin-to-skin warming for their newborns after Cesarean sections. The results go beyond just the childbirth experience; there is increased bonding with fathers and more intact families.
Notwithstanding good results, spreading effective perinatal care across the entire country took time, patience, persistence, and dedication. JSI involved policymakers and politicians, private sector hospital owners, religious leaders, and, of course, doctors, nurses, and hospital administrators. To improve results, JSI introduced and took to scale supportive supervision and continuous quality improvement practices.
And, women in increasing numbers voted with their feet. Hospitals offering modern, family-centered and respectful maternity care were seeing more clients, whereas old-fashioned, Soviet-style hospitals were nearly empty. Today, over 95% of Georgian maternity hospitals offer effective perinatal care, including major insurance plans and private hospital chains.
Perhaps not surprisingly, the maternal mortality ratio dropped by 40% between 2006 and 2012.
JSI has continued efforts by introducing effective perinatal care into medical school curricula, improving risk appropriate care for mothers and babies (this is called regionalization), and introducing accreditation of maternity care facilities. Accreditation and regionalization are now taking hospitals and maternity care in Georgia to a whole new level of sophistication and excellence.
One of Georgia’s most respected ob/gyns, Tamara Antelava, said,
“I came to the effective perinatal care training a total skeptic. I thought my hospital did the best obstetrics possible and that we had little to learn. The expert trainers brought by JSI changed my mind. I’m a scientist, and I respected the evidence. And as I began to visit and actually see effective perinatal care hospitals, happy clients, and better outcomes, I changed completely. I got inspired to become a rigorous advocate for evidence-based obstetric practices. I now think my career is divided into pre- and post-effective perinatal care. I was transformed! And the entire maternal and newborn care sector across Georgia has been transformed, too.”