Mobilising for Cardio-Obstetric Healthcare for Women with RHD in Mozambique
Ms Keila Jamal and Dr Ana Olga Mocumbi, Mozambique Institute for Health Education and Research (MIHER)
Project Title: Reproductive Health Services and Cardiovascular Health: The RESCUE RHD Project
"Rheumatic Heart Disease (RHD), is an important determinant of morbidity and mortality in lower- and middle-income countries, particularly in Sub-Saharan Africa where a high prevalence of RHD coincides with high maternal mortality rates. Rheumatic heart disease contributes to almost 30% of the cardiovascular disease seen in pregnancy in this region (and) is associated with a maternal mortality rate of 34%..."
The Pan-African Society of Cardiology position paper on reproductive healthcare for women with rheumatic heart disease, Ana Olga Mocumbi, Keila KF Jamal, Amam Mbakwem, Maylene Shung-King, Karen Sliwa Cardiovasc J Afr 2018; 29: online publication
These important statements were co-authored by our Small Grant Winners, Ms Keila Jamal and Prof Ana Olga Mocumbi from the Mozambique Institute for Health Education and Research in Maputo, Mozambique. Prof Mocumbi is well-known and respected in the RHD global community for her tireless efforts to improve health outcomes for her RHD patients, and for RHD patients around the world. Ms Jamal recently completed her college education and now works under Prof’s Mocumbi’s mentorship, co-coordinating health education activities and adapting RHD health education and training materials to the Mozambican context.
Global Rheumatic Heart Disease Registry - (the REMEDY study) found that RHD affects almost twice as many women as men, and most of those women are of child-bearing age at an average age of 28 years. Dr Ana and Ms Jamal designed their Small Grant Project upon the work of their existing REproductive Health Services and CardiovascUlar HEalth (RESCUE) project that targets this subgroup of vulnerable women among their RHD patients. Their project included training in Gynaecology-Obstetrics for health providers on early detection of common cardiovascular diseases. They also used their Small Grant to enhance their existing efforts to increase access to family planning services for women with cardiovascular diseases, particularly with RHD; and for holding focus group discussions to create a pool of peer-to-peer Heart Disease and Reproductive Health Educators.
Dr Ana has initiated a joint cardio-obstetric clinic consisting of one cardiologist, two gynaecologists, a general practitioner and a nurse at the Mavalane General Hospital in coordination with José Macamo General hospital in Maputo, the capital city of Mozambique. About 15 at-risk cardiac patients have been identified through an RHD registry maintained at the Mavalane General Hospital. These patients are now closely followed by the cardiologist, in terms of guidance in pregnancy, contraception and referral to the gynaecologist. A patient educational booklet is being designed to help patients stay in care – providing guidance on how to navigate and not get lost in a complex healthcare system.
Dr. Adjine Mastala, a clinician on the RESCUE project team, and Ms Jamal organised four health provider workshops at the Mavalane General Hospital over a 6-month period in 2018 that attracted nearly 80 specialists, residents and nurse participants. The main objective of the workshops was to equip the participants with basic echocardiographic skills for screening for RHD. Speakers were largely from the joint cardio-obstetrics clinic who introduced and discussed theories of echocardiography. This presentation was followed by hands-on echocardiography practice sessions with volunteer participants. These sessions focused on how to use and place the pointer (probe) for best results and then how to interpret the results. Sessions on the use of algorithms for detection and management of cardiac disease in pregnant women were also provided to the health workers.
While Dr Mastala focused on organising activities for the clinical participants, Ms Jamal organised and conducted three focus group sessions with RHD patients to assess their knowledge, perceptions and communication skills – skills needed to engage in peer-to-peer education on family planning and reproductive health. She was able to identify six peer-educators for further training and engagement to do outreach and to contribute to the joint clinic’s mission.
The team’s main challenge was scheduling the provider workshops. Busy work schedules made it difficult to schedule the workshops for the relevant stakeholders and they were disappointed by a less-than-hoped-for attendance in these first workshops. There was also a bit of a challenge getting participants to volunteer for the peer-to-peer educator initiative. Ms Jamal comments, “We struggled a little bit at first with the patients because there is still not much comprehension and understanding of the need of this approach, it’s new. We are slowly opting for a snowball approach and that has shown to be the best method to go about.”
Once identified and after some coaching, the peer leaders are now enthusiastic and engaged in making changes in their communities. Among the clinical staff, the project leaders report a good working relationship between the team members and an improved work flow between the cardiologists and obstetricians. They are excited to have 15 participants registered in the joint Cardio-obstetric clinic. Team members have developed a “better understanding of the need for awareness and are slowly embracing the cause of RHD.”
Moving forward, Ms Jamal and Dr Mocumbi have ambitious plans. They are developing the necessary skills in their peer educator group who will soon go out to recruit and support other peers. They feel they have built a strong and collaborative relationship with these patients. The joint clinic is established and functioning well. Getting pregnant women with RHD into care and follow up with this team of specialists will certainly lead to safer pregnancies and better outcomes in this vulnerable population.
Dr Mocumbi and her team are excited to further refine and use their RESCUE materials in training sessions for health providers to improve clinical skills and to raise awareness of the risks of cardiovascular disease in pregnancy in their patient population.