20 March 2018

Zimbabwe: Renewed Hope for Women With Pregnancy Complications

The Ministry of Health and Child Care (MoHCC) with support from its partners is implementing an intervention aimed at improving availability and accessibility of blood and blood-related products to women with pregnancy related complications.

The intervention, known as the blood coupon system, was commissioned by the Ministry in 2010, initially as a pilot project in 19 selected public (district, provincial and central) hospitals.

It was then successfully rolled out in 2013 to all public hospitals offering blood transfusion services in the country.

Since 2013 to date, a total of 43 000 units of blood have been procured (through the blood coupon system) and distributed to all transfusing public hospitals and more than 13 000 women (intended beneficiaries) have received blood transfusion through the coupon system.

The blood coupon system is a high impact intervention designed to provide blood and its related products for 'free', to women with pregnancy-related complications that require blood transfusion.

Examples of such pregnancy-related complications that can be managed through blood transfusion include ante-partum haemorrhage (bleeding during pregnancy), post-partum haemorrhage (bleeding after delivery), severe anaemia in pregnancy, bleeding following obstetric surgery/ruptured uterus, post miscarriage/abortal complications and ectopic pregnancy, among others.

'Free' blood is also provided to neonates (babies between the ages of 1- 28 days) who develop complications that require blood (exchange transfusion).

Apart from the fact that, all maternal deaths caused by the above mentioned pregnancy related complications are avoidable, haemorrhage (ante-partum, post-partum and peri-abortal bleeding) remains the leading direct cause of maternal mortality in Zimbabwe and it accounted for 36 percent of all maternal deaths reported in 2016, ahead of sepsis/infections (18 percent) and eclampsia (12 percent).

Four out of every 10 maternal deaths in Zimbabwe are due to haemorrhage.

"Reduction of maternal deaths due to haemorrhage will result in a significant drop in the country's Maternal Mortality Ratio currently pegged at 651 deaths per 100,000 live births according to the Zimbabwe Demographic and Health Survey published in 2015," says Dr Bernard Madzima, Director Family Health in the Ministry of Health and Child Care.

Ensuring that blood and its related products are readily and easily available, and that blood transfusion services can be accessed readily when needed by vulnerable women, will also easily avert maternal deaths due to haemorrhage.

While blood transfusion is known to be the high impact intervention that can easily avert maternal deaths due to haemorrhage, the high cost of blood and its related products has severely reduced access to the much needed intervention by vulnerable women.

From 2010 up to mid-year 2017, the average cost of a unit of blood was US$ 135 which was beyond the reach of many poor women who in most cases are vulnerable to the loss of blood due to complications before, during or after childbirth.

Before the commissioning of the Health Transition Fund (HTF) in 2011, a significant proportion of the country's public hospitals were struggling to operationalise the user fees policy (which stipulates that all maternity services should be offered free of charge) and hence had instituted full cost recovery fees for services offered, including blood transfusion.

Acknowledging the importance of the availability of blood and its related products in the fight against maternal mortality in Zimbabwe, the MoHCCis providing 'free' blood (through the blood coupon system) to women with pregnancy related complications that require blood transfusion. The objective is to reduce maternal mortality and ensure that every pregnancy results in a positive outcome.

Implementation of the blood coupon system is a combined effort by the MoHCC, its partners in the Health Development Fund (HDF) and the National Blood Services Zimbabwe (NBSZ).

The MoHCC is the end user of the blood coupon system, the NBSZ provides the blood and the HDF through UNICEF funds the system (i.e. pays for the blood). The system uses coupons which upon being printed (with support from UNICEF)and certified by the NBSZ are given to the MoHCC for distribution to all transfusing public hospitals in the country. One coupon represents one unit of blood or is equivalent to one blood product such as packed cells and fresh frozen plasma. Each transfusing public hospital keeps its blood coupons in a secure place and should maintain a blood bank.

When a pregnant woman at the hospital develops complications that require blood transfusion, she is given blood for 'free' by the hospital from its blood bank or from the NBSZ blood bank.

Depending on the number of blood units ordered by the doctor for transfusion, blood coupons (equivalent to the number of units ordered) are filled in with the necessary information from the woman by staff in the maternity department. The coupons are then submitted to the laboratory at the hospital where cross matching of blood is done. Upon completion of cross matching, blood is then released from the hospital bloodbank or is ordered from the NBSZ if there is no blood bank at the hospital and thereafter blood transfusion will take place.

Every month each transfusing hospital submits stabs of all the blood coupons used at the hospital to the NBSZ which compiles serial numbers of all the blood coupons utilized throughout the country. The NBSZ then submits a consolidated national report to the MoHCC for approval and authorization of payment by UNICEF.

The Ministry will then give authority to UNICEF to pay the NBSZ for blood supplied and utilised.

Hospitals are supplied with blood coupons on a monthly basis upon submission (to the MoHCC head office) of monthly data showing how the coupons were utilised.

Despite the fact that hospitals sometimes run out of the blood coupons due to limited supplies, also a result of limited resources, the blood coupon system has successfully averted some avoidable maternal deaths and has contributed to the overall reduction of maternal mortality in the country.

"Given the success of the blood coupon system, the MoHCC has secured additional financial support from the health levy to continue providing 'free' blood and its related products to women with pregnancy related complications and to children under 5 years of age who require blood transfusion.

"The health levy will complement the HDF and also the Government of Zimbabwe to finance the MoHCC to provide free blood through the blood coupon system," says Permanent Secretary for Health and Child Care, Major General (Dr) Gerald Gwinji.

Notwithstanding all the funding modalities availed to finance provision of free blood and its related products to women with pregnancy-related complications, it remains the mandate of all public hospitals to provide 'free' blood to their patients with or without the blood coupon system.

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