Radically transforming the policy, practice, and culture around RH and childbirth in the former Soviet Union.

A transformation in maternal and infant health care has spread throughout the countries of the former Soviet Union. Outdated, rigid, and highly medicalized methods are being replaced by modern evidence-based and integrated approaches that are more responsive to women and families, achieve better health outcomes, and reduce costs. JSI has been a key player in these advancements over a decade of dramatic change. The changes have resulted in substantial reductions in maternal death from hemorrhage and in neonatal deaths from hypothermia and birth asphyxia, while greatly reducing the reliance on abortion as birth control.

Beginning in 1999, JSI supported the governments of Russia, Ukraine, Georgia, and the five Central Asian Republics (Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan) to launch pilot projects, which were massively scaled-up, to improve maternal and infant care and reduce maternal and infant morbidity and mortality. Although there was strong government commitment to improving maternal and infant health care, there were many challenges.
JSI/WEI Photo Library Photo
Health provider with a pregnant woman in Tajikistan

Challenges
The care provided women in the former Soviet Union was overly medicalized, with ineffective and sometimes harmful interventions used instead of evidence-based practices. Women were often hospitalized during pregnancy, received many medications and tests, and spent over a week in the hospital for delivery, with no family members allowed to visit.

Another major challenge was the critical role that policy plays in post-Soviet environments, where the presumption is that things are forbidden unless explicitly authorized by law or policy. Most health workers will not implement practices that are not officially endorsed.

How change happened
Because backing from the highest government levels was critical, JSI started with discussions with ministers of health. JSI also collaborated with the World Health Organization, which facilitated the process of convincing MOHs to try the new approaches. JSI then worked to educate in-country health providers about how clinical policy and practice has evolved in other parts of world on the basis of evidence. JSI conducted many skills-building trainings for health providers. Local data collected at project sites reinforced international evidence and was especially valuable in convincing skeptics. JSI worked with the main stakeholders on new MNCH policies, practice guidelines and clinical protocols development, and overall MNCH system strengthening.

Throughout the pilot projects, JSI worked to build understanding of and commitment to the changes underway to facilitate subsequent expansion and policy changes. JSI introduced a simulation-based method of training, and helped modernize medical records and information systems. Also, JSI employed modern social marketing and health promotion to introduce the public to the new practices, both within the project areas and beyond to help spread change more rapidly. Finally, JSI worked to ensure a systematic scale-up.

What changed
National and regional policies opened the door to more family- and client-focused approaches in participating maternity hospitals. These included:
JSI/WEI Photo Library Photo
A baby-friendly delivery room in Russia
  • Partner support during labor and delivery was allowed and encouraged, leading to stronger bonding between parents and infants.
  • Unnecessary restrictions, including not walking, eating, or drinking during labor, were removed.
  • Unnecessary and harmful practices, including routine enemas, frequent episiotomies, and pubic shaving, have ended.
  • Private, more homey birthing rooms are used for delivery when possible.
  • Mothers are taught to start breastfeeding immediately after birth and babies now stay with the mother.
  • Most importantly, women are now counseled on their choices rather than having health professionals making all the health decisions.
Many non-evidence-based interventions were discontinued, while potentially life-saving interventions—including the use of WHO partograph for decisions about need for higher level of care and the “warm chain” to ensure that newborns are kept dry and warm from moment of birth, thus reducing hypothermia—have been introduced. Other initiatives were introduced as well: clean and safe delivery, AMTSL, new approaches to premature birth, essential newborn care, exclusive breastfeeding, neonatal resuscitation, and management of newborns with complications.

Furthermore, maternal care, especially in the areas of family planning and HIV, became more integrated and holistic.

Results
By 2011, modern maternal and neonatal methods had reached facilities handling 55 percent of Ukraine births, 78 percent of Georgian births, 62 percent of Kyrgyz Republic births, and 25 percent of Russian births. (Expansion has not reached the other Central Asian Republics.)

One of the most significant changes was the reduction in the rates of abortion throughout the region as family planning increased. In Russia, for example, between 2003 and 2010 there was a 52 percent decline in abortion rates in project-assisted regions, compared to a 34 percent drop nationwide. In Georgia, a country with one of the highest abortion rates in the world, the abortion rate declined by almost half between 2005 and 2010.

Hypothermia and mortality among newborns has been dramatically reduced, and maternal hemorrhage rates have also dropped. In Kyrgyzstan, for example, newborn asphyxia and fetal hypoxia have declined by nearly half since newborn resuscitation practices were implemented. Maternal mortality was reduced in Georgia during the expansion phase of the project.

The more client- and family-oriented service is also clearly welcomed by women and families. The humanization of care that underlies the new approaches is affecting health care providers, too. They are adopting more team-oriented ways of providing services that bring them greater job satisfaction and contribute to better, safer care. Finally, the health system is reaping benefits through better-integrated, more efficient care that is reducing costs while improving health outcomes.

JSI projects in the region continue to reinforce and spread the shift to family-friendly approaches to normal pregnancy, delivery, and neonatal care, coupled with improved management of complications. In addition to the promise of improved maternal and infant health, expanding evidence-based medicine and client-centered approaches to other medical specialties could have an even greater impact on the quality of health care in post-Soviet settings and contribute to healthier citizens and societies.


Learn more

Download this publication JSI's maternal and child health advances in Russia

The reproductive health and maternal revolution in Georgia

How JSI has improved maternal health in Ukraine

Experience from the Eastern Europe and Eurasia Region in improving family planning pre-service education

Revolutionizing Maternity Care in Georgia (photo essay)