4. In which ways is the initiative creative and innovative?
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Songpa planned the establishment of the Songpa Maternity Care Center after a policy meeting in September, 2010. We explained the causes and plans of the center to local residents, ward members and the Korea Postpartum Care Centers Association, while having several meetings with them to reach an agreement.
In 2011, we began on construction of the project after selecting a design through a design contest and employing workers and in November, 2013 the project was completed and the center finally opened in February, 2014.
In December, 2013, based on 『Regional Public Health Act』, 『Mother and Child Health Act』, 『National Health Promotion Act』 and 『Local Autonomy Act』, the 『Regulations and acts of the Songpa Maternity Care Center』 was set up to regulate the details of the establishment, management and operation of the center. In addition, a regulation that enables low-income mothers to use the service at a reduced fee was established. The service fee of our postpartum center is 1.9 million won for 2 weeks. It is lower than other centers run by private operators. The service fees of private centers are 3 million won on average and it can go up to 10 million won. However, the cost still can be a burden for low-incomers. We provide 30% discounts for beneficiaries of basic livelihood support, lower income households and family having more than two children, while 7 delivery rooms, accounting 25% of the total are allocated to low-incomers, multicultural family and family having more children preferentially.
The specified operation plans of the Songpa Maternity Care Center were arranged as below.
In January, 2013, Songpa signed an MOU with the nursing department of Seoul National University and started to develop standard protocols to improve the health of women both pregnant and otherwise. First of all, a survey was conducted on programs, current situations and workers in private postpartum centers in the same district and we analyzed their postnatal care and research documents. Based on the results, we developed management regulations and programs for mothers, infants and family members, while setting up integrated standard protocols for mothers’ health management. We also carried out training for internal employees to boost their capabilities.
The Songpa Maternity Care Center is located in a building with 5 levels and 2 basement levels and with an area of 2,893㎡, consisting of postnatal care facilities, pre- and post-natal healthcare and education and a public kindergarten. There are 27 rooms in total for pregnant women, neonatal units with the quality of a general hospital and mom’s clinic, which provides services from the moment conception was confirmed until childbirth. Previously, the place was used as a gynecology office of the Community Health Center and now gynecologists and nurses reside there to provide health information in a timely manner. It also provides folic acid and iron supplements and conduct a congenital anomaly test and ultrasound treatment. Consultancy is available at all times.
The center also helps mothers’ breast-feeding activity through running a rooming-in system and a customized breast-feeding education designed by international breast-feeding professionals. At a national level, the operation of the rooming-in system is recommended but the actual operation rate is not as high as expected. Without a rooming-in system, it is difficult perform breast-feeding. For mothers’ successful breast-feeding, Songpa provides education to mothers-to-be and continues the education system after childbirth.
On the 1st level of the center, a public kindergarten was built to provide an integrated service during the period of childbirth and parenting. Its education and other fees are lower than those of private kindergartens. The quality of education is relatively high. At the kindergarten, a strict monitoring is performed based on relevant regulations so that mothers are more confident with our kindergarten now.
Last May, three months after the opening of the center in February, 2014, there was no vacancy and the center was very popular as it was fully booked until January of next year.
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5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The Songpa Maternity Care Center project was suggested as part of the election campaign of the head of the Songpa office.
In 2012, Songpa’s rate of women in childbearing age(15~49) was 56.3%, which is a bit higher than the national rate, which is 51.6% and the rate in Seoul, which is 54.5%. This caused a strong demand for systematic education and support for healthy childbirth. In addition, the number of health institutions dedicated to childbirth (3) and postpartum centers (9) was relatively low compared to the number of pregnant women. Therefore, there was mothers’ demand for postnatal care services provided by the government.
When Songpa decided to establish a public postpartum center for the first time, private operators were strongly opposed to it. They claimed that it would harm private business since postnatal care services have not been run by community health centers in the past. In addition, the operators also explained that there are cases where the centers operated by the government previously had many operational and maintenance issues. That is why private operators currently provide postnatal care services.
However, Songpa did not stop what it was planning as we knew that private postnatal centers lack interest in the health of mothers and infants, while mothers leave private centers with heavy bills. Songpa believed that fees can be reduced and service quality can be improved if we build a public postpartum center and provide quality service at affordable fees.
Songpa developed a health program for mothers and promoted it to influence a private postpartum center market, while considering private postpartum centers as cooperative partners instead of competitors. It also cooperates with private centers for mothers to enjoy equal rates as to whether they are in a public center or private one. In addition, Songpa will see increased efficiency by cooperating with internal organizations and promoting health projects with community groups and bodies. Internally, we set up a task force with community health centers, departments of medicine, health and parenting and a support center for multicultural families, and promote an integrated project. Externally, we organized a community network linking with obstetrics clinics, hospitals, and private postpartum centers, Health Insurance Corporation, Doctors’ Association in Songpa, Korean Nurses Association, Universities and Consultants Board, while actively adopting external resources.
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6. How was the strategy implemented and what resources were mobilized?
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The Songpa Maternity Care Center was established using the Songpa’s budget, which is 8.878 billion won in total. When the project was promoted, the biggest issue was funding. There were various opinions and issues amongst different groups on the matters of finance and the effective allocation of it. However, Songpa worked very hard to persuade local residents opposed to the project and to win approval from the council with respect to universally providing health services according to the situations and needs of all women. We had several meetings with people from the Association of the National Postnatal Care Business and private operators, while holding a public hearing to accommodate different public opinions.
Mothers, who cannot afford several million won for postnatal care services, might experience discrimination and frustration from the beginning of childbirth. It costs money to employ a nurse, while the time is limited to 8 hours per day. Standards for appropriate fees and quality health care service should be established for every woman to enjoy quality service. This view was explained to the people involved and an agreement was finally reached.
The operation cost of the center in 2014 is 1.480 billion won in total, and 1.247 billion won was spent on the operation of the postpartum center, 179 million won on management of the facilities and 54 million won on the operation of programs for the health of mothers and newborn babies. Currently, the center is operated by the allocated budget by Songpa and profits from the operation of the center. The establishment of public postpartum centers started to be accentuated when it was mentioned as part of the election campaigns of many candidates for local election in 2014. It was right after the establishment of the Songpa Maternity Care Center.
Operational technology of the Songpa Maternity Care Center was designed after signing an MOU with the nursing department of Seoul University. It was promoted through developing and adopting programs for mothers, newborn babies and family members and integrated standard protocol for mothers’ health and trainings for internal employees, which was intended to strengthen the capabilities of the center.
It became possible to provide customized health services enabling the management of pregnant women’s individual health and habits instead of just offering iron supplements or performing an ultrasound. Furthermore, programs are provided online and offline to encourage participation. There were no specific educational institutions before and mothers acquired information only online or from acquaintances. Now Songpa suggests a new paradigm through offering offline lectures by professionals and online consultations in real time. Gynecologists, nurses and medical technologists reside at the center and take care of mothers and newborn babies. Mothers can learn about body correction, diet and baby food from professional health trainers and dieticians.
The most noticeable project could be ‘Songpa’s certified nurses for mothers and newborn babies’. Songpa signed a contract with 8 domestic nurse recruitment agencies and provides professional training to them with respect to breast-feeding, parenting newborn babies, emergency countermeasures and postnatal care. We also invite international breast-feeding experts, nursing professors and gynecologists and improve the quality of training provided. For 1 year in 2013, we educated 96 professional nurses and sent them to 501 households to provide postnatal care that women can trust.
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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First, we reduced the fee for postnatal care service.
There was discrimination and sentiment of frustration in the community as fees varied by district and the quality of facility even though each postpartum center provided similar services. As postpartum centers are becoming essential for the society, excessive raise and difference in the cost should be controlled. There have been efforts by the government to reduce the fees. The government waived the VAT for all postpartum centers. However, only 35.6% of the centers reduced their service fees while 34.6% of centers maintained the fees and 19.8% increased its fee.
The fee for the postpartum center of the Songpa Maternity Care Center is 190 million won for 2 weeks. It was 70% of the fee of a private center, while giving preferential benefit to low-income mothers. It also provides a 30% discounted fee to the beneficiaries of basic livelihood support, lower income families and mothers with a third child, while 25% of the total rooms are arranged for low-income and multicultural families or mothers who have more children.
Secondly, strict hygiene management is carried out to avoid accidents.
Currently, the most urgent issue to be addressed by private centers is protecting mothers and newborn babies staying within a limited space from the risk of infection. 453 infection related accidents occurred over 5 years, from 2009 to 2013 and 1 newborn baby lost his life.
The Songpa Maternity Care Center was designed to prevent accidents and maintain safety and we provided strict management for preventing infection. It includes education for preventing infection, medical examination, infection care and health care. In addition, we also arranged a systematic plan for management and compensation with respect to accidents. As a result, there has been no single accident since the opening of the center.
Third, time and costs are reduced by providing an integrated system.
Many women look for good and trustable postpartum centers for a healthy pregnancy and childbirth and they spend time and energy searching the internet or asking their mothers to get more information. However, they also feel confused as they are not sure if the information they acquired is professional and correct. Therefore, there was a demand for a public support center to provide one-stop infrastructure for women’s health all in one place.
The Songpa Maternity Care Center is equipped with an integrated care system, including a postpartum center, kindergarten, consultation for pregnant women, cooking class, kinesiatrics, and an insulin resistance syndrome management center. The information related to pregnancy and childbirth provided by professionals is classified by each stage and it is readily available. The environment for childbirth is arranged by connecting postpartum centers and day-care centers, while providing actual support for women seeking to return to the workplace.
Fourth, pressure for childbirth is reduced.
A woman after childbirth will learn parenting capabilities and carry out her role as a mother. She will undergo a process of trial and error in order to learn them, so it is critical to encourage and support her to learn how to perform parenting for her baby and to be confident in performing the role as a mother.
The Songpa Maternity Care Center carries out professional education to improve women’s capabilities, including a rooming-in system, one on one breast-feeding training and one on one Newborn Bathing Practices. In addition, for favourable parenting environment where parenting is not only mothers’ duty, but all other family members’(husband, mother, mother-in-law) duty, the center is providing classes for fathers and grandmothers.
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8. What were the most successful outputs and why was the initiative effective?
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Postpartum centers take care of newborn babies so strict management and inspections are required, but it has been out of the government’s control. Songpa performed strict infection management to prevent accidents.
Every floor of the Songpa Maternity Care Center is disinfected every day. There is a lift only for mothers to protect themselves from external risks and basins are installed in several places to encourage frequent hand washing. Furthermore, air sterilizers, oxygen generators, automatic temperature and humidity control systems and fire blocking devices are installed to prevent infection and safety issues. Training to prevent infections is provided to staffs for strict hygiene management and the officers from Songpa visit the center once a week to assess environmental and hygiene risks. Last July, the center cooperated with obstetrics and paediatrics departments for the stricter prevention of infection related accidents and health management.
The satisfaction survey is administered to mothers that have left the centers either over the phone or via email to improve management. The survey is classified into cleaning, laundry, diet, education programs, and the parenting of newborn babies, the health management of mothers and the professionalism of staff and scores will be given to each category. Results are reported every week. The satisfaction of 173 mothers was shown until the end of August, as an average of 4.28 out of 5, as the maximum score was received in 9 categories, which is relatively high. The highest score was 4.49 for educational programs and 8 other categories are all over 4, which means mothers are satisfied with most of the services provided.
Opinions suggested in the monitoring process are applied to the improvement in operations planning. Most mothers expressed difficulties in health management and parenting a newborn baby after leaving the center. We established a system that provides offline instruction, online consultation with professionals in real time for mothers to perform the role of parent after they leave the center. In addition, we also developed an application to provide real time health information and online consultation service via smart phones.
After all these efforts, Songpa has been selected as the best institution in the ‘assessment for the integrated health improvement project of the community’ by the Ministry of Health and Welfare in 2014 for 2 years running. The center received high scores in its health system and was the only organization, which received the best award in Seoul. The center received compliments for providing quality health services to women at the Songpa Maternity Care Center.
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9. What were the main obstacles encountered and how were they overcome?
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It costs 8 billion won to build 1 public postpartum center. There was opposition doubting the efficiency of the project as the construction of the center would be quite expensive while the number of beneficiaries is limited.
There should be more effective ways to support women’s postnatal care. One example is to sign an agreement with the Korea Postnatal Care Association and provide lower fees or a discounted rate to low-income mothers.
From 2006, the ‘support nurses for mothers and newborn babies’ have been promoted and vouchers have been offered enabling low-income households, which make less than 50% of the average income to use the nurse service. It varies, but most of time, approximately 85% is supported by the government and the user will pay the rest. In Songpa, 501 people have benefitted from the voucher program last year. However, cases have been reported that fees were unlawfully claimed or beneficiaries and agencies colluded and abused the use of the vouchers. Another problem was that if the vouchers are frequently used, then the fees might increase. Furthermore, the number of beneficiaries is reducing in the face of a lack of governmental support and budget.
Only with the support for lower-income mothers, there are still a number of women placed in the blind spots of the welfare. Songpa established the Songpa Maternity Care Center to provide direct support to more women. The number of mothers who can use the postpartum center of the Songpa Maternity Care Center stands at approximately 700 per year. However, the center offers preferential vouchers for low-income earners who cannot purchase the service by themselves, while reducing the fees for women to manage their health without experiencing financial difficulty.
In addition, the center is equipped with various facilities not only for pregnant women, but also for all family members. Single females, couples planning to get married and grandparents can enjoy the customized programs and exercise clinics, cooking class and the insulin resistance syndrome management center are available to local residents. From the opening of the center until the end of September, there were 2,280 that used the exercise clinic (hosted 306 times), 2,065 that used the cooking class (hosted 113 times) and 4,925 that used the educational programs (hosted 210 times).
The cost effectiveness of the center was doubted for the first time after it was established, but now there are positive responses as the center provides health services not only for women, but also for all local residents.
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