implementing best practices postpartum hemorrhage_crow and hovland_10.14.11

MULTI COUNTRY ANALYSIS OF PREVENTION OF PPH AND PE/E IN USAID PROGRAM- SUPPORTED COUNTRIES Carmen Crow & Mandy

Hovland

Jeffrey M. Smith Angie Fujioka14 October 2011

Overview

Broad Program Goal: Accelerate the scale up of high impact

interventions; Achieve high coverage Monitor catalytic role of USAID in program

expansion

Need for both horizontal and vertical program status analysis

Map USAID’s investment and country achievement over time

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Program analysis: Horizontally – globally across countries Vertically – specifically, within country Depth – of program penetration in

country Time – evolution or progress of programs

with a country

4th Dimension

Methodology

35 Countries January – March 2011 National level 46 item questionnaire Group consensus and

self reporting English, French,

Spanish

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Questionnaire on PPH and PE/E

Postpartum Hemorrhage Policy Training Misoprostol Logistics M&E Programming Scale Up / Expansion

Pre-Eclampsia/Eclampsia Policy Training Logistics M&E Programming Scale Up / Expansion

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Results

Responses from 31 Countries: Complete: 27 countries Partial: 4 countries Unable: 4 countries

Results presented 4 ways Main issues expressed horizontally, across

countries: • Dichotomous bar graphs - Global picture • Summary tables

Responses to questionnaires Scale – up maps

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Results

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ResultsResults

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THEME 1: Expansion and Scale up of Active Management of Third Stage of Labor

Figure 1: Survey responses from 31 countries: National expansion of AMTSL (Active management Third Stage Labor)

Aggregate responses by survey question

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THEME 2: Education and Training in AMTSL

Figure 4: Survey responses from 31 countries: Education and training in AMTSL (Active Management Third Stage Labor)

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THEME 3: Expansion and Scale up of PPH Reduction Programs Using Misoprostol

Figure 1: Survey responses from 31 countries: Expansion and scale up of PPH reduction programs using misoprostol


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THEME 4: Expansion and Scale up of Magnesium Sulfate Use

Figure 1: Survey responses from 31 countries: Expansion and scale up of MgSO4 use


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THEME 5: Education and Training on PE/E Management Principles

Figure 7: Survey responses from 31 countries: Education and training on PE/E management principles

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What we don’t have…




Lack of coverage data Not commonly in HMIS Hospital/facility-based, not population-based Unable to track coverage over time

MCHIP + WHO + CDC Global MNH benchmark indicators

• Use of a uterotonic immediately after birth• Use of MgSO4 for diagnosis of severe PE or E • Use of partograph for labor management • Others

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Child Mortality: 4 countries in Africa

Chad Ethiopia

Kenya

Zambia

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Maternal Mortality: 4 countries in Africa

Chad Ethiopia

Kenya

Zambia

PATHWAY TO IMPLEMENTATION OF POSTPARTUM HEMORRHAGE PREVENTION AND MANAGEMENT AT SCALE

Global ActionsNational Strategic Choices

Program ImplementationSustainability /

InstitutionalizationIntroduction Early Mature

Global advocacy and partnerships: Global action to support work on reduction of PPH

Global clinical and program approaches:

Evidence-based interventions for prevention and management of

PPH demonstrated

PPH policy: AMTSL/misoprostol use; Expanded job

descriptions for skilled birth

attendant cadres managing PPH; PPH

service delivery guidelines

Health system governance:

Proactive financing of maternal health

services

Drugs & equipment:

Oxytocin/ misoprostol procurement,

logistics, distribution

Service delivery capacity at sites:

Reliable infrastructure, personnel, and

systems to deliver services

Health workers training systems: For PPH prevention and management

Community mobilization:

Awareness raising of PPH;

Birth preparedness

Pilot programs:Phase 1

implementation of misoprostol and/or

AMTSL for all skilled birth

attendant cadres

Program initiatives in obstetric and postpartum

management: Quality of care; Clinical training;

Supervision

Pharmaceutical systems:

Uterotonics on Essential Drug List

and in Drug Registration; Supply chain management

National advocacy:

Expansion of national program

and highlight work of champions

Standardization: Quality of care approaches;

Government led training expansion

Programmatic growth:

Adding districts, partners, financing

Training programs: Government

budgeted training programs on PPH; PPH competencies in pre-service and

in-service curricula

Clinical coverage:

High coverage use of a uterotonic;

Public and private implementation

Drug & equipment availability:

Drugs and supplies in

government routine

procurement mechanisms

REDUCTION OF

PPH AND IMPROVE

D MATERNAL HEALTH STATUS

M&EReadiness

assessmentPilot project

dataSurvey data

Indicators in HMIS

Routine monitoring

INTRODUCING INNOVATION MOVING TOWARDS SUSTAINABLE IMPACT AT SCALE

Coverage of uterotonic in third stage of labour

0% 25% 50% 75% 100%

MCHIP/USAID active programsOther partners active programsAddressed previously, not activeNo programs

Maps on Postpartum Hemorrhage

ANGOLA: PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE





Global clinical and program

approaches: Evidence-based interventions for prevention and management of

PPH demonstrated







services

Drugs & equipment: Oxytocin/

misoprostol procurement,








Birth preparedness




attendant cadres

Program initiatives in obstetric and

postpartum management:

Quality of care; Clinical training;

Supervision




National advocacy:










Clinical coverage:High coverage use

of a uterotonic; Public and private implementation

Drug & equipment availability:Drugs and supplies in

government routine


REDUCTION OF PPH

AND IMPROVED MATERNAL

HEALTH STATUS

M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring



0% 25% 50% 75% 100%

MOZAMBIQUE - PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE







PPH demonstrated







services

Drugs & equipment:









Birth preparedness




attendant cadres



Supervision




National advocacy:










Clinical coverage:





government routine


REDUCTION OF

PPH AND IMPROVE


M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring

Introducing innovation Moving toward sustainable impact at scale


0% 25% 50% 75% 100%

GHANA - PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE







PPH demonstrated







services

Drugs & equipment:









Birth preparedness




attendant cadres



Supervision




National advocacy:










Clinical coverage:





government routine


REDUCTION OF

PPH AND IMPROVE


M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring



0% 25% 50% 75% 100%

GHS and partners active programing

Other partners, with GHS support

Addressed previously, not active

No programs

SOUTH SUDAN - PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE






approaches: Evidence-based interventions for prevention and management of

PPH demonstrated







services

Drugs & equipment: Oxytocin/

misoprostol procurement,








Birth preparedness




attendant cadres

Program initiatives in obstetric and

postpartum management:

Quality of care; Clinical training;

Supervision




National advocacy:










Clinical coverage:High coverage use

of a uterotonic; Public and private implementation

Drug & equipment availability:Drugs and supplies in

government routine


REDUCTION OF PPH

AND IMPROVED MATERNAL

HEALTH STATUS

M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring



0% 25% 50% 75% 100%

Maps on Pre-Eclampsia and Eclampsia

ANGOLA: PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE




Global advocacy and partnerships:

Global action to support work on prevention, early

detection, and management of PE/E


approaches: Evidence-based interventions for prevention, early


demonstrated

PE/E policy: Calcium

supplementation; Screening in ANC;

MgSO4 for clinically

diagnosed severe PE/E cases; PE/E service delivery

guidelines


Proactive financing of

maternal health services

Drugs & equipment:Procurement,


Service delivery capacity at

sites: Reliable infrastructure, personnel, and


Health worker training

systems: For PE/E

prevention and management


Awareness raising of PE/E;

Birth preparedness


implementation of MgSO4 and other interventions for

severe PE/E

Program initiatives in

ANC & obstetric management: Quality of care; Clinical training;

Supervision


Drug registration; Essential Drug

List; Supply chain management

National advocacy:



Standardization: Quality of Care

approaches; Government led

training expansion




budgeted training programs on PE/E;

PE/E competencies in

pre-service and in-service curricula

Clinical coverage:

High coverage use of MgSO4; High

coverage calcium supplementation; Public and private implementation


Drugs, supplies, and diagnostic

tools in government

routine procurement mechanisms

IMPROVEDMANAGEMENT OF PE/E CASES AND REDUCED

MATERNAL &

PERINATAL MORTALITY

M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring


Coverage of MgS04 for severe PE/E

0% 25% 50% 75% 100%

MALAWI - PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE










demonstrated





guidelines










systems: For PE/E




Birth preparedness



severe PE/E



Supervision




National advocacy:





training expansion







Clinical coverage:





tools in government



MATERNAL &

PERINATAL MORTALITY

M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring



0% 25% 50% 75% 100%

RWANDA - PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE










demonstrated





guidelines










systems: For PE/E




Birth preparedness



severe PE/E



Supervision




National advocacy:





training expansion







Clinical coverage:





tools in government



MATERNAL &

PERINATAL MORTALITY

M&EReadiness


dataSurvey data

Indicators in HMIS

Routine monitoring



0% 25% 50% 75% 100%

Conclusions

Policy is further ahead of practice – Oxytocin/AMTSL and MgS are authorized, but

not always completely practiced Key principles of PPH prevention and PE/E

management are generally in training and education (content not analyzed)

Implementation of PPH Prevention at Homebirth with misoprostol programs are patchy

Oxytocin and MgSO4 are not routinely available at health facilities28

Actions to be Taken

Use the data for addressing global issues and improving country programs Conversations with MCHIP country

offices Other bilaterals and partners

Repeat on annual basis Improve the quality of the data Engage more countries

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Thank you

implementing best practices postpartum hemorrhage_crow and hovland_10.14.11

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