Assessing the Quality of services to prevent and manage Postpartum Hemorrhage:

1. Assessing the Quality of services to prevent and manage Postpartum Hemorrhage: A report from the MCHIP Quality of care survey Linda Bartlett, MD, MHSc., JHSPH and MCHIP Feb. 20, 2011, Addis Ababa

2. Acknowledgments • Ministries of Health and staff of the study facilities in Ethiopia, Madagascar, Rwanda, and United Republic of Tanzania • Data collection teams in each country • Research team for MCHIP (alphabetical): , Linda Bartlett, Bob Bozsa, David Cantor, Patricia Gomez,Barbara Rawlins, Jim Ricca, Heather Rosen • Jhpiego headquarters and in-country staff, Tandem consulting (Madagascar)

3. MCHIP Quality of Care Survey: QoC- MNC Facility assessment toolkit to assess the Quality of Care for prevention, identification, and management of common serious Maternal & early Neonatal ComplicationsPost-partum hemorrhage Severe pre-eclampsia / Eclampsia Prolonged / Obstructed Labour Sepsis Essential newborn care and Resuscitation

4. QoC-MNC Assessments implemented in 5 countries in 2009-2010 • Ethiopia • Kenya • Tanzania & Zanzibar • Rwanda • Madagascar • Zimbabwe is planned for 2011 • Available to assist more countries

5. Goals of QoC MNC survey • Guide QoC improvement activities for maternal and newborn care at facility, regional and national levels • Provide baseline estimates for countries to monitor improvements in care • Develop indicators and data collection tools that can be used in multiple countries.

6. Survey toolkit: 8 data collection instruments • Tool 1: Health worker listing • Tool 2: Facility Inventory • Tool 3: Record review • Tool 4: ANC observation checklist • Tool 5: L&D observation checklist • Tool 6: Health worker interview with maternal and newborn knowledge tests • Tool 7: Policy review • Tool 8: Key informant interviews

7. Sample plan and size: • Nationally representative sample of facilities, HCWs and deliveries. • Focus on facilities with at least five deliveries per day • HCW and deliveries are observed for 48 hours • 250 deliveries  and 250 ANC consults • Baseline estimates

8. Surveyed 177 facilities in 4 countries; observed ~2500 deliveries and ANC consults, and interviewed ~600 health workers

9. Data collection using mobile smart phones Observers using Windows Mobile Smart Phones, for capturing data, enforcing quality checks and sending data

11. Results:PPH mortality prevention and management at ANC, L&D and PP levels

12. Screening for PPH risk and counselling during ANC (n=1151)

13. Observation of AMTSL (n=1045)

14. Correct administration of oxytocin

15. Harmful and un-indicated practices related to PPH during labor

16. Inventory of supplies for PPH management (n=177)

17. Health worker knowledge of PPH signs and management (n=564) * Values are mean score

18. Making sure that women get life-saving interventions: from policy to practice (1) Oxytocin registered, on EDL, indicated for AMTSL, AMTSL in current SDGs, oxytocin 1st line for AMTSL in SDGs, correct dose (10IU) in SDG, SDG mentions controlled cord traction, SADG mentions uterine massage, all SBAs eligible to administer oxytocin; (2) births attended by skilled attendants; (3) facilities stocked with oxytocin or ergometrine; (4) personnel received supervision within last 3 months; (5) personnel knowledgeable about signs to assess PPH, actions for PPH, actions for retained placenta

19. Ensuring women are provided life-saving interventions: from policy to practice (AMTSL) (1) Oxytocin registered, on EDL, indicated for AMTSL, AMTSL in current SDGs, oxytocin 1st line for AMTSL in SDGs, correct dose (10IU) in SDG, SDG mentions controlled cord traction, SADG mentions uterine massage, all SBAs eligible to administer oxytocin; (2) births attended by skilled attendants; (3) facilities stocked with oxytocin or ergometrine; (4) personnel received supervision within last 3 months; (5) personnel knowledgeable about signs to assess PPH, actions for PPH, actions for retained placenta

20. Management of PPH

21. Summary and Discussion • Preventive / risk screening practices low in ANC (22% - 46%) • Knowledge skill scores low (39-46%) • Harmful practices low but should be zero • In policy to action cascade for AMTSL: • Higher level interventions frequent • But translation to practice at front line low. • There are a number of strong areas of QoC and many areas that can be strengthened

22. Next steps: • Develop country-specific and overall reports and plans for response • Interventions focus on front line • Pre-service and in-service education, quality improvement • Research on gaps identified: • Understand disconnect between levels of cascade • Plan to address at least some of the answers as QoC data analyzed. • Possible further qualitative type research • Minimal effective intervention for PPH prevention: dose AND timing of uterotonic?

23. THANK YOU! www.mchip.net Research plan, tools and PDA data entry and analyses programs will be available on MCHIP website.

25. FIGO ICM definition of AMTSL Active management of the third stage of labor consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony.  • Administration of a uterotonic agents; • Controlled cord traction; • Uterine massage after delivery of placenta, as appropriate.

26. Summary and Discussion • Preventive / risk screening practices low in ANC (22% - 46%) • Knowledge skill scores low (39-46%) • Harmful practices low but should be zero • AMSTL: • 95% uterotonic given during third or fourth stage labour; • 72% within three minutes • 45% uterotonic within 1 minute • 22% complete AMTSL • Policy to practice 94 – 22%

27. Questions in survey to determine AMTSL performance • Note time the cord was clamped (uses 24-hour clock) •  Gives uterotonic (oxytocin, ergometrine, syntometrine, prostaglandins) • a) at delivery of the anterior shoulder • b) within 1 minute of delivery of baby • c) after delivery of the placenta • DOES NOT GIVE • Which uterotonic given? • Oxytocin •  Ergometrine • Syntometrine • Prostaglandins

28. Questions in survey to determine AMTSL performance • Dose of uterotonic given and type of units of medication (e.g. IU, mg) • Route uterotonic given • Applies traction to the cord while applying suprapubic counter traction • Performs uterine massage immediately following the delivery of the placenta • Palpates uterus 15 minutes after delivery of placenta

29. Components of the survey re: use of AMTSL Historical precedent, influence of leader, WHO, in-service training National guidelines Policy AMTSL protocol in hospital Expected behavior in hospital Presence in pre-service training “Champions” for use of AMTSL Woman receives AMTSL (per ICM/ FIGO Statement) Provider Implementation Know- ledge Skills in AMTSL Motivation to use Proper storage Logistics Sufficient availability of oxytocics, needles, syringe on site Amount procured Transport issues Procure- ment at hospital level Uterotonics included on Essential Drug List (oxytocin= drug of choice)