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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. Acknowledgments.

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slide1
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

acknowledgments
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)
mchip quality of care survey qoc mnc
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

qoc mnc assessments implemented in 5 countries in 2009 2010
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
goals of qoc mnc survey
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.
survey toolkit 8 data collection instruments
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
sample plan and size
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
slide8
Surveyed 177 facilities in 4 countries; observed ~2500 deliveries and ANC consults, and interviewed ~600 health workers
data collection using mobile smart phones
Data collection using mobile smart phones

Observers using Windows Mobile Smart Phones, for capturing data, enforcing quality checks and sending data

making sure that women get life saving interventions from policy to practice
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

ensuring women are provided life saving interventions from policy to practice amtsl
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

summary and discussion
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
next steps
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?
slide23

THANK YOU!

www.mchip.net

Research plan, tools and PDA data entry and analyses programs will be available on MCHIP website.

figo icm definition of amtsl
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.
summary and discussion1
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%
questions in survey to determine amtsl performance
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
questions in survey to determine amtsl performance1
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
slide29

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)