1. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 A SSESSING THE Q UALITY OF SERVICES TO PREVENT AND MANAGE P OSTPARTUM H EMORRHAGE : A REPORT FROM THE MCHIP Q UALITY OF CARE SURVEY Linda Bartlett, MD, MHSc., JHSPH and MCHIP Feb. 20, 2011, Addis Ababa

2. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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) 2

3. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 Complications Post-partum hemorrhage Severe pre-eclampsia / Eclampsia Prolonged / Obstructed Labour Sepsis Essential newborn care and Resuscitation

4. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 QoC-MNC Assessments implemented in 5 countries in 2009-2010 4 Ethiopia Kenya Tanzania & Zanzibar Rwanda Madagascar Zimbabwe is planned for 2011 Available to assist more countries

5. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Goals of QoC MNC survey 1.Guide QoC improvement activities for maternal and newborn care at facility, regional and national levels 2.Provide baseline estimates for countries to monitor improvements in care 3.Develop indicators and data collection tools that can be used in multiple countries. 5

6. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 6

7. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 7

8. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Surveyed 177 facilities in 4 countries; observed ~2500 deliveries and ANC consults, and interviewed ~600 health workers 8 SampleEthiopiaTanzaniaRwandaMada- gascar Total Facilities19527036177 -Hospital100%29%60%75%58% -Health Center/dispensary0%71%40%25%42% Observations3188806046712473 -Deliveries1924892933481322 *Initial assessment107306187268868 *3rd/4th stage of labor1174152252881045 -ANC consults1263913113231151 Health workers interviewed79206146140571 -Maternal health79202145138564

9. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Data collection using mobile smart phones Observers using Windows Mobile Smart Phones, for capturing data, enforcing quality checks and sending data 9

10. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 10

11. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 RESULTS: PPH MORTALITY PREVENTION AND MANAGEMENT AT ANC, L&D AND PP LEVELS 11

12. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Screening for PPH risk and counselling during ANC (n=1151) 12

13. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Observation of AMTSL (n=1045)

14. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Correct administration of oxytocin 14 %n Mode of administration IM90%783 IV push5%44 IV drip4%32 IV drip and IM1%10 Unknown0%4 Dose 10 IU81%703 Other dose16%144 Unknown3%26 Number observed 873

15. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Harmful and un-indicated practices related to PPH during labor 15

16. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Inventory of supplies for PPH management (n=177) 16

17. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Health worker knowledge of PPH signs and management (n=564) 17 * Values are mean score

18. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Making sure that women get life-saving interventions: from policy to practice 18 (1) Oxytocin registered, on EDL, indicated for AMTSL, AMTSL in current SDGs, oxytocin 1 st 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. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Ensuring women are provided life-saving interventions: from policy to practice (AMTSL) 19 (1) Oxytocin registered, on EDL, indicated for AMTSL, AMTSL in current SDGs, oxytocin 1 st 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. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Management of PPH 20 Item Total Cases of PPH observed 41 Type of treatment provided -massage the fundus 4 -repair of lacerations 18 -manual removal placenta 16 -bimanual compressions 1 -blood transfusion 1 Medications provided -oxytocin 5 -ergometrine/prost. 3 -parenteral analgesia 8 -prophylactic antibiotics 11 Outcome of woman: death 0

21. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 21

22. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Next steps: 1.Develop country-specific and overall reports and plans for response  Interventions focus on front line Pre-service and in-service education, quality improvement 2.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? 22

23. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 www.mchip.net THANK YOU! Research plan, tools and PDA data entry and analyses programs will be available on MCHIP website.

24. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 24

25. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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. 25

26. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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% 26

27. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 27

28. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 28

29. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Sufficient availability of oxytocics, needles, syringe on site Woman receives AMTSL (per ICM/ FIGO Statement) Policy Provider Logistics Historical precedent, influence of leader, WHO, in-service training National guidelines Presence in pre-service training AMTSL protocol in hospital Expected behavior in hospital Skills in AMTSL Motivation to use Implementation Uterotonics included on Essential Drug List (oxytocin= drug of choice) Amount procured Transport issues Procure- ment at hospital level Proper storage Components of the survey re: use of AMTSL “Champions” for use of AMTSL Know- ledge