Transcript Slide 1

Pathway for scaling up AMTSL
Name of presenter
Prevention of Postpartum Hemorrhage Initiative
(POPPHI) Project
Session objectives
By end of the session, participants will be able to
describe/define:
• Critical elements for expansion of AMTSL
• The need for a balanced strategy for expanding
AMTSL that includes facility and home births
• Strategies / interventions that can be implemented to
increase access to and uptake of AMTSL
• Country examples of scaling-up AMTSL.
Critical elements for expansion of AMTSL
• Policies, guidelines, protocols, standards in place
• Provider knowledge and skills up-to-date & providers
motivated to apply AMTSL according to standards
• Appropriate amount of drugs procured, appropriately
stored, & available for all births
• MIS & supervision system in place
Programmatic issues for scale-up activities: Determinants of the use of AMTSL
POLICY
Awareness &
endorsement
of national
expansion
Policies,
guidelines,
protocols,
standards in
place
PROVIDER
Standardized
pre- & inservice
training
Improved
provider
knowledge, skills
& motivation
LOGISTICS (DRUGS & SUPPLIES)
Drug
logistics
in place
Appropriate amount of
drugs procured,
appropriately stored, &
available for all births
MONITORING/SUPERVISION
MIS & supervision system in place
All women are
offered and
receive PPH
prevention
intervention
Reduced PPH
Reduced
mortality
Policy
• National policy and protocols for AMTSL are in place
• All SBAs are authorized to practice AMTSL
• All SBAs are authorized to use all uterotonic drugs for
AMTSL
Provider
• Pre-service education includes AMTSL
• Standardized in-service programs for AMTSL are
available
• Most delivery facilities offer AMTSL
• Most women having home births are offered and
receive AMTSL or a uterotonic drug before delivery of
the placenta
Logistics
• Oxytocin and misoprostol for prevention and
treatment of PPH are listed in National Essential
Drug List
• Oxytocin is first line drug and ergometrine is the
second line drug for AMTSL for all SBAs
• Misoprostol is used for PPH prevention in situations
where no oxytocin is available or birth attendants’
skills are limited
• Protocols are developed for quantification and
storage of all uterotonic drugs
Monitoring and Evaluation
• Number of women who were offered and received
AMTSL at home and in the facility is included in the
National HMIS
Suggested pathways to follow for
scaling up postpartum hemorrhage
prevention initiatives
Suggested pathways to follow for scaling up AMTSL:
Policy (1)
•
Conduct a national survey to evaluate the practice and uptake of
AMTSL
•
Hold national and provincial meetings to inform policy/decision
makers
•
Develop a balanced approach for facility births and home births
•
Update policies to authorize all cadres of skilled birth attendants
to perform AMTSL and give them legal authority to use injectable
(oxytocin and ergometrine) and non-injectable (misoprostol)
uterotonic drugs
•
Update service delivery guidelines to include protocols for
AMTSL in facilities and the community and widely disseminate
them
•
Promote the ongoing revision of policies, norms, and procedures
to reflect updated clinical information on prevention and
treatment of PPH
National surveys in 10 countries
Percent of observed deliveries w/ uterotonic given
during 3rd/4th stages of labor and correct use of
AMTSL (uterotonic administration within 1 mn)
100.0
99.7
100.0
97.6
95.6
National
surveys have
served to
inform and
influence
policy and
strategies for
scaling up
PPH
prevention
activities
100.0
95.6
92.6
89.2
90.0
86.7
80.0
70.0
60.0
% of deliveries
60.0
50.0
40.0
31.8
29.0
30.0
20.0
17.0
10.0
6.7
7.1
5.4
3.0
4.5
2.6
0.3
0.0
Indonesia
Benin
Ethiopia
Ghana
Tanzania
Uganda
Received uterotonic 3rd/4th stage
El
Salvador
Guatemala Honduras Nicaragua
AMTSL (1 min)
Suggested pathways to follow for scaling up
AMTSL: Policy (2)
• Develop national strategies to increase access to AMTSL,
e.g.:
 Promote policies that deploy skilled birth attendants to
rural areas
 Support community-based interventions
 Sensitize and educate all women about the benefits of
AMTSL
 Promote financing schemes / health insurance plans
that will reduce economic barriers to seeking care
during pregnancy, childbirth, and in the postpartum
period
Country example: Indonesia
Indonesia:(MOH/ HSP/
UNICEF
/POPPHI/VentureStrategies)
Creating a National Action Plan
for PPH Prevention to guide
activities for scale up of both
AMTSL and distribution of
misoprostol.
Suggested pathways to follow for scaling up AMTSL:
Policy - Seeking solutions for births that occur
without skilled care
Combine strategies for increasing AMTSL uptake in
facilities with community-based distribution of misoprostol
for births occurring in the home with or without a skilled
attendant
Why?
• We cannot predict PPH on the basis
of risk factors.
• In many countries very few deliveries
are attended by a skilled attendant.
• Once severe PPH occurs, death
follows very rapidly
• Timely referral and transport to
facilities is not available or affordable
• Availability of emergency obstetric
care services is grossly limited.
Country example: Afghanistan
(ACCESS / Jhpiego)
• Community health worker
identifies all pregnant women
in her area
• Pregnant woman and support
persons are educated about
PPH during home visits
• Misoprostol distributed when
woman is 8 months pregnant
with clear instructions on when
and how to use it
• Community health worker
conducts a postpartum home
visit to determine maternal and
newborn outcome
Afghanistan: photo by Nasrat Ansari
Indonesia: Information on Safe Use and Distribution of
Misoprostol (ACCESS / Jhpiego)
Community-based distribution of
misoprostol is an effective strategy to
complement facility-based efforts to
increase uptake of AMTSL
Medication to prevent PPH is offered when
the woman is 8 months pregnant. She is
carefully counseled on:
• Safe and correct timing for use of
misoprostol
• Risks of taking tablet prior to delivery
• Common side effects of misoprostol
• What to do in case side effects occur
• Where to go if PPH occurs even after
taking medication
Suggested pathways to follow for scaling up AMTSL:
Provider (1)
•
Standardize AMTSL in in-service and pre-service training
programs.
•
Where possible, integrate AMTSL into existing safe motherhood
programs
•
Develop alternate training strategies to reduce cost, increase
effectiveness, and increase access to training activities
•
Develop a system for informing public and private providers
about updates and changes in protocols for prevention and
treatment of PPH
•
Where needed, develop behavior change interventions to
address the continued lack of AMTSL provision even after
skilled attendants have been updated on AMTSL
•
Link managers, pharmacists, and clinicians to ensure that
supplies and drugs are available to practice AMTSL safely
Country example: Mali
•
Protocols changed from physiologic to
active management in 2003
•
2008: AMTSL training to be integrated
into learning materials used for existing
EONC and safe motherhood programs
•
2008: AMTSL to be introduced into preservice programs for obstetrical nurses,
midwives, and physicians
•
2008: Training in AMTSL is being
decentralized to the district level using
a mixed learning approach:
• Mixed learning approach to be used
for peripheral health centers –
- SAIN approach: Site and
Individual training –self-paced
learning + clinical practicum
• On-the-job: informal transfer of
skills
Country example: Uganda
•
AMTSL taught in pre-service
programs since 1960s but
practice of AMTSL to standard
is <10%
•
Using a behavior change
strategy to increase uptake of
AMTSL
Suggested pathways to follow for scaling up
AMTSL: Provider (2)
• Develop training “packages” that highlight
AMTSL but include other priority components
of maternal and newborn care
 Bangladesh (POPPHI/ EngenderHealth)
AMTSL training + registration of
misoprostol + community-based
distribution program of misoprostol
 Pakistan (PAIMAN/MAP/POPPHI):
AMTSL + infection prevention +
immediate management of PPH
 DRC (AXxes / BASICS / POPPHI):
AMTSL + immediate newborn care +
immediate postpartum care +
management of newborn asphyxia, low
birth weight infants, and newborn infection
 Benin (QAP): AMTSL + immediate
newborn care + immediate postpartum
care
Suggested pathways to follow for scaling up
AMTSL: Provider
Develop and disseminate
simple and adapted job
aids for developing a birth
preparedness plan
(including speaking to the
importance of giving birth
with an SBA so as to
receive AMTSL), AMTSL,
and monitoring in the
immediate postpartum
Suggested pathways to follow for scaling up AMTSL:
Logistics (1)
•
Revise essential medicine list to
include oxytocin (10 IU) as the first
line drug and misoprostol as an
alternative drug for the prevention of
PPH
•
Revise essential medicine list to
include oxytocin and misoprostol for
the treatment of PPH
•
Include central drug supply staff,
pharmaceutical managers and
pharmacists as key partners in
efforts to expand AMTSL
•
Update pharmaceutical managers
and pharmacists on uterotonic
drugs and the appropriate use and
indications of these drugs
•
Update drug management policies
for oxytocin and other uterotonic
drugs
Suggested pathways to follow for scaling up
AMTSL: Logistics (2)
•
Develop systems to ensure that
there is quality data for adequate
procurement and distribution of all
medications, supplies, and
consumables
•
Include a uterotonic drug security
plan in the RH commodity security
plan
•
Integrate or piggy-back injectable
uterotonics into existing cold
chain system (at lowest level of the
health system) or use an
alternative system to ensure cold
chain
•
Improve information for providers
on storage of uterotonics by
developing and distributing job
aids and posters explaining
storage conditions clearly and
precisely
Peut-être j’ai trop
commandé
Country example: Benin
Develop simple and
adapted job aids for
storage of uterotonics
Country example: Mali
Develop simple and
adapted job aid for
documenting
movement of
uterotonics
Suggested pathways to follow for scaling up AMTSL:
Monitoring and Evaluation
•
Develop relevant indicators for monitoring and evaluating the
practice of AMTSL
•
Set a goal coverage for AMTSL activities
•
Carry out AMTSL baseline and endline assessments
•
Integrate documentation of AMTSL into existing tools, medical
records, and registers
•
Integrate documentation of oxytocin availability (stock-outs
per year) into existing tools
•
Integrate AMTSL into existing supervisory tools
•
Introduce quality assurance techniques to reinforce the
practice of AMTSL at health care facilities
Country example: Mali
• Integration of PPH prevention activities into
national supervisory tools
Country example: Niger (QAP)
Use wall charts to track progress made towards
indicators
Summary: Determinants of the use of AMTSL
POLICY
Awareness &
endorsement
of national
expansion
Policies,
guidelines,
protocols,
standards in
place
PROVIDER
Standardized
pre- & inservice
training
Improved
provider
knowledge, skills
& motivation
LOGISTICS (DRUGS & SUPPLIES)
Drug
logistics
in place
Appropriate amount of
drugs procured,
appropriately stored, &
available for all births
MONITORING/SUPERVISION
MIS & supervision system in place
All women are
offered and
receive PPH
prevention
intervention
Reduced PPH
Reduced
mortality