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

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

ASSESSING THE QUALITY OF SERVICES TO PREVENT AND

MANAGE POSTPARTUM HEMORRHAGE:

A REPORT FROM THE MCHIP QUALITY OF CARE SURVEYLinda Bartlett, MD, MHSc., JHSPH and MCHIP

Feb. 20, 2011, Addis Ababa


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)

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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

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• Ethiopia • Kenya • Tanzania & Zanzibar• Rwanda • Madagascar

• Zimbabwe is planned for 2011

• Available to assist more countries


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.

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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

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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

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

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Sample Ethiopia Tanzania Rwanda Mada-gascar

Total

Facilities 19 52 70 36 177

-Hospital 100% 29% 60% 75% 58%

-Health Center/dispensary 0% 71% 40% 25% 42%

Observations 318 880 604 671 2473

-Deliveries 192 489 293 348 1322

*Initial assessment 107 306 187 268 868

*3rd/4th stage of labor 117 415 225 288 1045

-ANC consults 126 391 311 323 1151

Health workers interviewed 79 206 146 140 571

-Maternal health 79 202 145 138 564

lbartlet

therefore emoc vs cemoc capacity? This will impact on analyses re: capacity for blood transfusion, etc.


Data collection using mobile smart phones

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

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RESULTS:PPH MORTALITY PREVENTION AND MANAGEMENT AT ANC, L&D AND PP LEVELS

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

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Observation of AMTSL (n=1045)


Correct administration of oxytocin

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% nMode of administration IM 90% 783IV push 5% 44IV drip 4% 32IV drip and IM 1% 10Unknown 0% 4 Dose 10 IU 81% 703Other dose 16% 144Unknown 3% 26 Number observed 873


Harmful and un-indicated practices related to PPH during labor

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Inventory of supplies for PPH management (n=177)

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lbartlet

difference by hosptial vs health centre fr this and other results as well - bemonc vs cemonc


Health worker knowledge of PPH signs and management (n=564)

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* Values are mean score


Making sure that women get life-saving interventions: from policy to practice

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(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)

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(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


Management of PPH

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Item Total

Cases of PPH observed 41Type of treatment provided -massage the fundus 4 -repair of lacerations 18 -manual removal placenta 16 -bimanual compressions 1 -blood transfusion 1Medications provided -oxytocin 5 -ergometrine/prost. 3 -parenteral analgesia 8 -prophylactic antibiotics 11 Outcome of woman: death 0

lbartlet

check mcpc managemtn


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

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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?

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www.mchip.net

THANK YOU!

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


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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.

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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


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


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

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Sufficient availabilityof oxytocics,needles,syringe on site

Womanreceives AMTSL(per ICM/ FIGOStatement)

Policy

Provider

Logistics

Historicalprecedent, influence ofleader,WHO,in-servicetraining

Nationalguidelines

Presence inpre-service training

AMTSL protocolin hospital

Expectedbehaviorin hospital

Skills inAMTSL

Motivationto use

Implementation

Uterotonics included onEssentialDrug List(oxytocin=drug of choice)

Amount procured

Transportissues

Procure-mentat hospitallevel

Properstorage

Components of the survey re: use of AMTSL

“Champions” foruse of AMTSL

Know-ledge

Documents

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