Session Outline
Context for PPH assessment in Madagascar Objectives of the assessment Methods Results Conclusions
Context: In Madagascar
Globally, hemorrhage one of the lea ding ca uses of ma terna l dea th contributes to a third of ma terna l dea ths (Kha n 2006). Existing solutions ha ve uneven covera ge.
Maternal Mortality
MMR: 498 per 100,000 live births (DHS) Ra nked 141 out of 181 countries (Hoga n 2010 La ncet) Ma jor ca uses of ma terna l dea th (EmO NC survey 2010):
Study Objectives
Purpose: Study is the first to assess quality of actual PPH practices in Madagascars health facilities Specific objectives of this session:
To share analysis on facility and provider
readiness related to PPH prevention and management in facilities that address maternal complications To describe the observations of quality of PPH prevention and management interventions in facility-based care
Facility inventory re PPH: Done in n= 36 facilities Interview with provider on knowledge and experience: n= 139 (note: 69% were nurse/ midwives) Observations of Labor & Delivery clients: n= 347 (84% ended in spontaneous vaginal delivery; included 15 suspected PPH cases)
Collected by external trained medical staff Used smart phones Descriptive statistical analysis conducted Data reviewed from each suspected PPH case (n= 15)
The steps in ma na ging reta ined pla centa (13 items) (36%).
68 56 39 36
Postpa rtum Postpa rtum Postpa rtum hemorrha ge: signs to hemorrha ge: p ossible hemorrha ge: a ctions a ssess tea rs & la cera tions & tests, a tony
the 3rd sta ge of la bor in 85% of ca ses O xytocin a dministered within 1 minute in only 35% Uterine ma ssa ge conducted in only 55% 13% of observa tions were fully complia nt with AMTSL steps
Oxytocin administered
Oxytocin Oxytocin Oxytocin administered via administered with administered correct route correct dose/ units within 1 minute AMTSL Interventions
a ny of these ca ses Consistent with findings tha t few providers knew the steps in ma na ging reta ined pla centa
Conclusions
AMTSL and PPH management were not adequate even when drugs were available or special equipment was not required.
Consistent with findings of inadequate provider knowledge Equipment and supplies are not enough by themselves!
Recommendations:
AMTSL should be incorporated into national service delivery guidelines. Providers need more training and support to improve PPH knowledge and skills for prevention and care:
Recommend regular practice on simulators and updates by SMS/ phone
AMTSL should be supported through facility protocols posted, visible job aids, and improved provider supervision/ motivation. Facility inventory on oxytocin and related supplies should be monitored at central level.
Thank you
SUPPLEMENTAL SLIDES
Table 1: Distribution of observation sample and provider interviews by provider cadre and facility type
Characteristic L&D O bservation (n= 347) Cadre Midwife O bstetrician O ther physician Nurse O ther University hospital (5 facilities) Regional hospital (11 facilities) District hospital 2 (7 facilities) District hospital 1 (4 facilities) Basic health center 2 (9 facilities) 68.9% 6.6% 12.1% 3.7% 8.1% T ype of Facility 35.2% 24.5% 14.7% 6.6% 19.3% 64.0% 1.4% 23.7% 5.8% 4.3% 12.9% 33.1% 23.0% 10.1% 21.6% Provider Interview (n= 139)