FIGO 2012, Rome

Postpartum Hemorrhage (PPH) Prevention and Management: Quality of Care in Madagascar

Jean Pierre Rakotovao, MCHIP Chief of Party Eva Bazant, Sr. Monitoring, Evaluation and Research Advisor Vandana Tripathi, Consultant, Jhpiego Justin Ranjalahy Rasolofomanana, Professor of Higher Learning and Public Health Research & Tandem

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 and Reproductive Health

Popula tion: 20 million Tota l fertility ra te: 4.8 (per DHS IV 2008) Contra ceptive preva lence: 40% (modern methods: 29%) Antena ta l ca re: 86% for 1+ visit Home delivery is high: 64% (ha s rema ined high)

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):

Hemorrhage: 39% Prolonged la bor: 22% Infection: 20% PE/ E: 15%

No specific PPH policy statement, but RH norms do include PPH

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

Materials and Methods

A cross-sectional national assessment Sample: All facilities with > 2 births per day; n= 36 facilities Data sources:

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)

Results (1): Inventory

Characteristics Injecta ble uterotonic Syringes a nd needles IV infusion set Suture ma teria ls a nd needles MVA or D&C kit N= 36 Facilities 78% 61% 56% 42% 50%

Among n= 9 facilities where PPH cases occurred:

Guidelines for L&D: observed in only 2 fa cilities Guidelines for emergency obstetric ca re: O bserved in only 4 fa cilities

Results (2): Provider Knowledge

Mea n score to a ssess signs for PPH (8 items): 56% Few providers knew:

How to a ssess for a tonic uterus (9 items) (mea n score 39%), or

100 90 80 70 60 50 40 30 20 10 0

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

Reta ined pla centa / pro ducts: a ctio ns & tests

Results (3): PPH Prevention

Across a ll L&D observa tions:
O xytocin given during a ctive ma na gement of

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

Results (3): PPH Prevention (cont.)

Performance of the AMTSL intervention Performance of the AMTSL intervention shown and all previous (cumulative) 84% 70% 73% 60% 35% 21% 15% 13% 60% 55%

n= 288 observations of deliveries in 36 health fac

Oxytocin administered

Oxytocin Oxytocin Oxytocin administered via administered with administered correct route correct dose/ units within 1 minute AMTSL Interventions

Controlled cord Uterine massage traction performed performed

Results (4): PPH Management

A uterotonic wa s a dministered for trea tment in only 4 of 15 PPH ca ses. In a t lea st 5 of 15 PPH ca ses, reta ined pla centa wa s suspected by the provider a nd ma nua l remova l of the pla centa a ttempted:
Not performed a ccordingly to guidelines in

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)