postpartum hemorrhage (pph) prevention and management: quality of care in madagascar, jrakotovao,...

7/31/2019 Postpartum Hemorrhage (PPH) Prevention and Management: Quality of Care in Madagascar, JRakotovao, FIGO2012

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Quality of Care in Madagascar

Jean Pierre Rakotovao, MCHIP Chief of Party

Eva Bazant, Sr. Monitoring, Evaluation and Research AdvisorVandana Tripathi, Consultant, Jhpiego

Justin Ranjalahy Rasolofomanana, Professor of Higher Learning andPublic Health Research & Tandem

FIGO 2012, Rome


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Context for PPH assessment in MadagascarObjectives of the assessmentMethodsResultsConclusions


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In Madagascar

Population: 20 millionTotal fertility ra te: 4 .8 (per DHS IV2008)Contraceptive prevalence: 40 %(modern methods: 29%)Antena ta l care: 86% for 1+ visit

Home delivery is high: 64% (hasrema ined high)

MMR: 498 per 100,000 live births(DHS)Ranked 141 out of 181 countries(Hoga n 20 10 La ncet)Major causes of maternal death(EmONC survey 2010):

: 39%Prolonged labor: 22%Infection: 20%

: 15%

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

one of the leading ca uses of ma terna l dea th contributes to a third of ma terna l dea ths (Kha n 200 6). haveuneven covera ge .


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Purpose: Study is the first to assess quality ofactual PPH practices in Madagascars healthfacilitiesSpecific objectives of this session:

To share analysis onrelated to PPH prevention and

management in facilities that address maternalcomplications

To describe the of PPHprevention and management interventions infacility-based care


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A cross-sectional national assessmentSample: All facilities with > 2 births per day; n= 36 facilitiesData 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 inspontaneous vaginal delivery; included 15 suspected PPH cases)

Collected by external trained medical staff

Used smart phonesDescriptive statistical analysis conductedData reviewed from each suspected PPH case(n= 15)


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Inventory

Among n= 9 facilities where PPH cases occurred:Guidelines for L&D: observed in only 2 facilitiesGuide lines for emergency obstetric ca re: O bserved inonly 4 facilities

Injecta ble uterotonic 78%

Syringes a nd needles 61 %

IV infusion set 56%

Suture ma teria ls a nd needles 42 %

MVA or D&C kit 50%


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Provider Knowledge

Mean score to assess signs for PPH (8 items): 56%Few providers knew:

How to assess for atonic uterus (9 items) (mean score 39%), or

The steps in managing retained placenta (13 items) (36%).

01020

30405060708090

100

Postpartumhemorrhage: signs to

assess

Postpartumhemorrhage: possible

tears & lacerations

Postpartumhemorrhage : a ctions

& tests, a tony

Retainedplacenta/products:

actions & tests


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PPH Prevention

Across a ll L&D observa tions:Oxytocin given during active management of the 3rd sta ge of la bor in 85% of ca sesO xytocin a dministered within 1 minute in only35%Uterine ma ssa ge conducted in only 55%

13% of observations were fully compliant withAMTSL steps


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PPH Prevention (cont.)

Oxytocinadministered

Oxytocinadministered via

correct route

Oxytocinadministered withcorrect dose/ units

Oxytocinadministered

within 1 minute

Controlled cordtraction

performed

Uterine massageperformed

Performance of the AMTSL intervention

Performance of the AMTSL intervention shown and all previous(cumulative)

n= 288 observations ofdeliveries in 36 health fa


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PPH Management

A uterotonic was administered for treatment inonly 4 of 15 PPH cases.In at least 5 of 15 PPH cases, retainedplacenta was suspected by the provider andmanual removal of the placenta attempted:

Not performed accordingly to guidelines in

a ny of these casesConsistent with findings that few providersknew the steps in managing retained placenta


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AMTSL and PPH management were not adequate even when drugswere available or special equipment was not required.

Consistent with findings of inadequate provider knowledgeEquipment and supplies are not enough by themselves!

Recommendations:AMTSL should be incorporated into national service delivery .Providers need more to improve PPH knowledgeand skills for prevention and care:

Recommend regular practice on simulators and updates by SMS/ phone

AMTSL should be supported through facility ,, and improved provider / motivation.

and related supplies should be monitoredat central level.


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68.9% 64.0%

6.6% 1.4%

12.1% 23.7% 3.7% 5.8%

8.1% 4.3%

35.2% 12.9%

24.5% 33.1% 14.7% 23.0%

6.6% 10.1%

19.3% 21.6%

postpartum hemorrhage (pph) prevention and management: quality of care in madagascar, jrakotovao,...

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