Overcoming Barriers to Implementing PPH prevention

at the Facility Level The Role of Professional

Organisations

S ArulkumaranProfessor & Head of

Obstetrics & Gynaecology St George’s University of London

President Elect - FIGO

Objectives Describe success stories of professional

organisations that have worked to reduce barriers to access interventions to prevent and treat PPH

Provide recommendations for Country Professional Organisations

List major challenges/ solutions to using professional organisations to overcome barriers to implementation of interventions for PPH control

General Principle to Promote access to effective interventions

Service provisionData collection

Policy developmentAdvocacy Training

Facilitation

Champion

Implementation

consultatio

n

The Role of Professional Associations

Provide leadership on issues surrounding PPH

Advocate for PPH control initiatives Support research to update clinical

practices Promote best practices in clinical

guidelines and health care policies Facilitate knowledge and skill transfer Support efforts to assure quality

Global leadership: FIGO and ICM / POPPHI

FIGO and ICM were partners in the Prevention of Postpartum Haemorrhage Initiative (POPPHI) that ended in November, 2009

FIGO and ICM provided input into: Task forces Development of learning materials and job aids Strategies to promote expansion and improve the quality

and availability of AMTSL at the facility level and community level through work with their member associations around the world

Development and signing of joint statements work with their member associations around the world

Promoting best practices for the prevention and treatment of PPH

FIGO conducted workshops on post partum haemorrhage

FIGO’s collaboration with global partners on PPH reduction continues, and has expanded to address PE/E as well.

FIGO, ICM and MCHIP will be working together on a program to build collaboration of midwives and obstetricians for implementation of key interventions in numerous African countries

Global leadership: FIGO / MCHIP

FIGOAchievements:1. Development of a joint Statement FIGO/ICM on

active and physiological management of post partum haemorrhage

2. Production of a ‘flow chart’ to show how initial excessive bleeding should be managed

2. Production of models to demonstrate balloon techniques - suturing- manual removal

3. Guidelines for surgical techniques of balloon tamponade and compression sutures (vs internal iliac artery ligation or embolisation)

4. Guidelines for misoprostol use for prevention and treatment of PPH

Advocacy Reputation and position of health professionals in

society makes them ideal advocates at local, regional and national levels Make the public aware of MNCH national

problems and solutions Lobby the government for better health and

hold it accountable through MNCH progress reviews

Example Uganda ObGyn society advocates

parliamentary commission on MNCH progress. As a result of the review the President calls for maternal death audits

Joint statementsA joint statement Defines the public health problem Defines necessary actions that governments

and MOHs need to take to promote PPH control

Describes best practices to promoteInformation on the joint statement can be

used to: Develop clinical guidelines Develop national action plans

Signing joint statements – Mali, Benin, and Ghana

Mali

Benin

Ghana

During Ghana joint statement signing: Issues raised to ensure access to PPH interventions

1. Potency of the uterotonics 2. Low midwifery tutor: student ratios3. Insufficient numbers of clinical instructors to

support midwifery students in the acquisition of practical skills

4. Motivation and equipment for midwives posted to Community-based Health Planning and Services (CHPS) sites

5. Policy governing the use and application of misoprostol at the community level to manage PPH

6. Training of midwives in the seven basic functions of emergency obstetric and newborn care (EMONC)

7. Policy changes to enlarge midwives’ scope of practice to include selected EmONC interventions

Training Members of professional associations promote

best clinical practices and training techniques by: Collaborating with medical/ midwifery schools

in the development and deployment of curricula for all professional cadres

Collaborating with the MOH:in the design and implementation of curricula for non-professional workers – community health workers and non professional birth attendants

in the design and implementation of curricula for in-service education, e.g. promoting training activities at point of service, promoting interdisciplinary training activities

Examples: Associations involved in training activities DRC: Representatives of the ob/gyn

association participate in validation and review of curriculum for pre-eclampsia/eclampsia

Mali: Representatives of the midwifery and oby/gyn associations are members of the national maternal health task force that reviews curricula for in-service training and provides guidance on program implementation

Support research to update clinical practices Misoprostol Conservative surgical treatment for PPH

Misoprostol could play an important role in saving lives of thousands of women, particularly in low-resource settings

Conservative Surgical Treatment for PPH

MethodMethod No of CasesNo of Cases Success ratesSuccess rates

B-Lynch + other B-Lynch + other Compression Compression suturessutures

9494 90.4%90.4%

Arterial Arterial embolizationembolization

218218 91%91%

Arterial ligationArterial ligation 264264 83.7%83.7%

Uterine balloon Uterine balloon tamponadetamponade

135135 83.7%83.7%

Major challenges to using professional organisations to overcome barriers to implementation of interventions for PPH control Professional associations

May not have any legal standing in the country (e.g. they do not certify professionals, set national exams, etc.)

May be excluded from program implementation activities because they are not donors

Usually have budgetary constraints because they depend on meagre membership dues and sporadic grants

May not be systematically included in country-level maternal task forces

Gain visibility by seeking funding to support research activities

Promote membership by professionals working in the MOH, teaching institutions, etc., who can advocate for the presence of the professional institutions when developing and updating curricula, etc.

Develop champions who can serve as representatives of the professional organizations in activities involving maternal health

Garner support for the local associations by associating with the international professional associations

Solutions to challenges facing professional organisations

Recommendations for Country Professional Organisations (1) Keep abreast of research – you can only

promote best practices if you are aware of them

Advocate for the presence of representatives of the midwifery and ob/gyn associations on national maternal task forces

Foster close relationships with the MoH, Hospitals, and Training institutions

Keep abreast of health policies that may serve as barriers to access to important maternal health care

Recommendations for Country Professional Organisations (2) Serve as champions for policy change,

where needed, to increase access to PPH interventions

Advocate for the presence of representatives of the midwifery and ob/gyn associations on committees developing learning materials

Advocate for adequate Teaching and Training material and time for training

Advocate for adequate financial resources to carry out the proposed actions, medications and facilities

Lead the implementation of better monitoring and evaluation practices

“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” Mahmoud Fathalla - 1997

THANK YOU