dewan_pph prevention and management strategies at different levels of health system
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Prevention and ManagementStrategies of PPH
At Different Levels of Health System InBangladesh
Prof. Farhana DewanOGSB
Prof,Obs/Gyn
Shaheed Suhrawardy Medical College [email protected]
AcknowledgementMOHFW
EngenderHealth BangladeshJPHIEGO
MaMoni
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1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
BMMS
2001
BMMS
2010
MDG 5Target
Maternal mortality declines by 40% between 2001 and 2010
Maternal death due to PPH reduced 25%
Bangladesh is on track to achieve MDG 5
MMR Trend
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Statistics-2011Death due to PPH in different Medical
College Hospitals
Name ofhospital
TotalHospital
Bed
Total admin Gynae &
Obs
Totaladm in
Obs
Total Numberof cases of
PPH
Death dueto PPH
DMCH 1250 17962 14047 742 30
SSMCH 600 15845 13965 313 9
CMCH 1010 20994 16334 658 7
RMCH 530 16696 12276 592 28
SMCH 900 14276 13160 271 10
BMCH 500 13402 7151 293 15
RpMCH 500 11924 9117 731 42
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Source: HRD Datasheet -2011, HED Unit, MOHFW; * Health bulletin 2011, DGHS
Maternal Health Care: Service DeliveryStructure Facilities Level Services
National Total:35Medical UniversitySpecialized Institute, FP
institute
TertiaryCEmOC*All Medical college Hospital,
59 District Hospital, 3General hospital, 132Upazila health complex, 63MCWCs
BEmOC
Rest of the upazilas
Division: 7 Nos Total : 56Medical College Hospital,Other hospital (DGHS),Model clinic
TertiarySecondary
District 64 Nos
(2.3 Miliion)
Total : 221
District Hospital, MCWC(DGFP), MCH-FP clinic(DGFP)
Secondary
Upazila 483(0.3 million)
Total : 421Upazila Health Complex(DGHS)
Primary
Union : 4498
(0.03 million)
Total: 5168
USC (DGHS), UH&FWC(DGHS), UH&FWC (DGFP)
Primary Pregnancy Care
Normal delivery facility atvery few centers
Ward 13494Several villagemake a ward(11000)
Community Clinic (14025),Satellite Clinic (DGFP)(30000), Immunizationcenter
Primary Pregnancy care
Community Domiciliary workers 1/5-6
thousand (DGHS), DGFP
Domiciliary Pregnancy care
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UpazilaUpazila Health
Complex
Referral forcomplication
Community
Union/
Ward
Referral Network
FWC/ Satellite clinic/EPI Center
Community clinic
District/
Division
District Hospital/MCWC
Medical College hospital
Referral forANC and Immunization
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Strengthening of health facilities toprovide EmOC services
Demand Side Financing:Maternal Health Voucher Scheme
CSBAProgramme
Midwiferyprogram
MNH, MNCH,MNCS
ReduceMaternal
Mortality &Morbidity
Key Programs to reduce Maternalmortality
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Key ProgramCommunity based Skilled Birth Attendant(CSBA)
Total 6155 CSBAs completed basic training
(May 2011)
CSBA registration provided by BangladeshNursing Council
Target: to train 13,500 FWAs and FeHAs
At presentLow coverage- 0.3%
Health bulletin 2011, DGHS/BDHS 2011
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To address the equity issue
Coverage
502 unions of 46 upazillas of 38 districts
Total annual beneficiaries
in 46 upazillas are 113181 pregnant woman
(March 2011)
Financial incentive to health serviceproviders and mothers for providing andusing selected maternal health services
Key Program
Demand Side Financing (DSF)
Source: Health bulletin 2011, DGHS
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Key Program
Birth of Midwives in Bangladesh
Approx 27000 nurse-midwives
Existing nurse-midwives training not satisfying ICM/WHOstandard of midwifery training
Govt. commitment to train 3000 midwives by 2015
Action plan proposedEducation and training
6 months post basic advance training for existing nursemidwives
3 yeas diploma direct entry midwifery programme
Recruitment and deployment Reconstitution of Bangladesh Nursing council and Directorate of
Nursing
Create 1500 new position for Midwives in next 5 year
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Improve maternal health
Implement phase wise expansion of 24/7 EmOC services
Expanding DSF: on the basis of ecologic analysis
Develop and expand Midwifery services
Expand C-SBA: Involving community
Implement AMTSL at facility to prevent PPH and delivery by SBA
Use of Misoprostol to prevent PPH at community level
Use of Magnesium Sulphate to prevent eclampsia
Performance based financing
Incentive: hard to reach, under serve & low performance
Address maternal morbidity
fistula, cervical cancer
Health, Population and Nutrition Sector Development Program (HPNSDP),July 2011-June 2016
Strategic approach undertaken: Policy Level
Incorporated both
AMTSL andMisoprostol into the
Health population andNutrition sector
development Program
and Operation Plans(2011-2016)
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Strategic approach
Prevention Management
At CommunityAt Facility
(Varies on level offacility)
Strategic approach undertaken
Implementation Level
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Component-I: Use of Oxytocic Drug
25
7
4
11
7
2
24
3 3
26
6
0
30
3
00
5
10
15
20
25
30
Rajshahi Barisal Khulna Faridpur Hobiganj
Inj. Oxytocin Inj. Ergometrine Tab. Misoprostol
Assessment of AMTSL-OGSB,2004Pre knowledge assessment
54
6
32
12
16
0
20
1
0
5
10
15
20
Rajshahi Barisal Khulna Faridpur Hobiganj
Before delivery of placenta After delivery of placenta
11
4
12
0
14
3
25
4
13
1
0
5
10
15
20
25
Rajshahi Barisal Khulna Faridpur Hobiganj
Did not wait for sign of placental separation
Waited for sign of placental separation
Component-I: Time of giving Inj. Oxytocin
Component II ,Delivery of placenta by CCT Component- III, Time of givinguterine massage
Assessment after follow up
Majority of cases of normal labour were being
managed by AMTSL
4
0
2
43
20
13
4 4
8
0
5
10
15
20
Rajshahi Barisal Khulna Faridpur Hobiganj
Before delivery of placenta After delivery of placenta
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Prevention of PPH: At facility
Strategy
At the facility level, where 28.8 % deliveries takeplace, AMTSL is the most effective and simple
way to prevent PPH
Activity undertaken
AMTSL is being integrated in the broader life-
saving and midwifery training to ensure that allskilled birth attendants receive this training
District approach to reach all district and Upazillafacilities with AMTSL (25 districts so far)
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Prevention of PPH: AtCommunity
Strategy
At the community level, where 71 % of deliveries occur at home byunskilled birth attendants, Misoprostol is the best alternative toInjection Oxytocin to prevent PPH
Two tablets (400microgram) just after delivery to be taken orally Activity undertaken
Misoprostol tablet approved for PPH prevention by Drug Administration
Misoprostol tablet included in updated Essential Drug List (2008)
Agreement on National dose of Misoprostol (400 microgram) (2010)
Planned for a phased scale-up of Misoprostol, and in July 2011 began scale-up in four districts, with technical assistance from Mayer Hashi
Community implementation program started by NGOs
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Level of Facility EmOCService
ServiceProvider
Activity done to managePPH
Tertiary carelevel
-Medical CollegeHospital-SpecializedHospital
CEmOC Prof/Asso./Assis. Prof/Consultant/MO
For Atony
For Injury
For Retained Placenta
For Coagulation Failure/DIC
Management
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Level of Facility EmOC
Service
Service
Provider
Activity done to
manage PPH
Secondary carelevel
-District Hospital CEmOC/
BEmOC
Consultant,
MO
For Atony
For Injury
For Retained Placenta
Primary care level
-Upazilla HealthComplex-Union Sub centre
-Ward
CEmOCBEmOC
MO/MA
MO/MA
HA
For Atony
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PPH Management
The Innovative Condom Tamponade Unitdeveloped in Bangladesh by Akhter andteam
For Atony
Compression of aorta
Bimanual Compression
Balloon tamponade
Surgical Procedure
-Uterine artery Ligation
-B-Lynch Brace Suture
-Sub total hysterectomy
For Injury
Repair of Cervical/Perineal tear
For Retained Placenta
Manual removal of placenta
Removal of retained bits
For Coagulation Failure/DIC
Consultation with other discipline
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Manual removal of placenta
Active Management of Third Stage of Labour (AMTSL)
Glimpse of Technical Training
Bimanual compression of uterus
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Some BCC materials
19
Flip chart
Flip chart Poster
Sticker
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Demonstrated successful models ofimplementation at both facility and communitylevel
Wide coverage with facilities and CommunityClinic
Public-private partnership
CSBAs service at community level
Opportunities
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Conclusion
Ensure universal AMTSL at all facilities: can be done ina short time through a partnership betweenGovernment and OGSB
Scale up community use of misoprostol to all parts ofthe nation
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Thank you