Community and Clinical Action: Maternal and Newborn Health

Graciela Salvador-Davila, Senior Technical Advisor for Maternal and Newborn Health| Global Health Practitioner Conference, May 2014

BACKGROUND | PPH

• PPH is the leading direct cause of maternal deaths worldwide.– PPH accounts for nearly 1/4th of maternal mortalities

• Time is a major issue.– A woman can die within 2 hours of onset of PPH if she does not receive

proper treatment

• Barriers to life-saving care are many.– Slow recognition of danger, need for care– Distance– Lack of funds– Lack of transport – Weak referral systems – Stock-outs – Inadequate provider skills and attitudes

PATHFINDER’S CCA-PPH+ MODEL– IMPLEMENTATION COMPONENTS

PERUPiura, Lima and Ayacucho States

NIGERIAKatsina, Kano, Lagos, Nassarawa, Oyo, Yobe, Ebonyi,

BANGLADESHKishoreganj District

INDIAMaharashtra, Rajasthan, Bihar, Tamil Nadu , (Orissa) States

TANZANIARefugee camp and host community settings in Kigoma

PATHFINDER’S CCA-PPH+ MODEL- GLOBAL APPLICATION

THE COMMUNITY-FACILITY LINKAGE CONTINUUMCO

MM

UN

ITY

AWAR

ENES

S Widespread community knowledge of risks of unskilled birth attendance, & pregnancy and delivery danger signs

RECO

GN

ITIO

N O

F N

EED Family

members, friends, CHWs capable of identifying PPHCommunity systems activated to respond

TRAN

SPO

RT Community-level drivers coordinate with CHWs and/or family to transport women from community to facility

CLIN

IC L

EVEL

CAR

E Facility-level providers receive woman, apply Life Wrap, & initiate referrals for life-saving care as necessary

Community-wide education, sensitization, CHW and/or family

training

Community-transport systems established; contact information

made widely available; community creates incentives for drivers

Provider/CHW sensitization to ensure positive, productive working relationships; facility-wide training

on Life Wrap; provider trainings

THE CCA-PPH+ CONCEPT PR

EVEN

TIO

N Majority of PPH cases stopped before they start

RECO

GN

ITIO

N Capacity to identify PPH, so transport is timely

URG

ENT

CARE Providers have the skills necessary to address PPH

Life

Wra

p &

SH

OCK

Rx First aid

device applied to allow for referral to secondary level

DEFI

NIT

IVE

Rx Transport Appropriate care delivered

2% of women with PPH go into shock

25% of maternal mortality is caused by

hemorrhage

@ health system level

THE TREATMENT CONTINUUM

THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)

THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)

Evidence-basedSimple technologyLow-cost

= Object of desire(and forget about the rest!)

2011 external evaluation of Pathfinder CCA-PPH+ programs. Among the findings: “PPH in the facilities is decreasing…” “Promoting just the Life Wrap is not likely to have a large impact on

mortality because the Life Wrap is used in only the most extreme cases (only 2% of PPH cases lead to shock)… preventing PPH in the first place (as opposed to treating it when it gets out of hand) helps many, many more women.”

“…packaging of the full range of interventions to address PPH was unique and we believe was what made the difference…”

“The Life Wrap provided an entrée into the medical systems of both India and Nigeria; it served as the ‘admission ticket’ for the introduction of the continuum of care model.”

“the most effective way to address PPH is not through the Life Wrap but by strengthening the quality and availability of basic obstetrical care, including AMSTL…”

THINKING ABOUT THE LIFE WRAP & CONTINUUM OF CARE MACARTHUR EVALUATION FINDINGS

“All the model does is systematically highlight the various steps that need to be followed to provide very basic obstetrical care. But it is precisely because the required interventions are so basic, so old and ‘ho-hum’ that the introduction of the Life Wrap was so important.”

“Whether the same level of entrée could have been achieved by Pathfinder without the allure of the Life Wrap can be disputed. But what is undeniable is the role the Life Wrap played in introducing the continuum of care model– a model that definitely strengthened the government health systems in both countries.”

THINKING ABOUT THE LIFE WRAP & CONTINUUM OF CARE EVALUATION FINDINGS

IMPLEMENTATION SCIENCEThe right questions, the right answers?

“This is the next frontier …helping to advance a ‘science of delivery.’ Because we know that delivery isn’t easy – it’s not as simple as just saying ‘this works, this doesn’t.’ Effective delivery demands context-specific knowledge. It requires constant adjustments, a willingness to take smart risks, and a relentless focus on the details of implementation.”

-Jim Yong Kim, World Bank President2012 Annual Plenary Session

IMPLEMENTATION SCIENCE FOR MATERNAL HEALTH

• The world is seeing progress in stemming maternal deaths– nearly a 50% decline in MMR between 1990 and 2010.

• Looking forward to post-2015, there is still work to be done.• Majority of maternal death causes are preventable.• From a clinical practice perspective, we know what works. So what do we need to know to replicate “what works” & take it to

scale?

Z

IMPLEMENTATION SCIENCE FOR PPH & THE CCA-PPH+ MODEL

PREV

ENTI

ON Majority of

PPH cases stopped before they start RE

COG

NIT

ION Community

members can identify severe PPH Li

fe W

rap

&

SHO

CK R

x First aid device applied at community-level prior to initiation of transport

URG

ENT

CARE Providers

have the skills necessary to address PPH for stabilization

DEF

INIT

IVE

Rx Life-saving care delivered (surgery, blood transfusion, medication)

STRETCHING THE CCA-PPH+ TREATMENT CONTINUUM TO COMMUNITY LEVEL

• 25% of maternal mortality is caused by hemorrhage.• 2/3rds of women with PPH have no identifiable risk factors.• More than 50% of women in resource-limited settings have no skilled birth attendance and deliver at

community-level.

Community-level distribution of misoprostol to prevent PPH

(Potential to reduce PPH incidence by up to 50%, and severe PPH by 80%)

@ community level @ health system level

LOGICAL ORDER OF IMPLEMENTATION

The order of implementation is generally:1. Advocacy: Work with the government and professional organizations, so all

understand and support the initiative. Also donors, other linkage with other potential partners.

2. Prepare all levels of facilities, but start with the tertiary/referral level to make sure it is EOC referral ready, including AMTSL and the use of the Life Wrap, then moving to secondary, and primary levels once the referral hospitals are ready.

3. Once each facility level is ready, work with government supported front line workers and CBO’s to engage the communities in raising awareness of danger signs, and how to avoid the first 3 delays at community level including an established transport system.

THE CCA-PPH MODEL: A SUMMARY

• The CCA-PPH Model is comprehensive, practical, and adaptable

• The elements of the model taken together can have a significant impact on maternal mortality

• Elements implemented individually have less impact

• The model can be adapted for other causes of maternal mortality such as pre-eclampsia and eclampsia, sepsis, and prolonged labor

• The Project CD contains the PPH curriculum, the training video and a toolkit with job aids, a community survey tool and data collection instruments

ADDING PE/ECLAMPSIA TO THE CCA-PPH MODEL

• Pre-eclampsia/eclampsia (PE/E) can be easily rolled into the CAA/PPH Continuum of Care, utilizing the organized facility levels and community engagement systems already in place for PPH.

• This can be done after the PPH components are in place, or developed at the same time as the PPH components.

• Similarly, all the major causes of maternal mortality can be addressed with these same facility-community systems (sepsis, obstructed/prolonged labor, unsafe abortion)

Program Monitoring and Evaluation Plan

Effectiveness Indicators

Performance Monitoring System

Funds Staffing

Inputs

• Community sensitization and engagement

• Frontline workers trained in IEC and referral

• Community organizations equipped with emergency transportation

• IEC materials distributed

• Effective referral systems developed

• Job aids/protocols developed/adapted

• Health providers trained

• Supervision provided for sustained and improved quality of care

• Life Wraps provided to facilities

• Advocacy meetings with gov’t officials and other key stakeholders

Activities Objectives

Performance (output) Indicators

Outcom

e Indicators

GoalEffects

1. Increase awareness of community members of the danger signs of PPH and knowledge of technologies

2. Improve the capacity of community members to make the decision to seek medical care for PPH

3. Increase the ability of community members to identify and reach medical care for obstetric emergencies and complications including PPH

4. Improve the capacity of health care providers to provide high-quality appropriate care

Impact Indicators

Fig. 1. Program Framework: CCA-PPH Model

Decrease rates of PPH and shock

Decrease maternal mortality related to PPH

• Increased access to and use of emergency transportation

• Increased referrals from communities to lower level facilities to higher level facilities

• Job aids/protocols approved and in place

• Increased access to equipment and commodities

• Increased practice of AMTSL by providers

• Increased use of standard tools for estimating blood loss

• Appropriate and timely management of PPH

• Increased use of Life Wrap for management of shock

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For more information contact:Graciela Salvador-Davila, Senior Technical Advisor for Maternal and Newborn Health

GDavila@pathfinder.org

Thank you!