Overcoming Barriers to Implementing PPH prevention at the Facility Level The Role of Professional Organisations

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Overcoming Barriers to Implementing PPH
prevention at the Facility Level The Role of
Professional Organisations

• S Arulkumaran
• Professor Head of
• Obstetrics Gynaecology
• St Georges University of London
• President Elect - FIGO

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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

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General Principle to Promote access to
effective interventions
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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

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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

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Global leadership FIGO / MCHIP

• FIGOs 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

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FIGO

• Achievements
• Development of a joint Statement FIGO/ICM on
  active and physiological management of post
  partum haemorrhage
• Production of a flow chart to show how initial
  excessive bleeding should be managed
• Production of models to demonstrate balloon
  techniques - suturing- manual removal
• Guidelines for surgical techniques of balloon
  tamponade and compression sutures (vs internal
  iliac artery ligation or embolisation)
• Guidelines for misoprostol use for prevention and
  treatment of PPH

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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

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Joint statements

• A 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 promote
• Information on the joint statement can be used
  to
• Develop clinical guidelines
• Develop national action plans

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Signing joint statements Mali, Benin, and Ghana

• Mali

• Benin

• Ghana

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

1. Potency of the uterotonics
2. Low midwifery tutor student ratios
3. 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

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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

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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

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Support research to update clinical practices

• Misoprostol
• Conservative surgical treatment for PPH

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Misoprostol could play an important role in
saving lives of thousands of women, particularly
in low-resource settings
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Conservative Surgical Treatment for PPH
Method No of Cases Success rates
B-Lynch other Compression sutures 94 90.4
Arterial embolization 218 91
Arterial ligation 264 83.7
Uterine balloon tamponade 135 83.7
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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

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Solutions to challenges facing professional
organisations

• 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

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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

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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

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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