Pathway for Scaling up AMTSL

Publication date: 2008

Pathway for scaling up AMTSL Deborah Armbruster Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project Critical elements for expansion of AMTSL Policies, guidelines, protocols, standards in place Provider knowledge and skills up-to-date & providers motivated to apply AMTSL according to standards Appropriate amount of drugs procured, appropriately stored, & available for all births MIS & supervision system in place Determinants of the use of AMTSL Policy National policy and protocols for AMTSL in place National, regional, & district levels and in facilities All SBAs authorized to practice AMTSL All SBAs authorized to use all uterotonic drugs for AMTSL National strategies in place to increase access to AMTSL Provider Pre-service education (physicians, midwives, nurse, and others doing deliveries) includes AMTSL Standardized in-service programs for AMTSL are available Most delivery facilities offer AMTSL Most women having home births are offered and receive AMTSL Develop and disseminate simple and adapted job aids Work with community-based organizations and women’s groups to reinforce key message promoting AMTSL Logistics Oxytocin and misoprostol for prevention and treatment of PPH in National Essential Drug List Oxytocin is first line drug for AMTSL for all SBAs Misoprostol is used for PPH prevention in situations where no oxytocin is available or birth attendants’ skills are limited Protocols are developed for quantification and storage of all uterotonic drugs Monitoring and Evaluation AMTSL at home and facility levels included in National HMIS Suggested pathways to follow for scaling up postpartum hemorrhage prevention initiatives Hold national and provincial meetings to inform policy/decision makers Update policies to authorize all cadres of skilled birth attendants to perform AMTSL and give them legal authority to use injectable (oxytocin and ergometrine) and non-injectable (misoprostol) uterotonic drugs Update service delivery guidelines to include protocols for AMTSL in facilities and the community and widely disseminate them Promote the ongoing revision of policies, norms, and procedures to reflect updated clinical information on prevention and treatment of PPH Suggested pathways to follow for scaling up AMTSL: Policy (1) Suggested pathways to follow for scaling up AMTSL: Policy (2) Develop national strategies to increase access to AMTSL, e.g.: Promote policies that deploy skilled birth attendants to rural areas Support community-based interventions Sensitize and educate all women about the benefits of AMTSL Promote financing schemes / health insurance plans that will reduce economic barriers to seeking care during pregnancy, childbirth, and in the postpartum period Indonesia:(MOH/ HSP/ UNICEF /POPPHI/VentureStrategies) Creating a National Action Plan for PPH Prevention to guide activities for scale up of both AMTSL and distribution of misoprostol. Country example: Indonesia Standardize AMTSL in in-service and pre-service training programs. Where possible, integrate AMTSL into existing safe motherhood programs Develop alternate training strategies to reduce cost, increase effectiveness, and increase access to training activities Develop a system for informing public and private providers about updates and changes in protocols for prevention and treatment of PPH Where needed, develop behavior change interventions to address the continued lack of AMTSL provision even after skilled attendants have been updated on AMTSL Link managers, pharmacists, and clinicians to ensure that supplies and drugs are available to practice AMTSL safely Suggested pathways to follow for scaling up AMTSL: Provider Protocols changed from physiologic to active management in 2003 AMTSL training to be integrated into learning materials used for existing EONC and safe motherhood programs AMTSL to be introduced into pre-service programs for obstetrical nurses, midwives, and physicians Training in AMTSL is being decentralized to the district level using a mixed learning approach: Mixed learning approach to be used for peripheral health centers – SAIN approach: Site and Individual training –self-paced learning + clinical practicum On-the-job: informal transfer of skills Country example: Mali AMTSL taught in pre-service programs since 1960s but practice of AMTSL to standard is <10% Using a behavior change strategy to increase uptake of AMTSL Country example: Uganda Suggested pathways to follow for scaling up AMTSL: Provider Develop training “packages” that highlight AMTSL but include other priority components of maternal and newborn care Bangladesh (POPPHI/ EngenderHealth) AMTSL training + registration of misoprostol + community-based distribution program of misoprostol Pakistan (PAIMAN/MAP/POPPHI): AMTSL + infection prevention + immediate management of PPH DRC (AXxes / Basics / POPPHI): AMTSL + immediate newborn care + immediate postpartum care + immediate management of PPH / newborn asphyxia Benin (QAP): AMTSL + immediate newborn care + immediate postpartum care Suggested pathways to follow for scaling up AMTSL: Providers Toolkit CD-ROM Training manual for MATEP Simple job aids and materials Innovative training strategies SAIN: Site and Individual training –self-paced learning + clinical practicum On-the-job: provider to provider or through supervisory visits Integration of PPH prevention activities into supervisory tools Revise essential medicine list to include oxytocin (10 IU) as the first line drug and misoprostol as an alternative drug for the prevention of PPH Revise essential medicine list to include oxytocin and misoprostol for the treatment of PPH Include central drug supply staff, pharmaceutical managers and pharmacists as key partners in efforts to expand AMTSL Update pharmaceutical managers and pharmacists on uterotonic drugs and the appropriate use and indications of these drugs Update drug management policies for oxytocin and other uterotonic drugs Suggested pathways to follow for scaling up AMTSL: Logistics (1) Suggested pathways to follow for scaling up AMTSL: Logistics (2) Develop systems to ensure that there is quality data for adequate procurement and distribution of all medications, supplies, and consumables Include a uterotonic drug security plan in the RH commodity security plan Integrate or piggy-back injectable uterotonics into existing cold chain system (at lowest level of the health system) or use an alternative system to ensure cold chain Improve information for providers on storage of uterotonics by developing and distributing job aids and posters explaining storage conditions clearly and precisely Peut-être j’ai trop commandé Benin Develop simple and adapted job aid for storage of uterotonics Suggested pathways to follow for scaling up AMTSL: Monitoring and Evaluation Develop relevant indicators for monitoring and evaluating the practice of AMTSL Set a goal coverage for AMTSL activities Carry out AMTSL baseline and endline assessments Integrate documentation of AMTSL into existing tools, medical records, and registers Integrate documentation of oxytocin availability (stock-outs per year) into existing tools Integrate AMTSL into existing supervisory tools Introduce quality assurance techniques to reinforce the practice of AMTSL at health care facilities Country example: Mali Integration of PPH prevention activities into supervisory tools

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