Postpartum Hemorrhage Prevention and Management: Quality of Care in Madagascar

• Jean Pierre Rakotovao (MCHIP Chief of Party), • Eva Bazant (Sr. Monitoring, Evaluation and Research Advisor), • Vandana Tripathi (Consultant, Jhpiego), • Justin Ranjalahy Rasolofomanana (Professor of Higher Learning and

Public Health Research)

Introduction

This assessment provides the first data regarding quality of actual PPH-related practices in Madagascar

This analysis focuses on facility readiness, provider knowledge, and interventions related to postpartum hemorrhage (PPH).

Context

Population: 20 M DHS IV 2008

TFR: 4.8 CPR : 40% /Modern method: 29% ANC: 86% at least one MMR: 498 deaths per 100000 live births Home delivery: 64 %

EMONC survey 2010 Major causes of maternal death

• Hemorrhage : 38.89% • Prolonged labor: 22. 22 %PE/E • Infection: 20.37% • PE/E: 14.81%

Objective

To provide information on quality of prevention and management interventions in facility-based care that address maternal complications.

Materials and Methods

A cross-sectional national assessment in facilities with higher caseload of birth (>2 per day).

Descriptive statistical analysis was conducted Inventories : 36 facilities Interview : 139 providers, largely midwives, Observations : 347 labor & delivery (L&D) cases

occurred mostly in hospitals, of which 84% ended in the spontaneous vaginal delivery.

Data from observation of each of 15 suspected PPH cases was reviewed.

Results (1) Inventory

Injectable uterotonics were available in 78% of facilities,

Equipment and supplies (e.g., syringes, suture material) were less available (42-61%).

Half of facilities had items needed for removal of retained placenta.

L&D guidelines were observed in only 2 facilities, and guidelines for emergency obstetric care in only 4, among the 9 where PPH cases occurred

Characteristic N=36 Facilities

Injectable uterotonic 78% Syringes & needles 61% IV infusion set 56% Suture material & needles

42%

MVA or D&C kit 50%

Results (2)

Providers knowledge Mean score to

assess signs for PPH : 56%.

Few knew how to assess for atonic uterus (mean score 39%) or knew the steps in managing retained placenta (36%).

Results (3) PPH cases observed

Among suspected PPH cases, a uterotonic (oxytocin was available in all these cases ) was administered in AMTSL in only 4 of 8 cases where the patient delivered at the facility;

Uterine massage and controlled cord traction were not performed in most cases.

Results (4)

Cases observed Oxytocin was given

during active management of the 3rd stage of labor (AMTSL) in 85% of cases; however, only 13% of observations were fully compliant with AMTSL steps

AMTSL interventions performed* (n=8) Number of cases

Administration of uterotonic 4 Controlled cord traction 3 Uterine massage 3 All AMTSL interventions 2

Results (5)

Cases observed A uterotonic was

administered for treatment in only 4 of 15 PPH cases.

Manual removal of placenta was attempted in 5 cases, but not performed correctly.

Type of treatment provided Number of cases

Administration of uterotonic 4 Massage fundus 5 Repair of lacerations 2 Manual removal of placenta 5 Bimanual compression -- Blood transfusion 0 Surgery 3 Outcome Maternal deaths 0 Perinatal deaths 4**

Conclusions

AMTSL and PPH management were not adequate even when drugs were available or special equipment was not required.

Providers need more support to ensure complete provision of AMTSL and correct PPH management and improved PPH knowledge and skills.

Recommendations include visible job aids at each facility, and sustained training and regular supervision of providers.

AMTSL should be incorporated into national service delivery guidelines.

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