1. Pathway for scaling up AMTSL Name of presenter Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project

2. Session objectives By end of the session, participants will be able to describe/define: Critical elements for expansion of AMTSL The need for a balanced strategy for expanding AMTSL that includes facility and home births Strategies / interventions that can be implemented to increase access to and uptake of AMTSL Country examples of scaling-up AMTSL.

3. 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

4. Programmatic issues for scale-up activities: Determinants of the use of AMTSL All women are offered and receive PPH prevention intervention Reduced PPH Reduced mortality Drug logistics in place Appropriate amount of drugs procured, appropriately stored, & available for all births LOGISTICS (DRUGS & SUPPLIES) MIS & supervision system in place MONITORING/SUPERVISION Awareness & endorsement of national expansion Policies, guidelines, protocols, standards in place POLICY PROVIDER Standardized pre- & in- service training Improved provider knowledge, skills & motivation

5. Policy National policy and protocols for AMTSL are in place All SBAs are authorized to practice AMTSL All SBAs are authorized to use all uterotonic drugs for AMTSL

6. Provider Pre-service education 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 or a uterotonic drug before delivery of the placenta

7. Logistics Oxytocin and misoprostol for prevention and treatment of PPH are listed in National Essential Drug List Oxytocin is first line drug and ergometrine is the second 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

8. Monitoring and Evaluation Number of women who were offered and received AMTSL at home and in the facility is included in the National HMIS

9. Suggested pathways to follow for scaling up postpartum hemorrhage prevention initiatives

10. Suggested pathways to follow for scaling up AMTSL: Policy (1) Conduct a national survey to evaluate the practice and uptake of AMTSL Hold national and provincial meetings to inform policy/decision makers Develop a balanced approach for facility births and home births 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

11. Percent of observed deliveries w/ uterotonic given during 3 rd /4 th stages of labor and correct use of AMTSL (uterotonic administration within 1 mn) National surveys in 10 countries National surveys have served to inform and influence policy and strategies for scaling up PPH prevention activities

12. 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

13. 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

14. Suggested pathways to follow for scaling up AMTSL: Policy - Seeking solutions for births that occur without skilled care Why? We cannot predict PPH on the basis of risk factors. In many countries very few deliveries are attended by a skilled attendant. Once severe PPH occurs, death follows very rapidly Timely referral and transport to facilities is not available or affordable Availability of emergency obstetric care services is grossly limited. Combine strategies for increasing AMTSL uptake in facilities with community-based distribution of misoprostol for births occurring in the home with or without a skilled attendant

15. Country example: Afghanistan (ACCESS / Jhpiego) Community health worker identifies all pregnant women in her area Pregnant woman and support persons are educated about PPH during home visits Misoprostol distributed when woman is 8 months pregnant with clear instructions on when and how to use it Community health worker conducts a postpartum home visit to determine maternal and newborn outcome Afghanistan: photo by Nasrat Ansari

16. Indonesia: Information on Safe Use and Distribution of Misoprostol (ACCESS / Jhpiego) Community-based distribution of misoprostol is an effective strategy to complement facility-based efforts to increase uptake of AMTSL Medication to prevent PPH is offered when the woman is 8 months pregnant. She is carefully counseled on: Safe and correct timing for use of misoprostol Risks of taking tablet prior to delivery Common side effects of misoprostol What to do in case side effects occur Where to go if PPH occurs even after taking medication

17. Suggested pathways to follow for scaling up AMTSL: Provider (1) 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

18. Protocols changed from physiologic to active management in 2003 2008: AMTSL training to be integrated into learning materials used for existing EONC and safe motherhood programs 2008: AMTSL to be introduced into pre- service programs for obstetrical nurses, midwives, and physicians 2008: 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

19. 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

20. Suggested pathways to follow for scaling up AMTSL: Provider (2) 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 + management of newborn asphyxia, low birth weight infants, and newborn infection  Benin (QAP): AMTSL + immediate newborn care + immediate postpartum care

21. Suggested pathways to follow for scaling up AMTSL: Provider Develop and disseminate simple and adapted job aids for developing a birth preparedness plan (including speaking to the importance of giving birth with an SBA so as to receive AMTSL), AMTSL, and monitoring in the immediate postpartum

22. Suggested pathways to follow for scaling up AMTSL: Logistics (1) 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

23. 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

24. Country example: Benin Develop simple and adapted job aids for storage of uterotonics

25. Country example: Mali Develop simple and adapted job aid for documenting movement of uterotonics

26. 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

27. Country example: Mali Integration of PPH prevention activities into national supervisory tools

28. Country example: Niger (QAP) Use wall charts to track progress made towards indicators

29. Summary: Determinants of the use of AMTSL All women are offered and receive PPH prevention intervention Reduced PPH Reduced mortality Drug logistics in place Appropriate amount of drugs procured, appropriately stored, & available for all births LOGISTICS (DRUGS & SUPPLIES) MIS & supervision system in place MONITORING/SUPERVISION Awareness & endorsement of national expansion Policies, guidelines, protocols, standards in place POLICY PROVIDER Standardized pre- & in- service training Improved provider knowledge, skills & motivation