1. Overcoming provider barriers to introduction and sustainability of AMTSL at facilities Susheela M. Engelbrecht PATH / Oxytocin Initiative

2. Objectives List determinants of the use of AMTSL in a facility Describe three interventions that address facility-based provider-related barriers to introduction and/or sustainability of AMTSL in facilities Develop ideas for improving sustainability of AMTSL in facilities in your country

3. AMTSL defined: 1.Administration of a uterotonic drug within 1 minute of birth of the baby (oxytocin 10 IU IM is the uterotonic of choice; in its absence, use 0.2 mg ergometrine IM or 1 mL syntometrine IM or 600 mcg misoprostol po) 2.Controlled cord traction with counter-pressure to support the uterus 3.Immediate uterine massage following delivery of the placenta w/ evaluation of uterine contractedness and repeat massage every 15 minutes for at least 2 hrs NOTE: early cord clamping (defined as clamping immediately after birth of the baby) is not part of the ICM/FIGO definition

4. AMTSL coverage was low in facilities – 2007 national surveys Percent of observed deliveries w/ uterotonic given during 3rd/4th stages of labor and correct use of AMTSL (uterotonic administration within 1 minute)

5. Why don’t providers consistently use AMTSL in facilities? (1) Policies may prevent certain cadres from applying active management of the third stage of labor Providers may either not be trained or not be consistently trained AMTSL may not be integrated into supportive supervision activities There may not be indicators for AMTSL and uterotonic drugs to monitor progress

6. Barriers to the use of AMTSL in a facility (2) Uterotonic drugs may not be consistently available due to logistics problems Uterotonic drugs may not be stored correctly, making them less effective, which has a negative effect on use of AMTSL

7. What will address provider-related barriers to sustainability of AMTSL in the facilities? Policies that promote application of AMTSL by all birth attendants in the facility Training activities that ensure that at least 80% of the population of birth attendants apply AMTSL consistently and competently Internal and external supervisory systems that monitor the practice Indicators to follow progress

8. Developing evidence-based guidelines with providers Peer election of a facilitator for each facility Training elected facilitators in each facility to disseminate guidelines Training all providers in AMTSL Use of the oxytocin-Uniject device Use of reminders Intervention 1: Changing AMTSL Behavior in Obstetrics (CAMBIO)

9. Results of implementing CAMBIO in Argentina Belizán and Althabe (2009)

10. Training of clinical instructors (“mentors”) for each facility Clinical instructors guide all providers through blended learning materials: Self-directed learning Clinical practicum Clinical instructors work with pharmacy managers to ensure availability and correct storage of uterotonic drugs Clinical instructors work with facility managers to ensure availability of essential equipment, supplies, and consumables Intervention 2: Self and Individual learning (SAIN)- 1

11. Intervention 2: Self and Individual learning (SAIN)- 2 Additional interventions: Posted job aids Additional columns to track AMTSL in the delivery log Wall charts to follow progress Follow-up and supportive supervision

12. Results of implementing SAIN – Ghana (1) Baseline use in Ghanaian Hospitals of the complete AMSTL interventions: 3,0% (2007) Intervention: June – October, 2009 / Evaluation: November 2009 There were adequate stocks of oxytocin, ergometrine, and misoprostol in all of the facilities at the time of visit Coverage: By report: 100% coverage of AMTSL Observation of the delivery register: 91-100% was actually recorded In most cases when AMTSL was not checked, oxytocin was documented, indicating that there is most likely 100% coverage but not 100% documentation Anecdotal decrease in cases of PPH and retained placenta, and reduced need of uterotonic drugs for management of PPH

13. Results of implementing SAIN – Ghana (2) Findings on evaluation: Percentage of observed providers practicing selected components of third stage management to standard (Ghana)

14. Results of implementing SAIN – iLembe district, South Africa (1)

15. Results of implementing SAIN – iLembe district, South Africa (2)

16. Results of implementing SAIN – iLembe district, South Africa (3)

17. Intervention 3: Intensive post-training supervision Competency-based training for providers in integrated maternal and newborn care Supervisors included in training activities One to two providers trained per site in off-site training Providers returned to worksites to “brief” other providers Trainers made up to 3 post-training follow-up visits to assess practice and provide refreshers as needed Additional interventions: Posted job aids Delivery logs and partograph revised to include tracking AMTSL

18. Intensive post-training supervision - DRC

19. Peer training - DRC

20. Lessons learned Mentors / Clinical instructors can help introduce and ensure sustainability Monitoring provides incentives Supervision assures quality and sustainability Informal peer training works

21. PPH Prevention and Treatment Website www.pphprevention.org