1. Multi country Analysis of Prevention of PPH and PE/E in USAID Program- Supported Countries Carmen Crow & Mandy Hovland Jeffrey M. Smith Angie Fujioka 14 October 2011

2. Overview Broad Program Goal: Accelerate the scale up of high impact interventions; Achieve high coverage Monitor catalytic role of USAID in program expansion Need for both horizontal and vertical program status analysis Map USAID’s investment and country achievement over time 2

3. 3 4th Dimension Program analysis: Horizontally – globally across countries Vertically – specifically, within country Depth – of program penetration in country Time – evolution or progress of programs with a country

4. Methodology 35 Countries January – March 2011 National level 46 item questionnaire Group consensus and self reporting English, French, Spanish 4

5. Questionnaire on PPH and PE/E Postpartum Hemorrhage Policy Training Misoprostol Logistics M&E Programming Scale Up / Expansion Pre-Eclampsia/Eclampsia Policy Training Logistics M&E Programming Scale Up / Expansion 5

6. Results Responses from 31 Countries: Complete: 27 countries Partial: 4 countries Unable: 4 countries Results presented 4 ways Main issues expressed horizontally, across countries: Dichotomous bar graphs - Global picture Summary tables Responses to questionnaires Scale – up maps 6

7. Results 7 Results Results

8. 8

9. 9 THEME 2: Education and Training in AMTSL Figure 4: Survey responses from 31 countries: Education and training in AMTSL (Active Management Third Stage Labor)

10. 10

11. 11

12. 12 THEME 5: Education and Training on PE/E Management Principles Figure 7: Survey responses from 31 countries: Education and training on PE/E management principles

13. 13 What we don’t have… What we don’t have… What we don’t have…

14. What we don’t have… Lack of coverage data Not commonly in HMIS Hospital/facility-based, not population-based Unable to track coverage over time MCHIP + WHO + CDC Global MNH benchmark indicators Use of a uterotonic immediately after birth Use of MgSO4 for diagnosis of severe PE or E Use of partograph for labor management Others 14

15. Child Mortality: 4 countries in Africa 15 Chad Ethiopia Zambia Kenya

16. Maternal Mortality: 4 countries in Africa 16 Chad Ethiopia Zambia Kenya

17. PATHWAY TO IMPLEMENTATION OF POSTPARTUM HEMORRHAGE PREVENTION AND MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PPH; Birth preparedness MCHIP/USAID active programs Other partners active programs Addressed previously, not active Training programs: Government budgeted training programs on PPH; PPH competencies in pre-service and in-service curricula No programs National advocacy: Expansion of national program and highlight work of champions PPH policy: AMTSL/misoprostol use; Expanded job descriptions for skilled birth attendant cadresmanaging PPH; PPH service delivery guidelines Global advocacy and partnerships: Global action to support work on reduction of PPH Pilot programs: Phase 1 implementation of misoprostol and/or AMTSL for all skilled birth attendant cadres REDUCTION OF PPH AND IMPROVED MATERNAL HEALTH STATUS Clinical coverage: High coverage use of a uterotonic; Public and private implementation Standardization: Quality of care approaches; Government led training expansion Program initiatives in obstetric and postpartum management: Quality of care; Clinical training; Supervision Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Global clinical and program approaches: Evidence-based interventions for prevention and management of PPH demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugsand supplies in government routine procurement mechanisms Health workers training systems: For PPH prevention and management Pharmaceutical systems: Uterotonics on Essential Drug Listand in Drug Registration;Supply chain management Drugs & equipment:Oxytocin/ misoprostol procurement, logistics, distribution Coverage of uterotonic in third stage of labour 0% 25% 50% 75% 100%

18. Maps on Postpartum Hemorrhage

19. ANGOLA: PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PPH; Birth preparedness Training programs: Government budgeted training programs on PPH; PPH competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions PPH policy: AMTSL/misoprostol use; Expanded job descriptions for skilled birth attendant cadresmanaging PPH; PPH service delivery guidelines Global advocacy and partnerships: Global action to support work on reduction of PPH Pilot programs: Phase 1 implementation of misoprostol and/or AMTSL for all skilled birth attendant cadres REDUCTION OF PPH AND IMPROVED MATERNAL HEALTH STATUS Clinical coverage: High coverage use of a uterotonic; Public and private implementation Standardization: Quality of care approaches; Government led training expansion Program initiatives in obstetric and postpartum management: Quality of care; Clinical training; Supervision Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Global clinical and program approaches: Evidence-based interventions for prevention and management of PPH demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugsand supplies in government routine procurement mechanisms Health workers training systems: For PPH prevention and management Pharmaceutical systems: Uterotonics on Essential Drug Listand in Drug Registration;Supply chain management Drugs & equipment:Oxytocin/ misoprostol procurement, logistics, distribution Coverage of uterotonic in third stage of labour 0% 25% 50% 75% 100%

20. MOZAMBIQUE - PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PPH; Birth preparedness Training programs: Government budgeted training programs on PPH; PPH competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions PPH policy: AMTSL/misoprostol use; Expanded job descriptions for skilled birth attendant cadresmanaging PPH; PPH service delivery guidelines Global advocacy and partnerships: Global action to support work on reduction of PPH Pilot programs: Phase 1 implementation of misoprostol and/or AMTSL for all skilled birth attendant cadres REDUCTION OF PPH AND IMPROVED MATERNAL HEALTH STATUS Clinical coverage: High coverage use of a uterotonic; Public and private implementation Standardization: Quality of care approaches; Government led training expansion Program initiatives in obstetric and postpartum management: Quality of care; Clinical training; Supervision Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Global clinical and program approaches: Evidence-based interventions for prevention and management of PPH demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugsand supplies in government routine procurement mechanisms Health workers training systems: For PPH prevention and management Pharmaceutical systems: Uterotonics on Essential Drug Listand in Drug Registration;Supply chain management Drugs & equipment:Oxytocin/ misoprostol procurement, logistics, distribution Coverage of uterotonic in third stage of labour 0% 25% 50% 75% 100%

21. GHANA- PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services GHS and partners active programing Community mobilization: Awareness raising of PPH; Birth preparedness Other partners, with GHS support Addressed previously, not active Training programs: Government budgeted training programs on PPH; PPH competencies in pre-service and in-service curricula No programs National advocacy: Expansion of national program and highlight work of champions PPH policy: AMTSL/misoprostol use; Expanded job descriptions for skilled birth attendant cadresmanaging PPH; PPH service delivery guidelines Global advocacy and partnerships: Global action to support work on reduction of PPH Pilot programs: Phase 1 implementation of misoprostol and/or AMTSL for all skilled birth attendant cadres REDUCTION OF PPH AND IMPROVED MATERNAL HEALTH STATUS Clinical coverage: High coverage use of a uterotonic; Public and private implementation Standardization: Quality of care approaches; Government led training expansion Program initiatives in obstetric and postpartum management: Quality of care; Clinical training; Supervision Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Global clinical and program approaches: Evidence-based interventions for prevention and management of PPH demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugsand supplies in government routine procurement mechanisms Health workers training systems: For PPH prevention and management Pharmaceutical systems: Uterotonics on Essential Drug Listand in Drug Registration;Supply chain management Drugs & equipment:Oxytocin/ misoprostol procurement, logistics, distribution Coverage of uterotonic in third stage of labour 0% 25% 50% 75% 100%

22. SOUTH SUDAN - PATHWAY TO IMPLEMENTATION OF PPH PREVENTION AND MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PPH; Birth preparedness Training programs: Government budgeted training programs on PPH; PPH competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions PPH policy: AMTSL/misoprostol use; Expanded job descriptions for skilled birth attendant cadres managing PPH; PPH service delivery guidelines Global advocacy and partnerships: Global action to support work on reduction of PPH Pilot programs: Phase 1 implementation of misoprostol and/or AMTSL for all skilled birth attendant cadres REDUCTION OF PPH AND IMPROVED MATERNAL HEALTH STATUS Clinical coverage: High coverage use of a uterotonic; Public and private implementation Standardization: Quality of care approaches; Government led training expansion Program initiatives in obstetric and postpartum management: Quality of care; Clinical training; Supervision Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Global clinical and program approaches: Evidence-based interventions for prevention and management of PPH demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugs and supplies in government routine procurement mechanisms Health workers training systems: For PPH prevention and management Pharmaceutical systems: Uterotonics on Essential Drug List and in Drug Registration; Supply chain management Drugs & equipment:Oxytocin/ misoprostol procurement, logistics, distribution Coverage of uterotonic in third stage of labour 0% 25% 50% 75% 100%

23. Maps on Pre-Eclampsia and Eclampsia

24. ANGOLA: PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PE/E; Birth preparedness Training programs: Government budgeted training programs on PE/E; PE/E competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions Global advocacy and partnerships: Global action to support work on prevention, early detection, and management of PE/E PE/E policy: Calcium supplementation; Screening in ANC; MgSO4 for clinically diagnosed severe PE/E cases; PE/E service delivery guidelines IMPROVED MANAGEMENT OF PE/E CASES AND REDUCED MATERNAL & PERINATAL MORTALITY Pilot programs: Phase 1 implementation of MgSO4 and other interventions for severe PE/E Clinical coverage: High coverage use of MgSO4; High coverage calcium supplementation; Public and private implementation Standardization: Quality of Care approaches; Government led training expansion Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Program initiatives in ANC & obstetric management: Quality of care; Clinical training; Supervision Global clinical and program approaches: Evidence-based interventions for prevention, early detection, and management of PE/E demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugs, supplies, and diagnostic tools in government routine procurement mechanisms Health worker training systems: For PE/E prevention and management Pharmaceutical systems: Drug registration; Essential Drug List; Supply chain management Drugs & equipment: Procurement, logistics, distribution Coverage of MgS04 for severe PE/E 0% 25% 50% 75% 100%

25. MALAWI - PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PE/E; Birth preparedness Training programs: Government budgeted training programs on PE/E; PE/E competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions Global advocacy and partnerships: Global action to support work on prevention, early detection, and management of PE/E PE/E policy: Calcium supplementation; Screening in ANC; MgSO4 for clinically diagnosed severe PE/E cases; PE/E service delivery guidelines IMPROVED MANAGEMENT OF PE/E CASES AND REDUCED MATERNAL & PERINATAL MORTALITY Pilot programs: Phase 1 implementation of MgSO4 and other interventions for severe PE/E Clinical coverage: High coverage use of MgSO4; High coverage calcium supplementation; Public and private implementation Standardization: Quality of Care approaches; Government led training expansion Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Program initiatives in ANC & obstetric management: Quality of care; Clinical training; Supervision Global clinical and program approaches: Evidence-based interventions for prevention, early detection, and management of PE/E demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugs, supplies, and diagnostic tools in government routine procurement mechanisms Health worker training systems: For PE/E prevention and management Pharmaceutical systems: Drug registration; Essential Drug List; Supply chain management Drugs & equipment: Procurement, logistics, distribution Coverage of MgS04 for severe PE/E 0% 25% 50% 75% 100%

27. RWANDA- PATHWAY TO IMPLEMENTATION OF PE/E MANAGEMENT AT SCALE Health system governance: Proactive financing of maternal health services Community mobilization: Awareness raising of PE/E; Birth preparedness Training programs: Government budgeted training programs on PE/E; PE/E competencies in pre-service and in-service curricula National advocacy: Expansion of national program and highlight work of champions Global advocacy and partnerships: Global action to support work on prevention, early detection, and management of PE/E PE/E policy: Calcium supplementation; Screening in ANC; MgSO4 for clinically diagnosed severe PE/E cases; PE/E service delivery guidelines IMPROVED MANAGEMENT OF PE/E CASES AND REDUCED MATERNAL & PERINATAL MORTALITY Pilot programs: Phase 1 implementation of MgSO4 and other interventions for severe PE/E Clinical coverage: High coverage use of MgSO4; High coverage calcium supplementation; Public and private implementation Standardization: Quality of Care approaches; Government led training expansion Service delivery capacity at sites: Reliable infrastructure, personnel, and systems to deliver services Program initiatives in ANC & obstetric management: Quality of care; Clinical training; Supervision Global clinical and program approaches: Evidence-based interventions for prevention, early detection, and management of PE/E demonstrated Programmatic growth: Adding districts, partners, financing Drug & equipment availability: Drugs, supplies, and diagnostic tools in government routine procurement mechanisms Health worker training systems: For PE/E prevention and management Pharmaceutical systems: Drug registration; Essential Drug List; Supply chain management Drugs & equipment: Procurement, logistics, distribution Coverage of MgS04 for severe PE/E 0% 25% 50% 75% 100%

28. Conclusions Policy is further ahead of practice – Oxytocin/AMTSL and MgS are authorized, but not always completely practiced Key principles of PPH prevention and PE/E management are generally in training and education (content not analyzed) Implementation of PPH Prevention at Homebirth with misoprostol programs are patchy Oxytocin and MgSO4are not routinely available at health facilities 28

29. Actions to be Taken Use the data for addressing global issues and improving country programs Conversations with MCHIP country offices Other bilaterals and partners Repeat on annual basis Improve the quality of the data Engage more countries 29

30. Thank you 30