1. Community and Clinical Action:
Maternal and Newborn Health
Graciela Salvador-Davila, Senior Technical Advisor for Maternal and
Newborn Health| Global Health Practitioner Conference, May 2014

2. BACKGROUND | PPH
• PPH is the leading direct cause of maternal deaths worldwide.
– PPH accounts for nearly 1/4th of maternal mortalities
• Time is a major issue.
– A woman can die within 2 hours of onset of PPH if she does not
receive proper treatment
• Barriers to life-saving care are many.
– Slow recognition of danger, need for care
– Distance
– Lack of funds
– Lack of transport
– Weak referral systems
– Stock-outs
– Inadequate provider skills and attitudes

3. PATHFINDER’S CCA-PPH+ MODEL– IMPLEMENTATION COMPONENTS

4. PERU
Piura, Lima and
Ayacucho
States
NIGERIA
Katsina, Kano, Lagos,
Nassarawa, Oyo, Yobe,
Ebonyi,
BANGLADESH
Kishoreganj
District
INDIA
Maharashtra,
Rajasthan, Bihar,
Tamil Nadu , (Orissa)
States
TANZANIA
Refugee camp and host
community settings in
Kigoma
PATHFINDER’S CCA-PPH+ MODEL- GLOBAL APPLICATION

5. THE COMMUNITY-FACILITY LINKAGE CONTINUUMCOMMUNITYAWARENESS
Widespread
community
knowledge of
risks of unskilled
birth
attendance, &
pregnancy and
delivery danger
signs
RECOGNITIONOFNEED
Family
members, friend
s, CHWs capable
of identifying
PPH
Community
systems
activated to
respond
TRANSPORT
Community-
level drivers
coordinate with
CHWs and/or
family to
transport
women from
community to
facility
CLINICLEVELCARE
Facility-level
providers
receive
woman, apply
Life Wrap, &
initiate referrals
for life-saving
care as
necessary
Community-wide
education, sensitization, CHW
and/or family training
Community-transport systems
established; contact information
made widely available; community
creates incentives for drivers
Provider/CHW sensitization to
ensure positive, productive working
relationships; facility-wide training
on Life Wrap; provider trainings

6. THE CCA-PPH+ CONCEPTPREVENTION
Majority of
PPH cases
stopped
before they
start
RECOGNITION
Capacity to
identify
PPH, so
transport is
timely URGENTCARE
Providers
have the
skills
necessary to
address PPH
LifeWrap&SHOCKRx
First aid
device
applied to
allow for
referral to
secondary
level
DEFINITIVERx
Transport
Appropriate
care
delivered
2% of women
with PPH go
into shock
25% of maternal
mortality is
caused by
hemorrhage
@ health system level
THE TREATMENT CONTINUUM

7. THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)

8. THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)
 Evidence-based
 Simple technology
 Low-cost
= Object of desire
(and forget about the rest!)

9. 2011 external evaluation of Pathfinder CCA-PPH+ programs. Among
the findings:
 “PPH in the facilities is decreasing…”
 “Promoting just the Life Wrap is not likely to have a large
impact on mortality because the Life Wrap is used in only the
most extreme cases (only 2% of PPH cases lead to shock)…
preventing PPH in the first place (as opposed to treating it when
it gets out of hand) helps many, many more women.”
 “…packaging of the full range of interventions to address PPH
was unique and we believe was what made the difference…”
 “The Life Wrap provided an entrée into the medical systems of
both India and Nigeria; it served as the ‘admission ticket’ for
the introduction of the continuum of care model.”
 “the most effective way to address PPH is not through the Life
Wrap but by strengthening the quality and availability of basic
obstetrical care, including AMSTL…”
THINKING ABOUT THE LIFE WRAP & CONTINUUM OF
CARE MACARTHUR EVALUATION FINDINGS

10.  “All the model does is systematically highlight the various
steps that need to be followed to provide very basic
obstetrical care. But it is precisely because the required
interventions are so basic, so old and ‘ho-hum’ that the
introduction of the Life Wrap was so important.”
 “Whether the same level of entrée could have been
achieved by Pathfinder without the allure of the Life Wrap
can be disputed. But what is undeniable is the role the Life
Wrap played in introducing the continuum of care model–
a model that definitely strengthened the government
health systems in both countries.”
THINKING ABOUT THE LIFE WRAP & CONTINUUM OF
CARE EVALUATION FINDINGS

11. IMPLEMENTATION
SCIENCE
The right questions,
the right answers?

12. “This is the next frontier …helping to advance a ‘science of delivery.’
Because we know that delivery isn’t easy – it’s not as simple as just
saying ‘this works, this doesn’t.’ Effective delivery demands context-
specific knowledge. It requires constant adjustments, a willingness to
take smart risks, and a relentless focus on the details of
implementation.”
-Jim Yong Kim, World Bank President
2012 Annual Plenary Session

13. IMPLEMENTATION SCIENCE FOR MATERNAL HEALTH
• The world is seeing progress in stemming maternal deaths
– nearly a 50% decline in MMR between 1990 and 2010.
• Looking forward to post-2015, there is still work to be done.
• Majority of maternal death causes are preventable.
• From a clinical practice perspective, we know what works.
 So what do we need to know to replicate “what works” & take it to
scale?

14. Z
IMPLEMENTATION
SCIENCE FOR PPH &
THE CCA-PPH+
MODEL

15. PREVENTION
Majority of
PPH cases
stopped
before they
start
RECOGNITION
Community
members
can identify
severe PPH LifeWrap&
SHOCKRx
First aid
device
applied at
community-
level prior to
initiation of
transport
URGENTCARE
Providers
have the
skills
necessary to
address PPH
for
stabilization
DEFINITIVERx
Life-saving
care
delivered
(surgery,
blood
transfusion,
medication)
STRETCHING THE CCA-PPH+ TREATMENT CONTINUUM TO COMMUNITY LEVEL
• 25% of maternal mortality is caused by hemorrhage.
• 2/3rds of women with PPH have no identifiable risk factors.
• More than 50% of women in resource-limited settings have no skilled birth attendance and deliver at
community-level.
Community-level
distribution of
misoprostol to
prevent PPH
(Potential to reduce PPH
incidence by up to 50%,
and severe PPH by 80%)
@ community level @ health system level

16. LOGICAL ORDER OF IMPLEMENTATION
The order of implementation is generally:
1. Advocacy: Work with the government and professional organizations, so
all understand and support the initiative. Also donors, other linkage with
other potential partners.
2. Prepare all levels of facilities, but start with the tertiary/referral level to
make sure it is EOC referral ready, including AMTSL and the use of the
Life Wrap, then moving to secondary, and primary levels once the
referral hospitals are ready.
3. Once each facility level is ready, work with government supported front
line workers and CBO’s to engage the communities in raising awareness
of danger signs, and how to avoid the first 3 delays at community level
including an established transport system.

17. THE CCA-PPH MODEL: A SUMMARY
• The CCA-PPH Model is comprehensive, practical, and adaptable
• The elements of the model taken together can have a significant impact
on maternal mortality
• Elements implemented individually have less impact
• The model can be adapted for other causes of maternal mortality such as
pre-eclampsia and eclampsia, sepsis, and prolonged labor
• The Project CD contains the PPH curriculum, the training video and a
toolkit with job aids, a community survey tool and data collection
instruments

18. ADDING PE/ECLAMPSIA TO THE CCA-PPH MODEL
• Pre-eclampsia/eclampsia (PE/E) can be easily rolled into the CAA/PPH
Continuum of Care, utilizing the organized facility levels and community
engagement systems already in place for PPH.
• This can be done after the PPH components are in place, or developed at
the same time as the PPH components.
• Similarly, all the major causes of maternal mortality can be addressed with
these same facility-community systems (sepsis, obstructed/prolonged
labor, unsafe abortion)

19. Program Monitoring and Evaluation Plan
EffectivenessIndicators
Performance Monitoring System
FundsStaffing
Inputs
• Community sensitization and
engagement
• Frontline workers trained in
IEC and referral
• Community organizations
equipped with emergency
transportation
• IEC materials distributed
• Effective referral systems
developed
• Job aids/protocols
developed/adapted
• Health providers trained
• Supervision provided for
sustained and improved
quality of care
• Life Wraps provided to
facilities
• Advocacy meetings with
gov’t officials and other key
stakeholders
Activities Objectives
Performance(output)Indicators
OutcomeIndicators
GoalEffects
1. Increase awareness of
community members of
the danger signs of PPH
and knowledge of
technologies
2. Improve the capacity of
community members to
make the decision to seek
medical care for PPH
3. Increase the ability of
community members to
identify and reach
medical care for obstetric
emergencies and
complications including
PPH
4. Improve the capacity of
health care providers to
provide high-quality
appropriate care
ImpactIndicators
Fig. 1. Program Framework: CCA-PPH Model
Decrease rates
of PPH and
shock
Decrease
maternal
mortality
related to PPH
• Increased access to
and use of emergency
transportation
• Increased referrals
from communities to
lower level facilities to
higher level facilities
• Job aids/protocols
approved and in place
• Increased access to
equipment and
commodities
• Increased practice of
AMTSL by providers
• Increased use of
standard tools for
estimating blood loss
• Appropriate and timely
management of PPH
• Increased use of Life
Wrap for management
of shock

20. twitter.com/PathfinderInt
facebook.com/PathfinderInternational
Youtube/user/PathfinderInt
For more information contact:
Graciela Salvador-Davila, Senior Technical Advisor for
Maternal and Newborn Health
GDavila@pathfinder.org
Thank you!