National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia - MCHIP (2012)

Publication date: 2012

National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia A Global Survey, 2012 By: Jeffrey Smith Sheena Currie Julia Perri Julia Bluestone Tirza Cannon ph ot o by K at e H ol t/ Jh pi eg o National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia A Global Survey, 2012 By: Jeffrey Smith Sheena Currie Julia Perri Julia Bluestone Tirza Cannon Please visit www.mchip.net/globalstatusreport or scan the QR code to access electronic versions of the report and other related documents. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 i TABLE OF CONTENTS Abbreviations And Acronyms . ii Acknowledgments . iii Introduction . 1 Methods . 2 Survey Instruments . 2 Data Collection Procedures . 3 Data Analysis . 3 Findings . 4 Overview . 4 Theme 1A: Drug Availability: Uterotonics . 7 Theme 1B: Drug Availability: Magnesium Sulfate . 11 Theme 2: Medicines Approved at the National Level. 15 Theme 3: AMTSL . 19 Theme 4: Misoprostol . 23 Theme 5: Midwife/Skilled Birth Attendant Scope of Practice . 27 Theme 6: Education/Training . 31 Theme 7: National Reporting on Selected Maternal Health Indicators . 35 Theme 8: Potential for Scale-Up and Bottlenecks . 37 Discussion . 39 Limitations . 42 Conclusion, Recommendations and Opportunities for Expansion . 44 Appendix 1: Global Surveys of Scale-Up of National PPH and PE/E Programs in English, French and Spanish . 45 Appendix 2: Completed Global Surveys of Scale-Up of National PPH and PE/E Programs . 62 Appendix 3: Completed Scale-Up Maps . 231 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: ii A Global Survey, 2012 ABBREVIATIONS AND ACRONYMS AMTSL Active management of third stage of labor BEmONC Basic emergency obstetric and newborn care CCT Controlled cord traction DRC Democratic Republic of Congo EML Essential medicines list HCI Health Care Improvement Project HMIS Health management information system ICM International Confederation of Midwives IM Intramuscular IV Intravenous LAC Latin America and the Caribbean M&E Monitoring and evaluation MCHIP Maternal and Child Health Integrated Program MCPC Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors MgSO4 Magnesium sulfate MMR Maternal mortality ratio MNCH Maternal, neonatal and child health MOH Ministry of Health PE/E Pre-eclampsia/eclampsia PHC Primary health center PPH Postpartum hemorrhage SBA Skilled birth attendant SDG Service delivery guideline UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 iii ACKNOWLEDGMENTS We express our sincere gratitude to our partners and colleagues in the field who are working to reduce the incidence of the two leading causes of maternal death, postpartum hemorrhage and pre-eclampsia/eclampsia. Governments, Ministries of Health, partner organizations, including national and international nongovernmental organizations, and health workers demonstrate broad knowledge of challenges and roadblocks, commitment to overcoming these challenges and fresh ideas for the future. We recognize the generosity of their time in participating in this survey, and in working to improve maternal health worldwide. We would like to give a special thanks to the national Ministries of Health, and related departments, committees and working groups of maternal and reproductive health in the countries that completed the surveys. These groups met and answered the survey questions as a collective exercise to provide the requested data for this global survey and to analyze and further understand their national programs and efforts. We wish to thank the United States Agency for International Development (USAID), the Maternal and Child Health Integrated Program (MCHIP) and partner colleagues in the following countries: • Africa: Angola, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, South Sudan, Tanzania, Zanzibar and Zimbabwe. • Asia: Afghanistan, Bangladesh, Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, Timor Leste and Yemen. • Latin America: Bolivia, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua and Paraguay. MCHIP acknowledges the contributions from many partner organizations and USAID- supported programs, including: Abt Associates IntraHealth International Jhpiego John Snow, Inc. Management Sciences for Health PATH Pathfinder International Save the Children University Research Co., LLC USAID-supported HSSP in Afghanistan USAID-supported RBHS in Liberia USAID-supported SHTP II in South Sudan USAID-supported TSHIP in Nigeria USAID-supported STRIDES in Uganda USAID-supported MAISHA in Tanzania and Zanzibar USAID-supported SSDE Program in Malawi We also gratefully acknowledge our colleagues from USAID, Dr. Nahed Matta and Ms. Deborah Armbruster, who contributed by highlighting global priorities, offering their technical expertise and conducting reviews of survey instruments and report drafts. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: iv A Global Survey, 2012 We thank Deborah Estep, Trudy Conley, Jamie Wolfe, Youngae Kim, Alisha Horowitz, Rachel Rivas D’Agostino and Dana Lewison from Jhpiego and Lyndsey Wilson Williams from MCHIP/Save the Children for their data management expertise, collaboration on the analysis and production of the report. Thanks also to Linda Benamor from Jhpiego and Jessica Delgado for their expertise in French and Spanish translation. This program and report were made possible by the generous support of the American people through the U.S. Agency for International Development, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-00. The contents are the responsibility of MCHIP and do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. MCHIP is the USAID Bureau for Global Health’s flagship maternal, neonatal and child health (MNCH) program. MCHIP supports programming in maternal, newborn and child health, immunization, family planning, malaria, nutrition and HIV/AIDS, and strongly encourages opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health and health systems strengthening. Visit www.mchip.net to learn more. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 1 INTRODUCTION Programs to reduce mortality from postpartum hemorrhage (PPH) and pre-eclampsia/eclampsia (PE/E) are in place in many countries worldwide. The United States Agency for International Development (USAID), with the support of the Maternal and Child Health Integrated Program (MCHIP) and through its multiple partners, tracks the implementation and progress of these country programs. In support of this effort to understand global progress in reduction of maternal mortality, in 2010 MCHIP developed and continues to maintain a database of PPH and PE/E country-level information worldwide. A further update and analysis of this database are presented here for 37 countries worldwide. This exercise is a continuation of the MCHIP mandate to support the scale-up and expansion of proven public health program activities in the USAID priority countries. The database will continue to track ongoing progress of programs that target PPH and PE/E in multiple countries worldwide and provide that information for a global audience. More complete understanding of these data will better serve existing and new projects, and will be useful as a reference for USAID and partners as they advance program progress and scale-up. Maternal mortality ratios (MMRs) still remain unacceptably high worldwide, but there has been progress in recent years. According to Trends in Maternal Mortality: 1990 to 2010,1 the number of global maternal deaths has been cut in half over this 20-year period. Approximately 287,000 women died of pregnancy-related causes in 2010, a decline of 47% since 1990. Although the global estimate of MMR in 2010 was 210 maternal deaths per 100,000 live births, wide variations still exist among countries. The MMR in sub-Saharan Africa is well above this level and is the highest of any region, with 500 maternal deaths per 100,000 live births. Though South Asia is just above the global median, at 220 maternal deaths per 100,000 live births, it still represents 29% of the global burden of maternal mortality. Even as most countries are experiencing a decline in MMR, the pattern, pace and reasons for that decline vary. Furthermore, to maintain momentum in the reduction of maternal mortality, national programs will need to ensure both adequate coverage and sustainability. To this end, MCHIP undertook its second annual survey of national programs for the prevention and management of PPH and PE/E from January to March 2012. This country-level program analysis included countries from Africa, Asia and Latin America, focusing on those USAID priority countries that face the highest burden of maternal morbidity. The purpose of this review was to understand the status of national programs and to monitor their progress. Previously, the same survey was conducted from January to March 2011, allowing for comparison between the reported situation in 2011 and that in 2012. This survey offers opportunities to review and understand national programs for addressing PPH and PE/E. First, it provides a global snapshot of policy, practice, supplies and activities, and guides national and global program managers and policymakers in setting priorities. Second, it allows an understanding of where progress has been made from 2011 to 2012. Finally, for the 30 countries for which there are quantitative and scale-up map data from both years, the analysis allows for the tracking of specific, national progress on priority issues and more general tracking of evolution of national programs through the use of the scale-up maps. 1 WHO, UNICEF, UNFPA and The World Bank. 2012. Trends in Maternal Mortality: 1990 to 2010, http://www.who.int/reproductivehealth/publications/monitoring/9789241503631/en/index.htm National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 2 A Global Survey, 2012 METHODS The survey incorporates non-experimental methods, using available national data and collective discussion and information from key informants. It captures a cross-section of countries that are either priority countries within USAID’s global health strategy, or engaged in relevant maternal mortality reduction efforts. The questionnaire includes both quantitative and qualitative questions. The respondent teams in the countries aimed to answer the quantitative questions objectively, based on national policy and existent data and the current situation in- country, rather than based predominantly on opinion. The qualitative questions called for some subjective responses in order to triangulate and add depth to the quantitative responses. In addition, countries filled out conceptual “scale-up maps,” which are visual representations of national policy, rollout and scale-up of PPH and PE/E programs. Finally, the research team conducted a smaller analysis of 20 countries’ service delivery guidelines (SDGs) to delve into national-level policies with more specificity and to cross-check perceptions of policy with the actual policies. The maps and service delivery guidelines were used to gain a more comprehensive view of “policy to practice” in maternal health in 2012 in the 37 participating countries. It is anticipated that this survey will be conducted on an annual basis for the life of MCHIP. Once received by the research team in Washington, all surveys and maps were checked for completeness and clarity. When questions arose, the MCHIP maternal health team worked with country respondents to clarify responses. The MCHIP maternal health team conducted an analysis of quantitative responses, aggregating answers and comparing them to the 2011 responses. In addition, qualitative responses were coded, aggregated, analyzed, mined for illustrative quotes and compared to quantitative responses where appropriate. Survey Instruments The questionnaire that had been used for the 2011 survey was reviewed before the 2012 data collection began, and modifications were considered. In instances where the questions appeared confusing or elicited a wide variety of responses in 2011, they were made more specific. Changes were made to questions in cases where it was necessary to facilitate comparability between years. Ultimately, three questions were added, two questions were changed, 10 questions were modified slightly, eight response choices were modified and one question was removed. All survey instruments were translated from English into French and Spanish using professional translators. The 46-item questionnaire included six core components: policy, training, drug distribution and logistics, national reporting of key maternal health indicators, programming, and challenges to and opportunities for scale-up. The full survey questionnaire for 2012 is included in Appendix 2 in the full report. Perceptions of expansion and scale-up of national efforts are also visually represented in color-coded conceptual maps (see Appendix 3 in the full report) to indicate current national program progress in scaling up PPH and PE/E prevention and management interventions. Different colors were used by national teams to represent effort related to a specific program component, including components active under USAID support (red), components active under other partner support (blue) and components previously addressed and no longer active (green). Although this exercise operates under a fundamental supposition that all program components are guided and promoted by local government efforts, some respondent teams felt it necessary to demonstrate that through Six Core Components  Policy  Training  Drug distribution and logistics  National reporting of key maternal health indicators  Programming  Challenges to and opportunities for scale-up National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 3 shading with a different color (yellow). Lighter shades of the specified colors were used to indicate partial coverage of a program component or a focus on a specific element of the program component, rather than the entire component. Key components of the conceptual maps include: national strategic choices, phased program implementation, and sustainability and institutionalization. Data Collection Procedures Data collection was coordinated by the MCHIP maternal health team in Washington, D.C., during the months of January, February and March 2012. Contact information was compiled for an identified focal person in each of the 43 targeted countries. His or her name and contact information can be found at the top of each country’s survey in Appendix 2 in the full report. The contact list from 2011 was used and the individual’s continuing engagement with national activities was confirmed. Additional sources were contacted in an effort to ensure that there was an appropriate coordinator for the data- gathering activities in each country. The coordinator for each country was sent an e-mail with anticipated dates and activities six weeks in advance of receiving the survey. He or she was instructed to contact national counterparts in the government as well as leading implementing partners. The country coordinator was given a timeline of pending requests and asked to arrange meetings with national consultative groups to ensure a national participatory process for the completion of the survey instruments. In most cases this was possible. Key stakeholders from government, ministries, MCHIP programs, other USAID bilateral programs, UN partners and other implementing agencies met to collect data and respond to the 46-item questionnaire and the scale-up map. In most cases, these consultative groups found it necessary to meet twice to ensure accuracy and completeness of responses. The questionnaire and scale-up maps were revised from the 2011 versions, based on responses, questions and feedback from the 2011 survey administration. Surveys were sent out via e-mail in English French and Spanish, and countries received copies of their 2011 surveys, which served as a starting point. Stakeholders met in-country to collect data and respond to the survey, and contacted the MCHIP maternal health team with questions. Responses were shared via e-mail in English, French and Spanish. Professional translators translated French and Spanish survey responses into English. Data Analysis All survey responses were entered into a Microsoft Access Database to facilitate ease of data entry and analysis. Reports aggregating quantitative survey responses and graphs by region were created in Microsoft Excel. Qualitative responses were first collected in Access and then transferred by theme into Microsoft Excel. Responses were coded, aggregated, analyzed and compared to quantitative responses where appropriate. Country respondent teams were also asked to submit national SDGs and copies of essential medicine lists (EML). Twenty countries’ SDGs were reviewed, and the findings are presented under the corresponding themes in the Findings section. SDG documents that were submitted in English were reviewed for accuracy and completeness of the following necessary components: 1) active management of the third stage of labor (AMTSL), 2) the use of misoprostol for the prevention of PPH, 3) the diagnosis and management of PE/E, and 4) the use of National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 4 A Global Survey, 2012 antihypertensives for severe hypertension2 in pregnancy. Non-English national SDG documents were reviewed through discussion with country respondents to ensure that the data were accurately presented. The research team used a standardized checklist adapted from the World Health Organization (WHO) publication Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors (MCPC) 3 to review each SDG. FINDINGS Overview The findings presented in this section are a compilation of data collected from 37 countries in Africa, Asia and Latin America (see box at right for list of countries surveyed). These findings build upon those in last year’s report and explore additional themes relevant to the prevention and management of PPH and PE/E. Such in-depth analyses each year provide countries the opportunity to recognize progress in particular areas and identify other areas for development. In addition, the comparison of national programs will guide global prevention and management efforts moving forward. Despite initial correspondence and follow-up with in-country representatives, five countries were not able to complete the survey: Burkina Faso, Dominican Republic, Laos, Myanmar and Peru. Zambia completed the survey in 2011, but was unable to do so in 2012. The MCHIP maternal health team will continue to work with these countries and other countries not previously represented in the report to disseminate best practices in maternal health and to assist them should they be able to participate in the survey in the future. The figures and analyses presented in this section compare country responses to three or four questions, grouped by themes across the 37 countries. When data for a given question are present from both years, responses from 2012 are compared to those from 2011. 2 Diastolic blood pressure 110 mmHg or more after 20 weeks gestation and proteinuria 3+ or more are the cardinal signs of severe PE. If diastolic blood pressure remains above 110 mmHg, antihypertensive drugs should be given. 3 http://www.iawg.net/resources/RH%20Kit%2011%20- %20Complications%20of%20pregnancy%20and%20childbirth_midwives%20and%20doctors.pdf Countries Surveyed, by Region Region 2011 2012 Africa Angola Democratic Republic of Congo Equatorial Guinea Ethiopia Ghana Guinea Kenya Liberia Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal South Sudan Tanzania Zambia Zanzibar Zimbabwe Angola Democratic Republic of Congo Equatorial Guinea Ethiopia Ghana Guinea Kenya Liberia Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal South Sudan Tanzania Uganda Zanzibar Zimbabwe Asia Afghanistan Bangladesh India Indonesia Nepal Afghanistan Bangladesh Cambodia India Indonesia Nepal Pakistan Philippines Timor Leste Yemen Latin America Bolivia Guatemala Honduras Nicaragua Paraguay Bolivia Ecuador El Salvador Guatemala Honduras Nicaragua Paraguay National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 5 The findings are presented across the eight themes presented in the box at right. Please see Appendix 2 in the full report for each country’s full questionnaire and complete responses. An analysis of national SDGs from 20 countries and an extensive qualitative analysis of all surveys on reported bottlenecks and challenges were conducted. These analyses provide a greater understanding of the quantitative answers given on the surveys and triangulate responses from country teams. Specific findings from the national SDGs and qualitative data analyses are presented throughout the report. The purpose of the review of national SDGs was to determine the accuracy and completeness of guidelines for AMTSL and the management of severe PE/E. The following 20 reviews were conducted: • Independent review of English SDGs: Afghanistan, Cambodia, Ethiopia, Ghana, India, Kenya, Liberia, Malawi, Nigeria, Timor Leste, Yemen and Zimbabwe. • Joint review (with Jhpiego country representative) of non-English SDGs: Angola, Bolivia, Equatorial Guinea, Guinea, Indonesia, Madagascar, Paraguay and Rwanda. Each respondent team from participating countries also completed a scale-up map, coded to represent the current state of progress in the national scale-up of PPH and PE/E reduction and management programs. All 37 countries participating in the survey filled out these conceptual maps for their country, and the maps are presented in Appendix 3 of the full report. The scale- up maps are useful for global tracking, and completing them was a beneficial exercise for the national program management teams. The country respondents who met to fill out the surveys and maps were able to conceptualize where national progress and gaps are, and in which technical area. Qualitatively, it can be observed that the country teams were more familiar with the format of the maps this year, and potentially were able to complete them more accurately. It is notable that the scale-up maps for 2012 reveal that the majority of countries have PPH and PE/E programs that are based on broad partnerships, most notably collaboration among USAID programs and projects and other partners, or collaboration between the local Ministry of Health (MOH) and other partners. Findings Grouped by Themes 1. 1a. Availability of uterotonic medications 1b. Availability of magnesium sulfate (MgSO4) for the management of severe PE/E 2. Lifesaving medicines approved at the national level 3. National policies regarding AMTSL 4. Expansion and scale-up of misoprostol availability and PPH- reduction programs 5. Midwife and skilled birth attendant (SBA) scope of practice 6. Education and training in AMTSL and PE/E management principles 7. National reporting on selected maternal health indicators 8. Potential for scale-up and bottlenecks National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 6 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 7 Theme 1A: Drug Availability: Uterotonics Figure 1: Global Summary of Uterotonics, Selected Countries, 2012 The 2012 survey results show that access and availability of oxytocin has improved globally— increasing from regular availability in 74% of countries (23 of 31) in 2011 to 89% of countries (33 of 37) responding in 2012. Eighty-nine percent of countries surveyed report regular availability of oxytocin and 92% report oxytocin availability in the MOH medical store. Seventy percent of countries report that oxytocin is free of charge, and only four countries report that oxytocin is not available more than half the time. Qualitative data reveal that regular supply of oxytocin is still an issue. Nine countries cite that patients have to pay for oxytocin out of pocket at least some of the time. Of those nine countries, 50% exhibit a gap between national policy and practice. Their responses show that clients are paying for oxytocin out of pocket even though national policy states that it should be provided at no cost to the patient. Smaller gains, however, have been made regarding the availability of misoprostol. Respondents state that misoprostol is regularly available (more than half the time) in only 10 countries, while 73%, or 27 countries, state that misoprostol is available less than half the time or never in public health facilities with maternity services. Qualitative data show a correlation between national policy and availability: countries that do not support the provision of misoprostol at the national level do not have misoprostol at public health facilities. Sixteen countries provide additional qualitative comments to their answers. Three of these countries said that although misoprostol is available more than half the time, it is available at only certain types of health facilities, but not all. The majority of countries that provide additional qualitative comments state that they do not have misoprostol available in public health facilities. Four countries cite that patients can obtain the drug with an out-of-pocket cost, and two of those countries state that misoprostol can be purchased only in the private sector. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 8 A Global Survey, 2012 Oxytocin availability was a survey question in both 2011 and 2012. Regionally, mixed progress has been made regarding the availability of oxytocin in Asia. While India and Nepal now report that oxytocin is regularly available, Bangladesh considers it to be less available in 2012 than in 2011. Progress has been made in Latin America in the availability of oxytocin. In 2011, four of five countries reported regular availability of oxytocin, while Guatemala reported irregular availability of the medicine. In 2012, all countries surveyed from LAC, including Guatemala, report that it is now regularly available. Several African countries report improvements in oxytocin availability. Of the five countries that reported oxytocin as not regularly available in 2011, only South Sudan still reports oxytocin as not regularly available. Figure 2: Availability of Oxytocin in Health Facilities, 2011 and 2012 Figure 3: Availability of Misoprostol in Maternity Centers, 2012 Illustrative Qualitative Responses Several countries’ qualitative answers add important, complementary information to their quantitative responses. The first and second countries below state that misoprostol is never available in public maternity centers, while the third country says that it is available more than half the time. They qualified their answers with the following:  “Misoprostol is not on National EML of [our country], so whenever it is required, it is purchased.”  “The doctors prescribe it for the family of the patient, and the family buys it from the private pharmacy.”  “Depends on the workload at that facility and whether there is sharing of supplies between higher- and lower-level facilities in the same area.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 9 Figure 4: Oxytocin Cost to Patients in 37 Countries, 2012 Figure 5: Frequency of Oxytocin Stock-Outs, 2012 Illustrative Qualitative Responses Two of the countries stating that oxytocin is free of charge to patients in public health facilities qualify their answers with the following:  “It is free of cost, whenever available. Most of the time it is not available and patients have to buy it or it is provided through charity/ donation, but not refrigerated.”  “If the Medical Supply at the Ministry distributes it, it will be free. But most of the time, it may not be there, as the amount distributed to health facilities is not sufficient. If it is not available, the family may buy it from the private pharmacy.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 10 A Global Survey, 2012 Figure 6: Oxytocin Availability in 2011 and in 2012, by Region AFRICA: Uterotonics Survey Question Oxytocin regularly available in facilities National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 11 Theme 1B: Drug Availability: Magnesium Sulfate Figure 7: Global Summary of Magnesium Sulfate, Selected Countries, 2012 Globally, countries report that progress has been made in the availability of magnesium sulfate (MgSO4); the percentage of countries that report that it is regularly available has increased substantially from 48% (15 of 31 countries) in 2011 to 76% (28 of 37 countries) in 2012. Notably, 12 countries that did not report regular availability in 2011 now report regular availability in 2012. Despite this progress, in 2012, seven countries in Africa and two in Asia report that MgSO4 is still not regularly available at least half the time. More countries report that MgSO4 is available in the MOH medical store (86%) than regularly available in the facility (76%), revealing a supply chain and distribution problem. Of the 37 countries surveyed, 46% report that stock-outs of MgSO4 are rare, 30% that they occur sometimes and 16% that they are frequent (see Figure 9). Regionally, there has been progress in availability from 2011 to 2012. In Latin America, all five countries surveyed report regular availability both in 2011 and in 2012. In Asia, of the five countries with data from both years, three note progress in regular availability of MgSO4, with all five now responding positively regarding availability and inclusion in the national policy. In Africa, overall progress has been made between 2011 and 2012. Nine African countries that did not report regular availability of MgSO4 in 2011 now report regular availability. Four still do not have regular availability, and Liberia and Mali reported regular availability in 2011, but not in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 12 A Global Survey, 2012 Figure 8: Availability of Magnesium Sulfate in Health Facilities, 2011 and 2012 Figure 9: Magnesium Sulfate Stock-Out Frequency, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 13 Figure 10: Magnesium Sulfate Availability in 30 Countries in 2011 and in 2012, by Region AFRICA: MgSO4 Survey Questions MgS04 regularly available in facilities MgS04 is national policy for severe PE/E National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 14 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 15 Theme 2: Medicines Approved at the National Level Figure 11: Global Summary of Medicines Approved at the National Level, Selected Countries, 2012 There is global approval of oxytocin to prevent and manage PPH; all of the 31 countries surveyed in 2011 responded that oxytocin was approved on the EML, and in 2012 every country except for Equatorial Guinea reports that oxytocin is approved on the EML, although Equatorial Guinea reports that AMTSL is approved and that use of oxytocin is part of SDGs. All 20 SDGs recommended the provision of oxytocin, and 18 of the 20 SDGs reviewed included the correct dose of oxytocin within their recommendation for AMTSL. There was no progress in the inclusion of misoprostol on national EMLs for preventing/ managing PPH. Only 57% of the 37 countries surveyed in 2012 report that misoprostol is on the EML for PPH, while 61% of 31 countries responded positively in 2011. Few countries have clear national guidelines for the use of misoprostol to prevent PPH. Guidelines in India, Liberia and Nigeria indicate the use of 600 mcg of misoprostol to prevent PPH, while in Ethiopia the dose is 400–600 mcg and in Equatorial Guinea it is 400 mcg. Cambodia, Ghana, Kenya, Malawi and Rwanda state that misoprostol is on the EML for prevention and/or treatment of PPH, yet none contain guidance in their SDGs. All regions of the world show a similar lack of progress regarding the inclusion of misoprostol on the EML. In Latin America, Guatemala and Nicaragua continue to report the absence of misoprostol from the EML, and Paraguay clarified its response from 2011 to 2012 and now indicates that misoprostol is not on the EML. In Asia, the survey shows that misoprostol is not on the EML in Afghanistan and Indonesia. In Africa, the three countries that responded negatively in 2011, Liberia, Rwanda and South Sudan, now report that misoprostol is on the national EML in 2012. That progress is counterbalanced by three other countries, Democratic Republic of Congo (DRC), Equatorial National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 16 A Global Survey, 2012 Guinea and Tanzania, which reported misoprostol was on the EML in 2011, but in 2012 report that it is not. Figure 12: Misoprostol Inclusion on EML, 2011 and 2012 The 2012 survey results show that all 37 countries surveyed report that MgSO4 is approved in national policy as the first-line treatment for severe PE/E, representing a global commitment to its use. This was also the case in 2011, when all 31 countries surveyed reported MgSO4 as approved in the national policy guidelines. However, the 2012 survey shows that a majority of countries also include diazepam as a first-line anticonvulsant for severe PE/E, increasing from 19 countries in 2011 to 25 countries in 2012. Despite wide approval of MgSO4 for first-line treatment of PE/E, implementation guidance can be inconsistent. WHO documents such as the MCPC set forth a standard protocol for the use of MgSO4, including an initial loading dose by both intravenous (IV) and intramuscular (IM) routes, followed by IM maintenance doses. In the SDGs reviewed, however, some parts of the standard protocol lacked clarity or specificity. For example, SDGs from Zimbabwe and Angola did not contain guidelines for the use of MgS04 to prevent eclampsia and manage severe PE/E, and India’s SDG did not provide guidelines for the IV loading dose or maintenance doses. Documents from Yemen and Indonesia did not provide guidelines for the IM loading dose, and the document from Cambodia lacked guidance for the maintenance dose. Although it is encouraging that universal approval has been achieved, additional clarity in national clinical recommendations is needed. The majority of countries include administration of a recommended antihypertensive for diastolic BP ≥ 110 in severe PE/E. Most guidelines recommend the use of hydralazine (92%) or nifedipine (89%), although there is great variation in the specificity of treatment regimens. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 17 Figure 13: Approval of Maternal Health Medicines at the National Level in 2011 and in 2012, by Region AFRICA: Medicines approved at the national level Survey Questions Oxytocin on the EML for prevention/treatment of PPH Misoprostol on the EML for prevention/treatment of PPH MgS04 is national policy for severe PE/E Diazepam is national policy for severe PE/E National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 18 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 19 Theme 3: AMTSL Figure 14: Global Summary of AMTSL, Selected Countries, 2012 Acceptance of the use of AMTSL for the prevention of PPH is nearly universal, with 36 of 37 countries approving it as national policy, and 35 of 37 countries including it in national SDGs. The review of the 20 national SDGs, however, reveals a lack of clarity and specificity. The analysis of SDGs found that guidelines were sometimes incomplete or outdated. While all of the countries responded in the survey that AMTSL is included in their SDGs, the review of the SDGs showed that 48% of documents reviewed4 contained complete descriptions of all three components of AMTSL. Common omissions included failure to instruct administration of a uterotonic within one minute of birth (included in 48% of SDGs) and failure to instruct immediate uterine massage after delivery of the placenta (included in 24% of SDGs). Additionally, while prudent, immediate postpartum management includes ongoing assessment for uterine tone and appropriate action such as massage in the event that the uterus is found to be relaxed (soft), only 43% (six of 14 SDGs reviewed) provided this guidance. The accuracy and completeness of guidelines for AMTSL diminished with the inclusion of each additional component (Figure 14). Only the SDGs from Afghanistan, Ethiopia and Ghana correctly contained all components of AMTSL as defined by WHO. While the precision of the steps necessary to perform AMTSL remains a concern, the lack of data on the coverage of AMTSL is an additional lingering concern. Only 43% of the 37 countries track AMTSL in their national health management information systems (HMIS). Figure 15: Percentage of Service Delivery Guidelines Correctly Containing Components of AMTSL. 4 In Equatorial Guinea, Guinea, Indonesia, Paraguay and Rwanda, the first three components of AMTSL, as listed above, were reviewed. In Nigeria, Malawi and Kenya, the first four components were reviewed, and only the first three were written correctly. Palpation of the uterus is the fourth component. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 20 A Global Survey, 2012 Figure 15: Percentage of SDGs Correctly Containing Components of AMTSL (n=21*) *20 countries’ SDGs were assessed. However, there are 21 documents in this chart because Malawi and Nigeria submitted two AMTSL documents each, while Angola did not submit any documents related to AMTSL. In both the 2011 and 2012 surveys, countries were asked if AMTSL was the national policy and if it was included in the SDGs. The 10 countries with data from both years in Asia (five) and Latin America (five) responded positively for both years. Regionally, Africa made progress since 2011, with three of the four countries that responded negatively about SDGs in 2011 responding positively in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 21 Figure 16: AMTSL Policy and Guidelines in 2011 and in 2012, by Region AFRICA: AMTSL AMTSL is national policy AMTSL in service delivery guidelines National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 22 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 23 Theme 4: Misoprostol Figure 19: Global Summary of Misoprostol, Selected Countries, 2012 Lack of Progress Globally, progress with misoprostol has been slow, with only 57% of countries surveyed in 2012 reporting that it is on the EML, and 27% reporting that it is available in facilities regularly or more than half the time. Forty-three percent of countries report they are piloting or have piloted the use of misoprostol for prevention of PPH at home birth, yet only 14% report they are scaling up this program. Qualitative data reveal a recurrent theme—that there is a lack of government support for misoprostol use for the prevention of PPH in home births, both in piloting and in scale-up. Seven countries, of the 28 that responded with qualitative data, report that their governments do not support misoprostol for use at home births. The textbox below gives examples of written responses to the question of misoprostol for PPH piloting and scale-up. Illustrative Quotes from Countries on Misoprostol Policies:  “MOH supports primarily institutional births. In 2007, [a donor] proposed several efforts to MOH. No progress has been seen due to the fear among MOH officials that the use of misoprostol will encourage illegal abortion.”  “Pilot is ongoing, led by the University Department of Obstetrics and Gynecology. However, current policy does not support home births; mothers are supposed to deliver at health facilities.”  “It is implemented in some places, but not scaled up, as the misoprostol is not in the National Drug List. We are waiting for the result of the study (effect of misoprostol in preventing PPH) to convince the Supreme Board of Drugs at the Ministry to include misoprostol on the National Drug List. If we succeed, then it will be available for all midwives.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 24 A Global Survey, 2012 There are inconsistencies between approval and availability of such programs. The situation in Ghana presents an example of this inconsistency. While misoprostol has been piloted for prevention of PPH at home births, it is on the national EML for this indication and respondents say that it is available more than half the time at public health facilities with maternity services, there are no guidelines on its use in the SDGs. Cambodia, Ghana, Kenya, Malawi and Rwanda all state that misoprostol is on the EML for prevention and/or treatment of PPH, yet none contain guidelines in their SDGs. Figure 20: Misoprostol Programs, 2012 Regionally, the most progress has been made in Africa. Of the 30 countries asked these questions in 2011 and 2012, three countries that had not piloted misoprostol in 2011 (Ethiopia, Senegal, Uganda) reported piloting it in 2012, and Ethiopia now reports scale-up of misoprostol for home births. In Asia, Bangladesh now reports scaling-up of misoprostol for home birth in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 25 Figure 21: Misoprostol Programs in 30 Countries in 2011 and in 2012, by Region AFRICA: Misoprostol Misoprostol on the EML Misoprostol piloted for home birth Misoprostol at home birth scaling up National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 26 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 27 Theme 5: Midwife/Skilled Birth Attendant Scope of Practice Figure 22: Global Summary of Midwifery Scope of Practice, Selected Countries, 2012 Generally, there is strong support for a scope of practice for midwives that will allow them to provide the services needed to reduce the main causes of maternal mortality, as outlined in the essential competencies for midwifery practice by the International Confederation of Midwives (ICM).5 In 2012, there is more support for AMTSL (84%) and management of PE/E (78%) than there is for manual removal of the placenta (70%). Globally, there has not been much change in the percentage of midwives authorized to perform manual removal of the placenta. In 2011 (n=31), 77% of countries authorized it, while in 2012 (n=37), 70% of countries authorize it. 5 ICM. 2010, http://www.internationalmidwives.org/ National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 28 A Global Survey, 2012 Figure 23: Percentage of Countries Reporting Midwives Authorized to Perform Key Skills, 2011 and 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 29 The scope of practice for midwives follows a regional pattern more closely than for other themes, with Africa generally less restrictive than other regions. Midwives have a larger scope of practice in Asia and Africa compared to their scope in Latin America, where three LAC countries do not allow midwives to perform AMTSL. Only Nicaragua and Paraguay report allowing midwives to perform the three skills (AMTSL, manual removal of placenta and administration of MgSO4). Bolivia reports that it will graduate its first group of professional midwives in 2012. Of the 30 countries surveyed both years, in 2012 only South Sudan does not report that midwives are authorized to perform manual removal of the placenta. Ethiopia and Zimbabwe report more inclusive scope of practice in 2012 than in 2011. In Equatorial Guinea, Mali and South Sudan, in 2011, midwives were reported to be authorized to diagnose PE/E and provide MgS04, but, in 2012, they report that they are not authorized to perform that skill. It is possible that these changes are simply the result of clarification of the responses to the questionnaire, rather than policy changes. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 30 A Global Survey, 2012 Figure 24: Midwifery Scope of Practice in 2011 and in 2012, by Region AFRICA: Midwifery Midwives authorized to perfom manual removal of placenta Midwives authorized to perform AMTSL with oxytocin Midwives authorized to diagnose severe PE/E and administer MgSO4 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 31 Theme 6: Education/Training Figure 25: Global Summary of Education and Training, Selected Countries, 2012 Globally, most countries’ education and training programs for SBA cadres address prevention and management of PPH and PE/E. The majority of countries, 86%, report that AMTSL and current PE/E management are included in pre-service education curricula; however, only 70% report assessing student competency in performance of AMTSL. In addition, 92% of countries report including current global management principles of PE/E and 89% report including AMTSL as part of in-service training programs. Figure 26. Curriculum and Assessment of AMTSL, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 32 A Global Survey, 2012 Figure 27. Summary of Content Covered in In-Service Training Courses, 2012 Overall, global trends are moving in a positive direction, with progress in the inclusion of PPH and PE/E in education and in-service training programs. In Asia, India and Nepal report assessing students in AMTSL in 2012, although they had not done so in 2011. Similarly, in Latin America, Bolivia and Nicaragua report assessing students in AMTSL in 2012, though they had not in the previous year. Guatemala, however, responded positively to including AMTSL in pre-service education and in-service training, and assessing students in AMTSL in 2011, but not in 2012. Overall, African countries have integrated important topics into pre-service education and in- service training. Angola and Ethiopia, for example, have both made significant progress in education and training. Angola did not report positively regarding pre-service education in 2011, but, in 2012, reports including and assessing AMTSL and PE/E. However, South Sudan reported positively on all components in 2011, but in 2012, responds positively only about addressing PE/E in pre-service education. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 33 Figure 28. Education and Training in 2011 and in 2012, by Region AFRICA: Education/Training Pre-service education curricula include AMTSL Students assessed for competency in performance of AMTSL Pre-service education curricula include current global management principles for PE/E AMTSL included in in-service training curricula Current global management principles for PE/E included in in-service training courses National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 34 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 35 Theme 7: National Reporting on Selected Maternal Health Indicators Figure 29: Global Summary of National Reporting, Selected Countries, 2012 Globally, improvements are needed in national monitoring of key maternal health indicators. Forty-three percent of countries report that they track AMTSL, and 51% report that they track an indicator in their HMIS (either through delivery logs, maternity charts or other HMIS forms) to monitor severe PE/E. This information was not captured in 2011 so no assessment of progress can be discussed. In countries’ qualitative responses regarding bottlenecks to care, numerous respondents mention monitoring and evaluation (M&E) and supervision. Eight countries list poor supervision, limited clinical mentoring and inadequate M&E and supervision activities as bottlenecks. Illustrative examples of these issues from two countries include: “Enough resources to cover supervision once training has been done for AMTSL [are needed].” and “[There is] Weakness in tracking progress.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 36 A Global Survey, 2012 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 37 Theme 8: Potential for Scale-Up and Bottlenecks In an effort to provide a more comprehensive and substantive understanding of national work in PPH and PE/E, countries were asked to respond qualitatively to questions on opportunities for program scale-up and bottlenecks to scale-up. Recurring themes in relation to these two topics emerged across all countries that provided survey answers, with national policies and training and education mentioned most frequently. National Policy A supportive national policy is cited as a necessary component for scale-up by the majority of countries for both interventions (PPH=22, PE/E=19), the lack of which is also identified as one of the three most significant bottlenecks for many countries (PPH=14, PE/E=10). Countries trying to scale up PE/E programs cite a gap between policy and practice as a bottleneck (n=12); countries often included anecdotes illustrating the inconsistent implementation of policies and service protocols, as well as the inability to apply such protocols because of inadequate supplies and medicines (see textbox below). Some countries report that while the national policy atmosphere supports PE/E programming, providers lack confidence and/or competence in the administration of MgS04. Illustrative Examples of Policy Challenges PPH:  “Two national, separate guidelines are published; and they are not fully consistent.”  “Lack of political will to scale up [is a challenge].”  “By law, the public health system and private health sub-system must apply the health care guidelines established by the MOH. The approved activities in PPH prevention and management have been communicated to the [health service institutions] and the [medical provider clinics]; these are two types of health care providers outsourced by the national social security system. Only a few…monitor compliance with the MOH guidelines by [the institutions].” PE/E:  “The MOH has developed a policy, but needs support to implement it.”  “Policies, guidelines and protocols are being developed.”  “The development of a national PE/E monitoring system is under way, but it needs strong political commitment.”  “No formal program exists. Inconsistencies in supplies of magnesium sulfate.” Training, Education and Human Resources Training, education and human resources are mentioned almost as often as supportive national policy in relation to program expansion and scale-up for both PPH and PE/E. Training, education and human resource themes raised in relation to PPH and PE/E are similar and focus on pre-service and in-service training, subject-specific training in curricula used at medical colleges and midwifery/nursing schools, and the need for increased numbers of SBAs. As mentioned above, a lack of provider confidence or competence with administration of MgSO4 is prevalent specific to PE/E (see third textbox on the next page), along with human resources issues related to brain drain and motivation. Other challenges are retaining trained providers and addressing low morale; multiple countries mention these challenges, as illustrated by the following descriptions of bottlenecks: “Staff negative attitude. High staff turnover ratios” and “Trained staff turnover.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 38 A Global Survey, 2012 Illustrative Examples of Training, Education and Human Resources Challenges and Opportunities  “Onsite training approved by the MOH can also serve to train more providers and update the national pool of trainers.”  “Although PPH management is part of pre-service and in-service training, there is still a need for enhancing health worker knowledge and skills for better outcomes.”  “Lack of human resources [is a bottleneck].” Solutions to address the lack of adequately trained health personnel are mentioned for already existing cadres of health personnel by a number of countries. Eight countries report task- shifting as a strategy for scale-up of PPH, primarily focused on ensuring an expanded scope of practice for midwives. Examples of the ways in which countries are task-shifting are shown in the illustrative quotes in the box below. Illustrative Examples of Task-Shifting Opportunities  “Policy change allowing matrons to use AMTSL.”  “Currently, the MOH is in the process of updating the midwifery job description and curriculum.”  “Propose that the MOH allows the use of misoprostol by associate technical nursing staff attending home deliveries under the supervision of [the NGO sector].” Illustrative Examples of Issues with Provider Competence and Confidence in Administering MgSO4  “Lack of knowledge and skills to use MgSO4; its use depends on the ob/gyn's acceptance of it.”  “Directors lack skills to manage PE/E cases.”  “Reluctance to change to the use of magnesium sulfate.”  “Lack of competence in using MgSO4.”  “Resistance by few providers in using MgSO4 for PE/E.”  “Although PE/E management is part of pre-service and in-service training, most health providers are unable to detail the features of severe PE/E and are also reluctant to use MgSO4, as they fear the potential side effects. There is still a need for enhancing health worker knowledge and skills for better utilization.” Community versus Facility Other themes revealed in 10 countries’ qualitative responses include a focus on scale-up and program expansion of PPH, either at the facility or the community level. The majority of these countries are planning to focus on implementation in facilities, while only a few will focus on interventions at the community level. Misoprostol and AMTSL are cited as foci of facility-based interventions in two of the countries. Illustrative Examples of Countries Focusing on Either the Community or Facility  “Decide if/how to promote misoprostol as a supplement to treat PPH at the hospital level.”  “Government has been talking of increasing the number of SBAs at primary health centers (PHCs) through the Midwives Service Scheme (MSS).”  “PPH prevention with misoprostol at community level begins this quarter.”  “The Model Maternities Initiative is the vehicle for integrated scale-up of essential obstetric and newborn interventions as well as BEmONC [basic emergency obstetric and newborn care] interventions. It is currently in facilities covering about one-third of institutional births and will cover more than half by 2014. The MOH needs help directed through this mechanism.” National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 39 DISCUSSION The data across the eight themes highlight important successes and significant gaps in expanding programs for the prevention and management of PPH and PE/E. Globally, national approval of and access to oxytocin and MgSO4 are robust and have progressed, but approval and availability of misoprostol have not. It is of concern that nine countries respond that clients are paying for oxytocin at least some of the time, so free distribution and regular supply are ongoing challenges, despite nationally reported progress in availability across the globe. It is not surprising that misoprostol is rarely available, given that there are lower levels of national approval of misoprostol as an essential drug and poor or complete lack of service delivery guidance on its use. Discrepancies between reported accuracy and completeness of guidelines and findings from this review suggest that some program directors may be unaware of the state of national SDGs or internationally recommended best practices. Inconsistent availability of essential medications limits policy implementation and can lead to unclear treatment guidelines in the absence of alternative therapies. Qualitative data reveal that for PE/E in particular, regular MgSO4 availability is one of the most critical bottlenecks to scaling up the intervention. In addition to working toward inclusion of lifesaving medicines in national EMLs and SDGs, making certain that the specific instructions and dosages of these medicines are correct, and scaling up provider training in administration, ensuring the regular supply of these essential medicines is critical. Health personnel and programs can work with the central or regional medical store and supply chain programs to help resolve supply chain bottlenecks. Another complementary intervention is ensuring the cold chain for oxytocin. The lack of progress in approval of misoprostol for prevention of PPH and its limited usage are notable. As seven of 28 countries explain, their governments do not support misoprostol for use at home births. This finding presents an opportunity for global action and advocacy, especially given that in 2011 WHO included misoprostol on the EML for the indication of PPH, and because of the growing support for programs to address PPH prevention using misoprostol. While the scope of use of misoprostol has evolved with the growing evidence base, it is not apparent that national policies and programs have evolved apace. Two indicators of program progress might be inclusion of misoprostol on national EMLs and the piloting or scale-up of misoprostol for prevention of PPH. For these indicators, there has been essentially no progress from 2011 to 2012. Even in those countries where there have been pilots, there is limited movement regarding scale-up. This finding is of concern because it shows that countries may be reluctant to move forward, even after they have the results of pilot programs. Until now, this reluctance for robust program expansion could be understood as a result of conflicting global guidance. Global experience and enthusiasm have not completely matched the recommendations and guidelines issued by global agencies. In 2011, however, WHO revised its EML, including, for the first time, misoprostol with the specific indication of use for the prevention of PPH. It is hoped that this inclusion will trigger revisions to national EMLs in the coming year. In addition, WHO is currently working on revised PPH guidelines, which expand the recommendations for use of misoprostol for PPH prevention. The results suggest that although 2012 has shown expanded policy for and increased access to MgSO4, more support is needed regarding provider competence and confidence for its use. Providers’ reluctance to administer MgSO4 may be due to persistent, concurrent approval of National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 40 A Global Survey, 2012 diazepam as a first-line anticonvulsant for severe PE/E, found in 19 countries in 2011 but 25 countries in 2012. This finding presents a potentially confusing scenario for health care providers and managers. If both drugs are noted as “first-line anticonvulsants,” does this mean that the provider can choose between them? If they are given equal weight in national policy and program documents, what impact does this have on actual patient care? These questions should be explored further when the survey is repeated in 2013. Furthermore, qualitative responses reveal that providers still use diazepam, partly because of a lack of understanding of administration and usage of MgSO4, or fear of the medication’s perceived side effects. This concern persists, despite ongoing training and full inclusion in both education and training programs. The situation is perhaps exacerbated by incomplete, confusing and potentially conflicting EMLs, SDGs, training manuals and job aids from various sources. For example, India’s SDG did not provide guidelines for the IV loading dose or maintenance doses. This omission may be because the document reviewed for India described provision of MgSO4 before referral to a higher-level facility, and other documents unavailable to the reviewers may provide broader guidance. Additionally, some countries have approved health care providers to administer only the IM component of the loading dose. Innovative and accurate support materials and approaches are needed to help providers attain and maintain the confidence they need to administer and continue MgSO4 therapy and manage women with severe PE/E. The large majority of countries respond that education and training programs include AMTSL and management of PPH and PE/E. However, qualitative data indicate that the need for training, education and sufficient human resources for supervision is one of the top two themes identified as critical for scale-up, and one of the major bottlenecks. The lack of clinical exposure to complicated cases during training and inadequate clinical practice in pre-service education have been documented as problems.6 Furthermore, many in- service training programs still rely almost exclusively on ineffective teaching/learning techniques, such as lecture or reading,7 although simulations and in-hospital clinical practice are preferred educational techniques for critical lifesaving skills.8 Sufficient training and practice are needed for mastery of complicated skills.9 There is an urgent need for pre-service education programs to address both interventions sufficiently in clinical practice with clients, through realistic simulations and in the final clinical assessment. This issue with performance is further complicated by inaccuracies in SDGs regarding AMTSL and PE/E management, thereby creating confusion for students and providers. It is also noteworthy that in 2012, the midwifery scope of practice is not as comprehensive as is necessary to reduce maternal mortality. To save a mother’s life during childbirth when there are complications, a midwife or skilled birth attendant needs to be both empowered and competent to perform all aspects of BEmONC.10 Although there has been some progress in advancing the midwifery scope of practice related to AMTSL, manual removal of the placenta 6 Fullerton JT, Johnson PG, Thompson JB, Vivio D. 2011. Quality considerations in midwifery pre-service education: Exemplars from Africa. Midwifery 27(3): 308–315. 7 Bloom BS. 2005. Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. Int J Technol Assess Health Care 21(3): 380–385. 8 Issenberg SB, McGaghie WC, Petrusa ER, Gordon D, Scalese RJ. 2005. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 27(1): 10–28; Daniels K, Arafeh J, Clark A, Waller S, Druzin M, Chueh J. 2010. Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies. Simul Healthc 5(1): 40–45. 9 McGaghie WC, Siddall VJ, Mazmanian PE, Myers J, American College of Chest Physicians Health and Science Policy Committee. 2009. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: Effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 135(3 Suppl): 62S–68S. 10 UNFPA. 2011. The State of the World Midwifery Report 2011: Delivering Health, Saving Lives, http://www.unfpa.org/sowmy/report/home.html National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 41 and management of PE/E, there are still notable gaps. Not all countries consider these skills to be part of a midwife’s responsibilities. For example, only 70% of the countries in this survey allow a midwife to perform manual removal of the placenta although it has long been part of BEmONC. Furthermore, all of these skills are included in the 2011 ICM Essential Competencies for Basic Midwifery Practice and are listed as essential interventions by WHO.11 Task-shifting and supportive policies are reinforced in qualitative responses as essential for program scale-up. The variations in the scope of practice for midwives are detailed in Theme 5. The midwife’s scope of practice is most limited in Latin America, where three of the countries surveyed do not allow midwives to perform AMTSL. This may be due to definitional and linguistic differences, as some countries in Latin America appear to have different clinical cadres that address specific elements of midwifery, while other countries have midwives who meet a global definition. In addition, while it may be assumed that a physician is allowed to perform all BEmONC signal functions, it cannot be assumed that a midwife is allowed to do the same. Overall, although the role of the midwife varies by country, it is vital to define cadres clearly, to expand the role of the midwife to include all BEmONC skills (as endorsed by WHO, the United Nations Population Fund [UNFPA], ICM and the United Nations Children’s Fund [UNICEF]) and, further, to train midwives to competency to ensure that women who experience complications have improved access to skilled care. Finally, another issue identified as essential is the lack of national reporting on key indicators related to maternal health outcomes. Less than half of the countries respond that AMTSL and indicators related to severe PE/E are a part of the HMIS. This finding is reinforced by qualitative data reporting that poor supervision, limited clinical mentoring and inadequate M&E are barriers to scale-up of these services. Gathering sufficient data is important to ensure that these interventions are prioritized, recognizing that “what matters gets measured and what gets measured matters.” There is an urgent need to strengthen maternal health monitoring and reporting systems. Finally, the subset review of available SDGs was an important and positive exercise in the face of evolving global guidelines. National SDGs give vital clinical guidance and are widely used in all countries to establish and perpetuate clinical norms. Such a review was done with the knowledge that national SDGs also evolve with time and advancing global evidence. This analysis puts a priority on the accuracy of information in the SDGs related to the use of AMTSL. AMTSL is the intervention that has proven most successful in prevention of PPH.12 AMTSL includes the administration of a uterotonic medication immediately after birth, with oxytocin being the drug of choice. AMTSL (according to the WHO definition) has three components: 1. Oxytocin, 10 IU IM immediately after birth 2. Controlled cord traction 3. Uterine massage to ensure uterine tone 11 The Partnership for Maternal, Newborn and Child Health, WHO and Aga Khan University. 2011. Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health, http://www.who.int/pmnch/topics/part_publications/201112_essential_interventions/en/index.html 12 The Partnership for Maternal, Newborn and Child Health, WHO, and Aga Khan University.2011. Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health, http://www.who.int/pmnch/topics/part_publications/201112_essential_interventions/en/index.html National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 42 A Global Survey, 2012 The analysis of the SDGs found that although the majority of the critical information regarding AMTSL was present, there were certain gaps in guidance when compared to the WHO definition.13 The SDG review shows that there were instances of recommendations regarding dosing or timing of uterotonic that differed from internationally approved recommendations. These findings at times contradicted the answers to the survey, suggesting that some respondents may perceive their country guidelines to be more accurate than they in fact are. Several important findings emerge from the qualitative analysis, including the need for supportive national policies, gaps in training and education, challenges regarding the availability of essential medicines, issues with motivation and human resources, and gaps between policy and practice. In prevention of PPH, there is uncertainty about the correct and appropriate use of misoprostol, and in management of severe PE/E, there are significant issues with provider competence and confidence in the correct use of MgSO4. MgSO4 is the first-line drug of choice for prevention of and managing PE/E.14 Limitations Efforts were made to ensure that this global survey is as objective as possible, within the constraints of existing human resources and funding. Despite efforts to design an objective questionnaire and to provide clear instructions to national partners in the formation of responses, the data from this survey should be viewed in the context of certain limitations. Although the 2012 survey asks for objective, quantitative responses to a majority of questions, country respondents may not have had complete information or full access to such information to allow for thorough responses. For example, in certain countries, some key maternal health stakeholders may not have been involved in filling out the survey, and respondents had different levels of access to data and national documents. Therefore, not all of the country responses may reflect the exact situation in the country, or some current or planned activities may have been overlooked. In addition, although efforts were made for the same focal person and country respondents to complete the survey in both years, in some cases new MOH colleagues or other respondents participated in the survey. Necessarily, this can result in different responses. By the time the data are published, they are likely to be at least somewhat out of date, because responses were collected from January through March, 2012. What is more, there are multiple SDG documents in many of the countries surveyed, and in some countries, updated SDGs are awaiting approval. Finally, qualitative responses are opinion-based, and although they provide valuable information regarding opportunities and challenges and triangulate the quantitative responses, they may not represent the majority opinion of health professionals in a particular country. In some cases there may be a tendency for individuals to present overly encouraging or positive responses to certain questions or for the scale-up maps. As the MCHIP maternal health team tracks, compares and discusses the results objectively each year, this in turn encourages objective responses from the country teams completing the surveys. It appears that some respondents were too optimistic in 2011, and, given the more thorough review in 2012 and respondents’ greater comfort with the survey process, some results may appear to be more 13 WHO. 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors, https://www.google.com/search?aq=f&sugexp=chrome,mod=4&sourceid=chrome&ie=UTF- 8&q=WHO+(2000)+Managing+Complications+in+Pregnancy+and+Childbirth 14 WHO. 2011. Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia, http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/en/index.html National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 43 negative in 2012 than 2011. These results, which appear to show the opposite of progress, may in fact just indicate that the 2012 responses are simply more accurate. As the survey continues into the next year, we will continue to see true tracking of progress. With regard to nomenclature, different countries use different terms for similar cadres. For example, in Latin America, there are several names for midwives, and distinctions to be made among skilled birth attendants, midwives and traditional midwives. The MCHIP maternal health research team attempted to clarify questions containing the term “midwife” with each Latin American country. In addition, some questions will not necessarily pertain to all countries and, therefore, responses cannot always be answered yes or no or aggregated easily. For example, some countries may have regional medical stores but the survey asked questions about national medical stores. In addition, different countries and programs have varied definitions of “scale-up.” Some might believe moving into several regions can be termed scale-up, while others might use the phrase only when talking about national-level rollout. During data entry, grammatical and spelling changes were made to qualitative responses to facilitate ease of understanding and allow computer-aided analysis, without losing meaning or intent. It is possible some nuances were lost in translation from French or Spanish or were not always conveyed completely accurately in French or Spanish, although the questions and answers were translated by professionals well-versed in medical and public health terms. The scale-up maps show a broad range of responses and styles, given that related questions are open-ended and require creativity and subjective use of colors to represent programming. Accordingly, styles and colors are not uniform, and aggregation is difficult. In addition, the process to fill out the maps in 2011 was perhaps not as well understood as we had hoped, although countries often worked directly with the research team to fill out the maps to represent the situation as accurately as possible. In 2012, the instructions accompanying the maps were clearer and more detailed, and improvements can likely be made to further improve clarity in future surveys. Finally, while the maps do indicate that the majority of countries have PPH and PE/E programs, and represent which partners are implementing these programs, there are limitations to the comparison between the 2011 and 2012 maps. The quantitative data in this report provide a better basis for analysis of PPH and PE/E programming. Although more than 20 countries submitted documents to serve as SDGs, only the nationally approved SDGs could be used in the analysis. The 12 approved guidelines in English were independently reviewed by the research team, and the eight nationally approved, non-English SDGs were reviewed in conjunction with an MCHIP country representative using a shorter checklist. Therefore, the questions reviewed are not exactly the same, although only questions asked of all countries are included in the analysis. In several cases, especially with regard to the approved medicines questions for PE/E, there were gaps in answers. Where possible, the MCHIP research team worked with countries to fill in gaps and at times was able to verify the “Yes/No” response from the documentation sent by the countries. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 44 A Global Survey, 2012 CONCLUSION, RECOMMENDATIONS AND OPPORTUNITIES FOR EXPANSION This 2012 multi-country analysis of national programs for prevention and management of PPH and PE/E provides a large amount of useful data upon which actions can be based. The varied ways in which the data are presented allow for global and national understanding of important themes, as well as identification of progress on certain topics. While AMTSL and management of PE/E are strongly represented in the policy and education/ training initiatives of national programs throughout the 37 countries surveyed, many issues remain. It is encouraging to see widespread acceptance of AMTSL for prevention of PPH in facility births; however, there is substantially less support for use of misoprostol for prevention of PPH at home births. This finding could potentially represent a strategic choice for promotion of facility-based births, but overlooks a proven intervention that allows for a greater public health impact. This is especially important in areas with high maternal mortality, high home birth rates and low numbers of births attended by a SBA. Although approval of the use of MgSO4 is universal, its actual use is far from universal. Where availability of MgSO4 has expanded, those gains may not persist without regular use of the drug and, thus, awareness among clinicians and managers of the need to reorder, resupply and restock it regularly. Efforts must be made for appropriate and comprehensive management of women with PE/E, which includes the correct use of MgSO4, appropriate use of an antihypertensive, expedited termination of pregnancy and overall vigilance in patient care. Worldwide, midwives must deal with an identity crisis unknown to doctors. Throughout the world, when someone identifies himself or herself as a doctor, a clear picture of professional responsibilities is formed. This is not the case for a midwife. In virtually every health system in the developing world, the definition, role and scope of practice of a midwife differ. Introduction of the term must be followed by clarifying questions such as, what kind of midwife do you mean, what can she or he do, what are his or her competencies? The data from this survey yield similar responses, showing approval for varied scopes of practice and an incomplete set of skills. To improve access to and quality of maternal and newborn health care, in every country of the world, the midwifery scope of practice should be clearly defined and comprehensively and uniformly applied, consistent with the ICM’s recognized essential competencies15 and the international definition of a midwife.16 The publication of WHO’s Recommendations for the Prevention and Treatment of Pre-Eclampsia and Eclampsia in 2011 and the anticipated publication by WHO of new recommendations for preventing and managing PPH provide an excellent opportunity for the international community to work with Ministry of Health staff to update guidelines and expand programs. Robust national programs exist, solving problems with creative solutions and clear determination. We must continue to be engaged with such programs, to foster communication and information-sharing and to track progress of national programs as we support greater efforts to reduce maternal morbidity and mortality. 15 ICM.2011. Essential Competencies for Basic Midwifery Practice 2010, http://www.unfpa.org/sowmy/resources/docs/standards/en/R430_ICM_2011_Essential_Competencies_2010_ENG.pdf 16 http://www.internationalmidwives.org/Portals/5/2011/Definition%20of%20the%20Midwife%20-%202011.pdf National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 45 Appendix 1: Global Surveys of Scale-Up of National PPH and PE/E Programs in English, French and Spanish QUESTION RESPONSE AND FURTHER INFORMATION Country Is there an MCHIP presence in this country? Yes No If not, name the leading maternal health bilateral(s) or project(s), and who is implementing it (them). NOTE: Throughout this questionnaire, the term skilled birth attendant (SBA) is used to describe midwives, nurses with midwifery skills, non-physician clinicians with obstetric skills, general doctors with obstetric skills or obstetric specialists. Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL17 at every birth approved as national policy? Yes No 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes (Please attach a scanned/soft copy of the service delivery guidelines for PPH prevention.)18 No 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system?19 Yes If Yes, at which level(s) of the health system can the drug be administered? No 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes No 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes No 17 Active management of the third stage of labor 18 In 2011, countries were not asked to provide Service Delivery Guidelines or Essential Medicines Lists. 19 This question was changed in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 46 A Global Survey, 2012 6. Is oxytocin on the National EML for prevention and/or treatment of PPH?20 Yes If Yes, at which level(s) of the health system can the drug be administered? No Please include a scanned/soft copy of the section in the EML relating to oxytocin and misoprostol. Training 7. Do pre-service education curricula include AMTSL for all SBA21 cadres?22 Yes If Yes, which cadres? No 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes No 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes No Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted?23 Yes If Yes, please provide some brief details. No 11. Is the use of misoprostol for PPH prevention during home births being scaled up?24 Yes If Yes, please provide some brief details. No Logistics 12. Is oxytocin available at public facilities that offer maternity services?25 Regularly More than half the time Less than half the time Never 13. Is oxytocin free of charge to patients at public health facilities?26 Yes No 20 This question was changed in 2012. 21 Skilled Birth Attendant 22 The wording on this question changed slightly from 2011 to 2012. 23 The wording on this question changed slightly from 2011 to 2012. 24 The wording on this question changed slightly from 2011 to 2012. 25 The wording of this question and the response choices were changed in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 47 14. How frequently do stock-outs of oxytocin occur at the central/regional levels?27 Frequently (once in every 2 months or less) Sometimes (every 3 to 6 months) Rarely (once a year) 15. Is oxytocin currently available at the MOH28 medical store? Yes No 16. Is misoprostol available at public facilities that offer maternity services?29 Regularly More than half the time Less than half the time Never M&E 17. Is AMTSL included in the national HMIS?30,31 Yes If Yes, where are AMTSL data recorded? (e.g., delivery logs, maternity chart, other registers) No If No, are any organizations collecting data on AMTSL? What are their names? Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done.32 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. 21. What % of districts are covered by current national PPH programs? % 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? (Provide your best possible estimate and any details you think would be helpful.)33 26 This question was added in 2012. 27 The wording of this question changed slightly and the response choices were changed in 2012. 28 Ministry of Health 29 This question was added in 2012. 30 Health Management Information System 31 The response choices were changed in 2012. 32 The wording on this question changed slightly from 2011 to 2012. 33 This wording was added in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 48 A Global Survey, 2012 Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. (e.g., Champion exists who need support to disseminate messages; National conference scheduled for next year and curriculum revision planned; MOH has policy in place and needs support for program rollout.) 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol Yes No Hydralazine Yes No Nifedipine Yes No Methyldopa Yes No Other (Please describe) 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol Yes No Hydralazine Yes No Nifedipine Yes No Methyldopa Yes No Other (Please describe) 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes No Diazepam Yes No Other (Please describe) 4. Is MgSO434 on the National EML for: severe pre- eclampsia?; eclampsia?35 Pre-eclampsia Yes No Eclampsia Yes No Please attach a scanned/soft copy of the service delivery guidelines for the management of severe pre- eclampsia/eclampsia (PE/E), including the protocol for antihypertensives and administration of MgSO4. 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest level facility that they work at within the health system?36 Yes No 34 Magnesium Sulfate 35 The response choices were added in 2012. 36 The wording on this question changed slightly from 2011 to 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 49 Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres?37 Yes If Yes, which cadres? No 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes No Logistics 8. Is MgSO4 available at public facilities that offer maternity services?38 Regularly More than half the time Less than half the time Never 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels?39 Frequently (once in every 2 months or less) Sometimes (every 3 to 6 months) Rarely (once a year) 10. Is MgSO4 currently available at the MOH medical store?40 Yes No M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? Yes If Yes, what is this indicator and where is it recorded? (e.g., delivery logs, maternity chart, other registers) No PROGRAMMING 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done.41 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. 37 The wording on this question changed slightly from 2011 to 2012. 38 The response choices were changed in 2012. 39 The wording of this question changed slightly and the response choices were changed in 2012. 40 This question was added in 2012. 41 The wording on this question changed slightly from 2011 to 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 50 A Global Survey, 2012 15. What % of districts are covered by current PE/E programs? 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? (Provide your best possible estimate and any details you think would be helpful.)42 Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. (e.g., Champion exists who needs support to disseminate messages; National conference scheduled for next year and curriculum revision planned; MOH has policy in place and needs support for program rollout.) 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. 42 This wording was added in 2012. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 51 Enquête globale pour les passage à l’échelle national des programmes d’HPP et de PE/E QUESTION REPONSE ET INFORMATION SUPPLEMENTAIRE Pays Y a-t-il une présence MCHIP dans ce pays? Oui Non Si Non, quel est le principal projet bilatéral de santé maternelle et infantile et qui l’exécute ? NOTE: Dans ce questionnaire, le terme prestataire qualifié est utilisé pour décrire les sages-femmes, les infirmiers/es ayant des compétences obstétricales, les cliniciens autres que les médecins avec des compétences obstétricales, les médecins généralistes avec des compétences obstétricales ou des spécialistes en obtétriques. Section 1: Hémorragie du postpartum (HPP) Politique 1. Est-ce que la GATPA43 est approuvée pour chaque accouchement comme politique nationale? Oui Non 2. Est-ce que les étapes pour l’exécution correcte de la GATPA sont incorporées dans les directives de prestation de services? Oui (Veuillez joindre une copie scannée/téléchargée des directives de prestation de services pour la prévention de l’HPP.) Non 3. Est-ce que le misoprostol est sur la Liste nationale de médicaments essentiels (LME), en particulier pour la prévention et/ou le traitement de l’HPP à tout niveau du système de santé? Oui Si oui, à quel niveau du système de santé est administré le médicament? Non 4. Est-ce que les sages-femmes sont autorisées à faire la délivrance artificielle du placenta à tous les niveaux du système de santé? Oui Non 5. Est-ce que les sages-femmes sont autorisées à effectuer la GATPA en administrant l’ocytocine à tous les niveaux du système de santé? Oui Non 6. Est-ce que l’ocytocine est sur la LME nationale pour la prévention et/ou le traitement de l’HPP? Oui Si oui, à quel(s) niveau(x) du système de santé est administré le médicament? Non Veuillez inclure une copy scannée/téléchargée de la section dans la LME, liée à l’ocytocine et au misoprostol. 43 Gestion active de la troisième période du travail National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 52 A Global Survey, 2012 Formation 7. Est-ce que le programme d’études de base inclut la GATPA pour tous les cadres de prestataires44? Oui Si oui, quels cadres? Non 8. Les étudiants sont-ils évalués en compétences dans la performance de la GATPA comme une compétence clinique avant d’obtenir leur diplôme? Oui Non 9. Est-ce que la GATPA est inclue dans le programme de formation continue pour tous les cadres de prestataires qualifiés? Oui Non Distribution du misoprostol pour la prévention de l’HPP lors des accouchements à domicile 10. Est-ce que le misoprostol pour la prévention de l’HPP lors des accouchements à domicile en train d’être piloté? Oui Si Oui, veuillez donner des brefs détails. Non 11. Est-ce que l’utilisation du misoprostol pour la prévention de l’HPP lors des accouchements à domicile est passée à l’échelle? Oui Si Oui, veuillez donner des brefs détails. Non Logistique 12. Est-ce que l’ocytocine est disponible dans les structures de santé publique qui offrent des services de maternité: Régulièrement Plus de la moitié du temps Moins de la moitié du temps. Jamais 13. Est-ce que l’ocytocine est gratuit pour les clientes des structures de santé publique? Oui Non 14. Quelle est la fréquence des ruptures de stock en ocytocine au niveau central/régional? Souvent (une fois tous les 2 mois ou moins) Quelquefois (tous les 3 à 6 mois) Rarement (une fois par an) 15. Est-ce que l’ocytocine est disponible actuellement au dépôt médical du MSP45? Oui Non 16. Est-ce que le misoprostol est disponible dans les structures de santé publique qui offrent des services de maternité: Régulièrement Plus de la moitié du temps Moins de la moitié du temps. Jamais 44 SBA : prestataire qualifié 45 Ministère de la santé publique National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 53 S&E 17. Est-ce que la GATPA est incluse dans le Système national de Gestion de l’information sanitaire (SGIS)46? Oui Si Oui, où sont enregistrées les données de la GATPA? (par ex: dossiers d’accouchement, registre de maternité, autres registres) Non Si Non, est ce que d’autres organisations font la collecte des données de la GATPA? Lesquelles? Programmation 18. Quelles activités de prévention et de prise en charge de l’HPP sont réalisées par le MSP? Décrivez brièvement ce qui est fait. 19. Quelles activités de prévention et de prise en charge de l’HPP sont entreprises par les programmes parrainés par les Etats-Unis ? Décrivez brièvement ce qui est fait. 20. Quelles activités de prévention et de prise en charge de l’HPP sont entreprises par d’autres bailleurs ou partenaires? Décrivez brièvement ce qui est fait. 21. Quel est le pourcentage de districts couvert par les programmes nationaux actuels d’HPP? % 22. Quel pourcentage de prestataires qualifiés actuels est atteint par les efforts programmatiques des programmes nationaux actuels sur l’HPP? (Donnez votre meilleure estimation et tout détail que vous trouvez utile.) Possibilités d’expansion et de passage à l’échelle 23. Veuillez décrire les possibilités que vous envisagez pour l’expansion ou le passage à l’échelle du programme. (par ex: Champion en place qui a besoin de soutien pour disséminer des messages; conférence nationale prévue pour l’année prochaine et révision prévue des programmes; MSP a une politique en place et a besoin de soutien pour le déploiement du programme) 24. Quels sont les trois goulots d’étranglement les plus importants empêchant l’expansion des programmes de réduction de l’HPP dans votre pays? Décrivez brièvement ce qui est fait pour répondre à ces problèmes, le cas échéant. Personne contact 25. Contact qui sera responsable de la mise à jour de cette matrice. Veuillez inclure le nom, numéro de téléphone et l’adresse e-mail. 46 Système de gestion de l’information sanitaire (SGIS) National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 54 A Global Survey, 2012 Section 2: Pré-éclampsie/Eclampsie (PE/E) POLITIQUE 1. Quels sont les médicaments approuvés dans le cadre des directives nationales/directives de prestation de services pour l’administration des antihypertenseurs de première ligne pour la pré- éclampsie/éclampsie sévère (PE/E)? Labétolol Oui Non Hydralazine Oui Non Nifédipine Oui Non Méthyldopa Oui Non Autre (Veuillez décrire) 2. Quels sont les médicaments figurant sur la Liste nationale des médicaments essentiels (LME), comme antihypertenseurs pour le traitement de la PE/E sévère ? Labétolol Oui Non Hydralazine Oui Non Nifédipine Oui Non Méthyldopa Oui Non Autre (Veuillez décrire) 3. Quels sont les médicaments approuvés dans le cadre des directives nationales/directives de prestation de services en matière d’anticonvulsivants de première ligne pour la PE/E sévère? MgSO4 Oui Non Diazépam Oui Non Autre (Veuillez décrire) 4. Est-ce que le MgSO447 est sur la Liste nationale des médicaments essentiels (LME) pour la pré- éclampsie? Pour l’éclampsie? Pré-éclampsie Oui Non Eclampsie Oui Non Veuillez joindre une copie scannée/téléchargée des directives de prestation de services pour le traitement de la PE/E sévère, y compris les protocoles pour les antihypertenseurs et l’administration du MgS04. 5. Est-ce que les sages-femmes sont autorisées à diagnostiquer la PE/E sévère et administrer la dose de charge initiale de MgSO4 au premier niveau de site sanitaire dans lequel elles travaillent au sein du système de santé? Oui Non FORMATION 6. Est-ce que les programmes d’enseignement de base incluent les principes actuels de gestion globale pour la PE/E pour tous les cadres de prestataires? Oui Si Oui, quels cadres? Non 7. Est-ce que les principes actuels de gestion globale pour la PE/E sont inclus dans les stages de formation sur le tas pour les prestataires qualifiés? Oui Non LOGISTIQUE 8. Est-ce que le MgSO4 est disponible dans les structures de santé publiques qui offrent des services de maternité? Régulièrement Plus de la moitié du temps Moins de la moitié du temps. Jamais 47 Magnesium Sulfate National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 55 9. Quelle est la fréquence des ruptures de stock de MgSO4 au niveau central/régional? Souvent (une fois tous les 2 mois ou moins) Quelquefois (tous les 3 à 6 mois) Rarement (une fois par an) 10. Est-ce que le MgSO4 est disponible actuellement au dépôt médical du MSP? Oui Non S&E 11. Y a-t-il un indicateur pour le monitorage de la PE/E sévère dans le Système national de gestion de l’information sanitaire (SGIS) ? Oui Si Oui, quel est l’indicateur et où est-il enregistré? (par ex: dossiers d’accouchement, registre de maternité, autres registres) Non PROGRAMATION 12. Quelles activités de prévention et de prise en charge de la PE/E sont réalisées par le MSP? Décrivez brièvement ce qui est fait. 13. Quelles activités de prévention et de prise en charge de la PE/E sont entreprises par les programmes parrainés par les Etats-Unis ? Décrivez brièvement ce qui est fait. 14. Quelles activités de prévention et de prise en charge de l’HPP sont entreprises par d’autres bailleurs ou partenaires? Décrivez brièvement ce qui est fait. 15. Quel est le pourcentage de districts couvert par les programmes nationaux actuels de PE/E? 16. Quel pourcentage de prestataires qualifiés actuels est atteint par les efforts programmatiques des programmes nationaux actuels sur la PE/E? (Donnez votre meilleure estimation et tout détail que vous trouvez utile.) Possibilités d’expansion et de passage à l’échelle 17. Veuillez décrire les possibilités que vous envisagez pour l’expansion ou le passage à l’échelle du programme. (par ex: Champion en place qui a besoin de soutien pour disséminer des messages; conférence nationale prévue pour l’année prochaine et révision prévue des programmes; MSP a une politique en place et a besoin de soutien pour le déploiement du programme) 18. Quels sont les trois goulots d’étranglement les plus importants empêchant le passage à l’échelle des programmes de traitement de la PE/E dans votre pays? Décrivez brièvement ce qui est fait pour aborder ces problèmes, le cas échéant. Personne contact 19. Contact qui sera responsable de la mise à jour de cette matrice. Veuillez inclure le nom, numéro de téléphone et l’adresse e-mail. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 56 A Global Survey, 2012 Encuesta mundial sobre los programas de pre-eclampsia/eclampsia y hemorragia posparto a nivel nacional PREGUNTA RESPUESTA Y OTRA INFORMACIÓN País ¿Existe el programa de MCHIP en este país? Sí No Si respondió No, dé el nombre de los principales proyectos en salud materna y quién los está implementando. NOTA: En este cuestionario, el término “asistente de parto capacitado” está siendo usado para describir obstetrices, enfermeras con habilidades obstétricas, proveedores con habilidades obstétricas que no son médicos, médicos generales con habilidades obstétricas, o especialistas en obstetricia. Sección 1: Hemorragia posparto (HPP) Política 1. ¿El AMTSL48 está aprobado para cada parto en la política nacional? Sí No 2. ¿Las etapas para demonstrar correctamente el AMTSL están integradas en las directrices de la prestación de servicios? Sí (Por favor, adjunte copia digital de las directrices de la prestación de servicios para la prevención de la HPP) No 3. ¿El misoprostol aparece en la Lista Nacional de Medicamentos Esenciales, específicamente con una indicación para la prevención y/o tratamiento de la HPP en cualquier nivel del sistema de salud? Sí Si respondió Sí ¿en qué nivel(es) del sistema de salud se puede administrar el medicamento? No 4. ¿Las obstetrices49 están autorizadas para hacer remoción manual de la placenta en todos los niveles del sistema de salud? Sí No 5. ¿Las obstetrices están autorizadas para hacer AMTSL con oxitocina en todos los niveles del sistema de salud? Sí No 48 Manejo activo de la tercera etapa del trabajo de parto 49 El equipo MCHIP aclaró cada instancia de la palabra “obstetrices” con los equipos en los países donde se habla español, para confirmar que entendieron que las preguntas se refieren a una persona que se ajuste a la definición internacional de obstetra y es una "persona cualificada para atender los partos. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 57 6. ¿La oxitocina aparece en la Lista Nacional de Medicamentos Esenciales para la prevención y/o tratamiento de la HPP? Sí Si respondió Sí, ¿en qué nivel(es) del sistema de salud se puede administrar? No Por favor, adjunte copia digital de la sección de la Lista de Medicamentos Esenciales correspondiente a la oxitocina y misoprostol. Capacitación 7. ¿El plan de estudios pre-servicio está actualizado con temas sobre el AMTSL para todos los niveles de asistentes de parto capacitados50? Sí Si respondió Sí ¿qué niveles? No 8. ¿Los estudiantes son evaluados en sus habilidades para ejecutar AMTSL como calificación clínica antes de graduarse? Sí No 9. ¿El AMTSL se incluye en los planes de estudios de capacitación continua para todos los asistentes de parto capacitados? Sí No Distribución de misoprostol para la prevención de la HPP en partos domiciliarios 10. ¿Hay programas piloto sobre el uso de misoprostol para la prevención de la HPP en partos domiciliarios? Sí Si respondió Sí, por favor dé algunos detalles. No 11. ¿El uso de misoprostol para prevenir la HPP durante los partos domiciliarios se ha expandido en escala? Sí Si respondió Sí, por favor dé algunos detalles. No Logística 12. Hay disponibilidad de oxitocina en los establecimientos públicos con servicios de maternidad: De manera regular Más de la mitad de las veces Menos de la mitad de las veces Nunca 13. ¿Los establecimientos públicos ofrecen oxitocina al público sin cobrar a las pacientes? Sí No 50 “Asistentes de parto capacitado” o SBA por sus siglas en inglés. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 58 A Global Survey, 2012 14. ¿Con que frecuencia se agota la oxitocina en los niveles central/regional? Con frecuencia (una vez cada dos 2 meses o menos) Algunas veces (cada 3 a 6 meses) Muy pocas veces (una vez al año) 15. ¿Hay oxitocina disponible actualmente en la farmacia del MINSA51? Sí No 16. Hay disponibilidad de misoprostol en los establecimientos públicos con servicios de maternidad: De manera regular Más de la mitad de las veces Menos de la mitad de las veces Nunca Monitoreo y Evaluación 17. ¿El AMTSL está incluido en el SIGS52 nacional? Sí Si respondió Sí ¿dónde está documentado? (Ej. Registro de partos, Cuadro de maternidad, otros registros) No Si respondió No ¿existe alguna organización que documenta el AMTSL? ¿Cuál? Programación 18. ¿Qué actividades está ejecutando el MINSA para la prevención y manejo de la HPP? Explique brevemente qué se está haciendo. 19. ¿Qué actividades están ejecutando los programas auspiciados por USAID para la prevención y manejo de la HPP? Explique brevemente qué se está haciendo. 20. ¿Qué actividades están ejecutando otros donantes y socios para la prevención y manejo de la HPP? Explique brevemente qué se está haciendo. 21. ¿Qué porcentaje de distritos están cubiertos por los programas nacionales de HPP en la actualidad? % 22. ¿A qué porcentaje de asistentes de parto capacitados se puede llegar a través de los esfuerzos programáticos de los programas nacionales de HPP en la actualidad? (Proporcione su mejor estimado posible y algunos detalles que en su opinión sean útiles) 51 Ministerio de Salud 52 Sistema Informático de Gestión de la Salud National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 59 Oportunidades para la expansión y escala 23. Por favor, describa toda posible oportunidad que usted vea de expandir o llevar a escala el programa. (Ej. Hay gestores expertos que necesitan apoyo para diseminar mensajes; conferencia nacional programada para el próximo año y actualización de los planes de estudio; el MINSA cuenta con una política pero necesita apoyo para lanzar el programa) 24. ¿Cuáles son los tres obstáculos más significativos para escalar los programas de reducción de la HPP en su país? Explique brevemente qué se está haciendo para resolverlos, si fuera el caso. Persona de contacto 25. Persona que será responsable de las actualizaciones de este documento. Incluya nombre, número de teléfono y correo electrónico. Sección 2: Pre-eclampsia/Eclampsia (PE/E) POLÍTICA 1. ¿Cuáles son los medicamentos de la primera línea de tratamiento que están aprobados a través de la política nacional/directrices de prestación de servicios como antihipertensivos para tratar la pre-eclampsia grave/eclampsia? Labetalol Sí No Hidralazina Sí No Nifedipina Sí No Metildopa Sí No Otro (Por favor, describa) 2. ¿Cuáles son los medicamentos que aparecen como antihipertensivos en la Lista de Medicamentos Esenciales para el manejo de pre- eclampsia grave/eclampsia? Labetalol Sí No Hidralazina Sí No Nifedipina Sí No Metildopa Sí No Otro (Por favor, describa) 3. ¿Cuáles son los medicamentos de la primera línea de tratamiento que están aprobados a través de la política nacional/directrices de prestación de servicios como anticonvulsivos para tratar la pre- eclampsia grave/eclampsia? Sulfato de magnesio Sí No Diazepan Sí No Otro (Por favor, describa) 4. ¿El MgSO453 aparece en la Lista de Medicamentos Esenciales para pre-eclampsia grave/eclampsia? Pre-eclampsia Sí No Eclampsia Sí No Por favor, adjunte copia digital de las directrices de la prestación de servicios para el manejo de pre-eclampsia grave/eclampsia (PE/E), incluyendo el protocolo para antihipertensivos y administración de sulfato de magnesio. 5. ¿Las obstetrices están autorizadas a diagnosticar casos de pre-eclampsia grave/ eclampsia y administrar la dosis inicial de sulfato de magnesio en el establecimiento de más bajo nivel donde trabajen dentro del sistema de salud? Sí No 53 Sulfato de magnesio National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 60 A Global Survey, 2012 CAPACITACIÓN 6. ¿El plan de estudios pre-servicio incluye los principios en uso actualmente a nivel mundial para el manejo de la PE/E para todos los asistentes de parto capacitados? Sí Si respondió Sí ¿qué niveles? No 7. ¿Los principios en uso actualmente a nivel mundial para el manejo de la PE/E están incluidos en los cursos de capacitación continua para los asistentes de parto capacitados? Sí No LOGÍSTICA 8. Hay disponibilidad de sulfato de magnesio en los establecimientos públicos con servicios de maternidad: De manera regular Más de la mitad de las veces Menos de la mitad de las veces Nunca 9. ¿Con que frecuencia se agota el sulfato de magnesio en los niveles central/regional? Con frecuencia (una vez cada dos 2 meses o menos) Algunas veces (cada 3 a 6 meses) Muy pocas veces (una vez al año) 10. ¿Hay sulfato de magnesio disponible actualmente en la farmacia del MINSA? Sí No MONITOREO Y EVALUACIÓN 11. ¿Existe un indicador en el SIGS nacional para monitorear la calidad del manejo de la PE/E? Sí Si respondió Sí ¿cuál es este indicador y dónde está documentado? (Ej. Registro de partos, Cuadro de maternidad, otros registros) No PROGRAMACIÓN 12. ¿Qué actividades está ejecutando el MINSA para la prevención y manejo de la PE/E? Explique brevemente qué se está haciendo. 13. ¿Qué actividades están ejecutando los socios implementadores apoyados por USAID para la prevención y manejo de la PE/E? Explique brevemente qué se está haciendo. 14. ¿Qué actividades están ejecutando otros donantes y socios para la prevención y manejo de la PE/E? Explique brevemente qué se está haciendo. 15. ¿Qué porcentaje de distritos están cubiertos por los programas nacionales de PE/E en la actualidad? National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 61 16. ¿A qué porcentaje de asistentes de parto capacitados se puede llegar a través de los esfuerzos programáticos de los programas nacionales de PE/E en la actualidad? (Proporcione su mejor estimado posible y algunos detalles que en su opinión sean útiles) OPORTUNIDADES PARA LA INTRODUCCIÓN, EXPANSIÓN Y ESCALA 17. Por favor, describa toda posible oportunidad que usted vea de introducir, expandir o llevar a escala el programa. (Ej. Hay gestores expertos que necesitan apoyo para diseminar mensajes; conferencia nacional programada para el próximo año y actualización de los planes de estudio; el MINSA cuenta con una política pero necesita apoyo para lanzar el programa) 18. ¿Cuáles son los tres obstáculos más significativos para escalar los programas de manejo de la PE/E en su país? Explique brevemente qué se está haciendo para resolverlos, si fuera el caso. PERSONA DE CONTACTO 19. Persona que será responsable de las actualizaciones de este documento. Incluya nombre, número de teléfono y correo electrónico. National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 62 A Global Survey, 2012 Appendix 2: Completed Global Surveys of Scale- Up of National PPH and PE/E Programs AFGHANISTAN QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? If not, name the leading maternal health bilateral(s) or project(s), and who is implementing it (them). No Bilateral: USAID-HSSP, JICA Multilateral: UNICEF, UNPA, WHO, World Bank, EC Implementers: Ministry of Public Health (MoPH), NGOs Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL54 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? No Misoprostol is still on the national special medicines list. Advocacy to include the medicines in National Essential Medicines List (EML) is started. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes All levels of health facilities. Training 7. Do pre-service education curricula include AMTSL for all SBA55 cadres? Yes Medical doctors, Ob/Gyn, midwives. 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? Yes Initial efficacy study was conducted in 2006. Currently, operations research is being conducted to test implementation of prevention of PPH using misoprostol in real conditions. 54 Active management of the third stage of labor 55 Skilled Birth Attendant AFGHANISTAN National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 63 11. Is the use of misoprostol for PPH prevention during home births being scaled up? Yes It is scaled up as a part of operations research. Logistics 12. Is oxytocin available at public facilities that offer maternity services? Regularly 13. Is oxytocin free of charge to patients at public health facilities? Yes 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Rarely (once a year). 15. Is oxytocin currently available at the MOH56 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Never M&E 17. Is AMTSL included in the national HMIS57? No Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Provision of SBA-assisted delivery services through Basic Package of Health Services (BPHS) in 96% of districts. Provision of stewardship for public and professional awareness on prevention of PPH modalities through reproductive health directorate and NGOs. Maintenance of up-to-date knowledge and skills among SBAs by provision of BEmONC and CEmONC in-service trainings (directly or through training specialist NGOs). Monitoring and evaluation of provision of prevention of PPH activities are being conducted. Authorized Health Services Support Project (HSSP) to conduct operational study on effectiveness of misoprostol distribution at community level. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. A pilot project to see feasibility of PPH implementation conducted at community level. An expansion project is being conducted to collect further evidence for planning to increase the coverage. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. 21. What % of districts are covered by current national PPH programs? 96% 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? 100% 56 Ministry of Health 57 Health Management Information System AFGHANISTAN National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 64 A Global Survey, 2012 Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. 96% of the country is covered by BPHS. One study was conducted, and the second study is ongoing. Included in reproductive health policy and strategy. NGOs’ interest in implementation of prevention of PPH activities. USAID support to implemented activities for prevention of PPH. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Misoprostol is not approved for prevention of PPH at community level by WHO and MoPH; therefore, not included in the EML for this purpose. Underutilization of the institutional deliveries and unavailability. Security and geographical barriers. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Partamin E-mail: partamin@jhpiego.net Tel.: 93.799.235.085 Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes 4. Is MgSO458 on the National EML for: severe pre-eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? Doctors, midwives 58 Magnesium Sulfate AFGHANISTAN National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 65 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? Regularly 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? No data available. 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Provision of SBA-assisted delivery services through BPHS is 96%. Provision of MgSO4 in all levels of BPHS. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. Supporting BPHS in 13 provinces of Afghanistan. 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. WB, EC and other donors support other BPHS projects. 15. What % of districts are covered by current PE/E programs? N/A 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? N/A Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. HSSP is advocating for conducting (and ready and able to conduct) an operations study on prevention of PE/E using supplementary calcium. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Security barriers, geographical barriers, culture barriers. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Partamin E-mail: partamin@jhpiego.net Tel.: 93.799.235.085 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 66 A Global Survey, 2012 ANGOLA QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? If not, name the leading maternal health bilateral(s) or project(s), and who is implementing it (them). No Strengthening Angolan Systems for Health (SASH) implemented by Jhpiego Family planning implemented by Pathfinder Cuidados Obstétricos implemented by CUAMM Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL59 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? No 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? No 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes It is necessary to include it in national guidelines. 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes Training 7. Do pre-service education curricula include AMTSL for all SBA60 cadres? Yes Yes, only for Midwifery School (Obstetricians); not for other technical cadres. 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes Yes, only for Obstetrician School; not for other technical cadres. 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No Discussions within the National Committee of Public Health for an AVS project to introduce misoprostol at the community level. Approval is pending. 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No 59 Active management of the third stage of labor 60 Skilled Birth Attendant ANGOLA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 67 Logistics 12. Is oxytocin available at public facilities that offer maternity services? Regularly 13. Is oxytocin free of charge to patients at public health facilities? Yes 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Rarely (once a year). However, it is to be noted that data collection is difficult because the availability of oxytocin is not integrated with the reports of the Maternal Health Program Service Units. 15. Is oxytocin currently available at the MOH61 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Less than half the time. The problem derives from the fact that misoprostol is not included in the National Standards. The use of the medication at Service Units, mainly hospitals, depends on staff initiative to use it. M&E 17. Is AMTSL included in the national HMIS62? No No organization is documenting AMTSL. In 2010, SES advanced a proposal to include an AMTSL indicator, but no data have been collected yet. Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Developing standards for emergency obstetric care management. Elaborating on a learning package to train technical cadres. Creating awareness for staff from service units to comply with the standards to use oxytocin postpartum. Developing a pilot to use misoprostol at the community level. Elaborating on a proposed standard for use of misoprostol within service units. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. SASH, Pathfinder ASH and Pathfinder are focusing primarily on reproductive health initiatives (family planning). No directive has been issued for maternal health. USAID is committed to securing additional funds to expand SASH work into maternal health services. MCHIP has proposed a centralized fund to encourage an investment in the area of maternal health by the USAID Mission in Angola. Other partners of USAID are working mainly in the areas of HIV and malaria. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. CUAMM WHO technical assistance for standards development. 61 Ministry of Health 62 Health Management Information System ANGOLA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 68 A Global Survey, 2012 21. What % of districts are covered by current national PPH programs? There is no national PPH program. The National Maternal Health Program has implemented training activities addressing technical cadres; it is doing its best to secure the provision of oxytocin. 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? Up to 50% could be reached. The National Program is making its best effort to upgrade the skills of staff in 400 delivery wards nationwide, to train them on the use of PPH management best practices. Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. RH/FP Program meeting in September 2012. Meeting between PNSR/PF and the Congressional Public Health Committee to discuss the situation of maternal mortality in Angola. Provincial and municipal meetings to appoint committees to address maternal mortality prevention efforts, 2012. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. A decision is needed from MOH policymakers. The curricula used at nursing schools need to be updated to include PPH management and other obstetric emergency care practices. More in-service training programs on PPH management are needed to address the needs of birth attendants. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Ines Leopoldo Directora del Programa Nacional de SR/PF Tel.: +244 935768623 E-mail: ines_54@yahoo.com.br Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes 4. Is MgSO463 on the National EML for: severe pre-eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Yes, they are authorized, but this is limited to referral facilities and hospitals. 63 Magnesium Sulfate ANGOLA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 69 Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? Universities 7. Are current global management principles for PE/E included in in-service training courses for SBAs? No The curricula used in technical schools are not updated. Logistics 8. Is MgSO4 available at public facilities that offer maternity services? Regularly Available on a regular basis. The difficulty derives from the fact that technical staff lack self-confidence to use MgSO4 and prefer to refer the patient, many times without starting treatment. This increases the risk for the mother due to difficult conditions to access the facilities and lack of sufficient ambulance vehicles. 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Rarely (once a year). 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Updating the national standards. Elaborating on new learning packages to train cadres. Developing trainings to address the needs of birth attendants. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. No USAID-supported implementing partner is working in this area at this time. SASH and Pathfinder are focusing primarily on reproductive health initiatives (family planning). No directive has been issued for Maternal Health. USAID is committed to securing additional funds to expand SASH work into maternal health services. MCHIP has proposed a centralized fund to encourage an investment in the area of maternal health by the USAID Mission in Angola. Other partners of USAID are working mainly in the areas of HIV and malaria. 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. None 15. What % of districts are covered by current PE/E programs? There is no national PE/E program. The National Maternal Health Program has implemented training activities addressing technical cadres, and it is doing its best to secure the provision of MgSO4. 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? Up to 40% could be reached. The National Program is making its best effort to upgrade the skills of staff in 400 delivery wards nationwide, to train them on the use of PE/E management best practices. ANGOLA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 70 A Global Survey, 2012 Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. RH/FP Program meeting in September 2012. Meeting between PNSR/PF and the Congressional Public Health Committee to discuss the situation of maternal mortality in Angola, March 2012. Province and municipal meetings to appoint committees to address maternal mortality prevention efforts, 2012. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. A decision is needed from MoH policymakers. The curricula used at Nursing Schools need to be updated to include PE/E management and other obstetric emergency care practices. More in-service training programs on PE/E management are needed to address the needs of birth attendants. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Ines Leopoldo Directora del Programa Nacional de SR/PF Tel.: +244 935768623 E-mail: ines_54@yahoo.com.br National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 71 BANGLADESH QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? Yes . Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL64 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? Yes At home deliveries. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? No 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes All levels Training 7. Do pre-service education curricula include AMTSL for all SBA65 cadres? Yes Doctors, nurses, Family Welfare Visitors (FWVs), Community Skilled Birth Attendants (CSBAs). 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? Yes 11. Is the use of misoprostol for PPH prevention during home births being scaled up? Yes Logistics 12. Is oxytocin available at public facilities that offer maternity services? Less than half the time. 13. Is oxytocin free of charge to patients at public health facilities? Yes 64Active management of the third stage of labor 65 Skilled Birth Attendant BANGLADESH National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 72 A Global Survey, 2012 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Frequently (once in every 2 months or less). 15. Is oxytocin currently available at the MOH66medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Regularly Six districts covered by Mayerhashi and MaMoni. M&E 17. Is AMTSL included in the national HMIS67? No Mayerhashi Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Policy: AMTSL, oxytocin, misoprostol. Training: AMTSL. Services: AMTSL at all levels. Supply: Oxytocin in all institutions. Curriculum: All curricula now include AMTSL. Field Implementation: USAID assisted in Mayerhashi and MaMoni areas. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. Assistance to MOH for AMTSL and misoprostol introduction for PPH prevention. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. AMTSL, maternal and newborn health (MNH), maternal, newborn and child health (MNCH), MNCS. 21. What % of districts are covered by current national PPH programs? 21 districts for AMTSL, six districts for misoprostol. 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? AMTSL in 21 districts, misoprostol six districts, all districts SBA. Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. MOH has policy and activities. Local-level facilitation by partners. FWV recruitment for vacant posts. FWC upgrading. Champion exists: professional body, active role. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Fewer facility deliveries, lack of skilled manpower, lack of awareness. 66 Ministry of Health 67 Health Management Information System BANGLADESH National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 73 Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Sabbir Ahmed E-mail: sabbir.ahamed@savechildren.org Tel.: 0088 01730020276 Dr. Jebun Rahman Tel.: 0088 01819248721 Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol Yes Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes 4. Is MgSO468 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? Doctors, nurses, midwives, FWVs, CSBAs. 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? More than half the time. 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Frequently (once in every 2 months or less). 10. Is MgSO4 currently available at the MOH medical store? Yes 68 Magnesium Sulfate BANGLADESH National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 74 A Global Survey, 2012 M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Facility-based management of PE/E management in the system. Guidelines for management of PE/E available for all SBAs. MgSO4 on Essential Medicine List for PE/E management and prevention. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. Community-based prevention and management using MgSO4. National guidelines development and implementation in one district. Assistance for research. 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. Research by ICDDR,B for community-based PE/E prevention and management by CSBAs using MgSO4. 15. What % of districts are covered by current PE/E programs? All secondary and tertiary facilities. 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? All secondary and tertiary facilities. Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. Policy and training. Services at all facilities. Champion exits: professional body. OP indicator in HPNSDP. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Regular, uninterrupted logistics and medicine supply. Community-based diagnosis of cases and referral to appropriate facility. Lack of skilled manpower. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Sabbir Ahmed E-mail: sabbir.ahamed@savechildren.org Tel.: 0088 01730020276 Dr. Jebun Rahman Tel.: 0088 01819248721 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 75 BOLIVIA QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? Yes Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL69 at every birth approved as national policy? Yes National Policy on Maternal and Newborn Health Practices and Technologies, Resolution No. 0496, 2001 (MOH). 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes In December 2011, the MOH issued Resolution No. 240, regulating the provision of comprehensive services across the continuum of health: adolescent pregnancy, childbirth, postpartum, newborn and children under the age of five. Pages 37 and 63 provide a description of the steps for performing AMTSL. 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? Yes Misoprostol can be used at all three levels of care, in conformity with Resolution No. 142, MOH (p. 16): Uses of Misoprostol in Obstetric Care, 2009. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? No As of 2012, nine students are participating in a rotatory internship training program (First Graduating Class– Obstetrics Training Program) with participation of three state universities (Chuquisaca, Tarija and Potosi) and the support of UNFPA. Coordinators: nancymanjon@hotmail.com, Chuquisaca mvargasv@uajms.edu.bo, Tarija Flora Poma Jurado, flora_poma@hotmail.es, Potosi 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? No Bolivia will have its first graduating class by the end of 2012. 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes If Yes, which cadres? All three levels of care. Training 7. Do pre-service education curricula include AMTSL for all SBA70 cadres? Yes Primary, secondary and tertiary medicine education programs (ob/gyn and pediatrics interns, graduate residents), RN and associates from state universities and technical schools. Discussions with private universities are underway. 69 Active management of the third stage of labor 70 Skilled Birth Attendant BOLIVIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 76 A Global Survey, 2012 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes It is a requirement for undergraduate students. 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No No pilots have been conducted. The doctors and nursing associates attending home deliveries carry the "RED BOX" containing the medicine. 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No Logistics 12. Is oxytocin available at public facilities that offer maternity services? More than half the time. A national study to be published by MOH/USAID found 40% stock-out at visited facilities. Another difficulty results from the medicine cold chain requirement. 13. Is oxytocin free of charge to patients at public health facilities? Yes Covered by SUMI (national mother/child insurance plan). 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Rarely (once a year). 15. Is oxytocin currently available at the MOH71 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Less than half the time. Even though it is on the EML and its use is approved for all levels of health care, for municipalities to obtain funds to buy misoprostol for public facilities, first the SUMI system has to elaborate the protocol for use of the medicine at the beneficiary facilities. It is currently available within the private system. M&E 17. Is AMTSL included in the national HMIS72? Yes AMTSL data are collected through perinatal medical records, and then these can be entered into the National HMIS. The process is regulated by a Resolution of MOH, though not widely used yet. MCHIP and UNICEF document through monitoring of standards at the facilities selected by MOH/USSC (Unidad de Servicios de Salud y Calidad). 71 Ministry of Health 72 Health Management Information System BOLIVIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 77 Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. MOH has implemented specific policies to reduce maternal, perinatal and neonatal mortality in Bolivia. The government has established a Strategic Maternal, Perinatal and Newborn Health Plan for 2011–2015. Other social strategies have been launched to increase access to prenatal, birth, postpartum and newborn care, through a social incentive program (Juana Azurduy) that provides financial help to women and their children at different stages. On the other hand, the government is providing national coverage through a national insurance plan (Seguro Universal Materno Infantil or SUMI) offering free access to an array of services to children under the age of five and their mothers, including prenatal care, birth and postpartum care, family planning and assistance to prevent and manage malnutrition (AIEPI- NUT Program). MCHIP and UNICEF support the MOH through the monitoring of standards. In 2012, the institution Mesa de Maternidad y Nacimiento Seguros will launch a new strategy to reduce maternal mortality, focusing on four aspects: 1. PPH prevention; 2. Management of complications; 3. PPH monitoring based on national surveillance; 4. Regulations to integrate health education materials with high school programs. State-operated TV channels will reach 1,500,000 students every week. Maternal and newborn mortality will become the main focus. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. All organizations that receive USAID funding support the implementation of standards, protocols and policies of the MOH in: their different fields of intervention; level of management in the review, editing, publication and dissemination of standards at the request of the MOH officials and the level of health facilities; the updating of providers according to the national protocols, standards and scientific evidence; and provision of basic equipment for PPH. This activity takes place basically in geographical areas of the new strategy by the FORTALESSA Program. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. UNICEF: Implementation of a strategy to provide short- cycle secondary and tertiary health care services. JICA, GAVI, UNFPA follow MOH standards for the implementation; they are interested in implementing AMTSL standards. 21. What % of districts are covered by current national PPH programs? 100% SUMI offers national coverage at all levels of the health care system. 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? 80% BOLIVIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 78 A Global Survey, 2012 Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. 1. Developing collaboration alliances with the universities. 2. Supporting MOH education program. 3. Proposing MOH to allow the use of misoprostol by associate technical nursing staff attending home deliveries under the supervision of FORTALLESA. 4. Supporting MOH in its efforts to implement blood products management at secondary facilities in rural areas. 5. Improving management of the cold chain for oxytocin. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. 1. Local resources do not have timely access to evidence- based medicine data. 2. Jurisdiction and administrative barriers to municipalities hinder their efforts to maintain ongoing supply of oxytocin at the public facilities, especially in rural areas. 3. Community unawareness on PPH warning signs. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Jackeline Reyes Maldonado Responsable de Salud Materna, MCHIP Bolivia E-mail: jreyes@jhpiego.net Tel.: 591-77210980, 591-2-2971458 Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes Other (Please describe) MOH/USS has approached UNIMED (Unidad de Medicamentos) for inclusion of Labetolol on the EML. 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes Other (Please describe) The national maternal and newborn service delivery guidelines now include diazepam. 4. Is MgSO473 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 73 Magnesium Sulfate BOLIVIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 79 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? No Bolivia will see its first graduating class by the end of 2012, but the curriculum includes this diagnosis and the administration of MgSO4. Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? It is part of the curriculum for all training levels. 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes MOH is working with UNICEF, SBGO and MCHIP to develop PE/E standards at all levels of health care; also, training efforts have been made since 2011 to train staff. Logistics 8. Is MgSO4 available at public facilities that offer maternity services? More than half the time. 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Rarely (once a year). Sometimes the municipalities face jurisdiction barriers that make it dificult to maintian stocks of MgSO4; the beneficiary public facilities cannot receive resources from SUMI. 10. Is MgSO4 currently available at the MOH medical store? Yes In-country manufacturing capacity. M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? Yes The National HMIS includes an epidemiological monitoring component that issues weekly reports about PE/E cases; the perinatal clinic history includes the same indicator. Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Implementing standards at all three levels of health care. MOH/PAHO have recently issued Regulation N0. 240, regulating the provision of comprehensive services across the continuum of health: adolescent pregnancy, childbirth, postpartum, newborn and children under the age of five. Page 68 provides a description of PE/E standards. Coordinations are being advanced for inclusion of labetolol on the EML. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. In 2011, MCHIP/UNICEF supported the MOH to develop PE/E standards for primary, secondary and tertiary health care. The new health strategy launched through USAID/FORTALESSA will reinforce the implementation of these standards within new areas. 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. All the programs executed by other agencies and NGOs follow the policies of the MOH and help implement and disseminate them according to their respective agreements and areas of intervention. BOLIVIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 80 A Global Survey, 2012 15. What % of districts are covered by current PE/E programs? Departmental Health Services (known as SEDES) and health care networks receive 100% support at the national level. However, at the primary care level, there is poor availability/management of antihypertensive medicine. 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? As a collaborative effort among all implementing partners: 60%. Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. Supporting the implementation and rollout of MOH's strategic plan to reduce maternal and neonatal mortality. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. 1. Labetolol is not available for tertiary health care. 2. Hydralazine is not provided, even though it is listed on the EML. 3. The development of a national PE/E monitoring system is under way, but it needs strong political commitment. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Jackeline Reyes Maldonado Responsable de Salud Materna, MCHIP Bolivia E-mail: jreyes@jhpiego.net Tel.: 591-77210980, 591-2-2971458 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 81 CAMBODIA QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? No USAID: URC, RHAC (Reproductive Health Association of Cambodia), RACHA (Reproductive and Child Health Alliance) Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL74 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? Yes Level CPA2 and CPA3 hospitals. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes If trained; normally secondary midwives (MWs). 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes Health centers and hospitals. Training 7. Do pre-service education curricula include AMTSL for all SBA75 cadres? Yes Secondary MWs, which is the only MW category being educated today; also, previously educated primary MWs can do AMTSL. 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No It has been decided to not promote or test this, since we have a rapidly rising rate of facility births. 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No 74 Active management of the third stage of labor 75 Skilled Birth Attendant CAMBODIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 82 A Global Survey, 2012 Logistics 12. Is oxytocin available at public facilities that offer maternity services? Regularly 13. Is oxytocin free of charge to patients at public health facilities? Yes 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Rarely (once a year). 15. Is oxytocin currently available at the MOH76 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Regularly At hospitals, not at health centers. M&E 17. Is AMTSL included in the national HMIS77? No URC Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. New Safe Motherhood Protocols (SMPs) for health centers (2010) and hospitals (in press, 2012). Separate guidelines on PPH, not fully consistent with new SMPs, recently published. Mentions neither HC, MW nor simple algorithm, unfortunately. Held six "key intervention workshops" with URC, RHAC, RACHA and UNICEF in 2010. PPH topic often part of regional CME. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. As above. URC is now also planning pilot of NASG, in collaboration with national program. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. AMTSL being promoted by all partners. Trauma Care has been training on balloon tamponade. 21. What % of districts are covered by current national PPH programs? 100% 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? 80–90% Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. Print and disseminate SMPs for hospitals, see above. This would make it possible to move on, provide job aids, based on the SMPs. Decide if/how to promote misoprostol as a supplement to treat PPH at the hospital level. Adopt either NASG or balloon tamponade, or both as second-line treatment of severe PPH. Consider making metilergometrine available routinely, to supplement oxytocin. 76 Ministry of Health 77 Health Management Information System CAMBODIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 83 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Uncertainty about use of misoprostol. Two national, separate guidelines are published; and they are not fully consistent. Rejection of balloon tamponade quoting lack of evidence. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Jerker Liljestrand Tel.: 0855 16 242135 E-mail: jliljestrand@urc-chs.com Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine No Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam No 4. Is MgSO478 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? No 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? Regularly 78 Magnesium Sulfate CAMBODIA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 84 A Global Survey, 2012 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Sometimes (every 3 to 6 months). Since the rollout is recent, it is difficult to say. Rapid uptake of the new regimen caused national-level stock- out, which was resolved after two months. 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Training of trainers (TOT) for provincial trainers in 2011. Continued, multipronged efforts to roll out MgSO4. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. Strengthen providers' knowledge through midwife quarterly meeting. Provide one-on-one coaching for providers, to ensure that pregnant women receive proper care. 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. National workshop, training, PE/E posters, job aids, eclampsia kit. 15. What % of districts are covered by current PE/E programs? 100% 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? (Provide your best possible estimate and any details you think would be helpful.) 90% Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. New EmONC training by National Institute being accelerated. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Has not provided training for all health center midwives in the country yet. Referral system does not function well yet. Awareness of PE/E prevention for women is still limited. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Jerker Liljestrand Tel.: 0855 16 242135 E-mail: jliljestrand@urc-chs.com National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 85 DEMOCRATIC REPUBLIC OF CONGO QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? No Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL79 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? No 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes Training 7. Do pre-service education curricula include AMTSL for all SBA80 cadres? No 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? No 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No 74% of assisted deliveries. 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No Home births are not recommended in the national norms. Logistics 12. Is oxytocin available at public facilities that offer maternity services? More than half the time. 79 Active management of the third stage of labor 80 Skilled Birth Attendant DEMOCRATIC REPUBLIC OF CONGO National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 86 A Global Survey, 2012 13. Is oxytocin free of charge to patients at public health facilities? No 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Frequently (once in every 2 months or less). 15. Is oxytocin currently available at the MOH81 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Never Available in private pharmacies. M&E 17. Is AMTSL included in the national HMIS82? Yes Need to standardize the reporting format. Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Prevention: this is not really clear, iron folate supplementation, malaria prevention, presumptive treatment of hookworm infection during pregnancy, no systematic episiotomy, AMTSL. Treatment: management depending on the cause, uterotonics, uterine massage to treat atony, soft tissue repair in case of tears, manual removal of placenta, placental fragments, transfusion, etc. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. As above 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. As above 21. What % of districts are covered by current national PPH programs? Data not available. AMTSL training has been done in almost all the health zones (88 health zones covered by the project). 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? Data not available. Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. MNHI national norms and protocols developed; need support for implementing interventions in various health centers in the country. 81 Ministry of Health 82 Health Management Information System DEMOCRATIC REPUBLIC OF CONGO National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 87 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Insufficient resource for scale up. Lack of cold chain storage for oxytocin; negotiations with other partners (PARS, FED and others). Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Kalume Tutu Tel.: 0999913011 E-mail: tutukalume@yahoo.fr Dr. Marie Louise Mbo Tel.: 0815093945 E-mail: marielouisembo@yahoo.fr Dr. Marie Claude Mbuyi Tel.: 0817006411 E-mail: mbuyim@cd.afro.who.int Mme. Lucie Zikudieka Tel.: 0970007780 E-mail: lzikudieka@msh.org Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine No Methyldopa Yes Other (Please describe) Clonidine 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine No Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes Other (Please describe) If lack of MgSO4, diazepam is used. DEMOCRATIC REPUBLIC OF CONGO National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 88 A Global Survey, 2012 4. Is MgSO483 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? No 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? More than half the time. 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Frequently (once in every 2 months or less). Sometimes available in private pharmacies. 10. Is MgSO4 currently available at the MOH medical store? No M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Prevention: BP control, control of proteinuria, check for lower limb swelling, information/recognition of danger signs during pregnancy. Treatment: Rapid assessment, administration of antihypertensives/anticonvulsant, obstetric management. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. As above 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. As above 15. What % of districts are covered by current PE/E programs? Not available 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? (Provide your best possible estimate and any details you think would be helpful.) Not available Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. MNHI national norms and protocols developed; need support for implementing interventions in various health centers in the country. 83 Magnesium Sulfate DEMOCRATIC REPUBLIC OF CONGO National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 89 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. No formal program exists. Inconsistencies in supplies of magnesium sulfate. Lack of financial resources to scale up. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Kalume Tutu Tel.: 0999913011 E-mail: tutukalume@yahoo.fr Dr. Marie Louise Mbo Tel.: 0815093945 E-mail: marielouisembo@yahoo.fr Dr. Marie Claude Mbuyi Tel.: 0817006411 E-mail: mbuyim@cd.afro.who.int Mme. Lucie Zikudieka Tel.: 0970007780 E-mail: lzikudieka@msh.org National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 90 A Global Survey, 2012 ECUADOR QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? Yes Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL84 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? Yes At all levels, from outpatient care to hospital-based care. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes At all levels. Training 7. Do pre-service education curricula include AMTSL for all SBA85 cadres? Yes 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? No 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No Logistics 12. Is oxytocin available at public facilities that offer maternity services? Regularly 84 Active management of the third stage of labor 85 Skilled Birth Attendant ECUADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 91 13. Is oxytocin free of charge to patients at public health facilities? Yes 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Unknown 15. Is oxytocin currently available at the MOH86 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Regularly M&E 17. Is AMTSL included in the national HMIS87? Yes National service quality indicators and standards in the monitoring system. Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Monitoring the use of oxytocin. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. Technical support to the MOH. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. Unknown 21. What % of districts are covered by current national PPH programs? 95% 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? 70% Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. Developing career profiles of undergraduate and postgraduate students. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Difficulty to monitor the application of standard implementation of protocols. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Patricio Ayabaca Tel.: 095029473 E-mail: payabaca@urc-chs.com 86 Ministry of Health 87 Health Management Information System ECUADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 92 A Global Survey, 2012 Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam No 4. Is MgSO488 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? Yes Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? All three levels of the health care system. 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? Regularly 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? Yes PE/E service quality indicators in the monitoring system. Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Monitoring the application and implementation of standards. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. Technical support 88 Magnesium Sulfate ECUADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 93 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. 15. What % of districts are covered by current PE/E programs? 95% 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? (Provide your best possible estimate and any details you think would be helpful.) 80% Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. Scientific forums with the participation of professional schools and scientific associations; skills update trainings. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Non-application or poor application of the standard. Insufficient supervision to monitor the application of the standard. Resistance to use sulfate without an infusion pump. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Patricio Ayabaca Tel.: 095029473 E-mail: payabaca@urc-chs.com National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 94 A Global Survey, 2012 EQUATORIAL GUINEA QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? No 1. "Support to reduce maternal and neonatal mortality in the Province of Litoral" – Jhpiego 2. "Prosalud" Project in the Province of Centro-Sur – Montrose 3. Strengthening the health care system through primary care - FRS (religious NGO): this initiative reaches almost the entire country through antenatal care (ANC) clinics/medical centers; some of these also provide birth services. Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL89 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes Note: The program is using checklists introduced by Jhpiego in the target Province of Litoral; these are also being used in the Province of Centro-Sur as a result of a healthy relationship established with Prosalud. Jhpiego's work plan for 2012 includes the development of a national guideline to extend the use of AMTSL checklists to all regions in the country (plus other checklists). 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? No 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? No Not on the National EML (we will have to double-check with the National Direction whether this statement is incorrect); however, it has been integrated with the national guidelines for complications management; it is often available at hospital pharmacies and included in health care protocols. 89 Active management of the third stage of labor EQUATORIAL GUINEA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 95 Training 7. Do pre-service education curricula include AMTSL for all SBA90 cadres? Yes Doctors, nurses and assistants. 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? Yes 9. Is AMTSL included in in-service training curricula for all SBA cadres? No There is no in-service training in EG. Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No Logistics 12. Is oxytocin available at public facilities that offer maternity services? More than half the time. 13. Is oxytocin free of charge to patients at public health facilities? No Although a "public service," patients have to pay for everything. 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Sometimes (every 3 to 6 months). 15. Is oxytocin currently available at the MOH91 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Less than half the time. M&E 17. Is AMTSL included in the national HMIS92? No Jhpiego Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. The MOH is working in collaboration with Jhpiego to train maternity health care providers in the hospitals in Bata, Mbini and Kogo for PPH management. An additional register has been integrated with these services to monitor the administration of oxytocin within 1–3 minutes of birth (see #20 below). 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. There are no USAID-sponsored programs in EG. 90 Skilled Birth Attendant 91 Ministry of Health 92 Health Management Information System EQUATORIAL GUINEA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 96 A Global Survey, 2012 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. Jhpiego: Our work in one province includes BEmONC trainings, implementation of checklists, monitoring of quality service delivery and health provider practices, and recollection of data on complications. At a national level, we have proposed national guidelines and norms that have been validated, reviewed and disseminated nationwide. Montrose: Introduction of AMTSL checklists (with the support of Jhpiego). 21. What % of districts are covered by current national PPH programs? 16% Current health policies should be applied in the entire country; however, we cannot ensure that they are applied in other regions besides Jhpiego's target areas. I can ensure their application only in the three districts targeted by our initiative (out of a total of 18). 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? Through the Jhpiego program, 26 health care providers were trained in 2011. (No national data are available for a total number of providers working in the country; we estimate about 180 are working in the hospitals.) Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. The MOH has developed a policy, but needs support for expansion, implementation and monitoring. As per its work plan for 2012, Jhpiego will develop a national campaign and one of the activities will be the delivery of trainings on the use of checklists, and their dissemination (including the AMTSL checklist). 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Stock-outs of oxytocin (still a problem). Poor training and commitment of human resources. Poor supervision. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Almudena González-Vigil Tel.: +240 222 275335 E-mail: agonzalez@jhpiego.net Pastora Ndong Micué Coordinadora Regional SR Tel.: +240 222 278194 Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa No EQUATORIAL GUINEA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 97 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam Yes 4. Is MgSO493 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia No Eclampsia No Not on National EML (updated by MOH as of June 2010); integrated with emergency care protocols developed last year by Jhpiego, then validated and now undergoing final review for dissemination. 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? No They do diagnose, but they do not administer treatment as this step is a doctor's responsibility. If a doctor is not available, then they administer treatment. Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? Yes If Yes, which cadres? Doctors and midwives. 7. Are current global management principles for PE/E included in in-service training courses for SBAs? No UNFPA, Jhpiego and some other supporting organizations developed updates; this is not the case for MINSABS or the National University specifically (there are NO in- service training courses at all). Logistics 8. Is MgSO4 available at public facilities that offer maternity services? More than half the time. 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Sometimes (every 3 to 6 months). 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No The Jhpiego program is making an effort for these data to be collected. Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Same as #18 in Section 1 above. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. There are no USAID-sponsored programs in EG. 93 Magnesium Sulfate EQUATORIAL GUINEA National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 98 A Global Survey, 2012 14. Which activities in PE/E prevention and management programming are being undertaken by other donors or other partners? Please briefly specify what is being done. Jhpiego: trainings, supervision, registers. Prosalud/Montrose: ANC screening, in the province of Centro-Sur. 15. What % of districts are covered by current PE/E programs? We can only provide data for our area of intervention: 16%. 16. What % of current SBAs are being reached by programmatic efforts of the current national PE/E programs? (Provide your best possible estimate and any details you think would be helpful.) I wouldn't be able to provide sound data--it has to be very low. Opportunities for Introduction, Expansion and Scale-Up 17. Please describe any potential opportunities that you see for program introduction, expansion or scale-up. The MOH has developed a policy but needs support to implement it. 18. What are the three most significant bottlenecks to scaling up PE/E management programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Stock-outs of the necessary medications. Poor training and commitment of human resources. Poor supervision. Contact Person 19. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Almudena González-Vigil Tel.: +240 222 275335 E-mail: agonzalez@jhpiego.net Pastora Ndong Micué Coordinadora Regional SR Tel.: +240 222 278194 National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 99 EL SALVADOR QUESTION RESPONSE AND FURTHER INFORMATION Is there an MCHIP presence in this country? Yes Section 1: Postpartum Hemorrhage (PPH) Policy 1. Is AMTSL94 at every birth approved as national policy? Yes 2. Are the steps for correctly performing AMTSL incorporated into service delivery guidelines? Yes 3. Is misoprostol on the National Essential Medicines List (EML), specifically with the indication for prevention and/or treatment of PPH at any level of the health system? Yes Levels 1 and 2. 4. Are midwives authorized to perform manual removal of placenta at all levels of the health system? Yes 5. Are midwives authorized to perform AMTSL with oxytocin at all levels of the health system? Yes If level 1: only if delivery is imminent. 6. Is oxytocin on the National EML for prevention and/or treatment of PPH? Yes At all levels. Training 7. Do pre-service education curricula include AMTSL for all SBA95 cadres? No 8. Are students assessed for competency in performance of AMTSL as a clinical skill prior to graduation? No 9. Is AMTSL included in in-service training curricula for all SBA cadres? Yes Distribution of Misoprostol for PPH Prevention at Home Birth 10. Has the use of misoprostol for the prevention of PPH at home births been piloted? No Misoprostol can be used exclusively at hospitals. 11. Is the use of misoprostol for PPH prevention during home births being scaled up? No Misoprostol can be used exclusively at hospitals. 94 Active management of the third stage of labor 95 Skilled Birth Attendant EL SALVADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 100 A Global Survey, 2012 Logistics 12. Is oxytocin available at public facilities that offer maternity services? Regularly 13. Is oxytocin free of charge to patients at public health facilities? Yes 14. How frequently do stock-outs of oxytocin occur at the central/regional levels? Rarely (once a year). 15. Is oxytocin currently available at the MOH96 medical store? Yes 16. Is misoprostol available at public facilities that offer maternity services? Regularly M&E 17. Is AMTSL included in the national HMIS97? No A database measures this indicator against quality standards; also included in the perinatal information system. Programming 18. Which activities in PPH prevention and management are being undertaken by the MOH? Briefly specify what is being done. Disseminating the updated standard on PPH management. Developing trainings to update skills to manage obstetric complications. Monitoring and supervising regional facilitators on the appropriate application of the protocol. Assessing medical audit reports on obstetric morbidity and maternal mortality as a result of PPH. 19. Which activities in PPH prevention and management are being undertaken by USAID- sponsored programs? Briefly specify what is being done. Disseminating the updated standard on PPH management. Developing trainings to update skills to manage obstetric complications. 20. Which activities in PPH prevention and management are being undertaken by other donors or other partners? Briefly specify what is being done. Disseminating the updated standard on PPH management. Developing trainings to update skills to manage obstetric complications. Establishing alliances in the health sector to address PPH cases. Disseminating updated information on PPH management. Implementing the IMFC and birth planning and complication readiness strategies to identify warning signs and symptoms of birth complications. 21. What % of districts are covered by current national PPH programs? 100% 22. What % of current SBAs are being reached by programmatic efforts of the current national PPH programs? 100% 96 Ministry of Health 97 Health Management Information System EL SALVADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: A Global Survey, 2012 101 Opportunities for Expansion and Scale-Up 23. Please describe any potential opportunities that you see for program expansion or scale-up. Developing trainings on obstetric skills to be delivered by regional facilitators at all levels of the health system. Disseminating updated information on management of obstetric morbidity at all levels of the health care system. Monitoring and assessing compliance with protocols. Strengthening the skills of directors to secure a steady supply of equipment and supplies to manage obstetric complications. 24. What are the three most significant bottlenecks to scaling up PPH reduction programs in your country? Briefly describe what is being done to address the bottlenecks, if anything. Directors lack skills to manage PPH cases: based on medical audit results, create awareness to secure a steady supply of equipment and supplies to address PPH cases. Insufficient human resources to implement programs: advocate with key stakeholders to secure human resources. Poor coordination between education authorities and the MOH with regard to pre-service curricula: advocate with the corresponding bodies to coordinate with the MOH on the design of the curricula on PPH management. Contact Person 25. Contact person who will be responsible for updates to this matrix. Include name, telephone number and e-mail address. Dr. Sofia Villalta Coordinadora del SSR/MINSAL Tel.: 22057262 E-mail: sofiavillaltadelgado@gmail.com Section 2: Pre-Eclampsia/Eclampsia (PE/E) Policy 1. What drugs are approved through national policy/service delivery guidelines for administration as first-line antihypertensives in severe pre-eclampsia/eclampsia (PE/E)? Labetolol No Hydralazine Yes Nifedipine Yes Methyldopa Yes 2. What drugs are listed on the National Essential Medicines List (EML), as antihypertensives in management of severe PE/E? Labetolol Yes Hydralazine Yes Nifedipine Yes Methyldopa Yes 3. What drugs are approved through national policy/service delivery guidelines as first-line anticonvulsants for severe PE/E? MgSO4 Yes Diazepam No 4. Is MgSO498 on the National EML for: severe pre- eclampsia?; eclampsia? Pre-eclampsia Yes Eclampsia Yes 5. Are midwives authorized to diagnose severe PE/E and administer initial (loading) dose of MgSO4 at lowest-level facility that they work at within the health system? No 98 Magnesium Sulfate EL SALVADOR National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: 102 A Global Survey, 2012 Training 6. Do pre-service education curricula include current global management principles for PE/E for all SBA cadres? No 7. Are current global management principles for PE/E included in in-service training courses for SBAs? Yes Logistics 8. Is MgSO4 available at public facilities that offer maternity services? Regularly 9. How frequently do stock-outs of MgSO4 occur at the central/regional levels? Rarely (once a year). 10. Is MgSO4 currently available at the MOH medical store? Yes M&E 11. Is an indicator to monitor severe PE/E included in the national HMIS? No A database measures this indicator against quality standards. Programming 12. Which activities in PE/E prevention and management are being undertaken by the MOH? Please briefly specify what is being done. Disseminating the updated standard on PE/E management. Developing trainings to update skills to manage obstetric complications. Monitoring and supervising regional facilitators on the application of the protocol. Assessing medical audit reports on obstetric morbidity and maternal mortality. 13. Which activities in PE/E prevention and management programming are being undertaken by USAID-supported implementing partners? Please briefly specify what is being done. Disseminating updated information on the PE/E standard. Training on updated skills to man

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