dewan_pph prevention and management strategies at different levels of health system

8/2/2019 Dewan_PPH Prevention and Management Strategies at Different Levels of Health System

1/22

Prevention and ManagementStrategies of PPH

At Different Levels of Health System InBangladesh

Prof. Farhana DewanOGSB

Prof,Obs/Gyn

Shaheed Suhrawardy Medical College [email protected]

AcknowledgementMOHFW

EngenderHealth BangladeshJPHIEGO

MaMoni


2/22

574

143

322

194

0

100

200

300

400

500

600

700

1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

BMMS

2001

BMMS

2010

MDG 5Target

Maternal mortality declines by 40% between 2001 and 2010

Maternal death due to PPH reduced 25%

Bangladesh is on track to achieve MDG 5

MMR Trend


3/22

Statistics-2011Death due to PPH in different Medical

College Hospitals

Name ofhospital

TotalHospital

Bed

Total admin Gynae &

Obs

Totaladm in

Obs

Total Numberof cases of

PPH

Death dueto PPH

DMCH 1250 17962 14047 742 30

SSMCH 600 15845 13965 313 9

CMCH 1010 20994 16334 658 7

RMCH 530 16696 12276 592 28

SMCH 900 14276 13160 271 10

BMCH 500 13402 7151 293 15

RpMCH 500 11924 9117 731 42


4/22

Source: HRD Datasheet -2011, HED Unit, MOHFW; * Health bulletin 2011, DGHS

Maternal Health Care: Service DeliveryStructure Facilities Level Services

National Total:35Medical UniversitySpecialized Institute, FP

institute

TertiaryCEmOC*All Medical college Hospital,

59 District Hospital, 3General hospital, 132Upazila health complex, 63MCWCs

BEmOC

Rest of the upazilas

Division: 7 Nos Total : 56Medical College Hospital,Other hospital (DGHS),Model clinic

TertiarySecondary

District 64 Nos

(2.3 Miliion)

Total : 221

District Hospital, MCWC(DGFP), MCH-FP clinic(DGFP)

Secondary

Upazila 483(0.3 million)

Total : 421Upazila Health Complex(DGHS)

Primary

Union : 4498

(0.03 million)

Total: 5168

USC (DGHS), UH&FWC(DGHS), UH&FWC (DGFP)

Primary Pregnancy Care

Normal delivery facility atvery few centers

Ward 13494Several villagemake a ward(11000)

Community Clinic (14025),Satellite Clinic (DGFP)(30000), Immunizationcenter

Primary Pregnancy care

Community Domiciliary workers 1/5-6

thousand (DGHS), DGFP

Domiciliary Pregnancy care


5/22

UpazilaUpazila Health

Complex

Referral forcomplication

Community

Union/

Ward

Referral Network

FWC/ Satellite clinic/EPI Center

Community clinic

District/

Division

District Hospital/MCWC

Medical College hospital

Referral forANC and Immunization


6/22

Strengthening of health facilities toprovide EmOC services

Demand Side Financing:Maternal Health Voucher Scheme

CSBAProgramme

Midwiferyprogram

MNH, MNCH,MNCS

ReduceMaternal

Mortality &Morbidity

Key Programs to reduce Maternalmortality


7/22

Key ProgramCommunity based Skilled Birth Attendant(CSBA)

Total 6155 CSBAs completed basic training

(May 2011)

CSBA registration provided by BangladeshNursing Council

Target: to train 13,500 FWAs and FeHAs

At presentLow coverage- 0.3%

Health bulletin 2011, DGHS/BDHS 2011


8/22

To address the equity issue

Coverage

502 unions of 46 upazillas of 38 districts

Total annual beneficiaries

in 46 upazillas are 113181 pregnant woman

(March 2011)

Financial incentive to health serviceproviders and mothers for providing andusing selected maternal health services

Key Program

Demand Side Financing (DSF)

Source: Health bulletin 2011, DGHS


9/22

Key Program

Birth of Midwives in Bangladesh

Approx 27000 nurse-midwives

Existing nurse-midwives training not satisfying ICM/WHOstandard of midwifery training

Govt. commitment to train 3000 midwives by 2015

Action plan proposedEducation and training

6 months post basic advance training for existing nursemidwives

3 yeas diploma direct entry midwifery programme

Recruitment and deployment Reconstitution of Bangladesh Nursing council and Directorate of

Nursing

Create 1500 new position for Midwives in next 5 year


10/22

Improve maternal health

Implement phase wise expansion of 24/7 EmOC services

Expanding DSF: on the basis of ecologic analysis

Develop and expand Midwifery services

Expand C-SBA: Involving community

Implement AMTSL at facility to prevent PPH and delivery by SBA

Use of Misoprostol to prevent PPH at community level

Use of Magnesium Sulphate to prevent eclampsia

Performance based financing

Incentive: hard to reach, under serve & low performance

Address maternal morbidity

fistula, cervical cancer

Health, Population and Nutrition Sector Development Program (HPNSDP),July 2011-June 2016

Strategic approach undertaken: Policy Level

Incorporated both

AMTSL andMisoprostol into the

Health population andNutrition sector

development Program

and Operation Plans(2011-2016)


11/22

Strategic approach

Prevention Management

At CommunityAt Facility

(Varies on level offacility)

Strategic approach undertaken

Implementation Level


12/22

Component-I: Use of Oxytocic Drug

25

7

4

11

7

2

24

3 3

26

6

0

30

3

00

5

10

15

20

25

30

Rajshahi Barisal Khulna Faridpur Hobiganj

Inj. Oxytocin Inj. Ergometrine Tab. Misoprostol

Assessment of AMTSL-OGSB,2004Pre knowledge assessment

54

6

32

12

16

0

20

1

0

5

10

15

20


Before delivery of placenta After delivery of placenta

11

4

12

0

14

3

25

4

13

1

0

5

10

15

20

25


Did not wait for sign of placental separation

Waited for sign of placental separation

Component-I: Time of giving Inj. Oxytocin

Component II ,Delivery of placenta by CCT Component- III, Time of givinguterine massage

Assessment after follow up

Majority of cases of normal labour were being

managed by AMTSL

4

0

2

43

20

13

4 4

8

0

5

10

15

20


Before delivery of placenta After delivery of placenta


13/22

Prevention of PPH: At facility

Strategy

At the facility level, where 28.8 % deliveries takeplace, AMTSL is the most effective and simple

way to prevent PPH

Activity undertaken

AMTSL is being integrated in the broader life-

saving and midwifery training to ensure that allskilled birth attendants receive this training

District approach to reach all district and Upazillafacilities with AMTSL (25 districts so far)


14/22

Prevention of PPH: AtCommunity

Strategy

At the community level, where 71 % of deliveries occur at home byunskilled birth attendants, Misoprostol is the best alternative toInjection Oxytocin to prevent PPH

Two tablets (400microgram) just after delivery to be taken orally Activity undertaken

Misoprostol tablet approved for PPH prevention by Drug Administration

Misoprostol tablet included in updated Essential Drug List (2008)

Agreement on National dose of Misoprostol (400 microgram) (2010)

Planned for a phased scale-up of Misoprostol, and in July 2011 began scale-up in four districts, with technical assistance from Mayer Hashi

Community implementation program started by NGOs


15/22

Level of Facility EmOCService

ServiceProvider

Activity done to managePPH

Tertiary carelevel

-Medical CollegeHospital-SpecializedHospital

CEmOC Prof/Asso./Assis. Prof/Consultant/MO

For Atony

For Injury

For Retained Placenta

For Coagulation Failure/DIC

Management


16/22

Level of Facility EmOC

Service

Service

Provider

Activity done to

manage PPH

Secondary carelevel

-District Hospital CEmOC/

BEmOC

Consultant,

MO

For Atony

For Injury


Primary care level

-Upazilla HealthComplex-Union Sub centre

-Ward

CEmOCBEmOC

MO/MA

MO/MA

HA

For Atony


17/22

PPH Management

The Innovative Condom Tamponade Unitdeveloped in Bangladesh by Akhter andteam

For Atony

Compression of aorta

Bimanual Compression

Balloon tamponade

Surgical Procedure

-Uterine artery Ligation

-B-Lynch Brace Suture

-Sub total hysterectomy

For Injury

Repair of Cervical/Perineal tear


Manual removal of placenta

Removal of retained bits

For Coagulation Failure/DIC

Consultation with other discipline


18/22

Manual removal of placenta

Active Management of Third Stage of Labour (AMTSL)

Glimpse of Technical Training

Bimanual compression of uterus


19/22

Some BCC materials

19

Flip chart

Flip chart Poster

Sticker


20/22

Demonstrated successful models ofimplementation at both facility and communitylevel

Wide coverage with facilities and CommunityClinic

Public-private partnership

CSBAs service at community level

Opportunities


21/22

Conclusion

Ensure universal AMTSL at all facilities: can be done ina short time through a partnership betweenGovernment and OGSB

Scale up community use of misoprostol to all parts ofthe nation


22/22

Thank you

dewan_pph prevention and management strategies at different levels of health system

Documents