Table Of Contents
Why A Standardized Approach To PPH Treatment?
Scientific Recommendations By WHO & FIGO
Planning And Implementing A PPH Program
Data, Monitoring, And Improvement Activities
Data, Monitoring, & Improvement Activities
At SaveMothers.org, our mission is to prevent as many postpartum hemorrhage (PPH) deaths as possible. To reach this goal of preventing almost all maternal PPH deaths, one must regularly collect relevant PPH-related data, analyze them, and discuss the next steps. Discussing the current data is the basis for improvement.
Data and Monitoring
All countries routinely collect data covering various aspects of health, disease and health care. This is called “Health Management Information Systems”, or HMIS. The Ministry of Health decides what information to collect in the HMIS, and how the data is managed, analyzed and shared. Currently, most countries are at various stages of introduction of computer-based HMIS.
The two very important aspects to look out for when improving PPH outcomes are:
- Make sure the right information (indicators) is being collected
- Make sure this data is made available at the district level with minimum delay
Is the right information being collected through the HMIS?
This is a question that the MoH decides on, usually in consultation with the MNCH program, and perhaps with national and international partners. Number of births by facility, common complications, and outcomes are typically registered. Often only the most important interventions are registered– e.g. instrumental delivery, PPH, eclampsia, vaccinations or HIV treatment. If the information that is needed for improvement (ex. access to essential PPH drugs or devices, or use of these) is not included in the HMIS, providers can decide to locally collect supplementary data ("do we all have TXA in stock, and do we use it?") in order to be able to discuss improvement steps.
One important aspect is to continuously register maternal deaths, and analyze the causes of those deaths, both clinical causes (pre-eclampsia, PPH, sepsis and so on), and the background factors such as lack of transport, lack of drugs or devices in ANC or birthing care, or lack of competent staff and/or lack of authorization to perform certain life-saving procedures. The maternal death surveillance and response (MDSR) is a special part of the HMIS that does just this. Not only should MDSR collect as much information on the individual maternal death, but also analyze it, and discuss it in detail. Why did this woman die? What can we learn from it? What action shall we take in the district to avoid that this type of incident happens again?
Apart from this routine collection of data, by HMIS and MDSR, one can for shorter periods study severe events, to learn more on what is happening to mothers. This could be through a month or two of “near-miss analysis”, or the studying of all women who have received a blood transfusion at birth or post-partum. These women will be interviewed in detail, and their clinical records studied. Did she get the right treatment, was e.g. TXA given at the health center, and was it given twice? Was the UBT used, and if not, why not?
Similar factors can also be studied in small, local surveys, where the staffs in charge try to verify to what extent standard treatment guidelines for PPH are being followed.
Is the information available at the district level, with minimum delay?
HMIS data tend to be collected at the national level, by the MoH. The question is how soon they will be available at the district or hospital level. This is what facility managers need to know – how is my facility doing, are we better or worse than others in the country? Are UBTs being used, and how about NASG and TXA and uterotonics?
Arguably, the local data are first needed locally, where doctors and midwives get together locally to discuss the next steps, on how to improve PPH care and prevention.
In every catchment area, it should be the responsibility of a leading Primary Health Care (PHC) staff to go over the data regularly together with a leading hospital staff ( a senior obstetrician or midwife).
Saving a woman's life from postpartum hemorrhage is a dramatic and often very inspiring experience. When the new techniques for controlling PPH emergencies are initially becoming available, this is often inspiring to many staff. Improved PPH care can become a driver of MNCH quality improvement. To use these victories and this inspiration wisely is what improvement activities is all about.
Birthing care staff at primary health care level in a district need to meet at regular intervals, to discuss progress, challenges and shortfalls, and ways forward. Such meetings need to involve interested staff from the local referral hospital, and PHC leadership. The meeting program needs to include presentation of current data, some case discussions, perhaps some training, and joint troubleshooting.
Troubleshooting means joint discussion of a case, or number of cases, or current problems, and based on this discussion, jointly suggesting on what can be done. Are women coming too late for delivery? Is transport a problem, or is it the staffing, lack of drugs or devices, insufficient competence, or lack of delegation to midwives of life-saving procedures? Is there sufficient collaboration between PHC staff and hospital staff? Do hospital staff support the periphery?
A discussion that is as honest as possible, and joint debating of possible solutions, is what can result in realistic next steps that will improve PPH outcomes in the district.
Importantly, many problems cannot be solved locally and need the intervention of district or provincial managers at the national level. If a certain drug is often not available, this can be due to many reasons, some of which may need action at the national level. The local troubleshooting session should in such cases lead to communications upward, so that the national program director is fully aware, and can intervene appropriately. Again, it is important to include progress (stories of women saved with the new methods), to show the potential of further local improvement steps.
The cycle of “improvement meetings” => local actions => new discussions and actions is further discussed in the section on network integration.