Overcoming Barriers to Implementing
PPH prevention at the Facility Level
The Role of Professional Organisations
S Arulkumaran
Professor & Head of
Obstetrics & Gynaecology
St George’s University of London
President Elect - FIGO
Objectives
Describe success stories of professional organisations
that have worked to reduce barriers to access
interventions to prevent and treat PPH
 Provide recommendations for Country Professional
Organisations
 List major challenges/ solutions to using professional
organisations to overcome barriers to implementation
of interventions for PPH control

General Principle to Promote access
to effective interventions
Service provision
Data collection
Policy development
Advocacy
Training
Facilitation
consultation
Champion
Implementation
The Role of Professional Associations
Provide leadership on issues surrounding PPH
 Advocate for PPH control initiatives
 Support research to update clinical practices
 Promote best practices in clinical guidelines and
health care policies
 Facilitate knowledge and skill transfer
 Support efforts to assure quality

Global leadership: FIGO and ICM /
POPPHI


FIGO and ICM were partners in the Prevention of Postpartum
Haemorrhage Initiative (POPPHI) that ended in November, 2009
FIGO and ICM provided input into:
Task forces
 Development of learning materials and job aids
 Strategies to promote expansion and improve the quality and availability
of AMTSL at the facility level and community level through work with
their member associations around the world
 Development and signing of joint statements work with their member
associations around the world
 Promoting best practices for the prevention and treatment of PPH
 FIGO conducted workshops on post partum haemorrhage

Global leadership: FIGO / MCHIP
FIGO’s collaboration with global partners on PPH
reduction continues, and has expanded to address
PE/E as well.
 FIGO, ICM and MCHIP will be working together on a
program to build collaboration of midwives and
obstetricians for implementation of key interventions in
numerous African countries

FIGO
Achievements:
1.
Development of a joint Statement FIGO/ICM on active and
physiological management of post partum haemorrhage
2.
Production of a ‘flow chart’ to show how initial excessive
bleeding should be managed
2.
Production of models to demonstrate balloon techniques suturing- manual removal
3.
Guidelines for surgical techniques of balloon tamponade and
compression sutures (vs internal iliac artery ligation or
embolisation)
4.
Guidelines for misoprostol use for prevention and treatment
of PPH
Advocacy


Reputation and position of health professionals in society makes
them ideal advocates at local, regional and national levels
 Make the public aware of MNCH national problems and
solutions
 Lobby the government for better health and hold it
accountable through MNCH progress reviews
Example
 Uganda ObGyn society advocates parliamentary commission
on MNCH progress. As a result of the review the President
calls for maternal death audits
Joint statements
A joint statement
 Defines the public health problem
 Defines necessary actions that governments and MOHs
need to take to promote PPH control
 Describes best practices to promote
Information on the joint statement can be used to:
 Develop clinical guidelines
 Develop national action plans
Signing joint statements – Mali,
Benin, and Ghana

Mali


Ghana
Benin
During Ghana joint statement signing: Issues
raised to ensure access to PPH interventions
1.
2.
3.
4.
5.
6.
7.
Potency of the uterotonics
Low midwifery tutor: student ratios
Insufficient numbers of clinical instructors to support
midwifery students in the acquisition of practical skills
Motivation and equipment for midwives posted to
Community-based Health Planning and Services
(CHPS) sites
Policy governing the use and application of misoprostol
at the community level to manage PPH
Training of midwives in the seven basic functions of
emergency obstetric and newborn care (EMONC)
Policy changes to enlarge midwives’ scope of practice to
include selected EmONC interventions
Training

Members of professional associations promote best
clinical practices and training techniques by:
 Collaborating with medical/ midwifery schools in the
development and deployment of curricula for all
professional cadres
 Collaborating with the MOH:
 in the design and implementation of curricula for
non-professional workers – community health
workers and non professional birth attendants
 in the design and implementation of curricula for
in-service education, e.g. promoting training
activities at point of service, promoting
interdisciplinary training activities
Examples: Associations involved
in training activities
DRC: Representatives of the ob/gyn association
participate in validation and review of curriculum
for pre-eclampsia/eclampsia
 Mali: Representatives of the midwifery and
oby/gyn associations are members of the national
maternal health task force that reviews curricula
for in-service training and provides guidance on
program implementation

Support research to update
clinical practices
Misoprostol
 Conservative surgical treatment for PPH

Misoprostol could play an important role in saving lives
of thousands of women, particularly in low-resource settings
Conservative Surgical Treatment for PPH
Method
No of Cases
Success rates
B-Lynch + other
Compression sutures
94
90.4%
Arterial embolization
218
91%
Arterial ligation
264
83.7%
Uterine balloon
tamponade
135
83.7%
Major challenges to using professional organisations
to overcome barriers to implementation of
interventions for PPH control
 Professional associations
 May not have any legal standing in the country
(e.g. they do not certify professionals, set
national exams, etc.)
 May be excluded from program implementation
activities because they are not donors
 Usually have budgetary constraints because they
depend on meagre membership dues and
sporadic grants
 May not be systematically included in countrylevel maternal task forces
Solutions to challenges facing
professional organisations
Gain visibility by seeking funding to support research
activities
 Promote membership by professionals working in the
MOH, teaching institutions, etc., who can advocate for
the presence of the professional institutions when
developing and updating curricula, etc.
 Develop champions who can serve as representatives
of the professional organizations in activities involving
maternal health
 Garner support for the local associations by associating
with the international professional associations

Recommendations for Country
Professional Organisations (1)
Keep abreast of research – you can only promote
best practices if you are aware of them
 Advocate for the presence of representatives of the
midwifery and ob/gyn associations on national
maternal task forces
 Foster close relationships with the MoH,
Hospitals, and Training institutions
 Keep abreast of health policies that may serve as
barriers to access to important maternal health
care

Recommendations for Country
Professional Organisations (2)





Serve as champions for policy change, where needed,
to increase access to PPH interventions
Advocate for the presence of representatives of the
midwifery and ob/gyn associations on committees
developing learning materials
Advocate for adequate Teaching and Training material
and time for training
Advocate for adequate financial resources to carry out
the proposed actions, medications and facilities
Lead the implementation of better monitoring and
evaluation practices
“Women are not dying because of diseases we cannot treat.
They are dying because societies have yet to make the
decision that their lives are worth saving.”
Mahmoud Fathalla - 1997
THANK
YOU