1. MOVING TO ACTION: Identifying Responses

2. Learning objectivesBy the end of this session, participants will be able to: • Identify actions appropriate to data presented • Use the action tool and support its implementation • List ‘evidence based actions’ • Prioritise actions in a systematic way

3. Taking action to reduce avoidable maternal deaths is the reason for conducting MDSR

4. What are appropriate actions?

5. Scenario • A 21-year old had her 3rd baby at home. • Her first baby died after a difficult delivery. Her second baby was premature and survived. • During this pregnancy, she attended antenatal care at the local health centre. • She started bleeding 1 hour after delivery of a healthy baby. The local skilled birth attendant (SBA) came within 1 hour. • She found the woman very pale and collapsed and gave her oxytocin and then misoprostil. • The SBA suggested moving the woman to the local hospital , an hour away, as the bleeding continued. The husband did not agree and the woman died

6. Practical exercise • Work on your own • Consider the 9 possible actions listed on pg. 22 in the workbook • List the 3 actions you think would be most effective in this case

7. ?

8. What are evidence based actions? Actions for which there is over whelming evidence that maternal mortality and morbidity will be prevented if they are followed. • Usually refer to clinical actions, based on trials • Individual cases should be assessed to see if “best practices” were carried out or not • If not, appropriate action should be taken to ensure these are implemented to prevent further deaths • Ethiopian Guidelines (FMOH) for A/N and intrapartum care provide details

9. General Family planning Iron HIV Malaria SBA and Birth preparedness Health education & promotion

10. Eclampsia • Diagnosis and treatment of high blood pressure • Magnesium Sulphate • Timely delivery

11. Haemorrhage • Active management of third stage of labour • Misoprostil • Blood transfusion (dependent on environment)

12. Sepsis • Clean delivery • Antibiotics for prolonged ruptured membranes at term • Antibiotics for C/S • Avoid prolonged delivery

13. Abortion • Availability of safe abortion • Availability of post abortion care including safe MVA or D&C and i/v antibiotics

14. Obstructed labour • Facility delivery after 12 hours of labour • Use of partograph • Availability of C/S

15. Non clinical actions • Not all problems identified during the review and analysis have clinical solutions • Actions in the community e.g. Changing health-seeking behaviour, addressing transportation, reducing costs of accessing care, also play a role. • Innovative solutions come about through community participation in identifying and carrying out actions likely to be successful.

16. Prioritising!

17. Which actions? • Not all problems can be tackled simultaneously • Prevalence – how common is the problem? • Feasibility of carrying out the action – are there extra staff available? Is it technologically and financially possible? • What is the potential impact of the action? • If successfully implemented how many women would be reached and how many lives saved?

18. Prioritisation Exercise

19. Prioritisation

20. (Facilitated Discussion) • Which action(s) address the most prevalent problems • Which action(s) are most feasible? (Why or why not?) • Which action(s) will deliver the most impact? • Reminder that prioritisation is subjective and best done in a multi disciplinary team including community members ( especially non clinical)

21. Group exercise using action tool • 6 groups of 5-6 each • Details and scenario in Workbook • Exercise simulates facility committee • Action tool completed for the scenario described