S Arulkumaran Professor & Head of Obstetrics & Gynaecology St George’s University of London

1. 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

2. 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

3. Implementation Service provision Data collection Policy development Advocacy Training Champion consultation Facilitation General Principle to Promote access to effective interventions

4. 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

5. 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

6. 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

7. FIGO Achievements: • Development of a joint Statement FIGO/ICM on active and physiological management of post partum haemorrhage • Production of a ‘flow chart’ to show how initial excessive bleeding should be managed • Production of models to demonstrate balloon techniques - suturing- manual removal • Guidelines for surgical techniques of balloon tamponade and compression sutures (vs internal iliac artery ligation or embolisation) • Guidelines for misoprostol use for prevention and treatment of PPH

8. 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

9. 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

10. Signing joint statements – Mali, Benin, and Ghana • Mali • Benin • Ghana

11. During Ghana joint statement signing: Issues raised to ensure access to PPH interventions • 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

12. 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

13. Examples: Associations involved in trainingactivities • 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

14. Support research to update clinical practices • Misoprostol • Conservative surgical treatment for PPH

15. Misoprostol could play an important role in saving lives of thousands of women, particularly in low-resource settings

16. Conservative Surgical Treatment for PPH

17. 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 country-level maternal task forces

18. 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

19. 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

20. 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

21. “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