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Are national policies and programs for prevention and management of postpartum hemorrhage and preeclampsia adequate? A key informant survey in 37 countries.

Smith JM et al. Are national policies and programs for prevention and management of postpartum hemorrhage and preeclampsia adequate? A key informant survey in 37 countries. Glob Health Sci Pract July 3, 2014.
Abstract / Summary: 
ABSTRACT Introduction: Although maternal mortality has declined substantially in recent years, efforts to address postpartum hemorrhage (PPH) and preeclampsia/eclampsia (PE/E) must be systematically scaled up in order for further reduction to take place. In 2012, a key informant survey was conducted to identify both national and global gaps in PPH and PE/E program priorities and to highlight focus areas for future national and global programming.   Methods: Between January and March 2012, national program teams in 37 countries completed a 44-item survey, consisting mostly of dichotomous yes/no responses and addressing 6 core programmatic areas: policy, training, medication distribution and logistics, national reporting of key indicators, programming, and challenges to and opportunities for scale up. An in-country focal person led the process to gather the necessary information from key local stakeholders. Some countries also provided national essential medicines lists and service delivery guidelines for comparison and further analysis.   Results: Most surveyed countries have many elements in place to address PPH and PE/E, but notable gaps remain in both policy and practice. Oxytocin and magnesium sulfate were reported to be regularly available in facilities in 89% and 76% of countries, respectively. Only 27% of countries, however, noted regular availability in health facilities of misoprostol. Midwife scope of practice regarding PPH and PE/E is inconsistent with global norms in a number of countries: 22% of countries do not allow midwives to administer magnesium sulfate and 30% do not allow them to perform manual removal of the placenta.   Conclusions: Most countries surveyed have many of the essential policies and program elements to prevent/manage PPH and PE/E, but absence of commodities (especially misoprostol), limitations in scope of practice for midwives, and gaps in inclusion of maternal health indicators in the national data systems have impeded efforts to scale up programs nationally.
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Selected extracts: 
'In 2010, approximately 287,000 women worldwide died of pregnancy-related causes — a decline off 47% since 1990. Despite this considerable progress, maternal mortality remains unacceptably high in many
countries, with sub-Saharan Africa and South Asia having the greatest burden of maternal death.'
'Technical inconsistencies in national SDGs [service delivery guidelines] must be addressed. National guidelines were sometimes incomplete or out-of-date, a fact that sometimes conflicted with respondents’ answers to the survey. This suggests that stakeholders may perceive their country guidelines to be more accurate than they in fact are. Such discrepancies may be expected as national SDGs try to keep pace with the advancing and evolving global evidence. Efforts must be made, however, to disseminate new information and to support countries as they revise existing guidelines.'
KEY MESSAGE: Most surveyed countries have many supportive policies and program elements, but issues remain that impede maternal health efforts, including: inconsistent availability of essential commodities, particularly misoprostol; limitations on midwives' scope of practice; incomplete or out-of-date service delivery guidelines; and weak reporting systems.

[Neil Pakenham-Walsh comment: The paper also notes that WHO revised its PPH guidelines in 2012 to state that ˜when skilled birth attendants are not present and oxytocin is unavailable, community health care and lay health workers should administer misoprostol (600 mg PO) for PPH prevention." It would be interesting indeed to learn more about the process in different countries for consideration of these (and other) WHO guidelines, and how long it takes for such guidelines to be incorporated into national policy and practice.]

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Smith JM et al. 

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