FINAL AddisMeetingReport 0627

Interventions for Impact in Essential
Obstetric and Newborn Care

Africa Regional Meeting
2125 February 2011
Addis Ababa, Ethiopia
Meeting Report
Editors
Jeffrey Smith
Joseph de Graft-Johnson
Galina Stolarsky
Rachel Taylor
Interventions for Impact in Essential

Obstetric and Newborn Care
2125 February 2011
Addis Ababa, Ethiopia
Meeting Report
Editors
Jeffrey Smith
Galina Stolarsky
Rachel Taylor
TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ....................................................................................... v
ACKNOWLEDGMENTS .......................................................................................................... vii
INTRODUCTION ....................................................................................................................... 1
OPENING CEREMONY ............................................................................................................ 3
Individual Remarks ......................................................................................................................3
Keynote Address: Maternal and Newborn Health in the Africa Region................................4
PART I: INTERVENTIONS FOR IMPACT IN OBSTETRIC HEALTH

PLENARY SESSIONS .............................................................................................................. 7
Reducing Maternal Mortality Due to Postpartum Hemorrhage (PPH) .................................7
Panel #1. New Evidence for Prevention and Treatment of
Postpartum Hemorrhage ................................................................................. 7
Panel #2. Overcoming Programmatic Barriers to Implementing
PPH Prevention at the Facility Level ............................................................. 11
Panel #3. Experiences of Implementation of PPH Prevention and
Treatment at the Community Level ............................................................. 14
Panel #4. Quality of Care: Essential Obstetric Care ...................................................... 18
Understanding the Evidence: Preventing, Detecting and Managing
Pre-Eclampsia and Eclampsia (PE/E) ..................................................................................... 24
Panel #5. Evidence for Prevention and Detection of
Pre-Eclampsia................................................................................................. 25
Panel #6. Evidence for Management of Severe Pre-Eclampsia
and Eclampsia ................................................................................................ 29
Panel #7. Implementation of PE/E Programs ................................................................ 32
Cross-Cutting Issues in Making an Impact in Obstetric Health........................................... 38
Panel #8. Measurements and Indicators to Assist
PPH and PE/E Programming and Call to Action........................................... 38
Reducing Newborn Mortality Due to Asphyxia ...................................................................... 42
Panel #9. Improving Neonatal ResuscitationHelping Babies Breathe ...................... 42
GROUP AND TEAM ACTIVITIES ........................................................................................... 49

Skills and Discussion Sessions ................................................................................................ 49
Summary of Interventions for Reduction of Morbidity and Mortality ................................ 53
Addis Meeting Report
iii
CLOSING ACTIVITIES (OF PART I) ....................................................................................... 56

Individual Reflections ................................................................................................................ 56
Posters Awards Ceremony........................................................................................................ 57
Closing Remarks ........................................................................................................................ 57
PART II: HELPING BABIES BREATHE (HBB) REGIONAL TRAINING OF

TRAINERS (TOT) FOR AFRICA
A. OVERVIEW OF NEWBORN RESUSCITATION TRAINING .............................................. 58
B. ORIENTATION AND SETTING THE STAGE: PLENARY SESSION ON IMPROVING
NEONATAL RESUSCITATION23 FEBRUARY ................................................................... 58
C. HELPING BABIES BREATHE TRAINING OF TRAINERS
24, 25 FEBRUARY ................................................................................................................ 59
1.
2.
3.
4.
5.
6.
7.
8.
9.
Opening Session
Participants
HBB Course Design and Learning Materials
Session One: Provider Component
Session Two: Facilitator Component
Discussion of HBB Implementation at the Country Level
HBB Closing Ceremony and Presentation of Certificates
Course Evaluation
Next Steps
APPENDICES ......................................................................................................................... 69
Appendix A. List of Participants
Appendix B. Conference Agenda
Appendix C. Presenters Information
Appendix D: Results of Country Program Poster Reviews
Appendix E: HBB Course Objectives and Detailed Agenda
Appendix F: HBB Participant, Observer and Facilitator List
Appendix G: HBB Knowledge and Skills Assessments
Appendix H: Addis HBB Facilitator Guide
REFERENCES...................................................................................................................... 114
iv
ABBREVIATIONS AND ACRONYMS

AAP
American Academy of Pediatrics
AMTSL
Active management of third stage of labor
ANC
Antenatal care
CHW
Community health worker
CI
Confidence interval
EmOC
Emergency obstetric care
EmONC
Emergency obstetric and newborn care
EONC
Essential obstetric and newborn care
ECSACON
East, Central, and Southern African College of Nursing
FIGO
International Federation of Gynecology and Obstetrics
FP
Family planning
HBB
Helping Babies Breathe
HIS
Health information system
HMIS
Health management information system
ICM
International Confederation of Midwives
IU
International unit
LGA
Local government authority
mcg
Microgram
MCH
Maternal and child health
MCHIP
Maternal and Child Health Integrated Program
MDG
Millennium Development Goal
MgSO4
Magnesium sulfate
mL
Milliliter
MMR
Maternal mortality ratio
MNCH
Maternal, newborn and child health
MNH
Maternal and newborn health
MOH
Ministry of health
NGO
Nongovernmental organization
PE/E
Pre-eclampsia and eclampsia
POPPHI
Prevention of Postpartum Hemorrhage Initiative
PPH
Postpartum hemorrhage
QoC
Quality of care
RCQHC
Regional Centre for Quality of Health Care
SBA
Skilled birth attendant
SBM-R
Standards-Based Management and Recognition
TBA
Traditional birth attendant
USAID
United States Agency for International Development
VSI
Venture Strategies Innovations
WHO
World Health Organization
WHO/AFRO
WHO Africa Regional Office
vi
ACKNOWLEDGMENTS
This Africa Regional Meeting was organized by USAIDs flagship Maternal and Child Health
Integrated Program (MCHIP) with funding from the United States Agency for International
Development (USAID), as well as financial and administrative support from the Bill & Melinda
Gates Foundation-supported Oxytocin Initiative, and in collaboration with the WHO Africa
Regional Office (WHO/AFRO), the International Federation of Gynecology and Obstetrics
(FIGO), the International Confederation of Midwives (ICM) and the Federal Ministry of Health
of Ethiopia. Additional support was provided by Venture Strategies Innovations (VSI), USAIDfunded Africas Health in 2010, the American Academy of Pediatrics, the Laerdal Foundation
for Acute Medicine, the Regional Centre for Quality of Health Care (RCQHC)/Kampala and the
East, Central, and Southern African College of Nursing (ECSACON).
Special acknowledgment is made of the work of all colleagues at the MCHIP Office in Ethiopia
for their administrative, technical and logistical support.
MCHIP would like to thank the following organizations that supported participants, speakers
and facilitators at the conference:
American Academy of Pediatrics
PATH
Africas Health in 2010
Population Council
Bill & Melinda Gates Foundation
Regional Centre for Quality of Health Care (RCQHC)
International Confederation of Midwives
UNICEF
Gynuity
UNFPA
Jhpiego
University of British Columbia
Laerdal Foundation for Acute Medicine
University of Oxford
MacArthur Foundation
USAID/Washington
MCHIP/Washington, DC
USAID regional and country missions
MCHIP/Country Offices
Venture Strategies Innovations (VSI)
Management Sciences for Health (MSH)
World Health Organization
National Institutes of Health
We also would like to thank everyone whose special efforts helped to make this conference a
success.
This program and report were made possible by the generous support of the American people
through the United States Agency for International Development (USAID), under the terms of
the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-000. The contents are
the responsibility of the Maternal and Child Health Integrated Program (MCHIP) and do not
necessarily reflect the views of USAID or the United States Government.
The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global Health flagship
maternal, neonatal and child health (MNCH) program. MCHIP supports programming in maternal, newborn
and child health, immunization, family planning, malaria and HIV/AIDS, and strongly encourages
opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health
and health systems strengthening.
vii
viii
INTRODUCTION
The Africa Regional Meeting on Interventions for Impact in Essential Obstetric and Newborn
Care was held in Addis Ababa, Ethiopia, the week of February 2125, 2011. Organized by the
Maternal and Child Health Integrated Program (MCHIP), USAIDs flagship maternal, neonatal
and child health (MNCH) programwith financial and administrative support from the Bill &
Melinda Gates Foundation-supported Oxytocin Initiative; in collaboration with the
International Federation of Gynecology and Obstetrics (FIGO) and the International
Confederation of Midwives (ICM);and with additional financial, as well as material and/or
technical assistance from Venture Strategies Innovations (VSI), the USAID-funded Africas
Health in 2010, the American Academy of Pediatrics (AAP), the Laerdal Foundation for Acute
Medicine, the Regional Centre for Quality of Health Care (RCQHC) and the East, Central, and
Southern African College of Nursing (ECSACON)the meeting brought together policy leaders,
experienced clinicians and program managers with a goal to support accelerated
implementation and expansion of maternal and newborn health programs in countries
throughout Africa, with a specific focus on Prevention and Management of Postpartum
Hemorrhage, Pre-Eclampsia/Eclampsia and Newborn Asphyxia.
Over 300 individuals representing 36 countries attended the meeting (Appendix A), including
participants and presenters from the UK, Canada, Switzerland, Sweden, New Zealand, Norway,
USA and the following African countries:
Angola
Ghana
Mauritius
South Sudan
Benin
Kenya
Mozambique
Swaziland
Botswana
Lesotho
Nigeria
Tanzania
Congo
Liberia
Rwanda
Uganda
Equatorial
Guinea
Madagascar
Senegal
Zambia
Malawi
Somaliland
Zimbabwe
Ethiopia
Mali
South Africa
The Africa Regional Meeting on Interventions for Impact in Essential Obstetric and Newborn
Care was designed to help African countries pursue these evidence-based interventions and
strengthen national programs aiming to improve maternal and neonatal health.
Part I of the Meeting, February 21 to 23, focused on maternal healthsharing experiences
about implementation of programs for the prevention and management of PPH and PE/E.
Recognizing that a fundamental component of skilled attendance is the provision of essential
obstetric and newborn care (EONC), this meeting reviewed programmatic progress in
addressing PPH, presented technical evidence for interventions to prevent and manage PE/E,
and discussed the implementation of interventions to reduce PPH and PE/E in Africa. Part I
also included a plenary session on newborn asphyxia (Panel #9). This was intended to function
as a bridge to Part II of the meeting, which was a training-of-trainers event for the Helping
Babies Breathe (HBB) initiative. It also provided an update on critical issues in addressing
newborn asphyxia for attendees who would not be participating in Part II of the Meeting.
Part II of the Meeting, February 24 and 25, focused on the development of experts and
advocates to address newborn asphyxia by expanding their knowledge and skills in newborn
resuscitation techniques and state-of-the-art newborn care interventions. In collaboration with
the USAID-funded Africas Health in 2010, the AAP, Laerdal Foundation for Acute Medicine,
RCQHC in Kampala, and ECSACON, this two-day training workshop aimed to create national
and regional trainers for the HBB initiative, and support the expansion of programs for
neonatal resuscitation within the context of essential newborn care.
* * *
A detailed agenda for Part I is found in Appendix B; Part IIs objectives and detailed agenda are
found in Appendix E.
It is expected that this Meeting will assist country programs, donors and governments in
developing comprehensive and innovative programs to address public health priorities in
maternal and newborn health.
OPENING CEREMONY
The meeting was opened by Dr. Yassir Abduljewad, Deputy Country Director of Jhpiego
Ethiopia, who welcomed all participants of the Meeting to Addis Ababa, the capital of Africa.
It proceeded with welcome and remarks from organizers, funders and the host government.
INDIVIDUAL REMARKS
Dr. Koki Agarwal, Director of MCHIP, set the tone by highlighting the main goal of the
Meetingto improve the maternal and newborn health in African countries. The advent of the
Meeting has generated enthusiastic response, said Dr. Agarwal, which underscores the
importance of these issues. As the Meeting would represent a joint effort to reduce maternal
mortality by focusing on major causes of maternal mortality, postpartum hemorrhage and preeclampsia/eclampsia, sharing ideas to improve and further research and interventions would be
at the heart of it. Dr. Agarwal extended special thanks to USAID and the Bill & Melinda Gates
Foundation for their generous support and guidance.
Ms. Becky Ferguson, of the Bill & Melinda Gates Foundation, expressed her delight to be part
of the Meeting that would focus on three key causes of maternal and newborn mortalityPPH,
PE/E and newborn asphyxia; she emphasized the importance to the MNCH community of
sharing experiences. Ms. Ferguson communicated how proud the Foundation was to be part of
the event, as well as its commitment to being a leader in the area of maternal and neonatal
health. Ms. Ferguson closed her speech with a recommendation to the meeting participants to
focus on high-impact interventions.
Ms. Mary Ellen Stanton, Maternal Health Team Leader at USAID, welcomed the participants
on behalf of USAID and commented that the Meeting presented an opportunity to review
evolving evidence and keep a spotlight on key interventions that will make a difference. Ms.
Stanton underscored the notion that new policy work, including norms and guidelines, is
moving in the right direction, but that there remains a need for better indicators to monitor
high-impact interventions.
Her Excellency Advocate Bience P. Gawanas, Commissioner of Social Affairs, Africa
Union, proudly spoke about Addis Ababas being the capital of Africa, where the African Union
is based. She applauded the Meeting organizers for bringing the latest developments in
maternal and newborn care to Africa. For the African Union Commission, said H.E. Adv.
Gawanas, maternal health is a high priority, as was demonstrated at the Kampala Summit
"Maternal, Newborn and Child Health and Development in Africa," held in July 2010. The
Maputo Plan of Action, adopted at the Summit, aims to improve reproductive health conditions
for millions of women across the continent through providing sustainable financing, improving
integrated health services and systems, and monitoring and evaluation. Also, H.E. Adv.
Gawanas highlighted the Campaign for Accelerated Reduction of Maternal Mortality in Africa
(CARMMA), allocated at national level in 24 countries, which brings maternal health to the
center of attention in the country and encourages governments to improve the maternal health
situation and translate policy into action. This campaign is Africa owned and African led, she
saidpromoting good practices and encouraging and intensifying action. Support is needed for
the CARMMA campaign, explained H.E. Adv. Gawanas, who then identified Meeting
participants as the people on the ground who can make a difference. The causes of maternal
mortality are well known, she reiterated; we need to come up with guidance for interventions to
address them. She closed her speech with a moving sentence: Africa cares. No woman should
die while giving life.
Honorable Ambassador Michael Battle, US

Africa cares. No woman should
Ambassador to the African Union, congratulated the
die while giving life.
Meeting organizers for leadership and passion for
H.E. Adv. Bience P. Gawanas
improving health of women and children in Africa.
Maternal deaths in Africa are unacceptably high, said Mr.
Battle. The US government supports global health initiatives aimed at improving health
outcomes for women and girls and calls for more engagement of women and girls in education
and economic development. Commenting on the previous speaker, Mr. Battle noted that
CARMMA represents high-level commitment to improvement of health of nations; he said that
the US government supports the CARMMA campaign and looks forward to ongoing partnership
with the African Union for CARMMA.
Dr. Kesete Berhan Admasu, State Minister, Ministry of Health of the Federal Democratic
Republic of Ethiopia, welcomed the participants of the Meeting to Addis, the capital of Africa
and cradle of mankind. Dr. Kesete Berhan Admasu highlighted that the Ministry of Health
stays very committed to improving health of mothers, children and newborns and achieving the
Millennium Development Goals (MDGs). The next five years will be focused on improving the
quality of care; special attention will be given to maternal and neonatal care, he explained, as
the recent assessment of emergency maternal care demonstrated enormous gaps. The Ministry
of Health, Dr. Kesete Berhan Admasu continued, has a clear action to address those gaps
through procuring ambulances, distributing magnesium sulfate, and establishing mandates to
allow health workers to use misoprostol, oxytocin and other drugs available at health facilities.
KEYNOTE ADDRESS: MATERNAL AND NEWBORN HEALTH IN THE AFRICAN

REGION
Dr. Pyande Mongi, representing WHO/AFRO, delivered the keynote address. She focused on the
somber facts of maternal and neonatal health in Africa, the coverage for the key interventions
and the way forward.
Sub-Saharan Africa has dramatically higher maternal mortality ratios than any other part of
the worldthree out of five maternal deaths globally occur in Africa. Most countries are not on
track to meet MDGs 4 and 5: the maternal mortality ratio in Africa is currently 620, while the
MDG calls for a ratio of 228 or less. Newborn mortality is holding back progress on MDG 4 in
many countries: 1.16 million newborns die in the first month of life in Africa. Eritrea and
Equatorial Guinea are the only two African countries on track to meet MDG 5, and seven
countries have made no progress toward meeting the MDG. Figure 1 shows progress toward
MDG 5 by countries in the region.
Figure 1. Progress toward MDG 5 by Country
But we know who is at risk, where

they live, what we must do and
how to do it!
Pyande Mongi, WHO/AFRO
Of maternal deaths, 75% are directly due to obstetric complications; delays in decision-making
at all levels and transportation to facilities are also contributing factors. According to the WHO
World Health Statistics, coverage of key interventions for maternal and newborn health (MNH)
is very low, especially in the first hours and days and hours when mothers and newborns are
most at risk.
The inequities based on social and economic status, as well as geographic location, are great.
Further disparities exist between urban and rural settings. For example, in Ethiopia, only 6% of
women have access to skilled care; among them, urban women have far more access than rural
women. Furthermore, there is striking inequity in accessing midwifery care, with poor women
getting only limited services; this means that the national figure of the skilled birth attendant
coverage reflects the higher access of the countrys rich populations. Mothers education is also a
contributing factor to access to services.
To address the maternal and newborn health situation, the Ministries of Health of the Africa
Region adopted the MNH Roadmap in 2004, and the CARMMA campaign was launched in 23
countries. WHO/AFRO Strategic Directions 20102015 includes putting the health of mothers
and children first. As the next step, the African Union Summit in July 2010 in Kampala
announced the regional commitment to improve maternal and neonatal health.
But, despite all of the efforts and commitment of governments and partners, challenges remain
in government and leadership, health systems, infrastructure, funding and overall coordination.
Very few countries have the necessary resources and support to fully implement their MNH
Roadmaps toward universal access to key interventions. We dont have a lot of resources and we
arent getting the most for our money.
But we know who is at risk, where they live, what we must do and how to do it. To move
forward, we need to scale up the most effective interventions to achieve our goalswith a
special emphasis on skilled birth attendance. Solutions to improvements in maternal health
include: increasing access to skilled birth attendants; scaling up emergency care and family
planning; strengthening linkages between HIV and reproductive health, malaria and maternal
care; and empowering women. Solutions to improvements in newborn health should focus on
low-technology interventions and include better breastfeeding practices, warming, appropriate
hygiene and cord care, along with having skilled health care attendance for mothers and babies
at delivery and during the immediate postpartum period.
The WHO plays a significant role in generating and implementing solutions through advocacy,
policy strategy and development, and capacity-building. We use advocacy to increase funding
and ensure better use of it. The policy strategy and development includes decentralization,
health care financing, integrated MNCH service delivery, and human resource development.
And capacity-building is focused on ensuring the availability of skilled birth attendance and
emergency obstetric and newborn care.
We have a shared responsibility to reach all mothers with the services they need!
PART I: INTERVENTIONS FOR IMPACT IN

OBSTETRIC HEALTH
Severe bleeding after childbirth (postpartum hemorrhage, or PPH) and complications that arise
from uncontrolled increase of blood pressure (pre-eclampsia/eclampsia, or PE/E) are the most
common causes of maternal mortality in developing countries. Research shows that the majority
of maternal deaths in developing countries are due to PPH and PEE (Figure 1).
These deaths are tragic; they also could be prevented. Increasing evidence shows that simple,
cost-effective, low-technology interventions can significantly decrease the number of maternal
lives claimed by PPH and PE/E (Figure 2).
Day 1 of the Meeting was devoted to discussions of the evidence and recommendations for PPH
prevention and treatment at the facility and community levels. Information on the presenters is
provided in Appendix C.
Figure 2. Main Causes of Maternal Death and Interventions to Address Them
There is a core set of proven interventions

to address the leading causes of maternal death
Magnesium Sulfate
Aspirin
Anti-hypertensives
Cesarean section
Postabortion care
Eclampsia
Abortion
18%
Iron folate supplements

De-worming
Malaria intermittent treatment
Anti-retrovirals
Uterotonics: oxytocin &

misoprostol
Hemorrhage
Blood transfusion
35%
9%
Tetanus toxoid
Clean delivery
Antibiotics
Active management of
the third stage of labor
Pre-eclampsia
Family planning
Sepsis
8%
Indirect and Other

Direct
30%
Family planning
Nutrition
Underlying causes: unintended pregnancy

and under-nutrition
Source for Causes: Countdown to 2015
Part I: Interventions for Impact in Obstetric Health
Plenary Sessions
REDUCING MATERNAL MORTALITY DUE TO POSTPARTUM HEMORRHAGE
(PPH)
A leading cause of maternal mortality in the world, hemorrhage contributes to one of every
three maternal deaths (19972007). And women in the developing world are particularly
vulnerable14 million women (or 26 every minute) experience PPH there annually.
Postpartum hemorrhage (PPH) is commonly defined as blood loss >500 mL in the first 24 hours
after delivery and severe PPH is loss of 1000 mL or more. Although PPH is preventable and
treatable, it is unpredictable and requires rapid care to prevent life-threatening consequences.
Nearly half of all postpartum deaths are due to immediate PPH; a woman may die from
hemorrhage in as little as two hours of onset if she does not receive proper treatment.
Day 1 of the Meeting was devoted to discussions of the evidence and recommendations for PPH
prevention and treatment at the facility and community levels.
Panel #1: New Evidence for Prevention and Treatment of Postpartum

Hemorrhage. Moderator: Koki Agarwal, MCHIP.
New Guidance on PPH Prevention and Management
Matthews Mathai, representing WHO/Geneva, described the latest WHO recommendations
for the prevention of PPH and guidelines for its management.
PPH is the principal cause of maternal death in Africa, and there
was an increasing demand for guidance on misoprostol use in
African countries for prevention of PPH. WHO convened two
meetings on prevention (October 2006) and management
(November 2008) of PPH, which resulted in the development of
recommendations for prevention of PPH (2007) and guidelines for
treatment of PPH and retained placenta (2009).
The WHO recommendations for prevention of PPH state that
oxytocin is the preferred uterotonic, and that active management
of third stage of labor (AMTSL) by skilled attendants should be
offered to all women to prevent PPH. Misoprostol is less effective
than oxytocin and has more adverse effects, and ergometrine may
be used if oxytocin is not available but should be avoided in
women with hypertension and heart disease. In the absence of
personnel to offer AMTSL, trained health workers should offer 600 mcg misoprostol orally
immediately after birth of the baby. In such cases, no active intervention to deliver the placenta
should be carried out.
For management of PPH due to uterine atony, evidence from PPH prevention studies suggests
that oxytocin is preferable to other uterotonics. If oxytocin is not available or if bleeding
continues, ergometrine or fixed-dose combinations (FDC) of oxytocin and ergometrine are
recommended. If this second-line treatment is not available or if bleeding continues, a
prostaglandin should be used as third-line treatment.
In women who have received oxytocin during the third stage of labor, oxytocin alone should be
used (moderate-to-high quality strongly recommended). Studies did not find added benefit of
misoprostol as adjunct treatment. In women who have not received oxytocin for PPH
prevention, oxytocin alone should be offered for treatment (moderate-to-high quality strongly
recommended). Oxytocin has higher effectiveness than other uterotonics with fewer side effects.
WHO recommends making oxytocin available where it is currently not offered. Misoprostol may
be used if no other uterotonic is available but the safest dose is not yet clear.
Other recommendations for treatments for PPH include:
Uterine massagestart when PPH is diagnosed
Bimanual uterine compression and external aortic compression as temporizing measures
Uterine packing is not recommended!
Intrauterine balloon/condom tamponadeif no response to uterotonics or if uterotonics are

not available
There is currently no recommendation on the anti-shock garment. A trial is ongoing. The WHO
does not recommend distribution of misoprostol to community-level health workers or women
and their families for routine or emergency use. WHO recommends research at the community
level to investigate how PPH can be managed effectively at this level.
The next update of WHO guidance on PPH prevention and treatment is planned for 2012.
Updates on Use of Misoprostol for Prevention and Management of PPH

Dr. Beverly Winikoff, President of Gynuity Health Project, described results of two doubleblind, hospital-based studies to assess use of misoprostol as first-line treatment, and
discussed the recommendations for misoprostol use for prevention and management of
PPH.
Misoprostol is safe, affordable, easy to administer and logistically appropriate in many settings.
The perception of misoprostol is changing from that of an abortion drug to that of a maternal
health drug. Studies have shown that misoprostol reduces PPH with 2425% efficacy, compared
to placebo. It is safe and effective for PPH prevention in community settings; providers at all
levels can be trained to use it. Oxytocin is preferred, but misoprostol can fill gapsparticularly
in rural areas.
Because misoprostol does not require refrigeration, there are obvious logistical advantages for
its use in community settings. Currently, in fact, misoprostol may be the only PPH prevention
option that is feasible. Therefore, it should be recommended as a safe and effective alternative
intervention for use at home deliveries and in low-resource settings where injectable oxytocin is
not available or not feasible. There are no published comparative studies between misoprostol
and oxytocin in primary health centers (PHCs) or home delivery settings. Misoprostol can be
used for PPH treatment as:
First-line treatment after prophylactic uterotonic
First-line treatment after no prophylaxis
Adjunct treatment (with oxytocin)
Last resort
Secondary prevention/early liberal treatment
Misoprostol as a first-line treatment: To assess the use of misoprostol as a first-line

treatment for PPH, two double-blind, hospital-based studies were conducted to compare 800
mcg sublingual misoprostol and 40 IU intravenous oxytocin for the treatment of PPH after: (1)
oxytocin prophylaxis in third stage of labor, and (2) no oxytocin prophylaxis. Results showed
that with oxytocin prophylaxis, misoprostol worked similarly to IV oxytocin; without oxytocin
prophylaxis, oxytocin worked slightly better than misoprostol (96% vs. 90%). Conclusion:
Misoprostol is a good alternative when oxytocin is unavailable or not feasible to use.
Misoprostol as an adjunct treatment: Significantly more fever has been observed when
misoprostol is added to oxytocin. Therefore, there appears to be no reason to combine the two
drugs as there is no added benefit and more side effects.
Misoprostol as a last resort: There is little evidence on efficacy of misoprostol as a last effort
to save a womans life; while it is not ethical to conduct a study on this, the possible positive
effect probably outweighs the limitations, particularly in low-resource settings.
Misoprostol as a secondary prevention/early liberal treatment: To use misoprostol as a
secondary prevention or early treatment, a number of key questions should be discussed: Is
universal prevention needed? Do the costs outweigh the potential benefits? Does universal
prevention save lives? Would early treatment for some women be more effective both clinically
and programmatically versus prophylaxis for all?
Many questions are still unanswered, especially those around the comparable effectiveness of
misoprostol and oxytocin for prophylaxis and treatment, the appropriate dosage for lower level
facilities and home births, and the effectiveness of misoprostol as a prophylaxis for PPH
treatment. Working to address these issues will bring about new recommendations based on
recent evidence and broader consensus on recommended dose, route and use of the drugs.
Gynuity Heath Projects is implementing a five-year grant from the Bill & Melinda Gates
Foundation to answer remaining scientific questions around PPH and misoprostol and to
develop the policy approaches best suited to making this lifesaving technology available to
women.
Updates on New Technologies for Management of PPH

Dr. Sylvia Deganus, from Tema General Hospital, Ghana Health Services, spoke on the new
technologies for management of PPH.
PPH accounts for 25% of maternal deathsmore than any other cause. More than half of PPHs
occur within 24 hours of childbirth, but it is difficult to predict who will experience PPH, even
based on risk factors. New technologies for management of PPH include drapes for measuring
blood loss, balloon tamponade, anti-shock garments and new surgical methods.
Drapes: Prompt recognition of an emergency situation (hemorrhage) is often challenging as
blood loss is difficult to measure accurately; it can happen very quickly and delays can be costly.
Visual estimates of blood loss are far from accurate. In the past, pans and other primitive
means were used to collect blood. The Brass-V drape is a low-cost, plastic blood collection drape
that is accurate and easy to use. It also can be used in wide variety of settings.
Balloon Tamponade: Using a latex balloon inserted into the uterus to stop the bleeding by
applying pressure to the uterine wall is another promising technology that can effectively be
used in low-resource settings. (The balloon is filled with 250 to 500 mL with normal saline or
water; when bleeding is reduced, the technician stops further inflation.) The balloon tamponade
has proven very effective (85%) when uterotonics fail, is easy to use and reduces the need for
hysterectomy. The cost is between $77 and $250. A condom tamponade (a low-cost variation of
the balloon tamponade), however, has a total cost of about $5. Figure 3 provides a detailed
illustration of this cost-effective alternative.
New Intra-Operative
Techniques: These include uterine
compression sutures, arterial
ligation/pelvic devascularization,
selective arterial embolization and
use of topical hemostatic agents.
They control bleeding by
tamponade compression of the
uterus or by reducing blood flow to
the uterus.
Figure 3. Cotton Tamponade for Treating PPH
Non-Pneumatic Anti-Shock
Garment (NASG): This simple
device counteracts shock and
decreases blood loss by applying
direct counter-pressure to the lower
parts of the body. It was developed
by NASA over 20 years ago, and is
useful as a first aid tool that helps
to keep a woman alive during prolonged transportation to reach help, providing stability for up
to 48 hours. The device itself, consisting of neoprene segments with Velcro closures, can be
easily applied within 2 minutes by persons with minimal training.
There is a need to disseminate information about the availability of these new technologies to
prevent and manage PPH, as well as a need for further researching themto develop more
evidence for their use and promotion. Most of these technologies will work best where facilities
are already prepared with EmOC infrastructure and skills.
Landscape Study of Use of Uterotonics in Ghana

Patience Cofie, Research Coordinator at PATH, presented findings of the study on use of
traditional pharmaceutical uterotonics in births and assessment of availability of valid
medication in Ghana, and summarized recommendations that came out of these findings.
This study, conducted in 2010, was supported by the Oxytocin Initiative and managed by PATH
with funding from Bill & Melinda Gates Foundation. The study: (1) explored the knowledge,
perceptions and usage patterns of uterotonics around childbirth; and (2) assessed the chemical
potency of uterotonics in Ghana, specifically a sample of ampoules of oxytocin and ergometrine
purchased through private pharmacies, chemical sellers and markets in Ghana. The study
design included in-depth interviews with health providers and community representatives and
incorporated a stimulated client approach of purchasing the drugs.
The study found that place of labor and delivery is influenced by previous and current
complications experienced by women during childbirth and is a strong predictor of birthing
practices, particularly uterotonic use. There was no evidence of pharmaceutical uterotonic use
in communities and no evidence of traditional (herbal) uterotonic use in health facilities.
10
The study produced the following key findings and recommendations:
Among midwives, knowledge of the risks associated with uterotonics and appropriate
dosages is inconsistent. Some midwives administer oxytocin to augment prolonged labor.
Also, doctors are often unavailable or inaccessible to prescribe a uterotonic, so mid-level
providers are forced to make a decision regarding course of treatment independently.
Traditional birth attendants (TBAs) and new mothers are unaware of the risks associated
with use of traditional substances during pregnancy and labor. An enormous variety of
traditional substances are used throughout this period; the indications for their use vary
and are unclearwith very little consistency regarding which substances are to be used in a
given situation, by what route, and with what dosage and frequency.
Recommendation: Training, supervision and monitoring of midwives in both

AMTSL and PPH treatmentshould be strengthened.
Recommendation: Behavior change communication programs should be launched

at the community level using both mass media and traditional channelstargeting
mothers, TBAs and traditional/community leaders.
The majority of available pharmaceutical uterotonics (oxytocin and ergometrine) at the

peripheral level are of poor quality. None (0%) of the ergometrine samples met potency
specifications (with active ingredient level between 90% and 110% of the specified level; only
26% of oxytocin ampoules met specifications (90110%). However, only 4% of oxytocin
ampoules and none of the ergometrine ampoules were expired.
Recommendations: Based on findings, the following actions are warranted:

Further market surveillance and testing of uterotonic drug quality
Investigation of and improvements to transportation, distribution and storage of
uterotonic drugs
Enforcement of regulations on sale of uterotonic drugs (oxytocin and
ergometrine) by the Ghana Pharmacy Council
A general discussion that followed the presentations focused on issues regarding midwives and
their role in the use of uterotonics. Another topic for a short discussion was misoprostol and the
research needed to move it forward in the fight against PPH: specifically, there is a need for more
evidence and experience with its use, upon which WHO can develop its recommendations. Also,
more information was requested on traditional uterotonics and behavior change communication
strategies for use at the community level.
Panel #2. Overcoming Programmatic Barriers to Implementing PPH

Prevention at the Facility Level. Moderator: Alice Levisay, Oxytocin Initiative.
Postpartum Hemorrhage Prevention: Benin Experience
Dr. Aboudou Mama Sni, representing the Ministry of Health of Benin and the Hpital de la
Mreet de l'Enfant Lagune (HOMEL), where she is the Chief Medical Officer, spoke about
the process of introduction of AMTSL at the national level, described results and discussed
factors that contributed to success.
In Benin, issues of maternal health have national attention. EmOC was implemented in 1999,
AMTSL was introduced in 2003 and, in 2009, a joint statement for prevention of PPH was
signed by midwifery and obstetrics/gynecology (ob/gyn) associations. Because professional
11
associations in Benin have had good experiences working together, a national-level action plan
was developed to guide the integration of AMTSL with existing clinical guidelines. With the
incorporation of AMTSL in patient care, PPH incidence and, subsequently, maternal deaths
were reduced. Two studies to assess benefits of AMTSL initiated in Benin validated
international studies. The PPH study conducted at the Hpital de la Mreet de lEnfant
Lagune Mother and Child Hospital (HOMEL) showed significant reduction in maternal
deaths: from 6,628 PPH-related deaths when AMTSL was not used to 21 deaths with use of
AMTSL.
Training of providers was of the most importance in the introduction of the new practices.
Training of trainers (TOT) followed by training of providers and integration of AMTSL with the
pre-service curriculum were the steps toward improvement of services. Currently, 97% of health
zones (33 out of 34) in Benin have trained providers; a total of 2,461 providers were trained in
AMTSL using humanistic and competency-based approaches.
Other components of success include active coordination and collaboration with partners, strong
support from the national and zonal budget, rational use of fellowships that provided training
opportunities at no cost to providers, structured monitoring and evaluation of services, and
training of supervisors. Another very important factor was the readiness of the MOH to provide
strong support for the PPH prevention agenda, involving both public and private sectors.
Overcoming Provider Barriers to Introduction and Sustainability of AMTSL at

Facilities
Susheela M. Engelbrecht, representing PATH and the Oxytocin Initiative, discussed
determinants of the use of AMTSL in a facility, described three interventions that address
facility-based provider-related barriers to introduction and/or sustainability of AMTSL in
facilities, and explained successful interventions for improving sustainability of AMTSL in
facilities in a given country.
Active management of third stage of labor (AMTSL) is defined as combination of three steps: (1)
administration of a uterotonic drug within 1 minute of birth of the baby, (2) controlled cord
traction with counter-pressure to support the uterus, and (3) immediate uterine massage
following delivery of the placentawith evaluation of uterine tone and repeat massage at least
every 15 minutes for at least 2 hours. Early cord clamping (defined as clamping immediately
after birth of the baby) is not part of the ICM/FIGO definition of AMTSL.
The USAID-funded Prevention of Postpartum Hemorrhage Initiative (POPPHI), led by PATH,
conducted 10 national surveys in 2007 showing that while providers used uterotonic drugs
relatively consistently during third and fourth stages of labor, very few actually administered
them within the first minute after birth to prevent PPH (less than 30%).
The program identified a number of facility-based provider-related barriers to introduction
and/or sustainability of AMTSL in facilities: (1) Policies may prevent certain cadres from
applying AMTSL; (2) Providers may either not be trained or not be consistently trained in the
procedure; (3) AMTSL may not be integrated with supportive supervision activities; (4) There
may not be indicators for AMTSL and uterotonic drugs to monitor progress; (5) Uterotonic drugs
may not be consistently available due to logistical problems; and (6) Uterotonic drugs may not
be stored correctly, making them and thus AMTSL less effective. To address these barriers,
there is a need for: (1) Policies that promote application of AMTSL by all birth attendants in the
facility; (2) Training activities that ensure that at least 80% of the population of birth
12
attendants apply AMTSL consistently and competently; (3) Internal and external supervisory
systems that monitor the practice; and (4) Indicators to follow progress.
Examples of successful interventions to address provider-related barriers to sustainable
introduction of AMTSL include: (1) Changing AMTSL Behavior in Obstetrics (CAMBIO)
development and dissemination guidelines at the facility level, training and monitoring, use of
reminders and job aidsin Argentina; (2) Self and Individual learning (SAIN)training of
mentors/clinical instructors at each facility, use of a learning approach that combines selfdirected learning and clinical practicum under supervision at the facility level, wall charts to
monitor AMTSL coverage, and job aidsin Ghana and South Africa; and (3) Intensive posttraining supervision and peer training in Democratic Republic of Congo (DRC.)
A wealth of information on PPH prevention and management can be found on the POPPHI Web
site: www.pphprevention.org.
Overcoming Barriers to Implementing PPH Prevention at Facility Level: The

Role of Professional Associations
Dr. Sabaratnam Arulkumaran, Professor and Head of Obstetrics & Gynaecology, St.
Georges University of London and President Elect at FIGO, described success stories of
professional organizations that have worked to reduce barriers to access interventions to
prevent and treat PPH, provided recommendations for country professional organizations,
and listed major challenges and solutions for professional organizations to overcome
barriers to implementation of interventions for PPH control.
The role of professional associations in the prevention and treatment of PPH is to provide
leadership on issues surrounding PPH, advocate for PPH control initiatives, support research to
update clinical practices, promote best practices, facilitate knowledge and skill transfer, and
support efforts to assure quality. There are many examples of successful collaborationsuch as
the partnership of FIGO and International Confederation of Midwives (ICM) in the Prevention
of Postpartum Hemorrhage Initiative (POPPHI)that have resulted in new strategies to
promote: (1) expansion and improvement of the quality and availability of AMTSL at the facility
and community levels; (2) use of best practices and creation of new learning materials and job
aids; and (3) the development and signing of joint statements for work with their member
associations around the world. FIGO is collaborating with global partners on PPH reduction
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.
FIGOs contribution to the global effort to address PPH includes development of a joint
statement (FIGO/ICM) on active and physiological management of postpartum hemorrhage, as
well as the production of guidelines, models and job aids for prevention and treatment of PPH.
Joint statements are very effective in advocacy efforts, as they: define the public health
problem; describe best practices that should be promoted to screen for, prevent and manage the
problem; and spell out necessary actions that governments should to take to address the issue.
They also can be used in the development of clinical guidelines and national action plans.
Professional associations may also influence change by advocating on all levels and directly
promoting best clinical practices through active collaboration with the MOH and medical and
midwifery schools in the curricula-development process. Good examples of such collaborations
exist in DRC and Mali.
13
While many country-based professional associations still experience challenges ranging from
not having legal standing in the country to not having sufficient funding to carry out activities,
there are steps they can take to be able to offer input in the national health efforts. These
include seeking funding to support research and training activities, promoting membership and
developing champions, and strengthening their position by associating with the international
professional associations.
A general discussion that followed the presentations focused on the following issues:
How do blended learning and training time affect retention of information? As it is a
complicated and time-consuming learning method, support of the learner is very important.
How do we overcome political barriers to AMTSL scale-up? There are important issues
surrounding the qualifications of SBAs and policy changes for uterotonics. Each country must
analyze its own situation. Women are dying while we are arguing who is a skilled birth
attendant, said Dr. Arulkumaran.
Aggressive marketing of misoprostol now seems to have overtaken oxytocin. Need aggressive
marketing of Uniject as first-line treatment. If it becomes a national priority, the economy of
scale can be reached. (Note: As a pre-filled, non-reusable injection device, the Uniject
[developed by PATH] eliminates one route of disease transmission and ensures that the
correct amount of drug is delivered and that none is discarded unnecessarily.)
Panel #3: Experiences of Implementation of PPH Prevention and Treatment

at the Community Level. Facilitator: Becky Ferguson, Bill & Melinda Gates
Foundation.
PPH Prevention and Treatment in Africa Using Misoprostol at Community
Level
Dr. Ndola Prata, Associate Professor and Bixby Scientific Director, University of California
at Berkeley, spoke on considerations for PPH prevention and treatment on the community
level, described studies that demonstrate the feasibility and effectiveness of use of
misoprostol at home births and discussed how to prioritize program efforts at the
community level.
There are widespread disparities in maternal indicators based on socio-economic status,
including the MMR and access to skilled assistance and quality ANC and EmOC care.
Countries with limited resources and populations in the lower quintiles are those that could
benefit most from quality interventions for home births.
If a woman does not have regular access to quality ANC services and later to care during
delivery at the hospital, it is important to prevent PPH at the community levelby filling the
gap through utilizing existing resources and changing behaviors and practices. We need to look
at misoprostol at the community level and to introduce quality interventions that support its
use in this setting.
Critical considerations for PPH treatment at home birth include the following issues: Who is
present at the birth (who can be reached/trained before the delivery)? How will women/family
get the drug (distribution mechanism)? When is the drug administered and how is PPH
identified (issues of blood loss measurement)? What is the route of administration?
14
A number of studies have shown the feasibility and effectiveness of the introduction of PPH
treatment in the home birth setting. And operations research study in Northern Nigeria showed
that distribution of misoprostol to women increases the safety of birthing at home. A study in
Kigora, rural Tanzania, that looked at the use and effectiveness of misoprostol for treatment of
PPH at community level, showed that: (1) TBAs can effectively and safely administer the drug
for treatment of PPH; and (2) this resulted in fewer women with cases of PPH requiring
additional interventions after an estimated 500 mL of blood loss.
Misoprostol offers women the ability to deliver at home while being safer. It also allows TBAs to
be present and assist with giving the uterotonic. We need to identify the best way to reach
women through those who provide care for them during their pregnancy. Distributing
misoprostol during ANC is a possibility, but there is a need for strong community awareness.
We need figure out where to focus our efforts at the community level. Should it be prevention,
treatment, or another intervention? We need to try to maximize safe birth at home through
making as many interventions as possible available.
Programmatic and implementation strategies for effective misoprostol distribution at the
community level should include the following: know the community; have an effective
awareness campaign; integrate misoprostol distribution with community interventions; and
improve services in delivery rooms.
At the policy level, there is a need for commitment to protect all deliveries from PPH through
scale-up, proper allocation of human and financial resources, integration of PPH treatment in
the package of maternal health services, and strong procurement practices at all levels of
service.
When Active Management of Third Stage of Labor Is Not Possible

Karen Guilliland, representing the International Confederation of Midwives, examined the
evidence for the components of physiological management of the third stage of labor and
discussed its use and components when uterotonic drugs are not available.
Active management of third stage of labor (AMTSL) is recommended as the primary method for
prevention of postpartum hemorrhage, but what alternative methods are there if uterotonic
drugs are not available? This presentation focused on examining the evidence for and defining
the components of the physiological management of third stage of labor.
AMTSL country surveys (20072009) showed a wide difference in practices when uterotonic
drugs were not used for third stage management. There is little conclusive research to define
the components of physiological management of third stage; there is also considerable variation
of opinion among countries and disciplines regarding what is considered a component of
normal birth versus what is considered an intervention. Midwives, as the main practitioners
of physiological management of third stage, also differ but have the most similarities.
ICM and FIGO formed an expert taskforce to look at physiological management and the
standard of practice. ICM conducted a survey of current best practices; 39 ICM Member
Association Countries responded. The surveys showed that there was consensus around signs of
placental separation and how to support women to expel the placenta, and practices during the
first two hours after birth. There was also consensus on the practices regarding the cord care: to
not use controlled cord traction in the absence of uterotonic drugs and not clamp or cut the cord
until after the placenta is delivered.
15
Recommendations for moving ahead include the following: the physiological management of
third stage should be a common competency, and every birth attendant should be taught the
ways to assist the woman during the third stage of labor; more research is needed around
physiological management of third stage; and women need to be educated in self-care during
labor.
PPH Prevention through Platform of Antenatal Care

Dr. Albert Kitumbo, of Ifakara Health Institute, Tanzania, described testing the model of
misoprostol distribution during ANC visits, reviewed its results and discussed its
implications for other programs.
In Tanzania, 94% of women attend at least one ANC visit during their pregnancy, but 53% of
women give birth outside of facilities. Misoprostol has been shown to be safe for preventing PPH
at home deliveries. By educating women and distributing misoprostol during ANC visits,
women who deliver at home will have access to this lifesaving technology.
Operations research to test the model of misoprostol distribution during ANC visits was
conducted in four districts of Tanzania between January and December 2009, supported by
Ifakara Health Institute, Venture Strategies Innovations (VSI) and Bixby Center at the
University of California, Berkeley. The study provided evidence that:
Women can safely self-administer misoprostol for prevention of PPH at home births after
being educated on and receiving the drug at ANC visits,
ANC visits are a feasible and effective means of distributing misoprostol for PPH prevention
to women who cannot get to a facility to deliver and give birth at home, and
Women and communities find misoprostol to be an acceptable means of preventing PPH at

home births.
Figure 4 shows the components of a successful model of misoprostol distribution during ANC
visits.
Figure 4. Model for ANC Distribution of Misoprostol
Based on the tested knowledge of

women about PPH and birth, the
program was highly effective.
There was also a high level of
acceptability of the intervention
among women. The challenge
revealed by the study was that not
as many women return for an
ANC visit after 32 weeks
gestation, as was anticipated;
thus, they did not receive
misoprostol due to the gestational
age requirement (32 weeks or
more) to receive the drug for PPH
prevention.
The results of this study suggest

the following programmatic and
policy next steps: (1) Countries with similarly high rates of ANC visits and lower rates of facility
16
delivery should consider distribution of misoprostol during ANC visits; (2) The program should
be scaled up by training all ANC providers to distribute misoprostol during ANC; and (3) The
gestational age requirement for distributing misoprostol should be lowered or eliminated to
increase coverage.
Clinical and Community Action: Pathfinders Model to Address Postpartum

Hemorrhage
Dr. Farouk Mohammed Jega, Program Manager with Pathfinders Nigeria Country Office,
spoke on Pathfinders approach to reduction of maternal mortality and its key elements,
and described application of the approach in the field.
Pathfinder developed its Clinical and Community Action Model to address the four delays that
greatly contribute to maternal mortality. Delays 13 (recognition, decision and transportation)
occur at the community level, while Delay 4 (quality, timely care at the health facility) is
focused on the facility but also has a community component. The key elements of the Clinical
and Community Action Model to address PPH are advocacy, clinical interventions and
community engagement.
Advocacy interventions take on creating enabling policies for the introduction of innovations
and new technologies and working with the government to address sustainability and take the
model to scale. This effort involves pre-service and in-service training, recruitment and
retaining health workers, equipment and supplies for EmOC, permission to work with TBAs,
and other scale-up activities.
Clinical interventions focus on: (1) preventing, recognizing and managing PPH; and (2) ensuring
relevant skills, equipment and supplies, and protocols at each level to support the continuum of
care. Training activities include accurate estimated blood loss measurement, AMTSL and
appropriate management of PPH (identifying the cause of bleeding to determine treatment;
managing hypovolemic shock using a non-pneumatic anti-shock garment [NASG], IV fluid
replacement, blood replacement and surgery including b-lynch technique).
Community engagement is key, focused on creating awareness on the danger signs and
available interventions, establishing community-to-facility referral and transport mechanisms,
and promoting birth preparedness.
The program works in five countries (Nigeria, India, Bangladesh, Tanzania and Peru), with
different emphases on the three components. This model is complete, practical and adaptable
and has a resulted in significant reduction of PPH. While each element is valuable, the complete
modelincluding all three elementsmay have the most significant impact on maternal
mortality. The model can be adapted for other causes of maternal mortality, such as preeclampsia and eclampsia, as well.
17
Panel #4. Quality of Care: Essential Obstetric Care. Moderator:

Yirgu Gebrehiwot, Ethiopian Society of Obstetricians and Gynecologists
(ESOG).
Assessing the Quality of Services to Prevent and Manage Postpartum
Hemorrhage: A Report from the MCHIP Quality of Care Survey
Linda Bartlett, Associate Scientist at the Bloomberg School of Public Health, Johns Hopkins
University in Baltimore, Maryland, spoke on the Quality of Care Survey developed by
MCHIP, described facility assessment tools and instruments, and reflected on the
combined results of the survey in four countries.
Approximately half of all births in developing countries take place in facilities and yet the
quality of maternal and perinatal care is unknown in many settings. The MCHIP Quality of
Care Survey (QoC-MNC) was conducted to:
Guide QoC-improvement activities for maternal and newborn care at facility, regional and
national levels;
Provide baseline estimates for countries to monitor improvements in care; and
Develop indicators and data collection tools that can be used in multiple countries.
Whether there is a difference in outcome between distributing misoprostol at ANC visits in
rural versus urban communitiesWhile it is easier and more reliable to distribute and monitor
in urban areas, it does not make a difference in the ultimate outcome.
How to be sure that all of the women took the misoprostol when necessaryIn the study,
questionnaires were distributed and filled out after the birth by research assistants. They
included questions about whether the woman took the drug and about the birth experience.
One question that helped in determining whether the women had taken misoprostol was to
ask about any side effects they experienced.
How much misoprostol should be given at the community level and whether it is possible to
reduce the dose of misoprostol in the study protocols to determine if lower doses would be as
effective as the standard 600 mcg. (Note: It would be cheaper to use a lower dose. Also, there
is some debate as to what dosage is safe; with a large-scale intervention, careful consideration
should be given to potential widespread side effects when determining dosage amount.)
Reducing the dose is a good idea but it has not been done very often because of the
standard set by previous studies (using 600 mcg misoprostol). Also, it would be difficult to
convince countries to have a clinical trial of misoprostol at doses that have not already been
established/studied, although there is no reason why this might not change in the future.
The survey introduced a facility assessment toolkit with eight data collection instruments to
assess the quality of care for prevention, identification and management of common serious
maternal and early neonatal complications. The survey was modeled after the AMTSL survey,
with a special focus on pre-eclampsia/eclampsia, postpartum hemorrhage, prolonged/obstructed
labor, sepsis, essential newborn care and resuscitation. It was conducted in Ethiopia, Kenya,
Tanzania, Zanzibar, Rwanda and Madagascar (20092010), and will be conducted in Zimbabwe
(planned for 2011).
18
The survey can be done as a stand-alone activity, or embedded in other facility assessment or
readiness surveys, such as Service Provision Assessments (SPAs) developed by ICF MACRO. It
can also be done using personal digital assistants (PDA) for data entry and analyses or by
traditional paper and pencil. A single survey takes about two months to complete.
The combined results of surveys in four countries (Ethiopia, Tanzania, Rwanda and
Madagascar) show that: preventive and risk-screening practices in ANC are low (2246%);
knowledge/skill scores of providers are low (3946%); harmful practices are also low but should
be none. In the policy-to-action cascade for AMTSL, higher-level interventions are frequent,
whereas translation into actual practices on the frontlines is low. The relationship among the
components of AMTSL services is shown in Figure 5.
While there are some strong areas in quality of care, many areas can be strengthened. The next
steps suggested by the results of the surveys include: (1) development of country-specific and
overall reports and plans for how to respond, with interventions focused on the frontline, preservice and in-service education, and quality improvement, and (2) research on gaps identified,
including efforts to understand the disconnect between levels of the cascade and to determine
the dose and timing of uterotonic as the minimal effective intervention for PPH prevention.
Figure 5. Status of Policy-to-Practice Components for Preventing PPH
19
Emergency Obstetric and Newborn Care Assessments in Africa: Focus on

Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia
Dr. Koyejo Oyerinde, representing the Averting Maternal Death and Disability Program
(AMDD) at the Department of Population and Family Health, Columbia University, described
a series of cross-sectional, facility-based assessments of PPH and PE/E in Africa, discussed
their findings and shared examples of positive changes in countries with political will.
The Averting Maternal Death and Disability Program (AMDD) works to strengthen heath
systems to provide emergency care for all women experiencing life-threatening obstetric
complications; conducts research and policy analysis; provides technical expertise and advocates
for solutions; and collaborates with global, regional and local institutions, including NGOs and
academic centers. AMDD is part of the Mailman School of Public Health in the Department of
Population and Family Health at Columbia University in New York City.
The EmONC Needs Assessments are cross-sectional, facility-based studies of the capacity of a
health system to provide health services to mothers and newborns; they evaluate how well and
to what extent a health system is providing EmONC and serve as a basis for development of
indicators of the performance of health systems. The main focus of the assessment tools is
elements of quality of care, including: accessibility, coverage and equity, availability of aroundthe-clock services, capacity and availability of human resources, equipment and supplies, and
infrastructure. Countries customize tools to suit local needs for planning data.
Conducted surveys show chronic severe shortages of skilled birth attendants (SBAs) all over
Africa; inadequate infrastructure, lack of linkages between tiers of the health system; poorly
organized, nonexistent or ad hoc referral systems; and disabling policy environments. PPH is the
leading cause of maternal deaths in Africa; PE/E is a close second, and is the leading cause in
some countries. There are very low institutional delivery rates, especially in rural areas
(Ethiopia 7%, Madagascar 19%, Sierra Leone 10%), with higher rates in urban areas.
Nevertheless, there are some positive trends, including increasing global focus and funding for
MNH, such as the UN Secretary Generals Global Strategy on Maternal and Child Health, and
focus of the African Union Summit in Kampala in July 2010 on the MNH issues. Individual
countries have also demonstrated political will to improve health of women and children. Sierra
Leone, for example, made health services for pregnant and lactating mothers and children
under 5 years of age free in spring 2010, and initial reports suggest a phenomenal increase in
utilization. Madagascar has begun BEmONC training for midwives with emphasis on
supportive supervision. And Ethiopia has instituted a new health management information
system (HMIS) that captures major obstetric complications and performance of signal functions.
Many countries are beginning to authorize midwives and nurses to perform all basic EmOC
services (Nigeria, Ethiopia), and growing mobile-phone networks in most of Africa promise
opportunities for remote patient care, supportive supervision and HMIS data capture.
Useful resources on prevention and management of PPH and PE/E are available on the AMDD
Web site: www.amddprogram.org.
20
Tracking Scale-Up of Maternal and Newborn Health Interventions

Dr. Jeffrey Smith, Maternal Health Team Leader of MCHIP, described the conceptual map
of the process of scaling up national programs to prevent and treat PE/E and PPH.
Scaling up of critical interventions in maternal and newborn health is important to make an
impact on the health situation at the national level. We need data to understand the process of
scaling up; we also need to capture and understand the methods of scaling up. For maternal
health, we often lack country-specific data; only regional estimates are available. During this
meeting, participants would be talking about country-specific situations. As such, country teams
were asked to review their national situation in relation to PPH and PE/E before the meeting
and to summarize it on a poster that includes a conceptual map that we called a pathway to
implementation of critical interventions and management at scale.
These scale-up pathways will serve to organize data to inform national decisions for scaling up
critical interventions. A pathway describes phases of implementation that are sequential in
logicnot linear in time. It is an attempt to graphically represent the elements of a scale-up
approach, meant to track progress over time. It is envisioned that these pathways will create a
platform for national and international conversation about progress, as well as help to review
practical scale-up processes and identify gaps in and opportunities for securing additional
support/resources.
The pathway design includes phases of implementation and graphical representation of
elements of scale-up approach, global actions, interventions, monitoring and evaluation, and
degree of coverage. It presents information on national/country level and is not exhaustive. The
template of the pathway for PPH and PE/E is presented in the Figure 6 (A and B); the posters
presenting country-specific information on scale-up progress at the national level were
displayed in the hall. All participants were encouraged to review and discuss the posters.
All country-specific maps of scale-up progress (i.e., progress on the pathway) that were
developed as part of the preparatory exercise for this meeting, as well as review summaries, are
included in Appendix D.
21
22
Figure 6A. Template for Conceptual Map of PPH Scale-Up
23
Figure 6B. Template for Conceptual Map of PE/E Scale-Up
UNDERSTANDING THE EVIDENCE: PREVENTING, DETECTING AND MANAGING

PRE-ECLAMPSIA AND ECLAMPSIA (PE/E)
Pre-eclampsia, a life-threatening condition that may go undetected in pregnant women, is often
called a silent killer. Pre-eclampsia is characterized by high blood pressure accompanied by a
high level of protein in the urine, but without attention may go undetected and untreated.
When pre-eclampsia is left untreated, it develops into eclampsiathe final and most severe
phase of pre-eclampsia. Eclampsia can cause seizures, coma and even death of the mother and
baby and can occur before, during or after childbirth.
In many African countries, pre-eclampsia/eclampsia is the leading cause of maternal mortality,
often claiming as many womens lives as postpartum hemorrhage, sometimes more.
Day Twos plenary sessions focused on existing evidence to prevent, detect and manage preeclampsia and eclampsia, and on cross-cutting issuessuch as measurements and indicators to
assist PPH and PE/E programming. The sessions closed with a call to action.
Burden of Pre-Eclampsia and Eclampsia in Ethiopia

Dr. Mengistu Hailemariam, Maternal Newborn Health Advisor to the Federal Ministry of Health,
opened the session with an overview of maternal mortality in Ethiopia and its causes, described
the burden of pre-eclampsia/eclampsia, and reflected on interventions needed for improvement
of quality of care.
The latest statistic on the national maternal mortality ratio for Ethiopia is 470 (WHO 2008),
almost double the Millennium Development Goal target MMR of 267. While approximately 3
million pregnancies are expected annually, 25% of maternal mortality is due to hemorrhage and
12% hypertension; other causes are obstructed labor (20%), unsafe abortion (13%), and sepsis
(15%) and other causes (15%).
There is no national study on PE/E, and health institutions studies are scarce. Retrospective
review of the six available studies on hypertensive disorders of pregnancy (19662007)
demonstrated that 74.7% of the affected women were younger than 30 years of age and that
73.8% of pregnancy disorders were severe PE/E. Diazepam was used in the majority of cases for
management of PE/E, and mortality in cases of severe PE/E reached 23.8%.
Ethiopia has identified PE/E as one of the major causes of maternal mortality and is working on
improvement of the main components of quality health services. These include capacity-building
(ensuring pre-service and in-service training for health providers to detect and manage PE/E,
including magnesium sulfate in the national obstetric service guidelines), logistics (making
supplies available to health facilities for management of PE/E), and supportive supervision and
mentorship with the Obstetrics & Gynecological Society and other partners.
24
Panel #5. Evidence for Prevention and Detection of Pre-Eclampsia. Moderator:

Nahed Matta, USAID.
Calcium Supplementation for Preventing Pre-Eclampsia/Eclampsia
Justus Hofmeyr, representing the Calcium and Pre-Eclampsia (CAP) Study Group of the
University of the Witwatersrand and the Eastern Cape Department of Health, South Africa,
spoke about association of dietary calcium with rates of pre-eclampsia/eclampsia and
ways to ensure sufficient levels of calcium to prevent PE/E.
In 1962, a Lancet article described the astonishingly low incidence of pre-eclampsia (0.75%) in
Ethiopia, attributed to a diet rich in calcium and iron and low in carbohydrates (Hamlin 1962).
A study conducted between 1994 and 1999 in Ethiopia found eclampsia at the level of 7.1/1,000
deliveries, with a case fatality rate of 13%. This increase in eclampsia may have been due to a
change in diet that had reduced calcium and increased use of carbohydrates (Abate and Lakew
2006).
A growing body of evidence shows that calcium supplementation in the second half of pregnancy
decreases blood pressure and reduces serious complications related to hypertension, while
having no effect on other organ dysfunctions. Prevention of increased blood pressure helps to
prevent early deliveries and low birth weight, and postpones development of HELLP syndrome1
(Hofmeyr et al. 2007). While the trials of calcium supplementation to prevent pre-eclampsia/
eclampsia have a lot of discrepancies, the benefit is sufficient to justify programs to supplement
pregnant women with low-calcium diets. To prevent multisystem dysfunction, though, a woman
may need adequate calcium supplementation starting before pregnancy. Research is ongoing to
determine whether pre-pregnancy supplementation will reproduce the more dramatic
epidemiological differences.
The Calcium and Pre-Eclampsia (CAP) Study is being conducted at four sites in South Africa
and Zimbabwe. It is a randomized trial to evaluate the use of calcium 500 mg daily versus
placebo, commencing before conception and continuing to 20 weeks gestation. If found effective,
the next step will be trials of community-level calcium supplementation by food fortification.
Further research is needed to determine the ideal daily dose of calcium and where vitamin D
supplementation fits into the pre-eclampsia prevention strategy.
Options for calcium supplementation programs include: (1) individual supplementation during
pregnancy (limited to antenatal care attendees); (2) population supplementation through
fortification of staple foods; and (3) population dietary education. Food fortification has many
advantages, such as rapid improvements in the micronutrient intake and nutritional status of a
population, as well as being a cost-effective public health intervention. Fortifying staple foods
will provide physiological doses of micronutrients, will not require changes in existing food
patterns, does not depend on compliance, and presents minimal risk of toxicity when the
intervention is properly designed and regulated.
1HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels and a low platelet count; it may or may not be a
variant of pre-eclampsia.
25
Pre-Eclampsia/Eclampsia Interventions and Their Cost-Effectiveness

Steve Hodgins, the Global Leadership Team Leader for USAIDs MCHIP, reviewed costs and
efficacy of several maternal health interventions.
When making decisions about supporting new initiatives, we select among options based on
relative disease burden, effectiveness of the proposed intervention(s), feasibility and cost. This
presentation demonstrated the process of modeling to assess the efficacy and cost of key
interventions for PE/E prevention (antenatal calcium from 20 weeks and aspirin from 15 weeks,
compared with antenatal iron folate from 20 weeks) and treatment (MgSO4 loading dose),
compared with that of routine oxytocin during the third stage of labor to prevent postpartum
hemorrhage and iron-folate supplementation to prevent anemia.
To compare preventive and treatment interventions in a modeling exercise, we use averted
maternal and neonatal deaths per 100,000 pregnancies/deliveries reached. Depending on
evidence available, we use efficacy in reducing cause-specific mortality or overall maternal or
neonatal mortality.
To model mortality reduction efficacy, we multiply the MMR by the percentage of mortality
accounted for by the specific cause of death multiplied by the documented efficacy. Based on a
number of assumptions (MMR = 500, NNMR = 30, PPH% of MMR = 34%, PE/E% of MMR =
19%, Prematurity% of NNMR = 29%), the mortality-reduction efficacy of the interventions
under review is presented in Figures 7A and 7B.
Figure 7A. Maternal and Newborn Deaths Averted by
Key Interventions
Figure 7B. Cost of Key Interventions per 100,000

Reached
For simplicity of the presentation, costs in this modeling exercise have been restricted to those
that are commodity-related. Quantification was universal preventive versus case-management
for complications and the volume/quantity required per patient/beneficiary; unit costs are costs
per pill/ vial (from MSH price guide). The costs here are not fully loaded, as the intention here is
just to compare between interventions, focusing on commodity costs. Final calculations of the
costs will be available in a complete manuscript later in the year.
Conclusion: In deciding on new initiatives, it is necessary to consider disease burden,
effectiveness of interventions, feasibility and cost. Modeling helps to assess and compare
interventions and can be an aid to decision-makers, particularly in ministries of health and
among partner agencies. MCHIP is finalizing a more complete analysis, which is expected to be
available soon.
26
Pre-Eclampsia/Eclampsia: How Well Are We Screening for and Managing

PE/E?
Dr. Jim Ricca, Chief of Party for MCHIP in Mozambique, continued discussion on the MCHIP
Quality of Care survey, now focused on assessment of quality of screening and
management of PE/E.
Quality of care in maternal and newborn health comes to the center of attention of many
national governments and international organizations. Between 7% and 50% of countries
conducted assessment of facility-based births, and between 27% and 80% of countries assessed
quality of ANC coverage. While valuable in many respects, these surveys provide little
information on the quality of screening for and management of PE/E.
The MCHIP Quality of Care (QoC-MNC) survey focuses on routine care and prevention and
management of the most serious maternal and newborn complications, including PE/E. It was
described in Linda Bartletts presentation as part of the session on Quality of Care, with a focus
on PPH. In this presentation, we will review the results of this survey to identify quality of care
when it comes to screening for and management of PE/E.
Current WHO guidelines for ANC and care during labor and delivery (L&D) were used as
benchmarks, with a special focus on the WHOs Managing Complications in Pregnancy and
Childbirth (2000) guidelines. The sample represents 177 facilities in four countries (Ethiopia,
Tanzania, Rwanda and Madagascar); over 1,300 deliveries and over 1,100 ANC consults were
observed, and over 570 health
Figure 8. Gap Analysis for Screening for and Managing PE/E
workers were interviewed.
The studies concluded that there
are currently many missed
opportunities for PE/E screening.
Although taking blood pressure
correctly for screening during ANC
and L&D is relatively high (62%),
history taking for PE/E danger
signs in both the ANC clinic and
L&D ward is minimal, and urine
testing is very low (6%). Policies
need revision as in some countries
prevention and treatment of
eclampsia was found to be still
based on diazepam, and
commodities are often lacking, as
MgSO4 for treatment was
available in less than half (39%) of
facilities. As with PPH, knowledge/skills of providers and quality of supervision are also a
problem. Identified gaps were analyzed, as shown in Figure 8.
The studies demonstrated that there is an acute need to emphasize history taking and
counseling in addition to physical examination and testingwith strengthened training and
supervision, as well as improved commodity supply.
The finalized study protocol, assessment tools, smart phone applications and Web tables will
soon be available on the MCHIP Web site: www.mchip.net.
27
Screening and Early Detection of Pre-Eclampsia

Dr. Harshad Sanghvi, Vice President and Medical Director of Jhpiego, reflected on the large
unmet need for early detection of PE/E, missed opportunities at the facility level, and the
need to bring detection close to the womans home through a low-tech approach to testing
for PE.
Pre-eclampsia and eclampsia are now a focus of the MNH community for many reasons.
Mortality associated with PE/E shows little decline in more than 75% of low-resource countries;
between 7% and 15% of pregnant women develop pre-eclampsia (high BP and proteinuria), and
approximately 1% to 2% develop eclampsia. Pre-eclampsia and eclampsia contribute between
8% and 25% of maternal mortality and represent increased risk of perinatal mortality. Figure 9
shows recent maternal mortality data due to PPH and eclampsia.
For prediction of pre-eclampsia,
risk factors are not very useful.
Primigravidas are now about 50%
of the obstetric population, and a
significant proportion of PE occurs
postpartum; there is no effective or
affordable biochemical or
biophysical predictor available. All
pregnant women are potentially at
risk and need prevention or early
detection of PE.
Figure 9. Nepal Maternal Mortality Study 1998 and 2009

1998
2009
MMR
539
247
PPH
37%
19%
Eclampsia
14%
21%
Source: USAIDs Nepal maternal mortality and morbidity study 2008/09.
Aside from living a healthy lifestyle, using calcium has demonstrated decreased risk for PE/E in
pregnant women, although there is a concern that calcium supplements may be out of reach for
low-resource settings. And while many countries show a high level of at least one ANC visit, a
significantly lower number of pregnant women attend the recommended four ANC visits
(meaning there are fewer chances for early detection of PE). There is a large, unmet need for
early detection of PE/E and many missed opportunities. According to national Demographic and
Health Surveys (DHS), unmet need for checking BP during pregnancy ranges from 13.9% in
Indonesia to 53.1% in Bangladesh, and unmet need for urine testing to detect proteinuria
ranges from 39.8% in Zimbabwe to 81.3% in Malawi.
While BP and urine tests are necessary for early detection of PE/E, they may be challenging for
low-resource settings. Current BP measurement devices are relatively high-cost, cannot be
obtained easily and need frequent recalibration. Non-validated BP measuring devices are
marketed, and there is limited training of personnel in BP testing and managing problems
associated with high BP.
In the effort to detect all the pre-eclampsia before it becomes life-threatening, one approach is to
take testing for hypertension and proteinuria to women in their homesrather than depending
entirely on them to reach facilities. This calls for reliable, low-cost, culturally appropriate,
robust and innovative devices that can be used by semi-literate community workers.
Jhpiego has collaborated with the Johns Hopkins University's Center for Bioengineering
Innovation & Design to solve this problem with a low-tech approach. A number of innovative
solutions are currently being developed for this purpose. One of them is a manual, inflatable
device for BP testing. It features a self-deflating wrist cuff with digital pressure sensor to
provide feedback to a microcontroller connected to a hand-cranked generator, as well as
batteries and LED lights; a binary LED panel indicates sufficient power, inflation and color
codes that a semi-literate person can readily interpret. A red light indicates hypertension.
28
To measure urine proteinanother test for detection of

All pregnant women potentially
PEdeveloped countries commonly use urine dipstick
are at risk and need prevention or
tests. These tests are expensive even though the actual
early detection of PE.
test reagent is relatively cheap. A newly developed
Harshad Sanghvi, Jhpiego
prototype protein test is an extremely affordable pointof-care diagnostic device. A marker type pen is filled
with the test reagent in place of ink to mark an end of a strip of filter paper. Dipped in urine,
the marked strip of paper turns blue when there is elevated (0.7 g/L or more) protein. Pregnant
women can use this testing method at home and report to a provider if a color change from
yellow to blue occurs.
In addition to innovative, low-tech solutions to early detection of PE, use of the StandardsBased Management and Recognition (SBM-R) approach2 has been shown to improve quality of
screening, detection and management of PE/E among providersas demonstrated in the Nepal
experience.
Panel #6: Evidence for Management of Severe Pre-Eclampsia and Eclampsia.

Moderator: Deborah Armbruster, USAID.
Choice of Anticonvulsant for PE/E
Dr. Olufemi T. Oladapo, Senior Lecturer at the Department of Obstetrics & Gynecology,
Olabisi Onabanjo University in Sagamu, Nigeria, discussed the use of magnesium sulfate
for management of pre-eclampsia during labor.
Pre-eclampsia is a major cause of maternal death in Africa. Women can die from severe preeclampsia as well as from eclampsia. It is not necessarily a progression from one condition to
the other; women can suffer mortality and morbidity from severe PE as well.
Guidelines focused on pre-eclampsia are under development by WHO/Geneva and will be
discussed in a meeting in Geneva in April 2011. WHOs guideline development process is
rigorous in an effort to grade the evidence and comment on the strength of the recommendation.
The anticonvulsant of choice in severe pre-eclampsia and eclampsia is magnesium sulfate
(MgSO4), introduced for management of PE/E in the 1920s. While the mechanism of action is
still unclear, it can be safely and effectively used by practitioners. Mild side effects (flushing)
are common, but dangerous side effects (respiratory depression, cardiac depression) are very
rare. Magnesium sulfate results in a 59% reduction in the risk of an eclamptic seizure. It is
better than diazepam, phenytoin and lytic cocktail. Use of magnesium sulfate also has a lower
risk of 5-minute APGAR scores of less than 7 for the newborn.
There are few well-done studies that have looked at various regimens for use of MgSO4 for PE.
The majority of the studies have not been of sufficient quality to recommend a different
regimen. Measurement of serum levels of magnesium sulfate is not necessary for the
management of patients on MgSO4. Clinical management should be according to the WHO
Managing Complications in Pregnancy and Childbirth (2000).
2Jhpiegos practical management approach for improving the performance and quality of health services; it focuses not on
problems but rather on the standardized level of performance and quality to be attained.
29
Choice of Antihypertensive for PE/E

Dr. Peter von Dadelszen, Associate Professor of Obstetrics and Gynecology at the
University of British Columbia, described the requirements for an ideal antihypertensive
agent and evidence behind the choice recommendations for prevention of PE/E.
Severe hypertension is associated with the risk of maternal stroke, placental abruption and
many other maternal and perinatal risks. While there is no evidence of the benefit of using an
antihypertensive in non-severe hypertension (when BP is less than 160/110) (von Dadelszenet
al. 2000), there are many good reasons to use an antihypertensive when BP is greater than
160/110. The focus of this presentation was on pharmacological management of severe
hypertension.
The requirements for an ideal antihypertensive agent in rural and remote settings are: oral
administration, reliable and smooth reduction in BP, rapid onset of action and minimal
overshoot in order to keep the BP in target range. There are no randomized controlled trials for
placebo versus antihypertensive.
Magnesium sulfate is not an anti-hypertensive!
The selection of antihypertensives include hydralazine, beta-blockers (and alpha-/beta-blockers),
calcium channel blockers (CCBs), alpha-methyldopa, angiotensin-converting enzyme inhibitors
and angiotensin-II receptor blockers. The last two drugs should not be used in pregnancy due to
risks of fetal renal toxicity and intrauterine fetal death.
Most of the drugs can be administered orally. CCBs are more reliable than hydralazine in
lowering BP in pregnant women with severe hypertension, while hydralazine appears more
reliable than labetalol and is widely used. Nifedipine and labetalol are reliable in reducing the
BP, but methyldopa may be the best parenteral agent.
Reducing blood pressure acutely or too rapidly is not recommended because the womans brain
and the fetus may not tolerate it. CCBs and beta-blockers are less likely to cause overshoot than
hydralazine.
An intervention package should include up to three oral antihypertensive agent(s); the choice
for a single antihypertensive lies between methyldopa, nifedipine and another beta-blocker,
probably atenolol as labetalol may not be available on most essential drugs lists. There are
theoretical and practical reasons to have all available, including combined central nervous
system control, beta-blockade and vasodilatation. It is recommended to have a second effective
agent for women whose BP is resistant to another agent, and to reserve IV hydralazine for
obtunded/comatose women.
30
Timing of Delivery and Induction in Pre-Eclampsia

Dr. Matthews Mathai, Medical Officer at WHO/Geneva, spoke on the issue of induction of
delivery in case of pre-eclampsia or eclampsia and described the latest WHO
recommendations for induction of labor.
Pre-eclampsia affects both the mother and the fetus, reflecting that it is a multisystem disorder.
Elevated blood pressure and proteinuria are among the many other findings. The only definitive
treatment for pre-eclampsia is the delivery of the baby and the placenta.
Decision-making is based on the needs of both the mother and baby. Considerations of the
babys needs include gestation (delivery is more likely if baby is full-term), possibility of
stillbirth and newborn asphyxia. Maternal
Delivery of the baby and placenta
considerations are based on the degree of worsening of
must occur within 12 hours in the
disease (early delivery with severe disease) and possible
case of eclampsia.
complications. According to the WHOs Managing
Matthews Mathai, WHO
Complications in Pregnancy and Childbirth (2000),
delivery must occur within 12 hours of onset of
convulsions in eclampsia, and in severe pre-eclampsia, delivery should occur within 24 hours of
the onset of symptoms.
Trials that look at an expectant care (expectant management or watchful monitoring) approach
in severe pre-eclampsia when the gestation is remote from term have not demonstrated a
benefit of this approach; larger trials are needed. In addition, considerations regarding
availability of newborn intensive care unit (NICU) facilities, accessibility and costs of care, and
long-term survival of the neonate make this approach challenging (Churchill and Duley 2002).
A trial that looked at expectant management of PE at term showed that induction of labor is
preferred with no adverse fetal outcomes. For mild pre-eclampsia until 36 weeks, WHO
recommends expectant management with monitoring; after 37 weeks, the recommendation is to
induce labor (Koopmans et al. 2009).
The new WHO Recommendations for Induction of Labour (2011) recommend the following
induction techniques: oral misoprostol or vaginal misoprostol, low-dose vaginal prostaglandins,
balloon catheter, combination of balloon catheter plus oxytocin as an alternative method, and
oral or vaginal misoprostol in case of dead or anomalous fetus in third trimester. But it is not
recommended to do an amniotomy alone or use misoprostol in women with previous cesarean
section.
Current WHO Managing Complications in Pregnancy and Childbirth (2000) guidelines
recommend delivery within 24 hours for severe pre-eclampsia; and induction methods include
amniotomy, oxytocin, prostaglandins such as misoprostol, and balloon catheter.
PE/E Management Strategies at Different Levels of the Health Care System

Dr. Pius Okong, Associate Professor at Nsambya Hospital, Uganda, described how
involvement at each level of care could contribute to timely management of PE/E.
Case management of PE/E is based on early and appropriate diagnosis, prevention of seizures,
control of BP, evaluation of condition of the baby, evaluation of the condition of the mother (liver
function tests, renal function tests and complete blood count) and ongoing monitoring. Timely
management is of vital importance. As shown in Figure 10, there are many things everyone can
31
do at each level of care, including at the family and community levels, to help women and babies
survive PE.
Figure 10: Steps of Timely PE Management at
Each Level of Care
At the family/community level, pregnant women and

community health workers should be able to
recognize seizures and danger signs/symptoms, plan
for emergency and be ready to transfer to a basic
emergency obstetric and newborn care (Basic
EmONC) facility when needed. There is still a need
to have evidence to fill the gaps at the community
level, especially regarding information for
community health workers (CHWs) (diagnosis, urine
testing and choice of drugs).
The Basic EmONC facility should be able to

diagnose PE based on symptoms and tests; initiate
MgSO4 and antihypertensive; do ongoing monitoring for seizures, urine output and fetal status;
and plan for transfer to a Comprehensive EmONC facility when needed. More evidence is
needed regarding benefits of early PE treatment.
Comprehensive EmONC facility should have emergency plans, clinical drills and adequate
consumables, as well as be comfortable in using MgSO4 for PE/E. More evidence is needed
regarding the use of MgSO4 and timing of delivery in case of PE/E. It is necessary to practice
complex aspects of case management in health facilities, to prepare teams for adequate actions.
Job aids are very useful in supporting quality of care; Nsambya Hospital in Uganda developed a
job aid for the management of women with PE/E and use of MgSO4.
Dr. Okong closed by saying, We were excited about the Magpie trial,3 and thought that we
should use magnesium sulfate for seizure prophylaxis, but we are still a long way from routine
use of this.
Panel #7. Implementation of PE/E Programs. Moderator: Luc de Bernis,

UNFPA.
Induction in pre-eclampsia: Artificial rupture of membranes (AROM) is not recommended in
areas of high HIV prevalence. Sweeping of membranes is not a method of induction but can
reduce the need for formal induction.
Availability of MgSO4 means that sometimes you have 20% or 50% solutions; not
standardized. Need to ensure availability of correct formulation on the emergency tray at the
start of the shift.
Systolic blood pressure parameters for treatment: Women with a systolic BP >160 mm Hg will
start to stroke and therefore should be treated. This becomes more important as women
become older and heavier.
The principle of reduction of hypertension is to bring BP down about 10% per hour. It should
not be brought down too quickly. Hydralazine IV can have too acute an effect and is not
recommended.
3 The Magpie trial (19982001), a randomized trial comparing magnesium sulfate and placebo for women with pre-eclampsia,
demonstrated that MgSO4 reduces the risk of eclampsia without any substantive effect on longer-term morbidity and
mortality for the women or children.
32
Early Experience of Expansion of Use of MgSO4 in Nigeria

Dr. Jamilu Tukur, consultant ob/gyn at the Aminu Kano Teaching Hospital in Kano, Northern
Nigeria, described the introduction of magnesium sulfate to a state health system in an
area where it was not available and discussed the effects, results and challenges of its
introduction to the maternity.
Despite evidence, the use of magnesium sulfate is still not universal in Nigeria, but that is now
changing. The Society of Gynaecology and Obstetrics of Nigeria (SOGON) meeting in 2007,
which presented data on the efficacy and safety of MgSO4, served as the impetus. The
Population Council sought funding for the project from the MacArthur Foundation. Kano, the
most populous state (over 10 million) of Nigeria, was selected as the project site; the state has
44 local government areas (LGAs), 35 general hospitals and a free maternity scheme.
A survey in 2009 revealed that only Murtola Mohamed Specialist Hospital (MMSH) had
MgSO4, but used it rarely for PE/E. Through a cascade training of trainers, Population Council
trained midwives and physicians in 10 hospitals in Kano
Patients call MgSO4 the drug
State. They developed a protocol using IM MgSO4. Nearly
that prevents death!
60% of the women who were treated with MgSO4 had
Jamilu Tukur, Nigeria
attended the antenatal clinic. Staff reported 1.2% adverse
reactions and 4% of those treated for PE/E died. Overall,
reduction in maternal deaths from eclampsia during the project was 66%. The government was
so impressed with the results that they took over procurement of MgSO4 by the 10th month,
and trained staff initiated on-the-job training. MgSO4 protocols are now being taught in preservice education as well.
The project demonstrated not so much the benefits of MgSO4 (which were known) but that
evidence-based interventions are replicable and can be introduced into new areas, and that the
sustainability of a program is directly related to engagement of stakeholders.
The major challenges were stockouts in the early phase, the need for quality of ANC to be
improved, and inadequate transportation for women in labor, which delayed their access to
health facilities.
Management of Medicines and Pharmaceutical Supplies for Use in the

Prevention and Treatment of Pre-eclampsia and Eclampsia
Grace Adeya, Sr. Technical Manager for Maternal Child Health at the Strengthening
Pharmaceutical Systems (SPS) Program, described elements of the pharmaceutical
management cycle, and discussed pitfalls and steps to ensure sustainable supply of PE/E
medicines to the facilities.
Effective management of PE/E requires that necessary medicines and supplies are on hand for
immediate administration. PE/E medicines in many countries are part of the national
pharmaceutical supply system and are subject to the same structural, financial and human
resource constraints as all products that rely on this supply system. Effective management of
PE/E medicines and supplies requires careful procurement procedures with involvement from
the health staff who treat PE/E.
The pharmaceutical management cycle (Figure 11) involves selection, procurement, distribution
and use; its effectiveness depends on management support that includes standard operating
procedures, financing and management information system (MIS).
33

Figure 11: Elements and Framework of Pharmaceutical
Management Cycle
To ensure a sustainable supply of

PE/E medicines to the facilities,
each point in the pharmaceutical
management cycle should be
addressed. A procurement survey
conducted in Mali and DRC
assessed management of the
medicines and supplies for the
prevention and treatment of PE/E.
If uterotonics are available but not

included in the national standard
treatment guidelines or essential
medicine lists (EML), they are not
purchased with national funds.
Those who make procurement
decisions at the health facilities or
peripheral level need to know
whether the desired products are
on the EML. The education level
of staff working in the
procurement system is inconsistent; and, in many cases, no standards were in place to regulate
who should be making procurement decisions at different levels of health facilities. A Mali
survey revealed that 10% of the staff who are responsible for facility medical procurement have
a primary education and only 30% have an educational level above secondary. If the person
placing orders does not understand the need for PE/E medications, these drugs may be the ones
that are cut off the drug request due to budget restraints. The Mali assessment demonstrated
the inability of staff to maintain and utilize the data they have to estimate their medicine
requirements effectively.
Familiarity of the staff with a particular drug also influenced procurement decisions and
therefore the use of the drug. In DRC, 90% of staff knew that oxytocin is the recommended
medicine for the practice of AMTSL, but only 8% knew that MgSO4 is the recommended
medicine for the management of PE/E. Also, diazepam will continue to be available at the
health facilities due to its familiarity and lower cost, while MgSO4 is more expensive and still
unfamiliar.
To ensure proper pharmaceutical support for prevention and treatment of PE/E, the
pharmaceutical management cycle should be strengthened. This includes many steps, some of
which are as follows:
Selected PE/E drugs should be included in national EMLs and standard treatment
guidelines;
The appropriate cadre(s) should be involved in drugs and supplies procurement and
purchasing decisions at the national, regional and facility levels;
Every component of the procurement system should be regulated, have standard operating
procedures and be in compliance with best practices;
To introduce use of MgSO4 at all levels of service, it should be included in pre- and inservice training and continuing education programs; and
Maternal health issues should always be included among the health priorities.
34
Changing PolicyRwandas Change in Guidelines

Dr. Stephen Rulisa, obstetrician-gynecologist, lecturer at the University Teaching Hospital of
Kigali (CHUK), Rwanda, and the President of the Rwanda Medical Association, described
current national priorities in maternal and child health, changes made in the national
policies based on these priorities, and the effect that these changes had on the national
maternal mortality rate.
Maternal and child survival is on top of the list of Rwandas health priorities, having been
identified as absolutely crucial for the long-term health of the country on its road to
development. National priorities in maternal and child health include an affordable and quality
package of MNH services, improvement of EMOC, EONC and FP services; prevention and
treatment of fistula; gender and womens empowerment issues; male involvement; and
strengthening of the Ministry of Healths Health Information System (HIS). A combination of
approaches to support progressive developments includes active involvement of
parliamentarians in development issues, performance-based financing, incentives for women to
utilize ANC services, and involvement of communities and faith-based organizations.
If you want to change lives of women and children,
involve women in the decision-making process, said Dr.
Rulisa. Rwanda has the highest number of women in
decision-making positions in Africa.
Healthier mothers mean healthier

children, and healthier children
mean a healthier, more productive
society in the future.
Innovative changes in health policies include the

following:
Stephen Rulisa, Rwanda
Increased budget allocation for health over the years
Health insurance availability to 96% of the population in 2010, up from 3% in 2002
Involvement of professional bodies and other stakeholders
Oxytocin, MgSO4 and misoprostol introduced on essential drug list and decentralized to
health centers
Strengthened CHWs at the

community level; community
performance-based financing
through cooperatives
Formation of clusters from

different ministries to address
health issues
Use of innovative technologies

(Rapid SMS, phone for health,
phones to CHWs, Internet
access at the facilities)
Figure 12. Outcomes of Rwandas Policy Changes
The outcome of policy changes

and development has been the
rapid and sustainable decrease in
maternal mortality, as shown in
the Figure 12.
35
Midwives Lead in Detection and Management of PE/E in Tanzania

Gaudiosa Tibaijuka, Senior Technical Manager with the Jhpiego Tanzania office, presented
Tanzania national efforts toward addressing PE/E, described health policy and guidelines
to address PE/E, and discussed midwives role in detection and management of PE/Eas
well as strategies to address the challenges.
In Tanzania, despite the enabling environment and the health policy and guidelines to address
pre-eclampsia and eclampsia, these conditions represent the third most common cause of
maternal mortality (17%), after hemorrhage (28%) and unsafe abortion (19%) (WHR 2006). The
President called to Stop needless maternal and newborn deaths and is very supportive to
maternal and newborn health initiatives. Tanzania health policy supports positive
developments toward improved quality of services; it emphasizes skilled birth attendance (SBA)
and access to quality Basic and Comprehensive EmONC. The 20072017 Primary Health
Services Development Program includes accelerating and strengthening training of SBAs and
recruitment, rewarding and retention of providers.
Human resources play a significant role in the national MNH situation. According to the
Primary Health Services Development Program report (2007), the current ratio of Tanzania
skilled workers to the population is 1:2,244 people; and the highest maternal mortality rate
correlates with the lowest numbers of skilled health workers in the region. Studies showed that
a 10% increase in qualified health workers correlates with a 5% decline in mothers deaths and
2% decline in deaths of newborns and children under 5 (Joint Learning Initiative 2004).
Nurse-midwives form 60% of the national health sector workforce in Tanzania; the nursemidwife to population ratio is 1:1,600, versus the doctor to population ratio of 1:8,500. Over 50%
of deliveries are attended by a health professional (Tanzania DHS 2010), 75% of which are
attended by a nurse-midwifethus putting the midwife in a prime position to diagnose and
manage clients with pre-eclampsia or eclampsia.
Nurse-midwifery practice in Tanzania is guided by the Tanzania Nursing and Midwives Council
and supported by professional associations. The job description includes Basic EmONC Signal
Functions (2009), such as administering parenteral anticonvulsants (MgSO4). Programs have
standardized midwifery practice using SBM-R and current best practices in Basic EMONC.
Now, midwives diagnose and manage PE/Egiving the loading dose and maintenance dose(s) of
anticonvulsant and monitoring for toxicity. Overall, midwives provide care that women want,
care in clean facilities with availability of medicine/equipment, care that is culturally
appropriate and women-friendlythus promoting services and facility usage.
There are a number of challenges, though, hampering national efforts to improve maternal
health. The human resources crisis, remotely located government health facilities that are hard
to reach when stocks of MgSO4 run out, shortages of other needed drugs (calcium gluconate),
and an insufficient education system that is slow to change, all greatly contribute to the
magnitude of the problem. Performance standards are also hard to implement due to
overcrowded wards and clinics, and shortage of medications, equipment and supplies, including
blood pressure-measuring devices.
In summary, pre-eclampsia and eclampsia continue to be one of the leading killers of women in
Tanzania, despite the national efforts and government support to fight them. Midwives are on
the frontlines in detection and management of pre-eclampsia and eclampsia, but they need to be
properly trained to accomplish this role.
36
There is hope, however, that through the Primary Health Services Development Program
(20072017), progress will be achieved through implementation of EmONC via various
improvements in infrastructure, training, logistics, supervision and community linkages.
Creating an Enabling Environment for PE/E Interventions

Lindsey Morgan, a senior health analyst with MCHIP/Broad Branch Associates, described
components of the health system that influence a pregnant womans access to care and
ultimately help or hinder her access to effective PE/E interventions.
We know that most maternal mortality is avoidable with technical interventions. But we also
know that many women in developing countries continue to die of pregnancy-related
complications, not because we dont know how to deal with complications like PE, but because
these interventions take place in a context that can either help or hinder delivery of these
interventions. And if we miss the context or the system, we miss a key determinant of the
success or failure of these interventions.
The 2000 World Health Report defines the health system as all the activities whose primary
purpose is to promote, restore or maintain health. It includes many components, as well as
physical and social environment, on which lies the success of an intervention.
What needs to happen in the system for the effective PE/E prevention and management? The
process starts when a woman discovers that she is pregnant. As ANC is key to prevention and
detection of PE, the first thing we need is for a woman to access care. Components of the system
such as insurance (social insurance or community-based insurance), targeted subsidies
(vouchers or conditional cash or in-kind transfers) and overcoming geographic barriers through
bringing services to communities may help the woman seek and access care.
To ensure prevention, detection and treatment for PE/E and other pregnancy-related
complication at the health care facility, another set of conditions includes the presence of skilled
providers, drug availability, clinical guidelines and provider motivation to deliver quality care.
Introduction of continuous quality improvement processes (such as Standards-Based
Management and Recognition [SBM-R]) and rewarding quality of care through setting up the
voucher scheme (Kenya, Uganda), accreditation of facilities (Brazil) and institutionalizing
payment linked to quality score (Burundi, Rwanda) may be ways to improve quality of care at
the facility level.
In summary, success of PE/E interventions can be helped or hindered by strengths and
weaknesses in the health system.
37
CROSS-CUTTING ISSUES IN MAKING AN IMPACT IN OBSTETRIC HEALTH

Panel #8. Measurements and Indicators to Assist PPH and PE/E
Programming and Call to Action. Moderator: Pyande Mongi, WHO/AFRO.
Routine Measurements of Quality of Care
Barbara Rawlins, Senior Monitoring and Evaluation Manager at MCHIP/Jhpiego, and
Maryjane Lacoste, Tanzania Country Director/Mothers and Infants, Safe, Healthy, Alive
(MAISHA) and Program Director, Jhpiego, reviewed existing measurement methods for
routine quality of care, described gaps in routine quality of care data for maternal and
newborn health services, presented a case study from Tanzania and discussed future
measurement plans.
Measuring the quality of maternal and newborn health (MNH) care is multi-faceted and
complex, especially measurement of quality of intrapartum care as it includes both routine care
and management of complications. Periodic surveys and routine measurement mechanisms are
conducted to measure the quality of MNH services.
Routine measurements are needed to help program managers and policymakers to have regular
and reliable data for decision-making. Key methods for measuring MNH quality of care
routinely are:
Structured clinical observation of provider-client interactions that use clinical checklists for
data collection and capture compliance with clinical guidelines and standards;
Inventory of facility infrastructure/supplies/equipment that use facility audits and

supervision reports and capture stockouts of key supplies and organization of services; and
Record review to capture service utilization, management of complications and number of

deaths and complications through health management information system (HMIS) and
logistics management information systems (LMIS) reports, facility registers and patient
charts, maternal and perinatal death audits and sentinel site surveillance systems.
Although useful, routine MNH quality-of-care data have many gaps. For example, observational
assessments are not conducted routinely; logistics management information systems and
supervision reports include only a limited set of facility readiness indicators, such as stockouts;
and many MNH service indicators of interest are not captured in national HMIS, especially
those related to intrapartum care (e.g., AMTSL). HMIS contains many indicators, but they are
hard to retrieve and not standardized.
One idea for monitoring the quality of care routinely is the use of sentinel sites. Sentinel sites
are health facilities selected (using specific criteria) for monitoring of key indicators that are
generally not reported up through the national HMIS. Sentinel site surveillance (SSS)
traditionally has been used to track disease-related indicators, such as malaria.
MCHIP/Malawi and the MAISHA Program in Tanzania are in the process of applying an SSS
approach for the continuous quality monitoring of MNH services. The MNH SSS systems are
intended to complement MNH data available from national HMIS reports, test the feasibility of
collecting additional MNH quality indicators at facilities on a routine basis, and generate
national support for routine collection of facility-based quality indicators that prove feasible.
38
The ACCESS/Tanzania program initiated an SSS system for focused ANC (FANC) in 2006 and
expanded it under MAISHA in 2009 to include monitoring of basic emergency obstetric and
newborn indicators. It now covers 40 facilities across 21 regions plus Zanzibar, and MAISHA
staff conduct quarterly visits to all facilities in collaboration with district and regional Ministry
of Health and Social Welfare colleagues. The system includes indicators from the HMIS,
traditionally tracked indicators such as maternal and neonatal deaths, as well as: the number of
ANC clients with hemoglobin less than 8.5 g/dl; the number of functional BP machines with
stethoscopes; and stockouts of oxytocin, ergometrine, misoprostol and MgSO4in addition to
other data points. At the same time, MAISHA is working with the national HMIS system so
that all of these data can be available on a more routine and regular basis to stakeholders (at
which time the SSS system would phase out). So far, the MOH of Tanzania has been able to use
the facility data to make a number of programmatic decisions, including addressing the
stockout situation with malaria-preventive drugs (sulfadoxine-pyrimethamine [SP]).
As the next steps, MCHIP/Malawi is testing a routine MNH quality sentinel surveillance
system in the coming months. MCHIP will also be working to simplify its Quality of Care for
Maternal and Newborn Complications survey tools for use on a routine basis as part of
supervision visits. In Tanzania, MAISHA will be expanding the SSS system to collect quarterly
data from all (280+) program sites. Question to the participants: Are there aspects of MNH
quality of care that we could be monitoring but are not?
MNH Quality of Care Measurement Resources can be found at:
www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/index.htm
www.rollbackmalaria.org/partnership/wg/wg_pregnancy/docs/MIPMEFramework.pdf
Revisiting Global Benchmark Indicators for Maternal and Perinatal Health

Steve Hodgins, the Global Leadership Team Leader for USAIDs MCHIP, explained how
global indicators currently used for tracking progress in maternal health may not be
adequate and described efforts toward improving benchmark indicators to better reflect
content and quality of care.
We monitor overall program performance and key sub-systems and processes for accountability
and to direct our improvement efforts; the results of our monitoring should tell us where we
need to make adjustments in how were working. A good indicator is relevant, reasonably closely
approximates what were interested in, and can feasibly be collected on a regular basis. It is
very important that we have the right set of indicators, because what we measure is what we
pay attention to.
What we measure is what we pay
attention to.
Global benchmark indicators are used as overall
Steve Hodgins, MCHIP
measures of program performance, for tracking progress
on MDGs, planning purposes, prioritization and
projecting impact, holding countries and program managers accountable, reporting in global
fora (e.g., annual World Health Assembly) and global publications (e.g., annual UNICEF
reports), and as a basis for results-based financing schemes.
The primary indicator for Millennium Development Goal (MDG) 5 is the Maternal Mortality
Ratio (MMR), which is what we are interested in influencing; unfortunately it is not generally
feasible to measure this on a very frequent basis and when we do measure or model it, it is not
precise.
The two key secondary maternal health indicators for MDG 5 are ANC and SBA delivery
coverage. Both of these measure very important contacts between the system and beneficiaries
39
during the antenatal and intrapartum periods. However, they measure only contact (i.e., an
opportunity to provide a needed intervention or service), but do not tell anything about the
content and quality of care during that contact.
The SBA delivery rate indicator measures attendance of a delivery by a skilled birth attendant.
The MOHs HMIS data provide proportion of deliveries documented as having been attended by
a physician, midwife or other cadre classified by the MOH as an SBA, while survey data provide
the proportion of deliveries that, according to mothers surveyed, were attended by someone they
thought belonged to one of the categories above. At similar levels of MMR, SBA delivery rates
vary widely. Similarly, with very similar SBA delivery rates, MMR can vary enormously.
Like the SBA delivery rate indicator, the proportion of pregnant women receiving at least one
ANC visit tells us that a contact occurred, but it really tells us nothing about what was actually
done during that contact.
Although these are important and appropriate indicators to track, they tell us little more than
that weve been able to get these women through the front door into our clinics and hospitals.
They tell us nothing about content and quality of care. For those involved globally in maternal
health program performance measurement, this problem of an inadequate set of benchmark
indicators has been recognized for some time. How is this being addressed?
A process has begunled by the WHO Department of Reproductive Health and Research (RHR)
and Making Pregnancy Safer (MPS), and supported by MCHIP/USAID and the Centers for
Disease Control and Prevention (CDC)revisiting the issue of benchmark indicators used for
tracking maternal health program performance. At a meeting in Delhi in September 2010, it
was agreed that this issue is a priority. A follow-up working meeting was held in Geneva in
December 2010. Several key areas were identified for further development, including provision
of oxytocin (or other suitable uterotonic) in the third stage of labor, MgSO4 for severe preeclampsia and eclampsia, quality of intrapartum care (measured through intrapartum
mortality), obstetrical near-miss, and cesarean section (e.g., by absolute obstetrical indications;
disaggregating by district, by socio-economic status).
It is expected that by the fall of 2011, for several of these key areas, new recommendations will
be developed for how Ministries of Health track maternal health program performance. For
some of the areas, the process will likely take somewhat longer, as new indicators and ways of
collecting data on them through routine health information systems are tested and validated.
Over the coming year, some countries will be implementing new performance-monitoring
indicators and approaches. Some countries may already be tracking indicators closely related to
these areas. For those involved in this effort globally, we are particularly interested in looking
at such settings, where there has already been some experience in these areas. For more
information, contact the presenter at [email protected] or MCHIP at www.mchip.net.
40
Taking the Messages of Addis Ababa Back Home and Putting Them into
Action
Dr. Jeffrey Smith, Maternal Health Team Leader of MCHIP, summarized the Maternal
Health section of the Meeting by putting it in perspective and encouraged the participants
to use the new ideas and tools upon their return to advance PPH and PE/E national
programs.
This meeting can be viewed as having before, during and after segments. Before, you held
meetings of local maternal health committees, conducted a country analysis, reviewed current
national efforts and assembled beautiful country posters. During, we all shared, exchanged and
learned. The process was summarized in the Interventions for Reduction of Morbidity and
Mortality matrices for PPH and PE/E (Tables 1 and 2, pages 54 and 55)concise and
informative documents that were designed to help shape the vision of country programs. After,
you will be meeting with your local maternal health committee, share ideas and start planning
for action.
You now have tools for sharing, including country analysis and maps of scale-up process. You
also have tools for action: these are the toolkits prepared for PPH and PE/E country programs.
The toolkits include: program guidance, an advocacy briefer and presentation, a technical
briefer and presentation; and many examples of policy, standards, training and M&E tools, both
global and from national programs. Each country team received a printed copy of each toolkit,
and all participants received flash drives with the complete and expanded electronic versions.
The toolkits will soon be available electronically on the K4Health Web site (www.K4Health.org).
National maps of scale-up progress are another good tool for the country teams. We encourage
you to adapt and expand your map, modify it as a national tracking system for your program,
and consult it at least annually to identify gaps and areas for greater focus.
For more information, contact the presenter at [email protected] or MCHIP at www.mchip.net.
How do we assess training institutions? What do these institutions need? Research but also
assistance in incorporating evidence into interventions, translating evidence into practice.

Exit interviews are helpful and complementary but do not provide the whole picture.
How do we efficiently link tools and experience to MOH tools? There are lots of tools; it gets
confusing.
Senegal has incorporated AMTSL into its HMIS.
SBAs dont affect MMR? Concept: We need competent care to improve outcome. Data come
from surveys that may be of poor quality. For example, data will show only a category of
workers without measuring competence of the care they provide. Direct correlation if analyzed
by categories.
Should data be collected from the registers or from the HMIS? Who is paying for quarterly
visits? MOH versus The Program? The question reflects the issue of sustainability. Annual
observations should be based on SBM-R. We should have a quality improvement system for
teaching institutions, quality pre-service education, including setting up skills labs. Not adding
new indicators is an interim measure, with a goal to strengthen HMIS to make routine data
reliable and available.
Suggestion: Add a few indicators for AMTSL, not just oxytocin.
41
REDUCING NEWBORN MORTALITY DUE TO ASPHYXIA

Panel #9. Improving Neonatal ResuscitationHelping Babies Breathe
This series of presentations and discussions at the end of the Day 3 served as an introduction to
the next part of the meeting (Days 4 and 5) and focused on the issues regarding neonatal
healthspecifically newborn asphyxia.
Essential Newborn Care

Dr. Pyande Mongi, of WHO/AFRO, focused on the importance of neonatal resuscitation
within essential neonatal care (ENC), described the newborn health situation in Africa,
touched on key components of ENC, and described newborn resuscitation in context of the
WHO Essential Newborn Care Course.
Globally, there is a 30% decrease in under-5 mortality, from 12.4 million in 1990 to 8.8 million
in 2008, but neonatal mortality still represents about 40% (3.5 million) of under-5 mortality.
Most neonatal deaths occur in the first week of life.
In Sub-Saharan Africa, newborn deaths constitute 29% of under-5 mortality. The main causes for
almost 90% of newborn deaths are: infections (32%); pre-maturity and low birth weight (29%); and
birth asphyxia and birth trauma (27%). Most of these causes are preventable and/or treatable.
Data from DHS surveys in 20
African countries shows that 25% of
newborn deaths occur in the first
day of life, and more than 70% of
deaths occur in the first week after
birth (Figure 13). This is also the
time when the coverage of care is
the lowest. Prevention of these early
neonatal deaths will require
improvements in care at the time of
birth and improvements in care in
the early postnatal period.
Figure 13. When are the 1.2 Million African Newborn Deaths
Occuring?
WHO works to ensure that newborn

care is a focus for service providers
and policymakers. The concept of
ENC was developed at the WHO
Working Group Meeting in 1994 in
Trieste, Italy. ENC components
include cleanliness, thermal protection, early and exclusive breastfeeding, initiation of
breathing (resuscitation), eye care, immunization, management of newborn illness, and care of
the preterm and/or low birth weight newborn. ENC has been further divided into Basic Care
and Special Care
The WHO Essential Newborn Care Course is part of the Integrated Management of Pregnancy
and Childbirth (IMPAC) series, and is consistent with the guide for doctors, nurses and
midwives Managing Newborn Problems (2003). The IMPAC series offers clinical and program
guidelines, educational modules, advocacy materials, and tools for monitoring and evaluation.
42
The five-day Essential Newborn Care Course is designed for doctors, nurses and midwives, and
is applicable to any health facility treating mothers and newborns. By 2010, the ENC training
was introduced in 40 countries, including 20 African countries. The five modules include:
Care of the baby at the time of birth
Examination of the newborn baby
Care of the newborn baby until discharge (including sessions on routine care and
resuscitation of the newborn)
Special situations (e.g., overcoming difficulties in breastfeeding, the small baby, alternative
methods of feeding)
Optional module on kangaroo care
Newborn asphyxia (failure to breathe within 1 minute after delivery) is one of the leading
causes of newborn mortality, but is treatable if attended to by a health worker skilled in
neonatal resuscitation. While only 5% babies need resuscitation, it must be anticipated at each
delivery.
Newborn resuscitation is a critical component of ENC. The WHO ENC training package
contains a module on basic newborn resuscitation based on the 1998 guidelines, which are
currently being updated; however, countries may choose to replace that module with Helping
Babies Breathe (HBB). It is expected that introduction of the ENC course will trigger the review
of national neonatal resuscitation guidelines by level of care.
Efforts to improve ENC should be combined with efforts to improve good quality obstetric care,
to prevent adverse neonatal outcomes and thus reduce the need for resuscitation.
Improved Labor Care to Reduce Neonatal Asphyxia

Dr. Jeffrey Smith, Maternal Health Team Leader of MCHIP, described the links between
maternal care and labor practices and the status of the newborn, and listed good practices
to prevent the newborn asphyxia.
The Afghan Maternal Mortality Survey of 2002 showed
If we dont care for the mother,
a maternal mortality ratio of 1,600 maternal deaths per
we put the baby at serious risk of
100,000 live births. But equally shocking was the fact
death.
that 77% of newborns died if they were born to mothers
Jeffrey Smith, MCHIP
who also died (Bartlett et al. 2005). Newborn mortality
and health are directly linked to maternal mortality and
health. Improved maternal care will result in improved newborn outcomes. With use of
evidence-based labor and delivery practices, we can expect to reduce maternal and newborn
morbidity and mortality and improve quality of careas well as achieve a new level of respect
for women and newborns.
Good labor care is not so much doing something, as waiting to do something if needed.
Therefore, labor care involves being vigilant. Obstetrics and midwifery are about watchful
waitingfor mother, for newborn, for possible complications. Interventions should be done only
when they are proven to be effective and are necessary.
43
Clinical Practices to Be Avoided to

Reduce Asphyxia
Restriction of movement during labor
Supine position during labor and birth
Uninterrupted pushing during second
(expulsive) stage
Uncontrolled use of oxytocin
Clinical Practices to Be Promoted to

Reduce Asphyxia
Skilled attendance at every birth

Use of the partograph
Companionship in labor and birth
Rest between pushing in second stage
Food and drink during labor
Appropriate management of pre-eclampsia
Appropriate use of cesarean section
Pre-eclampsia is a major killer of women and can impact newborns as well. If pre-eclampsia is
not recognized and not managed appropriately, seizures can result, leading to profound
newborn asphyxia. The hypertension of pre-eclampsia can reduce uterine blood flow, again
resulting in asphyxia. All of this can lead to emergency, and sometimes unnecessary,
cesareanswhich also can contribute to asphyxia.
But to shift the focus to good practices during normal labor, consider the following
In the second stage of labor, the cervix is fully dilated. A woman should push only with
contractions and rest in between. During second stage, the brief rest between pushes is
essential to allow the mother to reoxygenate her blood and allow for that blood to flow to the
uterus and placenta. As essentially no blood flows through the uterus to the placenta during a
contraction, rest between contractions is the only way to deliver oxygen to the fetus.
Position is also important to help ensure adequate blood supply. A supine or lithotomy
position causes compression on the great vessels and reduces blood flow to the uterus.
Therefore, allow the woman to assume other positions during labor and birth. Most common
positions during the first stage of labor are on the left side, standing or walking, while during
the second stage, squatting, sitting, and hands-and-knees positions are common. Hydration
during labor is also essential to maintain intravascular volume and promote uterine and
placental perfusion.
If labor needs to augmented, it should be done for purely medical reasons, not due to the
requests to speed up labor. The partograph should be used in order to diagnose protracted
active phase. If oxytocin is to be provided, it should be provided according to the Managing
Complications in Pregnancy and Childbirth protocols. Uncontrolled oxytocin causes tetanic
uterine contractions and complete restriction of blood flow to fetus, which can lead to asphyxia.
There are other practices that help to ensure that babies are ready to breathe right when they
are born. Preventing infection and doing procedures correctly are part of it. Overall, efforts must
be made to keep normal births normal.
Examples of good maternal and newborn care, which can help to prevent asphyxia, include the
following:
Use partograph for vigilant labor monitoring
Allow companionship during labor and birth
Ensure hydration and proper position
Prevent and manage eclampsia correctly
Avoid uncontrolled oxytocin
44
Ensure supportive second stage management based on fetal and maternal condition
Avoid incorrect practices
But ultimately, preventing and managing asphyxia requires skilled attendance at birth.
Facility Assessment of Quality of Care for Essential Newborn Care and

Neonatal Resuscitation in Selected African Countries
Dr. Joseph de Graft-Johnson, Newborn Team Leader of MCHIP/Save the Children, presented
findings from the quality of care assessments for ENC and neonatal resuscitation in four
countries, and discussed the assumption that presence of a skilled birth attendant equals
quality newborn care.
MCHIP conducted a survey to assess quality of care for essential newborn care and neonatal
resuscitation in Ethiopia, Tanzania, Rwanda and Madagascar. Between February and
December 2010, the program visited 177 facilities in these four countries, observed 2,473
deliveries and ANC consults, and interviewed 571 health workers. The surveys looked at the
essential newborn care policy-to-practice components, including policies, supplies for immediate
newborn care and management of newborn complications, providers knowledge and practices of
immediate newborn care, and management of newborn asphyxia.
Findings show that policies are universally available. Supplies for immediate newborn care are
present at most of the facilities (mean score: 63%); supplies are also available for management
of newborn complications (mean score: 67%). Providers knowledge of the immediate newborn
care and management of complication was below 60% for all components, 44% for newborn
resuscitation. Correct newborn care practices vary from 90% for immediate drying of the
newborn to 32% for the skin-to-skin contact with the mother; overall, 24% of deliveries (range
1740%) received all essential newborn care elements. Unnecessary and harmful practices
such as slapping and holding the newborn upside downwhile not common, were still observed.
In simulation of management of newborn asphyxia, ventilation with bag and mask presented
the most challenge to the providers; only 31% of providers were able to correctly resuscitate an
asphyxiated baby.
These findings challenge the assumption that skilled birth attendance equals quality newborn
care. A sizable percentage of health facilities have newborn resuscitation equipment, but staff
skills need significant improvement. There is need to improve the quality of newborn care at
health facilities. Countries are committed to make these improvements and all must play their
part to make it happen.
45

Tore Laerdal, Chairman of Laerdal Medical and Executive
Director of the Laerdal Foundation for Acute Medicine, provided
an overview of the materials developed for the Helping Babies
Breathe program focused on newborn resuscitation.
Helping Babies Breathe (HBB) is an educational program built on
scientific principles and a wealth of evidence from the ILCOR
(International Liaison Committee on Resuscitation) guidelines,
which are revised every five years. The content of HBB has been
harmonized with international health policy and guidelines through
WHO technical expert review. As part of the USAID Global
Development Alliance (GDA)with the overall objective to reduce
newborn mortality due to asphyxiaLaerdal Medical is working to
improve the functionality and availability of both training materials
and clinical equipment.
The set of learning materials for HBB includes a learner workbook,
flip chart and posters, and is focused on Airways and Breathingthe key components of the
decision-making and management of newborn asphyxia. At the heart of HBB is the Action Plan.
This is a pictorial guide to the evaluations, decisions and actions that should be taken to help a
baby who does not breathe at birth; it is a resuscitation algorithm presented with images and
very few words.
The colors on the Action Plan poster signify the level of care needed by the baby. For example,
green represents the Routine Care needed by all babies; yellow signifies the key concept of The
Golden Minutethe first minute after birth, when prompt action to stimulate breathing or
begin ventilation is vital to a successful outcome. Finally, the red zone indicates the need for
more prolonged or advanced resuscitation. At this point, the Action Plan links to the advanced
techniques of resuscitation taught
Figure 14. Matching Images Link Materials, Reinforcing Key
in the Neonatal Resuscitation
Content
Program of the American
Academy of Pediatrics.
The graphic, pictorial style of the
tool helps learners recognize
babies who need help to breathe
and links together all the
materials. For example, the
images from the Flip Chart,
which is the core tool for
facilitating the learning,
matches/links to those used in the
Action Plan and the Learner
Workbook, as shown in Figure 14.
Skills practice forms the
foundation of the HBB course and
the Learner Workbook includes
a variety of exercises. Individual
skills are learned and practiced for each step in the Action Plan, and exercises help learners
integrate these skills, for each section of the Action Plan. The NeoNatalie Newborn
46
Simulatorthe mannequin upon which skills are practicedwas developed by Laerdal

Foundation and is purpose-built, with crying, breathing and heart rate (umbilical cord pulse)
features. It is a low-cost simulator and comes complete with an Ambu bag-valve-mask unit, as
well as a suction bulb. In support of the UN MDG 4, Laerdal has committed to providing the
NeoNatalie Newborn Simulator and the NeoNatalie resuscitation tools to developing countries
on a not-for-profit basis through 2015.
The mannequin ships flat, but when filled with 2 liters of warm water, it has the weight, the
warmth and the tone of a baby who needs help to breathe. The skills learned focus on
maintaining a clear airway, stimulation and ventilation as indicated by the newborns condition.
The baby is the focus for learning in pairs, with an educational methodology that emphasizes
facilitation of learning. Participants work together to help one another learn skills, recognizing
that we all learn best when we are teaching. The materials are very useful for learning a new
skill, as well as for refresher training at a facility.
The USAID GDA provides support to countries for HBB implementation, taking into
consideration the need to support national rollout plans based on strong local ownership.
Helping Babies Breathe Global Educational Program: Presentation of Field

Testing Results
Nalini Singhal, Professor of Pediatrics, University of Calgary, and Volunteer, American
Academy of Pediatrics, presented results from the evaluation of the HBB training in Kenya
and Pakistan.
Figure 15. Estimated Annual Newborn Deaths Due to Asphyxia
The Helping Babies Breathe
(HBB) program was developed to
address one of the major causes
of newborn deaths: failure to
breathe within the first minute of
birth. Globally, nearly 4 million
newborns die each year in the
first month of life. As shown in
Figure 15, about one-quarter of
these die because they fail to
breathe at birtha simple
definition of asphyxia. In
addition to these, there are over
3 million babies who are termed
stillbirths (Lawn et al. 2009),
among which are some babies
who just are not breathing but
who can be helped with simple
measures. Each year hundreds of
thousands of babies could be helped to breathe at birth.
In most African countries, fewer than half of births take place in health facilities. Much lower is
the percentage of births that take place where equipment is available to help a baby breathe.
And in only a small percentage of births is there someone present who has the knowledge and
skill to help a baby breathe (Wall et al. 2009). So the focus of Helping Babies Breathe is to meet
these needs.
47
What can be done in the face of such a large burden of mortality and limitations of workforce?
The answer lies in an understanding of the science of resuscitation. For 99% of babies, simple
interventions can be lifesaving. All babies need assessment and routine care at birth, and for
most, such simple care is enough. For babies who do not breathe at birth:
Many will respond to the basic steps of drying and warmth, plus clearing the airway and
specific stimulation to breathe;
Only a small percentage of babies will require bag and mask ventilation; and
Less than 1% of babies require advanced methods of resuscitation, such as chest

compressions and medications.
By focusing on the timely delivery of the essential interventions of drying, warmth, clearing the
airway, stimulation to breathe, and bag and mask ventilation, many babies can be saved.
Helping Babies Breathe is an educational program built on scientific principles and a wealth of
evidence coming from the ILCOR guidelines. Again, the content of HBB has been harmonized
with international health policy and guidelines through WHO technical expert review. Simple,
evidence-based and learner-focused, the HBB program highlights preparation for birth (both of
equipment and persons) including cleanliness, thermal management, and support for early
breastfeeding, but emphasizing the key concept of The Golden Minutethe first minute after
birth, when prompt action to stimulate breathing or begin ventilation is vital to a successful
outcome. As was described in the previous presentation, the training is focused on the Action
Plan and uses newborn simulators for hands-on practice.
Formative evaluation of effectiveness of HBB training (Phase 1) was conducted in Kenya and
Pakistan. The program trained master trainers and providers. Training activities were
conducted in small groups (six learners to one facilitator) using HBB learning materials: the
Action Plan and graphically linked Flip Chart and Learner Workbook for the learners, as well
as the instructional guide for facilitators. The skills were standardized using the newborn
anatomical simulators and case scenarios; participants worked together to help one another
learn skills.
The assessment tools included multiple-choice questionnaires for knowledge assessment and
objective structured clinical exam (OSCE) for skills assessment of simple and complicated cases.
In addition, qualitative assessment was conducted through focus group discussions.
Findings from Phase 1 indicated that the HBB training:
Increases knowledge of immediate care at birth and interventions to help babies who do not
breathe;
Improves bag-and-mask ventilation (BMV) skills; and
Improves the ability of birth attendants in the resource-limited setting to manage both
simple and complicated cases of newborns who do not breathe spontaneously.
Similarly, testing of the field implementation of HBB clinical training conducted in India,
Tanzania, Kenya and Bangladesh demonstrated that the training improves recognition of
babies not breathing at birth and decreases number of stillbirths. While the number of neonatal
deaths remained unchanged, the specific need for resuscitation decreased.
Overall, the HBB training program is simple, evidence-based, low-cost and effective, easy to
integrate, hands-on, empowers the learner and promotes life-long learning. It was well-received
48
in the field where it visibly improved knowledge and skills, but actual clinical impact needs
further study.
The presentation was followed by a demonstration of HBB training using the NeoNatalie
neonatal simulator conducted by Nalini Singhal and Georgina Msemo.
Discussion that followed the presentations focused on the issues of HBB training:
In discussion of the relationship between skilled birth attendants and level of quality of care,
an emphasis must be made to ensure there are skilled birth attendants available at deliveries.
However, there is still a need for health providers to have appropriate skills.
How is stillbirth rate reduced by HBB? A baby that is not breathing may be classified as
stillbirth if no interventions are taken to initiate breathing.
Checklists and job aids are available as part of the HBB learners package. Development of
more new job aids is planned, depending on what is required at the country level. An HBB
implementation guide and M&E tools are also in development.
HBB training should be part of pre-service education (nursing schools), as well as in-service
and refresher clinical training.
In the absence of bag-and-mask ventilation (BMV), mouth-to mouth-ventilation should not be
conducted due to the risks involved (e.g., risks of HIV). Therefore, it is important to make sure
a bag and mask are available!
Other HBB training materials (implementation guide, video) are expected in July 2011.
Group and Team Activities

SKILLS AND DISCUSSIONS SESSIONS
Skills and discussions sessions, held in the afternoon of
Our primary reason for doing this
Day 2 of the Meeting, provided participants with an
is to detect all the pre-eclampsia
opportunity to observe procedures that were discussed in
that there is in the community.
the presentations and practice new skills. It was also an
opportunity for participants to clarify statements, ask
questions and share ideas in a small group setting. Seven stations were set up throughout the
conference rooms; each session lasted 25 minutes with discussion, and then was repeated two
more times.
Skills Session 1: Screening for and Detection of PE/E. Facilitators:

Harshad Sanghvi, Kusum Thapa and Abigail Kyei.
Participants reviewed specifics of BP measurement and proteinuria testing and observed
demonstration of the use of new and innovative screening tools at the community level. After
the demonstration, the participants discussed the following issues:
Cost-effectiveness of a urine testing pen: It costs less than $5 to produce and will last
through 3,000 tests.
When will the final product be ready? Best case scenario, between 6 to 12 months. It is
important to reach the poor, the uneducated and the ruralwho are being marginalized by
our health systems.
49
BP cuff: It is very low-tech; even a non-literate person can use this. It will be less than $5
total cost. We want a low price so it can get out to the periphery.
Why not a solar charger? Solar chargers will add $3$4 to the cost. We want to keep the
total cost under $5.
Skills Session 2: Induction of Labor. Facilitators: Matthews Mathai and

Sheena Currie.
The goal of this session was to review the new WHO guidelines on induction of labor by using
three case studies to demonstrate recommended approaches. The guidelines are currently
available at the following link and will be published in the next few months:
www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241501156/en/ind
ex.html
Participants learned how to prepare a solution for oral administration of misoprostol. In many
countries, misoprostol is available only in 200 mcg tablets, as this is the prescribed dose for
AMTSL. The dose for induction is 25 mcg administered every 2 hours. To prepare the smaller
dose, providers must use a blade to cut the 200 mcg tablet into eight individual pieces. The
facilitators asked a volunteer to demonstrate how to divide the tablet and participants quickly
realized how difficult it is to accurately prepare the dose using this technique. Then facilitators
demonstrated how to dissolve the 200 mcg tablet into 200 mL of water to prepare a solution that
can be administered orally in 25 mL doses every 2 hours.
Because misoprostol is a powerful drug, an overdose can have dangerous effects on the patient.
Several participants shared experiences of using misoprostol for induction of labor and their
patients uterus then rupturingpossibly the effect of an overdose. Following these
traumatizing events, the providers were reluctant to use the drug again.
Participant Munir Kassa, a provider from the Dire Dawa
Health Bureau in Ethiopia, said, I know misoprostol is
cheap, effective and available, but there is no way to
accurately divide the 200 mcg tablets into 8 pieces, so we
are not using it in the facility. When I return, I will start
using the drug again because the risk of rupture is much
lower now that I am confident I can prepare the accurate
dose.
When I return I will start using the

drug again because the risk of
rupture is much lower now that I
am confident I can prepare the
accurate dose.
Munir Kassa, Ethiopia
Providers have various experiences with different drugs and they lose confidence with a bad
experience, Sheena Currie said. They need to be reassured that the evidence supports
misoprostol, while recognizing the difficulties and safety aspects of getting the right dosage
from a 200 mcg tablet.
Facilitators also demonstrated use of the balloon catheter, a mechanical method of induction
that ripens the cervix and induces labor. Participants appreciated the opportunity to gain
hands-on experience with methods they learned about during the conference presentations. It
is very useful to have the hands-on sessions following the theory-based plenaries, said
Tambudzai Rashidi, the Chief of Party for MCHIP Malawi. I will be recommending the
addition of these practical skills to the BEmONC trainings in Malawi since they enhance
individuals understanding.
50
Skills Session 3: Implementing MgSO4 Protocols. Facilitators: Blami Dao and

Catherine Carr.
In this session, participants had an opportunity to discuss how to implement MgSO4 protocols
for management of severe PE/E when faced with issues of different concentration, different
routes of administration and different dosing. A sample job aid for MgSO4 administration and a
monitoring template were distributed and discussed. Participants appreciated detailed
explanations of the calculation of loading and maintenance doses, the dosing regimen and
monitoring of toxicity; they commented on the need for standard operating procedures and
protocols.
As a recommendation for the future,
participants suggested that it would be helpful to make
demonstration and practice of dilution and
administration of MgSO4 in a simulation a component of
a training event. Participants also brought up the
following issues:
It would be very helpful to have strength per mL on

the vial of the drug to help providers to give the
accurate dosage.
At most times when MgSO4 is given, it is an

underdosepeople need to watch out for this!
Need to advocate for change of color-coding of these very important drugs that can be lifethreatening if misused. Lignocaine and MgSO4 are in VERY similar vials; calcium
gluconate and MgSO4 are in similar ampules.
Do we need potency testing for MgSO4?
Need to create a job aid for managing overdose of MgSO4, for situations with and without
calcium gluconate.
Need to develop easy to-use job aids for frontline health care providers.
Catherine Carr, Jhpiego, explains loading dose

of MgSO4 during the skills session.
Skills Session 4: Introduction of the Uterotonic Decision-Making Tool.

Facilitators: Susheela Engelbrecht and Steve Brooke.
In this session, participants reviewed the draft document Uterotonic selection tool for
prevention and treatment of PPH: A guide for policy makers, pharmacy managers and MOH
and the accompanying tool Selecting a rational mix of uterotonic drugs, developed by PATH.
The following issues related to these materials were discussed:
This tool is a great concept that has the potential for assisting people at all levels of
decision-making to choose a rational mix of uterotonic drugs.
However, the tool, in its present form, might be difficult for country implementation and
needs to be revised to make it more user-friendly.
Suggestions were made on how to revise it to make the tool more practical. There is a
possibility that, in the future, a larger document will be developed that has modules for each
use of uterotonic drugs. For the moment, we will limit content in the tool to uterotonic drugs
for prevention and treatment of PPH.
51
From this discussion, the next steps were identified: The PATH team will work with USAIDs
Strengthening Pharmaceutical Systems (SPS) and VSI to improve the quantification piece of
the tool, and VSI will work with the PATH team to make the tool more user-friendly.
Skills Session 5: Pre-Eclampsia/Eclampsia E-Learning Course. Facilitator:

Hannah Knight.
In this session, the presenter demonstrated The Evidence-Based Management of Pre-eclampsia
and Eclampsia: An Interactive E-Learning Course for Healthcare Professionals, developed by
the Maternal Health Task Force and University of
Oxford. The course has two versions:
Basic: For health care professionals who want to

know/revise the fundamentals, and
Advanced: For doctors, midwives and nurses who

want to know the evidence behind the
recommendations.
This course can be found online at: www.gfmer.ch/SRHCourse-2010/pre-eclampsia-University-of-Oxford.
Hanna Knight, University of Oxford,

demonstrates the interactive PE/E e-learning
course.
Skills Session 6: Teaching Maternity Care

using MamaNatalie. Facilitators: Tore Laerdal, Ingrid Laerdal, Hannah Gibson
and Angie Fujioka.
During this session, participants observed demonstration and
practiced use of the MamaNatalie model for teaching
management of childbirth and management of PPH.
MamaNatalie is a birthing simulator that allows the instructor
to create simulations of normal to more complex birthing
scenarios. The simulator is strapped onto the instructor, who
manually controls the amount of bleeding and the condition of
the uterus to set the scenario for the student and then responds
to the students performance.
Session participants try out

MamaNatalies special features.
The instructor can also control dilation of the cervix, position

and delivery of the baby, delivery of the placenta and fetal heart
sounds. The baby, NeoNatalie, is a neonatal simulator that has
the real feel of a newborn baby and can be used separately for
training in neonatal resuscitation. MamaNatalie and
NeoNatalie have been developed by Laerdal in response to
requests for training simulators that are low-cost, durable, easy
to disassemble and to clean, and culturally appropriate. More
information about the simulators is available at the Laerdal
Web site: www.laerdalglobalhealth.com.
During the session, participants were interested in the

following issues:
52
How much does the model cost? Approximately $150

USD per MamaNatalie, including NeoNatalie. It is
being produced in China and should be ready for
distribution in June. The organization will likely
MamaNatalie is fantastic because

it makes learning easy and
demonstrates all skills of a
midwife.
Hannatu Abubakar, Nigeria
charge developed countries a higher rate to afford to sell the models at cost to low-income
countries.
Can the model simulate twin delivery? Yes, two NeoNatalies can be used in the
MamaNatalie to simulate twin birth.
Participants feedback:
The MamaNatalie is so real. It is great for training. ~Rose Macavley
Its fantastic. Its good to be used for training. Its natural. But before you are the
MamaNatalie, you have to know how to use it to contract the uterus, pull out the placenta, and
cause the hemorrhage. ~ Jean Pierre Ratovaoc, Ob/Gyn, Madagascar
MamaNatalie is fantastic because it makes learning easy and demonstrates all skills of a
midwife; I would advocate for this. ~ Hannatu Abubakar, Midwife, Nigeria
Skills Session 7: Balloon Tamponade and Other Techniques. Facilitators:

Elizabeth Abu-Haydar and Sylvia Deganus.
Participants observed and discussed demonstration of innovative clinical interventions/
techniques for management of PPH using anatomic models. The demonstrations included
balloon tamponade to stop
PPH, plastic blood drape to
assess amount of
postpartum bleeding, and
non-pneumatic anti-shock
garment that counteracts
shock and decreases blood
loss by applying direct
counter-pressure to the
lower parts of the body.
Demonstrations and the
following discussion
highlighted several issues:
Use of water with

balloon tamponade
should not be
encouraged because of
possible rupture; using
saline is safer.
Dr. Sylvia Deganus demonstrates a plastic blood drape to assess amount of

postpartum bleeding.
Hospitals usually do not have condoms in stock; possibly need to use latex gloves.
Should the anti-shock garment be used on a woman not going into shock?
The anti-shock garment is often being used as a treatment for PPH rather than as a step to
reducing the fatal symptoms. People have to be trained on how to use it and why to use it.
SUMMARY OF INTERVENTIONS FOR REDUCTION OF MORBIDITY AND

MORTALITY DUE TO PPH AND PE/E
Groups that included country representatives and international experts convened to discuss
how to prevent and manage PPH and PE/E in the settings with and without a skilled provider.
The result of group work was recorded in large matrices, represented here in Tables 1 and 2.
53
54
Birth planning
Community emergency planning
Transport planning
Referral strategies
Use of misoprostol to treat PPH
Use of Non-pneumatic Anti-Shock Garment
Breastfeeding/nipple stimulation
Uterine massage
Empty bladder (urinate)
Measure blood loss accurately
Orally replace fluids
Position of woman to prevent shock (feet raised above level of heart, keep warm)
External bimanual compression
Oxytocin in Uniject to TBA, CHW
Pressure on laceration
education and communication (IEC)

Birth preparedness/complication readiness (BP/CR) include men
Promotion of skilled attendance at birth
Family planning and birth spacing
Detection and treatment of signs of anemia
Iron/folate supplement, de-worming, and IPT to prevent anemia
Use of mobile phone to connect to skilled providers when needed
Misoprostol for routine third stage use through ANC and community distribution
systems
Train community on measuring blood loss accurately
Oxytocin in Uniject to TBA, CHW
Community awareness behavior change communication (BCC)/information,
WITHOUT SKILLED BIRTH ATTENDANT
WITH SKILLED BIRTH ATTENDANT

Community awareness BCC/IEC
Quality Antenatal care (including BP/CR)
Free maternal services at facility
Detection and treatment of anemia
Iron/folate supplement, de-worming, and IPT to prevent anemia
Use of partograph to reduce prolonged labor
Limiting episiotomy in normal birth
Active management of third stage of labor (AMTSL) with oxytocin (1st line) or
misoprostol (2nd line)
Routine inspection of placenta for completeness
Routine inspection of perineum/vagina for lacerations
Routine immediate postpartum monitoring
Measure blood loss accurately
Kind and respectful care
Keep mother/baby together and skin to skin to promote breastfeeding
Active triage of emergency cases
Rapid assessment and diagnosis
Breastfeeding/nipple stimulation
Accurate measurement, diagnosis of blood loss
Emergency protocols for PPH management
Use of non-pneumatic anti-shock garment (NASG)
Condom uterine tamponade
Basic emergency obstetric and newborn care (EmONC)
Intravenous fluid resuscitation
Manual removal of placenta,
Uterine curettage for placental fragments
Parenteral oxytocics and antibiotics
Uterine massage
Bimanual aortic compression
Aortic compression
Emptying/catheterization of the bladder
Placenta inspection
Vulvar, vaginal, cervical inspection
Suturing tears
Comprehensive EmONC
Blood bank/blood transfusion
Operating theater/surgery
Uterine rescue surgical techniques: b-lynch, square sutures
Table 1. Interventions for Reduction of Morbidity and Mortality from Postpartum Hemorrhage
PREVENTION
MANAGEMENT
55
Birth planning and preparedness (include men)

Promotion of SBA at birth
Promotion of early and continuing ANC from SBA
Sensitization and counseling about pre-conceptual care (include men)
Promotion of use of maternity waiting homes
Community awareness for danger signs and emergency planning including transport
Home BP screening
Home urine testing
Nutrition education to increase dietary calcium
Calcium supplementations, calcium fortified foods
Low dose aspirin
Behavior change communication about PE/E
response
Community emergency planning
Strategies for timely and appropriate referral
Mobile phone to connect CHW to skilled provider
Obstetric first aid related to eclampsia
Birth planning (including advocacy with men)

Emergency planning including transport and where to go
Community education for recognition of dangerous situations/need for emergency
WITHOUT SKILLED BIRTH ATTENDANT
WITH SKILLED BIRTH ATTENDANT
Birth planning and preparedness (include men)

Promotion of SBA at birth
Counseling for family planning and birth spacing
Community awareness for danger signs and emergency planning including transport
Maternity waiting homes
Calcium supplementation, calcium fortified foods
Nutritional education to increase dietary calcium
Low dose aspirin
Appropriate and high quality ANC with screening for hypertension and urine protein at
each visit
Tracking of mothers with hypertension if they do not return to ANC for follow-up
Behavior change communication about PE/E
Detection and treatment of chronic hypertension
Increased monitoring for patients with h/o PE, and/or hypertension
Routine clinical drills to maintain provider skills to manage PE/E
Quality of care initiatives to improve appropriate management of severe PE/E
Rapid initial assessment and diagnosis of PE/E
Anticonvulsant therapy (MgSO4)
Antihypertensive therapy
Timed and prompt delivery including use of partograph during labor
Induction protocols including use of misoprostol
Cesarean section
Anticipate asphyxiated baby
Timely referral strategies to CEmONC facility
Lab testing if available (blood grouping and cross-matching, complete blood count,
renal and liver function testing, bleeding time)
Antenatal steroids for fetal lung maturity
Appropriate monitoring (fetal monitoring, blood pressure, respiratory rate, deep tendon
reflexes), fluid balance (fluid intake and urine output)
Immediate postpartum monitoring
Health system financing (including management of PE/E)
Health system strengthening
Pharmaceutical system strengthening to ensure drug availability
Table 2. Interventions for Reduction of Morbidity and Mortality from Pre-Eclampsia/Eclampsia
PREVENTION
MANAGEMENT
Closing Activities
INDIVIDUAL REFLECTIONS
Organizers and participants shared their reflections about the meeting and moving forward
with implementing/expanding programs to address major maternal mortality causes in their
countries. What follows are highlights from this final event.
Dr. Abdalla Mergani, South Sudan, noted that his country is Africas newborn nation and
asked for support and encouragement as the country works to improve maternal and neonatal
health.
Dr. Koki Agarwal, MCHIP, commented that she felt [at the Meeting] like she was back in
medical school due to the high-level technical content. She focused on key elements of the
conferencelearning, connecting, commitment and hope.
Dr. Harshad Sanghvi, Jhpiego, noted that there has been global progress in reducing
maternal deaths. He said he wished for this to continue through implementation of high-impact
interventions but was concerned about increasing access to poor-quality care. The promise of
SBAs cannot be realized without emphasis on quality, respectful care, infrastructure that is
functional and supplies what is needed, and recognition and reward for those on the frontline.
Health facilities do not support the poorest, least educated, most isolated, said Dr. Sanghvi.
What can we do for them? Need to take care to the community. Our focus must be on highimpact interventions; we should make them commercially available, improve quality of care and
ensure the enabling environment for providers.
Dr. Jrmie Zoungrana, Rwanda, suggested that countries look for local solutions close to
home and cited Rwandas experience as a good exampleWhen you have a problem, the
solution is sitting at your gate. He commented that all participants were now prepared with
information and analysis and will return and revisit information in their own countries.
Peggy Chibuye, Zambia, said that strengthening midwifery is a recognized need in all of the
countries represented, as midwives are the main providers of maternal and newborn care. An
acute shortage of midwives means there is an acute need to address pre-service training. She
suggested that more countries consider direct entry midwifery (Zambia has started) as a more
effective and efficient way to train midwives. There are interested nurses out there who want
to be midwives, she said; We need to get them into pre-service education soon rather than
making them wait.
Alice Levisay, PATH/Oxytocin Initiative, congratulated everyone on a wonderful conference
with lot of productive teamwork and clear outcomes to be taken forward. We know what we
know, we know what we need, said Levisay; The tide is beginning to turn and societies are
making choices to save lives.
Deborah Armbruster, USAID, said that USAID is very pleased to have supported this
conference. As a group of colleagues with a similar interest to save mothers and babies was
created, USAID is excited to hear how countries are actually scaling up or introducing the PPH
and PE/E prevention and treatment. Dr. Armbruster said, We have a lot of top-notch experts
here, and it has been inspiring to listen to all of them. She brought up an example of the South
Sudan teamthis new country is making plans because we worked during the meeting to think
about what we need to do next.
56
Key messages of the meeting:
Oxytocin should be available in all facilities.
Misoprostol can make an important contribution to saving lives, particularly at the home
birth.
More work is needed on the use of oxytocin and misoprostol for induction or augmentation of
labor component to make sure guidelines are updated.
MgSO4 should be available and usedthis is even more important in the current
introduction phase of PE/E.
All countries have great successes to share with each other, and the MCHIP team has put
together a good resource package that will provide answers. Lets go forward and save lives,
folks, exclaimed Dr. Armbruster at the end of sharing her thoughts.
Group reflections and Dr. Armbrusters energizing message were followed by a slide show that
captured memorable moments of the meeting.
POSTER AWARDS CEREMONY

Mary Ellen Stanton, in the Poster Award ceremony, announced that all energetic teams are
winners. A certificate of excellence and the prize trip to the International Confederation of
Midwives conference in Durban in June 2011 was awarded to Zambia team.
CLOSING REMARKS
Dr. Neghist Tesfaye, Director of Urban Health/MCH Focal Point, Ministry of Health of the
Federal Democratic Republic of Ethiopia, closed the meeting with thanks to the organizers and
participants for choosing Ethiopia as the place for this meeting. During the last three days, we
could see the global efforts in addition to African regions, Dr. Neghist Tesfaye commented; the
conference was very participatory for experience-sharing. She emphasized, however, the need to
focus on quality of care, to be critical in scaling up. She felt it helped to look at the big picture of
implementation, as many different things need to go into implementation. And when we talk
about maternal health care, it affects all levels of the health system. Another important thing
from this meeting, said Dr. Neghist Tesfaye, is that we have something for both the mother and
the newborn. They both go together. I hope we go home to our countries, more energized to
make more of a different for the lives of our mothers and children, she said, and wished
everybody a good stay and a safe trip home. When you go, take a part of Addis with you.
57
PART II: HELPING BABIES BREATHE (HBB)

REGIONAL TRAINING OF TRAINERS (TOT) FOR
AFRICA
Of the nearly 8 million children who die every year before reaching their fifth birthday, more
than 3 million are newborns who do not survive their first four weeks of life (Rajaratnam 2010).
The WHO estimates that one million of those babies die each year from birth asphyxia, or the
inability to breathe immediately after delivery. Most babies who are asphyxiated can be helped
to breathe using simple resuscitation techniques, including the use of bag and mask ventilation,
which are administered within the context of essential newborn care.
A. OVERVIEW OF NEWBORN RESUSCITATION TRAINING

The purpose of the newborn care session of the Africa Regional Meeting was to develop experts
and advocates to address newborn asphyxia by expanding their knowledge and skills in
newborn resuscitation techniques and state-of-the art newborn care interventions. The two-day
training workshop resulted in motivated national and regional trainers available for the
Helping Babies Breathe (HBB) initiative. In addition, the meeting stimulated discussion on the
expansion and strengthening of programs for neonatal resuscitation within the context of
essential newborn care.
B. ORIENTATION AND SETTING THE STAGE: PLENARY SESSION ON

IMPROVING NEONATAL RESUSCITATION23 FEBRUARY
A plenary session on Day 3 of the Africa Regional Meeting (Panel #9, pages 4249) provided an
overview of essential newborn care with a focus on neonatal resuscitation and HBB in
particular. Five presentations were made:
Neonatal Resuscitation in the Context of Essential Newborn Care (ENC), by Dr. Pyande
Mongi, WHO/AFRO;
Figure 16. Components of Essential Newborn Care
Prevention of Newborn
Asphyxia through Improved
Labor Care, by Dr. Jeffrey
Smith, MCHIP;
MCHIP Newborn Health

Quality of Care Survey
Results from Ethiopia and
Rwanda, by Dr. Joseph de
Graft-Johnson, MCHIP;
Introduction of the HBB

Training Materials, by Tore
Laerdal, Laerdal Medical AS
and the Laerdal Foundation
for Acute Medicine; and
Presentation of HBB FieldTesting Results, by Dr. Nalini Singhal, American Academy of Pediatrics.
58
Part II: Helping Babies Breathe (HBB) Regional Training of Trainers (ToT) for Africa
The plenary provided information for

policymakers, program managers,
donors and service providers on the
key components of ENC (Figure 16),
gaps in ENC and resuscitation
services, and how HBB could be used
to improve the knowledge and skills
of providers. It also set the stage for
the hands-on training of trainers
that followed on 24 and 25 February
2011.
Figure 17. Proportion of Newborns Requiring Intervention to

Breathe
It was emphasized that the majority

of asphyxiated babies could be
resuscitated by stimulation and
ventilation by bag and mask only
(see Figure 17).
8090%
Assessment at birth
and routine care
Drying, warmth, clearing the

airway, stimulation
Bag and mask ventilation
Chest compressions, medications
810%
36%
<1
C. HELPING BABIES BREATHE TRAINING OF TRAINERS24, 25 FEBRUARY

1. Opening Session
The opening session was
facilitated by Dr. Joseph de GraftJohnson, Newborn Health Team
Leader for MCHIP. Dr. Koki
Agarwal, Director of MCHIP,
welcomed participants. She
expressed her appreciation of the
interest of 137 participants from
24 African countries (and three
non-African countries) in
addressing newborn asphyxia. She
also shared a personal experience
HBB Opening Ceremony
from Bangladesh, where she
interacted with an auxiliary nurse-midwife who had trained in HBB in rural Habiganj District
and saved a baby using bag-and-mask ventilation (BMV). And this occurred after the babys
parents had come to believe that their baby was a stillbirth! Dr. Agarwal thanked the sponsors
of the meeting, USAID, WHO/AFRO, Africa 2010, RCQHC and the Laerdal Company and
Foundation, and she encouraged the participants to take this learning back to their countries to
make a difference in the lives of mothers and newborns.
Dr. Lily Kak, USAID Senior Maternal
and Newborn Health Advisor, also
welcomed the participants and expressed
her delight in how far the HBB program
had come as a result of a Global
Development Alliance (see Box). She
described that a global pool of master
trainers had been trained in Washington
when the GDA was launched in 2010 and
they were now cascading their learning to
USAID, through its Global Development Alliance

model, is partnering with the following on the
Helping Babies Breathe initiative:
The Eunice Kennedy Shriver National Institute
of Child & Human Development (NICHD)
Save the Children
Laerdal Medical AS
American Academy of Pediatrics (AAP)
59
all levels within their countries. She expressed the hope that similarly positive efforts would
result from this, the first ever Africa Regional HBB training of trainers. She explained how the
GDA was formed among USAID, NICHD, Save the Children/Saving Newborn Lives, American
Academy of Pediatrics (AAP), Save the Children and Laerdal Medical AS and described the
role of each in the GDA. Dr. Kak also introduced Dr. Troy Jacobs and Karen Fogg from USAID,
who will be supporting country-level HBB rollout in Africa.
Dr. Neghist Tesfaye, Director of the Reproductive and Child Health Division, Ministry of
Health, Ethiopia, welcomed the participants as the host from Ethiopia. She highlighted the
contribution of newborn mortality in Ethiopia to child mortality and reiterated that Ethiopia
could not reach MDG 4 unless newborn mortalityand specifically, newborn asphyxiawas
addressed. HBB training is ongoing in Ethiopia, she shared, and the Ministry of Health is
committed to scaling it up at every level. Dr. Neghist Tesfaye also served as a lead facilitator
in the HBB TOT.
Dr. Nalini Singhal, American Academy of Pediatrics, is
HBB should always be considered
one of the main authors of the HBB curriculum. She
part of the essential newborn care
spoke on the simplicity of the curriculum and the need to
curriculum.
unlearn some of the practices participants may have
Nalini Singhal
learned many years ago. She emphasized that HBB was
designed to reach the most peripheral-level providers,
and that policymakers should not see it as a vertical program. HBB should always be
considered part of the essential newborn care curriculum, she reminded participants.
Dr. Pyande Mongi, Director of Maternal and Newborn Health, WHO Regional Office for Africa
(AFRO), gave a presentation on the status of the newborn in Africa. She highlighted the main
causes of mortality and the interventions available to
The newborn asphyxia
address the burden. WHO/AFRO has developed an
management module of [WHOs
Essential Newborn Care curriculum that has been used
ENC] curriculum could be replaced
in over 20 countries to train providers. She stated that
by HBB where appropriate,
the newborn asphyxia management module of the
according to specific country
curriculum could be replaced by HBB where appropriate,
needs.
according to specific country needs.
Pyande Mongi
Dr. Stella Abwao, the lead coordinator for HBB at
MCHIP, subsequently reviewed the workshop agenda, provided details on logistics and
explained the participant roles. She then wrapped up the opening session.
See Appendix E for Part II objectives and detailed agenda.
60
2. Participants
A total of 121 participants from 27 countries were trained as HBB trainers (Table 3). An
additional 16 donors, program managers and policymakers received an in-depth, hands-on
orientation on the use of the newborn
Table 3. Participants by Country
resuscitation mannequin, the NeoNatalie
simulator, and the HBB program generally,
Angola
7 Nepal
bringing the total number of participants to 137.
Botswana
1 Nigeria
Twenty-six (26) facilitators from eight
countriesincluding 11 from Ethiopialed
the training. A detailed list of participants,
observers, facilitators and staff is available in
Appendix F.
3. HBB Course Design and Learning

Materials
1
8
Congo-Brazzaville
Rwanda
Equatorial Guinea
Seychelles
24
South Africa
Ghana
South Sudan
Kenya
Swaziland
Lesotho
Sweden
Ethiopia
Liberia
7 Tanzania
9
The HBB course is designed as a competencyMadagascar
2 Uganda
7
based skills training of trainers. Session 1, the
Malawi
7 USA
3
Provider Component, focused on refreshing
Mali
1 Zambia
7
participants clinical skills. and ensured that
all were familiar with the HBB materials and
Mauritius
1 Zimbabwe
7
messages. This session also gave participants
Mozambique
2
an opportunity to be the learners they would
Total 121
eventually be training. Session 2, the
Facilitator Component, focused on training
participants in HBB facilitation skills and providing them the opportunity to practice their
facilitation skills for the HBB skills course. Participants were assigned to 20 groups of six
learners each, spread out in three different rooms. A pre-test (Appendix G) was administered to
all participants.4
Participants were then introduced

to the HBB materials used
throughout the course, including
the NeoNatalie mannequin and
resuscitation equipment, the HBB
Learner Book and the HBB Flip
Charts and Action Plan/Poster 3
(shown at right). In each group of
six, participants learned in pairs
using the NeoNatalie mannequin
and reference materials. A
facilitator was assigned to each
group, while a lead facilitatorin
each of the three allocated rooms
demonstrated various skills and
NeoNatalie mannequin, HBB flip
continuously provided pertinent
chart and resuscitation equipment
information to the larger group. All
course facilitators had met for a preparatory meeting on 23
February and followed a Facilitators Guide (Appendix H) during the training sessions.
Results described in Participant Evaluation section below.
61
4. Session One: Provider Component

The Provider Component of the HBB TOT gave participants the opportunity to experience the
HBB clinical skills course as actual course participants wouldlearning, practicing and being
assessed on the knowledge and skills required for HBB. They also observed lead facilitators in
the role they would be adopting to teach the course themselves after the Meeting.
A. Overview
Participants were taken through the following HBB training sessions, allowing for questions
and discussion throughout. These sessions were designed to enable the participants to:
Describe the linkages among HBB materials
State the key messages of Helping Babies Breathe
Carry out all of the four key exercises in Helping Babies Breathe: (1) Preparation, (2)
Routine care for all babies, (3) The Golden Minute SM, and (4) Continued ventilation with
normal or slow heart rate
Identify regional practices in newborn resuscitation through group discussion and questions
Demonstrate mastery of bag-and-mask ventilation (skill check)
B. Opening Visualization Exercise

The first activity was a visualization exercise.
Participants were asked to follow these instructions:
Close your eyes and imagine the following in sequence. A
baby is born; the baby is not breathing; there is no one to
help the baby. The baby dies.
Participants were asked to reflect on this scenario. With
their eyes still closed, participants were then asked:
Opening visualization exercise
Imagine another scenario in which the baby is born and not breathing, but you are there to help
the baby breathe.
As a birth attendant skilled in Helping Babies

Breathe, you can save the lives of babies. You
must be present at birth and prepared to take
immediate action. By one minute after birththe
Golden Minutea baby should be breathing well or
you should be providing ventilation.
Helping Babies Breathe Learner Workbook
This exercise is used to assist participants

to reflect on what their feelings would be
if they resuscitated a baby who could not
breathe. It also helps to reinforce the
critical importance that every birth be
attended by a person skilled in
resuscitation.
C. The Four Key Exercises in Helping Babies Breathe
Preparation for a Birth: Facilitators then demonstrated and participants practiced the
steps necessary to prepare for a birth. Each identified a helper and reviewed the emergency
plan. The area was prepared for delivery and participants washed their hands. They then
prepared for ventilation and checked all equipment.
Routine Care: Facilitators demonstrated and participants practiced routine care provision
to the newborn. Participants dried the baby thoroughly and, if meconium was present,
62
cleared the airway prior to drying. They evaluated the babys cries, kept the baby warm,
checked its breathing and clamped or tied the umbilical cord.
The Golden Minute:
Part I (clear airway and stimulate breathing):

Facilitators demonstrated and participants practiced
proper positioning of the babys head, clearing of the
airway, stimulating breathing and evaluating
breathing. Working in pairs, one participant took the
role of the skilled birth attendant, while the other
provided the response of the baby and acted as a
helper when needed. Participants then switched roles.
Part II (ventilation): Facilitators demonstrated and
participants practiced in pairs the initiation of
ventilation, ventilation with bag and mask, and
evaluation of breathing.
Continued Ventilation with Normal or Slow Heart

Tore Laerdal demonstrates bag &
Rate: Facilitators demonstrated continued ventilation of a
mask ventilation during the Golden
baby with a normal and slow heart rate. Participants
Minute
practiced calling for helping and improving ventilation,
evaluating the babys heart rate, continuing ventilation and monitoring with the mother,
continuing ventilation and activating the emergency plan, and support to the family.
D. Participant Evaluation
Figure 18. HBB Pre- and Post-Test Results

100
Number of Participants (n = 111)
90
Knowledge Test: Participants took a
80
17-question newborn resuscitation
70
knowledge test before and after the
60
Provider Component of the training
50
during Session 1 (Appendix G). As
40
shown in Figure 18, the post-test
30
20
results reflected an improvement of
10
participants knowledge. Whereas 61%
0
of participants scored 94% or higher
94100%
8288%
76% and below
(i.e., perfect score or one incorrect
Correct Answers (out of 17)
answer) on the pre-test, 86% attained
that score in the post-test. While 9% of participants
scored 76% and below (i.e., four or more incorrect
answers) on the pre-test, no participant scored below
82% (i.e., three or more incorrect) on the post-test. The
purpose of the testing activity was to both test
participants knowledge and demonstrate how to
administer the test and share its results with trainees.
Skills Assessment: Throughout the course of HBB

Session 1, facilitators assessed the clinical resuscitation
skills of participants as providers (see Appendix G for
Pre-Test
Post Test
Practicing bag and mask ventilation
63
BMV and OSCE A and B5 assessment tools). This was both a means to demonstrate how to
assess skills using the HBB tools, as well as an opportunity for participants to demonstrate that
they possessed the necessary clinical skills to teach others in the future. After the training, all
participants demonstrated the ability to correctly provide routine care for babies breathing well,
and achieved competency in following the correct steps for using the bag and mask for
resuscitating asphyxiated babies.
5. Session Two: Facilitator Component

These HBB training activities were designed to enable
participants to:
Describe the evolution and purpose of the Helping

Babies Breathe training program
Demonstrate competent presentation of HBB

content, including key messages from the Facilitator
Flip Chart, and incorporation of all the HBB learning
materials
Explain the interaction that occurs between a pair of

HBB learners using the neonatal simulator (roles of
learner/teacher/baby)
Practicing facilitation
Facilitate learning in small groups to enable participants of various ability levels to

demonstrate skills in helping babies breathe
Lead skills practice and provide feedback on skills and performance
Moderate the experience of learners and obtain consensus on regional best practices
Provide cultural interpretation and localization (best and potentially harmful practices)
Create realistic scenarios
Evaluate learner performance using the written/verbal knowledge check, as well as OSCE A
and B
Prepare and supervise participants in continued learning in the workplace
Access resources to plan and evaluate courses
Explain the integration of HBB with other interventions according to the regional
implementation plan
The Facilitator Component of the HBB TOT gave participants the opportunity to act as
facilitators and practice their HBB facilitation skills.
Participants were given opportunity, in turns, to facilitate several of the course components.
They were able to practice and present to the other learners an overview of provider course
objectives and supplemental material. They also put to use facilitation techniques. Similar to
the process during Session 1, the inducting facilitators followed through on the opening
visualization. They went on to present the content of the Facilitator Flip Chart and ensured
that everyone practiced the use of the chart from page to page, as well as continued interaction
within each groups.
5The Objective Structured Clinical Evaluations (OSCEs) may be used as practice and/or qualifying evaluations. OSCE A
examines the skills and decision-making in Routine Care and the initial steps of The Golden MinuteSM. Learners must
correctly perform 10 of 13 actions to successfully complete this OSCE. OSCE B examines the skills of bag/mask ventilation
and assessment of heart rate. Learners must correctly perform 14 of 18 actions to successfully complete this OSCE. ~ HBB
Web site
64
Throughout the above-described activities, participants demonstrated and practiced techniques

to facilitate learning in a manner consistent with the varying abilities of participants to bring
all of them up to the same level. They also practiced the administration of OSCE A. All sessions
included related discussions and question-and-answer sessions, and encouraged continued
learning at the workplace. The lead facilitators provided guidance and concrete feedback to help
participants make necessary corrections and improvements to their facilitation techniques.
They requested repeat demonstrations as appropriate.
6. Discussion of HBB Implementation at the Country Level

In each of the three large groups, participants reviewed the AAP Draft HBB Implementation
Guide and discussed related issues following a discussion guide. Highlights from those
discussions are summarized below.
A. Goal of Country-Level Implementation of HBB

Participants agreed that the goal of country-level HBB
implementation is to ensure all newborns have access to
a birth attendant who is knowledgeable and skilled in
basic neonatal resuscitation, using the adapted/adopted
HBB training curriculum where appropriate. The
ultimate goal is to reduce the percentage/number of
babies who die as a result of asphyxia.
B. Critical Steps for HBB Implementation

Most country representatives stated that the Draft
Implementation Guide should acknowledge that
countries are not starting from scratch and that
Group discussion
resuscitation is already happening. However, all
acknowledged the need to greatly improve resuscitation skills in various countries. Participants
identified the following as critical steps for implementing HBB in their home countries:
Conducting a situational gap analysis
Seeking national consensus on HBB, a process that should be led and owned by the Ministry
of Health
Reviewing and revising of relevant national MNH plans and policies to include HBB
Integrating HBB with the existing essential newborn care, IMNCI and Life-Saving Skills
(LSS) components within programs (These should place more emphasis on HBB where
necessary.)
Developing a rollout plan for HBB training (OR, for those who already have a plan for
neonatal resuscitation: reviewing the plan to identify gaps and ways the plan can be
strengthened using HBB)
Developing a monitoring and evaluationas well as documentationplan for HBB
Forming a team of core master trainers
Incorporating HBB into pre- and in-service training
Identifying partners and mobilizing resources
Engaging the private sector
Procuring equipment
Developing behavior change communication (BCC) materials to encourage a change in

community attitudes toward newborns
65
Engaging professional associations
Instituting a system for HBB supportive supervision and mentoring, as well as for quality
assurance
Considering ways to ensure access to HBB at both community and facility levels
7. HBB Closing Ceremony and Presentation of Certificates

At the end of the last HBB session
on 25 February, a closing
ceremony was heldfacilitated by
Dr. Joseph de Graft-Johnson
and presided over by a
distinguished panel. Dr. de GraftJohnson highlighted the central
importance of Ministry of Health
buy-in, participation and followup. We want to have a national
program but to do so, it must be
HBB training participants after certificate ceremony
Ministry of Health owned and
led, remarked Dr. de GraftJohnson. Let us bring them on board and let them lead. We come in as support, not to lead. He
then asked each panelist to identify critical next steps for country implementation of HBB.
Tore Laerdal, Chairman of Laerdal Medical AS and Executive Director of The Laerdal
Foundation for Acute Medicine, expressed how proud Laerdal is to support the HBB Global
Development Alliance, and how the Addis meeting represented the start of a great wave in
Africa to ensure that no baby dies trying to take his or her first breath. We want more babies
breathing and crying, and this is what this partnership stands to do, he remarked.
Christine Omondi, Program Officer for the RCQHC at Ugandas Makerere University, also
spoke of the power and strength of the HBB partnership and remarked that when people come
together, much more can be achieved. She encouraged participants to work together to improve
the lives of African women and children and challenged them to ask yourself what you are
doing in your individual circle of influence to make that happen.
We are pleased so many countries are talking about strengthening programs and are now
working closely together on HBB, followed Dr. Doyin Oluwole, Director of Africas Health in
2010. That for me is a true partnership and I thank everyone who is going back to their
countries to get this work going.
Karen Fogg, Health Program Advisor at USAID, encouraged participants to use what they had
learned from this training to develop national plans for newborn resuscitation and to fully
commit to supporting HBB as a key component of essential newborn care. I also want to thank
the Government of Ethiopia for being our gracious hosts and to all of the facilitators who helped
with this training, she concluded.
Dr. Neghist Tesfaye, representing the Ethiopian Federal Ministry of Health, asked that
participants make sure that HBB is not a stand-alone program, but one that can complement
other newborn resuscitation efforts. We need to hold hands together, make sure we have all
partners, and work together on this important initiative, she stated.
66
Following the panelists remarks, Anita Gibson, Deputy Director of MCHIP, distributed
certificates of completion for the Regional Training of Trainers for Africa, Helping Babies
Breathe Training Course to all participants. Dr. Joseph de Graft-Johnson then thanked the
hosts, guests, participants and facilitators and called the meeting to a close.
8. Course Evaluation
Of the 121 participants who attended the training,
98% of respondents plan to serve as
102 completed the course evaluation. The vast
HBB master trainers in their countries.
majority stated they were very much committed to
roll out HBB training in their respective countries,
and stated that they planned to do so by: advocating for HBB; ensuring its inclusion in preservice and in-service curricula; bringing together stakeholders; participating in HBB training
rollout monitoring and evaluation; and supervising and mentoring other trainers.
Out of 96 respondents, 62 participants that said they considered themselves very well-prepared
to be HBB master trainers following the Addis regional training, 29 well-prepared, four OK and
one not well-prepared.
Results from participant evaluations of training sessions from HBB Session 1 are as shown in
Table 4:
Table 4. Participant Evaluations of Specific Training Sessions
HBB Session
Preparation for a Birth
Participant Rating
Great
Very
Good
Good
Fair
Poor
51%
30%
18%
1%
0%
Eighty-one percent (81%) of participants rated this session Very Good or Great. Participants recommended
that: the local context should be emphasized; preparation of the mother should be discussed; use of drugs
for AMTSL, PMTCT and safety of health workers should be addressed; and special considerations, such as
twins, should be included.
Routine Care
59%
25%
16%
0%
0%
Eighty-four (84%) of participants rated this session Very Good or Great. Participants commented that: gloves,
scissors and cord clamps should be added to the training package; the curriculum should mention or
discuss TTC eye ointment, vitamin K and vaccination; and facilitators should emphasize skin-to-skin contact
for baby and mother.
Golden MinuteAirway and Stimulation
64%
27%
7%
2%
0%
Ninety-one percent (91%) of participants rated this session Very Good or Great. Participants recommended
that future sessions: emphasize the importance of assessing for suction; address postpartum care for the
mother; and include the importance of talking to the mother about actions being taken to resuscitate the
baby.
Golden MinuteVentilation
67%
27%
6%
0%
0%
Ninety-four percent (94%) of participants rated this session Very Good or Great. Some participants
requested more time for equipment assembly and practice.
Mastering Bag & Mask Ventilation
69%
27%
4%
2%
0%
Ninety-six percent (96%) of participants rated this session Very Good or Great. Multiple participants
requested more time to practice with the bag and mask; one suggested a video demonstration would be
helpful; and one noted that it is sometimes difficult to achieve a complete seal on the NeoNatalie
mannequin without crushing its face. This latter point has also been noted by Laerdal Medical AS and efforts
are underway to design a better resuscitator.
67
HBB Session
Participant Rating
Great
Very
Good
Good
Fair
Poor
Continued VentilationNormal HR
40%
43%
13%
3%
0%
Continued VentilationSlow HR
42%
43%
13%
2%
0%
Eighty-three percent (83%) and 85% of participants rated the Normal and Slow Heart Rate sessions,
respectively, as Very Good or Great. Multiple participants commented that insufficient time was given for
this sessionboth for demonstration and practiceand that they needed more clear, step-by-step guidance
and instruction in order to train low-level providers.
9. Next Steps
A. Participants
Build consensus with country stakeholders for the way forward; meet with MNH staff in the
MOH and reflect the discussion back to them; establish HBB working group led by the MOH
Review the Draft Implementation Guide and provide feedback to its authors
At country level, emphasize to MOH and other stakeholders the importance of HBB
integration with existing programs and activities
Share with and advocate for the HBB training to other stakeholders in country (UNICEF,
UNFPA, etc.)
Build capacity/train others to strengthen HBB service implementation at the country level
Translate HBB materials as applicable (e.g., Portuguese for Mozambique)
Facilitators encouraged participants to:
Visit the HBB Web site (www.helpingbabiesbreathe.org) for links to HBB materials and
information on ordering equipment and learning materials
Join the HBB Community of Practice site at www.k4health.org/toolkits/hbb-community; this

will help participants engage in discussions with colleagues from across the globe
Remain in contact with one another
A list of all participants trained during the Addis HBB Regional Training is presented in
Appendix F and will be sharedalong with contact informationwith other participants.
B. HBB GDA Members

HBB GDA members stated their commitment to the following steps to help participants
advance HBB in their countries:
Use the HBB GDA implementation database to link the Addis participants to the other
trained HBB implementers in their respective countries by May 2011
Follow-up with each country team on what HBB activities have occurred since the Addis
training by June 2011
68
APPENDIX A. LIST OF PARTICIPANTS

ANGOLA
Ondina da Cruz Gonaves Cardoso, Agostinho
Neto University
Paulo Ado Campos, Agostinho Neto
University
Adelaide de Carvalho, Ministry of Health
Isilda Neves, Ministry of Health
Jhony Juarez, Jhpiego
Isabel Vashti Simbeye, UNICEF
Maria Costa, WHO Angola
BENIN
Aboudou Mama Seni, Ministry of Health
BOTSWANA
Keoagestse Kgwabi, Nurses Council
BRAZIL
Veronica Reis, Jhpiego
BRAZZAVILLE, CONGO
Mongi Pyande, WHO/AFRO
CANADA
Nalini Singhal, Alberta Children's Hospital
Diane Sawchuck, University of British
Columbia
Peter von Dadelszen, University of British
Columbia
EQUATORIAL GUINEA
Ann Davenport, Jhpiego
ETHIOPIA
Bogale Worku, AAU
Tigist Bacha, AAU
Getachew Teshome, Addis Ababa HB
Mohammed Ahmed, Afar RHB
Zebederu Zewde (Sr.), Amhara RHB
Joao Soares, AMREF
Jirra Filatie, Benishangule Gumez
Meskerem Timerga, Black Lion Hospital
Munir Kassa, Dire Dawa HB
Atnafu Setegn, DKT Ethiopia
Aster Berhe (Sr.), EMA
Feleje Mulat, EMA
Lynn Sibley, Emory University
Ashebir Getachew, ESOG
Berhanu Kebede, ESOG
Yirgu Gebrehiwot, ESOG
ETHIOPIA (cont.)
Biruk TekleSelassie, ESOG
Eskedar Mellese, FGAE
Mengistu Hailemariam, FMOH
Kesete Berhan, FMOH
Neghist Tesfaye, FMOH
Khor Pouch, Gambella RHB
Hailu Berhan, Ghandi Hospital
Alemtsehay Mekonen, Gondar University
Afendi Basha, Harari RHB
Achamyelesh, Hawassa University
Dilayehu Bekele, ICAP
Yoseph Gutema, ICAP
Merce Grasco, IFHP
Tesfaye Bulto, Integrated Family Health
Program (Pathfinder International)
Wasse Lengerhe, Integrated Family Health
Program (Pathfinder International)
Bezu Beshere, IntraHealth
Bezunesh Tesfaye, IntraHealth
Saba Kidane Mariam, IPAS
Shishay Tsadik, Islamic Relief
Abdu Nurhussien, Jhpiego
Alemnesh TekleBerhan, Jhpiego
Ashebir Kidane, Jhpiego
Berhane Fekade, Jhpiego
Daniel Dejene, Jhpiego
Ephrem Daniel, Jhpiego
Gebrehawariate Araya, Jhpiego
Hannah Gibson, Jhpiego
Mintwab Gelagay, Jhpiego
Naomi Jayaratne, Jhpiego
Sheena Currie, Jhpiego
Solomon Wolde, Jhpiego
Tegbar Yigzaw, Jhpiego
Yassir Abduljewad, Jhpiego
Yodit Kidane Mariam, Jhpiego
Hibret Alemu, L10K
Wuleta Betemariam, L10K
Abebe Gebremariam, MANHEP
Mohammed Reshid, MOH
Nighist Tesfaye, MOH
Getachew Letta, Oromia RHB
Meseret Yetube, Pastoralist Health Promotion
and Disease Prevention Directorate
Abeba Berhanu (Sr.), Population Council
Tekleabe Mekbebe, Population Council
69
Appendix A: List of Participants
ETHIOPIA (cont.)
Shirega Minuye, Prof. support & Research
Devt
Wondwosen Keremenz, PSI
Abeba Bekel, Save the Children- US
Abiye Siefu, Save the Children- US
Berkity Mengistu, Save the Children- US
Dolores Huberts, Save the Children- UK
Meena Gandhi, Save the Children- UK
Desalegn Ararso, Shashemene Health Science
College
Gizachew Kebede, SNNPR (Jhpiego)
Yusuf Mohammed, Somali Region (Jhpiego)
Hana Bekele, Sudent (OSU)
Negede Hailu (Sr.), The Hamlin College of
Midwives
Sarawit Yilala (Sr), The Hamlin College of
Midwives
Yohannes Tewelde, Tigray RHB ()VSI
Asheber Gaym, UNICEF
Luwei Pearson, UNICEF
Jeanne Rideout, USAID
Merri Sennit, USAID
Premila Bartlett, USAID
Yoseph Woldegebriel, USAID
Dollina Odera, VSI
Tesfanesh Belaye, VSI
Atnafu Getachew, WHO
Nebreed Fesseha, WHO
Mulualem Gessesse, Yekatit 12
Gebre Tensay Gebre Geiorgis, ZMH
Woizero Hiwot Mengistu, ESOG
GHANA
Frank Nyonator, Ghana Health Services
Gloria Asare, Ghana Health Services
Abigail A. Kyei, International Confederation of
Midwives
Chantelle Allen, Jhpiego
Joyce Ablordeppey, Jhpiego
Martha Serwah Appiagyei, Jhpiego
Patience Cofie, PATH
Sylvia Ayeley Deganus, Tema General Hospital
ISRAEL
Judith Standley, Save the Children
KENYA
Alice Ndave Mwangangi, Division of
Reproductive Health, Ministry of Health
Jane Wangui Machira, Division of
70
KENYA (cont.)
Assumpta Atamba Matekwa, Division of
Elijah Njeru Mbiti, Division of Adolescent
Health, Ministry of Health
Khadija A Abdalla, Division of Adolescent
Josephellar Mogoi, Department of Adolescent
Isaac Malonza, Jhpiego
Nancy Kidula, Jhpiego
Elizabeth Oywer, Nursing Council of Kenya
Dana Tilson, PSI
Peter Arimi, USAID
Lilian Mutea, USAID
Catherine Kamau, VSI
Natalie Williams, VSI
Asrat Dibaba, World Vision
LESOTHO
Maleshoane Seeiso, Ministry of Health &
Social Welfare
Thalebo Ramatlapeng, UNFPA
Nonkosi Tlale, UNFPA/MOHSW
LIBERIA
Nancy T. Moses, Liberia Prevention of
Maternal Mortality (LPMM)
Comfort T.Gebeh, MCHIP
Eshter K. Lincoln, Ministry of Health
Torsou Y. Jallabah, Ministry of Health
Odell Kumeh, Ministry of Health & Social
Welfare
Saye Dahn Baawo, Ministry of Health & Social
Welfare
Samson K. Arzoaquoi, Phebe Hospital
Rose Jallah Macauley, Rebuilding Basic Health
Services (RBHS)
Sarah Hodge, Rebuilding Basic Health
Services (RBHS)
Josephine L. N. Freeman, UNICEF
Stella Chinwe Subah, USAID
MADAGASCAR
Claudine Razafiharisoa, MCHIP
Jean Pierre Rakotovao, MCHIP
Heritiana Randrianjafinimpanana, SOMAPED
Jocelyne Andriamiadana, USAID
MALAWI
Abigail Kazembe, Kamuzu College of Nursing
Anna Chinombo, MCHIP
MALAWI (cont.)
Susan Moffson, MCHIP
Tambudzai Rashidi, MCHIP
Chimwemwe Mvula, Ministry of Health
Martha Mondiwa, Nurses and Midwives
Council
Fannie Kachale, Reproductive Health Unit,
Ministry of Health
Evelyn Zimba, Save the Children
Miriam Lutz, USAID
MALI
Toure Cheick Oumar, IntraHealth
MAURITIUS
Rajcoomaree Ramguttee, Nursing Association
MOZAMBIQUE
Jorge Anez, MCHIP
Natericia Fernandes, MCHIP
Jim Ricca, MCHIP
Aida Libombo, Ministry of Health
Cachimo Mulima, Ministry of Health
Juliana Malichocho, Ministry of Health
Cassimo Bique, VSI
NEPAL
Kusum Thapa, Jhpiego
THE NETHERLANDS
Ellen Nelissen, Laerdal Medical
NEW ZEALAND
Karen Guilliland, New Zealand College of
Midwives
NIGERIA
Jamilu Tukur, Aminu Kano Teaching Hospital
Aderinola Olaolu Moses, Federal Ministry of
Health
Olamuyiwa Oyinbo, Federal Ministry of Health
Kamil Shoretire, Jhpiego
Kole Shettima, MacArthur Foundation
Emmanuel Otolorin, MCHIP
Lydia Regina Airede, MCHIP
Amina Barau Ahmed, Ministry of Health
Abdullahi Mohammed J, National Primary
Health Care Development Agency
Ismail Binta, National Primary Health Care
Development Agency
Farouk M Jega, Pathfinder International
Hannatu Suleiman, Primary Health Care
Development Agency, Bauchi State
NIGERIA (cont.)
Babatunde Ahonsi, Population Council
Habib Muhammad Sadauki, TSHIP
Ibrahim Alhassan Kabo, TSHIP
Amina Bara'u Ahmad, State Ministry of Health
Olufemi T. Oladapo, WHO/Olabisi Onabanjo
University Teaching Hospital
NORWAY
Ingrid Laerdal, Laerdal Medicalo
Tor Inge Garvik, Laerdal Medical
Tore Laerdal, Laerdal Foundation for Acute
Medicine
Jon Steinar Tolo, The Laerdal Foundation for
Acute Medicine
Hege Langli Ersdal, SAFER
RWANDA
Andre Gitembagara, Kibagabaga Hospital
Viviane Mukakarara, Internal Health
Abayisenga Gloriose, MCHIP
Beata Mukarugwiro, MCHIP
Jrmie Zoungrana, MCHIP
Dorothee Bamurange, Muhima Hospital
Felix Sayinzoga, Ministry of Health
Stephen Rulisa, National University of Rwanda
Jocelyn Baker, Partners in Health
Juliet Mukankusi, School of Nursing &
Midwifery
Eric Kagame, USAID
Musoni, Canisious, USAID
Soukeynatou Traore, USAID
SENEGAL
Fatou Ndiaye, IntraHealth
SEYCHELLES
Gylian Dorothy Mein, Ministry of Health &
Social Welfare
SOMALILAND
Jennifer Mann, PSI
SOUTH AFRICA
Justus Hofmeyr, Frere Maternity Hospital
Wonder Pertunia Mlotshwa, DENOSA
Ida Asia, Jhpiego
SOUTH SUDAN
Janet Michael, Ministry of Health
Mergani Abdalla, Ministry of Health
Mary Rose Juwa Akile, Ministry of Health
71
SOUTH SUDAN (cont.)

Samson Paul Baba, Ministry of Health
Edward Eremugo Luka, MSH/SHTP II
Clifford Lubitz, USAID
Kawa Tong, USAID
SWAZILAND
Mavis Nxumalo, Ministry of Health & Social
Welfare
SWEDEN
Staffan Bergstrom, Karolinska Institute &
WLF/Tanzania
SWITERZLAND
Capo Chichi Isabelle, MSF
Matthews Mathai, World Health Organization
TANZANIA
Projestine Selestine Muganyizi, AGOTA
Odongo Odiyo, East Central and Southern
African Health Community
Sheillah Matinhure, East Central and Southern
African Health Community
Albert Kitumbo, Ifakara Health Institute
Maryjane Lacoste, Jhpiego
Gaudiosa Tibaijuka, Jhpiego
Sheena Currie, Jhpiego
Georgina Msemo, Ministry of Health and
Social welfare
Koholeth Winani, Ministry of Health and Social
Welfar
Margaret Kiambo, Ministry of Health and
Social Welfare
Neema Mrutu, Ministry of Health and Social
Welfare
Khadija Said, Ministry of Health and Social
Welfare
Jane Msilu Mazigo, Nurses and Midwives
Council
Rose Laisser, Tanzania Midwives Association
Felister Bwana, UNFPA
Asia Hussein, UNICEF
Emmanuel Rwamushaijam, VSI
UGANDA
Emmanuel Byaruhanga, Jhpiego
Kizito Mugenyi, Jhpiego
Miriam Gesa Mutabazi, Management
Sciences for Health
Jessica Nsungwa Sabiti, Ministry of Health
Miriam Sentogo, Ministry of Health
Sarah Naikoba, Ministry of Health
72
UGANDA (cont.)
Wakida John Kennedy, Ministry of Health
Pius Okong, Nsambya Hospital
Christine Omondi, RCQHC
Getachew Tefera, RCQHC
Latigo Mildred, STRIDES/MSH
Connie Namajji, URC/HCI Uganda
Janex Kabarangira, USAID
UK
Sabaratnam Arulkumaran, FIGO
Hannah Knight, University of Oxford
USA
Diana Beck, ACNM
Olaoyin Oluwole (Doyin), AED/Africa 2010
Koyejo A. Oyerinde, Columbia University
Robinson Karuga, Family Care International
Beverly Winikoff, Gynuity Health Projects
Hillary Bracken, Gynuity Health Projects
Sharon Arscott-Mills, IntraHealth
Cindy Stanton, Johns Hopkins
University/Oxytocin Initiative
Linda Bartlet, Johns Hopkins Bloomberg
School of Public Health
Alain Damiba, Jhpiego
Blami Dao, Jhpiego
Brenda Rakama, Jhpiego
Leslie Mancuso, Jhpiego
Peter Johnson, Jhpiego
Sharon Kibwana, Jhpiego
Anita Gibson, MCHIP
Angie Fujioka, MCHIP
Barbara Rawlins, MCHIP
Carmen Crow, MCHIP
Catherine Carr, MCHIP
Charlene Reynolds, MCHIP
Holly Blanchard, MCHIP
Jeffrey Smith, MCHIP
Joseph de Graft-Johnson, MCHIP
Kate Epting, MCHIP
Koki Agarwal, MCHIP
Lindsay Morgan, MCHIP
Rachel Taylor, MCHIP
Stella Abwao, MCHIP/Save the Children
Steve Hodgins, MCHIP
Winifride Mwebesa, MCHIP
Yaikah Jeng Joof, MCHIP
Grace A.Adeya, MSH
Alice Levisay, PATH/Oxytocin Initiative
Elizabeth Abu-Haydar, PATH
Emily Fritch, PATH/Oxytocin Initiative
USA (cont.)
Sarah Dillmuth, PATH/Oxytocin Initiative
Steve Brooke, PATH
Susheela Engelbrecht, PATH/Oxytocin
Initiative
Sylvia Boulos, PATH/Oxytocin Initiative
Cathy Solter, Pathfinder International
Ellen Israel, Pathfinder International
Ndola Prata, University of California, Berkeley
Luc Destanne de Bernis, UNFPA
Deb Armbruster, USAID
Douglas Laube, USAID
Karen Fogg, USAID
Lily Kak, USAID
Mary Ellen Stanton, USAID
Nahed Matta, USAID
Troy A. Jacobs, USAID/GH/HIDN/MCH
Yvonne Okoh Onyike, VCU/Fairfax Family
Practice
Amy Grossman, VSI
Martine Holston, VSI
Richard Lowe, VSI
Shannon Bledsoe, VSI
ZIMBABWE
Elizabeth Dangaiso, MCHIP
Engeline Mawere, MCHIP
Hillary Chiguvare, MCHIP
Rose A. Kambarami, MCHIP
Margaret Nyandoro, Ministry of Health and
Child Welfare
Regina Nsipa Kayemba, Parirenyatwa Hospital
School of Nursing
Partson Zvandasara, University of Zimbabwe
Shelly E. Chitsungo, UNICEF
Tarra McNally, VSI
ZAMBIA
Theresa Chansa Sikateyo, General Nursing
Council of Zambia
Michelle Wallon, Jhpiego
Peggy Chibuye, Midwifery Association of
Zambia
Chipepo lombe Chibesakunda, Ministry of
Health, Kafue District
Lois Munthali, Ministry of Health
Reuben Mbewe, Ministry of Health
Abdul Razak Badru, Mobilising Access to
Maternal Health Services in Zambia (MAMaZ)
Programme
Joyce Nachangwa Musenga, Ndola School of
Nursing, Midwifery & Theatre
Beatrice M. Zulu, University Teaching Hospital
Chipoya Chipoya, University Teaching Hospital
Jully Chilambwe, Society for Family Health
Rabecca Kalwani, VSI
Bernard K Kasawa, ZISSP
Christopher C B Ng'andwe, ZISSP
73
APPENDIX B: MEETING AGENDA
Interventions for Impact in EONC

Detailed Agenda
Day One: 21 February 2011 (Monday)
8:30
OPENING SESSION
Goals and overview of the meeting
Welcome and remarks from dignitaries, funders and organizers
9:45
Address on Maternal and Newborn Health in Africa
Pyande Mongi (WHO/AFRO)
NEW EVIDENCE FOR PREVENTION AND TREATMENT

OF POSTPARTUM HEMORRHAGE
MODERATOR: Koki Agarwal

(MCHIP)
New guidance on PPH prevention and management
Matthews Mathai (WHO/Geneva )
Updates on use of misoprostol for prevention and management of PPH Beverly Winikoff (Gynuity)
Updates on new technologies for the management of PPH
Sylvia Deganus (Ghana Health Service)
Landscape study on use of uterotonic substances at or around the

time of birth in Ghana
Patience Cofie (Oxytocin Initiative)
Discussion
11:00
TEA/COFFEE
11:30
OVERCOMING PROGRAMMATIC BARRIERS TO

IMPLEMENTING PPH PREVENTION AT THE FACILITY
LEVEL
MODERATOR: Alice Levisay

(Oxytocin Initiative)
Overcoming procedural and policy barriers
Aboudou Mama Sni (MOH/Benin)
Overcoming provider barriers to introduction and sustainability of

AMTSL at facilities
Susheela Engelbrecht (PATH)
Overcoming barriers to implementation: The role of professional

associations
Sabaratnam Arulkumaran (FIGO)
Discussion
12:30
LUNCH
13:30
EXPERIENCES OF IMPLEMENTATION OF PPH

PREVENTION AND TREATMENT AT COMMUNITY
LEVEL
MODERATOR: Becky Ferguson

(Bill & Melinda Gates Foundation)
PPH prevention and treatment in Africa using misoprostol at

community level
Ndola Prata (VSI)
When active management is not possible
Karen Guilliland (International

Confederation of Midwives)
PPH prevention through platform of antenatal care
Albert Kitumbo (Ifakara, Tanzania)
Clinical and Community Action to Address PPH
Farouk Jega (Pathfinder)
Discussion
74
Appendix B: Meeting Agenda

14:45
GROUP EXERCISE: INTERVENTIONS FOR PREVENTION AND MANAGEMENT OF PPH
15:45
TEA/COFFEE
16:15
QUALITY OF CARE ESSENTIAL OBSTETRIC CARE
MODERATOR: Yirgu G/Hiwot

(ESOG)
Results of MCHIP quality-of-care surveys from six countries
Linda Bartlett (Johns Hopkins

University /IIP)
EmOC assessments
Koye Oyerinde (AMDD)
Scale-up schematic
Jeffrey Smith (MCHIP)
Discussion
Day Two: 22 February 2011 (Tuesday)

8:30
9:00
OPENING OF THE DAY

Announcements and agenda
Burden of disease of PE/E in Ethiopia
Mengistu Hailemariam (MOH Ethiopia)
EVIDENCE FOR PREVENTION AND DETECTION OF

PRE-ECLAMPSIA
MODERATOR: Nahed Matta (USAID)
Calcium (or aspirin) for prevention of PE/E
Justus Hofmeyr (Frere Maternity

Hospital/South Africa)
Modeling for impact of calcium supplementation
Steve Hodgins (MCHIP)
Detection of PE/E during ANC data from QoC studies
Jim Ricca (MCHIP/Mozambique)
Screening and early detection of PE/E at the community level
Harshad Sanghvi (Jhpiego)
Discussion
10:30
TEA/COFFEE
11:00
EVIDENCE FOR MANAGEMENT OF SEVERE

PRE-ECLAMPSIA AND ECLAMPSIA
MODERATOR: Deb Armbruster

(USAID)
Choice of anticonvulsant for PE/E
Matthews Mathai (WHO/Geneva)
Choice of antihypertensive for PE/E
Peter von Dadelszen (Univ BC)
Induction of labor: new WHO guidelines
Femi Oladapo (WHO/Geneva)
PE/E management strategies at different levels of the health care

system
Pius Okong (Nsambya Hospital/

Uganda)
Discussion
12:30
LUNCH
13:30
GROUP EXERCISE: INTERVENTIONS FOR PREVENTION AND MANAGEMENT OF

PE/E
15:00
TEA/COFFEE
15:30
SKILL AND DISCUSSION SESSIONS:

Each lasts 25 minutes with discussion then
repeated
two times (three times total)
75
Skill and Discussion Sessions: 15:3017:00

Title
Details
Facilitator (s)
Screening for and

detecting PE/E
Review of specifics of BP measurement and proteinuria

testing. Demonstration of the use of new and
innovative screening tools at the community level
Harshad Sanghvi,
Kusum Thapa and
Abigail Kyei
Induction of labor
Detailed review of WHO induction of labor guidelines

with use of a clinical scenario to demonstrate timing of
induction of labor
Mathews Mathai and

Sheena Currie
Implementing MgSO4
protocols
How to implement MgSO4 protocols when faced with

issues of different concentration, different routes of
administration and different dosing. Use of job aids for
MgSO4 administration
Blami Dao and

Catherine Carr
Teaching PE/E
decision making (tool
intro) and LRP
Going through the PE/E Decision Making Tool and

reviewing content of the PE/E Learning Resource
Package
Peter Johnson and

Gaudiosa Tibaijuka
Introduction of the
uterotonic decisionmaking tool
Going through the uterotonic selection tool and

reviewing critical issues when choosing a uterotonic
drug for each point of service and by each type of birth
attendant
Susheela Engelbrecht and

Steve Brooke
Preeclampsia/
eclampsia e-learning
tool
Demonstration of The Evidence-Based Management of

Pre-eclampsia and Eclampsia: an Interactive E-learning
Course for Healthcare Professionals, developed by the
Maternal Health Task Force and University of Oxford
Hannah Knight
Teaching maternity
care using
MamaNatalie
Demonstration of the use of the MamaNatalie model

for teaching childbirth and the management of PPH
Tore Laerdal, Ingrid Laerdal,

Hannah Gibson and
Angie Fujioka
Balloon tamponade
and other techniques
Demonstration of clinical interventions/techniques for

management of PPH using anatomic models
Elizabeth Abu-Haydar and

Sylvia Deganus
76
Day Three: 23 February 2011 (Wednesday)

8:30
9:15
OPENING OF THE DAY
MODERATOR: Pyande Mongi

(WHO/AFRO)
Announcements and agenda
Routine measurement of quality of care
Barbara Rawlins (MCHIP)
Global benchmark indicators for maternal and perinatal health
Steve Hodgins (MCHIP)
Interventions frameworks for PPH and PE/E taking the message

back home
IMPLEMENTATION OF PE/E PROGRAMS
MODERATOR: Luc de Bernis (UNFPA)
Early experience of expansion of use of MgSO4 in Nigeria
Jamilu Tukur (Aminu Kano Teaching

Hospital, Kano, Nigeria)
Pharmaceuticals and logistic mechanisms
Grace Adeye (SPS)
Changing policy Rwandas change in guidelines
Stephen Rulisa
(Rwanda Research Council)
MCHIP TZ Midwives giving MgSO4
Gaudiosa Tibaijuka (MAISHA/Tanzania)
Looking at pre-eclampsia through a health systems lens
Lindsay Morgan (MCHIP/Broad Branch

Associates)
Discussion
10:45
TEA/COFFEE
11:15
IMPROVING NEONATAL RESUSCITATION HELPING BABIES BREATHE (HBB)

Neonatal resuscitation in the context of ENC
Pyande Mongi (WHO/AFRO)
Prevention of newborn asphyxia through improved labor care
Quality of care survey results for newborn care
Joseph de Graft-Johnson (MCHIP)
Introduction of HBB training materials
Tore Laerdal (Laerdal Foundation)
Presentation of HBB field-testing results
Nalini Singhal (American Association of

Pediatrics)
Demonstration of HBB using training simulators
Nalini Singhal and HBB Trainers
13:00
LUNCH
14:00
CONSOLIDATION AND EXPANSION:

Participants from same country will review posters and consider where
programs should be moving, based on the new information learned
14:45
NEXT STEPS:
Reflections from three representatives about moving forward and
implementing/ expanding programs
15:30
SUMMARY AND CLOSING
16:00
TEA/COFFEE
Facilitators and country teams at

posters
MODERATORS:
Koki Agarwal (MCHIP),
Alice Levisay (OI) and
Harshad Sanghvi (Jhpiego)
77
APPENDIX C: PRESENTERS INFORMATION

DAY 1: PANEL 1NEW EVIDENCE FOR PREVENTION AND TREATMENT OF POSTPARTUM
HEMORRHAGE
Moderator: Koki Agarwal, MCHIP
New guidance on PPH prevention and management
Matthews MathaiWHO/Geneva
Matthews Mathai was Professor of Obstetrics and Gynaecology at Christian Medical College,
Vellore, India until 2005. He has worked in many countries in Asia and the Pacific, training
health workers in reproductive health, particularly in maternal and perinatal care. He
established and directed the Regional Training and Research Centre in Reproductive Health at
the Fiji School of Medicine, Suva, Fiji (199697). Currently he works with the World Health
Organization (WHO) in Geneva, where he contributes to the development and update of WHO's
Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines and tools.
Updates on use of misoprostol for prevention and management of PPH

Beverly WinikoffGynuity
Beverly Winikoff, M.D., M.P.H., is President of Gynuity Health Projects and Professor of
Clinical Population and Family Health at the Mailman School of Public Health, Columbia
University. Before starting Gynuity in 2003, Dr. Winikoff was Program Director for
Reproductive Health and a Senior Medical Associate at the Population Council in New York.
There, she developed the Council's Ebert Program on Critical Issues in Reproductive
Health, including work on Safe Motherhood, STDs/AIDS, unsafe abortion, provision of safe
abortion care, and postpartum care for mothers and babies. Prior to joining the Council in 1978,
she was Assistant Director for Health Sciences, The Rockefeller Foundation. Her work has
focused on issues of reproductive choice, contraception, abortion and womens health. Dr.
Winikoff graduated from Harvard University magna cum laude and earned her M.D. degree
from New York University and her M.P.H. degree from the Harvard School of Public Health.
She is particularly interested in issues surrounding the abuse, misuse and non-use of medical
technology in terms of the impact these phenomena have on womens health and autonomy.
Updates on new technologies for the management of PPH

Sylvia DeganusGhana Health Services
Dr. Sylvia Deganus is an Obstetrician/Gynecologist and Public Health Specialist, while also
serving as the Head of Department of the Ob/Gyn Unit at Tema General Hospital, Tema,
Ghana. Dr. Deganus is also a master trainer in MNH and a keen researcher and advocate for
quality MNH care.
Landscape study on use of uterotonic substances at or around the time of birth in Ghana
Patience CofieOxytocin Initiative, PATH
Patience Cofie is the research coordinator for PATHs Oxytocin Initiative Project in Ghana. She
has over 15 years of experience in health systems and operational research. She is also a gender
and health advocate. Her interest has been in the area of Moving research into action:
communicating research to policy makers.
78
Appendix C: Presenters Information
DAY 1: PANEL 2OVERCOMING PROGRAMMATIC BARRIERS TO IMPLEMENTING PPH

PREVENTION AT THE FACILITY LEVEL
Moderator: Alice Levisay, Oxytocin Initiative, PATH
Overcoming procedural and policy barriers
Aboudou Mama SniMOH/Benin
Aboudou Mama Sni is a gynecologist/obstetrician in service at the Hpital de la Mre et de
l'Enfant-Lagune (HOMEL) since April 6, 1987 (24 years), and is currently the Chief Medical
Officer.
Overcoming provider barriers to introduction and sustainability of AMTSL at facilities

Susheela EngelbrechtPATH
Susheela Engelbrecht is a nurse-midwife with a Master of Public Health. She has spent more
than 15 years working in peripheral facilities in West Africa, and she has more than 25 years
experience in international health, mostly in Sub-Saharan Africa.
Overcoming barriers to implementation: The role of professional associations

Sabaratnam ArulkumaranFIGO
Sabaratnam Arulkumaran currently serves as Professor & Head of Obstetrics & Gynaecology,
St. George's University of London, Past President Royal College of Obstetricians &
Gynaecologists, UK; President Elect FIGO. He has indexed/peer-reviewed 250 publications and
has authored/edited 26 books. His main interest is high risk pregnancy and intrapartum care,
especially PPH. He has also been honored by Her Majesty the Queen of the UK for services to
medicine and health care. Dr. Arulkumaran has 38 years of experience working as a doctor and
28 years of experience as a clinical academic in Ob/Gyn.
DAY 1: PANEL 3EXPERIENCES OF IMPLEMENTATION OF PPH PREVENTION AND

TREATMENT AT COMMUNITY LEVEL
Moderator: Becky Ferguson, The Bill & Melinda Gates Foundation
PPH prevention and treatment in Africa using misoprostol at community level
Ndola PrataVSI
As an Angolan physician and medical demographer, Dr. Prata has worked throughout Africa
and Asia. In her role at VSI (Director, Medical and Programs), she has designed protocols and
directed technical assistance and training for the organizations clinical demonstration studies
in several countries. She is also an Associate Professor of MCH at the University of California,
Berkeley and serves as the Scientific Director for the Bixby Center for Population, Health and
Sustainability. Dr. Prata has published extensively in areas such as of family planning,
financing/payment for RH programs, the private sectors role in health care in developing
countries, priorities for maternal health, and the use of misoprostol for PPH. After she received
a doctor of medicine degree in Angola, she spent the next 10 years practicing medicine and
serving as Head of the Social Statistics Department at the National Institute of Statistics in the
country. She then received an MS in medical demography from the London School of Hygiene
and Tropical Medicine.
When active management is not possible

Karen GuillilandInternational Confederation of Midwives (ICM)
Karen Guilliland is currently the Chief Executive Officer of the New Zealand College of
Midwives with 40 years experience in a wide variety of clinical practice as a nurse and midwife,
which includes teaching and research, governance and management positions. She is an Advisor
on midwifery practice, regulation and education both to Government nationally and
79
internationally. She is a longstanding Asia Pacific representative on the International

Confederation of Midwives (ICM) Board and has published numerous papers, articles and book
chapters and presented at many international conferences as a keynote speaker on midwifery
and womens health.
PPH prevention through platform of antenatal care

Albert KitumboIfakara/Tanzania
Clinical and community action to address PPH
Farouk JegaPathfinder
Dr. Farouk Mohammed Jega is the Program Manager of the MacArthur-funded Clinical and
Community Actions to Address Postpartum Hemorrhage Project with Pathfinders Nigeria
Country Office. With a background in Obstetrics and Gynecology, Farouk also holds a Masters
degree in Community Health from the Liverpool School of Tropical Medicine. Before joining
Pathfinder, he has worked variously as a consultant for the UNFPA, Brooks Merseyside and the
Gujarat State Ministry of Health and Family Welfare.
DAY 1: PANEL 4QUALITY OF CARE: ESSENTIAL OBSTETRIC CARE

Moderator: Yirgu G/Hiwot, ESOG
Results of MCHIP quality-of-care surveys from six countries
Linda BartlettJohns Hopkins University/IPPEmOC assessments
Emergency Obstetric and Newborn Care Assessments in Africa: Focus on Postpartum
Hemorrhage and Pre-Eclampsia/Eclampsia
Koye OyerindeAMDD
Dr. Koyejo Oyerinde is an Assistant Clinical Professor for the Averting Maternal Death and
Disability Program (AMDD) at the Department of Population and Family Health, Columbia
University. He leads AMDDs work on Emergency Obstetric and Newborn Care Assessments
worldwide. Dr. Oyerinde has worked on several surveys focusing on maternal and newborn
health in Lesotho, Namibia, Somalia and Sierra Leone. He received medical training in Nigeria
and underwent graduate studies in general public health and epidemiology in Nigeria and
South Africa. He is a fellow of the American Academy of Pediatrics and a member of their
section on international health
Tracking scale-up of maternal and newborn health interventions

Jeffrey SmithMCHIP
Jeffery M. Smith, MD, MPH, is an Obstetrician-Gynecologist and public health practitioner
with 20 years of clinical and public health experience in developing countries. He is the
Maternal Health Team Leader at MCHIP and is based in Washington, D.C. He recently spent
10 years in Asia for Jhpiego, in Nepal, Afghanistan and Thailand.
80
DAY 2: PANEL 5EVIDENCE FOR PREVENTION AND DETECTION OF PRE-ECLAMPSIA

Moderator: Nahed Matta, USAID
Calcium (or aspirin) for prevention of PE/E
Justus HofmeyrFrere Maternity Hospital/South Africa
Justus Hofmeyr is an obstetrician working in the Eastern Cape, South Africa. His research is
focussed on randomized trials and systematic reviews addressing major causes of maternal
death in low-income countries.
Modeling for impact of calcium supplementation

Steve HodginsMCHIP
Steve Hodgins is the Global Health Team Leader of USAIDs MCHIP project. He comes to this
position after having spent much of the previous 10 years in the field, based first in Zambia,
where he worked in the USAID mission, and then more recently in Nepal, where he headed
USAIDs main MNCH/FP bilateral. He is a physician and epidemiologist by training, and has
broad technical interests. Although he is fundamentally a program person, he has had
continuing involvement in applied research throughout his career.
Detection of PE/E during ANCdata from QoC studies

Jim RiccaMCHIP/Mozambique
Jim Ricca is currently the Chief of Party for the MCHIP program in Mozambique. He has
previously worked with MCHIP/Washington and before that with one of its predecessor
projectsthe Child Survival Technical Support Plus Project. He has worked on Maternal and
Child health in clinical and community settings for the last 17 years and is a family doctor and
public health specialist by training.
Screening and early detection of PE/E at the community level

Harshad SanghviJhpiego
Dr. Harshad Sanghvi has made many invaluable contributions to the field of obstetrics,
gynecology and clinical epidemiology. He has extensive experience assisting low-resource
countries to adopt evidence-based guidelines, design training systems and develop health
trainers and leaders. He received his medical education in Kenya and his graduate, residency
and postdoctoral training in the United Kingdom and United States. As Jhpiegos Vice
President and Medical Director, Dr. Sanghvi is responsible for leading development of technical
and clinical approaches by designing low-cost solutions to strengthen health care for women and
their families. For the last 15 years, he has led the global effort in expanding emergency
obstetric care and moving forward innovations for preventing postpartum hemorrhage, cervical
cancer and pre-eclampsia/eclampsia.
DAY 2: PANEL 6EVIDENCE FOR MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND

ECLAMPSIA
Moderator: Deb Armbruster, USAID
Choice of anticonvulsant for PE/E
Matthews MathaiWHO/Geneva
Matthews Mathai was Professor of Obstetrics and Gynaecology at the Christian Medical
College, Vellore, India until 2005. He has worked in many countries in Asia and the Pacific,
training health workers in reproductive health, particularly in maternal and perinatal care. He
established and directed the Regional Training and Research Centre in Reproductive Health at
the Fiji School of Medicine, Suva, Fiji (1996-97). Currently he works with the World Health
81
Organization in Geneva, where he contributes to the development and update of WHO's

Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines and tools.
Choice of antihypertensive for PE/E

Peter von DadelszenUniversity of British Columbia
Peter von Dadelszen is an Associate Professor of Obstetrics and Gynecology (Maternal-Fetal
Medicine) at the University of British Columbia and consultant in Maternal-Fetal Medicine,
Children's and Women's Health Centre of BC. His appointment at UBC is that of a clinicianscientist, with 80% protected time for research; his research interests are focused on the area of
pre-eclampsia and pregnancy hypertension, from basic science to clinical epidemiology and
health services research. Peter is the principal investigator of the recently announced Bill &
Melinda Gates Foundation PRE-EMPT (PRE-eclampsiaEclampsia Monitoring, Prevention &
Treatment) project.
Induction of labor: new WHO guidelines

Femi OladapoWHO/Geneva
Dr. Olufemi T. Oladapo is an obstetrician-gynecologist working as a Senior Lecturer/Consultant
at the Maternal and Fetal Health Research Unit, Department of Obstetrics & Gynecology,
Olabisi Onabanjo University, Sagamu, Nigeria. He is the Clinical Research & Training
Coordinator of the Center for Research in Reproductive Health (a WHO collaborating center for
research in human reproduction) in Sagamu, Nigeria. His main research interest is in evidencebased obstetric care and strategies to reduce severe acute maternal morbidity and maternal
mortality in underserved populations. Dr. Oladapo is a reviewer for the Pregnancy and
Childbirth Group of the Cochrane Collaboration and a member of the Guideline Development
Group working on the 'WHO Recommendations for the Management of Pre-eclampsia and
Eclampsia'.
PE/E management strategies at different levels of the health care system

Pius OkongNsambya Hospital/Uganda
DAY 3: PANEL 7IMPLEMENTATION OF PRE-ECLAMPSIA/ECLAMPSIA PROGRAMS
Moderator: Pyande Mongi, WHO/AFRO
Routine measurement of quality of care
Barbara RawlinsMCHIP
Global benchmark indicators for maternal and perinatal health
Steve HodginsMCHIP
Steve Hodgins is the Global Health Team Leader for USAIDs MCHIP project. He comes to this
position after having spent much of the previous 10 years in the field, based first in Zambia,
where he worked in the USAID mission, and then more recently in Nepal, where he headed
USAIDs main MNCH/FP bilateral. He is a physician and epidemiologist by training, and has
broad technical interests. Although he is fundamentally a program person, he has had
continuing involvement in applied research throughout his career.
Interventions frameworks for PPH and PE/Etaking the message back home
Jeffery SmithMCHIP
Jeffery M. Smith, MD, MPH, is an Obstetrician-Gynecologist and public health practitioner
with 20 years of clinical and public health experience in developing countries. He is the
82
Maternal Health Team Leader at MCHIP, based in Washington, DC. He recently spent 10 years
in Asia for Jhpiego, in Nepal, Afghanistan and Thailand.
DAY 3: PANEL 8MEASUREMENTS AND INDICATORS TO ASSIST PPH AND PE/E

PROGRAMMING
Moderator: Luc de Bernis, UNFPA
Early experience of expansion of use of MgSO4 in Nigeria
Jamilu TukurAminu Kano Teaching Hospital, Kano, Nigeria
Dr. Jamilu Tukur is a consultant obstetrician and gynecologist working at the Aminu Kano
Teaching Hospital in Kano, Northern Nigeria, and works as the head of the department of
ob/gyn. He is also a senior lecturer with the Bayero University, Kano, and a consultant to
Population Council, Nigeria.
Pharmaceuticals and logistic mechanisms

Grace AdeyaSPS
Dr. Grace Adeya is the Senior Technical Manager for Maternal and Child Health with the
Strengthening Pharmaceutical Systems Program of the Center for Pharmaceutical Management
at Management Sciences for Health (MSH). Dr. Adeya has expertise in pharmaceutical
management and care including supply chain management/commodity security, capacity
building, selection and formulary management, pharmacovigilance and medicine safety,
rational drug use, drug information management and pharmacoeconomics and health
economics. Before joining MSH, Dr. Adeya worked as a physician in private and public sector
hospitals in Kenya. In addition to her medical degree, Dr. Adeya holds a Masters degree in
Public Health with a concentration in Epidemiology and Biostatistics, and a Masters degree in
Business Administration.
Changing policyRwandas change in guidelines

Stephen RulisaRwanda Research Council
Dr. Stephen Rulisa is an Obstetrician-Gynecologist & lecturer at the school of medicine,
National University of Rwanda. He is also the Department Head of clinical research at the
University Teaching Hospital of Kigali as well as the President of the Rwanda Medical
Association.
MCHIP TZMidwives giving MgSo4

Gaudiosa TibaijukaMAISHA/Tanzania
Gaudiosa Mugyabuso Tibaijuka is a certified Nurse Midwife with a Masters Degree in
Education and a Certification in Population, Development, Reproductive and Child Health.
Currently Senior Technical Manager with Tanzania Jhpiego office, key in the implementation of
MNH program on focused ANC, BEmONC, Supervision and SBM-R interventions national
wide.
Looking at pre-eclampsia through a health systems lens

Lindsay MorganMCHIP/Broad Branch Associates
Lindsay Morgan is a senior health analyst with Broad Branch Associates and previously served
with the World Bank in Tanzania, where she analyzed results-based financing for health
schemes across the continent. Before that, Lindsay was a policy analyst with the Center for
Global Development, a Washington DC-based think tank.
83
APPENDIX D: RESULTS OF COUNTRY PROGRAM

POSTER REVIEWS6
ANGOLA
I.
Five priority interventions that are appropriate to be introduced or expanded

in your country:
1. Make oxytocin and MgSO4 available to all health facilities providing delivery
services.
a. Review the drug and supply chain management
b. Link with all FPAs RH/contraceptive commodity security strategy
2. Strengthen pre-service training of doctors, nurses, midwives to ensure that the
curriculum includes prevention and management of PPH, PE/E and essential
newborn care
3. Review the existing in-service training curriculum to ensure strengthening of
prevention and management of PPH, PE/E and essential newborn care.
4. Review the successes/lessons learned/ best practices of community health workers in
Cacuacou municipal of Luanda province and plan to expand to other municipals.
II.
Two immediate steps that your country can take to disseminate information
from this meeting to your colleagues.
1. Organize meetings with the Associations of obstetricians/gynecologists, pediatricians
and midwives to share information from the Addis meeting.
2. Translate and disseminate all documents from the Addis meeting
3. To organize a meeting with international partners to mobilize support.
III.
Two challenges that might delay or interfere with introducing/expanding the

Five priority interventions.
1. Strengthening and increasing the human resource for health, particularly for
maternal and newborn.
2. Strengthening and augmenting capacity at the central level of the Ministry of
Health.
Country posters can be accessed through the MCHIP Web site (www.mchip.net).
84
ETHIOPIA
I.

in your country:
1. To scale up community use of misoprostol for PPH prevention and management.
2. To strengthen AMTSL at facility level.
3. Making available MgSO4 to health centers so that midwives could be using to treat
patients with PE/E.
4. Community awareness for danger signs and emergency planning including
transport.
5. Quality of care initiatives to improve appropriate management of severe PE/E.
II.
1. To communicate with health professionals, ESOG, midwifery associations on current
PPH prevention and management.
2. The participant will go back to their organization and brief their respective staff at
MOH, RHB and partners.
III.

1. Low level of utilization of health delivery services.
2. Inadequate supplies and trained personnel at community and facility level.
3. Distribution and utilization of MgSO4 in the country/timely distribution to health institutions.
GHANA
I.

in your country:
1. Surveillance of quality of uterotonics.
2. Increase MgSO4 availability and correct use at all levels.
3. Develop sentinel sites for maternal health focusing on QoC.
4. Community sensitization on recognition and action for PPH and PE/E.
5. Improve technical and supportive supervision.
II.
1. Share information at Family Health Division Biannual Conference.
2. Encourage content to be included in medical director meetings, midwife meetings, etc.
3. PPH/Family Health Division (Gloria, Frank, and Sylvia) and MCHIP to plan
dissemination roll out.
III.

1. Money: national budget already fixed for this year.
2. Must have buy in from decision makers at all levels.
3. Competing priorities on the ground.
4. Weak data to inform immediate program implementation.
85
KENYA
I.

in your country:
1. Scale up implementation of HII5 through the annual operational planning and
community strategy.
2. Capacity building for AMTSL, partograph and use of MgSO4 at all levels of the
health system.
3. Strengthening equipment, commodities and supply management for PPH and PE/E.
4. Adapt and disseminate IEC materials and job aids, etc. for PPH and PE/E.
5. Strengthen M&E/ support supervision for PPH and PE/E.
II.
1. Brief the heads of department and divisions in both Ministries of Health.
2. Prepare 1 page summary and convene a special TWY for MWCH to disseminate
outcomes of this meeting.
III.

1. Ensuring availability of drugs and commodities for PPH, PE/E at point of use.
2. Limited resources for up scaling interventions.
3. Re-deployment of trained staff to other departments.
LIBERIA
I.

in your country:
1. CBD-PPH prevention.
2. Supervision of facility proteinuria.
3. Need filter paper reagent for protein.
4. Need to get MgSO4 down to facility level with protocols.
II.
1. Training misoprostol at community/facility, misoprostol on EDL.
2. Supervision and M&E for all especially facility.
III.

1. Logistics for increased supervision.
2. HR for increased supervision.
86
MADAGASCAR
I.

in your country:
1. To ensure there is facility level quality improvement in PE/E and PPH.
2. Advocacy and early program implementation for use of misoprostol on demonstration
basis.
3. Work to reduce financial barriers to access intrapartum care.
4. Strengthening the logistics systems for these commodities.
II.
1. Disseminate PPH and PE/E tools at next MNH working group.
III.

1. Getting proper government approval and buy in from stakeholders to use
misoprostol.
MALAWI
I.

in your country:
1. Put use/pilot of misoprostol as an agenda item for subcommittee meeting on March
22nd.
2. Logistical officer at RHU to sound an alarm on the dwindling stock of oxytocin
(<3 months stock)
3. Disseminate the reliability and safety of MgSO4 to safe motherhood subcommittee,
DHO, training institutions, etc. to increase usage among SBAs.
4. Review forthcoming WHO guidelines for PE/E and evaluate calcium
supplementation in pregnancy in Malawi.
II.
1. Brief the Safe Motherhood subcommittee meeting on the deliberation of the impact
in essential obstetric and newborn care meeting.
2. Develop a fact sheet on use of MgSO4 at health center level (safety guidance).
III.

1. Funding for misoprostol pilot.
2. Supply chain management.
87
MALI
I.

in your country:
1. Pilot and advocate for misoprostol for routine AMTSL
2. Ensure the regularly availability of uterotonics (Uniject) and MgSO4 including
ensuring its quality.
3. Reinforce and advocate for the use of partograph.
4. Reinforce EMONC program.
5. Routine clinical drills to maintain providers skills to manage PE/E.
II.
1. Dissemination during a quarterly task force meeting.
2. Dissemination during the National Congress of Midwives (May 7, 8 2011).
3. Advocate for a West Africa regional meeting in French similar to this one.
III.

1. Drugs (Uniject and MgsO4) availability.
MOZAMBIQUE
I.

in your country:
1. There already is an integrated training package for MNCH being developed need to
finish this and put emphasis on NTSR, AMTSL, MgSO4.
2. Identify best job aids for AMTSL, MgSO4 use and reproduce and distribute.
3. Distribution of misoprostol through ANC and TBAs
4. Take Model Maternities standard for NTSR, MgSO4, AMTSL and disseminate to all
health facilities.
II.
1. Meeting with key Ministry personnel
2. Disseminate through APARMO, AMOG
III.

1. Logistics system for MgSO4, oxytocin, misoprostol.
2. Ensuring supervision and follow up after training.
88
NIGERIA
I.

in your country:
1. Scale up misoprostol and estimating improving blood loss estimation at community
and facility level.
2. Ensure availability of magnesium sulfate, oxytocin and misoprostol at all facilities.
3. Improve detection of proteinuria, blood pressure and anemia at facility level.
4. Scale up Helping Babies Breathe.
5. Strengthen the use of birth preparedness plan at community and facility level.
II.
1. National level advocacy meeting upon return.
2. Insert new learning into pre-service and in-service curriculum.
3. Hold a state level meeting to ensure procurement of misoprostol, oxytocin and
magnesium sulfate as part of Essential Medicine List.
III.

1. Sustainability/funding.
2. Supply chain for MgSO4 and misoprostol.
RWANDA
I.
Five priority interventions that are appropriate to be introduced or expended

in your country
1. Continue support to the introduction of PPH prevention at community level
2. Improve quality of care at facility level both for PPH, PE/E
3. Update guidelines norms and procedures for the use of misoprostol at community
level
4. Use the results of the quality of care survey for improving prevention and
management of PPH, PE/E
5. Strengthening essential new born care
II.
from this meeting to your colleagues
1. Report to the MCH TWG
2. Share results with each organization represented
3. Present the results at MCH annual conference
4. Create PPH sub TWG
III.
Two challenges that might or interfere with introducing/expending the Five

priority interventions
1. Funding
2. Procurement process and commodities management
89
SENEGAL
I.

in your country:
1. Extending AMTSL with oxytocin to whole country. Currently in 11 regions, 3 regions
are not covered.
2. Advocate for misoprostol approval for use by obstetricians.
3. Introduce misoprostol in all facilities including community level (Abt is
testing/piloting miso at community level).
4. Advocate for better supply chain management for MgSO4.
5. Expansion of training for PE/E prevention and management including Calcium.
II.
1. Organize a partner meeting with MOH and USAID and implementing partners to
share key outputs.
2. Share with midwife association the key outputs.
III.

1. Financial: to expand AMTSL into 3 additional regions of the country.
2. Obtaining approval for misoprostol for OB use.
SOUTH SUDAN
I.

in your country:
1. Policy change: misoprostol into EML, supply chain and procurement
2. Access to oxytocin and MgSO4 and other drugs and supplies at regional, state and
country; need to improve facilities
3. Focus training on big killers (PPH and PE/E) at regional, state, country level. Should
include monitoring and supervision and data collection and job aids
4. BCC to encourage woman to come to ANC for complications
5. Community-based distribution of misoprostol to woman
II.
1. Advocacy and training on two big killers
2. Policy change
III.

1. CHANGE-attitudes, etc.
2. Re-programming
3. Task shifting
4. Data not captured
5. Drug and logistic systems (supplies and missing staff)
90
UGANDA
I.

in your country:
1. Community awareness for both PPH and PE/E.
2. Scale up monitoring for labor progression using a partograph. We need champions to
help promote labor monitoring.
3. Expand AMTSL it needs to be available everywhere.
4. Quality of care for both AMTSL and PE/E including training, job aids, support for
existing human resources.
5. Screening for PE/E including BP screening and proteinuria testing.
II.
1. Modify policy briefs on PPH/ PE/E and include actions for National MOH, DHDs,
professional bodies, parliament and national death review committees.
2. Review Essential Drug List and supply list.
3. Create protocol for use of oxytocin, misoprostol and MgSO4 to be distributed in drug packs.
III.

1. Getting partnerships to support these issues, including funding and technical
assistance.
2. Provider attitudes: change takes time.
3. We need data and evidence.
ZAMBIA
I.

in your country:
1. Scale up of ANC distribution of misoprostol 600mcg orally for prevention.
2. Improve performance of AMTSL at facilities by using mentors, integrating AMTSL
into supply tools in future, having an indicator.
3. Expand maternity waiting homes to increase access to SBAs, management of PE,
prevention of eclampsia, etc.
4. Introduction of Brass V drape.
5. Introduce use of MgSO4 for severe PE
II.
1. Present at the next TAG for EmOC meeting.
2. Write a report and debrief management.
III.

1. Financial resources.
2. Human resources.
3. Supply chain.
91
ZANZIBAR
I.

in your country:
1. Development of job aids for prevention/management of PPH, PE/E.
2. Establish a MNCH technical working group and review data/presentations and
identify way forward.
3. Development if IEC/BCC campaign to improve community knowledge/awareness.
4. Stakeholder meeting to review/ revise logistics system to ensure drug and supply
availability.
5. Strengthen role of associations to play a more active role in monitoring quality.
6. Strengthen PSE.
II.
1. Report to everyones respective heads.
2. Report out at DPG and quality working group.
III.

1. Human resource shortages.
2. Current logistics system.
3. Lack of space/sufficient beds/equipment.
ZIMBABWE
I.

in your country:
1. Misoprostol pilot through hospital.
2. Skilled attendance at birth training.
3. Improvement in quality.
4. Free maternity services.
5. Communication and transport through telephone.
6. Waiting mother shelters-strengthen and revive.
II.
1. MNH-WG dissemination.
2. Revision of scale up map.
III.

1. Financial resources.
2. Systems for up skilling and pre-service.
92
APPENDIX E: HBB COURSE OBJECTIVES

AND DETAILED AGENDA

Regional Training of Trainers for Africa
SM
Course Objectives
DAY ONE: PROVIDER COMPONENT (Thursday)
At the end of the provider component of the Helping Babies Breathe (HBB) training course, the
participant will be able to:
Describe the linkages among HBB materials
State the key messages of HBB
Carry out all of the key four exercises in HBB (preparation, routine care for all babies, The
Golden Minute,SM continued ventilation with normal or slow heart rate)
Identify regional practices in newborn resuscitation through group discussion and questions
Demonstrate mastery of bag and mask ventilation (skill check)
DAY TWO: FACILITATOR COMPONENT (Friday)

At the end of the facilitator component of the HBB training course, the participant will be able to:
Describe the evolution and purpose of the educational program HBB
Demonstrate presentation of HBB content, including key messages from the Facilitator Flip
Chart and incorporation of all the HBB learning materials
Explain the interaction that occurs between a pair of participants using the neonatal
simulator (roles of learner/teacher/baby)
Facilitate learning in small groups to enable participants of various ability levels to:
Demonstrate skills in helping babies breathe
Lead practice and provide feedback on skills and performance
Moderate the experience of learners and obtain consensus on regional best practices
Provide cultural interpretation and localization (best and potentially harmful

practices)
Create realistic scenarios
Evaluate learner performance using the written/verbal knowledge check as well as OSCE A
and B
Prepare and supervise participants in continued learning in the workplace
Access resources to plan and evaluate courses
Explain the integration of HBB with other interventions according to the regional
implementation plan
93
Course Agenda
Provider Component
Day One: 24 February 2011 (Thursday)
8:00
REGISTRATION
9:00
OPENING CEREMONY WELCOME AND INTRODUCTION OF FACULTY, OVERVIEW

OF AGENDA
Welcoming remarks
Introduction of faculty
Overview of agenda
9:45
PRESENTATION NEONATAL RESUSCITATION IN THE CONTEXT OF ESSENTIAL

NEWBORN CARE
10:00
BREAK
10:30
PREPARATION FOR SMALL GROUP LEARNING
10:45
INTRODUCTION TO THE HELPING BABIES BREATHE (HBB) MATERIALS

(SIMULATOR, FLIP CHARTS AND LEARNER BOOK) PREPARATION FOR A BIRTH
Demonstration and skill practice of preparation for a birth:
Identify a helper and review the emergency plan
Prepare the area for delivery
Wash hands
Prepare area for ventilation and check equipment
Discussion and questions on preparation for a birth
11:15
ROUTINE CARE
Demonstration and skill practice on routine care
Dry thoroughly; if meconium, clear airway before drying
Evaluate crying
Keep warm
Check breathing
Clamp/tie and cut the cord
Discussion and questions on routine care
11:45
THE GOLDEN MINUTE (CLEAR AIRWAY AND STIMULATE BREATHING)

Demonstration and skill practice on The Golden Minute clear airway and stimulate breathing
Position the head, clear the airway, stimulate breathing
Evaluate breathing
Discussion and questions The Golden Minute (part 1)
12:30
LUNCH
13:30
THE GOLDEN MINUTE (VENTILATION)

Demonstration and skill practice on The Golden Minute ventilation
Initiate ventilation
Ventilate with bag and mask
Evaluate breathing
Discussion and questions on The Golden Minute (part 2)
94

14:15
CONTINUED VENTILATION WITH NORMAL AND SLOW HEART RATE

Demonstration and skill practice on continued ventilation with normal heart rate:
Call for help and improve ventilation
Evaluate heart rate
Continue ventilation and monitor with mother
Continue ventilation and activate the emergency plan
Support the family
Discussion and questions on continued ventilation with normal heart rate

Demonstration and skill practice of continued ventilation with slow heart rate
Discussion and questions on continued ventilation with slow heart rate
15:00
BREAK
15:30
PARTICIPANT EVALUATIONS MASTERING THE ACTION PLAN

Overview of participant evaluations
Practice and scenario development
Knowledge check:
Written
Bag and mask ventilation skill check
OSCE Station A (The Golden Minute, part 1)

OSCE Station B (Continued ventilation with normal heart rate)
FACILITATOR COMPONENT (PLENARY SESSION)

17:00
EVALUATION OF LEARNER KNOWLEDGE AND PERFORMANCE

Discussion and practice of administering:
Written/verbal knowledge check
Bag and mask skills check
OSCE A and B
Review program criteria for successful completion of each evaluation and review any regional criteria for
elements that must be successfully completed for each group trained
17:30
PREPARATION OF PARTICIPANTS FOR CONTINUED LEARNING IN THE

WORKPLACE
18:00
Elements of a successful scenario

In situ skills practice and case scenarios
ADJOURN FOR THE DAY
95
Provider Component
8:00
Day Two: 25 February 2011 (Friday)
OVERVIEW OF PROVIDER COURSE OBJECTIVES, SUPPLEMENTAL MATERIAL AND

FACILITATION TECHNIQUES
Review of opening visualization
9:00
PRESENTATION OF THE CONTENT OF THE FACILITATOR FLIP CHART

Practice exercise in use of the Facilitator Flip Chart
Demonstration and practice of techniques to facilitate learning among providers of varied abilities
Discussion and questions on continued learning at the workplace
10:30
BREAK
11:00
PRESENTATION OF CONTENT OF THE FACILITATOR FLIP CHART (CONTINUED)
12:30
LUNCH AND OPEN DISCUSSION
13:30
PLANNING AND EVALUATING COURSES (PLENARY SESSION)
15:00
BREAK
15:30
DISCUSSION OF COUNTRY LEVEL DEVELOPMENT, IMPLEMENTATION AND

MAINTENANCE OF HBB TRAINING QUALITY
Developing a sustainable HBB training program
Implementing quality HBB training
Program monitoring and evaluation
17:00
96
CONCLUSION
APPENDIX F: HBB PARTICIPANT, OBSERVER

AND FACILITATOR LISTS
PARTICIPANT LIST
NAME
COUNTRY
ORGANIZATION
Jhony Juarez
Angola
Jhpiego
Adelaide de Carvalho
Angola
Ministry of Health
Isilda Neves
Angola
Ministry of Health
Paulo Ado Campos
Angola
Agostinho Neto University
Ondina da Cruz Gonaves

Cardoso
Angola
Agostinho Neto University
Isabel Vashti Simbeye
Angola
UNICEF
Maria Costa
Angola
WHO
Keoagetse Kgwabi
Botswana
Nurses Council
Mongi Pyande
Congo-Brazzaville
WHO/AFRO
Ann Davenport
Equatorial Guinea
Jhpiego
Mataye Mideksa (Sr.)
Ethiopia
St. Luke Hospital
Eyaya Misgan (Dr.)
Ethiopia
Felege Hiwot Hospital
Sara Bahta (Sr.)
Ethiopia
Ayder Hospital
Achamyelesh Tsadik
Ethiopia
Hawassa University
Assalif Beyene
Ethiopia
D/Birhan/H/S/C
Hamdiya Mohammed (Sr.)
Ethiopia
Jijiga Karamara Hospital
Marta Kebede (Sr.)
Ethiopia
Yirgalem Hospital
Helen Menta (Sr.)
Ethiopia
Woliyta Hospital
Dula Ayana
Ethiopia
Pawe H/Sc/College
Solomon Gebre
Ethiopia
Wokiro Hospital
Birkety Mengistu
Ethiopia
Save the Children
Robel Alemu (Dr.)
Ethiopia
Gondar University
Abdujebar Ahmed
Ethiopia
Awash H/C
Mohammed Akber
Ethiopia
Semera H/Sc/College
Temesgen Mulugeta
Ethiopia
Mettu Karl Hospital
Aster Berhe
Ethiopia
Midwifery Association President
Abiy Seifu
Ethiopia
MCHIP/Save the Children
Bedru Areb
Ethiopia
Semera H/Sc/College
Tewodrose Tesfaye
Ethiopia
Assosa Hospital
Alemnesh TekleBerhan
Ethiopia
Jhpiego
Berhane Fekade
Ethiopia
Jhpiego
Roman Betru (Dr.)
Ethiopia
Yekatit Hospital
Lemlem Girma
Ethiopia
Jogula Hospital
Yodit Tegegn
Ethiopia
Dillchora Hospital
Abigail A. Kyei
Ghana
International Confederation of Midwives (ICM)
97

NAME
COUNTRY
ORGANIZATION
Martha Serwah Appiagyei
Ghana
Jhpiego
Joyce Ablordeppey
Ghana
Jhpiego Coporation
Sylvia Ayeley Deganus
Ghana
Tema General Hospital
Gloria Asare
Ghana
Ministry of Health
Elizabeth Oywer
Kenya
Nursing Council of Kenya
Nancy Kidula
Kenya
Jhpiego
Josephellar Mogoi
Kenya
Department of Adolescent Health
Khadija A Abdalla
Kenya
Division of Adolescent Health
Maleshoane Seeiso
Lesotho
MOHSW
Comfort T.Gebeh
Liberia
MCHIP
Odell Kumeh
Liberia
Mininstry of Health/Social Welfare
Samson K.Arzoaquoi
Liberia
Phebe Hospital
Rose Jallah Macauley
Liberia
Rebuilding Basic Health Services (RBHS)
Sarah Hodge
Liberia
Building Basic Health Services (RBHS)
Torsou Y. Jallabah
Liberia
MOH
Nancy T Moses
Liberia
UNICEF
Jean-Pierre Rakotovao
Madagascar
Jhpiego
Randrianjafimpanana
Heritiana
Madagascar
SOMAPED
Luwiza Soko Puleni
Malawi
Jhpiego/MCHIP
Tambudzai Rashidi
Malawi
Jhpiego/MCHIP
Abigail Kazembe
Malawi
Kamuzu College of Nursing
Anna Chinombo
Malawi
SAVE/MCHIP
Fannie Kachale
Malawi
Reproductive Health Unit, Malawi Ministry of

Health
Chimwemwe Mvula
Malawi
MoH
Martha Mondiwa
Malawi
Nurses & Midwives Council
Toure Cheick Oumar
Mali
IntraHealth International
Rajcoomaree Ramgutee
Mauritius
Nursing Association
Jiuliana Malichocho
Mozambique
Ministry of Health
Natercia Fernandes
Mozambique
MCHIP
Kusum Thapa
Nepal
Jhpiego Nepal
Kamil Shoretire
Nigeria
Jhpiego/TSHIP
Aderinola Olaolu Moses
Nigeria
Federal Ministry of Health, Abuja
Habib Muhammad Sadauki
Nigeria
USAID-TSHIP Project, Bauchi
Ibrahim Alhassan Kabo
Nigeria
Targeted states high impact project, Bauchi
Ismail Binta
Nigeria
National Primary Health Care Development Agency
Lydia Regina Airede
Nigeria
MCHIP
Farouk M Jega
Nigeria
Pathfinder International
Olamuyiwa Oyinbo
Nigeria
Federal Ministry of Health Dates
Abayisenga Gloriose
Rwanda
MCHIP
Beata Mukarugwiro
Rwanda
MCHIP
98

NAME
COUNTRY
ORGANIZATION
Dorothee Bamurange
Rwanda
Muhima Hospital
Felix Sayinzoga
Rwanda
Ministry of Health
Viviane Mukakarara
Rwanda
IntraHealth International
Juliette Mukankusi
Rwanda
School of Nursing and Midwifery
Stephen Rulisa
Rwanda
National University of Rwanda
Gylian Dorothy Mein
Seychelles
MOHSW
Wonder Petunia Mlotshwa
South Africa
DENOSA
Morgani Abdalla
South Sudan
Ministry of Health
Dr Mergani Abdalla
South Sudan
Ministry of Health
Janet Michael
South Sudan
Ministry of Health
Mary Rose Juwe Akile
South Sudan
Ministry of Health
Mavis Nxumalo
Swaziland
MOHSW
Staffan Bergstrom
Sweden
Karolinska Inst & WLF/Tanzania
Sheillah Matinhure
Tanzania
ECSA Health Community
Projestine Selestine
Muganyizi
Tanzania
AGOTA
Rose Laisser
Tanzania
Tanzania Midwives Association
Margaret Kiambo
Tanzania
MOHSW
Jane Msilu Mazigo
Tanzania
Nurses and Midwives Council
Koholeth Winani
Tanzania
MOH
Asia Hussein
Tanzania
UNICEF
Neema Mrutu
Tanzania
MOHSW
Gaudiosa Tibaijuka
Tanzania
Jhpiego
Miriam Gesa Mutabazi
Uganda
Management Sciences for Health
Latigo Mildred
Uganda
STRIDES/MSH
Wakida John Kennedy
Uganda
MoH
Emmanuel Byaruhanga
Uganda
Jhpiego GE MNH project
Kizito Mugenyi
Uganda
Jhpiego
Jessica Nsungwa Sabiti
Uganda
Ministry of Health
Miriam Sentongo
Uganda
MOH
Blami Dao
USA
JHPIEGO
Judith Standley
USA
Robinson Karuga
USA
Family Care International
Bernard K Kasawa
Zambia
ZISSP
Christopher C B Ng'andwe
Zambia
ZISSP
Beatrice M. Zulu
Zambia
University Teaching Hospital - UTH
Peggy Chibuye
Zambia
Midwifery Association of Zambia (in process)
Joyce Nachangwa Musenga
Zambia
Ndola School of Nursing, Widwifely & threatre
Chipoya Chipoya
Zambia
University Teaching Hospital
Theresa Chansa Sikateyo
Zambia
General Nursing Council of Zambia
Elizabeth Dangaiso
Zimbabwe
MCHIP
Engeline Mawere
Zimbabwe
Jhpiego
99

NAME
COUNTRY
ORGANIZATION
Hillary Chiguvare
Zimbabwe
MCHIP
Rose A. Kambarami
Zimbabwe
MCHIP
Margaret Nyandoro
Zimbabwe
Ministry of Health and Child Welfare
Shelly E. Chitsungo
Zimbabwe
UNICEF
Regina Nsipa Kayemba
Zimbabwe
Parirenyatwa Hospital School of Nursing
NAME
COUNTRY
ORGANIZATION
Peter Arimi
Kenya
USAID
Lilian Mutea
Kenya
USAID
Josephine Freeman
Liberia
Unicef
Stella Chinwe Subah
Liberia
USAID
Jocelyne Andriamiadana
Madagascar
USAID
OBSERVER LIST
Jrmie Zoungarana
Rwanda
Jhpiego
Soukeynatou Traore
Rwanda
USAID
Felister Bwana
Tanzania
UNFPA
Janex Kabarangira
Uganda
USAID
Deb Armbruster
USA
USAID
Holly Blanchard
USA
MCHIP
Karen Fogg
USA
USAID
Lily Kak
USA
USAID
Mary Ellen Stanton
USA
USAID
Nahed Matta
USA
USAID
Peter Johnson
USA
Jhpiego
NAME
COUNTRY
ORGANIZATION
Nalini Singhal
Canada
Alberta Children's Hospital and AAP Volunteer
Alemtsehay Mekonen
Ethiopia
Gondar University
Bogale Worku
Ethiopia
AAU
Gebretensay Gebregeiorgis
Ethiopia
ZMH
Hailu Berhan
Ethiopia
Ghandi Hospital
Meskerem Timerga
Ethiopia
Black Lion Hospital
FACILITATOR LIST
Mintwab Gelagay
Ethiopia
Jhpiego
Mohammed Reshid
Ethiopia
MOH
Mulualem Gessesse
Ethiopia
Yekatit 12
Nigist Tesfaye
Ethiopia
MOH
Tigist Bacha
Ethiopia
AAU
Woizero Hiwot Mengistu
Ethiopia
Jhpiego
100

NAME
COUNTRY
ORGANIZATION
Evelyn Zimba
Malawi
Save the Children
Emmanuel Otolorin
Nigeria
MCHIP
Hege Langli Ersdal
Norway
SAFER
Ingrid Laerdal
Norway
Laerdal Medical
Tore Laerdal
Norway
Laerdal Foundation for Acute Medicine
Georgina Msemo
Tanzania
Ministry of Health and Social welfare
Odongo Odiyo
Tanzania
East Central and Southern African Health

Community
Connie Namajji
Uganda
URC/HCI Uganda
Sarah Naikoba
Uganda
Ministry of Health
Doyin Oluwole
USA
Africa's Health in 2010
USA
MCHIP
Stella Abwao
USA
Troy A. Jacobs
USA
USAID/GH/HIDN/MCH
Winifride Mwebesa
USA
101
APPENDIX G: HBB KNOWLEDGE AND SKILLS

ASSESSMENTS
102
Appendix G: HBB Knowledge And Skills Assessments
103
104
105
APPENDIX H: ADDIS HBB FACILITATOR GUIDE

Regional Training of Trainers for Africa
SM
Facilitator Guide
Facilitators notes including session structure, process, responsible person(s) and
resources/materials needed are listed in orange boxes.
Provider Component
Day One: 24 February 2011 (Thursday)
8:00
REGISTRATION
9:00
OPENING CEREMONYWELCOME AND INTRODUCTION OF FACULTY, OVERVIEW

OF AGENDA
Welcoming remarks
Introduction of faculty
Overview of agenda
Plenary session:
Acknowledge leadership, stakeholders, supporters
Introduce faculty and staff
Explain course objectives and agenda
Lead facilitator
Course objectives
and agenda
Highlight:
Goal of the provider component of the HBB training is to have the knowledge,
skills and equipment to help a baby breathe at
Goal of facilitator component of the HBB training is to help others gain this
ability.
Emphasis is on paired learning.
Need for participants to suspend expert knowledge and become immersed as learners.
9:45
PRESENTATIONNEONATAL RESUSCITATION IN THE CONTEXT OF ESSENTIAL

NEWBORN CARE
Plenary session:
10:00
Guest presenter
PowerPoint presentation
BREAK
During the break, participants should assemble in the assigned training rooms.
106

10:30
PREPARATION FOR SMALL GROUP LEARNING

Small group learning session:
Course facilitators for each of the small groups to invite participants to

introduce themselves at the individual tables and share:
What brings you to this workshop?
What do you want to learn?
Why do you want to be a facilitator?
Ensure each participant in the small group has completed and submitted the
participant course expectation form.
Conduct pretest written knowledge check
Course
facilitators
Participant
course
expectation
forms
Pretest written
knowledge check
forms
Opening visualization:
10:45
Lead facilitator in each assigned training room to guide participants through the
visualization exercise of the birth of a baby who is not breathing and one who is
breathing.
INTRODUCTION TO THE HELPING BABIES BREATHE (HBB) MATERIALS

(SIMULATOR, FLIP CHARTS AND LEARNER BOOK) PREPARATION FOR A BIRTH
Introduction to the HBB materials:
Simulator
Flip chart -layout and sections (presentation/demonstration, Practice with the Action Plan,
Check yourself)
Learner workbook
Preparation for a birth:
Demonstration and skill practice of preparation for a birth:
Identify a helper and review the emergency plan
Prepare the area for delivery
Wash hands
Prepare area for ventilation and check equipment
Review the HBB training materials with participants and emphasize linkage
among HBB materials
Facilitators demonstrate preparation for a birth exercise
Learner pairs practice in turns to prepare for a birth
Course facilitators:
Observe and provide feedback to learners
Encourage repetition to correct/perfect
Course
facilitators
HBB materials
simulator, flip
chart, learner
workbook
Water to fill
simulator
Guide participants through the practice with the action plan and check
yourself questions
Group discussion
Discussion and questions on preparation for a birth
11:15
ROUTINE CARE
Demonstration and skill practice on routine care:
Dry thoroughly; if meconium, clear airway before drying
Evaluate crying
Keep warm
Check breathing
Clamp/tie and cut the cord
Discussion and questions on routine care
107

Course
facilitators
Facilitators demonstrate routine care exercise with emphasis on learning with
HBB materials
the neonatal simulator
simulator, flip
Learner pairs, in turns, practice the routine care steps (repeat above for each of chart, learner
four flip chart pages and skills)
workbook
Course facilitators
Water to fill
simulator
Guide participants through the practice with the action plan and check yourself
questions
Group discussion
11:45
THE GOLDEN MINUTE (CLEAR AIRWAY AND STIMULATE BREATHING)

Demonstration and skill practice on The Golden Minuteclear airway and stimulate breathing:
Position the head, clear the airway, stimulate breathing
Evaluate breathing
Course
facilitators
Facilitators demonstrate The Golden Minuteclear airway and stimulate

breathing
Learner pairs, in turns, practice clearing the airway and stimulating breathing
(repeat above for each of two flip chart pages and skills)
Encourage repetition to correct/perfect (scenarios with and without

meconium-stained amniotic fluid)
yourself questions
Group discussion
Discussion and questionsThe Golden Minute (part 1)
12:30
LUNCH
13:30
THE GOLDEN MINUTE (VENTILATION)

Demonstration and skill practice on The Golden Minuteventilation:
Initiate ventilation
Ventilate with bag and mask
Evaluate breathing
Discussion and questions on The Golden Minute (part 2)

Course
facilitators
Facilitators demonstrate The Golden Minuteventilation
Learner pairs, in turns, practice ventilation (repeat above for each of three flip
chart pages and skills)
yourself questions
Group discussion
108

14:15
CONTINUED VENTILATION WITH NORMAL AND SLOW HEART RATE

Demonstration and skill practice on continued ventilation with normal heart rate:
Call for help and improve ventilation
Evaluate heart rate
Continue ventilation and monitor with mother
Continue ventilation and activate the emergency plan
Support the family
Demonstration and skills practice of continued ventilation with slow heart rate
Facilitators demonstrate continued ventilation with normal heart rate
Learner pairs, in turns, practice continued ventilation with normal heart rate
(repeat above for each of five flip chart pages and skills)
Course
facilitators
yourself questions
Group discussion:
Facilitators demonstrate continued ventilation with normal heart rate

Group discussion
Demonstration and skill practice of continued ventilation with slow heart rate
15:00
BREAK
15:30
PARTICIPANT EVALUATIONSMASTERING THE ACTION PLAN

Overview of participant evaluations
Practice and scenario development
Knowledge check:
Written
Bag and mask ventilation skill check
OSCEStation A (The Golden Minute, part 1)

OSCEStation B (Continued ventilation with normal heart rate)
Explain expectations for the evaluations
Highlight the Trace Six Casesp. 37 of Learner Workbook
Faculty does first evaluation (bag and mask, OSCE A and OSCE B) with a single
participant, then participant who has successfully completed the evaluation
takes the role of a facilitator to qualify the next participant, etc. with feedback
from faculty and other small group members
Course
facilitators
109
FACILITATOR COMPONENT (PLENARY SESSION)

17:00
EVALUATION OF LEARNER KNOWLEDGE AND PERFORMANCE

Discussion and practice of administering:
Written/verbal knowledge check
Bag and mask skills check
OSCE A and B
Review program criteria for successful completion of each evaluation and review any regional criteria for
elements that must be successfully completed for each group trained.
Plenary session:
For the written/verbal knowledge checklocate answer key; practice verbal

administration of the questions; discuss advantages/disadvantages of written
and verbal formats; discuss any difficult questions and how to remediate
learners who do not pass
Lead facilitator
assisted by other
course facilitators
Discuss the use of Mastering bag and mask ventilation as a formative

evaluation (repeated until mastery 100% correct performanceattained)
For OSCE A and B, practice giving clear responses with the neonatal simulator or verbal
responses with a mannequin; hold feedback until the end of the scenario.
17:30
PREPARATION OF PARTICIPANTS FOR CONTINUED LEARNING IN THE

WORKPLACE
Elements of a successful scenario

In situ skills practice and case scenarios
Plenary session
Analyze the elements of a successful scenario (description of infant, mention of

pertinent complications or risk factors, decision on responses to evaluation
questions consistent with infant description and risk factors)
Invite facilitator candidates to describe a difficult resuscitation and have the

small group design a scenario; encourage facilitator candidates to share these
to start a file of scenarios for use in their courses
Lead facilitator
assisted by other
course facilitators
Review the self-reflection questions on page 38 of the Learner Workbook and

develop (or disseminate) locally appropriate systems to promote self-reflection
and peer learning (e.g., resuscitation logs, resuscitation debriefing in the
workplace, case audits)
Discuss the use of Mastering bag and mask ventilation as in situ skills practice and case
scenarios as ongoing performance improvementhow frequent, short refresher training
can be incorporated into existing training structures.
18:00
ADJOURN FOR THE DAY

Review of agenda for Day Two and assignments for facilitator candidates:
Prepare a regionally appropriate dialogue on causes of death in newborns
Course
facilitators
Present a page from the Facilitator Flip Chart to the small group
Lead an exercise for the small group.
110
Provider Component
8:00
Day Two: 25 February 2011 (Friday)
Overview of provider course objectives, supplemental material and facilitation techniques

Review of opening visualization
Review provider course objectives (What you will learn, pp. 4, 5 in Learner
Workbook). Highlight purpose is to practice facilitation skills and emphasize
localization of the course
Discuss what supplemental material to present in the orientation (use Tool 7
from Implementation Guide)
Course
facilitators
Implementation
Guide
Discuss techniques to draw out learner experiences and moderate them

Invite a facilitator candidate to present the opening dialogue and visualization exercise
for a provider course (and provide feedback from the group).
9:00
Presentation of the content of the Facilitator Flip Chart

Practice exercise in use of the Facilitator Flip Chart
Demonstration and practice of techniques to facilitate learning among providers of varied abilities
Discussion and questions on continued learning at the workplace
Small group learning session
Analyze the key learning points, skills and tips to promote learning for each
page of the Facilitator Flip Chart (include review of background and
educational advice section):
Emphasize active learning with practice during each page of Flip Chart
Identify the most frequent problems in performing skills and how to

remediate
Review the purpose and technique for providing feedback
Provide cultural interpretation and localization (Use Tools 5, 6 in

Implementation Guide) along with review of each Flip Chart page
Use check yourself questions to indicate gaps in understanding and need

for further explanation
Invite each facilitator candidate to present a page from the Facilitator Flip
Chart (and provide feedback from the group)
Invite each facilitator candidate to lead the small group in an exercise while
working through the content of the Facilitator Flip Chart (and provide feedback
from the group)
Discuss techniques to facilitate learning with providers of various abilities
Demonstrate, invite a learner to participate in demonstration, have a

learner demonstrate, have all learners practice in pairs with feedback
from one another and facilitator, invite learners to practice in pairs only
with feedback from one another
Use teaching tips provided in Tools 10 and 11 of Implementation Guide
Pair experienced and novice providers from the same workplace
Course
facilitators
Support the group in working together to help find solutions for

understanding difficult concepts or performing difficult skills
Lead group discussion questions with the goal of reaching consensus for a workplace;
help participants evaluate and interpret their experiences (e.g., helpful, harmful, neutral
practices; physiologic principles underlying some traditional practices).
10:30
BREAK
111

11:00
PRESENTATION OF CONTENT OF THE FACILITATOR FLIP CHART (CONTINUED)

Small group learning session
12:30
LUNCH AND OPEN DISCUSSION
13:30
PLANNING AND EVALUATING COURSES (PLENARY SESSION)
Course
facilitators
Plenary session:
Review the timeline for course preparation (Tool 8 in Implementation Guide)
Review advice for course facilitators in back of Facilitator Flip Chart (24b)
Discuss equipment procurementneonatal simulators, educational materials, bag

and mask and additional local equipment and supplies
Lead facilitator
assisted by other
course
facilitators
Review additional resources for facilitators:
Preparing the neonatal simulator (Tool 7 in Implementation Guide
Cleaning and testing equipment (Flip Chart page 25)
More resources section in Learner Workbook (pages 39-43)
Implementation Guide (Web resource and PDF of Tools)
www.helpingbabiesbreathe.org
Instructor video, videos of skills, videos of clinical evaluation points
Review a template for a course evaluation (Tool 16 in Implementation Guide)

modified to meet local needs
Practice emptying/filling neonatal simulator and dis-assembling/re-assembling the

ventilation bag
15:00
BREAK
15:30
DISCUSSION OF COUNTRY LEVEL DEVELOPMENT, IMPLEMENTATION AND

MAINTENANCE OF HBB TRAINING QUALITY
Implementing quality HBB training
Plenary session:
17:00
Share and discuss with MOH representatives/country teams:
Initial training of providers; integration of HBB and ENC (other interventions);

relationship of HBB and NRP
Supervision of continued learning in the workplace
Maintaining quality of training; updating with ILCOR neonatal resuscitation

guidelines
Documentation and reporting of program activity
Guest
presenter(s)
Question-and-answer session with facilitator candidates
CONCLUSION
Plenary session
112
Lead facilitator
assisted by other
course
facilitators
Recap facilitator responsibilities and regional commitment (expected number of

courses provided, learners trained, workplace supervision, etc.)
Answer questions regarding national or regional plan for dissemination
Describe the process to become a course leader or master trainer
Complete course evaluations
Present certificates and take pictures
Lead facilitator
assisted by other
course
facilitators
Certificates
Additional Notes on Course Organization and Facilitation
Facilitators and trainees will be pre-assigned into groups so that trainees when they register know
what group they belong to.
The total length of the provider course within the facilitator workshop will depend on the
participants. Master trainers should be alert that participants who have received prior training may
need to re-learn or un-learn some ways of thinking and patterns of behavior. The provider segment
may be completed in as little as two to four hours or as long as two days to allow for consolidation of
new learning prior to assessment of knowledge and skills.
The ideal facilitator workshop is small, with approximately 1824 participants. One master trainer
should lead the course, and each group of six participants works with a master trainer.
The participants should experience a provider course, given that they will present it for future
learners. The course leader (master trainer) presents each flip chart page and demonstrates each
skill to the entire group. During the presentation of each page of the Facilitator Flip Chart, the
participants in a facilitator workshop should be able to see simultaneously the front image under
discussion and the text on the back of the previous page that the master trainer is using for
guidance. Table facilitators (who are also master trainers) may choose to repeat the demonstration
for a group of six learners or simply provide feedback on their practice. Each page concludes with
linkage to the Action Plan and participant(s) answering the check yourself questions. This can be
done within the small groups.
Exercises after each section of the Learner Workbook should be demonstrated in the groups of six
learners. Participants should work through each exercise in the role of the birth attendant and the
role of the helper (who provides the responses of the neonatal simulator). Responses to the Group
Discussion questions may represent circumstances in a number of different facilities, so it may not
be possible to reach consensus on a technique or practice.
If video equipment is available, segments from the HBB Instructor Video can be used to model the
teaching and facilitation interaction. The video also presents demonstrations of each of the six
exercises, close-up views of the skills and clinical vignettes illustrating the evaluation points.
At the end of the provider course, participants should design scenarios for additional practice and
practice with the checklist Mastering bag and mask ventilation. The methods for promoting
continued learning should be discussed, but will be considered in depth in the facilitator segment.
Facilitator candidates must successfully complete all assessments (written/verbal, bag and mask
ventilation skills, OSCE A and B).
The proposed agenda can be modified to fit local timeframes and accommodate additional content.
For example, travel schedules may require a later start time or earlier conclusion. When training
master trainers or those who will serve as mentors at a national level, the final sessions on
dissemination, quality monitoring, sustainability and measurement of outcomes will be expanded.
The master trainer and mentor course presents information that is necessary to link local and
regional efforts to the national plan for resuscitation training and neonatal health.
113
REFERENCES
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teaching hospitals in Addis Ababa. Ethiop Med J Jan;44(1): 2731.
Bartlett LA et al. 2005. Where giving birth is a forecast for death: Maternal mortality in four
districts of Afghanistan, 19992002. Lancet 365: 864870.
Churchill D and Duley L. 2002.Interventionist versus expectant care for severe pre-eclampsia before
term. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003106. DOI:
10.1002/14651858.CD003106
Hamlin RHJ. 1962. Prevention of pre-eclampsia. Lancet 1: 864865
Hofmeyr GJ, Duley L and Atallah A. 2007. Dietary calcium supplementation for prevention of preeclampsia and related problems: A systematic review and commentary. BJOG 114: 933-943
Koopmans et al. 2009. Induction of labour versus expectant monitoring for gestational hypertension
or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): A multicentre, open-label randomised
controlled trial. Lancet 374: 979-988
Lawn JE et al. 2009. Two million intrapartum-related stillbirths and neonatal deaths: Where, why,
and what can be done? Int J Gynecol Obstet107: S5S19
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Rajaratnam JK et al. 2010. Neonatal, postneonatal, childhood, and under-5 mortality for 187
countries, 19702010: A systematic analysis of progress towards Millennium Development Goal 4.
Lancet375: 19882008.
Von Dadelszen et al. 2000. Fall in mean arterial blood pressure and fetal growth restriction in
pregnancy hypertension: A meta-analysis. Lancet 355: 8792
Wall SN et al. 2009. Neonatal resuscitation in low-resource settings: What, who, and how to
overcome challenges to scale up? IJGO 107:S47
WHO. 2000. Managing Complications in Pregnancy and Childbirth. A Guide for Midwives and
Doctors. WHO: Geneva. Available at:
www.who.int/reproductivehealth/publications/maternal_perinatal_health/9241545879/en/index.html
WHO recommendations for induction of labour. WHO 2011. At the time of the report, available at:
http://whqlibdoc.who.int/publications/2011/9789241501156_eng.pdf
WHO World Health Statistics 2006, 2007 and 2010.
114
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Interventions for Impact in Essential

Obstetric and Newborn Care

Interventions for Impact in Essential

PART I: INTERVENTIONS FOR IMPACT IN OBSTETRIC HEALTH

GROUP AND TEAM ACTIVITIES ........................................................................................... 49

Addis Meeting Report

CLOSING ACTIVITIES (OF PART I) ....................................................................................... 56

PART II: HELPING BABIES BREATHE (HBB) REGIONAL TRAINING OF

Addis Meeting Report

ABBREVIATIONS AND ACRONYMS

American Academy of Pediatrics

Active management of third stage of labor

Community health worker

Emergency obstetric care

Emergency obstetric and newborn care

Essential obstetric and newborn care

East, Central, and Southern African College of Nursing

International Federation of Gynecology and Obstetrics

Helping Babies Breathe

Health information system

Health management information system

International Confederation of Midwives

Local government authority

Maternal and child health

Maternal and Child Health Integrated Program

Millennium Development Goal

Maternal mortality ratio

Maternal, newborn and child health

Maternal and newborn health

Pre-eclampsia and eclampsia

Prevention of Postpartum Hemorrhage Initiative

Regional Centre for Quality of Health Care

Skilled birth attendant

Standards-Based Management and Recognition

Addis Meeting Report

Traditional birth attendant

United States Agency for International Development

Venture Strategies Innovations

World Health Organization

WHO Africa Regional Office

Addis Meeting Report

Africas Health in 2010

Bill & Melinda Gates Foundation

Regional Centre for Quality of Health Care (RCQHC)

International Confederation of Midwives

University of British Columbia

Laerdal Foundation for Acute Medicine

USAID regional and country missions

Venture Strategies Innovations (VSI)

Management Sciences for Health (MSH)

World Health Organization

National Institutes of Health

Addis Meeting Report

Addis Meeting Report

Addis Meeting Report

Honorable Ambassador Michael Battle, US

KEYNOTE ADDRESS: MATERNAL AND NEWBORN HEALTH IN THE AFRICAN

But we know who is at risk, where

Addis Meeting Report