Measuring availability of and facility readiness to deliver comprehensive abortion care: experiences and lessons learnt from integrating abortion into WHO's health facility assessments.

Routine assessment of health facility capacity to provide abortion and post-abortion care can inform policy and programmes to expand access and improve quality. Since 2018, abortion and/or post-abortion care have been integrated into two WHO health facility assessment tools: the Service Availability and Readiness Assessment and the Harmonised Health Facility Assessment. We discuss lessons learnt through experiences integrating abortion into these standardised tools. Our experiences highlight the feasibility of including abortion in health facility assessments across a range of legal contexts. Factors facilitating the integration of abortion include cross-country collaboration and experience sharing, timely inputs into tool adaptations, clear leadership, close relationships among key stakeholders as in assessment coordination groups, use of locally appropriate terminology to refer to abortion and reference to national policies and guidelines. To facilitate high-quality data collection, we identify considerations around question sequencing in tool design, appropriate terminology and the need to balance the normalisation of abortion with adequate sensitisation and education of data collectors. To facilitate appropriate and consistent analysis, future work must ensure adequate disaggregation of recommended and non-recommended abortion methods, alignment with national guidelines and development of a standardised approach for measuring abortion service readiness. Measurement of abortion service availability and readiness should be a routine practice and a standardised component of health facility assessment tools. Evidence generated by health facility assessments that include abortion monitoring can guide efforts to expand access to timely and effective care and help normalise abortion as a core component of sexual and reproductive healthcare.

Transitioning to the maternal death surveillance and response system from maternal death review in Ghana: Challenges and lessons learned.

OBJECTIVE: To assess the current system of maternal death review (MDR) in Ghana and identify the achievements, challenges, and gaps that will assist in transitioning to the maternal death surveillance and response system (MDSR). METHODS: A secondary analysis of data from a cross-sectional study on MDSR implementation was conducted between September and October 2018. The MDSR cycle served as an analytical framework to measure the country's performance in implementing MDSR. Common facilitating or hindering factors were also identified. RESULTS: The MDR system is moderately strong at regional level with timely receipt of data and regular review meetings and reports in most regions. At district level the MDR system is less well implemented, although there is evidence of good communication with regional teams in providing timely data. Communication between districts and communities about maternal deaths seemed to be poor in general. There was no MDR committee at national level and the recommendations made were poorly implemented. CONCLUSION: MDRs in Ghana were structurally sound, but recommendations were poorly implemented. Leadership at the national level needs to be developed to ensure that the current system could transition to an MDSR system.

Pilot monitoring and evaluation of the WHO postpartum family planning compendium mobile application: An in-depth, qualitative study.

OBJECTIVE: To assess the feasibility, functionality and acceptability of a mobile application (app), the World Health Organization (WHO) Postpartum Family Planning (PPFP) Compendium, in clinical care. METHOD: This prospective qualitative study was conducted among family planning providers routinely delivering PPFP care in Accra, Ghana. We conducted in-depth interviews at baseline and 3 months after app introduction. We elicited expected technological, psychological and environmental barriers to use, actual use in clinical settings, and feedback for app improvement. With inter-coder reliability, we analyzed the content of interview transcripts. RESULTS: Twenty providers participated in baseline interviews, and 19 participated in follow-up interviews. At baseline, providers did not have significant technological barriers to its use and felt the app was acceptable, but were concerned about the appropriateness of using an app during clinical care. At 3-month follow-up, 18 out of 19 participants reported using the app weekly, and found the app acceptable for use in clinical care. Providers recommended expanding clinical content and including similar guidance relevant to times outside the postpartum period. CONCLUSION: Use of a PPFP counseling app to aid family planning providers in clinical care delivery is feasible and acceptable. Providers recommended inclusion of similar guidance relevant to times outside the postpartum period.

Uterine Tonus Assessment by Midwives versus Patient self-assessment in the active management of the third stage of labor (UTAMP): study protocol for a randomized controlled trial.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries. PPH can be prevented by active management of the third stage of labor (AMTSL), a series of steps recommended by the World Health Organization to be performed by skilled birth attendants (SBAs). Task shifting in the AMTSL step of uterotonic drugs administration to community health workers, traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages. The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self-assessment. METHODS AND DESIGN: The study is an individual-level two-arm non-inferiority randomized controlled trial (RCT). A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra, Ghana. Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self-assessment of uterine tonus will be eligible for inclusion. Women with an increased risk for PPH will be excluded. Women will be randomized to uterine tone assessment by a skilled birth attendant (midwife) or uterine tone self-assessment (with the safety back-up of a midwife present in case of PPH or uterine atony). Postpartum blood loss will be measured through weighing of disposable mats. The main study endpoints are PPH (≥500 ml blood loss), severe PPH (≥1000 ml blood loss), mean blood loss, and routine maternal and neonatal outcomes. Participants and caregivers will not be blinded given the nature of the intervention. DISCUSSION: A reduction of PPH-related maternal mortality requires full implementation of AMTSL. Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in (clinical) settings where SBAs capacity is constrained. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02223806 , registration August 2014. PACTR: PACTR201402000736158 , registration July 2014. University of Ghana, Medical School Ethical and Protocol Review Committee: MS-Et/M.8-P4.1/2014-2015.