Step 6: Monitor and Evaluate Results
Monitoring and evaluation of programs to prevent and treat postpartum hemorrhage is critical for measuring progress towards expected results and to generate sound data to inform decisions made by policymakers and program implementers at all levels of the health system.
Conduct nationally representative household and facility surveys that include PPH-related indicators: Periodic national and/or sub-national household and facility surveys can help to document current clinical practices, such as PPH screening, counseling and management, raise awareness, and generate support for PPH programming. Facility surveys that POPPHI conducted in eight countries and MCHIP conducted in six countries identified areas of strength and areas for improvement in service quality. ICF Macro’s Service Provision Assessment (SPA) and WHO’s Service Availability Mapping (SAM) facility surveys collect information on health care provider training and drugs, supplies and equipment to detect and manage severe bleeding in pregnancy.7 The SPA also includes direct observation of ANC visits and ANC client exit interviews. ICF Macro’s Demographic and Health Surveys (DHS), conducted every five years, and UNICEF’s Multi-Indicator Cluster Surveys (MICS), conducted in select countries every two years, collect population-based data on ANC services received by pregnant women, including counseling about danger signs in pregnancy, specifically bleeding in pregnancy, anemia testing and receipt of iron tablets.
Integrate PPH-related indicators into the national government health sector M&E plan: Depending on the range and scale of PPH interventions, the national M&E plan can be developed to: assess PPH program baseline; identify key indicators to measure progress (outputs, outcomes and impact); and require review and strengthening of existing data collection systems. Revised global indicators to guide country health monitoring plans will be available in 2011 from a WHO-led maternal health indicators working group. An existing important resource that provides guidance on how to select and measure indicators related to antepartum and postpartum hemorrhage in the larger context of emergency obstetric care is WHO’s “Monitoring Emergency Obstetric Care: A Handbook,” published in 2009. Routine PPH-related data collection should be integrated into existing government health management information systems (HMIS) to the extent possible. Additional M&E requirements beyond those addressed through the HMIS will need to rely on national surveys, as described earlier, and special studies and monitoring efforts.
Ensure the national HMIS adequately captures PPH data, and the information is used for decision-making: Existing HMIS forms and reports at the community, facility and district levels may not be sufficient to track PPH-related data at home births attended by a skilled birth attendant and antenatal and delivery care at facilities. If the data are captured in the patient charts or registers, they still many not be aggregated and reported up to district/provincial/regional levels. And in areas with high levels of unattended home births, CHW-delivered services (such as misoprostol distribution) may not be reported into the HMIS at all. These data together are needed to monitor uterotonic coverage across a district/province/region, track stockouts, and recognize improvements over time.
Document and disseminate results: Complementing the M&E plan, a knowledge management (documentation) plan needs to be developed to ensure the PPH program will capture sufficient information from prevention and management activities to answer all key programmatic questions. Because programs often begin as small-scale pilots, lessons learned and cost-effectiveness information are desired, but not routinely collected as part of the M&E plan. To ensure results are monitored, documented and disseminated, a documentation plan can help country teams plan to comprehensively capture program process and outputs. Furthermore, qualitative case studies and success stories of women, families, CHWs and facility-based providers help illustrate the effect of these life-saving interventions on program beneficiaries. This plan can also include journal article submissions about innovative program approaches that are of interest to a wider audience.
Program Pitfalls and Lessons Learned: M&E
• Inclusion of a national-level indicator for AMTSL—or, at a minimum, the use of a uterotonic in the third stage of labor—in the HMIS requires providers and district and regional officials to report on its use on a regular basis, thus making it more likely to be routinely practiced and recorded.
• The POPPHI Project demonstrated that the use of national survey data can serve as a powerful advocacy tool, as these data can provide a base from which to develop strategic action plans, create partnerships, link allies, implement needed activities, and monitor progress toward goals.
• Stakeholders should be informed and involved throughout program implementation, monitoring progress and reviewing findings, especially during pilot studies on innovative interventions or approaches.
• Because the PPH prevention interventions are evidence-based, M&E can focus on program effectiveness in achieving coverage instead of measuring the reduction in mortality as a result. If there are sufficient resources, changes in mortality over time are powerful for advocating for scale-up.