​Implementation Guide

​July 2016
 ​HMS Implementation Guide

​Draft v 2 (July 2016)

​C opyright © Jhpiego Corporation, 2016. All rights reserved.

 01
Introduction to HMS
Table of Contents

Bleeding after Birth Basics

02
Program Design and Planning
03
Program Implementation
04
Program Monitoring and Evaluation
05
Annexes
06
This implementation guide was made possible through funding from the Laerdal Foundation for Acute Medicine. It
was created by Jhpiego, particularly Stephanie Suhowatsky, Cherrie Evans, Sara Chace, Jen Breads, Laura Fitzgerald,
Bernice Pelea, Megan Wysong, and Connie Lee. Editing, formatting, and graphic design support was provided by
Alisha Horowitz and Young Kim. Special thanks to all our excellent HMS trainers around the world who reviewed
earlier versions and provided feedback.
Abbreviations and Acronyms
​AMTSL Active Management of Third Stage of Labor
​BAB Bleeding after Birth
​BEmONC Basic Emergency Obstetric and Newborn Care
​C CT Controlled Cord Traction
​C EmONC Comprehensive Emergency Obstetric and Newborn Care
​DHO District Health Office
​EmONC Emergency Obstetric and Newborn Care
​EONC Essential Obstetric and Newborn Care
​HMIS Health Management Information System
​HMS Helping Mothers Survive
​HRH Human Resources for Health
​IRB Institutional Review Board
​L&D Labor and Delivery
​LDHF Low Dose, High Frequency
​LOE Level of Effort
​M&E Monitoring and Evaluation
​MNH Maternal and Newborn Health
​ModCAL® Modified Computer-Assisted Learning\
Abbreviations and Acronyms (continued)
​MOH Ministry of Health
​MOU Memorandum of Understanding
​N GO Nongovernmental Organization
​OJT On-the-Job Training
​OSCE Observed Structured Clinical Examination
​PPH Postpartum Hemorrhage
​QI Quality Improvement
​SBA Skilled Birth Attendant
​TAG Technical Advisory Group
​USAID U.S. Agency for International Development
​UUIFB Uterotonic Used Immediately Following Birth
​WHO World Health Organization
 Section 01

​Introduction to Helping Mothers

Survive
An overview of the HMS approach, including the
basics of district implementation

►Introduction to this Guide

►HMS Strategic Approach

►HMS at the Health Facility

►Developing HMS
Training/Mentoring Capacity

►HMS Summary
 section 01
About this Implementation Guide
The Helping Mothers Survive (HMS) Program aims to improve maternal and newborn care (MNH)
skills among midwives, nurses, doctors, and other health care providers. At scale, HMS can improve the
clinical practice in places where preventable deaths continue to occur.

HMS uses a single to several-day, facility-based learning approach that is followed by short, frequent
practice sessions to reinforce skills. The first module in the HMS suite developed in 2012 and tested in
2013—Bleeding after Birth (BAB)—prepares health care providers to prevent and manage
This guide shares the postpartum hemorrhage (PPH). Having demonstrated the effectiveness of the training approach,
additional modules were developed to target other causes of maternal death. The task ahead is to
essential information
implement HMS in countries where maternal mortality and morbidity remain unacceptably high. This
and provides the guide will focus on the BAB as an example module of the HMS approach, however the principles are
reader with resources applicable to all modules in the suite.
to be able to design ​For more information about HMS:
and implement HMS in § Helping Mothers Survive website: [Link]
a low-resource setting. § Helping Mothers Survive Bleeding after Birth demonstration Video (You Tube)
§ Laerdal Global Health: [Link]/doc/2538/Helping-Mothers-Survive-Bleeding-
After-Birth
Contact us at hms@[Link] § ReprolinePlus: [Link]/resources/helping-mothers-survive-bleeding-after-birth-training-
with questions about package
implementing HMS and to share
your experiences.

8
 section 01
HMS BAB
Getting Started: Using this Guide
​This guide has been developed to help introduce, integrate, and scale up HMS in low-resource settings. It
familiarizes the user with HMS approaches, using the BAB module to present concrete examples of how to
rapidly design, plan, implement, and monitor a HMS training program—along with links to available resources.

​ urpose: To provide straightforward, step-by-step guidance on

P
how to design and implement HMS

​Users: Program managers, technical advisors, and master trainers

​Structure: Sections provide general programming guidance and

direct the reader to additional tools and resources.

​Tools and Resources: The guide provides a number of materials

to help implement HMS and for BAB programs:

§ On a USB drive that accompanies

this guide

§ On the HMS website Look at Annex A for

the full list of tools
[Link] (also & resources
found on [Link])
9
 section 01
Helping Mothers Survive

​Helping Mothers Survive (HMS) is a package of targeted

HMS Mandate
capacity building modules delivered through a simulation-
based learning approach to build and sustain competencies § Equip all providers who care for women and
newborns with knowledge and essential
of the health workforce in countries with high burdens of
skills to prevent and manage the major
maternal mortality. causes of maternal and neonatal mortality
globally.
​HMS was developed by Jhpiego, in collaboration with Laerdal Global
Health, The International Confederation of Obstetricians and
§ Focus on improving quality of care on the
Gynecologists (FIGO), International Confederation of Midwives (ICM), day of birth—because over 40% of maternal
International Council of Nurses (ICN), UNFPA, and the American deaths occur in the first 24 hours after birth.2
Association of Pediatrics (AAP).
​It aims to improve and sustain critical MNH skills of midwives, nurses, § Scale an evidence-based learning and
mentoring approach to improve and
doctors, and others. It is targeted to address the leading causes of
maintain the competencies of health care
maternal and neonatal mortality—to end preventable deaths. providers.

​1 Ending Preventable Maternal Mortality: USAID Maternal Health Visionfor Action , June 2014
​ Every Newborn,An Executive Summary for The Lancet’s Series, May 2014
2
10
 section 01
HMS: Modules

Available Near Final, Available 2016 Under Development, 2016–2017

Bleeding After Birth Pre-Eclampsia & Labor &

(BAB) Eclampsia Birth

Bleeding After Birth Complications of

Pre-Term Birth Plus (BAB+) Labor & Birth

​While focused on maternal health, HMS modules cover clinical competencies which affect
newborn outcomes. HMS also considers the mother and newborn as a pair so newborn care is
integrated where appropriate.

F​ or newborn health, a similar series of Helping Babies Survive (HBS) modules have been
developed, focused on newborn care. Available modules include Helping Babies Breathe (HBB)
([Link]) and Essential Care for Every Baby ([Link]/en-
us/advocacy-and-policy/aap-health-initiatives/global/Pages/eceb. aspx).

​This guide highlights where there are natural synergies between HMS and HBS modules, such as
See Annex B for a
for intrapartum care, and provides suggestions on how they can be integrated during specific example
implementation. 11
 section 01
Helping Mothers Survive

​HMS is designed to change the practices of health care providers by increasing their knowledge, skills,
attitudes, and confidence. It also catalyzes support and a sense of teamwork among the staff who provide
maternal and newborn care within a health facility. This graphic summarizes the key elements of HMS that
together help create changes in practice.

​The ability of HMS to change practices has value added for

Mother and MNH programs because it complements and extends the
newborn are
a unit reach of:

Shared Train ALL 1. Quality improvement (QI) efforts to improve

facilitation authorized
of practice* providers maternal and newborn care services at health facilities.
Skilled providers are critical to deliver quality care to
Change in
Practice every pregnant woman, mother and newborn.

Highly 2. Competency-based training programs, particularly

Interactive graphic
simulators materials in-service training (such as essential obstetric and
newborn care [EONC]).
Concise
​HMS also can be integrated into pre-service education.

​* HMS uses a low-dose, high-frequency (LDHF) approach to the shared facilitation of practice, whichis described indetail laterin this section. 12
 section 01
Helping Mothers Survive:
Who is trained?

​All health care providers* authorized to provide maternal and newborn care can benefit from HMS training.
Within a facility, they are all trained together as a team.

​Skilled birth attendants (SBAs) can specifically benefit from HMS training in related advanced care.

Non-SBAs who assist with SBAs—midwives, nurses, auxiliary Other providers who manage
birth (nursing assistants, nurse midwives, doctors complications (doctors, clinical
health orderlies) officers, medical assistants,
specialists)

​* *HMS is not designed for traditional birth attendants. 13

 section 01
Helping Mothers Survive:
The HMS approach to maternal and newborn care

Lifesaving Focused Practical

Targets the leading Primarily focused on the Evidence-based action
causes of maternal intrapartum period when plans simplify care for
and neonatal death most deaths occur health care providers
HMS can be a useful tool to HMS materials are simple,
HMS improves care on the day
global and country-specific highly intuitive, and graphic.
of birth—for both mother and
programs to further reduce HMS teaches simple ways to
baby. HMS integrates care and
maternal and neonatal prevent, recognize, and
promotes survival.
mortality. respond to problems.

14
 section 01
Helping Mothers Survive:
The evidence for HMS
​The HMS approach was shaped by key findings from a 2011 Jhpiego
literature review 3 that identified effective training approaches for
continuing professional education for health workers (i.e., in-service
training).

§ The most effective educational techniques to improve and sustain

​ argeted, repetitive
T knowledge and skills acquisition and maintenance are:
interventions result in better § Case-based learning,
§ Clinical simulations, and
learning outcomes.
§ Practice and feedback.
​Training on-site at the provider’s § Passive instruction—such as reading or lecture—have little or no
workplace results in sustained impact on learning outcomes or improving clinical practice.
knowledge and skills.
§ Repetitive interventions, rather than single interventions, are better
for learning outcomes.

§ Settings in or closest to the workplace improve skill acquisition and

performance.

These findings together provide clear recommendations on how to

improve training for greater impact on learning and performance.
3
Bluestone J, Johnson P, Fullerton J, Carr C, Alderman J, Bontempo J. Effective in-service training design and delivery: evidence from an integrative literature
review. Hum Resour Health. 2013. 11(1):51. 15
 section 01
Helping Mothers Survive:
Low-dose, high-frequency approach

​C apitalizing on these findings, the HMS capacity building approach is designed to more effectively change the
practices of health care providers. HMS facility-based learning and practice are powerful and innovative because of
the low-dose, high-frequency (LDHF) approach. It is the principle of LDHF that is essential to HMS design and
implementation.

PART 1: HMS TRAINING PART 2: LDHF FACILITATED PRACTICE SESSIONS

Weekly Weekly Weekly Weekly Weekly Weekly Weekly Weekly
One-day HMS
practice practice practice team practice practice practice team
training
session session session simulation session session session simulation

​HMS one-day clinical ​Following the one-day training, a series of weekly LDHF practice sessions using clinical
training emphasizes simulations are conducted in the workplace to reinforce lifesaving practices. During the
simulation using weekly session, each health care provider practices key skills for 10–15 minutes with a
anatomic models, role peer. Practice options include: skills practice, scenario session, games, and team
play, and case-based simulation.
learning opportunities.
LDHF within HMS is not prescriptive in terms of numbers of sessions or the minimum
number of hours, although some guidance is provided within each module. The key to
success is that practice is facilitated by a “Peer Practice Coordinator” or “Clinical Mentor” to
help ensure all providers practice.
16
 section 01
Helping Mothers Survive:
Other key elements of HMS training approach

Hands-on On-site Team-oriented

Learning through case studies, Learning and practice in the Learning and practicing
role plays, skills stations, and health care provider’s facility together ensures all health
clinical simulations improves performance care providers are ready

Ideally, all providers and

HMS uses a simulation-based Evidence shows that using health
supervisors involved in labor and
training approach that enables workers’ daily work environment as
birth in the facility join the HMS
hands-on learning for skills the classroom improves learning
training and practice sessions. This
acquisition and repeated and changes in practice. HMS
strengthens teamwork and
practice, while also improving reduces service disruptions due to
communication, which are critical
provider knowledge. off-site training.
during emergencies.
17
 Sub-section
01-1

​HMS at a Health Facility

​ snapshot of HMS training and LDHF practice as it is
A
implemented at a health facility

If you are already

familiar with HMS,
skip ahead to
Section 2.
 section 01
Helping Mothers Survive:
HMS in a health facility

PART 1: HMS TRAINING PART 2: LDHF-FACILITATED

One-day training for all staff who are PRACTICE SESSIONS
involved in labor and delivery services, Weekly practice session or clinical simulation, based
conducted by a HMS Trainer. on a pre-defined scenario and organized by a Clinical
Health
center Mentor.

HMS Champions training is conducted for

all authorized providers and support staff
based on module content.
Each trainer is assigned several facilities. Two Peer Practice Coordinators at The Practice Coordinators organize
S/he visits each facility for HMS on-site learning. The each facility are selected and once-weekly practice after HMS
trainer brings the HMS materials.* Each training
oriented. training (e.g., eight weeks for HMS
should have no more than six participants (i.e., a ratio
After HMS Champions training, the trainer BAB).
of one trainer to six providers). Larger groups need
spends a day with two Clinical Mentors to Either Coordinator runs practice sessions or clinical
additional trainers, or multiple HMS Champions
orient them to the role as facilitator of the simulation individually or in groups each week
trainings can be scheduled. Providers, support staff,
LDHF phase. The Practice Coordinators are with all providers. For example, a practice session
and supervisors or in-charges are trained as a team so
given weekly practice session plans and a has each provider practice for approximately 15
roles are clear.
simulator if needed. minutes, based on a pre-defined scenario.
19
​* Some modules us e a clinical s imulator (s ee Annex H for information on s imulators for HMS BAB-related s imulators ).
 section 01
HMS:
LDHF Practice at a Facility, HMS BAB example

Health
center

Weekly Weekly Weekly Weekly Weekly Weekly Weekly Weekly

One-day HMS
practice practice practice team practice practice practice team
training
session session session simulation session session session simulation

Week 1: Prevention of postpartum hemorrhage (PPH): active Week 5: Retained placenta resolving with continued
management of third stage of labor (AMTSL) and review of controlled cord traction (CCT)
transport plan Week 6: Retained placenta requiring transfer
Week 2: Atony resolving with massage and medication Week 7: Retained placenta that resolves and then
Week 3: Atony requiring bimanual uterine compression becomes atony, resolving with massage and medication
Week 4: Team simulation—atony requiring bimanual Week 8: Team simulation—retained placenta requiring
uterine compression transfer

​
LDHF weekly practice s es s ions are illus trative and us e the s ix developed LDHF s es s ions plans developed by Jhpiego.
20
 Sub-section
01-2

​Developing HMS Training/Mentoring

Capacity

​Details on the roles needed to provide HMS in health facilities

and how they are developed, including:
• Training/Mentoring Roles
• HMS Champions
• Master Trainer and Trainer Preparation
• Peer Practice Coordinators OR Clinical Mentors
 section 01
HMS Training/Mentoring Roles
I organize the
I advocate for more
I use my HMS weekly practice
effective ways to train Now I am going
training daily to and simulations
providers, improve to a facility to I am ready to train
care for women for my co-
quality, and save lives! workers. train providers. HMS Trainers!
and newborns.

Peer Practice
HMS MNH HMS HMS Master
Coordinator/Clinical
Advocate Provider Trainer Trainer
Mentor
ROLE • National • Provider or a • Provider and facility • District advocate • National advocate
advocate national advocate • Training of providers: • Trainer of trainers for HMS BAB
advocate • Coordinates and conducts HMS Champions • Monitoring and evaluation (M&E)
• May be records LDHF training in a facility guidance
preparing for practice • Facilitates selection of • Training commodities support
HMS Trainer role • Coordinates with clinical mentors
HMS Trainer • Supports LDHF practice

QUALIFICATIONS • Proficient • Proficient MNH • Proficient MNH • Proficient MNH provider • Proficient MNH provider
MNH provider provider • Trained as HMS • Trained as HMS Champion
provider or • Trained as HMS • Trained as HMS Champion • Trained as HMS Master Trainer
stakeholder Champion Champion • Qualified trainer** • Mentored as HMS Master
for MNH* • Trained/mentored • Trained as HMS Trainer Trainer**
• Trained as • Oriented as clinical • Mentored as HMS Trainer • Positioned (professional
HMS mentor • Trained in clinical mentor association, nongovernmental
Champion • The title should suit selection, training, and association [NGO], government
the local context mentoring council)

​* The HMS Champions cours e is des igned for clinically active providers , but s takeholders (e.g., Minis try of Health officials , development partners ) participate.
22
​
** Jhpiego training pathway or other pathway recognized by a country’s national training board/organiza tio n.
 section 01
HMS Champion Training:
The gateway to HMS
At the heart of an HMS program are its Champions. All HMS programs start with the one-day HMS Champion
Training. This is the basic provider course, and all who successfully complete it are HMS Champions. The
course is for health care providers of all types who care for women during birth, their supervisors, and those who
advocate for quality maternity services. Providers, maternal health advocates, Peer Practice Coordinators / Clinical
Mentors, future HMS Trainers, and Master Trainers all begin their involvement in HMS programs as Champions.

We are ALL HMS Champions!

Who is an HMS Champion?

An individual who is highly committed to significantly reducing preventable
maternal and neonatal mortality—most often a health care provider who cares for
women and newborns at birth.

HMS Champions are primarily clinically active MNH care providers who use their new
skills to provide services, but can include advocates and stakeholders who want to
understand HMS better and promote its use.

HMS Champions become part of a global HMS Alumni network (database) and may
be contacted for updates on HMS progress within their community.

23
 section 01
The HMS Champion Training
Example from HMS BAB

​The one-day HMS Champion ​Objectives Design

Training presents the HMS ​The course objectives include: The one-day HMS Champion course remains the
§ Understand the principles of HMS training same whether it is run to launch an HMS program,
approach to capacity building,
to train health care providers at a facility, or to
provides clinical updates, orients § Demonstrate the clinical care and decision-
prepare a group of HMS Trainers.
making for the clinical topic —all according to
users to simulation for learning, standards What differs is the training participants (the
and provides participants with § Understand the importance of LDHF practice at “audience”), AND if there are other workshop days
the facility after training added to the original one-day training (for
hands-on practice. planning, facilitation support, mentoring, etc.).

Trainer: Participant Ratio

​The training uses a number of methods, including
role plays, demonstration, and return Interested in participating
One trainer to no more than six participants.
demonstrations using simulators and local supplies in an HMS Champion
and teaches clinical care algorithms based on HMS It is important to keep six or fewer participants per Training?
Action Plans. trainer so everyone has time for practice and the
Interested in running an
observed structured clinical examination (OSCE)
​The first Champion course in a project or country is HMS Champion Training?
typically conducted to launch HMS and is often
held as a workshop for advocates and trainers.
Contact us
hms@[Link]

24
 section 01
After the HMS Champion Training

HMS Champion Training

Advocates MNH Candidate HMS

Peer Practice Candidate
Providers Master Trainers
Coordinators/ HMS Trainers
Clinical
Mentors
Return to work and Return to work and Participate in a one-day Participate in HMS facilitation Participate in HMS facilitation
educate policymakers, adopt HMS-related orientation to facilitate training immediately following training immediately following
educators, clinicians, skills into care LDHF practice of the Champion training.* the Champion training.**
health administrators, and provision at the facility. essential skills for co-
members of professional MNH providers also workers. After HMS facilitation training, Similar to HMS Trainers, after
associations regarding the share HMS learning . a Candidate HMS Trainer is HMS facilitation training,
value of the HMS training with their peers. Return to work and supported by an HMS Master candidates conduct their first
approach. organize and facilitate Trainer to conduct an HMS HMS Champion training for
weekly HMS practice Champion training. They are HMS Trainers while being
The HMS Champions sessions or drills at the mentored and supported mentored throughout the day.
advocate for LDHF facility with all providers throughout the day, and then
practice to maintain individually or in teams. recognized as an HMS Trainer. Then they are recognized as
health care providers’ HMS Master Trainers.
skills.

​
* To become an HMS Trainer, individuals mus t be recognized by their profes s ional group as a Trainer. If not a certified Trainer, complete Modified Computer-As s is ted Learning (ModCAL®) online, [Link] ne plus .o rg /lea rni ng -o ppo rt uni ties /cou rs e/ m odcal -tr aini ng -s kills (s ee next page for details ).

​** To be prepared as HMS Mas ter Trainers , individuals mus t be recognized by their profes s ional group as a Mas ter Trainer.

25
 section 01
HMS Trainer Development:
After the HMS Champion Training
Only chosen if already
Candidate Candidate HMS recognized by their professional
HMS Trainer Master Trainer group as someone who is
qualified to train trainers (i.e.,
If not already a certified
trainer, ModCAL is needed
​+ ​+ already a “Master Trainer”)

before mentoring Facilitation Facilitation

Support Support
Modified Training (one day) Training (one day)
Computer-Assisted
Learning (ModCAL®) ​+
​+ Co-conduct HMS BAB
Champions Training
Co-conduct HMS BAB for Trainers,
Champions Training with a Mentor
for Providers,
Facilitators
with a Mentor
Orientation
for Trainers,
with a Mentor
Now I am going
to a facility to I am ready to train
train providers. HMS Trainers!

HMS HMS Master

Trainer Trainer
​* To become an HMS Trainer, individuals mus t be recognized by their profes s ional group as a Trainer. If not a certified Trainer, complete Modified Computer-As s is ted Learning (ModCAL®) online, [Link] ne plus .o rg /lea rn in g-o pp or tu nities /co urs e / mod cal-t rai nin g-s kills 26
​
** To be prepared as HMS Mas ter Trainers , individuals mus t be recognized by their profes s ional group as a Mas ter Trainer.
 section 01
Qualifying Trainers through Mentoring
Mentoring is critical to the design of HMS, and without it the effectiveness of the training cascade greatly
diminishes. Mentoring as a part of developing and qualifying HMS Trainers and Master Trainers is not optional—it is
essential to the design and implementation of HMS programs.

​For example, a candidate HMS Trainer Health

conducts an HMS Champion training with center
the support of a Master Trainer. The Master
Trainer helps prepare, guides the HMS
Candidate Trainer, answer questions, and
provides an extra set of hands when
needed during the training day. HMS Master Candidate
Trainer HMS Trainer
After the training is over, they debrief
about the day and if the Master Trainer
feels confident that the HMS Candidate
Trainer can independently conduct the
HMS Champion course and orient the
practice coordinators/clinical mentors, the
HMS Candidate Trainer is qualified.
The candidate HMS Trainer conducts the HMS Champion
training at a facility for providers while being mentored on-
site.
The HMS Master Trainer observes, provides support and feedback, and
ultimately qualifies the HMS Trainer at the end of the day.

27
 section 01
HMS Peer Practice Coordinator / Clinical Mentor
Development
Well-prepared, motivated Practice Coordinators are critical to HMS success. It does not matter what title is used and
this can be based on local preference. Although the word “mentor” often refers to a senior, experienced
professional guiding junior staff, in this role Clinical Mentors or Peer Practice Coordinators serve more as a facilitator
to make sure the LDHF practice sessions occur each week and that all staff participate. Two are chosen to make
practice easier and to help manage staff transfers. Practice can be scheduled or it can be opportunistic and occur
when staff are not busy.
MNH
Provider

​+
Immediately following the facility-
based HMS Champion training

HMS recommends Practice Coordinator

two Practice Orientation (one day)
Coordinators are
selected and oriented
per facility. I organize the
Health
weekly practice
center
and simulations
for my co-
workers.

Clinical
Mentor
Weekly Weekly Weekly Weekly Weekly Weekly Weekly Weekly
One-day HMS
practice practice practice team practice practice practice team
training
session session session simulation session session session simulation

28
 section 01
HMS Summary
​This first section introduces the key HMS
concepts and approaches that together create
changes in practice. This initial orientation to
HMS provides the context for thinking about
how HMS can fit into existing programs that
address the leading causes of maternal and
neonatal mortality.

​More detail is provided in the next sections of this

guide to assist in the development of HMS activities.

​Please also review the annexes for additional

resources, such as glossary of terms.

Weekly Weekly Weekly Weekly Weekly Weekly Weekly Weekly

One-day HMS team
practice practice practice practice practice practice team
training simulation
session session session session session session simulation

29
 Section 02

​Bleeding after Birth Basics

​The First HMS Module

►Key Interventions

►HMS BAB Resources

 section 02
Helping Mothers Survive:
Bleeding after Birth

​Bleeding after Birth is the first module in the Helping Mothers Survive
series.
​The first HMS module focuses on prevention and management of PPH—the
leading cause of maternal mortality globally. In Africa and Asia, PPH contributes to
approximately 30% of maternal deaths.4
​Many of these deaths can be averted through AMTSL. The HMS training package
clearly outlines the evidence-based practices for AMTSL in a visual Action Plan,
which is used during training and as a support tool for decision-making during
clinical care.

See Annex D for

more PPH-related
information

5
World Health Organization(WHO) recommendations for the prevention and treatment of PPH, 2012. 31
 section 02
PPH:
Key Interventions Action Plan

To make internationally-accepted clinical recommendations on PPH

prevention and management5 more accessible and actionable for
health care providers (and to reinforce prior learning), HMS BAB
translates global recommendations into a simple, visual action plan.
HMS BAB combines provider-focused, action-oriented materials with an
approach that simulates clinical experiences so providers can practice
and prepare for PPH emergencies.

Recommendations from WHO, ICM and FIGO:

§ Use a uterotonic immediately following the delivery of the
newborn, preferably oxytocin.
§ Delay cord clamping for 1–3 minutes following birth.
§ Utilize CCT to deliver the placenta if desired.
§ Assess uterine tone to identify uterine atony.
§ Give a second dose of oxytocin in the case of retained placenta.
§ Give a second dose of uterotonic in the case of atony.

​5 WHO, 2012; Lalonde, A. Prevention and treatment of postpartum hemorrhage in low-resource settings. International Journal of Gynecology and Obstetrics 117 (2012) 108–118 32
 section 02
HMS: BAB Advanced Care
Action Plan

For situations where PPH is not managed with BAB skills and women
need advanced care, HMS has developed an additional module to
extend training. The BAB Advanced Care module makes WHO
recommendations on PPH prevention and management5 part of
complementary learning materials that are visually accessible for health
care providers in these emergency situations.

This module completes the skills set for basic emergency obstetric and
newborn care (BEmONC) and includes selected comprehensive
emergency obstetric and newborn care (CEmONC) interventions.

BAB Advanced Care for PPH:

§ Shock management—including IV infusion and catheterization
§ Aortic compression
§ Repair of vaginal and cervical tears
§ Manual removal of the placenta
§ Use of a intrauterine balloon tamponade and non-pneumatic anti-
shock garment

33
 section 02
HMS BAB Resources
To see HMS BAB materials and understand how the clinical simulator works, take a moment to look online at the
Helping Mothers Survive website, [Link]

​Helping Mothers Survive Bleeding after Birth materials

​Training materials consist of the Provider’s Guide, Action Plan poster, and
the Flipbook.
​Materials currently are available in English, French, Portuguese, Russian,
Hindi, and Swahili. English materials are available in two versions, with
graphics appropriate for African or South Asian settings.
​[Link] org/resources/helping-mothers-survive-bleeding-
after-birth-training-package

​Helping Mothers Survive Bleeding after Birth video

​This four-minute video provides an introduction to one of the clinical
simulators that can be used during HMS BAB training.
​[Link]

Look at Annex A for

the full list of tools
& resources

34
 Section 03
​Design and Planning

A walk-through the initial design and planning to

determine how HMS can make the greatest
contribution
►Rapid Assessment

►Design Considerations

►Planning

►Work Planning
 Before You Begin
​C ertain elements should be in place before you design and implement an HMS BAB Program.

section 03
There is Ministry of Health (MOH) MoH
commitment/buy-in to:
• Address maternal health. For example Commitment
PPH—ideally HMS BAB introduced as an
integrated part of a comprehensive
PPH strategy within the national safe
motherhood program
• Implement at scale to have impact

A supportive policy environment exists.

Policies are in place to support implementation
(e.g., misoprostol is on the formulary or used
off label, appropriate personnel can administer
Policies
uterotonic, etc.)

​Resources are available (e.g., human

resources, funding beyond initial training) or
can be combined from various partners.
​Quality uterotonics exist and are in regular
supply (i.e., oxytocin currently in MOH store,
cold chain present, oxytocin regularly available, When not everything is in
oxytocin free of cost, misoprostol regularly place, consider BAB-
available, etc.). Resources related advocacy
(see Annex E)
36
HMS BAB Rapid Assessment

section 03
First, it’s important to understand the context so HMS can succeed.

A rapid assessment is useful to identify opportunities and barriers before designing and
planning a program. Most countries with high levels of maternal mortality are addressing PPH
with AMTSL or pre-eclampsia and eclampsia with anticonvulsants as part of SBA or BEmONC
activities, so much of the information will be known.

​This activity should not take more than a week (excluding site visits) and should be able to be
done jointly by the government (e.g., MOH, District Health Offices [DHOs]) and a mix of technical
and program staff of the organization planning to support HMS implementation.

​Even if the situation is well-known and a formal assessment is not believed to be necessary, do
take the time to briefly document the situation. The assessment tool (Annex C) can be a guide.
Documentation is helpful for comparison at the end of the program and for orientation as
stakeholders change over time. If multiple partners are engaged in HMS, document jointly or
share information (both can be done informally or formally through a technical advisory group
[TAG]).

See Annex F for a sample

assessment tool
37
HMS Program Design Principles

section 03
Using the rapid assessment findings and an understanding of the HMS approach to training, the next step is to
design the HMS program. Before looking at specifics, this section presents some design principles,
considerations, and lessons learned from HMS experience to date that shape program design.

HMS project Government

design team HMS (all levels),
stakeholders

​Build on what exists and design for ​Build consensus.

sustainability. ​During design and planning, there is an iterative
​Within government health systems, HMS should be process of building consensus with the government at
designed to build on and synergize with existing roles, all levels (e.g., central, regional, district) to ensure
programs, structures, and systems. It might make ownership from the start and with other stakeholders.
initial implementation more time-consuming, but can Allow opportunities for interaction and sufficient time
ultimately save time at scale-up (i.e., think about scale- in the design and planning process. This also will build
up from start-up). commitment to the approach—helpful if/when
challenges arise or to address larger policy or systems
​ hat is the simplest and most sustainable way to
W issues (e.g., stock-outs).
implement HMS through the existing health and clinical
training systems? ​W ho needs to be engaged? How frequently?

38
 HMS BAB Program Design Principles

section 03
Focus on areas of highest need. Keep your end results in mind. Integrate where feasible.
HMS was created to change clinical Often, programs look to integrate HMS
Where can HMS contribute most significantly? practice and improve health outcomes. It into their existing programs, which may
Who will benefit the most from HMS?
should reach all authorized providers at already be defined to geographic areas or
all health facilities in the implementation selected facilities.
area. At the end of the day, HMS should
help reduce maternal morbidity and Are there trainings and/or QI initiatives planned
or under way where HMS can be feasibly
mortality.
integrated (i.e., practical, cost-effective, efficient)?

How much can HMS contribute to reductions in

maternal deaths?

39
 Design and Planning Considerations

section 03
WHO? WHO ELSE? WHAT ELSE?
HOW?
WHERE?
Integration with other
Ongoing maternal health HMS or HBS modules
Identified resources in efforts—particularly for and/or QI activities
District selection the districts PPH

• Numbers of facilities, • Human resources: available • Ensure synergies of skills, • Has or will HBS be rolled
providers, district trainers and master trainers approaches, and messages out in the district/s?
supervisors (see Essentials #2), number of • Avoid duplication of efforts • If yes, HMS can be
• Priority areas (e.g., MOH, trainers needed • Reinforce existing SBA integrated?
donor) • Available transport for trainers training and extend the • Can HMS be used as part of
• Other factors that may to facilities reach QI activities?
affect implementation (e.g., • Any available simulators
rainy season) • Existing data recording and
reporting systems for maternal
See Annex B on
health implementing See Annex K on QI
multiple modules
40
 Design and Planning Considerations

section 03
WHO DOES
HOW TO WHAT? WHAT IS
PRACTICE? WORKING?
Defining roles and responsibilities
of key district-level HMS players Dynamics within the
Availability of
clinical simulators district health system

• Because HMS uses a simulation-based • Be clear about the other roles, • HMS often uses existing district
training approach, a sufficient number responsibilities, and commitments of systems (district trainers, within
of clinical simulators is critical to HMS HMS trainers, clinical mentors, and facilities, supervision, regular
success. supervisor at the start. meetings, etc.).
• If simulators are limited, consider • Unrealistic expectations and waning • Supervision may be weak (due to
some alternative LDHF designs motivation may hinder HMS over limited staff or vehicles, poor roads,
described in this section. time. security concerns, supervisor skills,
• Look for ways to strengthen existing etc.).
systems and build HMS into them. • Recognizing what is possible within
the district health system and how to
strengthen it should factor into the
design. 41
Design for Results—M&E

section 03
Early in the design process, determine your goal and build ways to measure progress into the HMS program
from the start. While training is central to HMS, “training all providers” is not the end goal. The ultimate aim
is to change clinical practice and improve health outcomes. Program scale and duration will vary, so
program goals will be tailored to the specific context. Some examples:
• Reach 100% of health facilities in the district as HMS BAB-ready in nine months—
meaning that all health care providers have been trained and have conducted their
clinical practice sessions
​ hen HMS is introduced as an
W
• Ensure 100% uterotonic use for every facility birth—100% of women receive a
intervention to improve quality
prophylactic uterotonic immediately following birth (measured at each health facility)
of care—through training and
practice—it is essential to • Note: This may require other activities be implemented to complement HMS BAB, such as a policy that promotes
100% uterotonic use for every birth.
measure and track progress on
care and clinical outcomes. • Decrease the number of facility-based maternal deaths from PPH by 75% within two
years*
​A dashboard is available to
• Decrease the PPH case fatality rate by 75% within two years*
support QI and track HMS
related data in facilities. • Halve the percentage of institutional (facility-based) maternal deaths from PPH within a
year*

See the M&E Section for

more detail on data
sources and
measurement

​
*Cons ult your M&E advis or to explore whether thes e are feas ible within the des ign and available budget 42
HMS:
Addressing challenges to LDHF practice

section 03
HMS starts with training—but the weekly clinical practice is the “LDHF” component that makes it
effective! LDHF practice may be difficult to plan, and even when planned, it may be difficult to run on a
regular basis. Having two Practice Coordinators appointed at each facility is key! Here are practical
solutions to ensure that LDHF practice occurs.

​HMS weekly practice sessions may be difficult to plan and organize in the
program design—for example, due to a limited number of clinical
simulators or a large number of community midwives who practice outside
of health facilities.
​Regular practice is essential
to HMS design. ​The LDHF component can be designed in different ways:

• Trainers can visit facilities each week with the simulator to facilitate the
​ reative solutions are
C
LDHF sessions (plan for the increased logistical and travel costs).
needed when LDHF practice
• Simulators can rotate every eight weeks to a different facility (plan for a
sessions that follow HMS slower rollout to reach all facilities).
training are difficult to • Practice sessions can be conducted during regular district or facility-
conduct on a weekly basis. level meetings, which may be monthly (plan to stretch the practice
sessions over eight months).
• Identify barriers to LDHF practice and find ways to stimulate
motivation to practice (e.g., small incentives for completion).

43
 HMS BAB:
Addressing challenges to LDHF practice

section 03
Getting providers to practice regularly can be a challenge at first. Consider adding

42%
activities into the design to better support and recognize health facilities running the
simulations as planned, such as:

​Only • If on-the-job training (OJT) or simulated practice at facilities is not common:

– Ensure that providers have been oriented at each facility to serve as Peer Practice
​of HMS BAB survey respondents Coordinators.
– Plan for phone calls or SMS at key points from the DHO, district trainer, or project staff
conducted LDHF practice with
to check in with practice coordinators on their progress.
providers following training – Integrate LDHF practice sessions into other QI activities at the health facility.
(HMS survey 2014). – Offer rewards/recognition from the DHO, MOH, or project to sites that run LDHF
sessions on schedule or complete as planned.

With peer support for practice, • Find ways to make practice convenient. Add clinical practice sessions at the worksite
onto existing events (e.g., at weekly facility meetings, begin or end with a LDHF
that number increased to,
practice session; supportive supervision visits include HMS session).

60%
• Review and address common barriers to LDHF upfront: lack of funding; lack of
equipment; lack of organizational support; lack of human resources to implement;
unsure how to lead on-site practice activities; lack of government support.

44
​
HMS BAB s urvey 2014; Saving Lives at Birth-funded s tudy in U ganda, preliminary findings , March 2015
 HMS Planning:
Thinking through district rollout

section 03
Table 3–1 is the starting point for planning, based on the number of health facilities and the number and
experience of the district trainers.

TABLE 3–1. HMS SCOPE AND REACH

District: Dado District: Moru

NUMBER OF SUB-DISTRICT UNITS 60 126

​S maller facilities will need a one- TOTAL NUMBER OF FACILITIES (highlight if facility has 60 129
day training (<6 providers). Keep more than six providers to be trained):
separate counts of total providers Hospital 1 3
at larger facilities to plan for (>6 providers) (>6 providers)
Health Center 3 37
enough training days.
Health post 56 89
​Disaggregate if useful TOTAL NUMBER OF PROVIDERS, BY CADRE: 224 330
SBA (doctor, midwife, nurse, auxiliary nurse-midwives)* 136 193

Other (specify) 86 137

District supervisors 2 3

45
​* Including community-based midwives ifrelevant
 HMS Planning:
Running the training numbers

section 03
Table 3–2 is an example of a training plan based on national and district rollout. There are a number of factors that
affect the number of trainings needed; see the following pages for considerations.

TABLE 3–2. HMS TRAINING CALCULATIONS

SCOPE National District: Dado District: Moru
TOTAL NUMBER OF FACILITIES 60 129
​1 trainer for every 6 participants # of HMS Champions to be trained: 40 17 22
Stakeholders and MNH Providers 35 11 14
​Both types of trainers need to
be oriented and mentored HMS master trainers 5 n/a n/a
(must be the same #) HMS trainers 6 12
# of trainers to orient on facilitation skills 5 6 12
# of trainers to be mentored 5 6 12
​Pull totals from Table 3–1 DISTRICT ROLLOUT:
# of district health workers to be trained n/a 224 330
​Pull total from Table 3–1; add more at # of additional clinical simulators needed (if 60 133
larger facilities (>6 providers) simulators needed)
# of HMS on-site trainings to be conducted 62 132
​2 per facility, 3 for hospitals # of Practice Coordinators to be supported 60 261
46
HMS Planning:
Running the training numbers

section 03
​Consider running back-to-back ​A ll trainers oriented and ​Remember the ratio for all
Champions training courses. mentored before they are Champions trainings is
Candidate trainers can qualified. If mentoring for
immediately be mentored to trainers will occur during facility- ​1 trainer: 6 champion
become qualified. It’s a level HMS trainings, budget for participants
particularly cost-effective and trainers’ costs to mentor each
​Double-check you are preparing
practical way to prepare district candidate HMS trainer.
enough Master Trainers to
training teams (See Essentials #2
support mentoring and enough
for another option)
trainers to roll out HMS to the
facilities at the pace you’d like.

47
HMS Planning:
Running the training numbers

section 03
Facilitators
HMS Champion Training
Orientation (one day)

​National and district levels:

• Try and accommodate as many people as are • Plan for one day after every Champion training
interested—as long as there are enough Master that produces Candidate Trainers or Master
Trainers and simulators (1:6 ratio) Trainers

• Schedule several back-to-back trainings, if needed,

(e.g., train district trainers) to give candidates easy
opportunities to become qualified

• Small numbers of Master Trainers should be

sufficient

48
 HMS Planning:
Running the training numbers

section 03
Health
center

Peer Practice Coordinator

HMS Champion Training
Orientation (one day)

​Facility level:

• From the total number of facilities, flag those with • Plan a day at each facility after the
more than six authorized providers so either two Champion training/s.
trainers go or back-to-back trainings are planned
(remember the 1:6 ratio). • Even if numbers at the facility are small,
orient two Practice Coordinators per facility
• Divide the facilities by the number of district for peer support and absences.
trainers for faster rollout, adjusting the schedule
based on travel distances/times and the number
of simulators.

49
HMS Planning:
Getting a workplan started

section 03
Before diving into detailed work planning,
review the number of health facilities and
providers to reach (Table 3–1). This is
particularly useful to think through the logistics
of training, mentoring, supportive supervision,
M&E, etc. It also helps to double-check that
there are sufficient resources (such as funding,
human resources) to fully implement HMS BAB
effectively at the scale proposed.

Take a quick look at the sample Gantt chart-

style implementation plan (Annex G) that can
be downloaded and adapted.
Take a look at the
Implementation plan in
Annex G

50
 HMS Planning:
Flagging time-consuming tasks upfront

section 03
Several activities may be time-consuming and therefore need to be planned well in advance. Invest time
early in understanding the steps and process.

1 ​Ensure government ​As HMS moves forward, it is critical that all key government counterparts at different
levels (e.g., within the MOH, the national in-service training institution, DHOs) are
buy-in and ownership
engaged in the design and are briefed on the final implementation plan. This can help
to clarify expectations, identify existing district mechanisms that can be used to
integrate HMS (i.e., training, supervision, or reporting), confirm numbers, discuss
logistics, and set basic fees and costs in line with government rates.

2 ​Procurement, logistics • Clinical simulators: Allow two to four months to order and receive them.
and supplies • Training materials: Materials can be downloaded for free and printed in-country or
ordered from Laerdal Global Health. Visit the HMS website to find translations for
download. Plan sufficient time and resources to distribute training materials. Purchase
or borrow delivery kits for Master Training.
• Uterotonic supply: If stock-outs or improper storage are issues, begin advocacy early
with the MOH and other development partners.
• Data collection systems: Elements of M&E (such as creating a database, new reporting
forms, SMS data collection platforms) may require time to procure and design.

51
HMS Planning:
Flagging time-consuming tasks upfront

section 03
3 ​Contracts and ​In some programs, partners will help implement and need to be subcontracted.
subagreements Allow sufficient time for a competitive bidding process and internal contract
approval process (total time estimated from two to four months).

​For example, programs with a strong M&E component may hire a research agency
or training and post-training supervision will be conducted by an NGO.

4 ​Ethical approval for ​If any part of the program will be studied or published, approval is needed from all
relevant bodies (such as the national research council, Institutional Review Board
research
[IRB], etc.). Total time estimated from 2 to 6 months

A B ? ​See the M&E section for more detail.

52
Roles and Responsibilities
​Defining the key roles and responsibilities (who will do what) at all levels (national, district, sub-district) is

section 03
important—across partners and with the government. Consider developing an MOU to clearly define roles at the
start, especially if there are multiple implementation partners.

Central Project
MOH
​K ey roles in HMS implementation include: Office

• Advocacy to address challenges (e.g., stock-

outs, cold chain issues)
• Procurement (clinical simulators, training
materials [translation (if needed), printing]
and workshop supplies)
• Training: HMS Champions, Master Trainer District Health
Office
and Trainers workshops, Clinical Mentor
orientation—including documentation and
coordination with national training
institutions for certification
• District rollout: facility visits; follow-up for
Clinical Mentors, supportive supervision
Health
• M&E: Data from existing systems, additional center/post
data collection; data aggregation, entry and
analysis, data use for decision-making

53
HMS Planning:
M&E

section 03
T​ here is a separate M&E section in this guide that should be reviewed in
detail in the planning phase (see M&E Section). During planning, it is
important to:
• Develop the M&E plan: Use the key HMS indicators (see Annex I),
“It is not possible to learn identify data sources, set targets, etc.
without measuring, but it
is possible—and very • Define roles and responsibilities for M&E: HMS programs need to
wasteful—to measure build monitoring and support into existing government systems
without learning.” instead of developing a “vertical” monitoring and support system.
Extensive recording and reporting can over-burden busy health care
—DM Berwick, 1998 providers.

• Determine if IRB approval is needed (see M&E Section for more

detail).

• Detail costs in the budget for M&E materials, staff time, supplies
and activities.
See Annex I
for M&E plan

54
Workplan:
Planning phase (quarter 1)

section 03
Be realistic in your start-up planning, especially if you include research, translation, and procurement. These
activities often run beyond one quarter. At the end of this phase, everything is ready to begin training.
Activity Budget Line Items Notes

1.1 Introductory • Local transport, meeting costs, local transport allowances* Integrate into existing fora
meetings – national where possible; engageHMS
and district master trainers
1.2 Focused rapid • Staff level of effort(LOE), travel, local consultant, per diem for
assessment assessment team
1.3 HMS program • Local transport, meeting costs, local transport allowances*, Integrate into existing fora
design • Visit to implementation areas: travel, per diem where possible
1.4 Procurement • Training: simulators (including shipping, customs), delivery kits Be realistic in terms of time and
for Master Training, HMS training materials (ordering or printing), costs for each step of
stationery, distribution procurement processes
• Partners (e.g., research agency, NGOs)
1.5 M&E design • Local IRB fees#, M&E forms printing, database development (for Integrate into existing fora
large-scale programs) where possible
• Training for program staff and master trainers: venue,
refreshments/meals, printing, photocopying
1.6 Other start-up • Materials translation; project registration*
support

Need a bit of advocacy to

make progress? see
Annex E
​* Local costs are illustrative and need to be relevant for the country context; # applicable if research is being conducted 55
Workplan:
Implementation phase (quarters 2–3)

section 03
Activity Budget Line Items Notes

2.1 Project kick-off • Ideally conducted in donated space by local • Often done at the first national
government Champions training (in
• Printing, photocopies, other promotional combination with Activity 2.2)
materials/activities
• Possibly travel costs, per diem, refreshments/food,
equipment rental for presentations
2.2 Champion trainings • Local transport, meeting costs (including venue • Expect one national and then
(national workshop) rental), certificates, local transport allowances* facility-level trainings. The number
• Total number depending on scope/breadth of of Champion courses will depend
program on the scale of rollout, # of
• For each training: Program staff LOE, participant costs available HMS Master Trainers, etc.
(travel, per diem) meeting space (if not done at • The number of participants per
health facility or free MOH space), trainers’ fees, course will depend on the number
refreshments/meals, printing, photocopying, of trainers (6:1 ratio) and
photographer^, training supplies/etc. simulators.
2.3 District-wide facility • Program staff LOE, trainer fees and travel costs*, • Depending on scope/breadth of
Champion trainings refreshments/meals, printing, photocopying, program (e.g., # of facilities,
photographer^, training supplies/etc. providers, districts, simulators)
2.4 LDHF practice • Program staff LOE, travel to sites (transport, per • Support during LDHF practice
diem), phone credit (text messaging), phase from program.
printing/photocopies (e.g., LDHF logs)

​* Local costs are illustrative and need to be relevant for the country context; ^ it is encouraged to document the event 56
Workplan:
Implementation phase (quarters 2–4)

section 03
Activity Budget Line Items Notes

2.5 Performance and QI • Depends on program design • Could include monthly/quarterly

support • Possible costs: travel, per diem, clinical mentoring, monthly
printing/photocopying (e.g., mentoring or supportive supervision visits
supervision checklists) (ideally by MOH district
supervisors or district trainers)
2.6 Regular stakeholder • Possible budget elements: staff LOE, meeting-related • Quarterly suggested but
meetings costs (e.g., printing, photocopying, refreshments, per determined by program needs
diem, meeting space if not at the MOH or program • Build into existing safe
office, etc.) motherhood technical advisory
groups if possible
3.1 M&E implementation • Program and M&E staff LOE • M&E monitoring visits, including
• Site visits for data quality audits and data review data quality audits as feasible
meetings: meetings to share feedback/data: travel
costs, per diem, meeting space, etc.
3.2 Program • Photographer/videographer • Based on initial plan and budget
communications • Graphic design, production, printing • Plan to send regular program
• Final dissemination event updates to the HMS Secretariat,
• Manuscript preparation, presentation at including success stories and
conferences** photos for the HMS website

​* Local costs are illustrative and need to be relevant for the country context; ** encouraged to document the event 57
​Implementation
Section 04

►Start-up

►Training

►Field visits

►Program management
Implementation:
Start-up

section 04
Whether integrating HMS into an existing program or conducting it as a
new project, consider the following:

• Orient office staff (including hands-on exposure to materials and

simulator), hire staff, etc.

• Develop a program communications plan to: collect stories from the

field, including photos; prepare quarterly and/or annual reports; and
capture any additional information on unique aspects of the program.

• Pay special attention to any activities or tasks that were flagged during
planning as time-consuming to be sure they stay on schedule.

• Spend time early with key stakeholders to address any issues.

59
Implementation:
Resources for Training Activities
Facilitators Orientation
HMS Champion Training
(One day)

section 04
Preparation • Candidate Trainers must pass all OSCEs
• Preparation checklist There are 3-5 checklists depending on
• One-day Training Agenda module.
• Training agenda
Training Day • HMS Trainer Participant Evaluation Form
• Knowledge Assessment Answer Key, • HMS Trainer and Master Trainer Certificate
Knowledge Pre/Post Test (after qualified)
• Pre/post confidence assessment • HMS Low Dose, High-Frequency Practice
• Participant Characteristics Sessions (with log)
• OSCE Pre/Post checklist (OSCE 1)
• Participant Sign-in Sheet Peer Practice Coordinator
• HMS Champions Participant Evaluation Form Orientation (1 day)
• Training Certificate
• HMS Participant Log and Scores • One-day HMS Practice Coordinator
Orientation Agenda
• HMS Low Dose, High-Frequency Practice
Sessions (with log)
• Evaluation Form
• HMS Practice Coordinator Certificate
60
Implementation:
Field visits
Plan joint visits with government officials from the national or district levels, particularly those with
supervisory responsibility. If not possible, brief and de-brief officials at the DHO and MOH on visit findings,
opportunities, and challenges.

section 04
• Program staff: Monitoring visits to sites during training, LDHF
practice, and afterwards:
​The HMS Supportive
• Review of M&E process, facility challenges (e.g., stock-outs, staffing issues)
Supervision form can be
• Collect program communications, including stories and photos
used for each facility visit
• Technical staff: Supportive supervision and clinical mentoring visits, to document progress and
including M&E: challenges.
• Connect District Trainers with facility Clinical Mentors who are conducting practice
after training with providers ​Field visits are a good time
to share available data
• M&E staff: Site visits to review data recording and collection; data use analysis and reinforce data
support at the facility; data quality audits (as feasible) use for decision-making.

61
Implementation:
Additional ways to support HMS and improved
practices

section 04
District Health
Health
Office
center

4 Reporting of HMS-
related data to DHO
so data can be
compiled and
compared across
facilities.
1 Trainers and/or district supervisors can
support Clinical Mentors through SMS
reminders for weekly clinical practice.

2 The DHO can include discussions on LDHF

practice and other issues impeding
5 Practice Coordinators
improved practice (e.g., low stock of
can send SMS or call the
uterotonics) during regular meetings with
district trainers about
health facilities’ in-charge and during
any challenges with Weekly practice after HMS training
supportive supervision visits.
LDHF practice.
After HMS LDHF sessions have finished,
3 clinical simulations can be run as refreshers
during monthly meetings or supportive
supervision visits.
62
Implementation:
Program management

section 04
• Documentation: Program reports, HMS global
trainer database

• Program communications: Success stories,

publications, quarterly updates to HMS global, ​As your HMS program unfolds, please share your
conference presentations,* manuscript*^ experiences from implementation—along with
photographs, videos, and stories about providers
• Regular stakeholder meetings to maintain and women who benefit from HMS—with the HMS
engagement, share results, get input/feedback; global team so we can feature your work on the HMS
meet individually to orient any new stakeholders website.
(e.g., staff changes at MOH)
​hmsglobal@[Link]
• Monthly workplan and budget review :
Timeline, expenditures in relation to budget

​* ensure IRB approval for these activities 63

​Monitoring & Evaluation

Section 05

►M&E Plan

►Data Collection and Collation

►Human Resources

►Training

►Monitoring Visits

►Data Use and Feedback

M&E:
Tracking progress, measuring success
Whether HMS is implemented as a separate project or within a larger MNH
program, it’s essential to have all of the following in place for M&E:

1. M&E plan with indicators

2. Data collection and collation tools—including paper

section 05
2. Data collection
forms, spreadsheets, and databases and collation tools

3. Human resources for data entry, analysis, synthesis, and

6. Data
interpretation/visualization quality, 3. Human
1. M&E plan
use, and with indicators resources
4. Training and on-site mentoring for site staff and in- feedback
country staff to standardize data collection, management,
reporting practices, and how to use data for decision- 5. Ongoing 4. Training
making monitoring and on-site
visits mentoring
5. Ongoing monitoring visits to review and verify the
quality of data

6. Data quality, use and feedback to sites on site-specific

and project-specific performance
65
M&E Plan
​The M&E plan serves as the “road map” to identify results to measure and indicate the success and/or
shortfalls of your HMS program. It’s expected that HMS training and LDHF practice (Objective 1) will lead to
improved readiness (Objective 2)—which should increase service provision (Objectives 3 and 4). The
ultimate aim is to reduce PPH-related maternal mortality (Objective 5), but the ability to demonstrate this at
a facility or across a program depends on the scale and duration. Indicators for each objective are presented
next.

Program Goal: To reduce the incidence of complications and the number of deaths due to
these complications

section 05
Objective 1 Objective 2 Objective 3 Objective 4

SERVICES DELIVERED MATERNAL

TO ALL WOMEN WHO MORTALITY
TRAINING DELIVERED READINESS
GIVE DUE TO PPH AND
& SUSTAINED DEMONSTRATED
BIRTH AT HEALTH ALL CAUSES
FACILITY DECREASED

66
 M&E Plan: HMS BAB example
Indicators
Program Goal: To reduce the incidence of PPH and the number of deaths due to PPH

Objective 1: TRAINING DELIVERED AND SUSTAINED Objective 2: READINESS DEMONSTRATED

​ .1 Number of HMS Trainers who have been certified after
1 ​ .1 Percentage (number) of birth attendants who are
2
participating in mentored training observed at their job site and determined to be HMS

section 05
competent
​1.2 Number of Clinical Mentors trained
​ .2 Percentage (number) of health facilities with at least 5
2
​1.3 Number of participants in Champions courses doses of un-expired uterotonic drugs (oxytocin and/or
misoprostol) in the labor ward on the day of the visit
​1.4 Percentage (number) of facilities that have HMS-trained providers

​ .5 Percentage (number) of SBAs and other providers trained in HMS

1
per facility

​1.6 Percentage (number) of providers who practiced HMS

​1.7 Percentage (number) of facilities that have at least 50% of the

providers who have practiced after training day

​*Additional data may be able to be gathered fromthe LMIS on a routine basis relatedto stock-out of drug 67
 M&E Plan: HMS BAB example
Indicators (pre-final version)
Objective 3: SERVICES DELIVERED TO ALL WOMEN Objective 4: MATERNAL MORTALITY
WHO GIVE BIRTH AT HEALTH FACILITY DECREASED DUE TO PPH AND ALL CAUSES

​3.1 If routinely collected, percentage (number) of women who ​4.1 PPH case fatality rate
received a uterotonic immediately after birth (within 1 minute)
(routine service delivery data if already captured in maternity register or ​4.2 Institutional maternal death rate

section 05
on partograph)
​4.3 Number of all deliveries at the health facility
​As part of supervisory visit and if a birth is observable, percentage
(number) of women who received a uterotonic within 1 minute after
vaginal birth (supervisory checklist or direct clinical observation
during birth)

​S pecific drugs: oxytocin and misoprostol

​3.2 PPH incidence in the facility (includes women who transfer into
the facility)

See Annex I for a

detailed M&E plan

​*Additional data may be able to be gathered fromthe LMIS on a routine basis relatedto stock-out of drug 68
Data Collection and Collation

​HMS is intended to use and strengthen the health ​Data collection and collation tools—including paper forms
management information system (HMIS) for routine data
• Training Log

section 05
collection to the extent feasible. For example, recording of
uterotonic for AMTSL or MgSO4 for pre-eclampsia use varies • Supportive Supervision Tool, with direct observation
(e.g., on a partograph, in a register), and not all national HMIS component tool
require reporting. • HMS Practice Log
• Uterotonic, MgSO4 etc, supply log
​The following pages describe where and by whom data
collection occurs.

As feasible, larger HMS projects may consider developing a

database and/or SMS data collection system.

See Annex A for

M&E forms

​M onitoring & Evaluation 69

Data Collection: HMS BAB example
At a glance
HMS BAB M&E Before facility-level During facility-level intervention After facility-level
implementation at intervention* intervention
different levels
Project/national ·# of Champions: trainers, Clinical • # of facilities (1.4)
Mentors, participants (1.1, 1.2,
1.3)
District (DHO) ·# of Champions: trainers, Clinical
Mentors, participants (1.1, 1.2,
1.3)

section 05
Facility ·# of Champions: Clinical Mentors,
participants (1.2, 1.3)
·% of providers who practiced (1.6)
→→→→→→→→→→
·% of providers BAB competent (2.1)
·#/% of facilities with uterotonic in labor room (2.2)
·% of women given UUIFB (3.1)
·PPH incidence (3.2)
·PPH case fatality rate (4.1)
·Institutional maternal death rate (4.2)
·# of deliveries at health facility (4.3)
* Facility-level intervention is the BAB one-day on-site training and the weekly simulated practice

Code:
blue=project to collect data
green=data likely collected in registers and probably by HMIS (no extra data collection required, TBD)
red=data unlikely to be regularly collected in HMIS/LMIS and would require additional recording/reporting
70
Human Resources:
Roles & responsibilities
ENTITY M&E ROLE / RESPONSIBILITY

HMS Trainers Completes training log for Champions training course, facilitation skills workshop, and clinical mentors
orientation. During supportive supervision visits, completes direct observation and/or practice tools.
Facility Providers Primary data collector of uterotonic use and PPH incidence data on partograph and in registers. Facility-in-
charge uses data to guide implementation at the facility level.
Peer Practice Complete LDHF practice logs and submit to HMS BAB program. Complete monthly summary form. During
Coordinatos/Clinical supportive supervision visits, complete tools on uterotonic supply in the labor ward.

section 05
Mentors
Facility/District Ensures data are checked and verified through periodic data quality assessments. Helps facility providers
Supervisors understand the data collected and implications for their activities. Helps facilities complete their monthly
reporting and transfers this knowledge to the providers to carry out on their own.
National, Regional DHO aggregates data from facilities and analyzing it monthly. Reviews progress and works to support low-
and District performing facilities. Identifies lessons learned and makes strategic recommendations/decisions.
Government
PROJECT:
Project technical staff Collaborates with M&E team on indicators that are useful to guide implementation. Lead analysis and
synthesis of data. End-user of the information for decision-making. Participates in monitoring visits. Submits
reports to DHO and MOH.
M&E point person(s) Coordination role. Develops project database; supervises data entry (assuming there will be a data clerk to
help with this). Provides training to facility providers and other project staff on standardized data collection.
Develops data visualization to facilitate review and analysis of data with technical staff. Provides results
against targets to donors and the MOH as well as the individual facilities generating the data. Conducts data
quality audits. Builds ownership and buy-in for the overall M&E system. Develops and updates manuals,
guidelines, training materials, and reports for program M&E. 71
 Training and On-Site Mentoring for M&E
​Training needs for M&E are minimal and can mostly be built into HMS BAB training events. In areas where
data use and visualization are not already practiced, some additional training and support will be needed
to help facility staff chart data on the dashboard/graph.

section 05
HMS Trainers Clinical Mentors Providers Supervisors

Trainers are oriented to Practice Coordinators are oriented Providers are responsible for District supervisors or project
training logs and the criteria after the on-site training at their recording service statistics. technical staff will be oriented
for qualification during the facility for a day. They are taught on how to conduct direct
facilitation workshop. how to complete the training log, observation and/or practice
(For trainers who conduct the uterotonic supply log and and complete the tools during
supportive supervision visits, see tally service statistics for the supportive supervision visits.
Supervisors.) monthly summary form and
dashboard.

See Annex A
for training materials

72
Data Quality, Use, and Feedback

​M&E is built into routine monitoring visits so data are reviewed and discussed with facility staff. Larger HMS
programs (or HMS activities implemented within a larger maternal health program) would benefit from routine data

section 05
quality assessments to track data from the original sources through the recording and reporting process to look
closely at data quality, consistency, and completeness. Data use and feedback are important practices at health
facilities, as well as at DHOs and program offices , but staff may need some additional training and mentoring to
improve their capacity-building in this area.

Data visualization, such as on dashboards, can be a powerful way to help staff understand their daily practice and
how well the facility performs over time. HMS will introduce two dashboards (see the next 2 pages).

Often, the combination of data quality assessments, data use, and data visualization all illustrate to providers the
importance of recording complete and accurate data on time—boosting data quality over time.

73
 HMS BAB:
Graph for facility dashboard
Uterotonic Used Immediately Following Birth (UUIFB)
100 Target: 90% UUIFB
90
80
70
60
50

section 05
40
30
20
10
0
January February March April May June July August September October November December

% of women who received uterotonic immediately following birth

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Numerator: Number of women who
receive a prophylactic uterotonic after
birth, before delivery of placenta
Denominator: Number of vaginal births
occurring in facility
UUIFB (%):
Numerator__ x 100
Denominator

74
​Source: MCSP dashboard, Clinical Governance draft, February 2015
 HMS BAB:
Graph for facility dashboard
PPH Incidence
10%
9%
8%
7%
6%
Percentage

5%
Target: <5% PPH

section 05
4%
3%
2%
1%
0%
January February March April May June July August September October November December

PPH incidence
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Numerator: Number of
PPH cases in the facility
Denominator: Number of
vaginal births occurring
in facility
PPH Incidence (%):
Numerator__ x 100
Denominator

75
​Source: MCSP dashboard, Clinical Governance draft, February 2015
Reasons to Invest In and Improve Data
Collection and Reporting

• What gets measured, gets done.

​Where are we now and

section 05
• If you don’t measure results, you can’t tell success from failure and you
where do we want to be?
can’t identify gaps and find solutions.
​… and how do we know if
• If you can’t see success, you can’t learn from it and share it.
we getting there?
• If you can’t see success, you can’t reward it.

• If you can’t reward success, you probably are rewarding failure.

• If you can’t recognize failure, you can’t correct it.

• If you can demonstrate cost-effective results, you can scale up.

​S ource: Jhpiego.2011. Cervical Cancer Prevention and Control Program: Monitoring and
Evaluation (M&E) Strengthening Guidance [Internal]. 76
M&E:
Other issues

section 05
• Ethical review and approval: For research, ethical approval is always required.
Increasingly, it is also required when using service statistics and routine monitoring data in
peer-review publications or in presentations at international conferences. Early in project
design, determine if national or organizational research ethical review approval (such as a
national research council or IRB) for your activities is necessary. An application often takes
2 to 6 months to be completed, so it needs to be worked into the timeline and budget. An
IRB application should be approved prior to any data collection activities.
• Contracts, subagreements, etc. in place/executed (as appropriate): Some programs with
a strong M&E or research component may hire a research agency. Allow sufficient time for
a competitive bidding process and internal contract approval process (total time estimated
from 2 to 4 months).

77
Implementation Guide Conclusion

​W hen implemented as designed, HMS can be a powerful way to

change provider practices, improve care, and save lives. This guide

section 05
provides practical information on how to use HMS to make a ​An in-depth understanding
difference to more rapidly end preventable maternal deaths.
of HMS makes it easy to find
​The global HMS Secretariat is available to respond to questions, provide a number of ways that it can
support, disseminate your successes, and cross-pollinate lessons learned be introduced and
across HMS programs. integrated into national
programs to end
​Stay in touch to learn about new materials—such as LDHF session plans—
and new content modules, including HMS BAB+ and HMS Pre-eclampsia &
preventable maternal
Eclampsia. mortality.

​Contact us at hms@[Link] questions or to share your experiences

implementing HMS.

78
​Annex A:
​HMS BAB Tools & Resources
The HMS website has full sets of downloadable resources
that can be adapted for use in specific HMS country
programs. This annex presents BAB-specific materials.

See [Link]
Section 06
Available HMS Training Resources
HMS Champions training
Available online in a combined PDF and in a zip file, HMS BAB Champions Sept2015
TRAINING MATERIAL FILENAME
HMS BAB Training and Mentoring Preparation HMS training prep checklist [Link]
Checklist
Helping Mothers Survive Champion Training HMS Champions Facility Training Agenda
Facility Agenda for District Trainers [Link]
HMS BAB Knowledge Assessment Answer Key HMS BAB Knowledge [Link]

HMS BAB pre-test knowledge assessment HMS BAB knowledge [Link]

HMS BAB post-test knowledge assessment HMS BAB knowledge [Link]

HMS BAB Pre-training Confidence Assessment HMS BAB PRE confidence assessment [Link]

Section 06
HMS BAB Post-training Confidence Assessment HMS BAB POST confidence assessment
[Link]
HMS BAB Participant Characteristics HMS Participant Characteristics [Link]

HMS BAB Pre-test OSCE 1 AMTSL Skills Checklist HMS BAB OSCE1 AMTSL pre test [Link]

HMS BAB Training Day Participant Sign in Sheet HMS Participant sign in sheet [Link]

HMS BAB HMS Champions Participant Evaluation Participant evaluation HMS Champion [Link]

HMS Champion certificate TEMPLATE_Jhpiego HMS Champion Certificate

[Link]
HMS Training Participant Log HMS Training Participant Log and [Link]

80
Available HMS Training Resources

Training for HMS Trainers and Master Trainers

Available online in a combined PDF and in a zip file, HMSTrainers MasterTrnr
Sept2015
TRAINING MATERIAL FILENAME
HMS Trainer Development Workshop HMS Master Trainer Workshop Agenda
template [Link]
HMS BAB OSCE 1: AMTSL Skills Checklist HMS OSCE 1 AMTSL post test [Link]

HMS BAB OSCE 2: Retained Placenta Checklist HMS BAB OSCE 2 Retained [Link]

HMS BAB OSCE 3: Severe Post-partum Hemorrhage HMS BAB OSCE 3 Severe PPH [Link]
(PPH)

Section 06
HMS BAB: HMS Trainer Participant Evaluation Participant evaluation HMS Trainer
[Link]
Master Trainer certificate TEMPLATE_Jhpiego HMS Master Trainer
certificate [Link]
HMS BAB low-dose, high-frequency practice HMS BAB LDHF session plans no log
sessions [Link]
HMS BAB LDHF session plans with log
[Link]

81
Available HMS Resources
Clinical Mentor Orientation
Available online in a zip file

TRAINING MATERIAL FILENAME

Orientation Session Plan for HMS/HBB HMS HBB Clinical Mentor Orient Session
[Link]
HMS BAB Low Dose, High-Frequency HMS BAB LDHF session plans no log [Link]
Practice Sessions HMS BAB LDHF session plans with log
[Link]
Clinical Mentor Orientation Evaluation Clinical mentor evaluation [Link]

Section 06
Other tools and resources
Available online in a zip file
RESOURCE FILENAME

HMS BAB Sample One-Year Workplan HMSBAB Workplan [Link]

HMS BAB Rapid Assessment Guide HMSBAB_rapid assessment_Sept2015.docx

82
​Annex B:
​HMS BAB Integration with the
Helping Babies Survive Suite and
Helping Babies Breathe
Section 06
Integration:
BAB and HBB

​In reality, health care providers need to be able to manage complex

emergency situations when they occur—often around the time of
birth. As described earlier, HMS is designed to address the needs of

Section 06
Mother and a mother and newborn as a unit.
newborn are
a unit
​HMS therefore provides guidance on integration where there are natural
synergies in terms of how care is provided, such as HMS BAB and HBS
HBB. In those first minutes after birth, a provider may need to help an
asphyxiated baby at the same time the mother experiences PPH.

​This section describes:

• Similarities and differences in HMS and HBS design
• Suggestions for reinforcing HBB within BAB training and LDHF
practice

84
HMS BAB & HBS HBB:
At a glance

DESIGN SIMILARITIES DIFFERENCES

ELEMENT BAB HBB
Approach • 1-day training followed by LDHF practice
• Focused on basic lifesaving skills, complemented
by advanced care skills
Participants • Health care providers at labor and childbirth in
resource-limited settings
• Same ratio of 1 trainer to 6 participants
Training • Flipchart, guide, action plan wall chart
materials
Equipment • Simulators used for training • Birth simulator • Newborn resuscitation simulator
• Basic supplies, delivery kits, towels for newborn,

Section 06
and supplies
uterotonic, syringe, bag and mask, gloves, etc.

Training • Focus of training is at the district and facility levels • Shorter training cascade: begins at • National master trainers, regional
cascade the district trainers, district trainers

On-site • 1 day • Team approach • Pairs providers for training and

design • On-site clinical practice
Post-training • Emphasis on clinical simulation and practice after • 8 weekly clinical simulations (6 • All staff should run the clinical
clinical the short 1-day course guides provided) simulation before beginning their
simulation • Simulator remains at the facility for shift
design the 8 weeks (longer if sufficient • Simulator remains at each facility
models) • HBB corner set up in each facility
85
HMS BAB & HBS HBB
​The synergy is in the approach. Integration for these modules occurs after both have been rolled out. For
example, in Uganda, BAB was conducted in its original design and following the 8 weeks of LDHF practice, HBB
was conducted as designed. At its conclusion, 4 additional weeks of clinical practice were supported using
scripted, combined scenarios for both mother and newborn. Read Annex F for more detail on the process and
findings from Uganda.

Facility-Based Facility-Based
4 weeks of
Training of Training of Training of Training of combined
District Providers and District Providers and HMS and
Trainers in Clinical Mentors Trainers in Clinical Mentors HBB
HMS-BAB in facilities HBB in facilities practice

Section 06
Mentored 8 weeks of Mentored 8 weeks of
Training of LDHF Practice Training of LDHF
District for HMS-BAB District Trainer Practice for
Trainers in in HBB HBB
HMS-BAB

See Annex J
About HMS in Uganda

86
​Annex C: Glossary of Terms

Section 06
HMS BAB Glossary of Terms
TERM DEFINITION

Active management of the third AMTSL is an intervention that requires the use of uterotonic, preferably oxytocin within one-minute
stage of labor (AMTSL) after birth, optional controlled cord traction (CCT), and checking uterine tone and giving massage if
needed to prevent PPH.

Clinical simulation A learning practice that allows students or service providers to practice a skill with real instruments on
anatomical models. This provides the learner an opportunity to practice in a life-like situation and
achieve competence prior to working with a real client.

Health care provider Traditionally, a health care provider for Helping Mothers Survive (HMS) is anyone who attends to a
woman and her child on the day of birth. This can include community health workers and unskilled
​AAAAAA
clinic staff. For HMS, health care providers are most often skilled birth attendants (SBAs) (midwives,
nurses, medical doctors), but include clinical officers, assistant medical officers, health extension
workers, or nurses aides.

Section 06
HMS Champion An HMS Champion is anyone who is interested in improving the care of women and babies on the day
of birth. A champion is an advocate for LDHF practice of essential skills by health workers who provide
care on the frontline. HMS Champions educate policymakers, educators, clinicians, and associations.

HMS Peer Practice Coordinator OR An HMS Clinical Mentor is a qualified trainer (by either the Jhpiego trainer pathway or other pathway
Clinical Mentor recognized by their country) and has undergone the HMS Master Training. They have experience in
mentoring other providers or trainers in HMS. Of course, they are proficient in providing clinical
services in their respective area and experienced in training learners in those skills.

HMS Trainer An HMS Trainer is a qualified trainer (by either Jhpiego trainer pathway or other pathway recognized
by their country) and is proficient in providing clinical services in their respective area and
experienced in training other providers in those skills. In addition to these minimum qualifications, an
HMS Trainer is trained in an HMS Champion training, completed an HMS facilitators training, and has
been mentored as s/he conducts an HMS Champion training.
88
HMS BAB Glossary of Terms

TERM DEFINITION

HMS Master Trainer An HMS Master Trainer is recognized (by either the Jhpiego trainer pathway or other pathway
recognized by their country) as a Master Trainer (i.e., a Trainer of Trainers). S/he is proficient in
providing clinical services in their respective area and experienced in training learners in those
skills. In addition to these minimum qualifications, an HMS Master Trainer has sufficient
experience and skills in developing clinical training and coaching skills in HMS Trainers.

Low-dose, high frequency (LDHF) Refers​AtoAAAAA

a training approach where a learner receives small “doses” of hands-on training spread
over time and preferably at the jobsite and also practices new or refreshed skills for a short period
of time, but repeated on a frequent basis.
Objective Structured Clinical A tool used by teachers or trainers to test the clinical skill performance and competence. Learners
Examination (OSCE) are assessed on a one-to-one basis where they perform different skills.

Section 06
Postpartum hemorrhage (PPH) Blood loss of 500 ml or more within 24 hours after birth and the leading cause of maternal
mortality in low-income countries. A majority of deaths due to PPH could be avoided with the use
of prophylactic uterotonics during the third stage of labor.

89
​Annex D: About PPH

Section 06
PPH by the Numbers
PPH is the leading cause of
maternal death.1
.
19.7%
Almost all PPH deaths occur
in developing countries.1

Ending Preventable
Maternal Deaths
from PPH

​W e know where women are dying

PPH is 99.8%
from PPH—in developing countries. preventable.

Section 06
Just 1,200 women in developed
countries died from PPH from 2003– Over 60% of PPH
2009, compared to 479,000 in the cases can be
developing world.1 prevented with
AMTSL.2
​PPH is the leading direct cause of
maternal death in northern Africa, 66% PPH can kill within 2
hours of onset.
Eastern Asia, Southern Asia, Western
Asia, Southeastern Asia, and
Oceania.1 Without immediate and
appropriate care, PPH
​It is estimated that worldwide PPH rapidly can be fatal.
kills 188 women every day—that’s 8
women dying from a preventable 2 hours
cause every hour.2

​
1Say et al. G lobal caus es of maternal death: A WHO s ys tematic analys is . Lancet May 2014; 2 Begley CM, G yte G ML, Murphy DJ, Devane D, McDonald SJ, McG uire W. Active vers us expectant management
​
for women in the third s tage of labour. Cochrane D atabase of Systematic Reviews 2010, Is s ue 7. Note: AMTSL reduced “primary maternal hemorrhage (more than 1000ml).
91
 The Basics of PPH Prevention and Management

​We know a lot about PPH and how to Oxytocin (IM/IV, 10 IU) is the uterotonic drug
Most deaths resulting from of choice. Misoprostol can be used where
prevent and manage it. Here are some
PPH occur during the first oxytocin is not available or injection is not
24 hours after birth: the of the basic facts. available.
majority of these could be ​There is no way to predict who will experience For women with PPH due to atony,
avoided through the use of PPH. When bleeding does occur, it can be immediate treatment involves uterine
difficult to measure and can go undiagnosed.
prophylactic uterotonics massage and additional uterotonics
PPH may occur slowly, over several hours. It (preferably oxytocin). Retained placenta
during the third stage of

Section 06
may not be recognized until the woman goes requires additional oxytocin and potentially
labour and by timely and into shock. manual removal and referral. HMS BAB
appropriate management. focuses on the elements of PPH prevention
​When blood loss is 500 cc or more in the first 24
hours after childbirth, bleeding after birth is and treatment that can be performed by
—WHO Recommendations for the called postpartum hemorrhage. Most PPH (70– most health workers and in any facility
prevention and treatment of conducting births.
90%) is caused by uterine atony—when the
postpartum haemorrhage
uterus doesn’t contract. When bleeding is difficult to control, there are
​Because all women are at risk for PPH, the WHO additional interventions (i.e., advanced care)
recommends that all women giving birth be that can provided by a SBA. Other more
offered uterotonics during the third stage of complex interventions require a specialist or
labor (immediately after birth within the first surgical expertise in a comprehensive
minute) for the prevention of PPH. emergency obstetric care facility (i.e.,
hospital).
92
 PPH Prevention and Management:
Opportunity
There are a number of reasons HMS BAB makes sense to implement now. HMS BAB has the potential to make a
difference in maternal survival in low-resource settings with limited human resources for health (HRH).

​Over half of women in developing The best clinical practices for PPH All frontline health workers can
countries are delivering in a health prevention and management are respond and save lives.

Section 06
facility.1 known, and most are feasible in Because PPH is the leading cause of
F​ acility-based births have steadily increased low-resource settings.2 maternal death, all health workers—
over the past 10 years; thus, interventions to WHO updated global recommendations especially in peripheral health facilities—
improve quality of care at facilities have the for PPH in 2012. Emphasis is placed on need to be able to manage bleeding after
potential to reach greater numbers of uterotonic immediately after birth for birth. This includes SBAs, but is especially
women and have a larger public health prevention, which can be provided by important where SBAs and doctors are in
impact. At the same time, facilities need to frontline health workers. short supply. Strategies are needed to
be ready to respond quickly with lifesaving In the case of hemorrhage, initial enable task-sharing and empower health
care when women arrive with PPH (e.g., interventions for management can be care workers to deliver maternal health
after a home birth). performed by frontline health workers. services.

​ United Nations. MillenniumDevelopment Goals Report 2010. Note: in 24 USAID priority countries, institutional delivery rate in 2013 is 34% and
1
93
expected to increase to 60% by 2020 (EndingPreventable Maternal Mortality: USAID Maternal HealthVision for Action, June 2014),p15.
​2 WHO recommendations for the preventionand treatment of postpartum haemorrhage, 2012.
​Annex E: HMS BAB-Related Advocacy

Section 06
Design:
When advocacy is needed

​Be resourceful in thinking ​There may be issues identified in the rapid assessment that need
about advocacy, and considerable attention to ensure HMS can be most effective. For example,
you may find regular stock-outs of oxytocin limit frontline health workers’
collaborate with other
ability to respond in PPH emergencies.
partners.
​During the design process, you will need to decide which issues can be

Section 06
addressed in the design, and others during HMS implementation. Some
may require more concentrated advocacy or policy-level work to ensure
HMS has maximum impact.

95
 Design:
When advocacy is needed

​ hen faced with issues much

W ​Here are some common issues that affect HMS implementation that can be
larger than the scope of HMS, addressed through advocacy. HMS BAB is the example here.

focused advocacy can be useful ​P OLICY ISSUES:

and very effective. • Some providers who attend births are not authorized to give injections

​Consider how available data • Private sector or NGO providers (SBAs) are not eligible for government-
can be visualized and used. For supported BEmONC and therefore have outdated PPH knowledge and

Section 06
example, uterotonic stock-outs skills

may get more attention when • Misoprostol is not on the Essential List of Medicines for the country
facility or district statistics are ​HEALTH SYSTEMS ISSUES:
graphed—and the drop in
• Stock-outs of oxytocin, cold chain issues for oxytocin storage
monthly AMTSL use is more
• No data on PPH are available because this information is not reported
obvious.
in HMIS.

​HRH ISSUES:

• Severe shortages of SBAs in peripheral facilities

96
​Annex F: HMS BAB Rapid
Assessment

Section 06
HMS:
Rapid assessment – BAB example
Elements of HMS BAB rapid assessment

MNH services

​1. Policies, strategies, and clinical guidelines

In addition to other related reports and documents, the Health care
following documents need to be collected and reviewed: Supportive supervision
workforce
§ Relevant national and local policies and strategies:
– National PPH strategy
M&E
Policies, strategies, Mapping of
– SBA policy and guidelines stakeholders Review of relevant indicators
and available data
– Misoprostol at home births* policy
§ Clinical guidelines and standards consistent with WHO 2012:

Section 06
​2. Mapping of stakeholders
list any points that differ
§ Performance and quality improvement tools/approaches in In some contexts, building your relationships for HMS BAB
use coordination and collaboration begins at this stage. At this
§ Supply chain management (procurement/logistics) stage, invest the time to meet key groups or individuals, such
– Uterotonics on national List of Essential Medicines (or as:
misoprostol approved for off-label use) § Potential collaborators/detractors (e.g., ob/gyns at leading
health facilities and medical colleges, professional
– Uterotonics included in the logistics management and
associations, White Ribbon Alliance)
information system
§ Existing programs (complementary vs. duplicative)
–Planning in place to supply sufficient quantities and ensure § Existing TAGs for MNH
quality (cold chain, quality control testing) § Donors or sources of cost-sharing opportunities
§ Other barriers to policy/guideline implementation, etc.
​`​* Misoprostol for PPH prevention at home births isprovided in many low-resource settings. PPH management after prophylactic use of misoprostol
should be specifically addressedin the HMS BAB training in these settings. 98
HMS BAB:
Rapid assessment

​3. M&E: Review of relevant MNH indicators/data ​4. MNH services

Gather this type of information from the HMIS or other sources: Clinical practices related to PPH prevention and management
§ Available national/provincial data on maternal mortality due need to be documented as actual practice (compared to
to PPH policies) at each level of the health system. A brief look at the
§ % of births with SBA; % of births in a health facility referral system would be useful to reduce delays.
(disaggregate by location and type of provider)
§ AMTSL recorded/reported in labor and delivery (L&D)

Section 06
registers, facility dashboards, HMIS
§ AMTSL performance (HMIS, other sources): disaggregate by Conduct site visits if needed to
type of facility; geographic region better understand how PPH
§ PPH cases in L&D registers, facility dashboards, HMIS emergencies are managed,
§ Maternal death audit (or near-miss) data on PPH reported, and supported.

99
HMS BAB:
Rapid assessment

​5. Health care workforce (i.e., HRH) ​6. Other issues (particularly opportunities and challenges)
In this section, it’s important to identify which cadres are ​Supervision systems in place for MNH—staff, tools, frequency,
“authorized providers ” for PPH prevention and management,
feedback, information and communication technology for
then roughly estimate numbers. Next, review basics of pre-
development (ICT4D)—need to be understood. Both gender
service education and in-service training for these cadres:
§ Number of trainers, training sites and equity issues also can be explored, in terms of training and
§ Training database/system; continuing medical education services.

Section 06
system; re-certification process
​Before concluding the assessment, explore other tangential
§ Current in-service training approach – BEmONC, SBA, EONC
information that might influence or impact HMS BAB. Some
§ Curricula on PPH consistent with WHO guidelines (HMS BAB)
§ Data on providers trained to date on PPH, AMTSL, BEmONC examples include: traditional use of tea with uterotonic
§ Post-training follow-up data properties in Madagascar, poor quality oxytocin in India and
Finally, explore other HRH issues including legal authorization Ghana, high levels of anemia in South Asia, and scale-up of
and task-sharing opportunities. misoprostol for PPH prevention at home births.

Use the HMS BAB rapid assessment tool to help

guide the review and document findings.

100
​Annex G: HMS BAB Sample
Implementation Plan

Section 06
HMS BAB Sample Implementation Plan
Planning
A Word/PDF version is available in Annex A.
YEAR 1
ACTIVITY RESPSONSIBLE BUDGET ELEMENTS DELIVERABLE
Q1 Q2 Q3 Q4
1. PROGRAM PLANNING
Introduction of HMS BAB in country—in the context of the National Safe Country Director/COP with
Motherhood Program: Identify and meet with key stakeholders (MOH) and key donors in-country MNH Advisor
either formally or informally to introduce the HMS concept and BAB approach. Get initial
buy-in to explore how HMS BAB will support and complement ongoing safe motherhood
program activities (especially PPH prevention and management).
Focused rapid assessment : § Depends on extensiveness Assessment results, X
§ Relevant national and local policies, guidelines, standards, formulary of assessment possible formal report,
§ Possible elements: program used to inform program
§ Mapping of stakeholders
staff LOE, travel, per diem design
§ Review of relevant MNH indicators/data
for assessment team
§ Pre-service, in-service training, supervision systems in place for MNH
§ Review of MNH health care workforce, health services/service delivery (including clinical
practices) and referral system; conduct site visits if necessary

Section 06
§ Equipment, procurement, and logistics
§ M&E: What relevant MNH data/indicators are currently collected/tracked by the MOH at
national/local levels?
Stakeholder engagement/buy-in and advocacy: Might depend on situation analysis § Depends on nature of Stakeholder engagement X
results to what extent this is needed (e.g., to advocate for program, for misoprostol to be engagement and advocacy activities conducted
activity
added to formulary, etc., or we can make assumption that misoprostol is available in
§ Possible budget elements:
country or okay to use off label – need to agree on assumptions before developing guide); program staff LOE, meeting-
or could have this as part of planning related costs (e.g., printing,
photocopying,
refreshments, per diem,
meeting space if not
donated by MOH or
program office, etc.)

102
HMS BAB Sample Implementation Plan
Planning and Implementation
YEAR 1
ACTIVITY RESPSONSIBLE BUDGET ELEMENTS DELIVERABLE
Q1 Q2 Q3 Q4
HMS Program Design: Based on results of assessment and ideally in collaboration with Program Manager/Officer § Program staff LOE Workplan X
the MOH counterpart to ensure buy-in/involvement from the start § Possible follow-up site visits
(travel, per diem)
§ Design elements to consider: Site selection and scope/breadth of program; roles and
responsibilities (who will do what if shared implementation); training; LDHF; quality and
performance support; M&E (M&E plan, select indicators from recommended list of key
HMS indicators, identify data sources, set targets, etc.)
Procurement of supplies/equipment : Estimate and order sufficient simulators for Program Manager/Officer § Cost for simulators, HMS Correct type/number X
project (e.g., for training, for LDHF, for mentoring if unable to provide MN x HF), HMS with Fin/Admin team training materials, other supplies and equipment,
training materials (Action Plan, flipbook, provider’s guide), other training materials (e.g., training materials, possibly available in timely
oxytocin, misoprostol, and manner
delivery kits, neonatal resuscitators, etc.).
costs r/t supporting cold
chain
2. PROGRAM IMPLEMENTATION
Preparation of training materials, supplies, and equipment: All things needed to Program Manager/Officer § Most costs captured in Training materials, X
support training are available and ready for implementation (e.g., simulators, program planning phase supplies, and
§ Other costs at time of equipment
supplies/equipment, HMS training materials, basic training supplies, etc.)

Section 06
implementation:
photocopying, printing,
program staff LOE, travel /
per diem (in case we need
to get supplies to site in
advance of training)

Project kick-off: To formally introduce program, orient stakeholders to program, Program Manager/Officer § Ideally conducted in § Project kick-off X
continued advocacy/awareness raising for program donated space by local event
government § Possible report of
§ Printing, photocopies, event, or notes
other promotional
materials/activities
§ Possibly travel costs, per
diem, refreshments/food,
equipment rental for
presentations

103
HMS BAB Sample Implementation Plan
Implementation
YEAR 1
ACTIVITY RESPSONSIBLE BUDGET ELEMENTS DELIVERABLE
Q1 Q2 Q3 Q4
Training implementation: Program Manager/Officer § Depending on § Trainings X X X
• Who: master trainers, HMS champions, Clinical Mentors, supervisors, include key scope/breadth of § Report of training
administrative “gatekeepers” program need to provide activities
• What (depending on who): HMS training, LDHF, mentoring, supportive supervision, specific guidance (e.g., for
and include M&E in trainings where appropriate x providers being trained,
2 trainers x 4 clinical
simulators, etc.)
§ For each training (some
costs already captured in
program planning phase):
Program staff LOE,
possibly MOH LOE, travel,
per diem, meeting space if
not done at health facility,
refreshments/meals,
printing, photocopying,
training supplies/etc.,
simulators.

Section 06
LDHF practice: Program Manager/Officer § Program staff LOE § Completed LDHF log X X X
• In terms of program staff, this means conducting activities that help to support LDHF § Some costs captured in sheets (and
(e.g., making calls to health facility to see how LDHF is going, possibly making site program planning (e.g., hopefully
visits in the first few weeks following training to trouble-shoot any barriers to LDHF, simulators for each site) concomitant
etc.). Some programs may incorporate other ways of supporting LDHF (e.g., text § Other possible costs: evidence of
messaging). travel to sites (fuel, per consolidation/
• In terms of MOH providers at the facility (assuming each facility has its own simulator), diem), text messaging, sustained provider
this refers to them actually doing LDHF, on-site practice with their peers (we know this printing/photocopies skills)
may ultimately take on different forms depending on the program/context) (e.g., LDHF logs) § Possible reports on
LDHF practice
developed by
program staff that
captures status of
LDHF (whether it’s
being done, any
trouble shooting,
etc.)

104
HMS BAB Sample Implementation Plan
Implementation, M&E
YEAR 1
ACTIVITY RESPSONSIBLE BUDGET ELEMENTS DELIVERABLE
Q1 Q2 Q3 Q4
Performance and QI support (supportive supervision, clinical mentoring) Program Manager/Officer • Depends on program Clinical mentoring or X X X X
• Activities that will help to improve/maintain performance and quality of care at point design for this supportive supervision
of care. component of the checklists and related
• Could include monthly/quarterly clinical mentoring, monthly supportive supervision program reports (and hopefully
visits. • Possible costs: travel, per concomitant evidence
• Ideally conducted by MOHstaffs who have been trained as Clinical Mentors and/or as diem, of improved
part of their existing supportive supervision scope of work. printing/photocopying performance, quality of
(e.g., mentoring or care)
supervision checklists)
Regular stakeholder meetings: Conduct regular stakeholder meetings to maintain Program Manager/Officer § Depends on nature of § Regular stakeholder X X X X
engagement, share results, get input/feedback – more meetings at start-up and thereafter engagement and meetings
on quarterly basis) advocacy activity § Meeting
§ Possible budget elements: notes/reports
staff LOE, meeting-related
costs (e.g., printing,
photocopying,
refreshments, per diem,
meeting space if not

Section 06
donated by MOH or
program office, etc.)
Program monitoring and evaluation: M&E team § Program and M&E staff § Collected M&E data X X X X
• Implement M&E plan LOE § Regular M&E
• Ensure data quality and management § M&E-related software or analysis and reports
• Routinely analyze data and share reports database § Stakeholder
• Hold regular meetings with stakeholders for continual feedback § Data collection meetings to share
• Analyze, share, and use results § Possibly site visits, results + meeting
meetings to share notes
feedback/data: fuel, per
diem, meeting space, etc.

105
​Annex H: Clinical Simulators

Section 06
HMS BAB Resources:
Clinical simulators Simulation is key to the success of learning. All
modules require local equipment, mock drugs
and local supplies for simulation. For some
modules, anatomic simulators are needed. Here
MamaNatalie Simulator are some simulators that can be used.

Laerdal Global
[Link]

Zoe Model
Gaumard

Section 06
[Link]

PartoPants
Pronto International
[Link]

107
​Annex I: HMS BAB M&E Plan

Section 06
 Objective 1

TRAINING DELIVERED
HMS BAB M&E Plan & SUSTAINED

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
1.1 Number of HMS Trainers who have To be certified equals a Champions course (1 OSCE), Training Log – Every training HMS Master
been certified after participating in facilitation day (2 remaining OSCEs), and mentored to be adapted Trainer / Project
mentored training training. Staff
1.2 Number of Clinical Mentors trained Providers complete BAB training, are selected as Training Log Every training HMS Trainers
(by cadre) Clinical Mentor to facilitate and record provider
practice sessions using simulator and session plans.
1.3 Number of participants in Participants are those that actively participated in the Training Log Every training HMS Trainers
Champions courses (by cadre, 1-day BAB course and receive a certificate.

Section 06
active or not actively providing Disaggregate by provider cadre (nurse, clinical
care) officer/assistant, midwife, doctor) and actively
providing care (providers) or not actively providing
care (advocates, stakeholders, etc.).
1.4 Percentage (number) of facilities Numerator: # of facilities in a district that have held a Training Log Every training HMS Trainers
that have HMS-trained providers 1-day facility-based BAB training or have staff attend
(by district, by location of training a workshop and practice. Denominator: Total
[facility-based or workshop-based, number of facilities in the district that conduct birth.
by levels of practice])

109
 Objective 1

TRAINING DELIVERED
HMS BAB M&E Plan & SUSTAINED

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
1.5 Percentage (number) of providers Denominator: Number of providers who have Practice log – to Once 8 weeks Clinical Mentors
who practiced (disaggregate by completed the HMS – BAB training. The HMS-BAB be adapted after completion
level of practice: <4 sessions and practice sessions (Duration of session: ~ 10 minutes of HMS – BAB
≥4 sessions) per learner) are expected to be completed over an 8- training (or if
week cycle (last 2 weeks are Clinical Mentor’s choice) combined with
Session topics include: Prevention of PPH – AMTSL HBB it would be
and review of transport plan; atony resolving with collected and
massage and medication; atony requiring bimanual reported every
uterine compression; retained placenta resolving
12 weeks)

Section 06
with continued CCT; retained placenta requiring
transfer; retained placenta that resolves and then
becomes atony, resolving with massage and
medication; and based on clinical events or Clinical
Mentor’s choice.
1.6 Percentage (number) of facilities Related to Indicator 1.5 Supportive Quarterly Supervisors
that have at least 50% of the Numerator: Number of facilities that have at least supervision tool
providers who have practiced 50% of the providers that have practiced. with direct
(disaggregate by level of practice Denominator: Number of facilities that have gone observation
(<4 sessions and ≥4 sessions) through the HMS – BAB training. component tool
– to be adapted

110
 Objective 2

READINESS
HMS BAB M&E Plan DEMONSTRATED

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
2.1 Percentage (number) of birth Denominator: All birth attendants observed and Supportive As part of HMS Trainer
attendants who are observed at previously trained. supervision tool supervisory (knowledge
their job site through simulation with direct visits and at 3 and skills
or through live observation to be
BAB competent (disaggregate by Structured observation of performance with observation and 6 months testing)
cadre) simulators or direct observation. Deemed component tool
competent if they have a 70% pass score on
knowledge tests and for skills assessments—OSCE 1
= 9 out of 12, OSCE 2 = 6 out of 8, OSCE 3 = 8 out of

Section 06
12 for simulation. Observation of a birth needs further
clarification.
2.2 Percentage (number) of health Denominator: Total number of health facilities Supportive Quarterly Clinical
facilities with at least 5 doses of visited during the quarter. supervision tool during Mentors
un-expired uterotonic drugs with direct supportive
(oxytocin and/or misoprostol) in
the labor ward on the day of the Target: 90 – 100% observation supervision visit
visit. component tool

*Additional data may be able to

be gathered from the LMIS on a
routine basis related to stock-out
of drug

111
 Objective 3

SERVICE DELIVERED
TO ALL WOMEN WHO
HMS BAB M&E Plan GIVE
BIRTH AT HEALTH
FACILITY

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
3.1 If routinely collected, percentage If data collected routinely on maternity register or Routine data Monthly for Providers;
(number) of women who received on partograph and collated into the monthly collection routine service external
a uterotonic in the third stage of summary form: (HMIS where delivery data or observers
labor (routine service delivery data
if already captured in maternity Numerator: Women who receive a prophylactic available) and / periodically
register or on partograph) uterotonic (specific drug) after birth, before delivery or Supportive through
of placenta supervision supervisory
As part of supervisory visit and if a Denominator: All vaginal births occurring in facility. tool with direct checklist / direct

Section 06
birth is observable, percentage observation clinical
(number) of women who received If supervisory checklist / direct observation: record component observation
a uterotonic within 1 minute after
exact timing of birth and administration of tool checklist
vaginal birth (supervisory checklist
or direct clinical observation during uterotonic and specify which drug.
birth) Denominator: Number of births observed.
Disaggregate data for uterotonic given within 1
Specific drugs: oxytocin and minute and 3 minutes of birth.
misoprostol
Target: 90–100%

112
 Objective 3

SERVICE DELIVERED
TO ALL WOMEN WHO
HMS BAB M&E Plan GIVE
BIRTH AT HEALTH
FACILITY

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
3.1 PPH incidence in the facility PPH is blood loss of 500 ml or more within 24 hours Routine data Monthly / Providers;
(includes women who transfer to of birth. Disaggregated by hemorrhage of >=500 ml collection Quarterly external
the facility) and >=1000 ml. (HMIS where (aggregated) observers
Denominator: Number of vaginal births (ideal) or available)
regular reporting norm to HMIS
Benchmark: 5–10% (but may increase initially with
more attention to PPH)

Section 06
113
 Objective 4

MATERNAL
HMS BAB M&E Plan MORTALITY
DUE TO PPH AND
ALL CAUSES
DECREASED

NO. ILLUSTRATIVE INDICATOR DEFINITION/CLARIFICATION TOOL FREQUENCY OF RESPONSIBLE

DATA PARTY
COLLECTION &
REPORTING
4.1 Percentage (number) of PPH- Numerator: All PPH cases that resulted in a death. Routine data Monthly Providers;
related deaths at health facility Denominator: All PPH cases prior to discharge. collection (aggregated external
Includes births that occurred at the facility or arrived (HMIS where into 8-week observers
with the complication.
available) blocks)
4.2 Number of all-cause maternal Maternal death of a woman at the health facility. Routine data Monthly Providers;
deaths at health facility Disaggregate by place of delivery. collection (aggregated external

Section 06
(HMIS where into 8-week observers
available) blocks)
4.3 Number of all deliveries at the (Denominator for deaths to calculate rates as well as Routine data Monthly Providers;
health facility other indicators.) Disaggregate by vaginal birth and collection (aggregated external
cesarean birth. (HMIS where into 8-week observers
available) blocks)

114
​Annex J: HMS BAB Country Examples

Section 06
Uganda: HMS BAB with HBB
The Saving Lives at Birth: Grand Challenges for Development award
presented a unique opportunity to study the implementation of the LDHF
approach twinning HMS BAB with the HBS HBB. This implementation
research allowed us to explore how varying amounts of support during
LDHF practice affected provider performance and clinical outcomes.

​With MOH participation, BAB and HBB were introduced sequentially in all 125 I​ n Uganda, the maternal
public facilities conducting birth in 12 remote districts. Jhpiego trained eight mortality ratio remains high
Master Trainers who trained and mentored 24 District Trainers. It was there
at 310 maternal deaths per
District Trainers who rolled out facility-based trainings and practice to all
100,000 live births. PPH is
providers on the labor ward team for BAB and HBB.
the leading direct cause.

Section 06
Following the 1-day training, health providers in each facility were expected
to conduct practice sessions using the simulators to simulate different
​The neonatal mortality rate
scenarios on a weekly basis (eight sessions). is 27 per 1,000 live births,
with the largest proportion
​After BAB LDHF practice concluded, HBB training was conducted by the same due to asphyxia.
trainers for the same providers. At the end of the eight weeks of practice for
HBB, providers practiced for an additional four weeks using scripted, ​ —WHO, 2013
combined scenarios for both mother and newborn. (see Annex B for specifics
on integrated implementation).

116
 HMS BAB in Uganda:
Implementation models in study
​ 1. Full support

Mobile phone reminders

​ 2. Standard:
for Peer Practice
Coordinators
​ Peer Practice Coordinators ​ Peer Practice Coordinators
oriented at each facility to oriented at each facility to ​ 3. Basic
support LDHF practice support LDHF practice

LDHF Practice Sessions LDHF Practice Sessions LDHF Practice Sessions

Section 06
HMS BAB, HBS HBB) HMS BAB, HBS HBB) HMS BAB, HBS HBB)

HMS BAB Champion training HMS BAB Champion training HMS BAB Champion training
+ + +
HBS HBB training HBS HBB training HBS HBB training

For groups 1 and 2, having two Practice Coordinators per facility will address
turnover and ensure practice occurs on a routine basis

​3 ) “training-only” as a comparison group. 117

HMS BAB & HBB in Uganda:
Results and Lessons learned
Using the LDHF approach, we achieved significant success. Across study facilities we saw a
A decrease in PPH by 17% and in retained placenta by 47%. Fresh stillbirth decreased by
34% and newborn death in the first 24 hours by 62%.

​Before implementation, health ​Initially, providers found it ​P roviders found it easier to do

care provider knowledge on difficult to adhere to the eight- the practice during the second
prevention and management of week schedule of LDHF round – After HBB, the majority of
PPH and management of simulated practice. After BAB facilities increased practice.
neonatal asphyxia was high— training, less than half of facilities Anecdotal reports from the

Section 06
but skills were low. After both submitted their practice log, and District Trainers and Practice
trainings, knowledge and skills about half of providers practiced Coordinators revealed that this
increased dramatically after the at least one time during the concept of LDHF practice at the
one-day BAB and HBB facility- eight-week LDHF period. Low facility was new to them and with
based training. reported practice was due to high the second training intervention,
workload, not having a partner to the emphasis helped them to
practice with, or they did not understand the goal and
have time. importance of LDHF practice.

118
HMS BAB in Malawi

​Through the Jhpiego-led USAID-funded Support for Service Delivery ​In Malawi, 675 women die in
Integration-Services (SSDI-Services) Project, HMS BAB has been every 100,000 live births.
implemented through facility-based mentoring. The SSDI approach is to
That’s 3,749 deaths each
visit to a facility each month for four hours during which providers have
year due to pregnancy and
their performance assessed on the job and then are mentored based on
its related complications.

Section 06
their particular needs (e.g., maternal health, child health, nutrition, family
planning, malaria). The maternal health mentors are HMS trainers who
​ PH is the cause of one of
P
travel with a simulator. They visit facilities and observe births to identify
every three of these deaths
gaps in performance (or run practice sessions if there are no deliveries).
(34%).
​As of 2013, there were 60 HMS district trainers (at least four per district),
and HBB has been synchronized with the BAB roll-out. The main challenges
​—Malawi Demographic and
have been the limited number of simulators (i.e., only one per district) and
referrals for advanced care, when needed. Health Survey, 2010

​N ational Statistical Office (NSO) and ICF Macro. 2011. Malawi Demographic and Health Survey 2010 Zomba, Malawi, and Calverton, Maryland, USA:
NSO and ICF Macro.
119
 HMS BAB in Nigeria
Nigeria has used HMS BAB in a different way—within pre-service education.
Jhpiego and the USAID-funded bilateral Targeted States High Impact Project
(TSHIP) worked with three higher-learning institutions to assist teaching faculty
in incorporating simulated-practice and competency-based training approaches
into their classes. With some minor adjustments, the on-site approach was well-
received and deemed cost-effective. Faculty knowledge scores increased from
80% to 96%.

The 13 new HMS

​With a maternal mortality
Trainers assisted in
the second training. ratio of 576 in Nigeria,1
13 Post-Basic Midwifery 30 Educators from
tutors participated in HMS PSE Institutions about 40,000 mothers die

Section 06
BAB Champions Course Sokoto State were
and Facilitation Training. trained in HMS BAB. each year due to pregnancy
and its related
complications.2
Postpartum hemorrhage
The 13 trainers were The new HMS
mentored during their Trainers were (PPH) accounts for 25% of
1st delivery of a assisted in the 3rd
Champions training. training. those deaths.3
20 Educators from PSE 26 Educators from
Institutions in Sokoto PSE Institutions
State were trained in Sokoto State were
HMS BAB. trained in HMS
BAB.

​ National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International.
1

​2 WHO Maternal Mortality in 1990-2013 (find full citation). 120

​ UNICEF Nigeria Maternal and Newborn Health(find full citation).
3
​Annex K: Additional Activities for
Quality Improvement
Although HMS focuses on increasing
knowledge and skills to change providers’
practice, it has been designed and
implemented to support other aspects of Section 06
quality care (e.g., communication, evidence-
based care, teamwork, and data use).
HMS Planning:
Quality and performance support
The way HMS has been designed and implemented supports other aspects of quality care (e.g.,
communication, evidence-based care, teamwork, and data use). There are other QI activities that can
address other issues not related to learning. Here are some examples of QI activities that could complement
HMS.

A well-stocked and equipped emergency trolley can address both

maternal and newborn care emergencies. A daily checklist helps
ensure the contents are complete.

In addition to HMS Action Plans,

other job aids are available: 3. Emergency trolley
​HMS complements ongoing
quality improvement activities,
• PPH management after misoprostol such as standards (e.g., SBM-R),
at a home birth (if PPH prevention at and helps reinforce key
4.

Section 06
home birth is implemented in the 2. practices.
Performance
same area) Job aids
• Drug charts for severe pre- standards
eclampsia 5.
Maternal death
1.
Clinical mentoring HMS BAB audits, near-miss
reviews
As part of HMS, existing supportive supervision L​ arger facilities typically conduct on-site maternal
and clinical mentoring systems within facilities and death audits and near-miss reviews as part of
districts will be used to implement and support HMS. Maternal and perinatal death surveillance and response
(MPDSR). In-depth reviews of complicated cases (both
deaths and saves) can help identify barriers and address
them.
122