Harshad Sanghvi

Preventing postpartum hemorrhage in low‐resource settings

Objectives: To review the literature to determine the most effective methods for preventing postpartum hemorrhage (PPH), the single most important cause of maternal death worldwide. Methods: Systematic review of published randomized controlled trials and relevant reviews. Results: Review of the literature confirms that active management of the third stage of labor, especially the administration of uterotonic drugs, reduces the risk of PPH due to uterine atony without increasing the incidence of retained placenta or other serious complications. Oxytocin is the preferred uterotonic drug compared with syntometrine, but misoprostol also can be used to prevent hemorrhage in situations where parenteral medications are not available (e.g. at home births in developing countries). Conclusions: The use of active management of the third stage of labor to prevent PPH due to uterine atony should be expanded, especially in developing country settings.

Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: Operations research study in Nepal

To determine feasibility of community‐based distribution of misoprostol for preventing postpartum hemorrhage (PPH) to pregnant woman through community volunteers working under government health services.

Cervical cancer screening using visual inspection with acetic acid: operational experiences from Ghana and Thailand

Abstract Thailand in 2000 and Ghana in 2001 initiated cervical cancer prevention programmes using a single-visit approach with visual inspection with acetic acid (VIA) with cryotherapy for pre-cancerous lesions. This service was integrated into existing reproductive health services, provided by trained nurses. The providers maintained a high level of competence and performance, including after the withdrawal of external funding. In Ghana, independent co-assessments revealed a high level of agreement in diagnosis between providers and a Master Trainer. In Thailand, high quality performance was associated with quality assurance mechanisms such as peer feedback and review of charts and service statistics. Provider performance was maintained at a high level in both countries: an average of 74% of providers from both countries met 85% or more of performance standards. The successful transition from a demonstration project to a national programme in Thailand was dependent on a strong commitment from government health bodies and health professionals. In contrast, the lack of health infrastructure and political will has prevented scale-up to a national programme in Ghana. However, this study shows that a single-visit approach with VIA and cryotherapy is programmatically feasible and sustainable and should be considered in national investments to control cervical cancer.

Saving women's lives from cervical cancer

Thanks to intensive research over the past two decades into viable prevention strategies that can work even in the lowest-resource com munities, we now have an extraordinary opportunity to address cervical cancer in developing countries, where 80% of the mortality occurs. These prevention strategies include visual inspection with acetic acid, human papillomavirus (HPV) testing (both linked to treatment), and vaccines. We, the undersigned, affi rm that we must address cervical cancer now. At the same time, we want to express concern over any rush into complex technologies, even low-cost ones, as the main solution. As organisations working in some of the poorest countries, we must “walk in the shoes” of the women we serve to assess the feasibility of any approach. The following criteria are crucial for success: • Local access—screening in a woman’s own community • Single visit—immediate results linked to timely treatment • Aff ordable—visual inspection with acetic acid costs US

Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature

0·23 per patient, HPV tests an expected

Preparing the next generation of maternal and newborn health leaders: The maternal and newborn health champions initiatives

5–10, and

Advancing implementation in maternal and newborn health: Two decades of experience

10–25 for vaccines • Reproducible—simple proto cols easily taught by local trainers or providers • Sustainable—proprietary sup plies and equipment present insurountable barriers for weak supplychain systems We believe the best option for successfully reducing mortality now lies in the model that links visual inspection with acetic acid and cryotherapy, which has been success fully implemented in remote regions of the world. Studies of visual inspection with acetic acid have reported sensitivity comparable to that of cytology while requiring fewer specialised personnel and less infrastructure, training, and equipment. A single screening with visual inspection with acetic acid in a woman’s lifetime, between the ages of 30 and 50 years, with immediate treatment for all women who screen positive, can reduce the risk of cervical cancer by about 30%. We are at a crossroads in the fi ght against cervical cancer. As stated at the Women Deliver Conference in June, 2010, we have an “unprecedented opportunity to give women and girls an equal chance at healthy and productive lives, free from cervical cancer”. The one immediately viable option at this time is visual inspection with acetic acid and the single-visit approach. Let us unite in the goal of delivering what has been found to be eff ective now. When the HPV test or other new methods can be off ered at an aff ordable price and sustainably in remote, low-resource settings, then we should embrace them as important options in the battle against this preventable disease. Now let us do what is proven and doable: let us aim for reducing mortality by 30%. That is an enviable goal for any cancer prevention strategy. high mortality, and in safeguarding the cognitive and mental capabilities of those who survive.

Optimizing the Design of a Device Targeted Towards Facilitating Adequate Neonatal Resuscitation in Low Resource Environments

Task sharing, the involvement of non-specialists (non-physician clinicians or non-specialist physicians) in performing tasks originally reserved for surgeons and anesthesiologists, can be a potent strategy in bridging the vast human resource gap in surgery and anesthesia and bringing needed surgical care to the district level especially in low-resource countries. Although a common practice, the idea of assigning advanced tasks to less-specialized workers remains a subject of controversy. In order to optimize its benefits, it is helpful to understand the current task sharing landscape, its challenges, and its promise.We performed a literature review of PubMed, EMBASE, and gray literature sources for articles published between January 1, 1996, and August 1, 2016, written in English, with a focus on task sharing in surgery or anesthesia in low-resource countries. Gray literature sources are defined as articles produced outside of a peer-reviewed journal. We sought data on the nature and forms of task sharing (non-specialist cadres involved, surgical/anesthesia procedures shared, approaches to training and supervision, and regulatory and other efforts to create a supportive environment), impact of task sharing on delivery of surgical services (effect on access, acceptability, cost, safety, and quality), and challenges to successful implementation.We identified 40 published articles describing task sharing in surgery and anesthesia in 39 low-resource countries in Africa and Asia. All countries had a cadre of non-specialists providing anesthesia services, while 13 had cadres providing surgical services. Six countries had non-specialists performing major procedures, including Cesarean sections and open abdominal surgeries. While most cadres were recognized by their governments as service providers, very few had scopes of practice that included task sharing of surgery or anesthesia.Key challenges to effective task sharing include specialists’ concern about safety, weak training strategies, poor or unclear career pathways, regulatory constraints, and service underutilization. Concrete recommendations are offered.

Single-disease health campaigns: the case of cervical cancer – Authors' reply

A champion in health care can be defined as any health professional who has the requisite knowledge and skills in a relevant health field, who is respected by his/her peers and supported by his/her supervisors, and who takes the lead to promote or introduce evidence‐based interventions to improve the quality of care. Jhpiego used a common approach during two distinct initiatives to identify individuals in Africa, Asia, and Latin America and the Caribbean whose expertise in their clinical service area and whose leadership capacity could be strengthened to enable them to serve as champions for maternal and newborn health (MNH). These champions have gone on to contribute to the improvement of MNH in their respective countries and regions. The lessons learned from this approach are shared so they can be used by other organizations to design leadership development strategies for MNH in low‐resource countries.

Coverage, compliance, acceptability and feasibility of a program to prevent pre-eclampsia and eclampsia through calcium supplementation for pregnant women: an operations research study in one district of Nepal.

arshad Sanghvi, Jeffrey Michael Smith, Koki Agarwal, Blami Dao, onald Magarick Jhpiego In the past 15 years, Jhpiego has had the privilege of working with governments and other partners to implement interventions for maternal and newborn health (MNH) in nearly 40 countries. This Supplement to the International Journal of Gynecology and Obstetrics (IJGO) is our attempt to share our analysis and learning from those experiences as the global health community looks toward 2030 and beyond, and to ensure that implementation challenges, aswell as the resources required to address them, are an important part of the post-MillenniumDevelopment Goals conversation. The new global paradigm for MNH envisioned by the UN Secretary General’s Sustainable Development Goals and the Global Strategy for Women’s, Children’s, and Adolescents’ Health aims to bring evidencebased MNH interventions to national scale, setting ambitious targets to reach the unreached in every country and end all preventable deaths among women and children. Scale is not only about what works; it is about how to make that which has been proven to work in small, controlled areas apply equally well across all contexts. So wemust ask ourselves: What does it take for health systems to reach every woman, every child, everywhere, every time? The answer to this classic implementation science question is difficult to quantify, but we do have some evidence, and as with any scientific inquiry, we should startwith the evidence thatwe have. The papers in the Supplement have beenwritten by and for implementers, describing in detail what has been accomplished and highlighting lessons about what did and did not work. The lessons themselves will not be new to anyone who has worked in MNH as long as we have, but we believe that their thoughtful analysis and collective and inductive presentation is a unique illustration of the complexity of achieving—and then reinforcing—implementation results. Implementation science for MNH has a long road ahead. The papers in the first section directly confront the “how” of implementation. Even if we have all the right interventions, we need political commitment and partnerships to bring those interventions to populations in need. Sometimes these elements are beyond the control of implementers owing to contextual factors and prioritizations inherent in real-world public health environments, but there are common principles that can help navigate politics and partnerships more strategically and systematically to reach goals more rapidly and with longer-lasting efforts. We should not, however, sacrifice quality for speed; quality improvement, particularly the linkages between quality and health outcomes, remains a critical but under-funded area of our work. The second section examines the “who” of implementation, documenting ways to empower all cadres of frontline health workers with appropriate competencies to deliver evidence-based interventions, wherever women and children need them. It is our belief that those