• Integration of PAC into existing infrastructure, systems and services

• Expansion of the pool of healthcare workers able to provide emergency services

• Incorporation of the community perspective into PAC services

• Ongoing provision of supplies and equipment needed for PAC services

• Role of misoprostol in PAC services

Because the themes are not mutually exclusive, there were a number of recommendations, such as involving the community in PAC and promoting a cadre-neutral approach, that were made by more than one working group.

Advocacy

• Define the purpose of the advocacy process.

• Make the advocacy strategy broader than PAC.

• Identify the advocacy tools that will be most useful for the specific situation 

• Develop the advocacy strategy:

  • Form a network; bring the community and partners in at the very beginning.
  • Identify key stakeholders.
  • Facilitate a needs assessment, with the community taking the leadership role.
  • Convene dissemination events; identify "champions."
  • Develop an advocacy "action plan," incorporating input from the community; include different strategies for different stakeholders.

  • Tailor the advocacy strategy to opportunities and situations existing in the community.

• Implement the strategy.

• Continually monitor and evaluate to assess impact.

• Use findings from evaluations to gain new support.

Access

• Involve the woman and her community:

  • Understand the community’s perspective on PAC and what the community wants.
  • Provide the community with information about the advantages of PAC.
  • Mobilize community leaders and build networks that include traditional leaders and traditional healthcare workers.

  • Mobilize the community to provide transport for PAC and emergency obstetric care.

• Focus on service providers:

  • Examine practice regulations that limit service provision and investigate how to change them.
  • Support a cadre-neutral approach.
  • Expand the provider pool.
  • Strengthen preservice education and inservice training systems.
  • Strengthen supervision capability.
  • Motivate providers to provide PAC services.

  • Consider provider attitudes and devise strategies for changing them if necessary.

• Work with the health facility:

  • Identify and mobilize key stakeholders at all levels of the health system who can work to improve access.
  • Reorganize services and systems to link FP and RH.
  • Integrate PAC services into existing maternal health programs.
  • Offer PAC services at the lowest level facility possible.
  • Provide coverage 24 hours a day.
  • Consider financial implications of introduction and expansion of PAC services.

  • Examine procurement systems and establish sustainable incountry resources for supplies.

• Work with government and regulatory bodies:

  • Consider PAC in all strategic health planning.
  • Explore new modalities for providing care at the community level.
  • Provide funding for PAC.
  • Support policies to provide quality PAC services.
  • Include PAC and MVA in service delivery guidelines.
  • Establish clear guidelines for use of misoprostol.
  • Develop necessary support systems for PAC.

Institutionalization of Training

• Integrate PAC into the existing infrastructure, systems and services:

  • Standardize PAC skills.
  • Emphasize maintenance as well as acquisition of skills.
  • Make competency-based PAC training an integral part of preservice education and inservice training in maternal health, safe motherhood, life-saving skills and emergency obstetric care.
  • Ensure that PAC is a part of the basic package of skills taught in the preservice setting.
  • Consider ways to avoid fragmentation of preservice training (i.e., different cadres being trained in different types of programs).
  • Each time a preservice curriculum is revised, add (or strengthen, as appropriate) PAC education.
  • Revise protocols and practices in the inservice setting.
  • Ensure that the inservice setting can support what providers learn in the preservice setting.
  • Use algorithms, learning guides and protocols in PAC training.

  • Consider providers’ attitudes; sensitize individuals being trained to the issues involved in PAC.

• Expand the role of the healthcare worker and the pool of providers:

  • Change laws that prevent certain cadres (e.g., midwives) from providing services.
  • Train sufficient numbers of providers so that facilities can be staffed 24 hours a day.
  • Train individuals in small groups so that they can get hands-on experience.
  • Improve training of trainers.
  • Ensure availability of anatomic models to be used when client caseload is low.
  • Train individuals from different cadres as a team in the inservice setting.
  • Identify or develop model clinical training sites where the team approach can be demonstrated.
  • Establish minimum service delivery criteria for model clinical training sites.

  • Address issues of maintenance of skills and quality of care.

• Know and include the community:

  • Ensure that needs assessments and subsequent training address community perspectives.

  • Consider a variety of IEC strategies, including group discussions, role plays, case studies and workshops to prepare the community for PAC.

• Ensure ongoing provision of equipment and supplies:

  • Link provision of PAC supplies to existing Safe Motherhood initiatives.
  • Develop or adapt PAC learning packages.
  • Ensure pelvic and other anatomic models are available for training.
  • Obtain supplies by working with the government and private sector and networking with other organizations and donors.
  • Recognize the importance of sustainable sources of equipment and supplies.

Sustainability

• Strengthen the political will:

  • Involve the community.
  • Identify community leaders and incorporate their ideas.
  • Realize that policies often follow, rather than precede, action.

  • Seek client feedback.

• Build on and improve institutional systems:

  • Use the structure and capacity of existing health systems.
  • Reorganize systems and services to form a solid base for PAC.

  • Build linkages between facilities and the community.

• Build financial systems:

  • Ensure funding for PAC services.
  • Estimate cost savings resulting from introduction and expansion of PAC services.
  • Identify resources for the ongoing provision of essential equipment and supplies.
  • Develop logistics management systems.
  • Improve procurement processes.

  • Remove import and tax barriers to procurement.

• Implement services:

  • Improve quality of services.
  • Assess provider performance.
  • Strengthen provider skills.

Technical Issues

• Address clinical issues:
• Provide better training in pain management.
• Improve counseling and clinical diagnostic skills.
• Differentiate between causes of bleeding.
• Improve emergency preparedness at clinical sites.
• Emphasize the importance of using recommended IP practices.
• Explore sources of MVA equipment and develop guidelines for its selection and use:
• Investigate new sources for procuring MVA equipment.
• Develop criteria for selection of high quality MVA equipment.
• Catalogue available equipment.
• Develop guidelines for reuse of MVA cannula and syringes.
• Conduct research on misoprostol:
• Do further studies on oral misoprostol.
• Develop guidelines on its use as a possible medical treatment of incomplete abortion.