Table 5 Possible action plans arising from the example in Table 2

Immediate (one-to-one guidance and supportive supervision)

• Identify who is in charge of quality assurance in midwifery at all health facilities and will take the lead on actions recommended

• Ensure immediate supervisory visits include aspects of proficiency in risk identification and assessment in ANC, controlled vaginal delivery, post-delivery examination of vagina and cervix for tears and injury, management of bleeding, resuscitation skills, recognition of seriously ill obstetric patients and when to act with urgency;

• Check when the next Emergency Obstetric Care (EmOC) or similar training is due to take place and prioritize this, bringing it forward if possible;

• Check that all facilities have protocols that include use of oxytocic agents, that they are using them, and if not, assess the barriers to use;

• Check that there is a guideline on logistics management of daily availability of blood supplies as per facility level, whether this is being used, and assess barriers to use.

Mid-term (training, drills, protocol review)

• Review that protocols are up-to-date, in place and being used for use of oxytocic agents;

• Organize drills in management of severe obstetric haemorrhage;

• Organize consultations on communications between senior and junior level health professionals, doctors and nurses, on how to get more expert advice provided by mobile phone and email, joint ward rounds including senior staff, specialist outreach visits to peripheral facilities to train, guide, mentor, create more ownership over guidelines and protocols; facilitate closer senior supervision of management of cases with risk factors

• Training and supervision of competent documentation and record keeping of clinical cases, vital signs and actions taken

• Clinical audits of management of patients for example in risk assessment at ANC, compliance with national or local protocols for a variety of conditions, feedback and re-audit

• Action to improve blood supply through mobilization of blood donors.

Long-term (systemic curricula review; policy guidance; changing attitudes and practices)

• Identify current competencies of staff against expected competencies for that level hospital, examine training curricula for relevance

• Develop new protocols and policies, update with reference to national and international evidence of effectiveness including policies on blood transfusion and logistical supplies of blood at facility level.