Prophylactic interventions after delivery of placenta for reducing bleeding during the postnatal period

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Effect of Homeopathy on Pain Intensity and Quality Of Life of Students With Primary Dysmenorrhea: A Randomized Controlled Trial

BACKGROUND

Observational studies indicate a positive association between homeopathy and pain relief and quality of life improvement in women with dysmenorrhea. However, there are no interventional studies in this area.

OBJECTIVES

To evaluate an association between homeopathy and pain relief and quality of life improvement in a double-blind placebo-controlled randomized trial with 2 parallel arms.

METHODS

Fifty-four students with primary dysmenorrhea residing at the dormitories of the Tabriz University of Medical Sciences, Iran, who had moderate or severe menstrual pain, were randomized to receive either homeopathic remedy or placebo. The homeopath and participants were blinded to treatment assignment. Primary outcomes were pain intensity and quality of life assessed using a 10-cm visual analog scale and short-form 36 (SF-36), respectively, and the secondary outcome was number of analgesic pills used.

RESULTS

Each group comprised 27 students; eventually, 26 in the homeopathic and 21 in the placebo group were followed up. There was no significant difference between the groups for either pain intensity (adjusted difference: -0.44; 95% CI: -1.43 to 0.54) or any other outcomes. Compared with the baseline scores, statistically significant improvements were observed in pain intensity (P = 0.021) and physical health (P = 0.020) scores only in the homeopathic group; and in the mental health score in both groups (P = 0.014 in the homeopathy group and P = 0.010 in the placebo group).

CONCLUSIONS

This study could not show any significant effect of homeopathy on primary dysmenorrhea in comparison with placebo. Considering the possible effect of the homeopath and the homeopathic remedies prescribed on the results of such interventions, further studies are needed to help us arrive at a conclusion.

Comparison of Policies for the Management of Care for Women and Newborns During the Third Stage of Labor Among Japanese Hospitals, Clinics, and Midwifery Birth Centers

OBJECTIVE: To determine the care policies for both mothers and newborns implemented during and after the third stage of labor and to compare the rate of adoption of these care policies among hospitals, clinics, and midwifery birth centers in Japan.

METHOD: A cross-sectional survey of the care policies affecting mothers and newborns during and after the third stage of labor was conducted from October 2010 to July 2011. A postal questionnaire with follow-up was sent to all 684 maternity institutions in Tokyo metropolitan areas.

RESULTS: The overall response rate was 255 (37%). Most hospitals and clinics had a policy of early cord clamping; however, nearly 70% of the midwifery birth centers adopted the policy of waiting until the cord stopped pulsating. The policy of administering prophylactic uterotonics was adopted by 50% of the hospitals and 63% of the clinics, although midwifery birth centers did not adopt this policy. All midwifery birth centers, 50% of the hospitals, and 50% of the clinics routinely adopted the policy of early skin-to-skin contact.

CONCLUSION: Adoption of various care policies differed considerably among the hospitals, clinics, and midwifery birth centers. In addition, there were several gaps between evidence-based care and care policies.