Uterotonic use at home births in low-income countries: A literature review

Women's use of non-conventional herbal uterotonic in pregnancy and labour: evidence from birth attendants

Background

Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs’ services, including herbal uterotonics. This has attempted to defeat stakeholders’ campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana.

Methods

This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers' (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants.

Results

Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth.

Conclusion

The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of ‘mansugo’ and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.

Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomised controlled trial

OBJECTIVE

To understand the prevalence of intrapartum oxytocin use, assess associated perinatal and maternal outcomes, and evaluate the impact of a WHO Safe Childbirth Checklist intervention on oxytocin use at primary-level facilities in Uttar Pradesh, India.

DESIGN

Secondary analysis of a cluster-randomised controlled trial.

SETTING

Thirty Primary and Community public health facilities in Uttar Pradesh, India from 2014 to 2017.

POPULATION

Women admitted to a study facility for childbirth at baseline, 2, 6 or 12 months after intervention initiation.

METHODS

The BetterBirth intervention aimed to increase adherence to the WHO Safe Childbirth Checklist. We used Rao-Scott Chi-square tests to compare (1) timing of oxytocin use between study arms and (2) perinatal mortality and resuscitation of infants whose mothers received intrapartum oxytocin versus who did not.

MAIN OUTCOME MEASURES

Intrapartum and postpartum oxytocin administration, perinatal mortality, use of neonatal bag and mask.

RESULTS

We observed 5484 deliveries. At baseline, intrapartum oxytocin was administered to 78.2% of women. Two months after intervention initiation, intrapartum oxytocin (I) was administered to 32.1% of women compared with 70.6% in the control (C) (P < 0.01); this difference diminished after the end of the intervention (I = 48.2%, C = 74.7%, P = 0.03). Partograph use remained at <1% at all facilities. Resuscitation was performed on 7.5% of infants whose mother received intrapartum oxytocin versus 2.0% who did not (P < 0.0001).

CONCLUSIONS

In this setting, intrapartum oxytocin use was high despite limited maternal/fetal monitoring or caesarean capability, and was associated with increased neonatal resuscitation. The BetterBirth intervention was successful at decreasing intrapartum oxytocin use. Ongoing support is needed to sustain these practices.

TWEETABLE ABSTRACT

Coaching + WHO Safe Childbirth Checklist reduces intrapartum oxytocin use and need for newborn resuscitation.

Barriers to optimal and appropriate use of uterotonics during active labour and for prevention of postpartum haemorrhage in public health care facilities: An exploratory study in five states of India

OBJECTIVE

The main objective is to understand the practices regarding use of uterotonics during active labour and for prevention of postpartum haemorrhage and the barriers for its optimal and appropriate use at different levels of health facilities in five states of India.

STUDY DESIGN

Mixed methods approach comprising of cross-sectional observational study of existing practices of uterotonics use during labour and early postpartum period for 1479 vaginal deliveries at 56 facilities. Quantitative data was collected using pre-tested proformas filled by on-site observers and qualitative data was collected by in-depth interviews of 125 maternity care providers of the observed facilities.

MAIN OUTCOME MEASURE

Providers' knowledge, attitude and patterns of use of uterotonics during active labour and for prevention of postpartum haemorrhage during childbirth.

RESULTS

On-site observation and interviews indicated inappropriate choice of uterotonics administered in varied doses for labour management across facilities. Unnecessary augmentation of labour was observed in 44.7% low-risk pregnancies and only 31% women were administered uterotonics in optimal doses for preventing postpartum haemorrhage. Only 46.4% providers in the observed facilities reported to have received maternal and child healthcare training according to the updated guidelines. Lack of supportive supervision for mandated practices among peers emerged as an important barrier for appropriate uterotonics usage in labour.

CONCLUSION

There is an urgent scope of standardizing the institutional health policies regarding administration of uterotonics during labour and for prevention of postpartum haemorrhage. Capacity building of maternity care providers regarding appropriate uterotonics usage is recommended for all levels of health facilities.

Antenatal Uterotonics as a Risk Factor for Intrapartum Stillbirth and First-day Death in Haryana, India: A Nested Case-control Study

BACKGROUND

Use of uterotonics like oxytocin to induce or augment labor has been shown to reduce placental perfusion and oxygen supply to the fetus, and studies indicate that it may increase the risk of stillbirth and neonatal asphyxia. Antenatal use of uterotonics, even without the required fetal monitoring and prompt access to cesarean section, is widespread, yet no study has adequately estimated the risk of intrapartum stillbirth and early neonatal deaths ascribed to such use. We conducted a case-control study to estimate this risk.

METHODS

We conducted a population-based case-control study nested in a cluster-randomized trial. From 2008 to 2010, we followed pregnant women in rural Haryana, India, monthly until delivery. We visited all live-born infants on day 29 to ascertain whether they were alive. We conducted verbal autopsies for stillbirths and neonatal deaths. Cases (n = 2,076) were the intrapartum stillbirths and day-1 deaths (early deaths), and controls (n = 532) were live-born babies who died between day 8 and 28 (late deaths).

RESULTS

Antenatal administration of uterotonics preceded 74% of early and 62% of late deaths, translating to an adjusted odds ratio (95% confidence interval [CI]) for early deaths of 1.7 (95% CI = 1.4, 2.1), and a population attributable risk of 31% (95% CI = 22%, 38%).

CONCLUSIONS

Antenatal administration of uterotonics was associated with a substantially increased risk of intrapartum stillbirth and day-1 death. See video abstract: http://links.lww.com/EDE/B707.

Perceptions of quality of care during birth at private Chiranjeevi facilities in Gujarat: lessons for Universal Health Coverage

The Indian national health policy encourages partnerships with private providers as a means to achieve universal health coverage. One of these was the Chiranjeevi Yojana (CY), a partnership since 2006 with private obstetricians to increase access to institutional births in the state of Gujarat. More than a million births have occurred under this programme. We studied women's perceptions of quality of care in the private CY facilities, conducting 30 narrative interviews between June 2012 and April 2013 with mothers who had birthed in 10 CY facilities within the last month. The commonly agreed upon characteristics of a "good (sari) delivery" were: giving birth vaginally, to a male child, with the shortest period of pain, and preferably free of charge. But all this mattered only after the primary outcome of being "saved" was satisfied. Women ensured this by choosing a competent provider, a "good doctor". They wanted a quick delivery by manipulating "heat" (intensifying contractions) through oxytocics. There were instances of inadequate clinical care for serious morbidities although the few women who experienced poor quality of care still expressed satisfaction with their overall care. Mothers' experiences during birth are more accurate indicators of the quality of care received by them, than the satisfaction they report at discharge. Improving health literacy of communities regarding the common causes of severe maternal morbidity and mortality must be addressed urgently. It is essential that cashless CY services be ensured to achieve the goal of 100% institutional births.

Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage

BACKGROUND

Advance community distribution of misoprostol for preventing or treating postpartum haemorrhage (PPH) has become an attractive strategy to expand uterotonic coverage to places where conventional uterotonic use is not feasible. However, the value and safety of this strategy remain contentious. This is an update of a Cochrane Review first published in 2012.

OBJECTIVES

To assess the effectiveness and safety of the strategy of advance misoprostol distribution to pregnant women for the prevention or treatment of PPH in non-facility births.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth Trial Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (19 December 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised, cluster-randomised or quasi-randomised controlled trials of advance misoprostol distribution to pregnant women compared with usual (or standard) care for the prevention or treatment of PPH in non-facility births. We excluded studies without any form of random design and those that were available in abstract form only.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in included studies. Two review authors independently assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Two studies conducted in rural Uganda met the inclusion criteria for this review. One was a stepped-wedge cluster-randomised trial (involving 2466 women) which assessed the effectiveness and safety of misoprostol distribution to pregnant women compared with standard care for PPH prevention during non-facility births. The other study (involving 748 women) was a pilot individually randomised placebo-controlled trial which assessed the logistics and feasibility of community antenatal distribution of misoprostol, as well as the effectiveness and safety of self-administration of misoprostol for PPH prevention. Only 271 (11%) of women in the cluster-randomised trial and 299 (40%) of the women in the individually randomised trial had non-facility births. Data from the two studies could not be meta-analysed as the data available from the stepped-wedge trial were not adjusted for the study design. Therefore, the analysed effects of advance misoprostol distribution on PPH prevention largely reflect the findings of the placebo-controlled trial. Neither of the included studies addressed advance misoprostol distribution for the treatment of PPH. Primary outcomes Severe PPH was not reported in the studies. In both the intervention and standard care arms of the two studies, no cases of severe maternal morbidity or death were recorded among women who had a non-facility birth. Secondary outcomes Compared with standard care, it is uncertain whether advance misoprostol distribution has any effect on blood transfusion (no events, 1 study, 299 women), the number of women not using misoprostol (2% in the advance distribution group versus 4% in the usual care group; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.13 to 1.95, 1 study, 299 women), the number of women not using misoprostol correctly (RR 4.86, 95% CI 0.24 to 100.46, 1 study, 290 women), inappropriate use of misoprostol (RR 4.97, 95% CI 0.24 to 102.59, 1 study, 299 women) or maternal transfer or referral to a health facility (RR 0.66, 95% CI 0.11 to 3.91, 1 study, 299 women). Compared with standard care, it is uncertain whether advance misoprostol provision increases the number of women experiencing minor adverse effects: shivering/chills (RR 1.84, CI 95% 1.35 to 2.50, 1 study, 299 women), fever (RR 1.87, 95% CI 1.16 to 3.00, 1 study, 299 women), or diarrhoea (RR 3.92, 95% CI 0.44 to 34.64, 1 study, 299 women); major adverse effects: placenta retention (RR 1.49, 95% CI 0.25 to 8.79, 1 study, 299 women) or hospital admission for longer than 24 hours (RR 0.99, 95% CI 0.66 to 15.73, 1 study, 299 women) after non-facility birth. For all the outcomes included in the 'Summary of findings' table, we assessed the certainty of the evidence as very low, according to GRADE criteria.

AUTHORS' CONCLUSIONS

Whilst it might be considered reasonable and feasible to provide advance misoprostol to pregnant women where there are no suitable alternative options for the prevention or treatment of PPH, the evidence on the benefits and harms of this approach remains uncertain. Expansion of uterotonic coverage through this strategy should be cautiously implemented either in the context of rigorous research or with targeted monitoring and evaluation of its impact.

New Evidence on Carbetocin: Another Arrow in Our Quiver

Carbetocin is more heat stable than oxytocin with at least equivalent efficacy for preventing postpartum hemorrhage. It will certainly be helpful if the supplier can make it available in low-income country settings at a price comparable to oxytocin. But even so, programs will still need oxytocin and other uterotonic medications.

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study

Background

In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal.

Methods

We conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community.

Results

Several women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position.

Conclusions

Our findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1724-2) contains supplementary material, which is available to authorized users.

Community-based misoprostol for the prevention of post-partum haemorrhage: A narrative review of the evidence base, challenges and scale-up

Achieving Sustainable Development Goal targets for 2030 will require persistent investment and creativity in improving access to quality health services, including skilled attendance at birth and access to emergency obstetric care. Community-based misoprostol has been extensively studied and recently endorsed by the WHO for the prevention of post-partum haemorrhage. There remains little consolidated information about experience with implementation and scale-up to date. This narrative review of the literature aimed to identify the political processes leading to WHO endorsement of misoprostol for the prevention of post-partum haemorrhage and describe ongoing challenges to the uptake and scale-up at both policy and community levels. We review the peer-reviewed and grey literature on expansion and scale-up and present the issues central to moving forward.

Perinatal mortality associated with use of uterotonics outside of Comprehensive Emergency Obstetric and Neonatal Care: a cross-sectional study

BACKGROUND

Prior studies have shown that using uterotonics to augment or induce labor before arrival at comprehensive Emergency Obstetric and Neonatal Care (CEmONC) settings (henceforth, "outside uterotonics") may contribute to perinatal mortality in low- and middle-income countries. We estimate its effect on perinatal mortality in rural Bangladesh.

METHODS

Using hospital records (23986 singleton term births, Jan 1, 2009-Dec 31, 2015) from rural Bangladesh, we use a logistic regression model to estimate the increased risk of perinatal death from uterotonics administered outside a CEmONC facility.

RESULTS

Among term births (≥37 weeks gestation), the risk of perinatal death adjusted for key confounders is significantly increased among women reporting uterotonic use outside of CEmONC (OR = 3 · 0, 95 % CI = 2 · 4,3 · 7). This increased risk is particularly high for fresh stillbirths (OR = 4 · 0, 95 % CI = 3 · 0,5 · 3) and intrapartum-related causes of early neonatal deaths (birth asphyxia) (OR = 3 · 1, 95 % CI = 2 · 2,4 · 5).

CONCLUSIONS

In this sample, outside uterotonic use was associated with substantially increased risk of fresh stillbirths, deaths due to birth asphyxia, and all perinatal deaths. In settings of high uterotonic use outside of controlled settings, substantial improvement in both stillbirth and early neonatal mortality may be made by reducing such use.

An exploration of village-level uterotonic practices in Fenerive-Est, Madagascar

Background

Pharmaceutical uterotonics are effective for preventing postpartum hemorrhage and complications related to unsafe abortion. In Madagascar, however, traditional birth attendants (Matrones) commonly administer medicinal teas for uterotonic purposes. Little is known about Matrone practices and how they might coincide with efforts to increase uterotonic coverage. The aims of this study were to: 1) identify indications for presumed uterotonic plant use by Matrones, 2) explore uterotonic practices at the village level, and 3) describe the response of health practitioners to village-level uterotonic practices.

Methods

Twelve in-depth interviews with health practitioners, Matrones and community agents were conducted in local dialect. All interviews were audio-recorded, transcribed, and translated into English for analysis using Atlas.ti. Medicinal plant specimens were also collected and analyzed for the presence of uterotonic peptides.

Results

While Matrones reported to offer specific teas for uterotonic purposes, health practitioners discussed providing emergency care for women with complications associated with use of specific teas. Complications included retained placenta, hypertonic uterus, hemorrhage and sepsis. Chemical analysis indicated the presence of cysteine-rich peptides in the Dantoroa/Denturus plant used in some Matrones’ teas.

Conclusions

The presence of uterotonic peptides in one plant used by Matrones may indicate that Matrones intend to administer uterotonics for safer childbirth. This finding, combined with practitioner reports of complications related to some medicinal teas, points to a need for availability of an evidence-based uterotonic at the village level, namely, misoprostol pills or oxytocin in the form of uniject.

Programmes for advance distribution of misoprostol to prevent post-partum haemorrhage: a rapid literature review of factors affecting implementation

Recent efforts to prevent post-partum haemorrhage (PPH) in low-income countries have focused on providing women with access to oral misoprostol during home birth. The WHO recommends using lay health workers (LHWs) to administer misoprostol in settings where skilled birth attendants are not available. This review synthesizes current knowledge about the barriers and facilitators affecting implementation of advance community distribution of misoprostol to prevent PPH, where misoprostol may be self-administered or administered by an LHW.We searched for and summarized available empirical evidence, and collected primary data from programme stakeholders about their experiences of programme implementation.We present key outcomes and features of advanced distribution programmes that are in operation or have been piloted globally. We categorized factors influencing implementation into those that operate at the health system level, factors related to the community and policy context and those factors more closely connected to the end user.Debates around advance distribution have centred on the potential risks and benefits of making misoprostol available to pregnant women and community members during pregnancy for administration in the home. However, the risks of advance distribution appear manageable and the benefits of self-administration, especially for women who have little chance of expert care for PPH, are considerable.

Uterotonic Use at Childbirth in Ghana: A Qualitative Study of Practices, Perceptions, and Knowledge Among Facility-Based Health Care Providers and Community Members

PURPOSE: Uterotonic drugs, administered immediately after delivery, can prevent postpartum hemorrhage (PPH). As programs expand uterotonic access in settings of high maternal mortality, it is important to understand why and how these drugs are currently used. This qualitative study aimed to describe Ghanaian health care providers’ and community members’ knowledge, perceptions, and practices of uterotonic usage at or near labor and delivery.

METHODS: In-depth interviews were conducted in 3 districts with 185 physicians, medical assistants, midwives, nurses, new mothers, mothers aged 50 years and older, traditional birth attendants, and chemists.

FINDINGS: Providers described using misoprostol most commonly for labor induction, oxytocin for labor augmentation and PPH prevention, and ergometrine for PPH treatment. Unsafe practices and knowledge gaps were identified regarding labor augmentation and uterotonic storage. Community members reported experience with uterotonics in facility deliveries. Community-based use of pharmaceutical uterotonics was rarely reported, except misoprostol for pregnancy termination; however, community members described use of herbal medicines for intended uterotonic effect. Across respondent categories, uterotonics were more commonly associated with accelerating delivery than PPH prevention.

CONCLUSION: Programs promoting facility childbirth and/or uterotonic coverage at home births should consider these underlying patterns of use and encourage safe practices through provider and community engagement.

The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands

Background

At present, there are no guidelines on prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. The first step towards implementing guidelines is the development of a set of quality indicators for prevention and management of postpartum haemorrhage for primary midwifery supervised (home) birth in the Netherlands.

Methods

A RAND modified Delphi procedure was applied. This method consists of five steps: (1) composing an expert panel (2) literature research and collection of possible quality indicators, (3) digital questionnaire, (4) consensus meeting and (5) critical evaluation. A multidisciplinary expert panel consisting of five midwives, seven obstetricians and an ambulance paramedic was assembled after applying pre-specified criteria concerning expertise in various domains relating to primary midwifery care, secondary obstetric care, emergency transportation, maternal morbidity or mortality audit, quality indicator development or clinical guidelines development and representatives of professional organisations.

Results

After literature review, 79 recommendations were selected for assessment by the expert panel. After a digital questionnaire to the expert panel seven indicators were added, resulting in 86 possible indicators. After excluding 41 indicators that panel members unanimously found invalid, 45 possible indicators were assessed at the consensus meeting. During critical evaluation 18 potential indicators were found to be overlapping and two were discarded due to lack of measurability.

Conclusions

A set of 25 quality indicators was considered valid for testing in practice.

Knowledge, attitudes, and practices related to uterotonic drugs during childbirth in Karnataka, India: a qualitative research study

BACKGROUND AND OBJECTIVES

India has the highest annual number of maternal deaths of any country. As obstetric hemorrhage is the leading cause of maternal death in India, numerous efforts are under way to promote access to skilled attendance at birth and emergency obstetric care. Current initiatives also seek to increase access to active management of the third stage of labor for postpartum hemorrhage prevention, particularly through administration of an uterotonic after delivery. However, prior research suggests widespread inappropriate use of uterotonics at facilities and in communities-for example, without adequate monitoring or referral support for complications. This qualitative study aimed to document health providers' and community members' current knowledge, attitudes, and practices regarding uterotonic use during labor and delivery in India's Karnataka state.

METHODS

140 in-depth interviews were conducted from June to August 2011 in Bagalkot and Hassan districts with physicians, nurses, recently delivered women, mothers-in-law, traditional birth attendants (dais), unlicensed village doctors, and chemists (pharmacists).

RESULTS

Many respondents reported use of uterotonics, particularly oxytocin, for labor augmentation in both facility-based and home-based deliveries. The study also identified contextual factors that promote inappropriate uterotonic use, including high value placed on pain during labor; perceived pressure to provide or receive uterotonics early in labor and delivery, perhaps leading to administration of uterotonics despite awareness of risks; and lack of consistent and correct knowledge regarding safe storage, dosing, and administration of oxytocin.

CONCLUSIONS

These findings have significant implications for public health programs in a context of widespread and potentially increasing availability of uterotonics. Among other responses, efforts are needed to improve communication between community members and providers regarding uterotonic use during labor and delivery and to target training and other interventions to address identified gaps in knowledge and ensure that providers and pharmacists have up-to-date information regarding proper usage of uterotonic drugs.

Injections during labor and intrapartum-related hypoxic injury and mortality in rural southern Nepal

OBJECTIVE

To estimate the association between unmonitored use of injections during labor and intrapartum-related neonatal mortality and morbidity among home births.

METHODS

Recently delivered women in Sarlahi, Nepal, reported whether they had received injections during labor. Data on breathing and crying status at birth, time to first breath, respiratory rate, sucking ability, and lethargy were gathered. Neonatal respiratory depression (NRD) and encephalopathy (NE) were compared by injection receipt status using multivariate regression models.

RESULTS

Injections during labor were frequently reported (7108 of 22352 [31.8%]) and were predominantly given by unqualified village "doctors." Multivariate analysis (excluding facility births and complicated deliveries) revealed associations with intrapartum-related NRD (relative risk [RR] 2.52; 95% CI, 2.29-2.78) and NE (RR 3.48; 95% CI, 2.46-4.93). The risks of neonatal death associated with intrapartum-related NRD (RR 3.78; 95% CI, 2.53-5.66) or NE (RR 4.47; 95% CI, 2.78-7.19) were also elevated.

CONCLUSION

Injection during labor was widespread at the community level. This practice was associated with poor outcomes and possibly related to the inappropriate use of uterotonics by unqualified providers. Interventions are required to increase the safety of childbirth in the community and in peripheral health facilities. Parent trial registered at clinicaltrials.gov (NCT00 109616).

Reduced postpartum hemorrhage after implementation of active management of the third stage of labor in rural Honduras

OBJECTIVE

To assess outcomes after auxiliary nurses were trained and given resources to use active management of the third stage of labor (AMTSL) for all women giving birth in a low-resource, low-risk, rural, public birth center setting in northern rural Honduras.

METHODS

Auxiliary nurses received training on estimation of blood loss before the preintervention phase of the study (July 2004 through April 2005) and AMTSL, including use of intramuscular oxytocin, and estimation of blood loss prior to the intervention phase (July 2007 through June 2008). Preintervention and intervention data on use of oxytocin, blood loss postpartum, hemorrhage rates, and management interventions were collected and compared.

RESULTS

After nurses received training on AMTSL using intramuscular oxytocin, the use of intramuscular oxytocin during the third stage of labor increased from 63.8% to 96.5%. Postpartum hemorrhage rates decreased from 14.8% to 5.9% (P=0.001). Use of intrapartum oxytocin, which can have adverse effects, also increased: from 6.1% to 22.7% (P<0.001).

CONCLUSION

Training auxiliary nurses to perform AMTSL using oxytocin in this birth center setting was effective in reducing the rate of postpartum hemorrhage; however, increased use of intrapartum oxytocin may be an unintended outcome of the increased accessibility of oxytocin.

The tibetan uterotonic zhi byed 11: mechanisms of action, efficacy, and historical use for postpartum hemorrhage

Objective. To explore evidence for the traditional Tibetan medicine, Zhi Byed 11 (ZB11), for use as a uterotonic. Methods. The eleven ingredients in ZB11 were chemically analyzed by mass spectroscopy. A review was conducted of Western allopathic literature for scientific studies on ZB11's individual components. Literature from Tibetan and other traditional paradigms were reviewed. Results. Potential mechanisms of action for ZB11 as a uterotonic include laxative effects, a dose-dependant increase in smooth muscle tissue peristalsis that may also affect the uterus smooth muscle, and chemical components that are prostaglandin precursors and/or increase prostaglandin synthesis. A recent RCT demonstrated comparable efficacy to misoprostol in reducing severe postpartum hemorrhage (PPH) (>1000 mL) and greater effect than placebo. Historical and anecdotal evidence for ZB11 and its ingredients for childbirth provide further support. Discussion. ZB11 and its ingredients are candidates for potentially effective uterotonics, especially in low-resource settings. Further research is warranted to understand the mechanisms of action and synergy between ingredients.

Expanding Postpartum Hemorrhage Prevention to the Community in Resource-Poor Contexts: Critical Considerations and Next Steps

Increasing the proportion of pregnant women with medically skilled care at childbirth is widely regarded as the best strategy for reducing maternal mortality and morbidity in resource-poor contexts. For many countries, however, local conditions necessitate continuing discussion concerning the role of targeted, community-based interventions in efforts to tackle this problem. One such intervention gaining momentum is community-based use of uterotonic drugs to prevent postpartum hemorrhage (PPH). But how this intervention fits within the larger maternal health agenda still needs addressing, as do questions regarding whether, where, and how to proceed. This article presents a usable framework for context-based decision making around PPH prevention, evaluating why and under what circumstances it might make sense to implement uterotonic drugs at the community level. Using Demographic and Health Surveys (DHS) data along with current evidence, we identify four critical considerations for policymakers to take into account: (a) where births are happening, (b) which women are delivering in what settings, (c) capacity of health care systems, and (d) criteria for selecting specific uterotonic drugs. Incorporating these considerations, we propose a checklist to aid policymakers in determining what strategy realistically suits the needs of their particular country contexts. Although a large and rigorous body of evidence supports PPH prevention methods, research gaps remain. Even with sufficient evidence, however, a global consensus may not be reached because of the ongoing debates over community- versus facility-based interventions. Despite these issues, it is still possible to arrive at policy decisions on community-based use of uterotonic drugs by taking a careful, context-based approach. In many settings, implementation of this intervention can be pursued in conjunction with improvements to facility-based care. As a complement to skilled attendance, expanding PPH prevention to the community can be part of a national push to target the reduction of PPH as an achievable goal.