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Morfaw F, Miregwa B, Bi A, Mbuagbaw L, Anderson LN, Thabane L. Comparing and combining evidence of treatment effects in randomized and nonrandomized studies on the use of misoprostol to prevent postpartum hemorrhage. J Evid Based Med 2021; 14:198-207. [PMID: 34388312 DOI: 10.1111/jebm.12440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) is a preventable condition and the main cause of maternal death worldwide. Evidence on the effectiveness of misoprostol in the prevention of PPH has been generated from both randomized controlled trials (RCTs) and nonrandomized studies (NRS). This study aimed to compare the results of RCTs and NRS, and to compare Classical and Bayesian approaches of combining the results of RCTs and NRS on the use of misoprostol versus placebo in the prevention of PPH. METHODS We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for appropriate studies. We pooled estimates of effects from RCTs and NRS seperately, using random-effects models, then merged them using classical and Bayesian random effects meta-analysis. RESULTS A total of 34 studies (20 RCTs and 14 NRS) involving 74 204 participants were identified. The summary odds ratio (OR) from RCTs for the use of misoprostol in the prevention of PPH was 0.69 (95% confidence interval [CI]: 0.59 to 0.80). The summary OR from NRS was 0.46 (95% CI: 0.36 to 0.63). Classical and Bayesian approaches of combining the two study designs both showed benefit of misoprostol in preventing PPH, with similar effects. CONCLUSIONS Both RCTs and NRS show comparable significant benefit for the use of misoprostol in the prevention of PPH.
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Affiliation(s)
- Frederick Morfaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicines and Biomedical Sciences, Department of Obstetrics and Gynaecology, University of Yaoundé, Cameroon
- Faculty of Health Sciences, University of Bamenda, Cameroon
| | - Bernard Miregwa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ayaba Bi
- Regional Hospital Bamenda, Cameroon
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St Joseph Healthcare-Hamilton, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Laura N Anderson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St Joseph Healthcare-Hamilton, Hamilton, Ontario, Canada
- Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, Ontario, Canada
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Mary M, Jafarey S, Dabash R, Kamal I, Rabbani A, Abbas D, Durocher J, Tan YL, Winikoff B. The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan. Matern Child Health J 2020; 25:118-126. [PMID: 33242210 PMCID: PMC7822773 DOI: 10.1007/s10995-020-03047-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/03/2022]
Abstract
Objective To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births. Methods A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes. Results Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries. Conclusions The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.
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Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Sadiqua Jafarey
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Rasha Dabash
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Imtiaz Kamal
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Arjumand Rabbani
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Dina Abbas
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Jill Durocher
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Yi-Ling Tan
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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3
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Oladapo OT, Blum J, Abalos E, Okusanya BO. Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd009336.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research; World Health Organization; Geneva Switzerland
| | | | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP); Rosario Argentina
| | - Babasola O Okusanya
- Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology; Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba; Lagos Nigeria
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4
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Tiruneh GT, Yakob B, Ayele WM, Yigzaw M, Roro MA, Medhanyi AA, Hailu EG, Bayou YT. Effect of community-based distribution of misoprostol on facility delivery: a scoping review. BMC Pregnancy Childbirth 2019; 19:404. [PMID: 31694580 PMCID: PMC6836344 DOI: 10.1186/s12884-019-2539-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Community distribution of misoprostol to pregnant women in advance of labor is one of the compelling strategies for preventing postpartum hemorrhage. Concerns have been reported that misoprostol distribution could reduce facility delivery or lead to misuse of the medication. This scoping review was conducted to synthesize the evidence on the effect of community-based misoprostol distribution on rates of facility delivery, and to assess the frequency of mothers taking distributed misoprostol before delivery, and any harmful outcomes of such misuse. METHODS We included peer-reviewed articles on misoprostol implementation from PubMed, Cochrane Review Library, Popline, and Google Scholars. Narrative synthesis was used to analyze and interpret the findings, in which quantitative and qualitative syntheses are integrated. RESULTS Three qualitative studies, seven observational studies, and four experimental or quasi-experimental studies were included in this study. All before-after household surveys reported increased delivery coverage after the intervention: ranging from 4 to 46 percentage points at the end of the intervention when compared to the baseline. The pooled analysis of experimental and quasi-experimental studies involving 7564 women from four studies revealed that there was no significant difference in rates of facility delivery among the misoprostol and control groups [OR 1.011; 95% CI: 0.906-1.129]. A qualitative study among health professionals also indicated that community distribution of misoprostol for the prevention of postpartum hemorrhage is acceptable to community members and stakeholders and it is a feasible interim solution until access to facility birth increases. In the community-based distribution of misoprostol programs, self-administration of misoprostol by pregnant women before delivery was reported in less than 2% of women, among seven studies involving 11,108 mothers. Evidence also shows that most women who used misoprostol pills, used them as instructed. No adverse outcomes from misuse in either of the studies reviewed. CONCLUSIONS The claim that community-based distribution of misoprostol would divert women who would have otherwise had institutional deliveries to have home deliveries and promote misuse of the medication are not supported with evidence. Therefore, community-based distribution of misoprostol can be an appropriate strategy for reducing maternal deaths which occur due to postpartum hemorrhages, especially in resource-limited settings.
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Affiliation(s)
- Gizachew Tadele Tiruneh
- JSI Research & Training Institute, Inc./ The Last Ten Kilometers (L10K) Project, Addis Ababa, Ethiopia. .,Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.
| | - Bereket Yakob
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Department of Global Health and Population /Fenot Project, Harvard T.H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Wubegzier Mekonnen Ayele
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Muluneh Yigzaw
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Jhpiego/HRH Project, Addis Ababa, Ethiopia
| | - Meselech Assegid Roro
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Araya Abrha Medhanyi
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Etenesh Gebreyohannes Hailu
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Yibeltal Tebekaw Bayou
- JSI Research & Training Institute, Inc./ The Last Ten Kilometers (L10K) Project, Addis Ababa, Ethiopia.,Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia
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Mary M, Diop A, Sheldon WR, Yenikoye A, Winikoff B. Scaling up interventions: findings and lessons learned from an external evaluation of Niger's National Initiative to reduce postpartum hemorrhage. BMC Pregnancy Childbirth 2019; 19:379. [PMID: 31651264 PMCID: PMC6814039 DOI: 10.1186/s12884-019-2502-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Niger has one of the highest maternal mortality ratios in Sub Saharan Africa, of which postpartum hemorrhage is the leading cause. In 2014, Health and Development International and the Ministry of Health of Niger launched an initiative to introduce and scale-up three PPH interventions in health facilities nationwide: misoprostol, uterine balloon tamponade, and the non-pneumatic anti-shock garment. Methods A two-phase mixed-methods evaluation was conducted to assess implementation of the initiative. Health facility assessments, provider interviews, and household surveys were conducted in May 2016 and November 2017. Results All evaluation facilities received misoprostol prevention doses. However, shortages in misoprostol treatment doses, UBT kits, and NASG stock were documented. Health provider training increased while knowledge of each PPH intervention varied. Near-universal uterotonic coverage for PPH prevention and treatment was achieved and sustained throughout the evaluation period. Use of UBT and NASG to manage PPH was rare and differed by health facility type. Among community deliveries, fewer than 22% of women received misoprostol at antenatal care for self-administered prophylaxis. Among those who did, almost all reported taking the drugs for PPH prevention in each phase. Conclusions This study is the first external evaluation of a comprehensive PPH program taking misoprostol, UBT, and NASG to national scale in a low resource setting. Although gaps in service delivery were identified, results demonstrate the complexities of training, managing stock, and implementing system-wide interventions to reach women in varying contexts. The experience provides important lessons for other countries as they develop and expand evidence-based programs for PPH care.
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Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Ayisha Diop
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Wendy R Sheldon
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Aichatou Yenikoye
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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Finlayson K, Downe S, Vogel JP, Oladapo OT. What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: A qualitative systematic review. PLoS One 2019; 14:e0215919. [PMID: 31067245 PMCID: PMC6505942 DOI: 10.1371/journal.pone.0215919] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/10/2019] [Indexed: 12/02/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH. Methods We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed. Results Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues. Conclusions Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the context of sufficient resources and effective implementation by competent, suitably trained providers.
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Affiliation(s)
- Kenneth Finlayson
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
- * E-mail:
| | - Soo Downe
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
| | - Joshua P. Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Olufemi T. Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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7
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Parashar R, Gupt A, Bajpayee D, Gupta A, Thakur R, Sangwan A, Sharma A, Sharma D, Gupta S, Baswal D, Taneja G, Gera R. Implementation of community based advance distribution of misoprostol in Himachal Pradesh (India): lessons and way forward. BMC Pregnancy Childbirth 2018; 18:428. [PMID: 30373537 PMCID: PMC6206722 DOI: 10.1186/s12884-018-2036-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Postpartum Hemorrhage remains the leading cause of maternal mortality. To prevent PPH, Misoprostol tablet in a dose of 600 micrograms is recommended for use immediately after childbirth in home deliveries wherein the use of oxytocin is difficult. The current article describes an implementation of "community based advance distribution of Misoprostol program" in India which aimed to design an operational framework for implementing this program. METHODS The intervention was carried out in Janjheli block in Mandi district of the state of Himachal Pradesh which is a mountainous terrain with limited geographical access and reported 90% home deliveries in the year 2014-15. An operational framework to implement program activities was designed which was based on WHO HSS building blocks. Key implementing steps included- Ensuring local ownership through program leadership, forecasting and procurement of 600 mcg misoprostol tablets, training, branding and communication, community engagement and counselling, recording and reporting, monitoring, supportive supervision and feedback mechanisms. RESULTS Over the one year of implementation, 512 home deliveries were reported, out of which 89% received the tablets and 84% consumed the tablet within one minute of delivery. No incidence of PPH in tablet consuming mothers was reported. On account of periodic counselling and effective community engagement the intervention also contributed to better tracking of pregnancies till delivery and institutional delivery rates which increased to 93% from 45% and 57% from 11% respectively as compared to the preceding year. CONCLUSIONS The model has successfully shown the use of single misoprostol tablets of 600 mcg, first time in this program. We also demonstrated a HSS based operational framework, based on which the program is being scaled to additional blocks in Himachal Pradesh as well as to other states of India.
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Affiliation(s)
| | - Anadi Gupt
- Maternal Health, Department of Health and Family Welfare, Government of Himachal Pradesh, Shimla, India
| | - Devina Bajpayee
- Maternal and Newborn Health, USAID-VRIDDHI/IPE Global, New Delhi, India
| | - Anil Gupta
- USAID-VRIDDHI/IPE Global, Shimla, Himachal Pradesh India
| | - Rohan Thakur
- USAID-VRIDDHI/IPE Global, Mandi, Himachal Pradesh India
| | - Ankur Sangwan
- USAID-VRIDDHI/IPE Global, Kinnaur, Himachal Pradesh India
| | - Anuradha Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Deshraj Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Sachin Gupta
- Maternal and Child Health, USAID-India, New Delhi, India
| | - Dinesh Baswal
- Maternal Health, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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Raams TM, Browne JL, Festen-Schrier VJMM, Klipstein-Grobusch K, Rijken MJ. Task shifting in active management of the third stage of labor: a systematic review. BMC Pregnancy Childbirth 2018; 18:47. [PMID: 29409456 PMCID: PMC5801808 DOI: 10.1186/s12884-018-1677-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/29/2018] [Indexed: 11/30/2022] Open
Abstract
Background Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants. Methods A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool. Results Of 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n = 15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n = 6083) and 63 to 100% (9 studies, n = 8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n = 6445); 80 to 99.4% (5 studies, n = 2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n = 6090). Conclusion Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users. In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended. Electronic supplementary material The online version of this article (10.1186/s12884-018-1677-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tessa M Raams
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands
| | - Verena J M M Festen-Schrier
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.,Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.,Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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9
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Ditai J, Frye LJ, Durocher J, Byrne ME, Ononge S, Winikoff B, Weeks AD. Achieving community-based postpartum follow up in eastern Uganda: the field experience from the MamaMiso Study on antenatal distribution of misoprostol. BMC Res Notes 2017; 10:516. [PMID: 29073923 PMCID: PMC5658951 DOI: 10.1186/s13104-017-2849-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 10/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance provision of misoprostol to women during antenatal care aims to achieve broader access to uterotonics for the prevention of postpartum hemorrhage. Studies of this community-based approach usually involve antenatal education as well as timely postpartum follow-up visits to confirm maternal and neonatal outcomes. The MamaMiso study in Mbale, Uganda sought to assess the feasibility of conducting follow-up visits in the postpartum period following advance provision of misoprostol for postpartum hemorrhage prevention. MamaMiso recruited women during antenatal care visits. Participants were asked to contact the research team within 48 h of giving birth so that postpartum follow-up visits could be carried out at their homes. Women's baseline and delivery characteristics were collected and analyzed with respect to follow-up time ('on time' ≤ 7 days, 'late' > 7 days, and 'lost to follow up'). Every woman who was followed up late due to a failure to report the delivery was asked for the underlying reasons for the delay. When attempts at following up participants were unsuccessful, a file note was generated explaining the details of the failure. We abstracted data and identified themes from these notes. RESULTS Of 748 recruited women, 700 (94%) were successfully followed up during the study period, 465 (62%) within the first week postpartum. The median time to follow up was 4 days and was similar for women who delivered at home or in facilities and for women who had attended or unattended births. Women recruited at the urban hospital site (as opposed to rural health clinics) were more likely to be lost to follow up or followed up late. Of the women followed up late, 202 provided a reason. File notes explaining failed attempts at follow up were generated for 164 participants. Several themes emerged from qualitative analysis of these notes including phone difficulties, inaccurate baseline information, misperceptions, postpartum travel, and the condition of the mother and neonate. CONCLUSIONS Keeping women connected to the health system in the postpartum period is feasible, though reaching them within the first week of their delivery is challenging. Understanding characteristics of women who are harder to reach can help tailor follow-up efforts and elucidate possible biases in postpartum study data. Trial Registration Number ISRCTN70408620 December 28, 2011.
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Affiliation(s)
- James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, P.O Box 2190, Mbale, Uganda.,Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's' Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - Laura J Frye
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Meagan E Byrne
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's' Hospital, Crown Street, Liverpool, L8 7SS, UK
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Rajbhandari SP, Aryal K, Sheldon WR, Ban B, Upreti SR, Regmi K, Aryal S, Winikoff B. Postpartum hemorrhage prevention in Nepal: a program assessment. BMC Pregnancy Childbirth 2017; 17:169. [PMID: 28583092 PMCID: PMC5460329 DOI: 10.1186/s12884-017-1347-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 05/25/2017] [Indexed: 12/04/2022] Open
Abstract
Background In 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program. Methods Data collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities. Results Among recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment. Conclusions In Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed.
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Affiliation(s)
| | | | - Wendy R Sheldon
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | | | - Senendra Raj Upreti
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Kiran Regmi
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Shilu Aryal
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
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11
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Hobday K, Hulme J, Belton S, Homer CS, Prata N. Community-based misoprostol for the prevention of post-partum haemorrhage: A narrative review of the evidence base, challenges and scale-up. Glob Public Health 2017; 13:1081-1097. [PMID: 28357885 DOI: 10.1080/17441692.2017.1303743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Karen Hobday
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Jennifer Hulme
- b Department of Emergency Medicine , University Health Network, University of Toronto , Toronto , Canada.,c Department of Family and Community Medicine , University of Toronto , Toronto , Canada
| | - Suzanne Belton
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Caroline Se Homer
- d Centre for Midwifery, Child and Family Health, Faculty of Health , University of Technology Sydney , Ultimo , NSW , Australia
| | - Ndola Prata
- e Bixby Center for Population Health and Sustainability, School of Public Health , University of California , Berkeley , CA , USA
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12
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Carnahan LR, Geller SE, Leshabari S, Sangu W, Hanselman B, Patil CL. Healthcare providers' knowledge and practices associated with postpartum hemorrhage during facility delivery in Dar es Salaam, Tanzania. Int J Gynaecol Obstet 2016; 135:268-271. [PMID: 27569024 DOI: 10.1016/j.ijgo.2016.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/24/2016] [Accepted: 08/04/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate healthcare providers' knowledge and practices associated with prevention and management of postpartum hemorrhage (PPH) to improve care in urban settings and reduce maternal morbidity and mortality. METHODS As part of a cross-sectional, survey-based study, providers from 14 government health facilities providing maternal delivery services in the Ilala Municipality, Dar es Salaam, Tanzania, were surveyed about PPH-related practices and knowledge in April 2015. The data were analyzed descriptively, and χ2 tests of independence were used to examine relationships between experience, facility type, and knowledge. RESULTS Among 115 respondents, 7 (6.1%) answered all PPH knowledge questions correctly. The mean knowledge score was 63.9%±21.1%. Non-calibrated methods for estimating postpartum blood loss were common; only 62 (53.9%) respondents reported direct collection. Referral of patients for PPH-related transfer was reported by 49 (42.6%) respondents; transportation and finances were barriers to transfer. Respondents requested continued training and additional supplies to address emergencies. CONCLUSION Healthcare providers had suboptimal knowledge of PPH risk factors, diagnosis, and causes. Strategies that provide ongoing education and equip lower-level facilities with adequate supplies might minimize PPH-related transfers. Providing prenatal women with basic delivery items (e.g. a blood collection device) and misoprostol is a viable option to ensure that essential PPH-prevention tools are available at delivery.
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Affiliation(s)
- Leslie R Carnahan
- Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, IL, USA.
| | - Stacie E Geller
- Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, IL, USA
| | - Sebalda Leshabari
- School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Willy Sangu
- Amana Hospital, Ilala Municipality, Dar es Salaam, Tanzania
| | - Bailey Hanselman
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Crystal L Patil
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
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13
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Cannon M, Charyeva Z, Oguntunde O, Sambisa W, Shoretire K, Orobaton N. A case study of community-based distribution and use of Misoprostol and Chlorhexidine in Sokoto State, Nigeria. Glob Public Health 2016; 12:1553-1567. [DOI: 10.1080/17441692.2016.1172102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | - William Sambisa
- GlenBill Evaluation and Research LLC, Fairfax, Virginia, USA
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14
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Wells E, Coeytaux F, Azasi E, Danmusa S, Geressu T, McNally T, Potts J, Otive-Igbuzor E, Tibebu S. Evaluation of different models of access to misoprostol at the community level to improve maternal health outcomes in Ethiopia, Ghana, and Nigeria. Int J Gynaecol Obstet 2016; 133:261-5. [PMID: 27158098 DOI: 10.1016/j.ijgo.2016.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | | | - Esther Azasi
- Millennium Promise's One Million Community Health Workers (1mCHW) Campaign, Ghana
| | | | | | | | - Jennifer Potts
- Innovations in HealthCare, Duke University, Durham, NC, USA
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15
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Aradeon SB, Doctor HV. Reducing rural maternal mortality and the equity gap in northern Nigeria: the public health evidence for the Community Communication Emergency Referral strategy. Int J Womens Health 2016; 8:77-92. [PMID: 27088844 PMCID: PMC4803262 DOI: 10.2147/ijwh.s94823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The Sustainable Development Goal (SDG) maternal mortality target risks being underachieved like its Millennium Development Goal (MDG) predecessor. The MDG skilled birth attendant (SBA) strategy proved inadequate to end preventable maternal deaths for the millions of rural women living in resource-constrained settings. This equity gap has been successfully addressed by integrating a community-based emergency obstetric care strategy into the intrapartum care SBA delivery strategy in a large scale, northern Nigerian health systems strengthening project. The Community Communication Emergency Referral (CCER) strategy catalyzes community capacity for timely evacuations to emergency obstetric care facilities instead of promoting SBA deliveries in environments where SBA availability and accessibility will remain inadequate for the near and medium term. Community Communication is an innovative, efficient, equitable, and culturally appropriate community mobilization approach that empowers low- and nonliterate community members to become the communicators. For the CCER strategy, this community mobilization approach was used to establish and maintain emergency maternal care support structures. Public health evidence demonstrates the success of integrating the CCER strategy into the SBA strategy and the practicability of this combined strategy at scale. In intervention sites, the maternal mortality ratio reduced by 16.8% from extremely high levels within 4 years. Significantly, the CCER strategy contributed to saving one-third of the lives saved in the project sites, thereby maximizing the effectiveness of the SBAs and upgraded emergency obstetric care facilities. Pre- and postimplementation Knowledge, Attitude, and Practice Survey results and qualitative assessments support the CCER theory of change. This theory of change rests on a set of implementation steps that rely on three innovative components: Community Communication, Rapid Imitation Practice, and CCER support structures. Innovative communication body tools and the rote learning Rapid Imitation Practice training methodology enabled low-literate volunteers to saturate their communities with informed group discussions transferring communication capacity and ownership to the discussion participants. CCER is especially efficient because virtually every timely, community referral for emergency maternal care results in a saved life, whereas on average, only one in every eight births delivered by an SBA (12%) is expected to be a delivery-associated complication requiring lifesaving care.
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Affiliation(s)
- Susan B Aradeon
- Freelance International Consultant (Social and Behavioral Change Communication), Aventura, FL, USA
| | - Henry V Doctor
- Department of Information, Evidence and Research, Regional Office for the Eastern Mediterranean, World Health Organization, Nasr City, Cairo, Egypt
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16
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Vallely LM, Homiehombo P, Walep E, Moses M, Tom M, Kelly-Hanku A, Vallely A, Nataraye E, Ninnes C, Mola GD, Morgan C, Kaldor JM, Wand H, Whittaker A, Homer CSE. Feasibility and acceptability of clean birth kits containing misoprostol for self-administration to prevent postpartum hemorrhage in rural Papua New Guinea. Int J Gynaecol Obstet 2016; 133:301-6. [PMID: 26971258 DOI: 10.1016/j.ijgo.2015.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/09/2015] [Accepted: 02/12/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the feasibility and acceptability of providing clean birth kits (CBKs) containing misoprostol for self-administration in a rural setting in Papua New Guinea. METHODS A prospective intervention study was conducted between April 8, 2013, and October 24, 2014. Eligible participants were women in the third trimester of pregnancy who attended a prenatal clinic in Unggai Bena. Participants received individual instruction and were then given a CBK containing 600μg misoprostol tablets for self-administration following an unsupervised birth if they could demonstrate their understanding of correct use of items in the CBK. Data regarding the use and acceptability of the CBK and misoprostol were collected during postpartum follow-up. RESULTS Among 200 participants, 106 (53.0%) had an unsupervised birth, and 99 (93.4%) of these women used the CBK. All would use the CBK again and would recommend it to others. Among these 99 women, misoprostol was self-administered by 98 (99.0%), all of whom would take the drug again and would recommend it to others. CONCLUSION The findings strengthen the case for community-based use of misoprostol to prevent postpartum hemorrhage in remote communities. Large-scale interventions should be planned to further evaluate impact and acceptability.
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Affiliation(s)
- Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Primrose Homiehombo
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Elizabeth Walep
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Michael Moses
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Marynne Tom
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Angela Kelly-Hanku
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Eluo Nataraye
- Eastern Highlands Provincial Health Authority, Goroka, Papua New Guinea
| | | | - Glen D Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Chris Morgan
- Centre of International Health, Burnet Institute, Melbourne, VIC, Australia; School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - John M Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Andrea Whittaker
- School of Social Sciences, Faculty of Arts, Monash University, Melbourne, VIC, Australia
| | - Caroline S E Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology, Sydney, NSW, Australia
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Browne JL, Damale NKR, Raams TM, Van der Linden EL, Maya ET, Doe R, Rijken MJ, Adanu R, Grobbee DE, Franx A, Klipstein-Grobusch K. Uterine Tonus Assessment by Midwives versus Patient self-assessment in the active management of the third stage of labor (UTAMP): study protocol for a randomized controlled trial. Trials 2015; 16:580. [PMID: 26683621 PMCID: PMC4684626 DOI: 10.1186/s13063-015-1111-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries. PPH can be prevented by active management of the third stage of labor (AMTSL), a series of steps recommended by the World Health Organization to be performed by skilled birth attendants (SBAs). Task shifting in the AMTSL step of uterotonic drugs administration to community health workers, traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages. The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self-assessment. METHODS AND DESIGN The study is an individual-level two-arm non-inferiority randomized controlled trial (RCT). A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra, Ghana. Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self-assessment of uterine tonus will be eligible for inclusion. Women with an increased risk for PPH will be excluded. Women will be randomized to uterine tone assessment by a skilled birth attendant (midwife) or uterine tone self-assessment (with the safety back-up of a midwife present in case of PPH or uterine atony). Postpartum blood loss will be measured through weighing of disposable mats. The main study endpoints are PPH (≥500 ml blood loss), severe PPH (≥1000 ml blood loss), mean blood loss, and routine maternal and neonatal outcomes. Participants and caregivers will not be blinded given the nature of the intervention. DISCUSSION A reduction of PPH-related maternal mortality requires full implementation of AMTSL. Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in (clinical) settings where SBAs capacity is constrained. TRIAL REGISTRATION Clinicaltrials.gov: NCT02223806 , registration August 2014. PACTR PACTR201402000736158 , registration July 2014. University of Ghana, Medical School Ethical and Protocol Review Committee: MS-Et/M.8-P4.1/2014-2015.
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Affiliation(s)
- Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - Nelson K R Damale
- School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana. .,Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana.
| | - Tessa M Raams
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - Eva L Van der Linden
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - Ernest T Maya
- School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana. .,School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana.
| | - Roseline Doe
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana. .,WHO Country Office Ghana, World Health Organization, Accra, Ghana.
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands. .,Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Richard Adanu
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana.
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - Arie Franx
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands. .,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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18
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Ononge S, Campbell OMR, Kaharuza F, Lewis JJ, Fielding K, Mirembe F. Effectiveness and safety of misoprostol distributed to antenatal women to prevent postpartum haemorrhage after child-births: a stepped-wedge cluster-randomized trial. BMC Pregnancy Childbirth 2015; 15:315. [PMID: 26610333 PMCID: PMC4662032 DOI: 10.1186/s12884-015-0750-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 11/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral misoprostol, administered by trained health-workers is effective and safe for preventing postpartum haemorrhage (PPH). There is interest in expanding administration of misoprostol by non-health workers, including task-shifting to pregnant women themselves. However, the use of misoprostol for preventing PPH in home-births remains controversial, due to the limited evidence to support self-administration or leaving it in the hands of non-health workers. This study aimed to determine if antenatally distributing misoprostol to pregnant women to self-administer at home birth reduces PPH. METHODS Between February 2013 and March 2014, we conducted a stepped-wedge cluster-randomized trial in six health facilities in Central Uganda. Women at 28+ weeks of gestation attending antenatal care were eligible. Women in the control-arm received the standard-of-care; while the intervention-arm were offered 600 mcg of misoprostol to swallow immediately after birth of baby, when oxytocin was not available. The primary outcome (PPH) was a drop in postpartum maternal haemoglobin (Hb) by ≥ 2 g/dl, lower than the prenatal Hb. Analysis was by intention-to-treat at the cluster level and we used a paired t-tests to assess whether the mean difference between the control and intervention groups was statistically significant. RESULTS 97% (2466/2545) of eligible women consented to participate; 1430 and 1036 in the control and intervention arms respectively. Two thousand fifty-seven of the participants were successfully followed up and 271 (13.2%) delivered outside a health facility. There was no significant difference between the study group in number of women who received a uterotonic at birth (control 80.4% vs intervention 91.4%, mean difference = -11.0%, 95% confidence interval [CI] -25.7% to 3.6%, p = 0.11). No woman took misoprostol before their baby's birth. Shivering and fever were 14.9% in the control arm compared to 22.2% in the intervention arm (mean difference = -7.2%, 95% CI -11.1% to -3.7%), p = 0.005). There was a slight, but non-significant, reduction in the percentage of women with Hb drop ≥ 2g/dl from 18.5% in the control arm to 11.4% in the intervention arm (mean difference = 7.1%, 95% CI -3.1% to 17.3%, p = 0.14). Similarly, there was no significant difference between the groups in the primary outcome in the women who delivered at home (control 9.6% vs intervention 14.5%, mean difference -4.9; 95% CI -12.7 to 2.9), p = 0.17). CONCLUSION This study was unable to detect a significant reduction in PPH following the antenatal distribution of misoprostol. The study was registered with Pan-African Clinical Trials Network ( PACTR201303000459148, on 19/11/2012).
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Affiliation(s)
- Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda.
| | - Oona M R Campbell
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Frank Kaharuza
- School of Public Health, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda
| | - James J Lewis
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Katherine Fielding
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Florence Mirembe
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda
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Lubinga SJ, Atukunda EC, Wasswa-Ssalongo G, Babigumira JB. Potential Cost-Effectiveness of Prenatal Distribution of Misoprostol for Prevention of Postpartum Hemorrhage in Uganda. PLoS One 2015; 10:e0142550. [PMID: 26560140 PMCID: PMC4641649 DOI: 10.1371/journal.pone.0142550] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 10/25/2015] [Indexed: 11/23/2022] Open
Abstract
Background In settings where home birth rates are high, prenatal distribution of misoprostol has been advocated as a strategy to increase access to uterotonics during the third stage of labor to prevent postpartum hemorrhage (PPH). Our objective was to project the potential cost-effectiveness of this strategy in Uganda from both governmental (the relevant payer) and modified societal perspectives. Methods and Findings To compare prenatal misoprostol distribution to status quo (no misoprostol distribution), we developed a decision analytic model that tracked the delivery pathways of a cohort of pregnant women from the prenatal period, labor to delivery without complications or delivery with PPH, and successful treatment or death. Delivery pathway parameters were derived from the Uganda Demographic and Health Survey. Incidence of PPH, treatment efficacy, adverse event and case fatality rates, access to misoprostol, and health resource use and cost data were obtained from published literature and supplemented with expert opinion where necessary. We computed the expected incidence of PPH, mortality, disability adjusted life years (DALYs), costs and incremental cost effectiveness ratios (ICERs). We conducted univariate and probabilistic sensitivity analyses to examine robustness of our results. In the base-case analysis, misoprostol distribution lowered the expected incidence of PPH by 1.0% (95% credibility interval (CrI): 0.55%, 1.95%), mortality by 0.08% (95% CrI: 0.04%, 0.13%) and DALYs by 0.02 (95% CrI: 0.01, 0.03). Mean costs were higher with prenatal misoprostol distribution from governmental by US$3.3 (95% CrI: 2.1, 4.2) and modified societal (by US$1.3; 95% CrI: -1.6, 2.8) perspectives. ICERs were US$191 (95% CrI: 82, 443) per DALY averted from a governmental perspective, and US$73 (95% CI: -86, 256) per DALY averted from a modified societal perspective. Conclusions Prenatal distribution of misoprostol is potentially cost-effective in Uganda and should be considered for national-level scale up for prevention of PPH.
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Affiliation(s)
- Solomon J. Lubinga
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Esther C. Atukunda
- Department of Pharmacology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - George Wasswa-Ssalongo
- Department of Obstetrics and Gynecology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Joseph B. Babigumira
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, Washington, United States of America
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Weeks AD, Ditai J, Ononge S, Faragher B, Frye LJ, Durocher J, Mirembe FM, Byamugisha J, Winikoff B, Alfirevic Z. The MamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community-based, placebo-controlled randomised trial. BMC Pregnancy Childbirth 2015; 15:219. [PMID: 26370443 PMCID: PMC4570250 DOI: 10.1186/s12884-015-0650-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 11/16/2022] Open
Abstract
Background 600 mcg of oral misoprostol reduces the incidence of postpartum haemorrhage (PPH), but in previous research this medication has been administered by health workers. It is unclear whether it is also safe and effective when self-administered by women. Methods This placebo-controlled, double-blind randomised trial enrolled consenting women of at least 34 weeks gestation, recruited over a 2-month period in Mbale District, Eastern Uganda. Participants had their haemoglobin measured antenatally and were given either 600mcg misoprostol or placebo to take home and use immediately after birth in the event of delivery at home. The primary clinical outcome was the incidence of fall in haemoglobin of over 20 % in home births followed-up within 5 days. Results 748 women were randomised to either misoprostol (374) or placebo (374). Of those enrolled, 57 % delivered at a health facility and 43 % delivered at home. 82 % of all medicine packs were retrieved at postnatal follow-up and 97 % of women delivering at home reported self-administration of the medicine. Two women in the misoprostol group took the study medication antenatally without adverse effects. There was no significant difference between the study groups in the drop of maternal haemoglobin by >20 % (misoprostol 9.4 % vs placebo 7.5 %, risk ratio 1.11, 95 % confidence interval 0.717 to 1.719). There was significantly more fever and shivering in the misoprostol group, but women found the medication highly acceptable. Conclusions This study has shown that antenatally distributed, self-administered misoprostol can be appropriately taken by study participants. The rarity of the primary outcome means that a very large sample size would be required to demonstrate clinical effectiveness. Trial registration This study was registered with the ISRCTN Register (ISRCTN70408620).
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Affiliation(s)
- Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital; and Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Brian Faragher
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Laura J Frye
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Florence M Mirembe
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
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Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG 2014; 122:202-10. [PMID: 25289730 DOI: 10.1111/1471-0528.13098] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 11/26/2022]
Abstract
Postpartum haemorrhage (PPH) remains a major cause of maternal deaths worldwide, and is estimated to cause the death of a woman every 10 minutes. This review presents the latest clinical advice, including new evidence on controlled cord traction, misoprostol, and oxytocin. The controversy around the diagnosis of PPH, the limitations of universal prophylaxis, and novel ways to provide obstetric first aid are also presented. It ends with a call to develop high-quality front-line obstetric services that can deal rapidly with unexpected haemorrhages as well as minimising blood loss at critical times: major abruption, placenta praevia, and caesarean for prolonged labour.
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Affiliation(s)
- A Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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22
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Smith JM, Baawo SD, Subah M, Sirtor-Gbassie V, Howe CJ, Ishola G, Tehoungue BZ, Dwivedi V. Advance distribution of misoprostol for prevention of postpartum hemorrhage (PPH) at home births in two districts of Liberia. BMC Pregnancy Childbirth 2014; 14:189. [PMID: 24894566 PMCID: PMC4055371 DOI: 10.1186/1471-2393-14-189] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background A postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia. Advance distribution of misoprostol was offered during antenatal care (ANC) and home visits. Feasibility, acceptability, effectiveness of distribution mechanisms and uterotonic coverage were evaluated. Methods Eight facilities were strengthened to provide PPH prevention with oxytocin, PPH management and advance distribution of misoprostol during ANC. Trained traditional midwives (TTMs) as volunteer community health workers (CHWs) provided education to pregnant women, and district reproductive health supervisors (DRHSs) distributed misoprostol during home visits. Data were collected through facility and DRHS registers. Postpartum interviews were conducted with a sample of 550 women who received advance distribution of misoprostol on place of delivery, knowledge, misoprostol use, and satisfaction. Results There were 1826 estimated deliveries during the seven-month implementation period. A total of 980 women (53.7%) were enrolled and provided misoprostol, primarily through ANC (78.2%). Uterotonic coverage rate of all deliveries was 53.5%, based on 97.7% oxytocin use at recorded facility vaginal births and 24.9% misoprostol use at home births. Among 550 women interviewed postpartum, 87.7% of those who received misoprostol and had a home birth took the drug. Sixty-three percent (63.0%) took it at the correct time, and 54.0% experienced at least one minor side effect. No serious adverse events reported among enrolled women. Facility-based deliveries appeared to increase during the program. Conclusions The program was moderately effective at achieving high uterotonic coverage of all births. Coverage of home births was low despite the use of two channels of advance distribution of misoprostol. Although ANC reached a greater proportion of women in late pregnancy than home visits, 46.3% of expected deliveries did not receive education or advance distribution of misoprostol. A revised community-based strategy is needed to increase advance distribution rates and misoprostol coverage rates for home births. Misoprostol for PPH prevention appears acceptable to women in Liberia. Correct timing of misoprostol self-administration needs improved emphasis during counseling and education.
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23
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Robinson N, Kapungu C, Carnahan L, Geller S. Recommendations for scale-up of community-based misoprostol distribution programs. Int J Gynaecol Obstet 2014; 125:285-8. [PMID: 24680582 DOI: 10.1016/j.ijgo.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 12/18/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in resource-poor settings has been shown to be safe and effective. However, global recommendations for prenatal distribution and monitoring within a community setting are not yet available. In order to successfully translate misoprostol and PPH research into policy and practice, several critical points must be considered. A focus on engaging the community, emphasizing the safe nature of community-based misoprostol distribution, supply chain management, effective distribution, coverage, and monitoring plans are essential elements to community-based misoprostol program introduction, expansion, or scale-up.
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Affiliation(s)
- Nuriya Robinson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA.
| | - Chisina Kapungu
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA; Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
| | - Leslie Carnahan
- Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
| | - Stacie Geller
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA; Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
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