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Candidori S, Osouli K, Graziosi S, Zanini AA, Costantino ML, De Gaetano F. A novel low-cost uterine balloon tamponade kit to tackle maternal mortality in low-resource settings. Sci Rep 2024; 14:10004. [PMID: 38693193 PMCID: PMC11063067 DOI: 10.1038/s41598-024-60064-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/18/2024] [Indexed: 05/03/2024] Open
Abstract
The 3.1 target of the Sustainable Development Goals of the United Nations aims to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. The last updates on this target show a significant stagnation in the data, thus reducing the chance of meeting it. What makes this negative result even more serious is that these maternal deaths could be avoided through prevention and the wider use of pharmacological strategies and devices to stop postpartum haemorrhage (PPH). PPH is the leading obstetric cause of maternal mortality in low- and middle-income countries (LMICs). Despite low-cost devices based on the uterine balloon tamponade (UBT) technique are already available, they are not safe enough to guarantee the complete stop of the bleeding. When effective, they are too expensive, especially for LMICs. To address this issue, this study presents the design, mechanical characterisation and technology assessment performed to validate a novel low-cost UBT kit, particularly a novel component, i.e., the connector, which guarantees the kit's effectiveness and represents the main novelty. Results proved the device's effectiveness in stopping PPH in a simulated scenario. Moreover, economic and manufacturing evaluations demonstrated its potential to be adopted in LMICs.
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Affiliation(s)
- Sara Candidori
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy
| | - Kasra Osouli
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Serena Graziosi
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy.
| | | | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Francesco De Gaetano
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
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Akter S, Forbes G, Vazquez Corona M, Miller S, Althabe F, Coomarasamy A, Gallos ID, Oladapo OT, Vogel JP, Lorencatto F, Bohren MA. Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 11:CD013795. [PMID: 38009552 PMCID: PMC10680124 DOI: 10.1002/14651858.cd013795.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries. OBJECTIVES Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings. SEARCH METHODS We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers. DATA COLLECTION AND ANALYSIS We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice. MAIN RESULTS We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence). AUTHORS' CONCLUSIONS Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.
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Affiliation(s)
- Shahinoor Akter
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Gillian Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, and Safe Motherhood Program, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, California, USA
| | - Fernando Althabe
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
- 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
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- 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
| | - 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
| | - Joshua P Vogel
- Maternal and Child Health, Burnet Institute, Melbourne, Australia
| | | | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Samenjo KT, Ramanathan A, Gwer SO, Bailey RC, Otieno FO, Koksal E, Sprecher B, Price RA, Bakker C, Diehl JC. Design of a syringe extension device (Chloe SED®) for low-resource settings in sub-Saharan Africa: a circular economy approach. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1183179. [PMID: 37727273 PMCID: PMC10505716 DOI: 10.3389/fmedt.2023.1183179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/16/2023] [Indexed: 09/21/2023] Open
Abstract
Underfunded healthcare infrastructures in low-resource settings in sub-Saharan Africa have resulted in a lack of medical devices crucial to provide healthcare for all. A representative example of this scenario is medical devices to administer paracervical blocks during gynaecological procedures. Devices needed for this procedure are usually unavailable or expensive. Without these devices, providing paracervical blocks for women in need is impossible resulting in compromising the quality of care for women requiring gynaecological procedures such as loop electrosurgical excision, treatment of miscarriage, or incomplete abortion. In that perspective, interventions that can be integrated into the healthcare system in low-resource settings to provide women needing paracervical blocks remain urgent. Based on a context-specific approach while leveraging circular economy design principles, this research catalogues the development of a new medical device called Chloe SED® that can be used to support the provision of paracervical blocks. Chloe SED®, priced at US$ 1.5 per device when produced in polypropylene, US$ 10 in polyetheretherketone, and US$ 15 in aluminium, is attached to any 10-cc syringe in low-resource settings to provide paracervical blocks. The device is designed for durability, repairability, maintainability, upgradeability, and recyclability to address environmental sustainability issues in the healthcare domain. Achieving the design of Chloe SED® from a context-specific and circular economy approach revealed correlations between the material choice to manufacture the device, the device's initial cost, product durability and reuse cycle, reprocessing method and cost, and environmental impact. These correlations can be seen as interconnected conflicting or divergent trade-offs that need to be continually assessed to deliver a medical device that provides healthcare for all with limited environmental impact. The study findings are intended to be seen as efforts to make available medical devices to support women's access to reproductive health services.
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Affiliation(s)
- Karlheinz Tondo Samenjo
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
- Nyanza Reproductive Health Society, Kisumu, Kenya
| | - Aparna Ramanathan
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Department of Obstetrics and Gynecology, National Center for Advanced Pelvic Surgery, Medstar Washington Hospital Center, Georgetown University, Washington, DC, United States
| | - Stephen Otieno Gwer
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Department of Obstetrics and Gynaecology, Maseno University, Kisumu, Kenya
| | - Robert C. Bailey
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | | | | | - Benjamin Sprecher
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Rebecca Anne Price
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Conny Bakker
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Jan Carel Diehl
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
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Parker ME, Qureshi Z, Deganus S, Soki J, Cofie P, Dapaah P, Owusu R, Gwako G, Osoti A, Ogutu O, Opira J, Sunkwa-Mills G, Boamah M, Srofenyoh E, Aboagye P, Fofie C, Kaliti S, Morozoff C, Secor A, Metzler M, Abu-Haydar E. Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study. BMJ Open 2023; 13:e066907. [PMID: 36737079 PMCID: PMC9900048 DOI: 10.1136/bmjopen-2022-066907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH. DESIGN A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months. SETTING Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities. PARTICIPANTS Obstetric staff (n=451) working within participating facilities. INTERVENTION PPH management training courses were conducted with obstetric staff. PRIMARY AND SECONDARY OUTCOME MEASURES Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility. RESULTS All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters. CONCLUSIONS The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package. TRIAL REGISTRATION NUMBERS NCT04502173; NCT05340777.
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Affiliation(s)
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Sylvia Deganus
- Department of Obstetrics and Gynecology, Tema General Hospital, Tema, Ghana
| | | | | | | | | | - George Gwako
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Omondi Ogutu
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Jacqueline Opira
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Gifty Sunkwa-Mills
- Awutu Senya East Municipal, Ghana Health Service, Kasoa, Central Region, Ghana
| | - Martin Boamah
- Department of Obstetrics and Gynaecology, Greater Accra Regional Hospital, Accra, Greater Accra, Ghana
| | - Emmanuel Srofenyoh
- Department of Obstetrics and Gynaecology, Greater Accra Regional Hospital, Accra, Greater Accra, Ghana
| | | | - Chris Fofie
- Ghana Health Service, Accra, Greater Accra, Ghana
| | - Stephen Kaliti
- Division of Reproductive and Maternal Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Chloe Morozoff
- Global Health, University of Washington, Seattle, Washington, USA
| | | | - Mutsumi Metzler
- Medical Devices and Health Technologies, PATH, Seattle, Washington, USA
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Posever N, Sipahi S, Shivkumar PV, Burke TF. Every Second Matters - uterine balloon tamponade implementation across ten medical colleges in Maharashtra and Madhya Pradesh in India: A qualitative study. Int J Gynaecol Obstet 2022; 159:817-824. [PMID: 35278216 PMCID: PMC9790385 DOI: 10.1002/ijgo.14178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To understand facilitators, barriers, and perceptions of the Every Second Matters uterine balloon tamponade (ESM-UBT) package implemented across 10 medical colleges in India, 3 years after the program was introduced. METHODS Semi-structured interviews were conducted until thematic saturation in March 2020. Multiple provider cadres, including nurses, Obstetrics/Gynecology residents, professors, and program leads, were eligible. Interviews were transcribed and thematically coded using an inductive method. RESULTS Sixty-two obstetric providers were interviewed. Facilitators of implementation included recurrent training, improved teamwork and communication, strong program leadership, and involvement of lower-level facilities. Barriers to implementation included administrative hurdles, high staff turnover, language barriers, and resources required to reach and train lower-level facilities. Overall, the majority of clinicians viewed the ESM-UBT package as a useful intervention in aiding efforts to reduce maternal deaths from postpartum hemorrhage. CONCLUSIONS Among 10 medical colleges in India the ESM-UBT package is seen as a beneficial intervention for managing refractory atonic postpartum hemorrhage, and for reducing maternal morbidity and mortality. Identified facilitators of and barriers to implementation of the ESM-UBT package in India should be used to guide future implementation efforts.
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Affiliation(s)
- Natalie Posever
- Harvard Medical SchoolBostonMassachusettsUSA,Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Sevgi Sipahi
- Global Health Innovation Laboratory, Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of Obstetrics and GynecologyAdvocate Lutheran General HospitalPark RidgeIllinoisUSA
| | - Poonam Varma Shivkumar
- Department of Obstetrics and GynaecologyMahatma Gandhi Institute of Medical SciencesWardhaMaharashtraIndia
| | - Thomas F. Burke
- Harvard Medical SchoolBostonMassachusettsUSA,Global Health Innovation Laboratory, Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of Global Health and PopulationHarvard TH Chan School of Public HealthBostonMassachusettsUSA
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Faria I, Thivalapill N, Makin J, Puyana JC, Raykar N. Bleeding, Hemorrhagic Shock, and the Global Blood Supply. Crit Care Clin 2022; 38:775-793. [PMID: 36162910 DOI: 10.1016/j.ccc.2022.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.
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Affiliation(s)
- Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Hungtington Avenue, Boston, MA 02115, USA; Faculdade de Medicina da Universidade Federal de Minas Gerais, 190 Avenida Professor Alfredo Balena, Belo Horizonte, MG 31130450, Brazil
| | - Neil Thivalapill
- Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 420 East Superior Street, Chicago IL 60611, USA
| | - Jennifer Makin
- Department of Obstetrics, Gynecology and Reproductive Science, The University of Pittsburgh Medical Center Magee - Women's Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Juan Carlos Puyana
- Critical Care Medicine, and Clinical Translational Science, Pittsburgh, PA 15213, USA; University of Pittsburgh, UPMC Presbyterian, F1263, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Hungtington Avenue, Boston, MA 02115, USA; Division of Trauma & Emergency Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA.
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Burke TF, Shivkumar PV, Priyadarshani P, Garg L, Conde-Agudelo A, Guha M. Impact of the introduction of a low-cost uterine balloon tamponade (ESM-UBT) device for managing severe postpartum hemorrhage in India: A comparative before-and-after study. Int J Gynaecol Obstet 2022; 159:466-473. [PMID: 35212417 DOI: 10.1002/ijgo.14156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the impact of introducing a uterine balloon tamponade (ESM-UBT) device for managing severe postpartum hemorrhage (PPH), mainly due to uterine atony, in health facilities in India on the rates of PPH-related maternal death and invasive procedures for PPH control. METHODS We used a quasi-experimental, difference-in-difference (DID) design to compare changes in the rates of a composite outcome (PPH-related maternal death and/or artery ligation, uterine compression sutures, or hysterectomy) among women delivering in nine intervention facilities compared with those delivering in two control facilities, before and after the introduction of ESM-UBT. RESULTS The study sample included 214 123 deliveries (n = 78 509 before ESM-UBT introduction; n = 47 211 during ESM-UBT introduction; and n = 88 403 after ESM-UBT introduction). After introduction of ESM-UBT, there was a significant decline in the rate of the primary composite outcome in intervention facilities (21.0-11.4 per 10 000 deliveries; difference -9.6, 95% confidence interval -14.0 to -5.4). Change in the rate of the primary composite outcome was not significant in control facilities (11.7-17.2 per 10 000 deliveries; difference 5.4, 95% confidence interval -3.9 to 14.9). DID analyses showed there was a significant reduction in the rate of the primary composite outcome in intervention facilities relative to control facilities (adjusted DID estimate -15.0 per 10 000 points, 95% confidence interval -23.3 to -6.8; P = 0.005). CONCLUSION Introduction of the ESM-UBT in health facilities in India was associated with a significant reduction in PPH-related maternal death and/or invasive procedures for PPH control.
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Affiliation(s)
- Thomas F Burke
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Poonam V Shivkumar
- Department of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, India
| | - Preeti Priyadarshani
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Lorraine Garg
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, US Department of Health and Human Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Moytrayee Guha
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Brown School of Public Health, Providence, Rhode Island, USA
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Dalmedico MM, Barbosa FM, Toledo CMD, Martins WA, Fedalto ADR, Ioshii SO. Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto. FISIOTERAPIA EM MOVIMENTO 2022. [DOI: 10.1590/fm.2022.35617.0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Introdução: A hemorragia pós-parto trata-se de uma emergência obstétrica com elevada prevalência e morbimortalidade significativa, sobretudo em contextos de baixa acessibilidade a serviços especializados de saúde. Objetivo: Avaliar a efetividade do tamponamento por balão intrauterino no controle da hemorragia pós-parto, redução da necessidade de intervenções cirúrgicas de emergência e redução da mortalidade materna. Métodos: Revisão sistemática de ensaios clínicos randomizados, orientada pelo Cochrane Handbook for Systematic Reviews of Interventions e relatada através do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram considerados como critérios de elegibilidade ensaios clínicos randomizados que avaliaram o uso de diferentes tipos de balão para tamponamento intrauterino enquanto estratégia para a redução ou cessação da hemorragia pós-parto quando comparados a outras intervenções (farmacológicas ou cirúrgicas). Resultados: Quatro estudos avaliaram 498 pacientes para os desfechos preconizados. Em 80% dos casos relatados observou-se a cessação da hemorragia em um intervalo médio de 15 minutos, após a inserção dos dispositivos. O tempo de permanência dos dispositivos foi de 24 horas. Não foram relatados eventos adversos graves. Devido à heterogeneidade clínica entre os estudos, não foi possível realizar síntese quantitativa. Conclusão: Os achados obtidos não fornecem evidências suficientes para sustentar a utilização rotineira dos dispositivos de tamponamento uterino enquanto prática protocolar no controle da hemorragia pós-parto refratária. A utilização destes dispositivos, no entanto, parece ser promissora diante da falha das intervenções de primeira linha, podendo desempenhar um importante papel em termos de redução de morbimortalidade materna e preservação uterina.
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Dalmedico MM, Barbosa FM, Toledo CMD, Martins WA, Fedalto ADR, Ioshii SO. Intrauterine balloon tamponade for postpartum hemorrhage. FISIOTERAPIA EM MOVIMENTO 2022. [DOI: 10.1590/fm.2022.35617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.
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Shetty SS, Moray KV, Chaurasia H, Joshi BN. Cost of managing atonic postpartum haemorrhage with uterine balloon tamponade devices in public health settings of Maharashtra, India: an economic microcosting study. BMJ Open 2021; 11:e042389. [PMID: 33653747 PMCID: PMC7929829 DOI: 10.1136/bmjopen-2020-042389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postpartum haemorrhage (PPH) is the worldwide leading cause of preventable maternal mortality. India offers free treatment for pregnancy and related complications in its public health facilities. Management with uterine balloon tamponade (UBT) is recommended for refractory atonic PPH cases. As part of health technology assessment to determine the most cost-effective UBT device, this study estimated costs of atonic PPH management with condom-UBT, Every Second Matters (ESM) UBT and Bakri balloon UBT in public health system of Maharashtra, India. DESIGN Health system cost was estimated using primary economic microcosting, data from Health Management Information System and published literature for event probabilities. SETTINGS Four public health facilities from the state of Maharashtra, India representing primary, secondary and tertiary level care were chosen for primary costing. OUTCOME MEASURES Unit, package and annual cost of atonic PPH management with three UBT devices were measured. This included cost of medical treatment, UBT intervention and PPH related surgeries undertaken in public health system of Maharashtra for year 2017-2018. RESULTS Medical management of atonic PPH cost the health system US$37 (95% CI 29 to 45) per case, increasing to US$44 (95% CI 36 to 53) with condom-UBT and surgical interventions for uncontrolled cases. Similar cost was estimated for ESM-UBT. Bakri-UBT reported a higher cost of US$59 (95% CI 46 to 73) per case. Overall annual cost of managing 27 915 atonic PPH cases with condom-UBT intervention in Maharashtra was US$1 226 610 (95% CI 870 250 to 1 581 596). CONCLUSIONS Atonic PPH management in public health facilities of Maharashtra with condom-UBT, ESM-UBT or Bakri-UBT accounts to 3.8%, 3.8% or 5.2% of the state's annual spending on reproductive and child health services. These findings can guide policy-makers to include PPH complication management in publicly financed health schemes. Economic evaluation studies can use this evidence to determine cost effectiveness of UBT in Indian settings.
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Affiliation(s)
- Siddesh Sitaram Shetty
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Kusum Venkobrao Moray
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Himanshu Chaurasia
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Beena Nitin Joshi
- Department of Operational Research, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
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Shi X, Wu H, Liu C, Zhu X. Circular suture of the uterine serosa and myometrium layer around placental attachment site for refractory postpartum hemorrhage. J Obstet Gynaecol Res 2021; 47:1735-1742. [PMID: 33590569 DOI: 10.1111/jog.14695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to analyze the clinical outcomes of circular suture at placental attachment site for refractory postpartum hemorrhage (PPH), which could block blood supply of the serosa and myometrium layer. METHODS Eighty cases of refractory PPH were enrolled and retrospective analyzed in this study for further analysis from a consecutive single center database between 2010 and 2018. After undergoing circular suture of the uterine serosa and myometrium layer around placental attachment site, surgical and perioperative outcomes were recorded and analyzed. RESULTS Among all the patients enrolled, 28 cases (35.0%) of refractory PPH were mainly caused by uterine inertia, 36 cases (45.0%) caused by ectopic placenta, and 2 cases (2.5%) caused by coagulation disorders. After circular suture of the uterine serosa and myometrium layer at placental attachment site, all the uterine active bleeding was controlled below 40 ml without recurrence. The perioperative results were similar between the vaginal and cesarean sections groups. CONCLUSIONS Circular suture of the uterine serosa and myometrium at the placental attachment site could control refractory PPH with few postoperative complications. Circular suture around placenta site could be applied in time to protect the endometrium even in primary hospital.
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Affiliation(s)
- Xueqin Shi
- Department of Obstetrics and Gynecology, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
| | - Han Wu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Changyue Liu
- Department of General Surgery, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
| | - Xiaoyan Zhu
- Department of Obstetrics and Gynecology, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
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Anger HA, Durocher J, Dabash R, Hassanein N, Ononge S, Burkhardt G, Frye LJ, Diop A, Beye Diop SBM, Darwish E, Ramadan MC, Kayaga J, Charles D, Gaye A, Eckardt M, Winikoff B. Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade. PLoS One 2021; 16:e0245988. [PMID: 33556104 PMCID: PMC7869979 DOI: 10.1371/journal.pone.0245988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objective We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care. Methods This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported. Results Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable. Conclusion UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.
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Affiliation(s)
- Holly A. Anger
- Gynuity Health Projects, New York, New York, United States of America
- * E-mail:
| | - Jill Durocher
- Gynuity Health Projects, New York, New York, United States of America
| | - Rasha Dabash
- Gynuity Health Projects, New York, New York, United States of America
| | | | - Sam Ononge
- Makerere University School of Health Sciences, Kampala, Uganda
| | - Gillian Burkhardt
- Gynuity Health Projects, New York, New York, United States of America
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, United States of America
| | - Laura J. Frye
- Gynuity Health Projects, New York, New York, United States of America
| | - Ayisha Diop
- Gynuity Health Projects, New York, New York, United States of America
| | | | - Emad Darwish
- Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | - Dyanna Charles
- Gynuity Health Projects, New York, New York, United States of America
| | - Alioune Gaye
- Obstetrician/Gynecologist Consultant, Dakar, Senegal
| | - Melody Eckardt
- Global Health Innovation Lab, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Beverly Winikoff
- Gynuity Health Projects, New York, New York, United States of America
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Vogel JP, Wilson AN, Scott N, Widmer M, Althabe F, Oladapo OT. Cost-effectiveness of uterine tamponade devices for the treatment of postpartum hemorrhage: A systematic review. Int J Gynaecol Obstet 2020; 151:333-340. [PMID: 32976634 PMCID: PMC7756424 DOI: 10.1002/ijgo.13393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/28/2020] [Accepted: 09/21/2020] [Indexed: 11/24/2022]
Abstract
Background Uterine tamponade is widely promoted for treating refractory postpartum hemorrhage (PPH); however, its cost‐effectiveness may vary depending on unit costs and setting. Objective To review available data on cost‐effectiveness of uterine tamponade devices when used for PPH treatment. Search strategy PubMed and EMBASE were searched (1980 to January 2020), as well as the National Health Services Economic Evaluation database from inception (1995) to March 2015. Selection criteria Eligible studies were any type of economic evaluation, or effectiveness studies that provided cost or economic data. Data collection and analysis Two reviewers independently screened studies, extracted data, and assessed quality. Main results Eleven studies using a range of devices (condom catheter, uterine suction devices, Bakri, Inpress, Ellavi) were identified. Cost of condom catheter devices or kits ranged from US$0.64 to US$6, whereas purpose‐designed device costs were up to US$400. Two studies that took a health system perspective assessed the cost‐effectiveness of using uterine balloon tamponade and suggested that it was highly cost‐effective because of the low cost per disability‐adjusted life‐year averted, although both used effect estimates from case series. Conclusions Evidence on the cost‐effectiveness of uterine tamponade devices was limited and not generalizable. Rigorous economic evaluations based on updated effect estimates are needed.
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Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Vic., Australia.,School of Population Health and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - Alyce N Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Vic., Australia
| | - Nick Scott
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Vic., Australia.,School of Population Health and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - Mariana Widmer
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Fernando Althabe
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev 2020; 7:CD013663. [PMID: 32609374 PMCID: PMC8407481 DOI: 10.1002/14651858.cd013663] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions. OBJECTIVES To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75). AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.
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Affiliation(s)
- Frances J Kellie
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Julius N Wandabwa
- Department of Obstetrics and Gynaecology, Busitema University, Mbale, Uganda
| | - Hatem A Mousa
- University Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine Unit, Leicester Royal Infirmary, Leicester, UK
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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Adegoke O, Danso-Bamfo S, Sheehy M, Tarimo V, Burke TF, Garg LF. A condom uterine balloon device among referral facilities in Dar Es Salaam: an assessment of perceptions, barriers and facilitators one year after implementation. BMC Pregnancy Childbirth 2020; 20:34. [PMID: 31931785 PMCID: PMC6958625 DOI: 10.1186/s12884-020-2721-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal death in Tanzania. The Every Second Matters for Mothers and Babies- Uterine Balloon Tamponade (ESM-UBT) device was developed to address this problem in women with atonic uterus. The objective of this study was to understand the barriers and facilitators to optimal use of the device, in Dar es Salaam Tanzania 1 year after implementation. METHODS Semi-structured interviews of skilled-birth attendants were conducted between May and July 2017. Interviews were recorded, coded and analyzed for emergent themes. RESULTS Among the participants, overall there was a positive perception of the ESM-UBT device. More than half of participants reported the device was readily available and more than 1/3 described ease and success with initial use. Barriers included fear and lack of refresher training. Finally, participants expressed a need for training and device availability at peripheral hospitals. CONCLUSION The implementation and progression to optimal use of the ESM-UBT device in Tanzania is quite complex. Ease of use and the prospect of saving a life/preserving fertility strongly promoted use while fear and lack of high-level buy-in hindered utilization of the device. A thorough understanding and investigation of these facilitators and barriers are required to increase uptake of the ESM-UBT device.
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Affiliation(s)
- Oluwakemi Adegoke
- Department of Emergency Medicine, Division of Global Health Innovation, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Sandra Danso-Bamfo
- Department of Emergency Medicine, Division of Global Health Innovation, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA
| | - Margaret Sheehy
- Department of Emergency Medicine, Division of Global Health Innovation, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Thomas F Burke
- Department of Emergency Medicine, Division of Global Health Innovation, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lorraine F Garg
- Department of Emergency Medicine, Division of Global Health Innovation, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA
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Frye LJ, Anger HA, Burkhardt G. Authors' reply re: The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum hemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped-wedge, cluster-randomized trial: Effectiveness trial on introducing condom-catheter UBT suggests a refocus on systems issues around PPH care. BJOG 2019; 127:426. [PMID: 31749303 DOI: 10.1111/1471-0528.16000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2019] [Indexed: 11/27/2022]
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17
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Mollazadeh-Moghaddam K, Dundek M, Bellare A, Borovac-Pinheiro A, Won A, Burke TF. Mechanical Properties of the Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) Device: In Vitro Tests. AJP Rep 2019; 9:e376-e383. [PMID: 31815053 PMCID: PMC6894953 DOI: 10.1055/s-0039-1697653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022] Open
Abstract
Objective Postpartum hemorrhage (PPH) is the most common cause of maternal mortality and morbidity worldwide, most of which occurs in resource-poor settings. Placement of a uterine balloon may be life-saving in uncontrolled PPH. The Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) device is an ultra-low-cost uterine balloon designed for global access. The purpose of this study was to evaluate the mechanical properties of the ESM-UBT device. Study design Intraluminal pressures, diameters, and burst volumes of condom uterine balloons and Foley catheter balloons of ESM-UBT devices were measured in open air and inside uterus models. Condom uterine balloons were tested with uterus model sizes of 100, 250, and 500mL. The condom-catheter O-ring attachment tensile strength was also evaluated. Results All 28 samples of ESM-UBT condom uterine balloons maintained their integrity for at least 3 hours when subjected to pressures of 200 mm Hg or greater across each of the tested uterine volumes. No Foley catheter balloons burst after instillation of 30mL, O-rings withstood forces of 15.4 ± 2.1 N, and condom uterine balloons stretched to 35.8 ± 2.1 cm without loss of integrity. Conclusion The mechanical properties of the ESM-UBT device make it attractive for scale across resource-poor settings.
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Affiliation(s)
- Kamyar Mollazadeh-Moghaddam
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle Dundek
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anuj Bellare
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anderson Borovac-Pinheiro
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Alice Won
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas F Burke
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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18
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Anger HA, Dabash R, Durocher J, Hassanein N, Ononge S, Frye LJ, Diop A, Beye SB, Burkhardt G, Darwish E, Ramadan MC, Kayaga J, Charles D, Gaye A, Eckardt M, Winikoff B. The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum haemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped wedge, cluster-randomised trial. BJOG 2019; 126:1612-1621. [PMID: 31410966 PMCID: PMC6899652 DOI: 10.1111/1471-0528.15903] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To assess the effectiveness of introducing condom-catheter uterine balloon tamponade (UBT) for postpartum haemorrhage (PPH) management in low- and middle-income settings. DESIGN Stepped wedge, cluster-randomised trial. SETTING Eighteen secondary-level hospitals in Uganda, Egypt and Senegal. POPULATION Women with vaginal delivery from October 2016 to March 2018. METHODS Use of condom-catheter UBT for PPH management was introduced using a half-day training and provision of pre-packaged UBT kits. Hospitals were randomised to when UBT was introduced. The incident rate (IR) of study outcomes was compared in the control (i.e. before UBT) and intervention (i.e. after UBT) periods. Mixed effects regression models accounted for clustering (random effect) and time period (fixed effect). MAIN OUTCOME MEASURES Combined IR of PPH-related invasive surgery and/or maternal death. RESULTS There were 28 183 and 31 928 deliveries in the control and intervention periods, respectively. UBT was used for 9/1357 and 55/1037 women diagnosed with PPH in control and intervention periods, respectively. PPH-related surgery or maternal death occurred in 19 women in the control period (IR = 6.7/10 000 deliveries) and 37 in the intervention period (IR = 11.6/10 000 deliveries). The adjusted IR ratio was 4.08 (95% confidence interval 1.07-15.58). Secondary outcomes, including rates of transfer and blood transfusion, were similar in the trial periods. CONCLUSIONS Introduction of condom-catheter UBT in these settings did not improve maternal outcomes and was associated with an increase in the combined incidence of PPH-related surgery and maternal death. The lack of demonstrated benefit of UBT introduction with respect to severe outcomes warrants reflection on its role. TWEETABLE ABSTRACT Stepped wedge trial shows UBT introduction does not reduce the combined incidence of PPH-related surgery or death.
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Affiliation(s)
- H A Anger
- Gynuity Health Projects, New York, NY, USA
| | - R Dabash
- Gynuity Health Projects, New York, NY, USA
| | - J Durocher
- Gynuity Health Projects, New York, NY, USA
| | - N Hassanein
- Obstetrician/Gynaecologist consultant, Alexandria, Egypt
| | - S Ononge
- Makerere University School of Health Sciences, Kampala, Uganda
| | - L J Frye
- Gynuity Health Projects, New York, NY, USA
| | - A Diop
- Gynuity Health Projects, New York, NY, USA
| | - S B Beye
- Centre De Santé Philippe Senghor, Dakar, Senegal
| | | | - E Darwish
- Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - M C Ramadan
- El Galaa Maternity Teaching Hospital, Cairo, Egypt
| | - J Kayaga
- Global Health Uganda, Kampala, Uganda
| | - D Charles
- Gynuity Health Projects, New York, NY, USA
| | - A Gaye
- Obstetrician/Gynaecologist, Dakar, Senegal
| | - M Eckardt
- Division of Global Health Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - B Winikoff
- Gynuity Health Projects, New York, NY, USA
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Escobar MF, Suso JP, Hincapié MA, Echavarría MP, Fernández P, Carvajal J. Experience of combined use of a Bakri uterine balloon and a non‐pneumatic anti‐shock garment in a university hospital in Colombia. Int J Gynaecol Obstet 2019; 146:244-249. [DOI: 10.1002/ijgo.12872] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/28/2019] [Accepted: 05/24/2019] [Indexed: 11/09/2022]
Affiliation(s)
- María F. Escobar
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - Juan P. Suso
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - María A. Hincapié
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - María P. Echavarría
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - Paula Fernández
- Centro de Investigaciones ClínicasFundación Valle del Lili Cali Colombia
| | - Javier Carvajal
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
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Efficacy and Feasibility of Chhattisgarh Balloon and Conventional Condom Balloon Tamponade: A 2-Year Prospective Study. J Obstet Gynaecol India 2019; 69:133-141. [PMID: 31686746 DOI: 10.1007/s13224-018-1185-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 03/26/2018] [Indexed: 10/27/2022] Open
Abstract
Objective To evaluate the clinical efficacy of two types of condom uterine balloon tamponade systems, namely Chhattisgarh condom balloon device "CG balloon (CGB)" having a central drainage channel as well as indigenous tying system to fasten condom to the catheter and conventional condom uterine balloon device (C-UBT) as a second-line intervention in post-partum haemorrhage (PPH). Materials and Methods The present non-randomised prospective case series was carried out from December 2014 to September 2016 and included 60 women having PPH which was refractory to first-line management and who were treated with either of the two condom balloon tamponade devices prepared on spot. Women with allergy to latex, retained placenta, uterine rupture, anomaly, genital infection and/or malignancy were excluded. Case report forms were filled for all participants and analysed. Primary outcome was arrest of haemorrhage, and one of the secondary outcomes was cost and consistency of the devices. Results CGB was used in 46 and C-UBT in 14 women. The overall success rate was 98.33%. The mean blood loss was 1417 mL. Women of C-UBT group had greater blood loss, higher inflation volume and delays due to technical issues (OR 7.6). CGB was cheaper and more consistent than C-UBT by omitting the use of suture material. Conclusion CGB and conventional condom balloon tamponade both are easy to use, feasible and efficacious for control of PPH, but CGB condom balloon device has the advantage of a central drainage lumen for real-time assessment of blood loss and therefore early corrective action.
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Perrin C, Hounga L, Geissbuhler A. Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus. BMJ Open 2018; 8:e022262. [PMID: 30121608 PMCID: PMC6104789 DOI: 10.1136/bmjopen-2018-022262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes. DESIGN Systematic review and Delphi study. METHODS We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists. RESULTS We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators. CONCLUSIONS The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable. PROSPERO REGISTRATION NUMBER CRD42015027351.
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Affiliation(s)
- Caroline Perrin
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lothaire Hounga
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Geissbuhler
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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22
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Innovative Uses of Condom Uterine Balloon Tamponade for Postpartum Hemorrhage in India and Tanzania. Case Rep Obstet Gynecol 2018; 2018:4952048. [PMID: 29967704 PMCID: PMC6008944 DOI: 10.1155/2018/4952048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/07/2018] [Indexed: 01/04/2023] Open
Abstract
Background Postpartum hemorrhage is the most common cause of maternal deaths worldwide, the majority of which occur in low-resource settings. Uterine balloon tamponade (UBT) is an effective method of addressing uncontrolled postpartum hemorrhage (PPH) from uterine atony; however, UBT devices are often not affordable. We report on three novel uses of an ultra-low-cost condom uterine balloon tamponade (ESM-UBT) device. Cases ESM-UBT devices were used in innovative ways to arrest severe uncontrolled pregnancy-related hemorrhage among three women in India and Tanzania. The first had sustained deep vaginal lacerations, the second a cervical pregnancy, and the third a complete molar pregnancy. Conclusion The ESM-UBT device may be useful for control of obstetric hemorrhage caused by complex vaginal tears as well as cervical and molar pregnancies.
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Ramanathan A, Eckardt MJ, Nelson BD, Guha M, Oguttu M, Altawil Z, Burke T. Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone. BMC Pregnancy Childbirth 2018; 18:168. [PMID: 29764416 PMCID: PMC5952618 DOI: 10.1186/s12884-018-1808-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 04/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. METHODS Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. RESULTS Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. CONCLUSION The ESM-UBT device appears safe for use in women with uncontrolled PPH. TRIAL REGISTRATION Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit.
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Affiliation(s)
- Aparna Ramanathan
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Melody J Eckardt
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA
| | - Brett D Nelson
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, USA
| | - Moytrayee Guha
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA
| | | | - Zaid Altawil
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA
| | - Thomas Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St, Suite 910, Boston, MA, 02114, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Burke TF, Thapa K, Shivkumar P, Tarimo V, Oguttu M, Garg L, Pande S, Fidvi J, Bangal V, Ochoa J, Amatya A, Eckardt M, Horo A, Rogo K, Kedar K, Manasyan A, Khalatkar P, Ku S, Seim A, Suarez S, Guha M, Abdalla K, Fuchtner C, Escobar MF, Arulkumaran S. Time for global scale-up, not randomized trials, of uterine balloon tamponade for postpartum hemorrhage. Int J Gynaecol Obstet 2018; 142:115-118. [DOI: 10.1002/ijgo.12492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/15/2018] [Accepted: 03/21/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Thomas F. Burke
- Division of Global Health and Human Rights; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Kusum Thapa
- Nepal Society of Obstetricians and Gynaecologists (NESOG); Propokar Maternity and Women's Hospital; Thapathali Kathmandu Nepal
| | - Poonam Shivkumar
- Department of Obstetrics and Gynecology; Mahatma Gandhi Institute for Medical Sciences; Wardha Maharashtra India
| | - Vincent Tarimo
- Department of Obstetrics and Gynecology; Muhimbili National Hospital; Dar es Salaam Tanzania
| | - Monica Oguttu
- Kisumu Medical and Education Trust (KMET); Kisumu Kenya
| | - Lorraine Garg
- Division of Global Health and Human Rights; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Saroja Pande
- Nepal Society of Obstetricians and Gynaecologists (NESOG); Propokar Maternity and Women's Hospital; Thapathali Kathmandu Nepal
| | - Juzar Fidvi
- Department of Obstetrics and Gynecology; Vidarbha Institute of Medical Sciences; Nagpur Maharashtra India
| | - Vidyadhar Bangal
- Department of Obstetrics & Gynecology; Rural Medical College; Pravara Institute of Medical Sciences (Deemed University); Loni Ahmednagar Maharashtra India
| | - José Ochoa
- Department of Obstetrics and Gynecology; Hospital General San Felipe; Tegucialpa Honduras
| | - Archana Amatya
- Nepal Society of Obstetricians and Gynaecologists (NESOG); Propokar Maternity and Women's Hospital; Thapathali Kathmandu Nepal
| | - Melody Eckardt
- Division of Global Health and Human Rights; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Apollinaire Horo
- Department of Obstetrics and Gynecology; Teaching Hospital of Yopougon; Abidjan Côte d'Ivoire
| | - Khama Rogo
- African Institute for Health Transformations; Sagam Community Hospital; Luanda Kenya
| | - Kshama Kedar
- Department of Obstetrics and Gynecology; Indira Gandhi Government Medical College; Nagpur Maharashtra India
| | - Albert Manasyan
- Division of Pediatric Neonatology; Department of Pediatrics; The University of Alabama at Birmingham Hospital; Birmingham AL USA
| | - Pragati Khalatkar
- Khalatkar Hospital Paediatric Maternity and Surgical Hospital; Nagpur Maharashtra India
| | - Susana Ku
- Midwifery Services of Lambton-Kent; Bluewater Health Hospital; Sarnia ON Canada
| | - Anders Seim
- Health & Development International; Fjellstrand Norway
| | - Sebastian Suarez
- Division of Global Health and Human Rights; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Moytrayee Guha
- Division of Global Health and Human Rights; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Khadija Abdalla
- United Nations Children's Fund; UNICEF Kenya Country Office; Nairobi Kenya
| | - Carlos Fuchtner
- International Federation of Gynecology and Obstetrics (FIGO); London UK
| | - Maria F. Escobar
- Department of Obstetrics and Gynecology; Fundacion Valle del Lili; Cali Colombia
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Herrick T, Mvundura M, Burke TF, Abu-Haydar E. A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africa. BMC Pregnancy Childbirth 2017; 17:374. [PMID: 29132342 PMCID: PMC5683546 DOI: 10.1186/s12884-017-1564-5] [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: 09/19/2016] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) is the leading cause of maternal deaths worldwide. This study sought to quantify the potential health impact (morbidity and mortality reductions) that a low-cost uterine balloon tamponade (UBT) could have on women suffering from uncontrolled PPH due to uterine atony in sub-Saharan Africa. Methods The Maternal and Neonatal Directed Assessment of Technology (MANDATE) model was used to estimate maternal deaths, surgeries averted, and cases of severe anemia prevented through UBT use among women with PPH who receive a uterotonic drug but fail this therapy in a health facility. Estimates were generated for the year 2018. The main outcome measures were lives saved, surgeries averted, and severe anemia prevented. Results The base case model estimated that widespread use of a low-cost UBT in clinics and hospitals could save 6547 lives (an 11% reduction in maternal deaths), avert 10,823 surgeries, and prevent 634 severe anemia cases in sub-Saharan Africa annually. Conclusions A low-cost UBT has a strong potential to save lives and reduce morbidity. It can also potentially reduce costly downstream interventions for women who give birth in a health care facility. This technology may be especially useful for meeting global targets for reducing maternal mortality as identified in Sustainable Development Goal 3.
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Affiliation(s)
- Tara Herrick
- PATH, Market Dynamics, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA.
| | - Mercy Mvundura
- PATH, Market Dynamics, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA
| | - Thomas F Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
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26
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Miller S, Burke T, Belizán JM, Fuchtner C, Lalonde A, Malhorta J. Tranexamic acid for post-partum haemorrhage in the WOMAN trial. Lancet 2017; 390:1583. [PMID: 28980957 DOI: 10.1016/s0140-6736(17)32408-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/04/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA 94158, USA.
| | - Thomas Burke
- Department of Emergency Medicine, Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA, USA
| | - José M Belizán
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Carlos Fuchtner
- International Federation of Gynecology and Obstetrics, Barrio Equipetrol Norte, Santa Cruz de la Sierra, Bolivia
| | - Andre Lalonde
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada; Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
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Dumont A, Bodin C, Hounkpatin B, Popowski T, Traoré M, Perrin R, Rozenberg P. Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali. BMJ Open 2017; 7:e016590. [PMID: 28864699 PMCID: PMC5589006 DOI: 10.1136/bmjopen-2017-016590] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of low-cost uterine tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage (PPH) in low-resource settings. DESIGN Randomised controlled trial. SETTING Seven healthcare facilities in Cotonou, Benin and Bamako, Mali. POPULATION Women delivering vaginally who had clinically diagnosed PPH that was suspected to be due to uterine atony, who were unresponsive to oxytocin and who needed additional uterotonics. METHODS Women were randomly assigned to receive uterine balloon tamponade with a condom-catheter device or no tamponade; both groups were also given intrarectal or sublingual misoprostol. MAIN OUTCOME MEASURE Proportion of women with invasive surgery or who died before hospital discharge. RESULTS The proportion of primary composite outcome did not differ significantly between the tamponade arm (16%; 9/57) and the standard second line treatment arm (7%; 4/59): relative risk 2.33 (95% CI 0.76 to 7.14, p=0.238). A significantly increased proportion of women with tamponade and misoprostol versus misoprostol alone had total blood loss more than 1000 mL: relative risk 1.52 (95% CI 1.15 to 2.00, p=0.01). Case fatality rate was higher in the tamponade group (10%; 6/57) than in the control group (2%; 1/59) (p=0.059). TRIAL REGISTRATION NUMBER ISRCT Registry Number 01202389; Post-results.
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Affiliation(s)
- Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Paris, France
| | - Cécile Bodin
- Research Institute for Development, Université Paris Descartes, Paris, France
- Community of Practice QUAHOR, Quality of Care in Referral Hospitals, Paris, France
| | - Benjamin Hounkpatin
- Department of Obstetrics and Gynaecology, CHU-MEL, University Hospital for Mother and Child of Lagune, Cotonou, Benin
| | - Thomas Popowski
- Department of Obstetrics and Gynaecology, Poissy Saint Germain Hospital, Poissy, France
| | - Mamadou Traoré
- Department of Obstetrics and Gynaecology, Referral Health Center of the Commune V, Bamako, Mali
| | - René Perrin
- Department of Obstetrics and Gynaecology, CHU-MEL, University Hospital for Mother and Child of Lagune, Cotonou, Benin
| | - Patrick Rozenberg
- Department of Obstetric and Gynecology, Poissy Saint Germain Hospital, Poissy, France
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Burke TF, Danso-Bamfo S, Guha M, Oguttu M, Tarimo V, Nelson BD. Shock progression and survival after use of a condom uterine balloon tamponade package in women with uncontrolled postpartum hemorrhage. Int J Gynaecol Obstet 2017; 139:34-38. [PMID: 28675419 DOI: 10.1002/ijgo.12251] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/03/2017] [Accepted: 06/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the outcomes of women in advanced shock from uncontrolled postpartum hemorrhage (PPH) who underwent placement of an Every Second Matters for Mothers and Babies Uterine Balloon Tamponade (ESM-UBT) device. METHODS In a prospective case series, data were collected for women who received an ESM-UBT device at healthcare facilities in Kenya, Senegal, Sierra Leone, and Tanzania between September 1, 2012, and September 30, 2016. Shock class was assigned on the basis of recorded blood pressures and mental status at the time of UBT placement. RESULTS Data for 306 women with uncontrolled PPH from uterine atony across 117 facilities were analyzed. Normal vital signs or class I/II shock were reported for 166 (54.2%). In this group, one death occurred and was attributed to PPH (survival rate 99.4%). There were no cases of shock progression. One hundred and eleven (36.3%) were in class III shock and 29 (9.5%) in class IV shock; the respective survival rates were 97.3% (n=108) and 86.2% (n=25). CONCLUSION The ESM-UBT device arrests hemorrhage, prevents shock progression, and is associated with high survival rates among women with uncontrolled PPH from uterine atony.
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Affiliation(s)
- Thomas F Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sandra Danso-Bamfo
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Moytrayee Guha
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Brett D Nelson
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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29
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Affiliation(s)
- G J Hofmeyr
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa.,Department of Nursing Sciences, University of Fort Hare, East London, South Africa.,Eastern Cape Department of Health and Walter, Sisulu University, Umthatha, South Africa
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In Pursuit of Solving a Global Health Problem: Prototype Medical Device for Autotransfusing Life-Threatening Postpartum Hemorrhage in Resource-Limited Settings. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0213-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Darwish AM, Abdallah MM, Shaaban OM, Ali MK, Khalaf M, Sabra AMA. Bakri balloon versus condom-loaded Foley’s catheter for treatment of atonic postpartum hemorrhage secondary to vaginal delivery: a randomized controlled trial. J Matern Fetal Neonatal Med 2017; 31:747-753. [PMID: 28274173 DOI: 10.1080/14767058.2017.1297407] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Atef M. Darwish
- Woman’s Health University Hospital, Assiut University, Assiut, Egypt
| | | | - Omar M. Shaaban
- Woman’s Health University Hospital, Assiut University, Assiut, Egypt
| | - Mohammed K. Ali
- Woman’s Health University Hospital, Assiut University, Assiut, Egypt
| | - Mohamed Khalaf
- Woman’s Health University Hospital, Assiut University, Assiut, Egypt
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Mvundura M, Kokonya D, Abu‐Haydar E, Okoth E, Herrick T, Mukabi J, Carlson L, Oguttu M, Burke T. Cost‐effectiveness of condom uterine balloon tamponade to control severe postpartum hemorrhage in Kenya. Int J Gynaecol Obstet 2017; 137:185-191. [DOI: 10.1002/ijgo.12125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/06/2017] [Accepted: 02/09/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | - Donald Kokonya
- School of Medicine Masinde Muliro University of Science and Technology Kakamega Kenya
| | | | - Eunice Okoth
- APHIAplus Western Kenya Project PATH Kisumu Kenya
| | - Tara Herrick
- Strategy and Learning Management PATH Seattle WA USA
| | - James Mukabi
- APHIAplus Western Kenya Project PATH Kisumu Kenya
| | - Lucas Carlson
- Division of Global Health and Human Rights Department of Emergency Medicine Massachusetts General Hospital Boston MA USA
| | | | - Thomas Burke
- Division of Global Health and Human Rights Department of Emergency Medicine Massachusetts General Hospital Boston MA USA
- Harvard Medical School Boston MA USA
- Harvard T.H. Chan School of Public Health Boston MA USA
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Natarajan A, Alaska Pendleton A, Nelson BD, Ahn R, Oguttu M, Dulo L, Eckardt MJ, Burke TF. Provider experiences with improvised uterine balloon tamponade for the management of uncontrolled postpartum hemorrhage in Kenya. Int J Gynaecol Obstet 2016; 135:210-213. [PMID: 27530220 PMCID: PMC5073071 DOI: 10.1016/j.ijgo.2016.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 05/10/2016] [Accepted: 07/18/2016] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To understand healthcare providers' experiences with improvised uterine balloon tamponade (UBT) for the management of uncontrolled postpartum hemorrhage (PPH). METHODS In a qualitative descriptive study, in-depth semi-structured interviews were conducted between November 2014 and June 2015 among Kenyan healthcare providers who had previous experience with improvising a UBT device. Interviews were conducted, audio-recorded, and transcribed. RESULTS Overall, 29 healthcare providers (14 nurse-midwifes, 7 medical officers, 7 obstetricians, and 1 clinical officer) were interviewed. Providers perceived improvised UBT as valuable for managing uncontrolled PPH. Reported benefits included effectiveness in arresting hemorrhage and averting hysterectomy, and ease of use by providers of all levels of training. Providers used various materials to construct an improvised UBT. Challenges to improvising UBT-e.g. searching for materials during an emergency, procuring male condoms, and inserting fluid via a small syringe-were reported to lead to delays in care. Providers described their introduction to improvised UBT through both formal and informal sources. There was universal enthusiasm for widespread standardized training. CONCLUSION Improvised UBT seems to be a valuable second-line treatment for uncontrolled PPH that can be used by providers of all levels. UBT might be optimized by integrating a standard package across the health system.
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Affiliation(s)
- Abirami Natarajan
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Anna Alaska Pendleton
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Brett D Nelson
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Roy Ahn
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Lidu Dulo
- Kisumu Medical Education Trust, Kisumu, Kenya
| | - Melody J Eckardt
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas F Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Pendleton AA, Natarajan A, Ahn R, Nelson BD, Eckardt MJ, Burke TF. A qualitative assessment of the impact of a uterine balloon tamponade package on decisions regarding the role of emergency hysterectomy in women with uncontrolled postpartum haemorrhage in Kenya and Senegal. BMJ Open 2016; 6:e010083. [PMID: 26747039 PMCID: PMC4716247 DOI: 10.1136/bmjopen-2015-010083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To assess the impact of a every second matters for mothers and babies uterine balloon tamponade package (ESM-UBT) on provider decisions regarding emergency hysterectomy in cases of uncontrolled postpartum haemorrhage (PPH). DESIGN Qualitative assessment and analysis of a subgroup extracted from a larger database that contains all UBT device uses among ESM-UBT trained health providers. SETTING Health facilities in Kenya and Senegal with ESM-UBT training and capable of performing emergency hysterectomies. PARTICIPANTS All medical doctors who had placed a UBT for uncontrolled PPH subsequent to implementation of ESM-UBT at their facility, and who also had the capabilities of performing emergency hysterectomies. PRIMARY OUTCOME MEASURES The impact of ESM-UBT on decisions regarding emergency hysterectomy in cases of uncontrolled PPH. RESULTS 30 of the 31 medical doctors (97%) who fulfilled the inclusion criteria were independently interviewed. Collectively the interviewed medical doctors had placed over 80 UBT devices for uncontrolled PPH since ESM-UBT implementation. All 30 responded that UBT devices immediately controlled haemorrhage and prevented women from being taken to emergency hysterectomy. All 30 would continue to use UBT devices in future cases of uncontrolled PPH. CONCLUSIONS These preliminary data suggest that following ESM-UBT implementation, emergency hysterectomy for uncontrolled PPH may be averted by use of uterine balloon tamponade.
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Affiliation(s)
- Anna Alaska Pendleton
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Abirami Natarajan
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Roy Ahn
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Brett D Nelson
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melody J Eckardt
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas F Burke
- Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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