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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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Getting the message across: Characterizing a need to bridge public health messaging for tuberculosis across a rural/urban and CHW/traditional healer divide in Madagascar (A review). SCIENTIFIC AFRICAN 2020. [DOI: 10.1016/j.sciaf.2020.e00321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Tiruneh GT, Yakob B, Ayele WM, Yigzaw M, Roro MA, Medhanyi AA, Hailu EG, Bayou YT. Effect of community-based distribution of misoprostol on facility delivery: a scoping review. BMC Pregnancy Childbirth 2019; 19:404. [PMID: 31694580 PMCID: PMC6836344 DOI: 10.1186/s12884-019-2539-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Community distribution of misoprostol to pregnant women in advance of labor is one of the compelling strategies for preventing postpartum hemorrhage. Concerns have been reported that misoprostol distribution could reduce facility delivery or lead to misuse of the medication. This scoping review was conducted to synthesize the evidence on the effect of community-based misoprostol distribution on rates of facility delivery, and to assess the frequency of mothers taking distributed misoprostol before delivery, and any harmful outcomes of such misuse. METHODS We included peer-reviewed articles on misoprostol implementation from PubMed, Cochrane Review Library, Popline, and Google Scholars. Narrative synthesis was used to analyze and interpret the findings, in which quantitative and qualitative syntheses are integrated. RESULTS Three qualitative studies, seven observational studies, and four experimental or quasi-experimental studies were included in this study. All before-after household surveys reported increased delivery coverage after the intervention: ranging from 4 to 46 percentage points at the end of the intervention when compared to the baseline. The pooled analysis of experimental and quasi-experimental studies involving 7564 women from four studies revealed that there was no significant difference in rates of facility delivery among the misoprostol and control groups [OR 1.011; 95% CI: 0.906-1.129]. A qualitative study among health professionals also indicated that community distribution of misoprostol for the prevention of postpartum hemorrhage is acceptable to community members and stakeholders and it is a feasible interim solution until access to facility birth increases. In the community-based distribution of misoprostol programs, self-administration of misoprostol by pregnant women before delivery was reported in less than 2% of women, among seven studies involving 11,108 mothers. Evidence also shows that most women who used misoprostol pills, used them as instructed. No adverse outcomes from misuse in either of the studies reviewed. CONCLUSIONS The claim that community-based distribution of misoprostol would divert women who would have otherwise had institutional deliveries to have home deliveries and promote misuse of the medication are not supported with evidence. Therefore, community-based distribution of misoprostol can be an appropriate strategy for reducing maternal deaths which occur due to postpartum hemorrhages, especially in resource-limited settings.
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Affiliation(s)
- Gizachew Tadele Tiruneh
- JSI Research & Training Institute, Inc./ The Last Ten Kilometers (L10K) Project, Addis Ababa, Ethiopia. .,Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.
| | - Bereket Yakob
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Department of Global Health and Population /Fenot Project, Harvard T.H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Wubegzier Mekonnen Ayele
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Muluneh Yigzaw
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Jhpiego/HRH Project, Addis Ababa, Ethiopia
| | - Meselech Assegid Roro
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Araya Abrha Medhanyi
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Etenesh Gebreyohannes Hailu
- Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia.,Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Yibeltal Tebekaw Bayou
- JSI Research & Training Institute, Inc./ The Last Ten Kilometers (L10K) Project, Addis Ababa, Ethiopia.,Members of the National Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition (RMNCAH-N) Research Advisory Council (RAC), Addis Ababa, Ethiopia
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Mary M, Diop A, Sheldon WR, Yenikoye A, Winikoff B. Scaling up interventions: findings and lessons learned from an external evaluation of Niger's National Initiative to reduce postpartum hemorrhage. BMC Pregnancy Childbirth 2019; 19:379. [PMID: 31651264 PMCID: PMC6814039 DOI: 10.1186/s12884-019-2502-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Niger has one of the highest maternal mortality ratios in Sub Saharan Africa, of which postpartum hemorrhage is the leading cause. In 2014, Health and Development International and the Ministry of Health of Niger launched an initiative to introduce and scale-up three PPH interventions in health facilities nationwide: misoprostol, uterine balloon tamponade, and the non-pneumatic anti-shock garment. Methods A two-phase mixed-methods evaluation was conducted to assess implementation of the initiative. Health facility assessments, provider interviews, and household surveys were conducted in May 2016 and November 2017. Results All evaluation facilities received misoprostol prevention doses. However, shortages in misoprostol treatment doses, UBT kits, and NASG stock were documented. Health provider training increased while knowledge of each PPH intervention varied. Near-universal uterotonic coverage for PPH prevention and treatment was achieved and sustained throughout the evaluation period. Use of UBT and NASG to manage PPH was rare and differed by health facility type. Among community deliveries, fewer than 22% of women received misoprostol at antenatal care for self-administered prophylaxis. Among those who did, almost all reported taking the drugs for PPH prevention in each phase. Conclusions This study is the first external evaluation of a comprehensive PPH program taking misoprostol, UBT, and NASG to national scale in a low resource setting. Although gaps in service delivery were identified, results demonstrate the complexities of training, managing stock, and implementing system-wide interventions to reach women in varying contexts. The experience provides important lessons for other countries as they develop and expand evidence-based programs for PPH care.
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Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Ayisha Diop
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Wendy R Sheldon
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Aichatou Yenikoye
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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Finlayson K, Downe S, Vogel JP, Oladapo OT. What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: A qualitative systematic review. PLoS One 2019; 14:e0215919. [PMID: 31067245 PMCID: PMC6505942 DOI: 10.1371/journal.pone.0215919] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/10/2019] [Indexed: 12/02/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH. Methods We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed. Results Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues. Conclusions Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the context of sufficient resources and effective implementation by competent, suitably trained providers.
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Affiliation(s)
- Kenneth Finlayson
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
- * E-mail:
| | - Soo Downe
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
| | - Joshua P. Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Olufemi T. Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Hobday K, Hulme J, Belton S, Homer CS, Prata N. Community-based misoprostol for the prevention of post-partum haemorrhage: A narrative review of the evidence base, challenges and scale-up. Glob Public Health 2017; 13:1081-1097. [PMID: 28357885 DOI: 10.1080/17441692.2017.1303743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Achieving Sustainable Development Goal targets for 2030 will require persistent investment and creativity in improving access to quality health services, including skilled attendance at birth and access to emergency obstetric care. Community-based misoprostol has been extensively studied and recently endorsed by the WHO for the prevention of post-partum haemorrhage. There remains little consolidated information about experience with implementation and scale-up to date. This narrative review of the literature aimed to identify the political processes leading to WHO endorsement of misoprostol for the prevention of post-partum haemorrhage and describe ongoing challenges to the uptake and scale-up at both policy and community levels. We review the peer-reviewed and grey literature on expansion and scale-up and present the issues central to moving forward.
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Affiliation(s)
- Karen Hobday
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Jennifer Hulme
- b Department of Emergency Medicine , University Health Network, University of Toronto , Toronto , Canada.,c Department of Family and Community Medicine , University of Toronto , Toronto , Canada
| | - Suzanne Belton
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Caroline Se Homer
- d Centre for Midwifery, Child and Family Health, Faculty of Health , University of Technology Sydney , Ultimo , NSW , Australia
| | - Ndola Prata
- e Bixby Center for Population Health and Sustainability, School of Public Health , University of California , Berkeley , CA , USA
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