A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africa

Uterine massage to reduce blood loss after vaginal delivery

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and disability. A need for simple, inexpensive techniques to prevent PPH and provide treatment exists, particularly in cases where uterotonics cannot be accessed. Uterine massage is recommended as part of the routine active management of the third stage of labor. This study was conducted to determine the effectiveness of uterine massage after delivery of the placenta in reducing postpartum blood loss. Thus, a randomized controlled trial was conducted in Turkey between March 2018 and September 2018. A total of 176 pregnant women (88 in the control and 88 in the uterine massage groups) were randomly allocated to the two groups: one group receiving sustained uterine massage, while the other comprising the control group. The uterine massage group was administered transabdominal uterine massage, starting immediately after delivery of the placenta and continuing every 15 min for a duration of 2 h until the uterus hardened. The blood loss within 2 h of delivery was recorded. Level of significance was taken as p < 0.05, and the chi-square, t, and Mann-Whitney U tests as well as Spearman's correlation and linear regression were employed in the analysis of the data. The average amount blood loss within 2 h of the delivery was significantly higher in the control group than in the massage group (X = 170.49 ± 61.46 and X = 186.20 ± 47.59, p < 0.05). A statistically significant difference was present between the uterine massage and control groups in terms of hemoglobin, hematocrit, WBC, and RCB pre-delivery and pre-discharge (first 24 h) values and in the use of additional uterotonics and the amount of blood loss (p < 0.05). The results of the analysis show that postpartum uterine massage has a reducing effect on the amount of PPH.

Every Second Matters - uterine balloon tamponade implementation across ten medical colleges in Maharashtra and Madhya Pradesh in India: A qualitative study

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.

Obstetric hemorrhage: effective methods for addressing the menace in Sub-Saharan Africa

Obstetric hemorrhage is a serious emergency. It can occur late in pregnancy and in the immediate postpartum period. Postpartum hemorrhage is the major contributor of maternal deaths worldwide. The incidence of PPH-associated death across the African continent is at least three times higher than in other regions of the world. About 17% of PPH result in severe morbidity, including significant organ impairment. Maternal death and disability have long-lasting negative consequences for children, families, and communities. There are considerable variations across regions with for instance PPH accounting for about 8.0% of maternal deaths in developed countries compared to 19.7% in the developing countries. This disparity suggests that the majority of lives lost from PPH are preventable. Instituting primary preventive measures, prenatal care, comprehensive antenatal care, understanding the concept of birth preparedness and complication readiness, skilled birth attendant at delivery, avoiding delays, availability of comprehensive emergency obstetric care (CEmOC), good political will and disseminating the information on maternal mortality from PPH to the community are among key elements necessary to address the menace of PPH in developing countries. The aim of this review is to highlight the contributions of obstetric hemorrhage as a significant cause of maternal morbidity and mortality and suggest measures of prevention.

Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto

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.

Intrauterine balloon tamponade for postpartum hemorrhage

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.

Resource use decrease after implementation of care bundles for treatment of postpartum hemorrhage

OBJECTIVE

To evaluate whether the implementation of care bundles has an impact on resource utilization in the care of patients with postpartum hemorrhage (PPH).

METHODS

Retrospective, cross-sectional, observational study of 404 patients with stage II or greater PPH. Periods 2011-2014 and 2015-2017, before and after the introduction of care bundles, were compared. Billing reports were analyzed, and all services provided to treat these events were extracted. Use of resources within the two periods was computed.

RESULTS

The amount billed per episode decreased 18.66% from the first to the second period. Most PPH cases used fewer resources after introduction of care bundles. The greatest reduction was in the use of medications, with a decrease of charges by 56.3%. Diagnostic procedure charges decreased by 47.6% and consultation charges decreased by (37.7%).

CONCLUSIONS

The use of PPH care bundles may be associated with lower resource use and fewer interventions.

Cost-effectiveness of uterine tamponade devices for the treatment of postpartum hemorrhage: A systematic review

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.

Digital postpartum hemorrhage management device (DPHMD)

Background

Primary postpartum hemorrhage (PPH) is an obstetric emergency caused by excessive blood loss that occurs most commonly after the placenta is delivered. PPH can lead to volume depletion, hypovolemic shock, anemia, and it is the leading cause of maternal mortality worldwide. With 470 deaths per 100,000 live births, the maternal mortality ratio in Ethiopia is one of the highest in the world. It is estimated that 94% of births occur at home in Ethiopia and that 10% of maternal deaths are attributed to PPH. Currently, physicians use visual estimation to calculate blood loss and provide fluid during delivery. This traditional method is subjective and generally inaccurate.

Method

In this project, after delivery blood loss measurement system integrated with fluid delivery and vital sign monitoring method is proposed. The collection and measurement system collects blood loss after delivery and measures the amount of blood loss. The management system continuously monitors the mother’s heart rate and blood pressure. These vital sign values are integrated with the measured blood loss to estimate the amount of IV fluid required to be delivered for the mother. The rate of IV fluid delivery is regulated by a flow rate sensor and solenoid valve.

Results

The prototype was built and undergone through different tests and iterations. The proposed device was tested for accuracy, cost effectiveness and ease to use. 91.28% accuracy has been achieved and the prototype was built with less than 210 USD.

Conclusion

The proposed design allows physicians, especially those in low resource setting, to estimate blood loss and deliver fluid accurately. This helps to reduce maternal mortality rate that may occur due to postpartum hemorrhage.

Are there decision support tools that might strengthen the health system for perinatal care in South African district hospitals? A review of the literature

Background

South Africa has a high burden of perinatal deaths in spite of the availability of evidence-based interventions. The majority of preventable perinatal deaths occur in district hospitals and are mainly related to the functioning of the health system. Particularly, leadership in district hospitals needs to be strengthened in order to decrease the burden of perinatal mortality. Decision-making is a key function of leaders, however leaders in district hospitals are not supported to make evidence-based decisions. The aim of this research was to identify health system decision support tools that can be applied at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Methods

A structured approach, the systematic quantitative literature review method, was conducted to find published articles that reported on decision support tools to strengthen decision-making in a health system for perinatal, maternal, neonatal and child health. Articles published in English between 2003 and 2017 were sought through the following search engines: Google Scholar, EBSCOhost and Science Direct. Furthermore, the electronic databases searched were: Academic Search Complete, Health Source – Consumer Edition, Health Source – Nursing/Academic Edition and MEDLINE.

Results

The search yielded 6366 articles of which 43 met the inclusion criteria for review. Four decision support tools identified in the articles that met the inclusion criteria were the Lives Saved Tool, Maternal and Neonatal Directed Assessment of Technology model, OneHealth Tool, and Discrete Event Simulation. The analysis reflected that none of the identified decision support tools could be adopted at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Conclusion

There is a need to either adapt an existing decision support tool or to develop a tool that will support decision-making at district hospital level towards strengthening the health system for perinatal care in South Africa.