Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

Effect of phenylephrine infusion on postpartum blood loss after cesarean delivery: a placebo-controlled, randomized clinical trial

BACKGROUND

Preclinical studies have documented the role of alpha-adrenergic agonists in myometrial contraction. Phenylephrine is frequently used to prevent and treat post-spinal hypotension during cesarean delivery. We hypothesized phenylephrine would reduce postpartum blood loss due to alpha-1 receptor-mediated uterine and vascular smooth muscle contraction.

OBJECTIVES

This translational study aimed to evaluate the role of phenylephrine in reducing postpartum blood loss due to alpha-1 receptor mediated uterine and vascular smooth muscle contraction.

METHODS

This was a prospective, randomized, placebo-controlled, blinded, pilot, clinical trial. Low-risk parturients undergoing cesarean delivery under spinal anesthesia were recruited in this study. The women were randomized to receive phenylephrine or placebo (normal saline) infusion. Each mL of phenylephrine contained 60 micrograms. The study drug began simultaneously with the start of spinal anesthesia, and was stopped at the end of surgery. The infusion rate was started at 50 mcg/min and was titrated to maintain the systolic blood pressure between 80% and 120 % of baseline. The primary outcome measure was postpartum blood loss till 24 hours postpartum, and it was assessed using a surgical swab weighing technique added to suction canister blood contents. The secondary outcomes were incidence of hypertension, hypotension, Apgar score, cord blood gas analysis and neonatal intensive care unit admission (NICU) admission.

RESULTS

One hundred six women received study drugs and were eligible for final analysis. The demographic data, obstetric profiles, and medications were comparable. In the phenylephrine group, the mean postpartum blood loss (median [interquartile range]) was significantly lower ([420 {349-502} vs 494 {397-600} mL; p=.009]). Additionally, a significantly lower number of women had >500 mL of blood loss in the phenylephrine group (26.4% vs 47.1%; p=.02). Furthermore, more women in the control arm needed blood transfusion (37.7% vs 16.9%; p=.01). Six women each had bradycardia and hypertension in the phenylephrine group. NICU admission, Apgar score, and umbilical artery PH were comparable.

CONCLUSION

Continuous phenylephrine infusion led to a statistically significant but clinically inconsequential reduction in postpartum blood loss in low-risk parturients undergoing cesarean delivery under spinal anesthesia.

A cost-effectiveness analysis of early detection and bundled treatment of postpartum hemorrhage alongside the E-MOTIVE trial

Timely detection and treatment of postpartum hemorrhage (PPH) are crucial to prevent complications or death. A calibrated blood-collection drape can help provide objective, accurate and early diagnosis of PPH, and a treatment bundle can address delays or inconsistencies in the use of effective interventions. Here we conducted an economic evaluation alongside the E-MOTIVE trial, an international, parallel cluster-randomized trial with a baseline control phase involving 210,132 women undergoing vaginal delivery across 78 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania. We aimed to assess the cost-effectiveness of the E-MOTIVE intervention, which included a calibrated blood-collection drape for early detection of PPH and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination and escalation), compared with usual care. We used multilevel modeling to estimate incremental cost-effectiveness ratios from the perspective of the public healthcare system for outcomes of cost per severe PPH (blood loss ≥1,000 ml) avoided and cost per disability-adjusted life-year averted. Our findings suggest that the use of a calibrated blood-collection drape for early detection of PPH and bundled first-response treatment is cost-effective and should be perceived by decision-makers as a worthwhile use of healthcare budgets. ClinicalTrials.gov identifier: NCT04341662 .

The cost of inaction on preconception health in Nigeria: An economic impact analysis

A growing body of evidence has shown the effects of poor preconception health on adverse pregnancy outcomes and, subsequently, maternal and child morbidity and mortality. However, the cost of poor preconception health remains relatively unexplored. Using the case of Nigeria, this study provides the first estimate of the disease and economic burden of poor preconception health at a country level. Using data from international databases and the scientific literature, the study used a cost-of-illness approach to quantify the foregone productivity and direct healthcare costs resulting from six preconception risk factors (adolescent pregnancy, short birth interval, overweight and obesity, intimate partner violence, female genital mutilation, folate deficiency). The results indicate that 6.7% of maternal deaths, 10.9% of perinatal deaths, and 10.5% of late neonatal deaths were attributable to the selected preconception risk factors in 2020. The economic burden of poor preconception health in Nigeria was estimated at US$ 3.3 billion in 2020, of which over 90% was generated by premature mortality. If prevalence rates remain constant, total economic losses could amount to US$ 46.2 billion by 2035. This analysis paves the way for further studies investigating the economic costs and benefits of preconception interventions and policies in low and middle-income countries.

Influencia de los hábitos y los conocimientos sobre alimentación en la sobrecarga ponderal según el ámbito de residencia: estudio transversal

OBJETIVO

comprobar la influencia de los conocimientos y los hábitos alimenticios en la sobrecarga ponderal según el ámbito de residencia (urbano o rural).

MÉTODO

se administró un cuestionario a 451 personas, residentes en la zona básica de salud de Villaviciosa (Asturias, España), entre 35 y 65 años, distribuidas en zona rural y urbana, formulario compuesto por preguntas sobre datos sociodemográficos, hábitos y conocimientos nutricionales. Se calcularon frecuencias relativas (%) para las variables cualitativas, y medias aritméticas (desviaciones estándar) para las cuantitativas. Se empleó la correlación de Pearson para comprobar o descartar la relación entre la puntuación en el cuestionario de conocimientos sobre nutrición y el índice de masa corporal (IMC). Para estudiar la relación entre cada pregunta del cuestionario de hábitos y el ámbito de residencia se empleó la prueba chi-cuadrado. Para comparar las medias del IMC por ámbito se aplicó la prueba t para muestras independientes. Se realizaron regresiones logísticas para calcular las odds ratio (OR) entre la variable dependiente (sobrecarga ponderal) y las variables sociodemográficas.

RESULTADOS

la edad media de los encuestados fue de 49.96 años y el IMC promedio de 26.87 kg/m2, presentando sobrecarga ponderal el 57.6 % total. No leer las etiquetas nutricionales aumenta el riesgo de tener sobrecarga ponderal (OR = 2.2; p = 0.001); quienes consideran que comen en exceso muchas veces presentan mayor probabilidad de sobrecarga ponderal (OR = 8.6; p < 0.001); comer fuera de casa varias veces por semana (OR = 11.6; p = 0.019), así como el consumo de refrescos o zumos procesados (OR = 3.3; p = 0.013) y alcohol de baja graduación (OR = 2.8; p = 0.003) durante las comidas aumentan la probabilidad de sobrecarga ponderal.

CONCLUSIONES

los hábitos alimenticios y los patrones de actividad física son los principales responsables de sobrecarga ponderal. El adecuado conocimiento en la población puede ayudar a la elaboración de un plan preventivo que permita frenar el crecimiento del sobrepeso y la obesidad.

Economic cost of secondary postpartum haemorrhage: A case-control study at a tertiary hospital in Australia

BACKGROUND

Secondary postpartum haemorrhage (PPH) is a condition which affects 0.2-3.0% of women. Despite its impact on maternal morbidity, there is a lack of understanding of the cost burden of disease.

AIMS

To determine the economic cost of secondary PPH in the postpartum period, compared to the costs for women without this diagnosis.

MATERIALS AND METHODS

Data were prospectively collected on a cohort of 97 women who presented with secondary PPH to the emergency department (ED) between July 2020 and February 2021. A case-control design was then used to compare postpartum cost data from these patients to a group of 97 controls who were matched to maternal demographics, and who did not present with secondary PPH.

RESULTS

For women with secondary PPH, there were significantly more hospital attendances, and postpartum costs were higher for all cost subcategories across ED, admissions, and outpatient attendances (P < 0.0001), compared to controls. The total cost of postpartum care for 97 patients with secondary PPH was $254 377.62 with an average cost per patient of $2622.45, compared to $26 670.46 for 97 controls with an average cost of $274.95 per patient (P < 0.0001). This demonstrates a 9.5-fold increase in postpartum costs per woman with secondary PPH.

CONCLUSIONS

Secondary PPH is an under-researched condition which presents a significant cost burden for the health system. Evidence-based guidelines addressing the prevention and management of secondary PPH may assist in minimising this cost burden for both the health service and the patient.

Characteristics of obstetric urogenital fistulas in a regional teaching hospital in Burkina Faso: a retrospective cross-sectional study

Introduction

Obstetric fistula (OF) remains a major public health problem in low-income countries. This study aimed to investigate the sociodemographic, clinical, and therapeutic characteristics of obstetric urogenital fistulas in a regional teaching hospital in Burkina Faso.

Methods

a retrospective cross-sectional study from 1st January 2015 to 31st December 2019 included 50 women who underwent OF surgery repair in the regional teaching hospital of Ouahigouya in Burkina Faso. Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Data on socio-demographic, clinical, and therapeutic characteristics have been collected from the hospital medical records and analyzed.

Results

the mean age of the patients was 29.40 ± 9.4 years (range 15 -55 years). The majority of patients were in the age group between (15-25) years old (44%). Forty-three patients (86%) were residing in rural areas and forty-seven patients (94%) were housekeepers. Twenty-six patients (52%) were primiparous. The majority of patients had received no prenatal care 29 (58%). The majority of patients had a spontaneous vaginal delivery 36 (72%). The duration of labor was greater than 48 hours in 31 (62%) patients. Vesicovaginal fistulas (VVF) accounted for 80% of cases. Ten (20%) patients had previously undergone surgery for the same fistula. The mean size of the fistulas was 1.8±1.4 cm (range 0.5 - 6 cm). At three months of follow-up, the successful closure rate was 68%. Sixteen (32%) patients have experienced a failure of fistula closure.

Conclusion

the majority of fistula survivors were women of reproductive age who were living in rural areas and housekeepers. Mothers having no antenatal care, and having prolonged labor were at increased risk of developing OF. The majority of fistulas were simple fistulas and the most common type of OF was VVF. Surgical outcomes showed a high failure rate.

Either 'a blessing in disguise', or 'I couldn't get help,': Australian and Aotearoa NZ women's experiences of early infant feeding during COVID-19

BACKGROUND

To manage the COVID-19 pandemic, public health restrictions and a rapid pivot to telehealth occurred. Peripartum services were significantly affected by a strained infrastructure. Decreased face to face access to health services and support affected maternal experiences and confidence internationally, yet little was reported with the Australian and Aotearoa New Zealand context.

AIM

To explore the early parenting and infant feeding experiences of new mothers from Australia and Aotearoa New Zealand in the context of a pandemic.

METHODS

An interpretive qualitative approach and thematic analysis obtained an in-depth understanding of the experiences of 27 mothers who gave birth during the first wave of the COVID-19 pandemic in 2020.

FINDINGS

Australian and Aotearoa New Zealand women reported similar experiences, which varied contextually. Restrictions and requirements impacted favourably and unfavourably. Many women found the peace and space of social distancing an unexpected benefit and were proud of their achievements, whilst others shared feelings of isolation and distress. Some women felt they instinctively did what they needed to do. Experiences correlated with differing levels of self-efficacy.

DISCUSSION

While many women relished the freedom from social obligations when faced with feeding challenges, there was general dissatisfaction with the level of support available. Care was fragmented, and health care needs were unmet, impacting feeding and parenting decisions and mental health.

CONCLUSION

Access to timely and appropriate professional support is an important factor in establishing breastfeeding and developing parenting confidence, particularly in the context of a pandemic and should be a health policy priority.

Implementing Heat-Stable Carbetocin for Postpartum Haemorrhage Prevention in Low-Resource Settings: A Rapid Scoping Review

Heat-stable carbetocin (HSC), a long-acting oxytocin analogue that does not require cold-chain transportation and storage, is effective in preventing postpartum haemorrhage (PPH) in vaginal and caesarean deliveries in tertiary-care settings. We aimed to identify literature documenting how it is implemented in resource-limited and lower-level maternity care settings to inform policies and practices that enable its introduction in these contexts. A rapid scoping review was conducted with an 8-week timeframe by two reviewers. MEDLINE, EMBASE, Emcare, the Joanna Briggs Institute Evidence-Based Practice Database, the Maternity and Infant Care Database, and the Cochrane Library were searched for publications in English, French, and Spanish from January 2011 to September 2021. Randomized and non-randomized studies examining the feasibility, acceptability, and health system considerations in low-income and lower-middle-income countries were included. Relevant data were extracted using pretested forms, and results were synthesized descriptively. The search identified 62 citations, of which 12 met the eligibility criteria. The review did not retrieve studies focusing on acceptability and health system considerations to inform HSC implementation in low-resource settings. There were no studies located in rural or lower-level maternity settings. Two economic evaluations concluded that HSC is not feasible in terms of cost-effectiveness in lower-middle-income economies with private sector pricing, and a third one found superior care costs in births with PPH than without. The other nine studies focused on demonstrating HSC effectiveness for PPH prevention in tertiary hospital settings. There is a lack of evidence on the feasibility (beyond cost-effectiveness), acceptability, and health system considerations related to implementing HSC in resource-constrained and lower-level maternity facilities. Further implementation research is needed to help decision-makers and practitioners offer an HSC-inclusive intervention package to prevent excessive bleeding among pregnant women living in settings where oxytocin is not available or of dubious quality.

Correction to: Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

An amendment to this paper has been published and can be accessed via the original article.