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Adebayo T, Adefemi A, Adewumi I, Akinajo O, Akinkunmi B, Awonuga D, Aworinde O, Ayegbusi E, Dedeke I, Fajolu I, Imam Z, Jagun O, Kuku O, Ogundare E, Oluwasola T, Oyeneyin L, Adebanjo-Aina D, Adenuga E, Adeyanju A, Akinsanya O, Campbell I, Kuti B, Olofinbiyi B, Salau Q, Tongo O, Ezekwe B, Lavin T, Oladapo OT, Tukur J, Adesina O. Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals. BJOG 2024. [PMID: 38686455 DOI: 10.1111/1471-0528.17822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/24/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To determine the prevalence of primary postpartum haemorrhage (PPH), risk factors, and maternal and neonatal outcomes in a multicentre study across Nigeria. DESIGN A secondary data analysis using a cross-sectional design. SETTING Referral-level hospitals (48 public and six private facilities). POPULATION Women admitted for birth between 1 September 2019 and 31 August 2020. METHODS Data collected over a 1-year period from the Maternal and Perinatal Database for Quality, Equity and Dignity programme in Nigeria were analysed, stratified by mode of delivery (vaginal or caesarean), using a mixed-effects logistic regression model. MAIN OUTCOME MEASURES Prevalence of PPH and maternal and neonatal outcomes. RESULTS Of 68 754 women, 2169 (3.2%, 95% CI 3.07%-3.30%) had PPH, with a prevalence of 2.7% (95% CI 2.55%-2.85%) and 4.0% (95% CI 3.75%-4.25%) for vaginal and caesarean deliveries, respectively. Factors associated with PPH following vaginal delivery were: no formal education (aOR 2.2, 95% CI 1.8-2.6, P < 0.001); multiple pregnancy (aOR 2.7, 95% CI 2.1-3.5, P < 0.001); and antepartum haemorrhage (aOR 11.7, 95% CI 9.4-14.7, P < 0.001). Factors associated with PPH in a caesarean delivery were: maternal age of >35 years (aOR 1.7, 95% CI 1.5-2.0, P < 0.001); referral from informal setting (aOR 2.4, 95% CI 1.4-4.0, P = 0.002); and antepartum haemorrhage (aOR 3.7, 95% CI 2.8-4.7, P < 0.001). Maternal mortality occurred in 4.8% (104/2169) of deliveries overall, and in 8.5% (101/1182) of intensive care unit admissions. One-quarter of all infants were stillborn (570/2307), representing 23.9% (429/1796) of neonatal intensive care unit admissions. CONCLUSIONS A PPH prevalence of 3.2% can be reduced with improved access to skilled birth attendants.
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Affiliation(s)
| | | | - Idowu Adewumi
- Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | | | - Bola Akinkunmi
- University of Medical Sciences Teaching Hospital Ondo, Ondo, Nigeria
| | | | | | - Ekundayo Ayegbusi
- Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | | | | | - Zainab Imam
- Lagos State University Teaching Hospital, Ikeja, Nigeria
| | - Olusoji Jagun
- Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
| | | | - Ezra Ogundare
- Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | | | - Lawal Oyeneyin
- University of Medical Sciences Teaching Hospital Ondo, Ondo, Nigeria
| | | | | | | | | | | | - Bankole Kuti
- Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | | | | | | | - Bosede Ezekwe
- Department of Ageing and Life Course, World Health Organization, Nigeria Country Office, Abuja, Nigeria
| | - Tina Lavin
- 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
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Finlayson K, Vogel JP, Althabe F, Widmer M, Oladapo OT. Healthcare providers experiences of using uterine balloon tamponade (UBT) devices for the treatment of post-partum haemorrhage: A meta-synthesis of qualitative studies. PLoS One 2021; 16:e0248656. [PMID: 33735300 PMCID: PMC7971480 DOI: 10.1371/journal.pone.0248656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH. METHODS Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual. RESULTS Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation. CONCLUSIONS Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts is required to address wider acceptability and feasibility issues.
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Affiliation(s)
- Kenneth Finlayson
- Research in Childbirth and Health (ReaCH) Unit, University of Central Lancashire, Preston, Lancashire, United Kingdom
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Fernando Althabe
- 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
| | - Mariana Widmer
- 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
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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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Kim DR, Pinheiro E, Luther JF, Eng HF, Dills JL, Wisniewski SR, Wisner KL. Is third trimester serotonin reuptake inhibitor use associated with postpartum hemorrhage? J Psychiatr Res 2016; 73:79-85. [PMID: 26692255 PMCID: PMC4738036 DOI: 10.1016/j.jpsychires.2015.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/02/2015] [Accepted: 11/11/2015] [Indexed: 11/17/2022]
Abstract
As serotonin reuptake inhibitor (SRI) use may decrease platelet function, previous research has shown a relationship between SRI use and an increased risk for bruising and bleeding. The literature regarding the association between SRI use during pregnancy and increased bleeding at delivery, referred to as postpartum hemorrhage (PPH), is mixed. In secondary analyses from two prospective observational studies of pregnant women with mood disorders, 263 women were exposed to an SRI (n = 51) or not (n = 212) in the third trimester. To be precise, we used the terminology estimated blood loss (EBL) >600 cc rather than the term PPH because the current definition of PPH differs. The occurrence of EBL >600 cc was determined using the Peripartum Events Scale (PES) completed from obstetrical records by a blinded medically trained member of the study team. EBL >600 cc occurred in 8.7% of women in this cohort. There was no statistically significant difference in the rates of EBL >600 cc in the 24 h after delivery in women taking SRIs during the third trimester (9.8%) compared to non-exposed women (8.5%). Utilizing generalizing estimating equations, the odds of EBL >600 cc in each group were not significantly different (OR 1.17, CI-0.41-3.32, p = 0.77). When the SRI group was limited to women with exposure at the time of delivery, the difference in the odds of EBL >600 cc was unchanged (OR 1.16, CI = 0.37-3.64, p = 0.79). In population, both third trimester and use at delivery of SRIs during pregnancy was not associated with an increased risk of excessive blood loss.
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Affiliation(s)
- Deborah R Kim
- Department of Psychiatry, Penn Center for Women's Behavioral Wellness, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Pinheiro
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA.
| | - James F Luther
- Department of Epidemiology Graduate School of Public Health University of Pittsburgh, Pittsburgh, PA, USA
| | - Heather F Eng
- Department of Epidemiology Graduate School of Public Health University of Pittsburgh, Pittsburgh, PA, USA
| | - John L Dills
- Department of Epidemiology Graduate School of Public Health University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen R Wisniewski
- Department of Epidemiology Graduate School of Public Health University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine L Wisner
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA
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Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, Le Ray C, Senat MV, Winer N, Maillard F, Deneux-Tharaux C. Study protocol. TRAAP - TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. BMC Pregnancy Childbirth 2015; 15:135. [PMID: 26071040 PMCID: PMC4465316 DOI: 10.1186/s12884-015-0573-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/28/2015] [Indexed: 01/31/2023] Open
Abstract
Background Postpartum hemorrhage (PPH) is a major cause of maternal mortality, accounting for one quarter of all maternal deaths worldwide. Estimates of its incidence in the literature vary widely, from 3 % to 15 % of deliveries. Uterotonics after birth are the only intervention that has been shown to be effective in preventing PPH. Tranexamic acid (TXA), an antifibrinolytic agent, has been investigated as a potentially useful complement to uterotonics for prevention because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. Randomized controlled trials for PPH prevention after cesarean (n = 10) and vaginal (n = 2) deliveries show that women who received TXA had significantly less postpartum blood loss without any increase in their rate of severe adverse effects. However, the quality of these trials was poor and they were not designed to test the effect of TXA on the reduction of PPH incidence. Large, adequately powered, multicenter randomized controlled trials are required before the widespread use of TXA to prevent PPH can be recommended. Methods and design A multicenter, double-blind, randomized controlled trial will be performed. It will involve 4000 women in labor for a planned vaginal singleton delivery, at a term ≥ 35 weeks. Treatment (either TXA 1 g or placebo) will be administered intravenously just after birth. Prophylactic oxytocin will be administered to all women. The primary outcome will be the incidence of PPH, defined by blood loss ≥500 mL, measured with a graduated collector bag. This study will have 80 % power to show a 30 % reduction in the incidence of PPH, from 10.0 % to 7.0 %. Discussion In addition to prophylactic uterotonic administration, a complementary component of the management of third stage of labor acting on the coagulation process may be useful in preventing PPH. TXA is a promising candidate drug, inexpensive, easy to administer, and simple to add to the routine management of deliveries in hospitals. This large, adequately powered, multicenter, randomized placebo-controlled trial seeks to determine if the risk-benefit ratio favors the routine use of TXA after delivery to prevent PPH. Trial registration ClinicalTrials.gov NCT02302456 (November 17, 2014)
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Angers University Hospital, 4, rue Larrey, 49933, Angers, France.
| | - Valérie Daniel
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Astrid Darsonval
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille, France.
| | - Delphine Vardon
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France.
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France.
| | - Camille Le Ray
- Port-Royal Maternity Unit, Department of Obstetrics and Gynecology, Cochin University Hospital, APHP, Paris, France. .,INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Kremlin-Bicetre University Hospital, APHP, Paris, France.
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France.
| | - Françoise Maillard
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Catherine Deneux-Tharaux
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
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Khooshide M, Mirzarahimi T, Akhavan Akbari G. The impact of physiologic and non-physiologic delivery on the mother and neonate outcomes; a comparative study on the primi gravid mothers. J Family Reprod Health 2015; 9:13-8. [PMID: 25904962 PMCID: PMC4405511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare the effect of the physiologic and facilitated labor on the mother and neonate outcomes in the prim gravid women referring to Arash Hospital. MATERIALS AND METHODS This clinical trial study was performed on 200 low risk pregnant women referring to Arash Women's Hospital in 2012-2013. Mothers were divided into two groups of 100 patients using a simple random sampling method. The first group received the on-pregnancy and physiologic labor training and the second group was nominated for facilitated labor without training. The mother and neonate outcomes in these two delivery methods were then compared. RESULTS The rate of cesarean section in the physiologic group was significantly lower compared with the intervention group (p = 0.001). Also in the first stage of labor, VAS was measured to be noticeably lower in the physiologic group in comparison with the intervention group (p = 0.001), while the difference of VAS between the two studied groups was found not to be significant in the second stage of labor. In terms of duration of the labor and neonatal Apgar score two groups were not considerably different (p > 0.05). Moreover, the laceration rate in the physiologic group was determined to be noticeably higher as compared to the intervention group (p = 0.001). The groups were considerably different in terms of the vaginal bleeding and maternal satisfaction (p = 0.001). CONCLUSION This study revealed the lower rate of cesarean section, abnormal vaginal bleeding and pain score in the physiologic group compared with the facilitated group. Moreover, mothers of the first group were more content with the labor process.
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Affiliation(s)
- Maryam Khooshide
- Department of Obstetrics and Gynecology, Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Tiba Mirzarahimi
- Department of Obstetrics and Gynecology, Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghodrat Akhavan Akbari
- Department of Anesthesiology Fatemi Hospital, Ardebil University of Medical Sciences, Ardebil, Iran
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Prata N, Bell S, Weidert K. Prevention of postpartum hemorrhage in low-resource settings: current perspectives. Int J Womens Health 2013; 5:737-52. [PMID: 24259988 PMCID: PMC3833941 DOI: 10.2147/ijwh.s51661] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal death in low-income countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to provide a review of PPH prevention interventions, with a particular focus on misoprostol, and the challenges and opportunities that preventing PPH in low-resource settings presents. METHODS Using PubMed, we conducted a review of the literature on the randomized controlled trials of interventions to prevent PPH. We then searched PubMed and Google Scholar for nonrandomized field trials of interventions to prevent PPH. We limited our review to interventions that are discussed in the current World Health Organization (WHO) recommendations for PPH prevention and present evidence regarding the use of these interventions. We focused our review on nondrug PPH prevention interventions compared with no intervention and uterotonics versus placebo; this review does not decipher the relative effectiveness of uterotonic drugs. We describe challenges to and opportunities for scaling up PPH prevention interventions. RESULTS Active management of the third stage of labor is considered the "gold standard" strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord traction and cord clamping) with the administration of an uterotonic drug, the preferred uterotonic being oxytocin. Unfortunately, oxytocin has limited application in resource-poor countries, due to its heat instability and required administration by a skilled provider. New heat-stable drugs and drug formulations are currently in development that may improve the prevention of PPH; however, misoprostol is a viable option for provision at home by a lay health care worker or the woman herself, in the interim. CONCLUSION As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the burden of this complication.
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Affiliation(s)
- Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California (Berkeley), Berkeley, CA, USA
| | - Suzanne Bell
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California (Berkeley), Berkeley, CA, USA
| | - Karen Weidert
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California (Berkeley), Berkeley, CA, USA
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Gibson M, Bowles BC, Jansen L, Leach J. Childbirth education in rural haiti: reviving low-tech teaching strategies. J Perinat Educ 2013; 22:93-102. [PMID: 24421602 PMCID: PMC3647738 DOI: 10.1891/1058-1243.22.2.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
On a medical mission into rural mountainous regions of Haiti, the authors were charged with teaching safer childbirth practices to untrained, mostly illiterate traditional birth attendants (TBA) who spoke Haitian Creole. In this isolated region with no physician or accessible hospital, almost all births occur at home. With no electricity, safe water supply, or sanitation facilities, childbirth education was a challenge. Accustomed to electronic, high-tech teaching aids, these childbirth educators had to modify educational strategies for these extraordinary circumstances. A successful solution was to revive decades-old teaching techniques and visual aids once used in Lamaze classes. The purpose of this article is to describe the teaching environment, the target audience, and the low-tech approach to childbirth education in Haiti.
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Chu CS, Brhlikova P, Pollock AM. Rethinking WHO guidance: review of evidence for misoprostol use in the prevention of postpartum haemorrhage. J R Soc Med 2012; 105:336-47. [PMID: 22907551 DOI: 10.1258/jrsm.2012.120044] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
This article describes and critically appraises clinical trials assessing misoprostol effectiveness in preventing primary postpartum haemorrhage (PPH) in home and community settings in low- and middle-income countries. Of 172 identified studies of misoprostol use in labour only six fulfilled the inclusion criteria. All trials used 600 μg misoprostol in the intervention arm; three assessed misoprostol alongside components of active management of the third-stage labour (AMTSL), two used expectant management of labour and one allowed birth attendants to choose management practice. The three AMTSL studies showed no significant differences in PPH incidence or referral to higher centres and only one study showed significant decrease in severe PPH using misoprostol. One expectant management study and the choice of management by birth attendants study found significant decreases in PPH incidence with misoprostol. All studies showed significantly increased risk of shivering with misoprostol. Studies were biased by use of alternative uterotonics in the control arm, confounding management practices, and subjective assessment and, with one exception, exclusion of high-risk women. PPH incidence fell in both the control and intervention groups in both the landmark papers that informed the World Health Organization (WHO) decision to admit misoprostol to the Essential Medicines List. This suggests factors other than misoprostol use are crucial. Current evidence does not support misoprostol use in home and community settings in low- and middle-income countries for PPH prevention. WHO should rethink its recent decision to include misoprostol on the Essential Medicines List.
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Affiliation(s)
- Christina S Chu
- School of Social and Political Science, University of Edinburgh, Edinburgh EH8 9LD, UK
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Abrams ET, Rutherford JN. Framing postpartum hemorrhage as a consequence of human placental biology: an evolutionary and comparative perspective. AMERICAN ANTHROPOLOGIST 2012; 113:417-30. [PMID: 21909154 DOI: 10.1111/j.1548-1433.2011.01351.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide, is responsible for 35 percent of maternal deaths. Proximately, PPH results from the failure of the placenta to separate from the uterine wall properly, most often because of impairment of uterine muscle contraction. Despite its prevalence and its well-described clinical manifestations, the ultimate causes of PPH are not known and have not been investigated through an evolutionary lens. We argue that vulnerability to PPH stems from the intensely invasive nature of human placentation. The human placenta causes uterine vessels to undergo transformation to provide the developing fetus with a high plane of maternal resources; the degree of this transformation in humans is extensive. We argue that the particularly invasive nature of the human placenta increases the possibility of increased blood loss at parturition. We review evidence suggesting PPH and other placental disorders represent an evolutionarily novel condition in hominins.
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Polus S, Lerberg P, Vogel J, Watananirun K, Souza JP, Mathai M, Gülmezoglu AM. Appraisal of WHO guidelines in maternal health using the AGREE II assessment tool. PLoS One 2012; 7:e38891. [PMID: 22912662 PMCID: PMC3418264 DOI: 10.1371/journal.pone.0038891] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/14/2012] [Indexed: 11/20/2022] Open
Abstract
In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.
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Affiliation(s)
- Stephanie Polus
- Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Munich, Bavaria, Germany
- UNDP/UNFPA/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
| | - Priya Lerberg
- UNDP/UNFPA/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
- Department of Community Medicine, University of Oslo, Oslo, Norway
| | - Joshua Vogel
- UNDP/UNFPA/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
- School of Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Kanokwaroon Watananirun
- UNDP/UNFPA/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
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Joao Paulo Souza
- UNDP/UNFPA/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
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - A. Metin Gülmezoglu
- UNDP/UNFPA/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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Almerie Y, Almerie MQ, Matar HE, Shahrour Y, Al Chamat AA, Abdulsalam A. Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study. BMC Pregnancy Childbirth 2010; 10:65. [PMID: 20959012 PMCID: PMC2973846 DOI: 10.1186/1471-2393-10-65] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Accepted: 10/19/2010] [Indexed: 12/02/2022] Open
Abstract
Background Investigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities. Methods Retrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions. Results There were 28 025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100 000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU). Conclusion Near-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post-partum haemorrhage and training health care professionals to manage infrequent but fatal conditions like sepsis. An urgent review of the referral system and the emergency obstetric care in Syria is highly recommended.
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Affiliation(s)
- Yara Almerie
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Damascus University, Damascus, Syria
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Zhang WH, Deneux-Tharaux C, Brocklehurst P, Juszczak E, Joslin M, Alexander S. Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries. BMJ 2010; 340:c293. [PMID: 20123835 PMCID: PMC2815270 DOI: 10.1136/bmj.c293] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of the systematic use of a transparent plastic collector bag to measure postpartum blood loss after vaginal delivery in reducing the incidence of severe postpartum haemorrhage. DESIGN Cluster randomised trial. SETTING 13 European countries. PARTICIPANTS 78 maternity units and 25 381 women who had a vaginal delivery. INTERVENTIONS Maternity units were randomly assigned to systematic use of a collector bag (intervention group) or to continue to visually assess postpartum blood loss after vaginal delivery (control group). MAIN OUTCOME MEASURES The primary outcome was the incidence of severe postpartum haemorrhage in vaginal deliveries, defined as a composite of one or more of blood transfusion, intravenous plasma expansion, arterial embolisation, surgical procedure, admission to an intensive care unit, treatment with recombinant factor VII, and death. RESULTS Severe postpartum haemorrhage occurred in 189 of 11 037 of vaginal deliveries (1.71%) in the intervention group compared with 295 of 14 344 in the control group (2.06%). The difference was not statistically significant either in individual level analysis (adjusted odds ratio 0.82, 95% confidence interval 0.26 to 2.53) or in cluster level analysis (difference in weighted mean rate adjusted for baseline rate 0.16%, 95% confidence interval -0.69% to 1.02%). CONCLUSION Compared with visual estimation of postpartum blood loss the use of a collector bag after vaginal delivery did not reduce the rate of severe postpartum haemorrhage. TRIAL REGISTRATION Current Controlled Trials ISRCTN66197422.
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Affiliation(s)
- Wei-Hong Zhang
- Perinatal Epidemiology Research Unit, School of Public Health, Université Libre de Bruxelles, Route de Lennik 808, CP 597, B-1070 Bruxelles, Belgium.
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Gülmezoglu AM, Widmer M, Merialdi M, Qureshi Z, Piaggio G, Elbourne D, Abdel-Aleem H, Carroli G, Hofmeyr GJ, Lumbiganon P, Derman R, Okong P, Goudar S, Festin M, Althabe F, Armbruster D. Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial. Reprod Health 2009; 6:2. [PMID: 19154621 PMCID: PMC2647525 DOI: 10.1186/1742-4755-6-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 01/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60-70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care. OBJECTIVE The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package. METHODS A hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period. MANAGEMENT Overall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field. EXPECTED OUTCOMES The main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field. TRIAL REGISTRATION ACTRN12608000434392.
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Affiliation(s)
- A Metin Gülmezoglu
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mariana Widmer
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mario Merialdi
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Gilda Piaggio
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Diana Elbourne
- London School of Hygiene and Tropical Medicine, London University, London, UK
| | - Hany Abdel-Aleem
- Department Obstetrics and Gynaecology, Assiut University Hospital, Assiut, Egypt
| | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of Witwatersrand, University of Fort Hare, East London, South Africa
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
| | | | - Pius Okong
- Department Obstetrics and Gynaecology, San Raphael of St. Francis Hospital Nsambya, Kampala, Uganda
| | - Shivaprasad Goudar
- Department of Medical Education, K L E Society's J N Medical College, Belgaum, India
| | - Mario Festin
- Philippine General Hospital, Manila, Philippines
| | - Fernando Althabe
- Department of Mother and Child's Health Research, Buenos Aires, Argentina
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Mathai M, Gülmezoglu AM, Hill S. Saving womens lives: evidence-based recommendations for the prevention of postpartum haemorrhage. Bull World Health Organ 2007; 85:322-3. [PMID: 17546315 PMCID: PMC2636323 DOI: 10.2471/blt.07.041962] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Matthews Mathai
- Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland.
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