This document outlines an integrated approach for preventing postpartum hemorrhage (PPH) at both health facilities and in home births. It discusses how hemorrhage is a leading cause of maternal mortality globally. It then describes how active management of the third stage of labor (AMSTL) can prevent PPH for births attended by skilled providers at health facilities. It also discusses evidence that distributing misoprostol in communities can prevent PPH for home births. The document advocates for integrating facility-based AMSTL and community-based misoprostol distribution to provide broader prevention of PPH and reduce maternal mortality.
2. Outline
• Maternal Mortality
• Causes of Maternal Mortality
• Prevention of PPH at Health Facility
• Prevention PPH at Home Births
• A world FREE from PPH mortality
4. Leading Causes of Maternal Death
Cause of death Developed
countries
Africa Asia LAC
Hemorrhage 13% 34% 31% 21%
Hypertensive
disorders
16% 9% 9% 26%
Sepsis/infections 2% 10% 12% 8%
Abortion 8% 4% 8% 12%
Obstructed labor 0% 4% 9% 13%
Anemia 0% 4% 13% 0%
HIV/AIDS 0% 6% 0% 0%
Source: Khan et al, WHO analysis of causes of maternal death: a systematic review,
The Lancet, March 28, 2006 -- % rounded
5. Causes of Maternal Mortality
Indirect
14%
HIV
3%
Other direct causes
5%
unclassified
6%
Sepsis
11%
Anemia
8%
Hypertensive
Disorder
10%
Hemorrhage
31%
Unsafe Abortion
5%
Obstructed Labor
7%
Source: Adapted from " WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1,
2006.
7. 7
Preventing PPH in Births Attended Skilled
Providers
Physiologic
management
Active management OR and 95% CI
Bristol Trial 152/849 (17.9%) 50/846 (5.9%) 3.13
(95% CI 2.3 - 4.2)
Hinchingbrooke Trial 126/764 (16.5%) 51/748 (6.8%) 2·42
(95% CI 1·78-3·30)
p<0·0001
Prendiville et al 1988, Rogers et al 1998.
8. Niger: Reduction in Post-partum
Hemorrhage
8 USAID HEALTH CARE IMPROVEMENT PROJECT
11. “A woman who
is pregnant has
one foot in the
grave”
. . .
Local Proverb, Chad
12. Parent Death & Child Survival in
Bangladesh
Cumulative probability of survival of child to age 10 years
Father alive: 88.6%
Father dead: 89.3%
Mother alive: 88.9%
Mother dead: 23.8%
Ronsmans LANCET 2010
14. “The significant
problems we face
cannot be solved at
the same level of
thinking we were at
when we created
them.”
Albert Einstein
16. Components of Community Based
Prevention of PPH
BCC component :
• Counseling pregnant
women on BP & CR
• Danger sings of
pregnancy
• Importance of presence
of SBA during delivery
• Misoprostol ( use & side
effects)
Enabling environment
component :
• Distribution of
Misoprostol at 8th month
of pregnancy
• Improving the quality of
AMSTL (SBM-R)
• Community mobilization
to strengthen emergency
transportation services
19. Evidence from community based
PPH prevention
Indonesia
Safety: No women took medication
at wrong time
Acceptability: women who used
medication said they would
recommend it and purchase the
drug for future births
Feasibility: Community volunteers
successfully offered information
about PPH and safely distributed
the medication
Effectiveness: the combination of
skilled providers using oxytocin and
community distribution of
misoprostol allowed 94% coverage
with PPH prevention method
In partnership with Depkes, POGI, IBI &
supported by USAID through the MNH program
20. Evidence from community based
PPH prevention
Afghanistan
Safety: 100% took correctly after
birth including 22 sets of twins
Acceptability: 92% said they would
recommend it and purchase the
drug for future births
Feasibility: Community volunteers
successfully offered information
about PPH and safely distributed the
medication
Effectiveness: the combination of
skilled providers using oxytocin and
community distribution of
misoprostol allowed 93% coverage
with PPH prevention method
Sanghvi, et al. 2009.
21. Evidence from community based
PPH prevention
“Our wives will not die
anymore because of bleeding,
if they take this drug after
birth of the baby and before
expulsion of Baar ( placenta).
We must support and
encourage you. Thank you for
distributing the drug
to our district.”
(A community leader, Afghanistan)
22. Evidence from community based
PPH prevention
• 18,761 pregnant women were dispensed misoprostol by
FCHVs with no significant adverse events or misuse or
incorrect use
• Proportion of deliveries protected by a uterotonic rose from
10.4% to 72.5%; largest gains were among the poor, illiterate
and those living in remote areas
• Institutional deliveries increased from 9.9% to 16.0%
• MMR among 13,969 misoprostol users was 72/100,000;
significantly lower than among non-users (304/100,000), as
well as the national level of 281/100,000
Rajbhandari, Hodgins, Sanghvi, IJGO march 2010
23. Evidence from community based
PPH prevention
• 1620 women, placebo-controlled trial
• Misoprostol: oral, stable, positive safety profile—can be
used in the absence of a skilled birth attendant
• Misoprostol associated with
– Reduction in PPH (12% to 6.4%; p<0.0001)
– Reduction in acute severe PPH (1.2% to 0.2%; p<0.0001)
– Decrease in mean PP blood loss (262.3 to 214.3ml; p<0.0001)
– Transitory chills and fever
Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities:
A randomized controlled trial, The Lancet, Oct. 7, 2006.
24. Global Policy Change
“ After consideration of the evidence for efficacy
and safety , the Committee decided to add
misoprostol to the List, for the prevention of
PPH in settings where parenteral uterotonics
are not available or feasible”.
World Health Organization, 18th expert committee on the selection and use
of essential medicines (21 to 25 March 2011 Accra, Ghana).
25. Vision for the future
“ A world FREE
from PPH
mortality”.
World Map in Proportion to Maternal Mortality
26. Integration: AMTSL & CB prevention of
PPH
Integration will enable the facility based and
community based health care providers to
deliver quality health services;
• Team formation :
• SBAs and CHWs
• Provide CHWs better leadership (SBA Vs CHS)
• SBAs better linked with the communities
• Fallow up of the MCH services clients (ANC, PNC, FP)
• Better tracking of the commodities (misoprostol, FP
pills)
27. Integration: AMTSL & CB prevention of
PPH (cont …)
• Improved Quality of counseling:
• SBAs no longer doing the routine BP & CR counseling
• CHWs totally responsible for BP & CR counseling
• SBA asking each women visiting the health facility
targeted questions about BP & CR
– Danger sings of pregnancy ?
– Diet during pregnancy ?
– TT vaccination and why?
• Provide feedback to the visiting women
• Quality of counseling (inquiring Vs providing)
• Quality of counseling (listening Vs talking)
28. Currently how counseling is done ?
• IEC is the duty of every health worker
• CHW is counseling (??) a client
• SBA is counseling(??) a client
• The only time that a woman get a better
counseling is, during the supervisory visits (?)
(filling the checklist)
• Client just listens and providers talks (75% Vs 25%)
• No mechanism to check the quality of counseling
within system only checklists (fear)
29. Collaboration: AMTSL & CB prevention
of PPH
• Collaboration will enable different partners to
deliver health services at a larger scale
• Effectiveness = Quality * Coverage
• Remaining focused by delivering quality
services to achieve our goals ( Facility based Vs
Community based services/ Facility based and
Community based services)
30. Collaboration: AMTSL & CB prevention
of PPH
Making this world FREE from PPH mortality ?
Can I do it ?
“NO !”
But Why ?
Change your question.
OK
Can We?
Yes, We can.