Title: Preventing Postpartum Hemorrhage at homebirth: Global experience and evidence
1Preventing Postpartum Hemorrhage at homebirth
Global experience and evidence
- Koki Agarwal
- ACCESS/JHPIEGO
- October 19, 2007
2The home birth
3Analysis of causes of maternal death a
systematic review
Khan et al Lancet 367 1066-1074, 2006
4Problem
Postpartum hemorrhage - leading cause of
maternal mortality globally
Large proportion of women give birth at
homeskilled care and uterotonics are not
available
5Seeking Solutions for Births That Occur Without
Skilled Care
- We cannot predict PPH on the basis of risk
factors. - In many countries very few deliveries are
attended by a skilled attendant. - Once severe PPH occurs, death follows very
rapidly - Timely referral and transport to facilities is
not available or affordable - Availability of emergency obstetric care services
is grossly limited.
6Misoprostol mounting evidence
- Clinical demonstration
- Oral Misoprostol reduced PPH incidence to 6
- Double-blind placebo controlled
- Oral Misoprostol reduced need for treatment of
PPH from 8.4 ? 2.8 - Rectal Misoprostol vs. Syntometrin for 3rd stage
3 - Similar reduction in length of 3rd stage,
postpartum blood loss and postpartum hemglobin
Higher BP with Syntometrin - Oral Misoprostol vs. Placebo 4
- PPH 7 vs 15
- Need for therapeutic Oxytocin 16 vs. 38
1 El-Refaey, 1997 2 Hofmeyr, 1998 3
Bamigboye, 1998 4 Surbek, 1999
7More evidence
- Double-blind placebo controlled WHO multicenter
study Oxytocin vs. Misoprostol in hospital 1 - 8 countries
- N9266 Oxytocin N9264 oral Misoprostol
- Severe PPH (1000cc) 3 vs. 4
- Misoprostol higher incidence of shivering
- Conclusion Oxytocin preferred over Misoprostol
in a hospital when both available - Double blind placebo controlled RCT in rural HCs
in Guinea Bissau of Misoprostol vs. placebo - Misoprostol alone reduces severe PPH (1000mls)
- 11 vs. 17
- RR 0.66 (0.44-0.98)
5 Gulmezoglu,et al., Lancet 2001 6. lars Hors
BMJ 2005
8The Belgaum Study, India
- Randomized
- Double-blind
- Placebo-controlled
- Stage II, Phase III Clinical Trial
9Primary Outcome PPH Rates
Derman et al, Lancet, 2006
10Belgaum study conclusions
Oral Misoprostol
- Reduced
- Risk of acute PPH
- Risk of acute severe PPH
- Mean Blood Loss
- Duration of blood loss
- Decreased need for
- Transfusion
- Transfer
- Additional uterotonics and surgery
11WHO Recommendations for the Prevention of PPH
(2007)
- In the absence of AMTSL, should uterotonics be
used alone for prevention of PPH? - Recommendation
- In the absence of AMTSL, a uterotonic drug
(oxytocin or misoprostol) should be offered by a
health worker trained in its use for prevention
of PPH (strong recommendation, moderate quality
evidence) - .
12Programming interventions
- Is the problem a major public health concern?
- Is there a high demand for a solution?
- Is there a readily available (or can be
developed) safe solution? - Will the solution have a significant impact on
correcting the problem - Is the solution feasible to implement (i.e. will
it reach the most vulnerable population) - Are the limitations of the solution acceptable?
13 Evidence from community based PPH prevention
programs
- 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
Indonesia
In partnership with Depkes, POGI, IBI
supported by USAID through the MNH program
14Keep it simplePPH Education Safe Use of
Misoprostol
- Safe and correct timing for use of misoprostol
- Risks of taking tablet prior to delivery
- Common side effects of Pas Bayi
- What to do in case side effects occur
- Where to go if PPH occurs. even after taking
medication
15Lesson Keep it simpleRole of Community Volunteer
- Identification of all pregnant women in her area
- Education of pregnant woman and her support
persons about PPH during home visits - Distribution of Misoprostol (Pas Bayi or Matri
Suraksha Chaki) when woman is 8 months pregnant - Postpartum home visit to determine maternal and
newborn outcome - Collect unused drug
16Lesson Keep it simpleBirth Preparedness
Complication Readiness
- PPH
- Warning signs of dangerous bleeding
- What to do if hemorrhage occurs during or after
delivery - Where to seek emergency medical care
- Preventing PPH
- The role of the midwife in active management of
third stage - Use of oxytocin injection and common side effects
17Lesson Address concerns Measures to Eliminate
Drug Misuse
- In the Distribution system
- Procurement done centrally
- Repackaging and Branding with safety leaflet and
numbering - Main stock kept at nearest health center under
direct control of nurse in charge - Tracking the distribution on weekly basis
- Only small number of doses with CHW, to be
replenished on turning in recruitment information
- By clients
- Emphasis on educating client and support persons
- Distribution at 8 months
- Package with safety information
- Retrieval of unused drug
18Nepal
19Integrated Approach
- Household-level antenatal contact for health
education, assessment dispensing of medications
by Female Community Health Volunteers (FCHV) - Strengthening of formal health services
- Early post-natal home visit by FCHV to assess,
educate dispense, document ( recover unused
misoprostol)
20POPULATION COVERAGE FOR PPH PREVENTION(from
program monitoring data, first 17 months)
Expected pregnancies 16,500
100
Reached by intervention 10,964
66
Received misoprostol
64
no HW, no miso
w/ health worker
No health worker, took misoprostol
22
39
5
61
?
Received PPH protection
21Impact of Misoprostol distribution on Mortality
Nepal
22Partnerships critical for success
- Global level
- 8 years from Innovation to adoption
- Regional Level
- The catalytic value of regional meetings
- National level
- Wide stakeholder participation, the role of the
TAG - Community level
- Process of socialization
23In summary
- Research and programmatic evidence suggests that
misoprostol can be safely and effectively used in
the community setting - Women desire to use it and would be willing to
pay for this product if they chose to deliver at
home - Until AMTSL becomes an option for all women, we
should make all efforts to provide Misoprostol to
women who deliver at home with no skilled
provider
24We may have a long way to go.
- But we have solutions at hand
25..and make their journey safe
Photo Lora Lannotti