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Preventing Postpartum Hemorrhage at homebirth: Global experience and evidence

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Title: Preventing Postpartum Hemorrhage at homebirth: Global experience and evidence


1
Preventing Postpartum Hemorrhage at homebirth
Global experience and evidence
  • Koki Agarwal
  • ACCESS/JHPIEGO
  • October 19, 2007

2
The home birth
3
Analysis of causes of maternal death a
systematic review
Khan et al Lancet 367 1066-1074, 2006
4
Problem
Postpartum hemorrhage - leading cause of
maternal mortality globally
Large proportion of women give birth at
homeskilled care and uterotonics are not
available
5
Seeking 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.

6
Misoprostol 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
7
More 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
8
The Belgaum Study, India
  • Randomized
  • Double-blind
  • Placebo-controlled
  • Stage II, Phase III Clinical Trial

9
Primary Outcome PPH Rates
Derman et al, Lancet, 2006
10
Belgaum 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

11
WHO 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)
  • .

12
Programming 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
14
Keep it simple PPH 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

15
Lesson Keep it simple Role 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

16
Lesson Keep it simple Birth 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

17
Lesson 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

18
Nepal
19
Integrated 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)

20
POPULATION 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
21
Impact of Misoprostol distribution on Mortality
Nepal
22
Partnerships 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

23
In 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

24
We may have a long way to go….
  • But we have solutions at hand
  • Let us TAKE ACTION NOW!

25
..and make their journey safe
Photo Lora Lannotti
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