Prevention of Postpartum Hemorrhage: Implementation

Lessons from MCHIP

Core Group Spring Meeting

May 2014

Hot off the press this week! Information on causes of maternal deaths

A WHO study of causes of more than 60 000 maternal deaths in 115 countries shows that pre-existing medical conditions exacerbated by pregnancy (such as diabetes, malaria, HIV, obesity) caused 28% of the deaths.

Other causes included: severe bleeding (mostly during and after

childbirth) 27% pregnancy-induced high blood pressure 14% infections 11% obstructed labour and other direct causes 9% abortion complications 8% blood clots (embolism) 3%2

Comprehensive PPH Reduction Approach

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PROMOTION OF COMPREHENSIVE PACKAGE OF INTERVENTIONS TO PREVENT AND MANAGE PPH

EDUCATION: Birth planning/complication readiness; Promotion of ANC; encouragement of facility birth with SBA

Facility Birth: • Correct management of labor

and birth, including partograph • Routine administration of

uterotonic immediately after birth (oxytocin preferred, if not, misoprostol)

• Uterotonic availability and quality

• Postpartum vigilance for PPH • Proper management of PPH

Home Birth: • Education about PPH

detection • Education about use of

misoprostol • Advanced distribution of

misoprostol for self administration after birth

• Education about what to do for continued bleeding

Transport: • Initial dose of

uterotonic • Use of Non-

pneumatic Anti Shock Garment

• Uterine Balloon Tamponade

PPH Prevention & Management

PPH PREVENTION PPH MANAGEMENT

WITHOUT ANSBA

Community awareness—BCC/IEC Birth preparedness/complication readiness (BP/CR) Promotion of skilled attendance at birth Family planning and birth spacing Prevention, detection and treatment of anemia Advanced distribution of misoprostol for self-administration

Complication readiness Community emergency planning Transport planning Referral strategies Use of misoprostol to treat PPH

WITH AN SBA

Community awareness—BCC/IEC Antenatal care (including BP/CR) Prevention, detection and treatment of anemia Family planning and birth spacing Use of partograph to reduce prolonged labor Limiting episiotomy in normal birth Active management of 3rd stage of labor (AMTSL) Routine inspection of placenta for completeness Routine inspection of perineum/vagina for lacerations Routine immediate postpartum monitoring Vigilant monitoring during “4th stage” of labor

Active triage of emergency cases Rapid assessment and diagnosis Emergency protocols for PPH management Basic emergency obstetric and newborn care (EmONC) Intravenous fluid resuscitation Manual removal of placenta, removal of placental fragments, suturing genital lacerations Parenteral uterotonic drugs and antibiotics Comprehensive EmONC Blood bank/blood transfusion Operating theater/surgery

New WHO Guidelines September 2012

Main changes: Focus on uterotonic in

AMTSL Promote delayed cord

clamping Misoprostol can be

administered by community-level health worker

Advanced distribution of misoprostol for self administration – in context of research or strong M&E 5

MCHIP supported introductory PPH programs in 5 countries  

Key findings from the learning phase in South Sudan 94% of births protected from

PPH 99% of women who had

misoprostol and delivered at home, took misoprostol

No women took the drug prior to delivery

Facility birth rate increased

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PPH Toolkit on K4H

Now includes section on Advance Distribution of Misoprostol with:

Implementation guide, plans, budget and job aids

Program study briefs and case studies

Clinical guidelines and protocols Advocacy materials and references Training materials, job aids and

supportive supervision tools IEC materials M&E tools

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http://www.k4health.org/toolkits/postpartumhemorrhage/advance-distribution-misoprostol-program-resources

MCHIP held 2 regional workshops Asia & Africa on implementing PPH programs

Across both workshops in India and Mozambique128 participants18 countries41 orgs/Governments e.g. ADRA, AMOG (Mozambican

Association of Obstetrics and Gynaecology), CHAI, JSI, Médecins du Monde, MSH, Pathfinder, PSI, RCQHC, SolidarMed, UNFPA, WHO, World Vision

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Conducted integrative review on misoprostol for PPH prevention at home birth

Which approaches achieve highest distribution and coverage of women?

Distribution of misoprostol by community workers (TBAs or CHWs) during home visits late in pregnancy achieved greatest distribution and coverage, potentially more than double the coverage achieved by programs where distribution was through health workers or as a part of ANC services.

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UTEROTONIC USE IMMEDIATELY FOLLOWING BIRTHNew Methodology for Estimating National Coverage

In 4 countries to date

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Mozambique

Tanzania Jharkhand Yemen0%

20%

40%

60%

80%

100%

Figure 1: (STEP 1) Distribution of birth locations

Home birth w/out SBA

Home birth w/ SBA

Public facilities

Private facili-ties

Other facilities (FBO/NGO**)

Missing data

Setting (country or state)

% o

f b

irth

s

* In Yemen, public and private facility data are combined; both public and private facility births are repre-sented under "Public facilities" in Figure 1.** FBO/NGO = Faith-based organizations/Non-governmental organizations.

*

0%

20%

40%

60%

80%

100%Figure 2: National UUIFB coverage estimate, by birth

locations

Setting (country or state)

% o

f b

irth

s

See Figure 1 for legend

43% 40% 44%

32%

15%

Prevention PPH can be achieved regardless of where women give birth

MCHIP’s work to scale up use of uterotonics and improve data collection of this important life saving intervention will continue