Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14

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
3
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
AN
SBA
 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
6

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
7
http://www.k4health.o
rg/toolkits/postpartum
hemorrhage/advance-
distribution-
misoprostol-program-
resources

MCHIP held 2 regional workshops Asia &
Africa on implementing PPH programs
Across both workshops in India
and Mozambique
128 participants
18 countries
41 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
8

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.
9

UTEROTONIC USE IMMEDIATELY FOLLOWING BIRTH
New Methodology for Estimating National Coverage
 In 4 countries to date
10
0%
20%
40%
60%
80%
100%
Mozambique Tanzania Jharkhand Yemen
%ofbirths
Setting (country or state)
Figure 1: (STEP 1) Distribution of birth locations
Missing data
Other facilities
(FBO/NGO**)
Private facilities
Public facilities
Home birth w/
SBA
Home birth w/out
SBA
* In Yemen, public and private facility data are combined; both public and private facility births are represented under "Public
facilities" in Figure 1.
** FBO/NGO = Faith-based organizations/Non-governmental organizations.
*
0%
20%
40%
60%
80%
100%
Mozambique Tanzania Jharkhand Jharkhand
(w/ quality
adjustment)
Yemen
%ofbirths
Setting (country or state)
Figure 2: National UUIFB coverage estimate, by birth locations
See Figure 1
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

Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14

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Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14

Editor's Notes