community midwifery and prevention of postpartum hemorrhage_kate brickson_5.8.14
TRANSCRIPT
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