Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14


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  • 45% reduction in maternal deaths since 1990. An estimated 289 000 women died in 2013 due to complications in pregnancy and childbirth, down from 523 000 in 1990.
  • South Sudan, Madagascar, Liberia, Rwanda and Guinea. Where is Mozambique? MCHIP DID NOT CONDUCT A PPH/MISO PILOT IN MOZAMBIQUE
  • Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14

    1. 1. Prevention of Postpartum Hemorrhage: Implementation Lessons from MCHIP Core Group Spring Meeting May 2014
    2. 2. 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
    3. 3. 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
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. 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%
    11. 11. 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