Postpartum Hemorrhage in Sudan: Magnitude and implications By: Dr: Waled Amen Mohammed Dr. Dina Sami Khalifa Geneva Foundation for Medical Education and Research GFMER Sudan 2012 Forum No: ( 1 )
Name of presenterName Position InstitutionWaled Amen Mohammed Head, Community Health UMST Nursing Name of contributorsName Position InstitutionWaled Amen Mohammed Head, Community Health UMST NursingDina Sami Khalifa Epidemiologist Ahfad University for Women
Content of the presentation• Background• Definition of PPH• Etiology : 4Ts• Contribution of PPH in MMR in Sudan• Factors that put Sudanese women at added risk• Protocols and guidelines for management of PPH (FIGO)• Benefits of effective prevention and treatment of PPH• Sudan health Policy implications on PPH• Problem In Sudan• Success stories for combating PPH from developing countries• Recommendations for PPH prevention and management in Sudan• Conclusion
Background Despite efforts and activities, maternal mortality rate is still high in developing countries (WHO, 2007). MMR in Sudan is (1107 in 2006 and 750 in 2010) ¹ Three quarters of maternal deaths occur during delivery and immediate postpartum period. ² ¹ SHHS, 2006 &SHHSII, 2010 ² Abdel-Tawab N, El-Rabbat M, 2010.
Definition of PPH WHO defines PPH as:Primary PPH: bleeding from the genital tract in excess to 500 ml in the first 24 hours after deliverySecondary PPH: bleeding from the genital tract in excess to 500 ml in the after 24 hours after delivery till end of puerperium. (WHO, 1989).
Etiology : 4TsTone : Uterine atonyTrauma : Uterine, cervical or vaginal lacerationsTissue : Retained placental tissueThrombin : Coagulopathy delay in recognition & referral Maternal Near Miss or Mortality
Contribution of PPH in MMR in SudanOut of 535164 live births in 2010, 957 were maternal deaths.¹Out of 957 maternal deaths, 806 cases (84.2%) occurred in health facilities, while 151 cases (15.8%) occurred at community settings.¹Maternal death from obstetric hemorrhage affects 225 cases (25.1%), PPH is 183 (81.4%).¹ ¹ (FMoH, Sudan, 2010).
Contribution of PPH in MMR in Sudan• Study conducted in Kassala State-Eastern Sudan to assess MMR found that the case fatality rate of PPH is 2.6%).¹Proper management of PPH reduction of 25% of MM in Sudan i.e. reduce more than 90,000 deaths/year¹ Mohammed AA, 2009
Factors that put Sudanese women at added risk:• Home deliveries by Village Midwives (VMWs) and Traditional Birth Attendants (TBA) 79 %. ¹• High unmet need for family planning 29%. ¹• Anaemia (nutritional, malaria)• Early marriage• FGM and de-infibulation• Routine episiotomy performed as standard ¹ (SHHS II 2010)
Protocols and guidelines for management of PPH (FIGO):• Prevention Utero-tonic drugs + Active Management of Third Stage of Labour (AMTSL)• Treatment Utero-tonic drugs +/- Blood transfusion +/- Surgical interference;
Protocols and guidelines for management of PPH (FIGO):• Currently no standard protocol and guidelines in FMoH for management of PPH had been implemented.• All protocols require highly skilled birth attendants at level of Health facility• Both accurate knowledge about AMTSL and its correct use remains low in developing countries.
Benefits of effective prevention and treatment of PPH ¹ • Less maternal deaths • Fewer admissions to intensive care unit • Less blood loss • Less use of blood transfusion • Less use of additional utero-tonics • Less postpartum anemia • Earlier establishment of breastfeeding • Less anemia in infancy¹ WHO Recommendations, 2007.
Sudan health Policy implications on PPH:• RH Policy encourages home delivery for low risk women; PPH can happen in low risk pregnancy• Village Midwives are not empowered by policy makers to deal with emergency cases and use of active management of third stage of labour (use of oxytocine).
Sudan health Policy implications on PPH:• Low quality of health services and inequity in distribution; delay in referral and delay in proper management at health facilities are key reasons for high PPH mortality.
Problem In Sudan:• Women are delivering at home (79%) Village Midwives not equipped with prevention mechanisms Policy does not support VMWs to perform PPH prevention and treatment late recognition of PPH late referral to health facilities ( delay in decision making/inequity in distribution of Emergency & Comprehensive facilities) delay in service and/or inappropriate management low availability of drugs/blood banks exacerbation of haemorrhage Maternal Death.
Success stories for combating PPH from developing countries: 1. Anti Shock devices (Life-wrap suit): to treat PPH. Evidence so far; decrease fatality in PPH cases by 69% in Egypt, Nigeria, Zambia & Zimbabwe. Stabilizes bleeding at community till referral to an EmOC facility.
2. Misoprestol (at the community level):For preventing PPH, oral misoprostol (600 mcg) and for treatment sublingual (800 mcg) can be safely and effectively administered by lower- level health providers. Trails proved effectiveness & acceptability of drug by women in (Burkina Faso, Ecuador, Egypt, Turkey, and Vietnam)
Misoprestol (at the community level): Cheap Needs no refrigeration Oral and needs no injection VMW can easily be trained to administer it. Its a good solution for low income settings.
Recommendations for PPH prevention and management in Sudan:• Setting specific standard guidelines and protocols for PPH prevention and treatment AT FACILITY & COMMUNITY level with massive dissemination and implementation.• Targeted and evidence based capacity building of VMW SKILLED birth attendants
• Community awareness raising for recognition of danger signs during and after delivery.• Introduction of effective evidence based interventions that help in reduction of the impact of PPH ( e.g. uterotonic drugs by VMWs)
• Developing countries experiences for prevention and treatment of PPH should be analysed and studied and then modified for national application.• Focusing on Health services providers (VMWs) to raise community awareness.
CONCLUSION• Postpartum hemorrhage is still one of the leading causes of maternal near miss & maternal mortality in Sudan.• Sudanese women are at higher risk for postpartum hemorrhage due to many social determinants.• There are no standard guidelines for prevention and treatment for PPH in Sudan.
References• WHO. Reducing the Global Burden: Postpartum Haemorrhage. A n e w s Le t t e r o f Wo r l d w i d e A c t i v i t y. 2007.• Abdel-Tawab N, El-Rabbat M. Maternal and Neonatal Health Services in SUDAN: Results of a Situation Analysis. Sudan; 2010.• World Health Organization. The prevention and management of postpartum haemorrhage. Report of a technical working group of the WHO. Geneva: WHO; 1989 Contract No.: Document Number|.• Federal Ministry of Health-Sudan. National Maternal Death Review report Khartoum: Federal Ministry of Health-Sudan; 2010 Contract No.: Document Number|.• Mohammed AA. Postpartum haemorrhage, hospital experience in high maternal. World Congress of Gynaecology & Obstetrics International Federation of Gynecology & Obstetrics and South African Obstetrical & Gynaecological Society of 4- 9 October 2009; 2009; Cape Town- South Africa. Researchgate; 2009.• Miller S, Ojengbede O, Turan JM, Morhason-Bello IO, Martin HB, Nsima D. A comparative study of the non-pneumatic anti- shock garment for the treatment of obstetric hemorrhage in Nigeria. Int J Gynaecol Obstet. Volume 107, Issue 2, Pages 121- 125 (November 2009) PubMed PMID: 19628207• A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. Int J Gynaecol Obstet. 2010 Jan 21. [Epub ahead of print] PubMed PMID: 20096836
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