This document summarizes research on strategies to reduce postpartum hemorrhage (PPH) and pre-eclampsia/eclampsia (PE/E) through the use of misoprostol and magnesium sulfate (MgSO4). It finds that:
1) Community-based distribution of misoprostol for home births achieved higher coverage rates than programs that only distributed in antenatal care or health facilities. Distribution by community health workers during home visits late in pregnancy resulted in the highest coverage.
2) Studies found very low rates of adverse outcomes from misoprostol use, including few instances of mistimed administration. No maternal deaths were attributed to misoprostol.
3)
Prevention of Postpartum Haemorrhage (An Integrated Approach)Akmal Samsor
This document outlines an integrated approach for preventing postpartum hemorrhage (PPH) at both health facilities and in home births. It discusses how hemorrhage is a leading cause of maternal mortality globally. It then describes how active management of the third stage of labor (AMSTL) can prevent PPH for births attended by skilled providers at health facilities. It also discusses evidence that distributing misoprostol in communities can prevent PPH for home births. The document advocates for integrating facility-based AMSTL and community-based misoprostol distribution to provide broader prevention of PPH and reduce maternal mortality.
Update (2021) Oral Contraceptive Pill : Dr. Jyoti Agarwal Dr Sharda Jain Lifecare Centre
Update (2021) Oral Contraceptive Pill : Dr Sharda Jain
7 Billion 2011 & increasing a rate of 150 million per year
INDIA
Today – 1.3 billion 2050 – 1.628 expected
Intra module-1-global-diversity-in-iuc-usemanuela farris
This document discusses variation in the prevalence and provision of intrauterine contraception (IUC) worldwide. It finds wide variation between continents, regions, and countries. Prevalence is highest in Asia, at 83% of global users, with nearly two-thirds of users located in China. Prevalence varies greatly within regions, with some countries having rates above 40% while others have rates below 2%. Variation is influenced by the types of providers authorized to place IUC, locations where it can be accessed, funding models, medico-legal environments, and availability of trained providers. Expanding provider types and locations, as seen in the example of authorizing midwives in Turkey, can increase IUC utilization and uptake.
LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sha...Lifecare Centre
The document discusses the use of levonorgestrel-releasing intrauterine systems (LNG-IUS), such as Mirena, for treating heavy menstrual bleeding. It provides an overview of LNG-IUS, including how it works locally in the uterus to reduce bleeding. Studies show LNG-IUS reduces bleeding by over 90% and is more effective than oral treatments. It is recommended as the first-line treatment for heavy bleeding by international guidelines and has fewer side effects than other options like endometrial ablation or hysterectomy. LNG-IUS is found to improve quality of life more than surgical treatments and is more cost-effective in the long run.
Uterus (womb) as an organ is pivotal not only to giving birth, but also to the overall well-being of women and their physical, emotional, and sexual health.
Prevention of Postpartum Haemorrhage (An Integrated Approach)Akmal Samsor
This document outlines an integrated approach for preventing postpartum hemorrhage (PPH) at both health facilities and in home births. It discusses how hemorrhage is a leading cause of maternal mortality globally. It then describes how active management of the third stage of labor (AMSTL) can prevent PPH for births attended by skilled providers at health facilities. It also discusses evidence that distributing misoprostol in communities can prevent PPH for home births. The document advocates for integrating facility-based AMSTL and community-based misoprostol distribution to provide broader prevention of PPH and reduce maternal mortality.
Update (2021) Oral Contraceptive Pill : Dr. Jyoti Agarwal Dr Sharda Jain Lifecare Centre
Update (2021) Oral Contraceptive Pill : Dr Sharda Jain
7 Billion 2011 & increasing a rate of 150 million per year
INDIA
Today – 1.3 billion 2050 – 1.628 expected
Intra module-1-global-diversity-in-iuc-usemanuela farris
This document discusses variation in the prevalence and provision of intrauterine contraception (IUC) worldwide. It finds wide variation between continents, regions, and countries. Prevalence is highest in Asia, at 83% of global users, with nearly two-thirds of users located in China. Prevalence varies greatly within regions, with some countries having rates above 40% while others have rates below 2%. Variation is influenced by the types of providers authorized to place IUC, locations where it can be accessed, funding models, medico-legal environments, and availability of trained providers. Expanding provider types and locations, as seen in the example of authorizing midwives in Turkey, can increase IUC utilization and uptake.
LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sha...Lifecare Centre
The document discusses the use of levonorgestrel-releasing intrauterine systems (LNG-IUS), such as Mirena, for treating heavy menstrual bleeding. It provides an overview of LNG-IUS, including how it works locally in the uterus to reduce bleeding. Studies show LNG-IUS reduces bleeding by over 90% and is more effective than oral treatments. It is recommended as the first-line treatment for heavy bleeding by international guidelines and has fewer side effects than other options like endometrial ablation or hysterectomy. LNG-IUS is found to improve quality of life more than surgical treatments and is more cost-effective in the long run.
Uterus (womb) as an organ is pivotal not only to giving birth, but also to the overall well-being of women and their physical, emotional, and sexual health.
Optimizing The outcome of Threatened Abortion Dr Sharda Jain Lifecare Centre
- Around 70% of conceptions are lost prior to live birth, with 30% lost before implantation and 30% after implantation but before a missed period. Threatened abortion refers to vaginal bleeding or pain, or both, in early pregnancy when the cervical os remains closed.
- Studies have shown that counseling reduces adverse psychological effects from miscarriage. Treatment with dydrogesterone has been shown to reduce pregnancy loss in threatened abortion during the first trimester compared to placebo or no treatment. However, treatment with vaginal progesterone compared to placebo appears to have little effect on reducing miscarriage rates.
- Meta-analyses of multiple randomized controlled trials found that treatment with dydrogesterone for threatened miscarriage significantly reduced miscarriage
- There is consensus that submucosal fibroids interfere with fertility and should be removed in infertile patients, regardless of size or symptoms. Subserosal fibroids do not impact fertility.
- The impact of intramural fibroids on fertility is still uncertain. Some studies show they may reduce clinical pregnancy and increase miscarriage rates, while other studies show no effect.
- The benefits of myomectomy for interstitial or intramural fibroids are unclear, as evidence is limited and conflicting. Myomectomy may be considered for failed IVF cycles or large fibroids distorting the cavity.
- There are ongoing controversies around the impact of fibroid number, location and size,
The document provides information about the qualifications and achievements of Dr. Laxmi Shrikhande. It lists her positions including Chairperson Elect of ICOG, National Corresponding Editor of a journal, founder and president of various organizations. It also lists some of the awards she has received for her work in women's health and related fields. The document then provides her name and credentials as Medical Director of Shrikhande Fertility Clinic in Nagpur, Maharashtra.
1. The document discusses unsafe abortion, which is defined as a procedure done by untrained people or in unsanitary conditions. It notes that unsafe abortion accounts for 13% of maternal mortality globally.
2. Statistics on the magnitude of unsafe abortion worldwide are provided, with over 20 million unsafe abortions estimated to occur annually. The abortion case fatality rate is highest in Africa at 0.7% and lowest in Europe.
3. The document outlines management of abortion complications, including life support measures, infection prevention, manual vacuum aspiration, counseling and post-abortion family planning. Effective interventions to reduce maternal mortality from unsafe abortion include contraception access and safe abortion services.
Most unintended pregnancies in the US occur due to inconsistent or no contraceptive use. About half of women at risk of unintended pregnancy are not fully protected. The most effective methods like IUDs, implants and sterilization are not user dependent. It is important to consider efficacy, side effects, costs and patient preferences when counseling on contraceptive options. Enhancing access, adherence and follow up support can help reduce unintended pregnancies.
Infertility is typically defined as the inability to achieve pregnancy after
one year of unprotected intercourse. If you have been trying to conceive
for a year or more, you should consider an infertility evaluation.
Prevalence of Maternal Morbidity in Bangladesh, 2016: A National Estimation MEASURE Evaluation
The document describes a study that aimed to estimate the prevalence of obstetric fistula (OF) and pelvic organ prolapse (POP) in Bangladesh through a validation study. The study found:
1) A screening questionnaire to identify suspected OF and POP cases was administered in both a national maternal morbidity survey (BMMS) and a validation study (MMVS) with clinical examinations.
2) In the MMVS, 149 women self-reported POP symptoms but only 28 were clinically diagnosed with 3rd/4th stage POP, indicating low diagnostic value of self-reports.
3) Sensitivity of the BMMS tool for POP was 78% but specificity was only 67%, showing many false positives. The
Unnecessary investigations in reproductive medicineAboubakr Elnashar
The document discusses unnecessary investigations in reproductive medicine. It provides examples of tests that should not be routinely performed when evaluating infertility, during IVF treatment, in cases of recurrent implantation failure, and recurrent pregnancy loss. Specific tests that are deemed unnecessary include post-coital testing, thrombophilia testing without a clinical indication, immunological testing, and advanced sperm function tests for initial infertility evaluations. The document also recommends limiting hormonal assessments during IVF cycle monitoring.
This document provides evidence-based recommendations for managing unexplained infertility. It discusses various treatment options including expectant management, oral agents with or without IUI, gonadotropins with IUI, and IVF. The key recommendations are that IUI in natural cycles or with oral agents is no more effective than expectant management. Gonadotropins with IUI can be offered but carries a higher risk of multiple pregnancy. IVF demonstrates superior pregnancy rates compared to other options and should be offered after failed ovarian stimulation cycles. Immediate IVF is recommended for women over 38 years old with unexplained infertility.
The document discusses long-acting reversible contraceptives (LARCs) available in Malaysia, including intrauterine devices (IUDs) and implants. It notes that LARC usage in Malaysia is low compared to contraceptive pills. The main types of LARCs are described - copper IUDs, hormonal IUDs, and implants. Benefits include high effectiveness, reversibility, and not requiring daily adherence. Side effects like irregular bleeding are also discussed. Religious views on spotting are provided.
This document discusses emergency contraception options. It provides details about various emergency contraception methods including the Yuzpe method, levonorgestrel pills, mifepristone, and copper IUDs. It summarizes the mechanisms of action, efficacy, side effects, and limitations of each method. The document emphasizes that emergency contraception pills and IUDs are underutilized in India but can significantly reduce unintended pregnancies and abortions if used correctly after unprotected intercourse.
Contraception, Hormones, Progestogens: Update : Dr. Jyoti agarwal Dr. Sharda ...Lifecare Centre
This document discusses oral contraceptive pills, specifically those containing progestogens like desogestrel. It provides information on the history and development of oral contraceptives, including how progestogen formulations have evolved to reduce androgenic side effects. Clinical trial results are presented showing that contraceptives containing desogestrel have good cycle control and low rates of side effects. Desogestrel is highlighted as having favorable characteristics like high selectivity and specificity for progesterone receptors over other steroid receptors.
Maternal health care situation in Bangladesh: Status and utilization of healt...Abdullah Maswood
This document summarizes a study on maternal healthcare in Bangladesh. The objectives were to analyze key causes of maternal morbidity and mortality by considering antenatal care, postnatal care, TT vaccination rates, child delivery practices, and postpartum hemorrhage. Key findings included that 63% of mothers do not receive antenatal care, 85% of births occur at home, and the maternal mortality ratio is 320 deaths per 100,000 births. Major causes of maternal death were direct obstetric complications (63.5%) and indirect medical conditions (35.5%). The conclusion was that increasing access to skilled birth attendants and institutional deliveries is needed to reduce Bangladesh's unacceptably high maternal mortality rate.
1. The document discusses new concepts in infertility including updated WHO reference values for semen analysis, the use of ICSI for male factor infertility, and success rates varying based on the cause of infertility.
2. ICSI, where surgically retrieved sperm are injected into eggs, has become an established procedure for couples with male subfertility to have a biological child, with reassuring post-natal outcomes reported so far.
3. The success of IVF depends on the type of infertility, with male factor infertility seeing live birth rates around 40% and female factor infertility around 25%, higher than other causes of infertility.
Dydrogesterone versus progesterone for luteal-phase support: systematic review and meta-analysis of randomized controlled trials
M. W. P. Barbosa, L. R. Silva, P. A. Navarro, R. A. Ferriani, C. O. Nastri and W. P. Martins
Volume 48, Issue 2, Pages 161–170
Slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15814/full
Bangladesh Maternal Mortality and Health Care Survey 2016MEASURE Evaluation
Presentation from the dissemination of the Bangladesh Maternal Mortality and health Care Survey 2016. Dhaka, Bangladesh, November 22, 2017. United States Agency for International Development; UKaid; MEASURE Evaluation, the International Centre for Diarrhoeal Disease Research, Bangladesh; Bangladesh Ministry of Health and Family Welfare, and the Bangladesh National Institute of Population Research and Training
This article discusses the use of magnesium sulfate (MgSO4) for treating severe preeclampsia and eclampsia. It summarizes evidence from the Magpie Trial showing MgSO4 significantly reduces the risk of eclampsia recurrence and maternal mortality compared to other anticonvulsants. The article reviews MgSO4 regimens, monitoring for toxicity, and the need for training health workers in developing countries on its proper use. It concludes increased availability and training on MgSO4 could help reduce eclampsia's contribution to maternal mortality.
Optimizing The outcome of Threatened Abortion Dr Sharda Jain Lifecare Centre
- Around 70% of conceptions are lost prior to live birth, with 30% lost before implantation and 30% after implantation but before a missed period. Threatened abortion refers to vaginal bleeding or pain, or both, in early pregnancy when the cervical os remains closed.
- Studies have shown that counseling reduces adverse psychological effects from miscarriage. Treatment with dydrogesterone has been shown to reduce pregnancy loss in threatened abortion during the first trimester compared to placebo or no treatment. However, treatment with vaginal progesterone compared to placebo appears to have little effect on reducing miscarriage rates.
- Meta-analyses of multiple randomized controlled trials found that treatment with dydrogesterone for threatened miscarriage significantly reduced miscarriage
- There is consensus that submucosal fibroids interfere with fertility and should be removed in infertile patients, regardless of size or symptoms. Subserosal fibroids do not impact fertility.
- The impact of intramural fibroids on fertility is still uncertain. Some studies show they may reduce clinical pregnancy and increase miscarriage rates, while other studies show no effect.
- The benefits of myomectomy for interstitial or intramural fibroids are unclear, as evidence is limited and conflicting. Myomectomy may be considered for failed IVF cycles or large fibroids distorting the cavity.
- There are ongoing controversies around the impact of fibroid number, location and size,
The document provides information about the qualifications and achievements of Dr. Laxmi Shrikhande. It lists her positions including Chairperson Elect of ICOG, National Corresponding Editor of a journal, founder and president of various organizations. It also lists some of the awards she has received for her work in women's health and related fields. The document then provides her name and credentials as Medical Director of Shrikhande Fertility Clinic in Nagpur, Maharashtra.
1. The document discusses unsafe abortion, which is defined as a procedure done by untrained people or in unsanitary conditions. It notes that unsafe abortion accounts for 13% of maternal mortality globally.
2. Statistics on the magnitude of unsafe abortion worldwide are provided, with over 20 million unsafe abortions estimated to occur annually. The abortion case fatality rate is highest in Africa at 0.7% and lowest in Europe.
3. The document outlines management of abortion complications, including life support measures, infection prevention, manual vacuum aspiration, counseling and post-abortion family planning. Effective interventions to reduce maternal mortality from unsafe abortion include contraception access and safe abortion services.
Most unintended pregnancies in the US occur due to inconsistent or no contraceptive use. About half of women at risk of unintended pregnancy are not fully protected. The most effective methods like IUDs, implants and sterilization are not user dependent. It is important to consider efficacy, side effects, costs and patient preferences when counseling on contraceptive options. Enhancing access, adherence and follow up support can help reduce unintended pregnancies.
Infertility is typically defined as the inability to achieve pregnancy after
one year of unprotected intercourse. If you have been trying to conceive
for a year or more, you should consider an infertility evaluation.
Prevalence of Maternal Morbidity in Bangladesh, 2016: A National Estimation MEASURE Evaluation
The document describes a study that aimed to estimate the prevalence of obstetric fistula (OF) and pelvic organ prolapse (POP) in Bangladesh through a validation study. The study found:
1) A screening questionnaire to identify suspected OF and POP cases was administered in both a national maternal morbidity survey (BMMS) and a validation study (MMVS) with clinical examinations.
2) In the MMVS, 149 women self-reported POP symptoms but only 28 were clinically diagnosed with 3rd/4th stage POP, indicating low diagnostic value of self-reports.
3) Sensitivity of the BMMS tool for POP was 78% but specificity was only 67%, showing many false positives. The
Unnecessary investigations in reproductive medicineAboubakr Elnashar
The document discusses unnecessary investigations in reproductive medicine. It provides examples of tests that should not be routinely performed when evaluating infertility, during IVF treatment, in cases of recurrent implantation failure, and recurrent pregnancy loss. Specific tests that are deemed unnecessary include post-coital testing, thrombophilia testing without a clinical indication, immunological testing, and advanced sperm function tests for initial infertility evaluations. The document also recommends limiting hormonal assessments during IVF cycle monitoring.
This document provides evidence-based recommendations for managing unexplained infertility. It discusses various treatment options including expectant management, oral agents with or without IUI, gonadotropins with IUI, and IVF. The key recommendations are that IUI in natural cycles or with oral agents is no more effective than expectant management. Gonadotropins with IUI can be offered but carries a higher risk of multiple pregnancy. IVF demonstrates superior pregnancy rates compared to other options and should be offered after failed ovarian stimulation cycles. Immediate IVF is recommended for women over 38 years old with unexplained infertility.
The document discusses long-acting reversible contraceptives (LARCs) available in Malaysia, including intrauterine devices (IUDs) and implants. It notes that LARC usage in Malaysia is low compared to contraceptive pills. The main types of LARCs are described - copper IUDs, hormonal IUDs, and implants. Benefits include high effectiveness, reversibility, and not requiring daily adherence. Side effects like irregular bleeding are also discussed. Religious views on spotting are provided.
This document discusses emergency contraception options. It provides details about various emergency contraception methods including the Yuzpe method, levonorgestrel pills, mifepristone, and copper IUDs. It summarizes the mechanisms of action, efficacy, side effects, and limitations of each method. The document emphasizes that emergency contraception pills and IUDs are underutilized in India but can significantly reduce unintended pregnancies and abortions if used correctly after unprotected intercourse.
Contraception, Hormones, Progestogens: Update : Dr. Jyoti agarwal Dr. Sharda ...Lifecare Centre
This document discusses oral contraceptive pills, specifically those containing progestogens like desogestrel. It provides information on the history and development of oral contraceptives, including how progestogen formulations have evolved to reduce androgenic side effects. Clinical trial results are presented showing that contraceptives containing desogestrel have good cycle control and low rates of side effects. Desogestrel is highlighted as having favorable characteristics like high selectivity and specificity for progesterone receptors over other steroid receptors.
Maternal health care situation in Bangladesh: Status and utilization of healt...Abdullah Maswood
This document summarizes a study on maternal healthcare in Bangladesh. The objectives were to analyze key causes of maternal morbidity and mortality by considering antenatal care, postnatal care, TT vaccination rates, child delivery practices, and postpartum hemorrhage. Key findings included that 63% of mothers do not receive antenatal care, 85% of births occur at home, and the maternal mortality ratio is 320 deaths per 100,000 births. Major causes of maternal death were direct obstetric complications (63.5%) and indirect medical conditions (35.5%). The conclusion was that increasing access to skilled birth attendants and institutional deliveries is needed to reduce Bangladesh's unacceptably high maternal mortality rate.
1. The document discusses new concepts in infertility including updated WHO reference values for semen analysis, the use of ICSI for male factor infertility, and success rates varying based on the cause of infertility.
2. ICSI, where surgically retrieved sperm are injected into eggs, has become an established procedure for couples with male subfertility to have a biological child, with reassuring post-natal outcomes reported so far.
3. The success of IVF depends on the type of infertility, with male factor infertility seeing live birth rates around 40% and female factor infertility around 25%, higher than other causes of infertility.
Dydrogesterone versus progesterone for luteal-phase support: systematic review and meta-analysis of randomized controlled trials
M. W. P. Barbosa, L. R. Silva, P. A. Navarro, R. A. Ferriani, C. O. Nastri and W. P. Martins
Volume 48, Issue 2, Pages 161–170
Slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15814/full
Bangladesh Maternal Mortality and Health Care Survey 2016MEASURE Evaluation
Presentation from the dissemination of the Bangladesh Maternal Mortality and health Care Survey 2016. Dhaka, Bangladesh, November 22, 2017. United States Agency for International Development; UKaid; MEASURE Evaluation, the International Centre for Diarrhoeal Disease Research, Bangladesh; Bangladesh Ministry of Health and Family Welfare, and the Bangladesh National Institute of Population Research and Training
This article discusses the use of magnesium sulfate (MgSO4) for treating severe preeclampsia and eclampsia. It summarizes evidence from the Magpie Trial showing MgSO4 significantly reduces the risk of eclampsia recurrence and maternal mortality compared to other anticonvulsants. The article reviews MgSO4 regimens, monitoring for toxicity, and the need for training health workers in developing countries on its proper use. It concludes increased availability and training on MgSO4 could help reduce eclampsia's contribution to maternal mortality.
Therapeutic startegies for human papillomavirus infection and associated cancersAdeniyiAkiseku
Human papillomavirus (HPV) infection is linked to development of cancer of cervix, vagina, vulva, penis, ano-genital and non-genital oro-pharyngeal sites. HPV being a sexually transmitted virus infects both genders equally but with higher chances of pathological outcome in women. In the absence of organized screening programs, women report HPV-infected lesions at relatively advanced stages where they are subjected to standard treatments that are not HPV-specific. HPV infection-driven lesions usually take 10–20 years for malignant progression and are preceded by well-characterized pre-cancer stages. Despite availability of window for pharmacological intervention, therapeutic that could eradicate HPV from infected lesions is currently lacking. A variety of experimental approaches have been made to address this lacuna and there has been significant progress in a number of lead molecules which are in different stages of clinical and pre-clinical development. Present review provides a brief overview of the magnitude of the problem and current status of research on promising lead molecules, formulations and therapeutic strategies that showed potential to translate to clinically-viable HPV therapeutics to counteract this reproductive health challenge
Adjuvant therapy, also known as adjunct therapy or add-on therapy, is therapy given in addition to the primary or initial therapy to maximize its effectiveness.
Add-ons have become ubiquitous with the process of assisted reproduction (ART) which is markedly more complex than it was at its inception.
Explore the intricacies of ovulation induction in intrauterine insemination (IUI) with Dr Laxmi Shrikhande's informative slide share presentation. From understanding the hormonal mechanisms to the latest techniques, this presentation offers insights into optimizing fertility through IUI. Whether you're a clinician seeking to enhance patient outcomes or an individual navigating fertility treatments, this resource provides valuable knowledge for your journey towards conception.
This document discusses preventing preterm labour. It begins by providing statistics on the incidence of preterm birth in various locations. It then discusses the magnitude of the problem, highlighting the high costs of preterm birth. Several studies on outcomes of extremely preterm infants are summarized. The document is then organized into sections on primary, secondary, and tertiary prevention of preterm labour. Key points are made about various risk factors and diagnostic tools, as well as treatments such as progesterone, cerclage and antibiotics.
Screening for and treatment of asymptomatic bacteriuria in high-risk pregnant women reduces the risk of preterm birth. However, routine screening of all pregnant women in the first trimester with urine culture is not currently recommended due to the low prevalence of asymptomatic bacteriuria in the general pregnant population and the costs of universal screening.
Community Midwifery and Prevention of Postpartum Hemorrhage_Kate Brickson_5.8.14CORE Group
This document summarizes information from a meeting on preventing postpartum hemorrhage (PPH). It discusses:
1) The leading causes of maternal death globally based on a WHO study, with severe bleeding during and after childbirth accounting for 27% of deaths.
2) MCHIP's comprehensive approach to PPH prevention, which promotes a package of interventions before, during, and after birth to prevent and manage PPH at both health facilities and in the community.
3) New WHO guidelines from 2012 that focus on uterotonic use immediately following birth to prevent PPH and allow misoprostol administration by community health workers.
This document summarizes maternal mortality in Malaysia from 1950 to 2003. Some key points:
- Maternal mortality ratio (MMR) in Malaysia declined significantly from 540/100,000 live births in 1950 to 28.1/100,000 in 2000, meeting the national goal of under 20/100,000.
- Leading causes of maternal death were postpartum hemorrhage (PPH), hypertensive disorders of pregnancy (HDP), and medical conditions like heart disease. PPH accounted for about 25% of deaths.
- Recommendations to further reduce MMR focused on increasing access to family planning, emergency transportation, treatment for conditions like PPH and HDP, and training
This document summarizes injectable contraceptives. There are two main types - progestogen-only injections which are effective for 2-3 months, and combined injections containing estrogen and progestogen effective for 1 month. Progestogen-only injections like DMPA are widely used and provide highly effective contraception through thickening cervical mucus and impairing ovulation. Combined injections like Mesigyna also suppress ovulation and are effective immediately with 1 injection. Common side effects include menstrual irregularities but are generally safe and reversible methods of contraception.
PCOD,How are they different ??Difficulties & Solutions made Easy , Dr. Sharda...Lifecare Centre
Tremendous advances and extensive human studies have uncovered the complexity and management of PCOD
Global prevalence -2.2% to 26% Roughly 1 in 15 women worldwide, (Lancet, 2007)
1. The document provides information on the emergency contraceptive ulipristal acetate (UPA), including its mechanism of action, pharmacokinetics, clinical evaluations in randomized studies, contraindications, precautions, adverse reactions and drug interactions.
2. Key points include that UPA prevents pregnancy by inhibiting or delaying ovulation and altering the endometrium; clinical trials found it to be over 99% effective in preventing pregnancy when taken as directed within 120 hours of intercourse.
3. Common adverse reactions included headache, nausea and menstrual irregularities. UPA should not be used by women with current or history of certain cancers, liver disease or high risk of arterial or venous thrombotic diseases.
This study assessed the acceptability and feasibility of menstrual regulation with medication (MRM) among early pregnant women in Bangladesh. 294 women underwent MRM using mifepristone followed by misoprostol. 91% had successful termination, with most complaining of moderate bleeding and pain. 87% found the side effects acceptable. 90% were satisfied with MRM and said they would recommend it. The study concluded MRM is a safe, effective and acceptable method for early termination in Bangladesh that could help reduce unsafe abortions.
Antibiotic in incomplete abortion by liza tarca, mdLiza Tarca
The document discusses the use of antibiotic prophylaxis for incomplete abortion. Studies show that bacterial vaginosis organisms are commonly found in cervical canals of incomplete abortion patients. Prophylactic antibiotics are recommended to prevent infection, though evidence is unclear on specific regimens. Nitroimidazoles and tetracyclines like doxycycline are good options for prophylaxis or treatment of post-abortion infection. The need for antibiotic treatment should be individualized based on risk factors.
General considerations and maternal evaluationDR MUKESH SAH
It should be axiomatic that a woman must never be penalized because she is pregnant. To ensure this, several questions should be addressed:
What management would be recommended if the woman were not pregnant?
If the proposed management is different because the woman is pregnant, can this be justified?
What are the risks versus benefits to the mother and her fetus, and are they counter to each other?
Can an individualized management plan be devised that balances benefits versus risks of any alterations?
Maternal mortality remains a significant issue worldwide, with over 500,000 deaths annually. Through initiatives like the Confidential Enquiries into Maternal Deaths system, Malaysia has significantly reduced its maternal mortality rate from 540/100,000 live births in 1950 to 28.1/100,000 in 2000. Postpartum hemorrhage is a leading cause of death in Malaysia, while medical conditions, sepsis, and hypertensive disorders also contribute substantially. Recommendations focus on increasing access to emergency care and transportation, improving provider training, and expanding family planning programs.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Similar to Program Strategies to Reduce Post-Partum Hemorrhage and Pre-Eclampsia_John Varallo_Khatidja Naithani_Rehana Gubin_4.24.13 (20)
Presentation_Behar - Private Public Partnerships and CKDuCORE Group
The document summarizes statistics and information about the sugarcane agribusiness in Mexico, including:
- It produced over 6 million tons of sugar in 2017/2018 and generated nearly 500,000 direct jobs.
- It has a complex supply chain involving sugarcane suppliers, mills, transportation, and the food industry.
- It has a legal framework including laws governing sustainable development of sugarcane and labor relations in mills.
- The government has a National Sugarcane Agribusiness Program to increase productivity and competitiveness.
Presentation_World Vision - Private Public Partnerships and CKDuCORE Group
The Fields of Hope project by World Vision Mexico seeks to prevent and reduce child labor in the sugarcane and coffee sectors in the states of Veracruz and Oaxaca. It aims to benefit 1,520 children at risk of or engaged in child labor across 24 communities and 4 municipalities. The project takes an integral approach through advocacy, collaboration with the private sector, and sensitizing communities and workers, while also promoting access to education.
Presentation_Wesseling - Private Public Partnerships and CKDuCORE Group
This document discusses the epidemic of chronic kidney disease of unknown etiology (CKDu) affecting agricultural workers along the Pacific coast of Central America. It provides evidence that the disease has an occupational etiology related to heat stress and dehydration experienced by sugarcane and other field workers. Studies show physiological changes in workers consistent with heat stress and dehydration across work shifts. Longitudinal studies find declines in kidney function over harvest seasons among heat-exposed occupations. Intervention studies reducing heat stress through water, rest, and shade have shown reduced declines in kidney function. While some non-occupational factors may also contribute, the evidence strongly suggests that prolonged occupational heat stress is a primary driver of the CKDu epidemic.
Presentation_NCDs - Private Public Partnerships and CKDuCORE Group
Non-communicable diseases like cardiovascular disease, cancer, chronic respiratory disease, and diabetes are leading causes of death and disability globally but receive little focus from global health initiatives. While communicable diseases have declined in recent decades, deaths from non-communicable diseases have increased and pose growing health and economic challenges as treatments remain limited. Experts call for greater prioritization and resources for non-communicable diseases on the global health agenda.
Presentation_HRH2030 - Opportunities to optimize and integrate CHWCORE Group
This document summarizes a conference session on integrating and optimizing community health workers (CHWs) in health systems from global and local perspectives. The session included a fishbowl-style debate where attendees were invited to discuss questions about implementing the WHO CHW Guideline recommendations, important partnerships for training CHWs, priorities for managing and supporting newly recognized CHWs, considerations for optimizing the role of CHWs, and innovations needed to shape and sustain CHWs' roles by 2030.
Presentation_Save the Children - Building Partnerships to Provide Nurturing CareCORE Group
This document discusses the experiences of a mother giving birth to a preemie baby named Becky at 30 weeks gestation. Some key points include:
- Becky spent time in the NICU and the mother felt her discharge was rushed, leaving her unprepared to deal with feeding and breathing issues at home.
- Becky faced various developmental issues over time, including low muscle tone, sensory processing disorder, autism, ADHD, and scoliosis.
- The mother advocates for increased support for preemie babies and their families, including more parent education, counseling, early intervention services, and IEP supports over time.
Presentation_Video - Building Partnerships to provide nurturing careCORE Group
This 4 minute video provides an overview of the key events in the history of the United States from 1492 to the early 2000s. It touches on major milestones like the founding of colonies, the American Revolution, westward expansion, the Civil War, industrialization, both World Wars, the Cold War, and events of the early 21st century. The video presents a high-level chronological summary of major political, economic and social developments that shaped America over the past 500+ years.
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Program Strategies to Reduce Post-Partum Hemorrhage and Pre-Eclampsia_John Varallo_Khatidja Naithani_Rehana Gubin_4.24.13
1. ProgramStrategies to Reduce Post-
PartumHemorrhage and Pre-
Eclampsia/Eclampsia: A practical
review of research findings
John Varallo, Khatidja Naithani, & Rehana Gubin
on behalf of the MCHIPMaternal Health Team
Lunchtime Roundtable
CORE Group Spring Meeting 2013
1
3. Side effects of magnesium
sulfate forPE/E management
3
IS MgSO4 A
DANGEROUS
DRUG?
4. What is PE/E?
Pre-eclampsia / eclampsia (PE/E) is a life-
threatening multisystem disorder
A common cause of maternal and perinatal
morbidity and mortality
9% of maternal deaths in Asia / Africa
25% of maternal deaths in Latin America / Caribbean
Global focus on prevention, detection and
management strategies
Expansion of use of MgSO4
4
5. Magnesiumsulfate (MgSO4)
Drug of choice for prevention and management
of eclamptic seizures
5
Significantly more effective
than diazepam or
phenytoin in preventing
seizures in PE/E
MCETG, Magpie, Cochrane
Use re-affirmed in WHO
Clinical Guidelines 2011
7. Fearthat MgSO4 is highly toxic
“We all know of many cases of death due to
MgSO4 overdose.”
“We mustn’t let lower level workers use it due to
toxicity”
“Hospitals and facilities should have calcium
gluconate available to manage overdose”
“Magnesium sulfate is a dangerous drug!”
7
8. Potential Side Effects of MgSO4
Minor - feeling of warmth, flushing, nausea
and vomiting, muscle weakness,
somnolence, dizziness, and irritation at the
injection site
More serious
Loss of patellar reflex (typically at a serum
concentration of >8 -10 mEq/L)
Respiratory depression (>15 mEq/L)
8
9. Research Questions
Incidences of side effects of absent
patellar reflex and respiratory
depression?
Frequency of use of Ca++
gluconate to counteract the effects
of MgSO4 in response to detected
side effects?
9
Frequency of skipped or delayed doses of MgSO4 in
response to development of side effects?
How many maternal deaths of women with severe PE/E
have been reported to be attributed to toxicity of MgSO4
rather than from manifestations of the underlying
disease?
10. Results Overview
Overall Outcome Rates all studies in 9556 subjects
Affected
Patella
Reflex
Respiratory
Depression
Oliguria Skipped
Dose
Calcium
Gluconate
use
Incidence 1.6% 1.3% 2.5% 3.6% 0.2%
One maternal death reported by authors as due to MgSO4
10
11. Results:
Maternal death attributed to MgSO4
0.01%
1 / 9556 women in all groups
Total maternal deaths (all causes) 91 / 9556
Authors reported that cause was severe respiratory
depression.
Woman’s serum magnesium was 24 mEq/L,
which is well above therapeutic level
Death reported in small trial with 54 participants
Magpie trial (n= 5055) had no deaths
11
12. Estimates of clinical impact
Affected
Patellar
Reflex
Respiratory
depression
Skipped or
delayed dose
Calcium
gluconate use
Incidence 1.6% 1.3% 3.6% 0.18%
NNH:
Number
needed to
harm
61 77 27 555
Scenario: Hospital delivers 5000 women annually. Assuming 5% rate of PE/E,
250 women annually will require MgSO4 in treatment
Frequency of
1 case
2.9 months 3.7 months 1.3 months 26.7 months
12
13. Routine Monitoring of MgSO4 Use
Neurologic status (level of alertness and
patellar reflexes)
Respiratory rate
Urinary output (Oliguria is element of disease
process)
Typical management of more serious side
effects: ↑ monitoring, delay next dose or
suspend MgSO4 therapy, counteraction with
calcium gluconate
13
15. Conclusions:
MgSO4 is a safe drug
Findings indicate:
Low incidence of severe side effects (1-2%)
When adverse effects occur, delaying the next
scheduled dose is generally sufficient to mitigate
the effect.
Maternal mortality directly attributable to use of
MgSO4 was extremely rare.
15
MgSO4 is NOT a dangerous drug
16. Conclusions:
Policy and Practice
Severe PE/E should be diagnosed and treated
with appropriate drugs,
MgSO4 is anticonvulsant of choice
Women under treatment with MgSO4 need
reasonable vigilance for side effects
Simple protocols should be in place to manage
side effects
All clinical leaders in maternal health should guide
adoption / use of MgSO4 as standard of care
Including ensuring adequate supply of MgSO4
16
18. What is PPH?
Blood loss >500mL in the
first 24 hours after
delivery
Severe PPH is loss of
1000mL or more.
Accurately quantifying
blood loss is difficult in
most clinical or home
settings.
Many severely anemic
women cannot tolerate
even 500 mL blood loss
19. PPH: Leading Cause of Maternal
Mortality
Hemorrhage is a leading
cause of maternal deaths
35% of global
maternal deaths
estimated 132,000
maternal deaths
14 million women in
developing countries
experience PPH—26
women every minute
34%
31%
21%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Africa Asia Latin America & the
Caribbean
Sources: Khan et al., 2006; POPPHI, 2009;
Taking Stock of Maternal, Newborn and Child
Survival, 2000–2010 Decade Report
20. PPHPrevention
1. Active management of the third stage of labor
(AMTSL)
During deliveries with a skilled provider
Prevents immediate PPH
Associated with almost 60% reduction in PPH
occurrence
1. Misoprostol
During home births without a skilled provider
Community-based counseling and distribution of
misoprostol
21. Global Context
Inclusion on 2011 WHO Essential Drug
List
Qualifications in 2012 WHO
Recommendations
“If a skilled attendant is not present, and
oxytocin is not available (such as at an
unattended home birth), lay health
workers should administer 600 mcg
of oral misoprostol.”
“There is insufficient evidence to
recommend the antenatal distribution of
misoprostol to pregnant women for self-
administration for the prevention of
PPH.”
22. Evidentiary Gaps
2012 Cochrane review noted
need for more information
on:
Feasibility of misoprostol
reaching the end-user (coverage)
Patient outcomes after use
Adverse effects from misuse
Outcomes useful to
policymakers, such as resource
utilization
23. Research Questions
What is the range of implementation
strategies for programs distributing misoprostol
for the prevention of PPH at home births?
Which strategies achieve high distribution
and coverage rates?
Do misoprostol programs adversely affect
facility birth rates?
What is the incidence of adverse outcomes for
misoprostol users, especially of mistimed
administration before birth?
24. 33
Country # enrolled # tookmiso
Afghanistan 2 039 1 350
Bangladesh 53 897 46 561
Bangladesh 1 009 884
Bangladesh 19 497 9 228
Ethiopia 500 485
Gambia 630 630
Ghana 5 345 1 261
India 812 809
Indonesia 1 322 999
Kenya 3 844 1 084
Mozambique 11 927 4 781
Nepal 18 761 13 969
Nigeria 1 875 1 421
Pakistan 534 533
Pakistan 872 678
Tanzania 12 511 1 826
Zambia 5 574 233
Zambia 31 315 Not reported
18 studies or programs
included
Not all enrolled women
received misoprostol
86,732 women took
misoprostol
12,615 were followed-up
Results presented based on
number of women on whom
condition was reported (i. e . ,
data is inco m ple te )
Results Overview
25. 34
When was misoprostol distributed?
Timing of Distribution
# programs
(n =18)
% of
programs
Any antenatal care visit (>12
weeks)
4 22.2%
Late pregnancy home visit
(28–32 weeks)
4 22.2%
Late pregnancy antenatal
care visit (>28 weeks)
3 16.7%
At home birth 10 55.6%
26. 35
Who distributed the misoprostol?
Distributing Cadre
# programs (n
=18)
% of
programs
Community health worker 5 27.8%
Traditional birth attendant 7 38.9%
Health workers/ANC providers 8 44.4%
Other (FP field worker,
community drug keeper)
2 11.1%
27. 36
Who administered the misoprostol?
Person Administering
# programs (n
=18)
% of
programs
Self-administered 11 61.1%
Traditional birth attendant 9 50.0%
Community health worker 1 5.6%
SBA or semi-skilled health
worker
3 16.7%
28. 37
Distribution rates: 21.0% – 96.6%
% of women in target population who received misoprostol
Coverage rates: 16.2% – 93.8%
% of women who delivered at home who used misoprostol
Only 10 of the 18 programs provided sufficient
information to reliably calculate coverage rates
Measuring “Success”: Distribution
and Coverage Rates
29. 38
Distribution Timing Distributing Cadre Administration Method
ANC Distribution
Home Visit
(late
pregnancy)
At home
birth
Comm-
unity
health
worker
Traditional
birth
attendant
Health
worker/
ANC
provider
Self
Traditional
birth
attendant
SBA or
semi-
skilled
health
worker
Any visit Late visit
Distribution
Rate orRate
Range
22.5–
49.1%
21.0–
26.7%
54.5–
96.6%
22.5–
83.6%
54.5–
96.6%
25.9–
86.5%
21.0–
49.1%
21.0–
96.6%
25.9–
86.5%
22.5%
Coverage
Rate orRate
Range
16.8–
65.9%
16.2–
35.9%
55.7–93.8%
16.8–
73.5%
87.9–
93.8%
35.9–
73.5%
16.2–
65.9%
16.2–
93.8%
35.9–
73.5%
16.8%
Distribution & Coverage Rates by
Implementation Strategy
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.
30. 39
Three programs (Nepal,
Afghanistan and Zambia)
reported the change in facility
birth rate in program areas
Programs were not powered to
measure a statistically
significant change
In these three programs, facility
birth rates increasedin the
target areas
No Adverse Change in Facility Birth
Rates
31. 40
Low Incidence of Adverse Outcomes
Outcomes # of occurrences
(total # of women taking
misoprostol at home
births)
Frequency
(Range)
Administration Priorto
Birth
7 (12 615) 0.06% (0%–0.23%)
Total Maternal Deaths 51 (86 732) 0.06% (0%–1.72%)
Deaths due to PPH 24 (86 732) 0.03% (0.00%–0.16%)
Deaths attributed to
misoprostol
0 (86 732) 0%
Perceived PPH 194 (72 534) 0.3% (0%–8.9%)
Otheradverse outcomes
requiring hospital referral 27 (86 732) 0.03% (0%–0.3%)
32. 41
If programs want high coverage, they should design
programs with population coverage in mind, considering:
In-home distribution, by CHWs or TBAs, and
Self-administration with adequate education & counseling.
Mistimed self-administration is rare and should not be a
reason to limit program development.
Limited available data suggest that programs do not counter
national strategies to promote facility-based births.
Ourreview suggests that ANC-only distribution
achieves 50% less coverage, so it likely does not
protect those who need coverage the most.
Conclusions forPractice
Introductions from John, Khatidja & Rehana We’re here on behalf of the entire MCHIP Maternal Health Team, led by Jeff Smith. At this roundtable, we’ll be discussing the findings of two recent publications that were led by Jeff Smith and that discuss two key maternal health commodities: magnesium sulfate for the management of pre-clampsia/eclampsia, or PE/E, and misoprostol for the prevention of postpartum hemorrhage, or PPH. We’ll be highlighting the findings that are most relevant for program managers and the steps that programs can take to incorporate these lessons into their work. As you all know, PPH and PE/E continue to be leading causes of maternal mortality in developing countries, so we think it’s helpful to have this forum to discuss them together.
Both of the articles we’re discussing were published earlier this year in BMC Pregnancy and Childbirth . They’re available for free online, and we also have copies available here. Both articles were collaborations with Venture Strategies International, or VSI, in Berkeley, California, and the PE/E article has an author from the Johns Hopkins Bloomberg School of Public Health. Judith Fullerton, a nurse-midwife and independent consultant, is the one who suggested the “integrative review” design. For those who aren’t familiar with “integrative reviews,” they’re similar to systematic reviews in that they use a pre-defined literature search strategy, but they include grey literature in addition to peer-reviewed literature, so they’re a more useful way to find and evaluate operational evidence that isn’t often published in peer-reviewed literature. We’ll talk about each article for approximately 15 minutes and then leave 30 minutes for discussion. John and Khatidja will take the first article, which examines the safety of magnesium sulfate for PE/E. Rehana will take the second article, on community-based distribution of misoprostol for the prevention of PPH at home birth.
As with any drug, we have to balance the risk of side effects with potential benefits. But we also have to have good data on side effects to appropriately estimate risk. This picture depicts a woman suffering from severe pre-eclampsia, and therefore a candidate for magnesium sulfate.
MgSO4 is an anti-convulsant. We have a copy of the 2011 WHO Clinical Guidelines here for anyone who is interested.
This shows countries’ uptake of four maternal health commodities: oxytocin and misoprostol for PPH, and magnesium sulfate and diazepam for severe PE/E. Many countries (those with both green and purple bars above the line) include both MgSO4 and diazepam as their national policy standard for severe PE/E, which creates confusion and resistance among providers who are more comfortable using diazepam, even though magnesium sulfate is the drug of choice. We are working to make magnesium sulfate the sole national standard for PE/E.
These are some common statements we hear about magnesium sulfate in the countries in which we work. Overdose and toxicity is a big concern -- but this can usually be addressed by simply delaying the next scheduled dose. The goal of our review was to systematically identify any data that might support or refute these claims.
From our review of the clinical literature on magnesium sulfate, we knew that these are the potential side effects of magnesium sulfate.
Based on the potential known side effects, we came up with these research questions and designed our literature search strategy around them. We searched for all types of prospective clinical studies where (1) magnesium sulfate was used to manage pre-eclampsia or eclampsia, (2) the study was conducted in a developing country, and (3) the study recorded the incidence of any adverse side effect resulting from magnesium sulfate use.
We included a total of 24 studies, which in the aggregate administered magnesium sulfate to 9556 women and recorded adverse events. This chart presents the overall incidence of five adverse events: affected patella reflex, respiratory depression, oliguria, skipped dose, and calcium gluconate use. As you can see, the incidence of each is extremely low!
There was only one maternal death attributed to magnesium sulfate use among the 9556 women using magnesium sulfate in these 24 studies. There were 90 maternal deaths attributed to other causes. The one attributed death was in a small trial, of a woman who had an extremely elevated serum magnesium level. A large trial with over 5000 participants reported no deaths attributed to magnesium sulfate use.
Taking the incidence rates from the previous slide, we show here the frequency of having one case experiencing these side effects in a hospital that delivers 5000 women annually and where the prevalence of PE/E is 5%, the average global prevalence. Again, these effects are rare. [John to provide explanation of the NNH row if needed.]
To manage the side effects that do occur, a few simple routine monitoring steps can be taken, including a neurologic and respiratory status check and measurement of urinary output. All of these should be performed anyway for patients with severe PE/E! For more serious side effects, magnesium sulfate therapy can be delayed or suspended, or calcium gluconate can be administered.
These picture show a patient with severe PE being monitored.
Our review concluded that magnesium sulfate should be considered a safe drug, with a low incidence of severe side effects and almost no attributable mortality. Side effects can usually be managed by simply delaying the next scheduled dose.
Our findings call for increased awareness of magnesium sulfate as the drug of choice to manage severe PE/E, and for better understanding of the actual incidence of its side effects and ways to best manage them. Clinical leaders and program staff should enable the use of magnesium sulfate as the standard of care for PE/E, a significant cause of maternal mortality.
Specifically reported for 25 study groups. Overall incidence among all 9556 women was 1.3%, with the incidence ranging from 0-8.2%. In the three studies that reported very high incidences of absent patellar reflex, the incidence of respiratory depression was less than 1%.
Use of calcium gluconate reported for 12 of the 34 subject groups. Administered only 17 times, resulting in an overall rate among 9,556 women of less than 0.2%. In one study, Ca gluconate was administered following a dosing error which resulted in administration of 4g of MgSO4 in one hour instead of four hours.
We now turn to the second article, on implementation strategies for community-based distribution of misoprostol for PPH prevention. As you all know, community-based care is essential to reach those women who don’t come to facilities. This review asked the question: what do we know about ways in which misoprostol has been distributed at the community level for the prevention of PPH at home births, which often make up the majority of births in developing countries?
First, a brief primer on PPH. It is very difficult to determine and treat PPH in most clinical settings in developing countries, let alone at home births, so we need PREVENTION .
PPH is the leading cause of maternal mortality—accounting for more than 1/3 of global maternal deaths--and disproportionately affects the developing world. Women in sub-Saharan Africa have a 1 in 39 lifetime risk of dying from pregnancy or childbirth, contrasted with 1 in 3800 in developed countries.
There are two strategies that we know prevent PPH: active management of the third stage of labor and administration of misoprostol immediately after birth. Misoprostol is the only one of the two that is possible without a skilled provider present. It can be distributed before birth and administered either by the women herself or by a person attending the birth, such as a TBA. It’s most commonly distributed as a small package of three sea-blue tablets, each 200mcg for a total dose of 600mcg.
In 2011, WHO reversed its previous position not to include misoprostol on its Model List of Essential Medicines for the prevention of PPH. In 2012, however, the WHO qualified its endorsement of misoprostol for PPH prevention by recommending its administration by CHWs but not by self-administration. The WHO stated that there was insufficient evidence to distribute misoprostol to pregnant women through antenatal care for self-administration at birth. We have a copy of these 2012 WHO Recommendations for anyone interested.
There was also a 2012 Cochrane review that requested more information on misoprostol coverage and adverse outcomes.
MCHIP and VSI were aware of a number of programs that were using community-based distribution of misoprostol both by CHWs and for self-administration at home births. We asked ourselves, what information could we collect and publish about these programs to give WHO and the global community the information they needed to feel comfortable recommending advance distribution of misoprostol for use at home births? We chose these research questions to inform our literature search strategy—only literature that was responsive to at least one of these questions was included in our review. In addition to publishing the integrative review answering these research questions, MCHIP is working closely with WHO to prepare a database of evidence on projects that are predominately using self-administration.
Through our integrative review, we identified 18 studies or programs in 14 separate countries, which had administered misoprostol to more than 86,000 women. Some of those programs were designed to follow up with a small subsample of women to obtain information about use, so we tried to identify the subpopulation of misoprostol users on whom follow-up data was collected and found 12,615 women across these 18 programs.
We found three main types of program design characteristics, what we’ve called “implementation strategies”: the timing of distributing, the person distributing the misoprostol, and the person administering the misoprostol. Some programs used more than one strategy, such as programs that distributed misoprostol at ANC and then, as a catch-all, to women at home birth. This shows the range of timing choices that programs reported using: at any ANC visit after 12 weeks, at a late pregnancy home visit, at a late ANC visit, or at the home birth itself.
This shows the range of cadres that the programs reported using—again, some programs used more than one distribution strategy and cadre, such as health workers at ANC visits and then TBAs at birth.
This shows the range of persons permitted by the program to administer the misoprostol. A majority of the programs allowed self-administration, which gave us useful information responding directly to the WHO’s concerns.
We decided that one way to measure the success of these programs was to determine how well they got misoprostol into the hands of pregnant women or providers who could use it, what we called the “distribution rate,” and also how well they got pregnant women to actually take it, what we called the “coverage rate.” More specifically, we defined the “distribution rate” as the proportion of pregnant women in a program’s catchment area who received misoprostol for PPH prevention. We defined the “coverage rate” as the proportion of women who delivered at home in the catchment area (actual or estimated) who used misoprostol for PPH prevention. As you might expect, a number of the program reports did not contain definite information about these specific numerators and denominators. In fact, only 10 of the 18 programs contained sufficient information to calculate at least one of these two rates. Part of the intent of this review was to suggest the type of data that we think programs should collect so we can build a sufficient evidence base.
When we disaggregated the few distribution and coverage rates that we could collect, we found that distribution by community workers late at home visits late in pregnancy achieved the greatest distribution and coverage. If more programs collected this information, we would have more data points to cross-reference.
One common concern about community-based misoprostol programs is that giving women misoprostol will encourage them to deliver at home and not come to facilities. The programs we reviewed did not contain much concrete data to support or refute that claim, but the three programs that did try to measure a change in facility use among misoprostol users found an increase in facility birth rates in the target areas.
Similar to magnesium sulfate, concerns persist about adverse outcomes in women using misoprostol, so we collected whatever information was available on these outcomes in the program reports. There appears to be a very low incidence of these outcomes, including the PPH that misoprostol is designed to prevent, in women using misoprostol. While there were a total of 51 deaths attributed to misoprostol among the more than 86,000 users, no maternal death was attributed to misoprostol . To the specific concern that women might take the drug at the incorrect time, and particularly taking it before birth occurs, we found that only 7 out of more than 12,000 women, or just 0.06%, reported this happening. Associating those cases with their program implementation strategies, we found that: More cases reported when distributed at any ANC visit compared to home distribution, and More cases when distributed by health worker or ANC provider compared with distribution by any other distributing cadre. Incorrect administration might not be an issue that requires ANC distribution or distribution by a skilled health provider.
Misoprostol is safe and effective for PPH prevention at home births. Programs need to be designed with population coverage in mind and consider using home visits for distribution and allowing self-administration with appropriate education and counseling. Distributing misoprostol at ANC visits only, as the WHO currently recommends, is not likely to achieve the coverage needed to protect women at home births.
We conclude with the story of our first misoprostol client, Alice, this past August in South Sudan, a country with an MMR above 2000. Alice took the 3 misoprostol tablets given to her by an attendant immediately after the delivery of the baby. She explained that she was examined on the abdomen after baby was born and, before delivery of the placenta, swallowed the misoprostol tablets with a glass of water. Alice reported that she experienced coldness, was covered by a blanket for a short time and the coldness disappeared. She had little bleeding which was normal. She is now happy with her baby. We’re continuing to gather evidence to show that community-based distribution of misoprostol works. We encourage all of you who work on misoprostol programs to look at our recommendations for the data that we think should be collected and get this data into the peer-reviewed or grey literature.
If you don’t have time to read the entire articles, we have 2-page briefs with us about each one. You can also find these briefs and other information about our PE/E and PPH programs at www.mchip.net.