PPH is excessive vaginal bleeding of greater than 500 ml after childbirth. Even a small amount of blood loss can be life-threatening for anemic women—the great majority of women in the developing world. Annually, PPH is a major cause of the more than 500,000 maternal deaths that occur, responsible for approximately 25% of all maternal deaths globally. Nearly 34% of maternal deaths in Africa and more than 30% in Asia are due to PPH.
Caused by a variety of conditions, immediate PPH—excessive bleeding directly following childbirth or within the first 24 hours—is the most common type, and 80% of immediate PPH is caused by uterine atony (failure of the uterus to contract properly after delivery). Factors that can contribute to PPH due to uterine atony are high parity, PPH in a previous delivery, a large fetus, multiple fetuses, or excessive amniotic fluid. Other causes include retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal lacerations. However, the majority of cases occur in women without these factors who otherwise have normal pregnancies and labors. “Secondary” PPH, defined as hemorrhage after the first 24 hours but less than 6 weeks postpartum, can be produced by retained placental fragments and infection.
Evidence-Based Interventions to Prevent PPH
Evidence-based interventions suitable for low-resource settings are available that reduce the incidence of PPH and can be implemented by skilled providers or trained community health workers. These include the use of AMTSL by a skilled provider, or use of misoprostol by women who give birth without a skilled provider. Uterotonics (such as oxytocin and misoprostol) cause uterine contractions and have long been used to treat uterine atony and reduce the amount of blood lost following childbirth. Use of a uterotonic drug immediately after the delivery of the newborn is one of the most important interventions to prevent PPH.
AMTSL has been shown to decrease the incidence of PPH by up to 66%. The procedure involves three basic steps: injection of a uterotonic agent (preferably oxytocin) within one minute following the delivery of the baby; delivery of the placenta with controlled cord traction and counter-traction to the uterus; and massage of the uterus after delivery of the placenta, with palpation of the uterus to assess the need for continued massage for the two hour period following delivery of the placenta.
Recent WHO recommendations approve administration of misoprostol by a health worker trained in its use for PPH prevention in the absence of a skilled provider who can perform AMTSL. Misoprostol tablets are ideally suited for PPH treatment at home births and in resource-poor settings due to their ease of use, effectiveness and safety.
Several interventions have shown the feasibility of an approach that educates women on the need for a skilled provider at birth, provides counseling on use of and distribution of misoprostol to be used in the event that the birth takes place without a skilled provider, and follows up women after birth. Findings conclude that use of skilled providers (and thus AMTSL) increases, and women who do not have access to skilled providers still have the protection against PPH afforded by misoprostol.
Using Misoprostol at Homebirths to Prevent PPH
The WHO now recommends3 administration of misoprostol by a lay health worker trained in its use for PPH prevention in the absence of a skilled birth attendant who can perform AMTSL. Misoprostol is ideally suited for PPH prevention at home births and in resource-poor settings due to its stability, ease of use, effectiveness and safety. Currently, MCHIP works in 13 African and Asian countries, using misoprostol at homebirths to prevent PPH.
Due to its high maternal mortality ratio (the highest in the world) and rate of home births, as well as limited access to health care, South Sudan was the first country in which MCHIP rolled out the community distribution of misoprostol for prevention of PPH to help reduce maternal deaths. This program has two parts—a learning phase,4 during which the Ministry of Health (MoH) questions of feasibility and program structure will be answered; and an expansion phase, during which lessons learned in the learning phase will be scaled up through MoH, USAID and other development partners. The program strengthens AMTSL and management of PPH at health facilities, combined with counseling and distribution of misoprostol by health care providers and Home Health Promoters (Community Health Workers in South Sudan) for use at home births. The intervention is being implemented in two counties of South Sudan: Mundri East and Mvolo. (To learn more about MCHIP’s work in community distribution of misoprostol in South Sudan—and how the program helped to save a mother of five—click here.)
In partnership with the MoH&Social Welfare, MCHIP in Liberia is working in two districts and 189 villages to build the skills of health workers, including their ability to provide counseling on: birth preparedness and complication readiness; referral of pregnant women for antenatal care; and counseling and distribution of misoprostol for self-administration by women at the time of birth. MCHIP is also strengthening the capacity of skilled birth attendants in provision of AMTSL as part of clean and safe delivery at health facility level.
In Rwanda, the PPH Prevention Project was implemented in four districts—Nyanza, Musanze, Gakenke, and Rubavu—by MCHIP and the Maternal and Child Health Unit of the MoH in collaboration with Venture Strategies Innovations. The project includes a phased approach in the distribution and use of misoprostol and facility level training for health providers. The program has used a combined strategy that includes: educating women on the risks of PPH; strengthening provision of AMTSL in facilities; and provision of misoprostol at home deliveries to protect women from PPH.
The introductory program to reduce the incidence of PPH is being carried out in the Fenerive East District of Madagascar, where only 13.25% of pregnant women deliver at a health facility. The goal of this program is to demonstrate that women can correctly self-administer misoprostol for prevention of PPH at home births after being educated on its use and receiving the drug at home visits, and to show that trained Community Health Workers (CHWs) can distribute misoprostol to women for home deliveries. In this project, MCHIP has trained about 92 CHVs on distribution of misoprostol and counseling on birth preparedness and complication readiness. The project has obtained its misoprostol supply from Marie Stopes/Madagascar. (To learn more about how MCHIP-trained CHWs are instructing women on misoprostol use to prevent PPH, click here.)
Key MCHIP PPH Activities
1 Rajbhandari S, et al, Expanding uterotonic protection following childbirth through community-based distribution of misoprotol: Operations research study in Nepal. Int J Gynecol Obstet (2009). doi:10.1016/j.igo 2009.11.006
2 Sanghvi H, et al, Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynecol Obst (2009). Doi:10.1016/j.igo.2009.12.003
3 WHO. 2012. WHO recommendations for the prevention and treatment of postpartum haemorrhage. WHO: Geneva.
4 The learning phase was implemented by MCHIP, Jhpiego, VSI, SIAPS, Save the Children, and the Mundri Relief and Development Association in collaboration with the Ministry of Health.