Prevention of Postpartum Hemorrhage

Postpartum Hemorrhage (PPH) is excessive vaginal bleeding of greater than 500 ml after childbirth. However, even a small amount of blood loss can be life-threatening for anemic women—and the great majority of women in the developing world are anemic. 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. Notably, the majority of PPH cases occur in women without these factors and 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 active management of third stage of labor (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
Currently, MCHIP works in 11 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. (To learn more about MCHIP’s work to teach community health workers in Rwanda about misoprostol and how to educate pregnant women to recognize the danger signs of life-threatening complications, click here.)

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 PPH Activities
MCHIP is a key contributor to WHO recommendations on PPH, which are likely to be revised in the coming months to include a recommendation in support of advanced distribution of misoprostol for self-administration to prevent postpartum hemorrhage at home birth. This has come through our extensive advocacy and programmatic work in the field. USAID’s MCHIP program is implementing and/or providing technical assistance to several PPH Prevention programs currently underway- in about 13 countries- which are either introducing for country specific learning or scaling up the advanced distribution of misoprostol for self-administration to prevent PPH.

MCHIP has developed a program database which tracks a core set of indicators aimed at assuring program quality as well as generating evidence so that we may continue to learn from these important programs.  In order to help ensure appropriate standardized implementation approaches and data collection through this global database, MCHIP plans to provide technical assistance to monitor and support other similar programs. As part of the larger PPH toolkit that MCHIP continues to promote at meetings and online, is the development of a PPH Prevention/Misoprostol Program toolkit that will provide the tools, materials and guidance necessary for implementing this type of program involving community based distribution of misoprostol.  This toolkit will serve as the basis for Washington based and regional trainings whose target audience is respectively, development and humanitarian organizations seeking to implement similar PPH prevention programs.

Results
MCHIP published three briefs—on active management of the third stage of labor (AMTSL)PPH, and delayed cord clamping (DCC)—that highlight key recommendations from World Health Organization (WHO) guidelines. Aimed at program managers and staff working at all levels of the health system, these briefs explain in simple, user-friendly terms the latest best practices from WHO in maternal health.  They have been translated in Spanish, French and Portuguese and are being widely disseminated at the country level as well as at key health conferences, including the Global Maternal and Newborn Health conferences, the ICM conference in Ecuador, and the Women’s Deliver Conference.

An MCHIP article in BMC Pregnancy and Childbirth presents the results of a review of program implementation strategies for the use of misoprostol for the prevention of PPH at home birth. “Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date” co-authored by MCHIP examines the outcomes of various implementation strategies and concludes that advanced distribution of misoprostol by community health agents during home visits late in pregnancy achieved the greatest distribution and coverage rates. The findings of paper were shared at the Global Maternal Health Conference in Arusha 2013, and a research summary briefer was also produced and disseminated.  MCHIP has supported the May in-country dissemination workshop of the final results for the South Sudan PPH Prevention Program and has worked with the country team to finalize a manuscript for submission to a journal by the end of June, 2013.  Preparation of manuscripts for the other 3 PPH prevention programs is underway and in-country dissemination workshops and manuscripts are expected to be finalized before the end MCHIP Year 5.

To attempt to overcome the lack of national coverage data for the key intervention of uterotonic use in the third stage of labor (UUTSL), MCHIP convened a meeting of measurement experts in December 2012 to come to a consensus about the best approaches for estimating UUTSL. With input from these experts, MCHIP also developed a strategy document for estimating uterotonic coverage and presented this to USAID, the WHO, and selected countries.  The uterotonic estimation exercise has been conducted in Tanzania, Mozambique, and India where selected members of the Washington based MCHIP PPH Measurement Technical working group have provided support remotely and have provided in-country TA in 2 of the 3 pilot countries (India, Mozambique).  MCHIP will reconvene the panel of PPH measurement experts here at MCHIP/Washington the second week of July 2013, to share results and review final estimates on national UUTSL.  The expected outcome of this exercise is that the UUTSL strategy document- which provides detailed guidance about how to estimate uterotonic coverage using modeling approaches- can be used elsewhere to credibly estimate uterotonic coverage. MCHIP expects that through dissemination of results and of the UUTSL strategy document, country level stakeholders will be motivated to obtain better data on uterotonic coverage and advocate for its inclusion on health facility registers and in the national Health Management Information System. MCHIP also plans to use the results to advocate for increased uterotonic coverage at facility and home births.


 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

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

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.