An Integrated Approach For Prevention of PPH

Akmal Samsor

December, 2011.

Outline

• Maternal Mortality

• Causes of Maternal Mortality

• Prevention of PPH at Health Facility

• Prevention PPH at Home Births

• A world FREE from PPH mortality

Leading Causes of Maternal Death

Cause of death Developed

countries

Africa Asia LAC

Hemorrhage 13% 34% 31% 21%

Hypertensive

disorders16% 9% 9% 26%

Sepsis/infections 2% 10% 12% 8%

Abortion 8% 4% 8% 12%

Obstructed labor 0% 4% 9% 13%

Anemia 0% 4% 13% 0%

HIV/AIDS 0% 6% 0% 0%

Source: Khan et al, WHO analysis of causes of maternal death: a systematic review,

The Lancet, March 28, 2006 -- % rounded

Causes of Maternal Mortality

Indirect

14%

HIV

3%

Other direct causes

5%

unclassified

6%

Sepsis

11% Anemia 8%

Hypertensive

Disorder 10%

Hemorrhage 31%

Unsafe Abortion 5%

Obstructed Labor

7%

Source: Adapted from " WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

Skilled Care During Delivery (AMSTL)

7

Preventing PPH in Births Attended Skilled Providers

Physiologic

management

Active management OR and 95% CI

Bristol Trial 152/849 (17.9%) 50/846 (5.9%) 3.13

(95% CI 2.3 - 4.2)

Hinchingbrooke Trial 126/764 (16.5%) 51/748 (6.8%) 2·42

(95% CI 1·78-3·30) p<0·0001

Prendiville et al 1988, Rogers et al 1998.

Niger: Reduction in Post-partum Hemorrhage

8 USAID HEALTH CARE IMPROVEMENT PROJECT

Percentage of deliveries where Active Management of Third Stage of Labor -AMTSL- was

implemented in accordance to standards. Three groups of hospitals (started 2003-2004,

n=55; 2005, n=21; 2007, n=10) . Total 86 hospitals reporting 2003-2009. Ecuador.

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

% 2003-2004 0. 1514 1621 3237 3739 4142 4048 5159 5755 55 5857 6565 6168 6665 6966 6571 6463 6771 73 7681 8080 8579 7679 8679 8683 9095 9495 9795 93 8990 9495 9796 9692 9793 9391 9594 9697

% 2005 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1538 5559 4367 6277 8481 8474 7878 7984 82 8889 9389 8277 8182 8079 8487 8892 9084 8892 88 8991 8592 9592 9693 8889 9492 8891 9192

% 2007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 4044 5156 8879 9485 7693 90 8985 8987 8596 9795 9497 10 1010 9810

Jl-03AgSpOt NvDcEn FbMr ABMyJn Jl AgSpOcNvDcEnFb MrAbMyJn Jl AgSpOcNvDcEnFb MrAbMyJn Jl AgSpOcNvDcEn FbMr AbMyJn Jl AgSpOcNv DcEnFb MrAbMyJn Jl AgSpOcNvDcEnFb MrAb

2003 2004 2005 2006 2007 2008 2009

USAID HEALTH CARE IMPROVEMENT PROJECT9

Deliveries Attended by SBAs

“A woman who is pregnant has one foot in the

grave”. . .

Local Proverb, Chad

Parent Death & Child Survival in Bangladesh

Cumulative probability of survival of child to age 10 years

Father alive: 88.6%Father dead: 89.3%

Mother alive: 88.9%

Mother dead: 23.8%

Ronsmans LANCET 2010

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

Albert Einstein

New Thinking : Community Based Prevention of PPH

Components of Community Based Prevention of PPH

BCC component :

• Counseling pregnant women on BP & CR

• Danger sings of pregnancy

• Importance of presence of SBA during delivery

• Misoprostol ( use & side effects)

Enabling environment component :

• Distribution of Misoprostol at 8th month of pregnancy

• Improving the quality of AMSTL (SBM-R)

• Community mobilization to strengthen emergency transportation services

Implementation

Implementation

Evidence from community based PPH prevention

Indonesia Safety: No women took medication

at wrong time

Acceptability: women who used medication said they would recommend it and purchase the drug for future births

Feasibility: Community volunteers successfully offered information about PPH and safely distributed the medication

Effectiveness: the combination of skilled providers using oxytocin and community distribution of misoprostol allowed 94% coverage with PPH prevention method

In partnership with Depkes, POGI, IBI & supported by USAID through the MNH program

Evidence from community based PPH prevention

Afghanistan Safety: 100% took correctly after

birth including 22 sets of twins

Acceptability: 92% said they would recommend it and purchase the drug for future births

Feasibility: Community volunteers successfully offered information about PPH and safely distributed the medication

Effectiveness: the combination of skilled providers using oxytocin and community distribution of misoprostol allowed 93% coverage with PPH prevention method

Sanghvi, et al. 2009.

Evidence from community based PPH prevention

“Our wives will not die anymore because of bleeding, if they take this drug after birth of the baby and before expulsion of Baar ( placenta). We must support and encourage you. Thank you for distributing the drugto our district.”

(A community leader, Afghanistan)

Evidence from community based PPH prevention

• 18,761 pregnant women were dispensed misoprostol by FCHVs with no significant adverse events or misuse or incorrect use

• Proportion of deliveries protected by a uterotonic rose from 10.4% to 72.5%; largest gains were among the poor, illiterate and those living in remote areas

• Institutional deliveries increased from 9.9% to 16.0%

• MMR among 13,969 misoprostol users was 72/100,000; significantly lower than among non-users (304/100,000), as well as the national level of 281/100,000

Rajbhandari, Hodgins, Sanghvi, IJGO march 2010

Evidence from community based PPH prevention

• 1620 women, placebo-controlled trial

• Misoprostol: oral, stable, positive safety profile—can be used in the absence of a skilled birth attendant

• Misoprostol associated with– Reduction in PPH (12% to 6.4%; p<0.0001)

– Reduction in acute severe PPH (1.2% to 0.2%; p<0.0001)

– Decrease in mean PP blood loss (262.3 to 214.3ml; p<0.0001)

– Transitory chills and fever

Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities:

A randomized controlled trial, The Lancet, Oct. 7, 2006.

Global Policy Change

“ After consideration of the evidence for efficacy and safety , the Committee decided to add misoprostol to the List, for the prevention of PPH in settings where parenteral uterotonicsare not available or feasible”.

World Health Organization, 18th expert committee on the selection and use of essential medicines (21 to 25 March 2011 Accra, Ghana).

Vision for the future

“ A world FREEfrom PPH mortality”.

World Map in Proportion to Maternal Mortality

Integration: AMTSL & CB prevention of PPH

Integration will enable the facility based and community based health care providers to deliver quality health services;

• Team formation : • SBAs and CHWs

• Provide CHWs better leadership (SBA Vs CHS)

• SBAs better linked with the communities

• Fallow up of the MCH services clients (ANC, PNC, FP)

• Better tracking of the commodities (misoprostol, FP pills)

Integration: AMTSL & CB prevention of PPH (cont …)

• Improved Quality of counseling: • SBAs no longer doing the routine BP & CR counseling

• CHWs totally responsible for BP & CR counseling

• SBA asking each women visiting the health facility targeted questions about BP & CR– Danger sings of pregnancy ?

– Diet during pregnancy ?

– TT vaccination and why?

• Provide feedback to the visiting women

• Quality of counseling (inquiring Vs providing)

• Quality of counseling (listening Vs talking)

Currently how counseling is done ?

• IEC is the duty of every health worker

• CHW is counseling (??) a client

• SBA is counseling(??) a client

• The only time that a woman get a better counseling is, during the supervisory visits (?) (filling the checklist)

• Client just listens and providers talks (75% Vs 25%)

• No mechanism to check the quality of counseling within system only checklists (fear)

Collaboration: AMTSL & CB prevention of PPH

• Collaboration will enable different partners to deliver health services at a larger scale

• Effectiveness = Quality * Coverage

• Remaining focused by delivering quality services to achieve our goals ( Facility based Vs Community based services/ Facility based and Community based services)

Collaboration: AMTSL & CB prevention of PPH

Making this world FREE from PPH mortality ?

Can I do it ?

“NO !”

But Why ?

Change your question.

OK

Can We?

Yes, We can.

This in not a Mission Impossible

Thank you

Comments/Questions ?