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Expert Panels [ARCHIVED] Preventing Maternal Hemorrhage: The Case of Nigeria and Tools that Can Save Lives

When: Aug. 19, 2013 - Aug. 23, 2013 | Where: Virtual, online panel at GHDonline.org Community: Site-wide

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Panelists of Preventing Maternal Hemorrhage: The Case of Nigeria and Tools that Can Save Lives and GHDonline staff

Dear Colleagues,

By the time you read through this post, at least one woman in Sub-Saharan Africa will have died from avoidable complications caused by pregnancy. It is not without reason that the United Nations has defined "Maternal Health Care" as one of the Millennium development goals: 99% of all maternal deaths occur in developing countries, and about half of these deaths occur in sub-Saharan Africa.

Worldwide, maternal hemorrhage contributes a whopping 25% to the 358,000 and more women who die annually in pregnancy or within 42 days of delivery, excluding accidental or incidental causes. (WHO). Bleeding after childbirth (postpartum haemorrhage) therefore is the single most important health issue facing obstetricians and other skilled birth attendants in countries with limited resources.

Professor Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists (FIGO) once said “women are not dying of diseases we can't treat… They are dying because societies have yet to make the decision that their lives are worth saving.” We all have to realize that maternal mortality is not just an issue for public health experts. It is a human right scandal. The women who die are our wives; they are our sisters, our daughters, and our mothers. They all have a right to quality maternal healthcare regardless of race, income or ethnicity.

Please join our expert panel discussion to discuss the situation in your country, taking a clue from the example of Nigeria, and help us collect protocols, guidelines, tools and technologies that can save lives. Panelists are:

• Chiamaka Uchegbulam, MD, is program director at the Girl Child Education and women Health Development Foundation (GEWHDF), a nonprofit that promotes girl education and women health in rural areas. Dr. Uchebulam’s work includes identifying young girls from poor background to help them achieve their dreams through education as well as raising awareness and advocating for antenatal care in remote places.

• Paschal Okoye, MD, works at the Department of Obstetrics & Gynecology at the Federal Teaching Hospital of Abakaliki in the Ebonyi State, Nigeria. Dr. Okoye has worked on community health research on awareness, attitude, and practice of cervical cancer screening (PAP SMEAR) among women.

• Meg Wirth is the founder of Maternova Inc. and Maternova Research which focus on ideas and technologies saving mothers and newborns. Meg has researched and written extensively on maternal and newborn health and is particularly interested in speeding the pace at which low-cost, effective innovations are spread globally.

Thank you in advance. Looking forward to this discussion.

Obioma Chijioke-Akaniro, MD
Scientist, Federal Ministry of Health, Nigeria
Founder, The Girl Child Education and women Health Development Foundation (GEWHDF)

 
Sandeep Saluja
Replied at 5:28 PM, 16 Aug 2013

I come from India which is famous for Taj Mahal.Many may not be aware that it is was bult in the memory of a Queen who died of post partum hemorrhage.

Onyekachi Obioma Uwaezuoke MD
Replied at 5:58 PM, 16 Aug 2013

Thank you Sandeep for sharing with us.
This topic brings a lot of emotions to bare.

In my country we have an adage which says that "maternity ward is the part of the hospital where you meet healthy people".
PPH in most cases take away "healthy women" and it's preventable with good management and extra care.
We would focus on these preventive measures.

Obioma Chijioke-Akaniro MD.

Onyekachi Obioma Uwaezuoke MD
Replied at 6:07 PM, 16 Aug 2013

In Nigeria, as in much of Africa, the situation of women at delivery is dire and deteriorating. It is a patriarchal society and the majority of women are illiterate. Doctors and nurses are stretched to the limit and unable to provide sufficient care in rural areas. The national Safe Motherhood Initiative, adopted in 1990, has failed. Around 40% of pregnant Nigerian women now experience pregnancy-related problems during or after pregnancy and childbirth. The national average maternal mortality ratio (MMR) is 800–900 per 1001000 live births. Many women do not reach health facilities until it is almost too late, and the MMR in hospitals is often higher than the national average. For example, at a hospital in Kano, Northern Nigeria the MMR is an astonishing 7523 per 1001000 live births. PPH accounts for a quarter of the 551000 annual maternal deaths in Nigeria. The Nigerian Federal Ministry of Health has recognised this growing problem: “failure to factor population figures in earlier planning ... has led to the provision of inadequate facilities for the teeming and increasing population”.1 Between 1990 and 2003, the percentage of deliveries attended by a trained person fell from 45% to 36.3%, and the use of modern contraceptives also declined (12% to 8%). It is clear that new strategies are needed to reverse these trends and reduce maternal mortality in Nigeria.

Attached resources:

    Link leads to: http://bixby.berkeley.edu/tackling-the-unacceptable-nigeria-approves-misoprostol-for-postpartum-haemorrhage/

    Link leads to: http://www.uptodate.com/contents/overview-of-postpartum-hemorrhage

Chiamaka Uchegbulam
Replied at 12:33 AM, 17 Aug 2013

According to World Health Organisation, the numbers of women dying in pregnancy and childbirth in Nigeria are among the highest in the world.
Postpartum hemorrhage is a leading cause of maternal mortality accounting for nearly one quarter of maternal deaths worldwide (WHO 2006).

In Nigeria, low use of antenatal care and delivery services contribute greatly to maternal hemorrhage.

Also, for women who actually seek care, the quality of rendered service is affected by lack of trained personnel, lack of essential equipment and other factors.

For these reasons proper education of the public on preventive measures is key to reducing the morbidity and mortality rates in Nigeria.

Attached resources:

Joseph Aghatise
Replied at 2:47 AM, 17 Aug 2013

This topic brings back my memories of 11th May 2013. This was a personal experience with my wife on the day she had our twin babies, but thank God she survived it after infusing 10 pints of blood.

Availability of patient's medical history is vital prior to delivery. I will be willing to share from my sad experience.

Joseph Aghatise
Replied at 3:00 AM, 17 Aug 2013

I agree with Onyekachi on preventive measures. From my sad experience, I would say two major things contribute to high rate of PPH. First lack of adequate patient's medical history and attitude of medical personnel to managing patients.

I also notice that it is a practice in some hospitals in Nigeria to deprive patients from having access to their 'case notes' or medical files, so when they change medical facility, it becomes very difficult to share what their medical conditions are from the outcome of previous clinical consultations.

Onyekachi Obioma Uwaezuoke MD
Replied at 3:25 AM, 17 Aug 2013

Joseph, thank you for opting to share your story with us during this panel.
Thankful that she survived.
This shows the importance of making cross matched blood available for every woman about to put to bed. It can be a life saver.

I remember making a comment when a woman passed on due to PPH, " she didn't do anything to deserve this, she only took in, which is supposed to be good news".
Her husband was torn in between crying and running up and down to get formula for the newborn baby. He told the neonatal department that he would leave his baby in the incubator and travel to bury his wife first.

These things are preventable;
We would talk about the preventive measures this week.
Thank you.

Obioma Chijioke-Akaniro MD.

Onyekachi Obioma Uwaezuoke MD
Replied at 3:41 AM, 17 Aug 2013

Joseph I believe that a patient should have access to her records. She should also be made to know what her condition is.
In Ukraine, a woman carries a copy of her case note which contains every detail of her and the fetus and all the test results including coagulation time. Previous complications and what she's at risk of.
You must present it to the hospital where you will be delivered of your baby. This will make them to be prepared for you.

We are talking about the life of the woman and and precaution that can be taken to preserve her is important.

Joseph Aghatise
Replied at 3:58 AM, 17 Aug 2013

Thank you Onyekachi, lets see how best we can deliberate on this with a view to providing workable preventive measures for Nigerian women.

Paschal Okoye
Replied at 4:13 AM, 17 Aug 2013

Obstetric haemorrhage is a leading cause of maternal mortality in West Africa about 25-30%.Yet it is the most preventable direct cause of maternal mortality. It is also a major contributor to perinatal mortality.
Whether or not a woman dies from haemorrhage depends largely on access to timely and competent obstetric care.
It must therefore be a point of emphasis to antenatal women that any vaginal bleeding is potentially dangerous , and must be reported to a skilled care provider without delay
In developed countries such as the United States and UK,obstetric haemorrhage currently ranks as the third and fourth leading cause of maternal mortality respectively.In contrast,in developing countries such as Turkey,Saudi Arabia,South Africa,Ghana and Nigeria,the leading cause of maternal mortality remains primary postpartum haemorrhage,which accounts for 25-43% of all maternal deaths.

Seun Adebiyi
Replied at 5:26 AM, 17 Aug 2013

What time is the panel please?

Onyekachi Obioma Uwaezuoke MD
Replied at 6:09 AM, 17 Aug 2013

Seun the panel starts on Monday (19th August) to friday.


Obioma Chijioke-Akaniro MD.

Morroson Sinvula
Replied at 1:46 PM, 18 Aug 2013

Maternal Mortality in Botswana is a public health crisis. Botswana is unique. Over 95% of pregnant women access antenatal services; over 98% deliver in hospitals or clinics with maternity and so skilled attendance at delivery is a non-issue here AND yet the maternal mortality rate is unacceptably high(163/100 000 in 2010 and 189/100 000 in 2011). The killers are still notoriously like anywhere else where maternal mortality is high(PPH, complications of hypertensive disorders in pregnancy and abortion0. Protocols are available, clear and they do work. There is no issue of home deliveries here and almost all(98%) maternal deaths occur in health institutions.
Most women here seek ANC and do not have issues with seeking help when problems or complications arise. In any case, there have been a huge investment from government in accessing health. Over 85% of the population live within 15km of a health facility..
There generally seems to be trust in health services
The road infrastructure is good. There are very few areas where accessibility is of concern and we are now thinking of maternity homes or early admissions to tackle this problem. The centralized transport system and over-reliance on government to provide transport and ambulance system is worrying BUT does not seem to significantly contribute to maternal mortality rate. Despite shortcomings transportation is reasonable well managed.
Over 98% of pregnancy related deaths occur in hospitals. This is where things go wrong. We are a relatively small country with a population of just over 2 000 000. There are on average 45-47000 deliveries annually. Though our health model was designed on primary healthcare we have over the years slowly shifted towards treatment and paid less emphasis on disease prevention. We literary wait for the sick to come to us in our nice hospitals for cure. This is futile as quite often the patients find us "with our pants down". There is a huge attitude problem among health providers.
The medical population is predominantly expatriate and we should be thankful for their help, and in fact without these foreigners the situation would be futile. I strongly believe that the we should invest heavily in educating, training and grooming of citizen professionals for a sustainable public health. Maternal mortality would be reduced by a group of nationals dedicated on positive change and working with our expatriate friends.
Achieving MDG target should be easy for Botswana. We need attitude change in health workers.

Morrison Sinvula
Coordinator-National Maternal Mortality Reduction Initiative
Former Medical Superintendent(Nyangabgwe Referral Hosp, Sekgoma Memorial Hosp
Former acting Director/Permanent Secretary, Ministry of Health Botswana

Onyekachi Obioma Uwaezuoke MD
Replied at 3:11 PM, 18 Aug 2013

Hi Morroson.
Thank you for sharing Botswana's experience with us.
In this case, the patient has kept her own side of the deal but the health worker is yet to.
When I hear about health workers attitude it baffles me because I know we all took oaths. What was the oath for? Was it a criterium for certificate collection or is it for saving lives.
It still boils down to the question I heard in GHDI program, " is healthcare a right or a privilege?"
Just the mortality rate should put everyone on their feet, we are not doing them a favour, it's their right.

I agree with Morroson, attitudes should be looked into.


Obioma Chijioke-Akaniro MD.

Chiamaka Uchegbulam
Replied at 7:11 AM, 19 Aug 2013

Maternal haemorrhage: Postpartum haemorrhage
Post-partum haemorrhage (PPH) is a clinical problem of indisputable importance to patients, clinicians and to those interested in achieving equity in reproductive health. As a condition it is almost always associated with meaningful implications to patients. Even the mild self-limiting cases have consequences for the patient’s puerperium in the form of fatigue, tiredness, failure to breast-feed and possible need for haematinics or blood transfusion. All are symptoms and consequences of anaemia and acute blood loss.
What actually is the definition of PPH?
Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
The definition of PPH indeed has stood the test of time, it was once defined as blood loss more than 500ml, but this would not apply in countries where severe anaemia is common and blood loss as little as 250ml would constitute a clinical problem.
PPH CAN BE CLASSIFIED INTO:
a)PRIMARY: WITHIN 24 hrs of Child Birth
SECONDARY: 24hrs-12 weeks
b)Mild(500-1000ml) , Moderate(1000-2000 ml) or Severe(greater than 2000ml)
What are the Major Causes of PPH?
1) Uterine Atony
2) Abnormal placentation
3) Obstetric trauma
4) Coagulopathies

Interestingly all of these causes can be properly managed, which means death as a result of postpartum hemorrhage can be prevented if and when managed properly.

Onyekachi Obioma Uwaezuoke MD
Replied at 7:46 AM, 19 Aug 2013

In Nigeria, I have observed that attention is not given to clotting time/ factors.
Most coagulopathies are discovered in labour or in the theatre.
Women with this are at great risk of PPH and they go through antenatal clinic without it being detected.
When it's stumbled upon during delivery it becomes a matter of emergency. Within this you will hear that there's no blood in the bank for her.
The husband starts scouting for a relation to donate blood. There and then the story tends towards the bad news.

Clotting time or coagulopathy check should be part of antenatal clinic .





Obioma Chijioke-Akaniro MD.

Chiamaka Uchegbulam
Replied at 8:41 AM, 19 Aug 2013

I agree with you. So far with my work I have observed that mortality and morbidity as a result of maternal hemorrhage are factors not of difficulty to manage but of carelessness on the side of the physician and unawareness on the patients end... More time has to be spent educating women on their rights and duties.

Joseph Aghatise
Replied at 9:27 AM, 19 Aug 2013

Thank you Morroson. The first issue we should all try to address is the patient-provider relationship. Yes, there are very good Doctors in public hospitals like in Nigeria, but the doctors are 'small gods' to their patients. The are simply after the 'big' clients and those who cannot afford AMENITY ward are left to their fate.

Here is what I think we should work on:
1. Doctor-patient relationship
2. Discourage VIP/AMENITY wards in all public hospitals so the best doctors could also attend to 'common' patients.
3. Work around electronic health records system for ANC patients.

In my wife's case, my previous relationship with the facility did the magic. I was able to pull together about six (6) doctors and a visiting consultant.

Meg Wirth
Replied at 10:01 AM, 19 Aug 2013

I am very interested in how innovation can change the odds for women, particularly in the case of postpartum hemorrhage, but also eclampsia and sepsis.

I am interested in the subject of Clotting time or coagulopathy check-- so often you hear from those on the 'policy' side of things that postpartum hemorrhage cannot be predicted in any way--that we must have emergency obstetric care available for every woman at any time.

But this is not entirely the case.. for example if a woman is severely anemic or if a woman has had prior c-section, she has certain greater risks.

Are there any studies ongoing in Nigeria to look at the feasibility of testing clotting time and coagulopathy in women during ANC?

Meg Wirth
Replied at 10:51 AM, 19 Aug 2013

Thank you very much Morrison Sinvula for the analysis of the situation in Botswana as well. There are other countries who have very high antenatal care coverage but poor maternal mortality statistics. Your idea of citizen professionals is a good one. A lot of effort goes into teaching women danger signs of postpartum hemorrhage-- but there have to be interim measures for during transport.. recognizing the signs is probably not enough! Citizen professionals could know early techniques like putting in an IV, administering
misoprostol, potentially even being trained in the condom balloon tamponade methods and the non-pneumatic anti-shock garment.

Onyekachi Obioma Uwaezuoke MD
Replied at 11:44 AM, 19 Aug 2013

Dear Meg,
I have not seen any yet. From my research we've had one to check the effect of pregnancy on clotting factors. I will post the link below
Checking clotting time in ANC has really been down played. I had two of my kids in here and was never checked to note that.
I believe it is important.


Obioma Chijioke-Akaniro MD.

Onyekachi Obioma Uwaezuoke MD
Replied at 11:54 AM, 19 Aug 2013

Influence of Pregnancy and Gestation Period on Some Coagulation Parameters among Nigerian Antenatal Women

http://www.medwelljournals.com/abstract/?doi=rjmsci.2008.275.281


Obioma Chijioke-Akaniro MD.

Onyekachi Obioma Uwaezuoke MD
Replied at 11:57 AM, 19 Aug 2013

You are right Joseph. How many people can pull Doctors like that?
Everyone should be treated well as much as possible.


Obioma Chijioke-Akaniro MD.

Chidiebere Okezie
Replied at 12:02 PM, 19 Aug 2013

I think educating people most especially those dwelling in the rural areas and the illiterates amongst the general public and most especially ladies of child breaking age could help reduce the risk and occurrence of post partum hemorrhage because most mothers living in sub Saharan Africa prefer giving birth at home or do not even know or understand the importance of ANC and some health care providers don't follow the guidelines for the prophylaxis of PPH (active management of the 3rd stage of labour.

nancy nhendodzashe
Replied at 12:15 PM, 19 Aug 2013

If we engage medical librarians, we can actually reduce the challenge.
Lack of information affects people's health decisions

Meg Wirth
Replied at 12:20 PM, 19 Aug 2013

Nancy
Thanks for your comments.. do you see this working in Nigeria--this is a great concept. Lack of information is extremely important.. particularly in obstetric emergencies.. how to predict, how to handle them.

nancy nhendodzashe
Replied at 12:29 PM, 19 Aug 2013

Librarians should work closely with health promotets and educators and have
some sort of reading circles around obstetric emergencies. At times some
problems do not require the services of a practitioner but just relevant
information.

Onyekachi Obioma Uwaezuoke MD
Replied at 1:12 PM, 19 Aug 2013

Yes Chidi, educating the two parties are important.
In the rural areas, the health care worker has to be patient to break these things down to make them understand. Avoid medical terms.

But in Nigeria. An average health care worker wouldn't want to be posted to the suburbs. Everyone likes the city. This makes these areas to lack skilled hands.
In one of the cases we treated in GHDI, the use of community health workers may be of help. These people can be recruited and trained to spread the news.
I really believe that NGOs are the only ones to effectively run this program if we must have results with community health workers.

Obioma Chijioke-Akaniro MD.

Sophie Beauvais
Replied at 2:26 PM, 19 Aug 2013

Dear All,

Thank you for a great start at this panel discussion, and to all for sharing your professional and personal experiences with maternal hemorrhage, the situation in Nigeria and other countries, as well as posting tools and resources that can save mothers' lives.

I have found a few resources that I wanted to share here.

Scaling up Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Action. 2012: A policy brief published by Family Care International in partnership with Gynuity Health Projects, PATH, and FIGO, explores strategies to help governments and partners improve maternal health by expanding access to misoprostol for postpartum hemorrhage (PPH).

> Key strategies for introducing and expanding access to misoprostol for PPH treatment and prevention include:
• Creating a supportive national policy
• Providing national guidance and training
• Ensuring consistent supply and distribution
• Building community awareness and demand

Available in English – PDF: http://www.familycareintl.org/UserFiles/File/Miso_PolicyBrief_ENG_web.pdf

> Disponible en Français: http://www.familycareintl.org/UserFiles/File/Miso_PolicyBrief_FR_web.pdf

Cette note d’information stratégique, publié par la FCI en partenariat avec Gynuity Health Projects, PATH, et la FIGO, explore des stratégies pour aider les gouvernements et les partenaires améliorer la santé maternelle en élargissant l'accès au misoprostol pour l'hémorragie du post-partum (HPP), l'une des principales causes de mortalité maternelle. Les principales stratégies pour introduire et élargir l'accès au misoprostol pour le traitement et la prévention de l'HPP comprennent:
• Mettre en place une politique nationale favorable
• Inclure le misoprostol dans les budgets nationaux pour la santé
• Préparer et diffuser des directives cliniques au niveau national
• Former les prestataires de santé
• Assurer un approvisionnement et une distribution constants
• Sensibiliser les communautés et renforcer leur demande

Also by Amy Boldosser-Boesch, Family Care International: A May 8, 2013 PowerPoint presentation with lessons learned on the use of Misoprostol in Tanzania, Uganda, and Somaliland: http://www.familycareintl.org/UserFiles/File/Advocacy,%20Approval,%20Access%2...

Last, 3 publications on the use of misoprostol in Nigeria from Venture Strategies Innovations. In 2006, Nigeria became the first country in the world to approve the use of generic misoprostol tablets for control of postpartum hemorrhage; and in 2011, misoprostol was approved for use in postabortion care (PAC).

1. Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria
Abstract: Focusing on the community-oriented approach, this article highlights the successful results of an operations research program assessing the safety and feasibility of community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in five communities around Zaria, Nigeria.
http://vsinnovations.org/assets/files/Published%20Articles/Prata%20et%20al;%2...

2. Saving Women's Lives: Nigeria
Abstract: In Nigeria - the most populous country in Africa - women have a 1 in 23 lifetime risk of dying from maternal causes; an estimated 23,000 mothers die each year due to excessive bleeding after childbirth, or postpartum hemorrhage (PPH), and the vast majority deliver at home.
http://vsinnovations.org/assets/files/Program%20Briefs/SWL-Nigeria%202010%201...

3. Prevention of Postpartum Hemorrhage in Northern Nigeria
Postpartum hemorrhage (PPH) makes a significant contribution to the number of maternal deaths in Nigeria. This brief summarizes research demonstrating misoprostol is a safe and effective means to control PPH at home births in five communities in Northern Nigeria.
http://vsinnovations.org/assets/files/Program%20Briefs/VSI_PRHP%20Miso%20PPH%...

Adenrele Adebisi
Replied at 6:32 PM, 19 Aug 2013

A number of factors contribute to PPH especially in Nigeria. These range from lack of accessible health facilities, trained health care worker, non availability of health centers with emergency obstetric care, to women refusing to use health facilities, religious and community believe about delivery, level of education, occupation, economic status etc. These factors must be addressed adequately to prevent postpartum hemorrhage.
Primary prevention of PPH with the use of active management of the third stage of labour is important, as a good number of health care workers in rural areas are not aware of the component of these management, training and retraining, information dissemination necessary.
Traditional birth attendants constitute another major obstacle, efforts are ongoing in different areas to collaborate with them.
A national guideline will be good though.

Attached resources:

Paschal Okoye
Replied at 7:58 PM, 19 Aug 2013

It is also important to explore Antepartum hemorrhage (APH).APH just like any other obstetric emergency carries an increased risk of maternal and perinatal morbidity and mortality. The risk increases because the obstetrician is managing at least two individuals,the fetus(es) and the mother.An attempt is made to optimise the outcome for both of them.
It complicates 3-4% of all pregnancies.
It is classified into:
1.Placenta praevia
2.Abruptio placentae
3.Local causes(polyps,friable condyloma acuminata,cervicitis,carcinoma of the cervix
4.Vasa praevia.)
PLACENTA PRAEVIA. It is
It is defined as placenta that is wholly or partially located at the lower uterine segment. It constitutes 30% of APH
PP is classified into 4 types :1-1V
1.placenta is partially located in the lower segment but does not reach the internal os
11.Placenta is attached to the lower segment with its lower margin reaching the internal os but does not cross it(divided into a and b,ie,anterior and posterior respectively)
111.Placenta eccentrically reaches the internal os and crosses to the other side but does not completely cover the os.
1V.Placenta completely covers the internal os when the cervix is dilated or not dilated
Predisposing factors include:
I .Faulty implantation of the ovum
ii .High parity
iii .Advanced age
iv .Uterine fibroid
v .Large placental surface
vi .Previous uterine surgery including caesarean section
vii .Intrauterine synechiae
viii .Abnormality of endometrial vascularisation
ABRUPTIO PLACENTAE
It is the premature separation of a normally situated placenta before delivery of the fetus. Bleeding could be revealed or concealed.
The incidence is approximately 1.1% in Korle Bu Teaching Hospital,Accra and nearly 95% results in perinatal death.
It constitutes 25% of APH
Predisposing factors
I. Hypertention
ii. Severe pre-eclampsia and eclampsia
iii. Direct trauma
iv. High parity
v. Advanced maternal age
vi. Low socio-economic status
vii. Polyhydramnios
viii. multiple pregnancy
ix. Uterine Fibroids
x. Short umbilical cord
xi. Chorioamnionitis
Vasa praevia
It is bleeding from fetal vessels
It often results from velamentous insertion of the umbilical cord.
The incidence is approximately 1 per 5000 singleton deliveries

References

1. Benedetti T.J: Obtetric Haemorrhage.P 573.In Gabbe SG, Neibyl JR,Simpson JL(eds).Obstetrics:Normal and Problem Pregnancies 2nd Ed.Churchill LivingStone,New York,1991
2. Akin Agboola.Textbook of Obstetric and Gynaecology for medical Student 2nd Ed
3.
Offiong RA.Obstetric Hemorrhage:West African College of Surgeon Postgraduate Update course April 2013

Paschal Okoye
Replied at 10:27 AM, 20 Aug 2013

In the 5-year study carried out in Obafemi Awolowo University Ile Ife Osun State Nigeria,PPH represents 1.68% of the total vaginal deliveries .Primary PPH constituted 67.87% while secondary PPH constituted 32.14%.PPH occured in 12% of booked patients while 88% occured in unbooked and booked patients that delivered outside the facility.
It was also found out that the commonest cause of PPH in the hospital was retained placenta which accounted for 78.5% of all cases of PPH.This was followed by uterine atony 10.71%.That due to injuries was11.84%.Only one patient was managed for DIC.
Apart from the basic intervention offered , 1.79% had hysterectomy when attempts at stopping the haemorrhage failed , while 45.5% of cases had blood transfusion.There were 6 maternal deaths.
Culled from- Afr Health Sci.2010 March ; 10 (1) : 71 - 74

Paschal Okoye
Replied at 10:48 AM, 20 Aug 2013

This study explains why effort should be made to reduce morbidity and mortality from PPH.
Every attendantat delivery needs to have knowledge,skills and critical judgement required to carry out active management of 3rd stage of labour and have access to appropriate supplies and equipment .However expectant management of 3rd stage of labour should be discouraged.
Women should be encouraged to make use of existing health facilities by booking and receiving antenatal care.
Traditional Birth attendants should be made to know their limits and possibly teach them the active management of 3rd stage of labour.
Placenta should be examined after its delivery to minimize the risk of retained placenta
Genital tract should be promptly examined to rule out laceration.
Prophylaxis with oxytocin infusion helps prevent uterine atony

Paschal Okoye
Replied at 10:52 AM, 20 Aug 2013

I think its time to also look at prevention of APH.We have dwelt more on the prevention of PPH

Chiamaka Uchegbulam
Replied at 11:09 AM, 20 Aug 2013

Thank you so much pascal, and yes I agree with antepartum hemorrhage is also very important and a matter of great concern, I think preventing antepartum hemorrhage still boils down to reporting any sign to the physician on time and also for proper diagnostic measures to be carried out by the physician.

Meg Wirth
Replied at 11:19 AM, 20 Aug 2013

Thank you very much for sharing the study from Obafemi Awolowo University Ile Ife Osun State Nigeria,PPH. The level of retained placenta is very high!

Meg Wirth
Replied at 11:35 AM, 20 Aug 2013

As most ob/gyns will know, a final step after uterotonics, aortic compression, bimanual compression, etc. is the uterine balloon tamponade. Many of the commercially available uterine balloon tamponades (UBT) cost several hundred U.S. dollars.

As many will know (but not all!), a rather brilliant do-it-yourself version of the tamponade using a condom tied around IV tubing and infused with water or IV fluid, making a balloon that pushes against the walls of the uterus to achieve haemostasis. The condom balloon method has been used in Ghana, South Sudan, parts of Nigeria, parts of Tanzania, parts of Nepal, India and Pakistan. We do talk with obstetricians and midwives every month who are not yet aware of this method--which can indeed prevent the need for a hysterectomy--or worse, death.

At Maternova we are looking at the evidence on the condom balloon tamponade and creating a new VISUAL protocol based on an Ad hoc advisory committee --the protocol is now being tested in Tanzania.

Chiamaka Uchegbulam
Replied at 11:36 AM, 20 Aug 2013

In an attempt to reduce maternal mortality due to placenta previa, doctors carry out ultrasound scan for placenta presentation in the mid trimester more readily to pregnant women, especially for those who have risk factors.
Knowledge of risk factors is also essential.

Chiamaka Uchegbulam
Replied at 11:51 AM, 20 Aug 2013

Thank you so much meg, yes that is a method that should be encouraged and it is also cheap and relatively easy to perform, i recently saw a video showing how to perform the procedure so i believe there is ongoing work, but definitely more has to be done especially in Nigeria.
I think that every woman, especially those with high risk of postpartum hemorrhage ought to have access to a uterine balloon.

Meg Wirth
Replied at 12:03 PM, 20 Aug 2013

We would like to be sure that everyone knows about the terrific resources listed on the Global Library of Women's Medicine here:

They have an excellent WALL CHART on he management of postpartum hemorrhage

They have a great patient guide on warning signs here

For experts they have a FREE online TEXT book on Postpartum hemorrhage

Attached resources:

Meg Wirth
Replied at 12:21 PM, 20 Aug 2013

So glad that Chiamaka Uchegbulam notes the need for widespread knowledge of the condom balloon tamponade method. There are some who will note the danger associated with inserting an inflated condom filled with liquid (danger of infection) and even more dangerous--taking it out too early.

HOWEVER, this method can save lives where surgery is simply not an option and/or where nothing else has worked.

We are haunted by the case in Uganda where a husband brought his wife to the hospital and begged the nurses to attend to her (they were watching t.v.). She died slowly on the table in her own blood. Those of us on this discussion know this happens every day.

Like the way that CPR was rolled out to the general public, there simply have to be more interim methods that the general public and others know about UNTIL there are enough midwives and ob/gyns to cover the population. The CBT method may be one of those methods.

We also are tracking several efforts to create an ultra low cost uterine balloon that would inflate with AIR, making it even safer.

If the Ugandan woman's husband had even seen a poster on the wall he could have saved the life of his wife.

A recent paper published by a team working in South Sudan showed that even community health workers can use a simple method of the condom balloon tamponade (filling a tube with water and a syringe)!!!

Pierrette Cazeau
Replied at 12:54 PM, 20 Aug 2013

Thank you very much for sharing it with the rest of us.

Paschal Okoye
Replied at 5:12 AM, 21 Aug 2013

Meg, yes that was the finding in Obafemi Awolowo University.In our centre,uterine atony is common.This is because a reasonable number of pregnant mothers were unbooked and presented as emergencies.They prefered to patronize traditional birth attendants and faith churches.
I think that proper enlightenment campaign should be carried out to educate women, especially those in the villages, on the importance of antenatal care.

Paschal Okoye
Replied at 6:29 AM, 21 Aug 2013

Thank you very much Meg.I have heard about UBT but have not seen it used in my centre.may be i will be the one to introduce it.
Condom filled with water is a good improviso.
I think its better to save life first and then treat any infection that might result from the procedure .

Onyekachi Obioma Uwaezuoke MD
Replied at 7:40 AM, 21 Aug 2013

Meg, when you mentioned CPR, I was touched.
Rolling out CPR to the public has saved thousands of people. This shows that when we are determined to carry everyone along in the fight against something, it works better.

I believe that at the end of this panel we would arrive on points that can help in saving the lives of our women.

Obioma Chijioke-Akaniro MD.

Chiamaka Uchegbulam
Replied at 8:32 AM, 21 Aug 2013

Yes meg, the balloon tamponade method is definitely a good idea,

Presently in Nigeria and prospectively in other parts of Africa, Gewhdf a volunteer organisation for women and girl children, organises campaigns for volunteer Health workers to educate women on :

- proper antenatal care
- possible risk factors of both APH and PPH
- early signs and what to do next

Also we organise training program's to teach community health workers on the proper ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR.

This I believe should be promoted in every state in Nigeria.

Kristyn Zalota
Replied at 11:06 AM, 21 Aug 2013

Wonderful discussion. I have learned so much. The women that I work with in Laos have little access to trained practitioners or clinics. We are working to spread information to women and girls in remote villages about hygienic birthing practices, warning signs in pregnancy and postpartum. We fund nurses to train a local woman in each village to be the "oracle" of information about safe birthing practices. One of their roles is to refer women who are at risk of complications to clinics before it is too late. At the moment, however, these volunteers are not trained in life-saving techniques. That is a future goal. Thanks for sharing all of this information about ways to improve women's and babies' chances for survival.

Pierrette Cazeau
Replied at 12:18 PM, 21 Aug 2013

Thank you for sharing this article with us. Since Haiti fall into the third world category which most third world countries are facing I will be very happy if Dr Paul Farmer will read your article and see if he could applied some kinds of help to reduce Postpartum haemorrhage in Haiti.

Chiamaka Uchegbulam
Replied at 4:03 PM, 21 Aug 2013

Yes, I'm certain not only Haiti would benefit from this panel but other third world countries facing the same difficulty.

Chiamaka Uchegbulam
Replied at 4:11 PM, 21 Aug 2013

The best preventive strategy is active management of the third stage of labor

Hospital guidelines encouraging this practice have resulted in significant reductions in the incidence of massive haemorrhage.

Active management, which involves administering a uterotonic drug with or soon after the delivery of the anterior shoulder, controlled cord traction, and, usually, early cord clamping and cutting, decreases the risk of postpartum hemorrhage and shortens the third stage of labor with no significant increase in the risk of retained placenta.

Compared with expectant management, in which the placenta is allowed to separate spontaneously aided only by gravity or nipple stimulation, active management decreases the incidence of postpartum hemorrhage by 68 percent.

Early cord clamping is no longer included in the International Federation of Gynecology and Obstetrics (FIGO) definition of active management of the third stage of labor, and uterine massage after delivery of the placenta has been added.

Delaying cord clamping for about 60 seconds has the benefit of increasing iron stores and decreasing anemia, which is especially important in preterm infants and in low-resource settings.The delay has not been shown to increase neonatal morbidity or maternal blood loss.

Prophylactic administration of oxytocin (Pitocin) reduces rates of postpartum hemorrhage by 40 percent; this reduction also occurs if oxytocin is given after placental delivery.
Oxytocin is the drug of choice for preventing postpartum hemorrhage because it is at least as effective as ergot alkaloids or prostaglandins and has fewer side effects.

Misoprostol (Cytotec) has a role in the prevention of postpartum haemorrhage ,this agent has more side effects but is inexpensive, heat- and light-stable, and requires no syringes.

Pierrette Cazeau
Replied at 4:33 PM, 21 Aug 2013

Chiamaka Uchegbulam Yes I would love for other third countries will benefit as well.

@ Joseph you made a good point by involving physicians and patients to create a bond among both parties that will also reduce the cost of both mother and newborn.
@Nancy Nhendodzashoe you made such great point by having the idea of medical library that will also educate and save lives but as you could see certain countries that have electricity and economic crisis like Haiti this will benefit to a point and will not benefit to another point the fact not having the privilege of electricity for them to read the material and also to educate their peers other controversy could be came across first language barriers and also how they could applied what they have learn from a medical library

Pierrette Cazeau
Replied at 4:35 PM, 21 Aug 2013

Chiamaka Uchegbulam Yes I would love for other third countries will benefit as well.

@ Joseph you made a good point by involving physicians and patients to create a bond among both parties that will also reduce the cost of both mother and newborn.
@Nancy Nhendodzashoe you made such great point by having the idea of medical library that will also educate and save lives but as you could see certain countries that have electricity and economic crisis like Haiti this will benefit to a point and will not benefit to another point the fact not having the privilege of electricity for them to read the material and also to educate their peers other controversy could be came across first language barriers and also how they could applied what they have learn from a medical library

Onyekachi Obioma Uwaezuoke MD
Replied at 2:57 AM, 22 Aug 2013

We know that no matter what is done a lot of women in the rural area would still patronise delivery homes. These homes have birth attendants who were trained by generations. I mean by their grand mums or mums who practise by talent and culture.

They tend to trust these attendants because they are seen as skilled.
We have to incorporate these attendants into the plan by teaching them the ABC of managing haemorrhage.
That's why I believe the post of making balloon tamponade lesson available just like CPR.

Onyekachi Obioma Uwaezuoke MD
Replied at 3:04 AM, 22 Aug 2013

Also Female genital mutilation is an aspect that has to be looked into.
I did a documentary on this which was aired on televisions. While compiling this documentary I did a lot if research and discovered that in some cases the sew up the labia after cutting the clitoris and leave a small opening. This sometimes heals with scarring because of mutilations and cannot dilate in labor. The attendants end up cutting to let the baby out and lots of blood loss due to scarring.

Do you think that fgm should be guarded against in females en lieu to the fight against maternal haemorrhage.

Chiamaka Uchegbulam
Replied at 3:52 AM, 22 Aug 2013

I totally agree with you, African women seem to have more confidence in their traditional midwives, and I think that instead of taking that away from them these midwives can actually be educated.

Paschal Okoye
Replied at 8:52 AM, 22 Aug 2013

yes,Onyekach I agree with you about teaching the traditonal birth attendants how to manage obstetric haemorrhage and possibly how to perform the UBT.
It has been suggested that one of the following devices (foleys catheter balloon,the Sengstaken-Blakemore tube, the Rusch catheter,and condom catheter) that can be used for uterine balloon tamponade be included in postpartum haemorrhage kit.

Paschal Okoye
Replied at 8:59 AM, 22 Aug 2013

Chiamaka you are correct.midwives and even TBAs are closer to the rural women.they should not be let out of the chain.

Sophie Beauvais
Replied at 12:00 PM, 22 Aug 2013

Dear Panelists, Dear All,

Thank you for such an important discussion.

I might have missed this but wanted to ask to our panelists and everyone:
- Is Misoprostol available in your clinic/hospital? Yes/No
- If no, why? Problem with government ordering or supply management? other? What would it take to advocate for the ordering and proper use of Misoprostol in your opinion?

Also, I wanted to share 2 comments received on other channels here to nourish our discussion:

1. A physician working in a rural hospital in Honduras shared this with me:

Preventing PPH is fairly simple in the hospital setting and I would imagine, very difficult in the community setting. In the hospital, it would revolve around recognizing patients at higher risk (grand multiparous) followed by fundal massage. In the community, it would involve fundal massage for home births for up to 12 hours post partum. This is a difficult skill to teach in the community, because it requires practice so that adequate fundal pressure is applied that will cause myometrial contraction.

Treating PPH is different. In a non-hospital setting, it would still require fundal massage, fluid resucitation, and transport to a medical facility where uterotonics and IV hydration/transfusion are available. In our hospital we have a protocol of giving 10u oxytocin in 1 liter of saline at 125ml/hr on all post partums to prevent PPH and this has been very successful. For cesarian patients, we do 2 liters of oxytocin solution. Our nurses are becoming good at doing fundal massage every hour post partum for 8 hours, but even after several years of training, some are still hesitant to apply enough pressure to facilitate myometrial contractions. As an alternative, prophylactic oxytocin can be administered intramuscularly if cost of IV fluids is prohibitive. Methergine is another uterotonic that is given intramuscularly. Both of these can be used as prophylaxis or treatment of PPH.

---

2. Angela Gorman, the founder of "Life for African Mothers" http://lifeforafricanmothers.org/ a UK charity that provides misoprostol to health centers in sub-saharan Africa, shared this in the Misoprostol for Postpartum Hemorrhage group on Knowledge Gateway: https://knowledge-gateway.org/misoprostol:

Our organisation has been supplying Misoprostol to several hospitals across SubSaharan Africa for about the last 6yrs. We have several individual stories of how it has saved lives and others where the request has come too late. The latter was graphically illustrated last year when I received a voicemail from a Nigerian woman here in the UK whom I had met a few months before when I presented our charity. The message said... "Angela, I hope you remember me.......I just want to let you know that my niece died back in Nigeria last week. She had just given birth to twins and haemorrhaged to death...can you help?" How could I respond to that? This is a film clip about the need for Misoprostol in Sierra Leone. I was contacted by ABC News in November 2011. It transpired that they would be filming in Freetown at the same time as our visit. It just about says it all. http://tinyurl.com/cle87zo

Conversely, I have received texts at odd times of the day and night, saying "Angela just want to let you know that a woman arrived here an hour ago, haemorrhaging and we were able to save her with your medication!" In Liberia's Redemption Hospital, there have been no deaths from eclampsia for almost a year and a handful of deaths from PPH where the women have arrived too late. It has been estimated that the hospital would have had over 100 deaths in that period and the only factor which has been in place has been our medications.

It is disgraceful that women are dying for the want of medications which cost less than the price of a postage stamp..per woman. We could do so much more if we had the financial resources. Sometimes we receive donations of Misoprostol, but shipping is costly. The medications need to get to countries quickly, so air freighting is necessary. So much more could be done with political will and resources. I always ask this question when I present.."If 300,000 men were dying every year, do you think that someone would have done something about it?" I always get the same reply...it's about the status of women.

---

I invited her to join us hoping she can share some lessons about delivering Misoprostol better and training midwives.

Thank you, Sophie

Onyekachi Obioma Uwaezuoke MD
Replied at 12:58 PM, 22 Aug 2013

Thank you Sophie for this wonderful post you shared with us.
In my country, our problem is not the availability of misoprostol.
It's well available in Nigeria.
Our challenges are;
the attitude of health workers
Knowledge of birth attendants in rural areas
Late ANC booking
Identifying the women at risk.
Non availability of professionals in suburban dwellings.
maternal hemorrhage can be minimized if we make it a point of duty.


Obioma Chijioke-Akaniro MD.

Meg Wirth
Replied at 1:06 PM, 22 Aug 2013

Which programs in Nigeria are known for changing knowledge of birth attendants in rural areas?

Just knowing danger signs is not enough-- not enough time to refer women with massive PPH!

Susan Moffson
Replied at 12:37 AM, 23 Aug 2013

MCHIP (Maternal Child Health Integrated Program) is conducting an upcoming 3-day PPH Program Implementation Workshop scheduled in DC for late September, focused predominantly on teaching NGOs and partners implementation approaches for preventing PPH at homebirth using misoprostol. The workshop- organized by MCHIP in collaboration with partners VSI, PSI, and Engenderhealth- will also provide organizations with the knowledge and tools to successfully implement a comprehensive PPH program using strategies for births either at home or in a facility. See attached the workshop SAVE the DATE. This workshop will also be followed up by two regional workshops, one in Nepal in mid. December and one in Mozambique, in January 2014.

The main reference document for these workshops will be an updated PPH Program Implementation Guide, which will also include several useful documents from PPH Programs, such as training materials, background/strategy documents, and tools.

All these materials- including the guide- will also be uploaded to the existing PPH Prevention and Management Toolkit- in time for the September workshop. Note that there are already some related materials in the PPH toolkit but in the coming weeks we will be including many more from recent PPH programs. Therefore, many of these training and other implementation materials will soon be widely available. The PPH Prevention and Management Toolkit can be found at:
www.k4health.org/toolkits/postpartumhemorrhage

Attached resources:

Susan Moffson
Replied at 1:23 AM, 23 Aug 2013

On this site, there is a description of MCHIP's work in PPH and there are links to MCHIP's PPH related briefers, articles, and descriptions of pilot programs that use a comprehensive approach to PPH prevention at homebirth and the facility.

Attached resource:

Onyekachi Obioma Uwaezuoke MD
Replied at 2:45 AM, 23 Aug 2013

Wow Susan, this has blown my mind. This is just what we need. I have down loaded the tool kit and will make it available.
This is exactly what we have been talking about, making the abc of handling pph available and easy to access knowing that it is a matter of emergency.

Onyekachi Obioma Uwaezuoke MD
Replied at 3:02 AM, 23 Aug 2013

Meg, as part of the MDG target, policies have been rolled out to incorporate these birth attendants in workshops to enlighten them, knowing that a lot of women depend and believe these attendants more than any hospital.
The challenging factor we have is that some of them practise secretly and wouldn't want their delivery homes to be recognised with fear of it being closed down.
You cannot help what you don't know.
Also loss in these places are unaccounted for. Though some are rushed to the hospital, some of them come in bad shape.

Jumatil Fajar
Replied at 3:48 AM, 23 Aug 2013

Study that was done by Jekti and Suarthana (attached) in Indonesia using Basic Health Research (Riskesdas) data on 2010 found that Eclampsia was the strongest risk factor of PPH. Other risk factors of PPH include premature rupture of the membranes, placenta previa, premature or post-term pregnancies, and high parity.

During my worked at very remote area in Central Kalimantan (Borneo), Indonesia, I found two cases of eclampsia. Fortunately, after giving initial treatment and send them to district general hospital, there was no PPH.

Our problem in Central Kalimantan for PPH cases are about the availability of blood and accessibility to referral hospital.

Attached resource:

Chiamaka Uchegbulam
Replied at 8:40 AM, 23 Aug 2013

How about antepartum hemorrhage, this also poses a great difficulty in Nigeria
The incidence of Antepartum Haemorrhage (APH) was 3.5%. Placenta praevia with an incidence of 2.0% constituted 58.4% of the cause of APH, followed by placental abruption with an incidence of 1.3% constituted 35.6% of the cause of APH. The most common presentation of APH was mild vaginal bleeding (22.3%), followed by combination of abdominal pains and vaginal bleeding (20.8%). APH accounted for 11.1% of maternal deaths and 19.2% of perinatal deaths in the study period. Early pregnancy bleeding (bleeding in the first 20 weeks of pregnancy) and pre-eclampsia/eclampsia were most commonly associated with placenta praevia and placental abruption respectively. It is to be noted that APH remains a dangerous complication of pregnancy with high maternal and perinatal morbidities and mortalities.

Chiamaka Uchegbulam
Replied at 8:41 AM, 23 Aug 2013

This survey was carried out by a university In lagos Nigeria.

Chiamaka Uchegbulam
Replied at 12:19 PM, 23 Aug 2013

It is known that few women in Nigeria have the attitude of reporting to a physician when there is an early sign not just because they don't notice but self medication is the order of the day, any thoughts on how this can be avoided?

Meg Wirth
Replied at 1:15 PM, 23 Aug 2013

For Paschal Okoye please send your email to so that we may
send you the condom balloon tamponade protocol.

Meg Wirth
Replied at 1:22 PM, 23 Aug 2013

No discussion about postpartum hemorrhage would be complete without mentioning some of the new technologies just coming along to address this problem. The non-pneumatic anti-shock garment (NASG) is just such a device.

Many of you will have been following Suellen Miller's work on the non-pneumatic anti-shock garment the wetsuit-like medical device that can reverse shock and buy a woman time while she is awaiting transfusion or IV, or while she is being transported over long distances.

Some of the UCSF and Pathfinder teams who did extensive clinical studies--worked with Nigerian colleagues. The device is now available at a low cost of approximately $70 US and may be washed and re-used 40 or 50 times.

Please see the links below for ALL of the studies.

Below is the cost-effectiveness study.

Attached resources:

Meg Wirth
Replied at 1:23 PM, 23 Aug 2013

IT is terrific to see that Susan Moffson's posting of MCHIP resources has been immediately well-received!

Meg Wirth
Replied at 1:27 PM, 23 Aug 2013

In the interest of keeping everyone informed of upcoming developments, another team in Nepal is working on a PNEUMATIC anti-shock device that can literally be made in country. The device uses locally available bicycle inner tubes which can be inflated using a simple pump. Called the CAPP device (for now), the prototypes are being tested by rural midwives in Nepal and they are already saving lives. The investigators are involved in another clinical study to be certain that this incredibly simple device is safe.

Attached resource:

Meg Wirth
Replied at 1:42 PM, 23 Aug 2013

Overlap between eclampsia and PPH.

We are so glad to see the mention of the overlap of eclampsia and postpartum hemorrhage and to see the study from Indonesia by Jumatil Fajar.

Are there any other excellent studies looking at comorbidity of eclampsia and PPH?

Chiamaka Uchegbulam
Replied at 2:04 PM, 23 Aug 2013

More info on Relationship of Reported Clinical Features of Pre-eclampsia and Postpartum Haemorrhage

Attached resource:

Chiamaka Uchegbulam
Replied at 2:13 PM, 23 Aug 2013

The maternal health community must also "increase awareness of technologies and mobilize the community to be able to access health facilities and care when emergencies arise.Financial constraints, migration, poor referral systems, and transportation issues make it difficult for pregnant women to seek timely and appropriate care. The maternal health community should work to create an enabling environment by orienting community and household-level decision-makers as well as disseminate key health messages through active involvement of front line health workers and local NGOs.

To expand effective programs and ensure that effective interventions reach pregnant women, it is critical the maternal health community advocates for policy changes that encourage national expansion, standardize provider training, engage community and family decision-makers, improve availability and access to commodities, and lead to an effective monitoring and evaluation system. Combined interventions at the clinical, community, and policy levels can together have a major impact on reducing maternal mortality.

edward chilolo
Replied at 2:33 PM, 23 Aug 2013

Dear colleagues,
In Tanzania Maternal Mortality Rate (MMR) is estimated to be around 454/100,000 live births with infant mortality rate of 51/1,000 live births (Tanzania DHS,2010).
Most cause of MMR in Tanzania as is in Nigeria and other sub saharan countries is maternal haemorrhage.
As others contributed in this discussion,the MMR can be reduced by imparting knowledge and skills to Health Care Providers (HCPs) on proper active management of third stage of labour AND how to use Misoprostol as most of HCPs in rural Tanzania (80% of Tanzanians live there) are not competent enough to use this important uterotonic agent.This is medical perspective.
Social perspective,it is a time now to fully involve communities in increasing knowledge and attitudes on importaance of hospital delivery.We can start by including the basics of maternal care in primary and seconadry schools curricula.
In Tanzania,the antenatal attandence is above 85% but hospital delivery is below 50%.
This low hospital delivery is caused by inadequate women empowerment (husband decides when and where his wife will deliver), long distance of travelling/walking to hospital where the services such as blood transfusion and surgical delivery takes place,few skilled HCPs working in rural areas (highly qualified HCPs work in urban areas), inadequate obstetrical equipments,poor infrastructure of roads and delivery rooms (no adequate light to conduct delivery).
It is a time for African leaders to actively allocate adequate funds (15%) for health expenditure as per Abuja declaration in 2000.
It is also a time for international community to fully engage in providing/supporting quality obstetric and gynaecological services for resource limited countries.
I am asking the team: What will be the life of our beloved expectant mothers after 2015 if MGDs end?
Regards, Chilolo.

Chiamaka Uchegbulam
Replied at 2:47 PM, 23 Aug 2013

Thank you so much Edward, yes a lot has to be done, it is a wake up call for everyone!!!!

Megan Arnold
Replied at 6:37 PM, 23 Aug 2013

Dear All,

I wish to reply to several comments made over the past several days.

First, I noticed that many of us are very concerned about women’s utilization of ANC; even if a woman does have access to ANC, this prenatal care and birth planning often remains underutilized. While I certainly agree that “more time has to be spent educating women on their rights and duties,” as Chiamaka wrote on the first day of this panel, I also think it is critical to consider the possibility of "backlash" women might experience through greater education and agency. I think that any program working to educate and empower women absolutely MUST involve men. (Here I think that the work of Sonke Gender Justice Network in South Africa is a wonderful example of the positive role men can play in women's empowerment and gender equality.) If what I have read in the comments is true – that “Nigeria is a patriarchal society where many women are illiterate,” then I do think education and community action must engender collaboration between both men and women on pregnancy and childbirth so that men do not feel dis-empowered or neglected and women do not face backlash in the home. Furthermore, I agree with Chiamaka – that these changes must occur at the clinical, community and policy levels in order to create sustainable change.

Finally, I want to share about a project our organization is working on. Please bear with me as I explain. Our organization, the Salt Creek International Women’s Health Foundation, is made up primarily of physicians and engineers. Together, we have developed a medical device to prevent and manage postpartum hemorrhage if and when it commences. Our founder is the primary inventor of the device as well as the author of a chapter in the postpartum hemorrhage textbook (accessible on GLOWM) mentioned above by Meg. In this chapter he discusses hemodynamics, which leads me to explain the device we hope to get in the hands of trained birth attendants in the lowest-resource settings of the world:

The device is a pair of paracervical clamps. They are intended to be applied after the delivery of the baby but before the expulsion of the placenta. The device is used to enter through the vagina and to temporarily occlude the uterine arteries, which represent about 90% of the blood flow to the uterus. When these arteries are occluded, blood flow stops, initiating a clotting cascade on the uterine wall. This aided coagulation allows the placenta to detach more easily and with minimal blood loss.

This device has been tested in a small pilot study; however, our small foundation is currently seeking a clinical partner interested in performing a 200-patient RCT that will demonstrate the device feasibility with statistical significance.

I am keen on hearing your thoughts about our project. If you have identified potential barriers to the success of this technology in saving women’s lives, I hope to hear your critique and concerns. Furthermore, I invite collaboration - this project must involve the support and knowledge of many.

Many comments have discussed monitoring of coagulation and clotting factors. Perhaps this device would also answer these concerns in the future. Whether or not a woman has been detected as being “high risk” for PPH, use of this device should be added to AMTSL protocol. It is reusable and thus inexpensive. We are expecting it to cost approximately 10 USD or less per device. Furthermore, it is simple and easy-to-use. Of course, I realize I may be getting too far ahead of myself – this device cannot be used publicly until it has undergone clinical testing in a large population of women.

In any case, I invite any questions, comments, or inquiries. You may reply here or email me separately any time (). as I realize this panel is about to end.

I am so grateful to be a part of this discussion. Many thanks to you all!

Megan Arnold
Salt Creek International Women’s Health Foundation

+1 (214) 517-4422 (mobile)
+1 (888) 721-1117x123 (office)

Paschal Okoye
Replied at 6:23 AM, 24 Aug 2013

Sophie,misoprostol is very much available in Nigeria.
Thank you for sharing the Honduras physician and Angela Gormans' experiences.

Paschal Okoye
Replied at 6:26 AM, 24 Aug 2013

Susan thank you very much.I have downloaded the tool kit.I will do what I can to make it available to health workers within my reach.

Paschal Okoye
Replied at 6:33 AM, 24 Aug 2013

Onyekachi,yes you can only help what you know.We can enlighten the nurses,midwives and other health workers close to us and admonish them to reach out to the TBAs and other health practitionersin their rural localities.

Paschal Okoye
Replied at 6:38 AM, 24 Aug 2013

Jumatil thank you for sharing the study done by Jekti and Suarthana.In my environment,uterine atony ranks first followed by retained products of placenta.

Onyekachi Obioma Uwaezuoke MD
Replied at 3:44 AM, 26 Aug 2013

Dear All,
The reason for virtual panel is to educate, bring to ones notice the ongoing events in different parts, decipher solutions and maybe push further to include organizations to do something.

This panel did all these for us. It brought out personal stories and recalled memories for some.
During this panel I was also going through some postings with my colleagues and we had time to discuss a lot.

Thanks everyone for the links and contributions. It will go a long way.
Most doctors around me told me that they have taken note of this and would improve where necessary.

I heard of a lady lost because the hospital pharmacy ran out of stock of a particular drug.
All these and many more.
We really do appreciate and look forward to a time like this again.

Thank you.








Obioma Chijioke-Akaniro MD.

Chiamaka Uchegbulam
Replied at 4:24 AM, 26 Aug 2013

Thank you so much, this has really been informative and has broadened my vision. This would indeed help propagate the ongoing work GEWHDF is doing all over Africa to effect necessary changes. Thank you so much. Looking forward to doing this again!

Chinomnso Obi peter
Replied at 5:20 PM, 1 Sep 2013

I look forward to this panel . I am from Nigeria, one of the Maternal health young champions 2013 cohort , -an initiative of Maternal Health Task Force of Harvard School of public Health . Also the Program Director , Traffina Foundation For Community Health . Glad to find this forum and also excited to see Meg Writ (Maternova) here our fellow women Deliver awardee.

Many Nigerians are making great effort towards reducing the maternal mortality burden in our country. Its indeed a scandal against human right. Saving the lives of our Mothers is the goal of goals and must be achieved.

James Ryan
Replied at 4:18 AM, 20 Nov 2013

Thanks for all the links here. Last night was able to find some things on induction with misoprostol that even UptoDate didn't have (unusual). Its all we had. Still not out of the woods but really appreciated the information found here.
Thanks,
Mitch

Sophie Beauvais
Replied at 4:16 PM, 21 Jan 2014

Dear All, just learned about this funding opportunity - thought this might be of interest to you.

Saving Lives at Birth: Round 4 RFA is open

The U.S. Agency for International Development (USAID), the Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada and the U.K.’s Department for International Development (DFID) invite global problem solvers to answer their fourth call for groundbreaking prevention and treatment approaches for pregnant women and newborns in poor, hard-to-reach communities around the time of childbirth.

Specifically, the challenge seeks to identify and develop transformative approaches that integrate new technologies, better service delivery models and improved “demand side” innovations that empower pregnant women and their families to practice healthy behaviors and be aware of and access health care during pregnancy, childbirth and the early postnatal period, especially the first 2 days after birth.

The partners anticipate awarding 25 seed grants and 5 transition-to-scale grants as a result of the final RFA. The actual number of awards in each category may vary.

Learn more and answer their call for innovative ideas.

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AMINA HAMZA
Replied at 6:19 AM, 22 Jan 2014

Dear Sophie,

I will like to ask some questions on maternal hemorrhage based on this TRUE LIFE story.
A lady gave birth to a baby weighing 3.4kg at birth through normal vaginal delivery. she had a tear which was stitched immediately before she came out of the second stage delivery to the ward. At the ward where is suppose to rest, she could not lay down on her sides only on her back complaining of pains at the upper part of her thighs mostly the right side but the doctors said its normal she kept complaining of the pains it graduated to shivering, the body was cold and could not move the right leg, before they checked her and rushed her to the theater. it took them about three hours before she was brought back to the ward under special supervision. she had blood transfusion of more than 3 pants and was not allowed to eat for a month.

my questions are
- is what happened to her postpartum hemorrhage, because we dint see her loose blood during and after delivery?
- why did she have to use carter-ta for five days?
- can it affect her chances of conceiving and having a normal delivery?
- how does she prevent such occurrence from happening to her again?
- what went wrong because she been taken to the ward and was congratulated for a save delivery doctor and nurses?

Thank you.

Onyekachi Obioma Uwaezuoke MD
Replied at 8:55 AM, 22 Jan 2014

Thanks Amina for this story but we still need details to be able to explain out this.
What did they do at the theatre? What did they say happened to her?
Was she a victim of female genital mutilation?
Kindly provide the detail, it will help us.
Although shivering and cold can come up after IV fluid rush or during blood loss.
Was there a surgical procedure, what type! Was there placenta remnant?etc
If you can get the details, we would like to talk about it.




Obioma Chijioke-Akaniro MD.

OBINNA AJUZIEOGU
Replied at 10:02 AM, 22 Jan 2014

Dear Amina,
I agree with Obioma that more details are needed. She qualifies for postpartum hemorrhage in receiving 3 pints of blood within hours of delivery if the reason for the transfusion was blood loss within that time. However it is only on getting a history of what transpired in the OR that we can say what was the cause and if it can recur or affect her chance of being pregnant again. The possibilities range from primary bleeding from the site of tear to intrapartum adverse events

Christophe Milien
Replied at 4:58 AM, 23 Jan 2014

I would like to have a better history for a better comprehension of this case. but I have some question.
1- did she deliver on the back position for a long time or in another position?
I would like to search a relationship with the sciatic nerve compression or stretching.
2-Why did she have a foley for 5 days.
Did she have a laborious labor that brings the doctor to think to Fistula of the bladder or the urether.
Best regards.
Millien

AMINA HAMZA
Replied at 7:00 AM, 23 Jan 2014

All i know is that the doctor's din't give any reason apart from its an emergency and they need to rush her to the theater, after the claimed successful delivery. what we suspect is their was internal bleeding which was not noticed by the doctor who stitched the external tear which occurred during delivery which caused the pain at the thigh which resulted to her not being able to move the right leg.

AMINA HAMZA
Replied at 8:19 AM, 23 Jan 2014

To answer your questions Millien
1- she was laying on her back facing that is the position she was when she delivered.
2- i don't know why she had to wear a Foley may be to restrict her movement but she was allowed to have her bath while she had it on
3- i think she had a slow labor which made them induced her using drip. (she came to the hospital with 2 cm dilation and after 10 hour it was 4 cm with no pains)
Thank you

Christophe Milien
Replied at 9:16 PM, 23 Jan 2014

I think she can have a sciatic stretching if she stay for long time in this position for deliver. In think also she looks like to have a laborious labor that can be a factor for post partum hemorrhage and the tear.
Best regards.
Millien

Angela Kerchner
Replied at 8:26 PM, 25 Jan 2014

Does anyone know where to purchase paragard (copper T IUD) for use in global health setting at low cost?  We are trying to set up an IUD program to help decrease pregnancy risk in women who have had high complications at a maternity center in Haiti.  Trying to find a reliable, affordable supplier.  Thank you.

Morroson Sinvula
Replied at 4:19 PM, 26 Jan 2014

Thank you all for your insightful comments on maternal mortality in Africa esp sub-Saharan Africa. 
My name is Dr Morrison Sinvula.  I am the National Maternal Mortality Reduction Initiative Coordinator in Botswana.  In 1990 the MMR was 325/100 000. In 1991 Botswana like any other country became signatory to the Millennium Development Goals and promised yo reduce maternal mortality by 75% by 2015. Our target for 2015 is 81/100 000 live births.  Over the next 15 years MMR reduced significantly and in 2005 it was 135/100 000. Ever since MMR has stagnated at this rate and fluctuations of up to 190/100 000.
The Ministry of Health in Botswana is at its wit's end on strategies to reduce maternal mortality. Several strategies are in place including Safe Motherhood Initiative and EmONC. Despite all these women still die from "silly" causes of death.
To the academic the commonest killers ard well known: PPH, Complications of Hypertensive Disorders of pregnancy and complications of of abortion, and infact if we just reduced maternal mortality due to PPH alone we woild achieve our goal for MDG 5.
An evaluation of EmONC shows that both doctors and midvives have a very good theoretical knowledge in managing these dreaded killers of pregnant women BUT failed dismally in applying this knowledge(they were scoring on average 38-40% in practical skills before EmONC). Such discrepancy betwwen knowledge and ability to execute is a dangerous cocktail as it is generally assumed knowledge is synonymous with practical application of such knowledge. The curriculum for both midwives and doctors (including Obstetrician/Gynaecologists) in Sub-Saharan Africa should be deliberately designed to target maternal mortality reduction. 
Confidential Inquiries into Maternal Deaths clearly reveal that slthough PPH, Hypertension and Abortion are the causes of death, these deaths are entirely preventable if we had the requisite skills and complimentary attitudes to prevent them. So knowledge alone vould be treacherous if we do not deal with dimple stuff such as "bad attitudes". In my practice I find passion and good attitudes as essential requirements in reducing maternal deaths. 
We need to constantly look at our near misses and learn from them and reinforce Best Practice in our work. Perhaps the most recent best practice was learnt from the work in Niger on prevention of PPH. By tackling PPH with just applying the active management of the third stage of labour PPH incidence reduced and hence deaths caused by PPH reduced. 
In Botswana we have just started on applying QI strategies to augment our knowledge in reduction of maternal deaths and I am convinced this will bear good results.
Knowledge alone is not enough and it is not static. We need to focus, promptly review each maternal death and apply the lessons learnt to prevent similar deaths. 
Let us join hands and make pregnancy safe. Our women are dying simply because we have not yet decided to save them. God Bless!

Dr Morrison Sinvula
COORDINATOR
National Maternal Mortality Reduction Initiative Botswana
 
+267 71316947


Sent from Samsung Mobile

Christophe Milien
Replied at 10:52 PM, 26 Jan 2014

Maternal mortality is still challenge in the world. I would like to propose these points.
1- reinforcement of your family planing program by the way you can decrease your maternal mortality considerably. In the same time you act for the future development of your country.
2- you need to well organize your community net work health worker by transferring pregnant women to the hospital. Bedside that this community net work have to do education of the community for helping them to recognize harm signs of pregnancy to make decision to come in the hospital. Also this community net work can be part of your family planing program as well. Some people propose to train them for doing delivery at home. I think this is not a good strategy because patients who die are who are complicated. Someone propose to train gand to give traditional birth attendance misoprostol for doing prevention for post partum hemorrhage. Misoprotol will prevent approximately 70 percent of post partum hemorrhage by atony utering but the rate remaining will die in the community.In the same time you will increase you death rate by abortion. I think The best way to use them is train them to bring patients to hospital for deliver. Don't for post partum hemorrhage represent 25 percent of maternal death. The others 75 are repsented by hypertension, infection,abortion, obtructed labor and 20 percent of indirect causes.
3- good organization of your ambulance net work for the transportation of patients to the hospital with a good coordination with the community net worker is very important. That will help you to fight against delay of transportation. Beside that you have to influence the politic power by creating road for transportation. This last point is a long term vision.
4- you have to reinforce your hospital in material, medication and human resources to take care of your patients.
5- as you said already you have to go beyond the number by verbal autopsy, clinical audit of maternal death, near miss to analyze them for making decision.
6- all that suppose a good system of monitoring and evaluation of your program for making the right decision at time . Priority,objectives, vision,strategy, work plan must be well established.

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