Variation in the postpartum hemorrhage rate in a clinical trial of oral misoprostol (original) (raw)
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Is attendant at delivery associated with the use of interventions to prevent postpartum hemorrhage
2014
Background: Hemorrhage is the leading cause of maternal mortality in Bangladesh, the majority of which is due to postpartum hemorrhage (PPH), blood loss of 500 mL or more. Many deaths due to PPH occur at home where approximately 77% of births take place. This paper aims to determine whether the attendant at home delivery (i.e. traditional birth attendant (TBA) trained on PPH interventions, TBA not trained on interventions, or lay attendant) is associated with the use of interventions to prevent PPH at home births. Methods: Data come from operations research to determine the safety, feasibility, and acceptability of scaling-up community-based provision of misoprostol and an absorbent delivery mat in rural Bangladesh. Analyses were done using data from antenatal care (ANC) cards of women who delivered at home without a skilled attendant (N = 66,489). Multivariate logistic regression was used to assess the likelihood of using the interventions. Results: Overall, 67% of women who delivered at home without a skilled provider used misoprostol and the delivery mat (the interventions). Women who delivered at home and had a trained TBA present had 2.72 (95% confidence interval, 2.15-3.43) times the odds of using the interventions compared to those who had a lay person present. With each additional ANC visit (maximum of 4) a woman attended, the odds of using the interventions increased 2.76 times (95% confidence interval, 2.71-2.81). Other sociodemographic variables positively associated with use of the interventions were age, secondary or higher education, and having had a previous birth. Conclusion: Findings indicate that trained TBAs can have a significant impact on utilization of interventions to prevent PPH in home births. ANC visits can be an important point of contact for knowledge transfer and message reinforcement about PPH prevention.
Prevention of Postpartum Hemorrhage in Home Births (Non Randomized Trail)
Context : Postpartum hemorrhage (PPH) is leading cause of maternal mortality in Afghanistan, where majority of women deliver at homes without the assistance of a skilled birth attendant. A community based intervention to prevent PPH in homebirths is needed. Objectives: To show that proper counseling and distribution of misoprostol (community based intervention) results in an increased utilization of skilled delivery care and results in universal uterotonic agent coverage among pregnant women of the 20 districts of Afghanistan. Design, Setting, and Patients: The intervention was implemented in 20 districts of five provinces of Afghanistan from November 2011 to January 2012. Postpartum interviews were conducted among 166 recently delivered women using a structured questionnaire. Data about signs of PPH, causes of PPH, strategies to prevent PPH, correct use of misoprostol, place of delivery and number of misoprostol tablets used, was collected. Intervention: All recently delivered women received two counseling visits during the first and third trimesters of pregnancy and a fallow up visit in postpartum period by community health workers (CHWs). CHWs counseled the women on sign, cause and strategies for prevention of PPH. Women were also counseled benefits of skilled care during delivery and use of misoprostol. The first counseling visit was conducted during the first trimester of pregnancy. Then all the pregnant women were revisited by CHWs at 8th month of pregnancy to reinforce the messages and to provide misoprostol tablets to pregnant women. Finally, CHWs visited the pregnant women in postpartum period to record the pregnancy outcome and use of misoprostol tablets. Main Outcome Measures: The endpoint was childbirth either assisted by a skilled birth attendant or not assisted by a skilled birth attendant, in which either Oxytocin or Misoprostol was used as a uterotonic agent for prevention of PPH. Results: 40% (67/166) deliveries were assisted by a skilled birth attendant while 60% (99/166) deliveries occurred at homes without the assistance of a skilled birth attendant. The deliveries assisted by skilled birth attendants in the interventions districts are significantly higher than the national average with a p-value of 0.0271. Among women who delivered at home 97% of them took the correct dose of misoprostol. High (97%) coverage of uterotonic use was achieved among the recently delivered women. The odds of having a delivery assisted by a skilled birth is 2.5 times higher (p=0.053) among women who knew the causes of PPH as compared to women who did not. Also the odds of having a skilled delivery was 7 times higher (p=0.065) among women who knew the signs of excessive bleeding as compared to women who did not. While the odds of having a delivery not assisted by skilled birth attendant is higher among women who showed a poor understanding about PPH. Conclusion: Community based intervention for prevention of PPH at homebirths lead to increased utilization of skilled delivery care and almost all women can be protected against PPH through the use of either Oxytocin or misoprostol.
Prevention of Post Partum Hemorrhage in a Low Resource Setting
2011
Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death in lowincome countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to provide a review of PPH prevention interventions, with a particular focus on misoprostol, and the challenges and opportunities that preventing PPH in low-resource settings presents. Methods: Using PubMed, we conducted a review of the literature on the randomized controlled trials of interventions to prevent PPH. We then searched PubMed and Google Scholar for nonrandomized field trials of interventions to prevent PPH. We limited our review to interventions that are discussed in the current World Health Organization (WHO) recommendations for PPH prevention and present evidence regarding the use of these interventions. We focused our review on nondrug PPH prevention interventions compared with no intervention and uterotonics versus placebo; this review does not decipher the relative effectiveness of uterotonic drugs. We describe challenges to and opportunities for scaling up PPH prevention interventions. Results: Active management of the third stage of labor is considered the "gold standard" strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord traction and cord clamping) with the administration of an uterotonic drug, the preferred uterotonic being oxytocin. Unfortunately, oxytocin has limited application in resource-poor countries, due to its heat instability and required administration by a skilled provider. New heat-stable drugs and drug formulations are currently in development that may improve the prevention of PPH; however, misoprostol is a viable option for provision at home by a lay health care worker or the woman herself, in the interim. Conclusion: As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the burden of this complication.
Postpartum haemorrhage (PPH) rates for low-risk women having vaginal births in the Western world are reported as 5% (500ml), 1% (>1000ml), and 1% of women receiving blood transfusions as a result of these events. While it could be argued that these are accepted by-products of birth, there is a need to question why both active and expectant management appear to show no reduction in those rates and whether this is because speed of placental delivery is the critical factor that has not been emphasised. Active management causes PPH because of increased manual removal rates and expectant management causes increased atony by delaying placental delivery. Where there is greater acknowledgement that a shorter third stage results in a lower PPH rate, this leads to reappraisal of third stage management. The knowledge that the vast majority of placentas deliver in five minutes was seemingly forgotten during the period of putting women under anaesthesia during delivery. Waiting for signs of separation causes unnecessary delay in third stage, thereby increasing the PPH rate. A protocol was devised based on timing the actions and non actions necessary at three, four and five minutes from the birth for delivery of the placenta using a squatting position. This idea was born out of an attempt to eliminate PPH, based on the logic that vaginal delivery of a placenta weighing one kilo requires maternal effort, not passivity. In my practice, 350 consecutive attended homebirths resulted in a 0.6% PPH rate (500ml ), which compares favourably to the published PPH rates of other third stage protocols.
Prevention of postpartum hemorrhage in low-resource settings: Current perspectives
2013
Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death in lowincome countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to provide a review of PPH prevention interventions, with a particular focus on misoprostol, and the challenges and opportunities that preventing PPH in low-resource settings presents. Methods: Using PubMed, we conducted a review of the literature on the randomized controlled trials of interventions to prevent PPH. We then searched PubMed and Google Scholar for nonrandomized field trials of interventions to prevent PPH. We limited our review to interventions that are discussed in the current World Health Organization (WHO) recommendations for PPH prevention and present evidence regarding the use of these interventions. We focused our review on nondrug PPH prevention interventions compared with no intervention and uterotonics versus placebo; this review does not decipher the relative effectiveness of uterotonic drugs. We describe challenges to and opportunities for scaling up PPH prevention interventions. Results: Active management of the third stage of labor is considered the "gold standard" strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord traction and cord clamping) with the administration of an uterotonic drug, the preferred uterotonic being oxytocin. Unfortunately, oxytocin has limited application in resource-poor countries, due to its heat instability and required administration by a skilled provider. New heat-stable drugs and drug formulations are currently in development that may improve the prevention of PPH; however, misoprostol is a viable option for provision at home by a lay health care worker or the woman herself, in the interim. Conclusion: As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the burden of this complication.