| | Management of post-partum hemorrhage in low-income countries published online 28 August 2008. The provision of safe and effective delivery care for all women in poor countries remains elusive, resulting in a continuing burden of mortality in general and mortality from post-partum haemorrhage in particular. Deployment of a functional health system and effective linkage of the health system to communities are the necessary prerequisites for the provision of the life-saving technical interventions that will make a difference in individual cases. Sadly, two factors militate against progress: the mantra that ‘we know what works’ (resulting in some serious gaps in evidence for best practice in resource-poor settings) and a lack of large-scale investment in maternity services to counteract the degradation of infrastructure and depletion of human resources evident in many countries. Introduction  At the start of the global Safe Motherhood Initiative in 1987, more than half a million women – 99% of them in the developing world – were dying each year in pregnancy and childbirth. Today, 21 years into the initiative, this has not changed, and the gap between rich and poor women, both between and within countries, is widening.1 Haemorrhage is thought to be the most important direct cause of maternal death, accounting for about 25% of the total and claiming an estimated 150,000 lives annually.2 Most of these deaths are due to post-partum haemorrhage (PPH), resulting from an atonic uterus. The rapidity with which a woman dies (often within 2 hours) when she has PPH presents a major problem in settings where delays in reaching and receiving effective intervention are common. This chapter describes the reasons why women in developing countries face a much greater risk of dying from PPH than in developed countries, and investigates what can be done to reduce mortality due to PPH in resource-poor settings. Making use of available evidence, interventions are discussed that could address socio-economic and cultural barriers that prevent women from accessing the necessary health care during pregnancy, childbirth and post-partum. Other points for discussion include how to raise community awareness of poor maternal health, increase recognition of danger signs, improve birth preparedness, and ensure that a skilled health provider with midwifery skills attends every birth. Finally, an overview is given of what is needed to upgrade health facilities with adequate transportation and communication structures, and the necessary supplies, drugs and equipment, and how to engage specialist obstetricians in training and support of service initiatives including ‘task shifting’. Why do women die from PPH? PPH can result in a maternal death in developed countries, but it a very rare event. Women in developing countries face a much greater risk of dying from PPH because: •the prevalence of severe anaemia is substantial, so that a given degree of blood loss is more likely to cause haemodynamic instability; •many women deliver at home and are often attended by unskilled providers (traditional birth attendants, family members) who are unable to recognize the signs of excessive bleeding; •once the problem is recognized and the decision to take the woman to a health facility is made, emergency transport might not be available or affordable, and distances might be long; •gender relations can present barriers to care seeking; for example, it might not be possible to arrange transfer to a health facility without the authority of male relatives; •even if a woman arrives at a health facility or hospital in time, the facility might not have the trained staff available or the necessary supplies and equipment to treat her. The provision of effective care for women with haemorrhage is often beyond the capacities of health systems and communities in countries where maternal mortality is high. What can be done to reduce maternal deaths due to PPH? To reduce maternal deaths due to PPH, and to make pregnancy and motherhood in general safer for all women, communities, governments, NGOs, healthcare providers, and civil society can support actions that include: 1.address the socio-economic and cultural barriers that prevent women from accessing necessary health care during pregnancy, childbirth and post-partum; 2.raise community awareness of poor maternal health, increase recognition of danger signs and improve birth preparedness; 3.ensure that a skilled health provider with midwifery skills attend every birth: policies need to support the training, deployment and ongoing professional support of skilled personnel, especially in rural and underserved areas; 4.upgrade health facilities to ensure adequate transportation and communication structures, as well as the necessary supplies, drugs and equipment; 5.engage specialist obstetricians to contribute to the training and support of service initiatives, including ‘task shifting’. 1. Address the socio-economic and cultural barriers that prevent women from accessing necessary health care during pregnancy, childbirth and post-partum Studies across a number of countries have indicated the importance of maternal education on the use of obstetric services.3, 4 Information on the best places to seek care is additionally required. A related issue is that others, including men, mothers-in-law and community leaders, make decisions on care-seeking for women. In Senegal, for instance, a study found that more than 50% of decisions regarding female treatment were made by men.5 In a number of societies, the mother-in-law dominates decisions on childbirth. In these circumstances, whether the woman is delivered at home by a relative or traditional birth attendant (TBA) or at a health facility, much depends on the mother-in-law's beliefs.6 At the community level, the TBA is also vital in the decision-making process. One study in Rajasthan, India, found that more than 90% of women who did not obtain referral care were advised against such care by the TBA.7 There is a need for contextually relevant evidence of the specific socio-cultural dynamics that operate in particular regional settings. For example, in four states of rural North India, access to antenatal care was associated with differing patterns – in each state – with respect to educational attainment of women and their husbands, economic status, measures of women's autonomy, caste and religion.8 Such contextual information is needed to frame relevant interventions directed towards the most vulnerable. To some extent, cultural barriers might also be related to information failures where they arise as a consequence of a lack of information about what constitutes obstetric care and how women will be treated once at a healthcare facility. So, for example, information might be used to reassure female patients that they will be treated by a female healthcare provider. The importance of misinterpreting health messages given out by healthcare staff has been demonstrated in a number of studies. One, examining the reasons for choosing delivery sites in Uganda, suggests that if a woman is told during antenatal care that there are ‘no problems’, this is often interpreted as a sign that the delivery itself will be normal and that therefore attendance at a healthcare facility is not required.9 Financial barriers, which include indirect costs, such transport costs, and time lost by women and relatives in receiving health care, can be of great importance. Transport costs have been estimated at almost half of total expenditure for a normal delivery in studies in Tanzania and Nepal, and 25% for a complicated delivery.*10, 11 User fees have almost always been shown to hurt poor people and prevent them from gaining access. Use of maternal health services is highly sensitive to fees charged. Several reports show that utilization of services at health facilities fell after user fees were introduced.12, 13, 14, 15 Interventions aimed at improving education and information have frequently centred on the training of community educators. Three such schemes in Nigeria, Sierra Leone and Ghana all led to substantial increase in admission to hospital for normal and complicated deliveries.16, 17, 18 One cross-country project implemented community education, transport and training of TBAs in Indonesia, Bolivia and Guatamala in order to stimulate use of essential obstetric care. Although no results are reported for the interventions in Indonesia, substantial increases in referrals were reported in both Guatamala and Bolivia.19, 20 Via its National Rural Health Mission, the Government of India has rolled out a very large-scale programme of community educators and mobilizers called ‘Asha’, or ‘accredited social health activists’, who have key roles in promoting birth preparedness and accompanying women to health facilities.21 Evaluations of the impact of this programme on the utilization of health facilities for childbirth and maternal mortality will be of great interest. A variety of interventions have helped to reduce delay in reaching a facility. In northwest Nigeria, a project worked with transport unions to provide reliable and affordable transport.22 A seed fund for the cost of fuel was provided, which was replenished with contributions from users. Drivers were trained to be respectful to those using the transport by avoiding smoking, talking loudly or showing impatience. A project in Sierra Leone provided radios to summon vehicles to take women to hospital in the case of obstetric emergency.23 Both interventions reported an increase in admissions. Further research is needed on methods to target financial assistance for transport and time costs. Available evidence demonstrates a strong case for the removal of user fees and the provision of universal coverage for pregnant women, particularly for delivery care.10 However, for this to be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people. Community-based schemes that operate more informally and on a smaller scale have developed in many low-income settings. Schemes have been successful in increasing skilled assisted-delivery rates for scheme members by 45% in Rwanda and 12% in The Gambia.24, 25 A seven-fold higher rate of hospital delivery was reported in scheme members compared to non-members in the Democratic Republic of Congo.26 One way of promoting equity in access is to exempt poor people from paying premiums, or relating premiums to ability to pay. Voucher schemes to generate demand have been used in several Asian countries under the World Bank Pro-Poor project to increase access by poor women to maternal and neonatal health care.27 However, these schemes have so far been funded largely by donor sources and have operated on a small scale, so their effectiveness, costs and financial sustainability at scale remain to be tested. 2. Raise community awareness of poor maternal health, increase recognition of danger signs and improve birth preparedness Traditionally, health education interventions at both community and health-facility level have been key elements of most safe motherhood programmes, despite little hard evidence that they are effective in resource-poor settings.28 To improve preventive and care-seeking behaviours, an increase in knowledge and a change in attitudes is necessary.29 Whereas earlier studies suggested that women as individuals do not have a comprehensive awareness of maternal problems that affect them30, 31, a study from rural Malawi suggests that this capacity can be assessed and channelled through women meeting and discussing these issues collectively.32 The five problems identified and subsequently prioritized by the women's groups as most important included anaemia, retained placenta and PPH. Such a process could potentially enable women not only to identify their maternal health problems and recognize their importance, but could also generate the motivation to address them. Birth preparedness includes planning for transport to a health facility where available, and for the costs: even where user fees are not charged, more out-of-pocket maternity-care expenses are inevitably incurred. Some programmes are now testing the distribution of misoprostol to women in the third trimester of pregnancy, to enable self-treatment in the absence of skilled assistance. The potential advantage of this approach is that it could overcome the challenge of lack of readily accessible skilled help. There is the risk of inappropriate use of misoprostol prior to delivery, although limited experience to date indicates that this seems not to be a major problem and has provided insight on the potential of the drug for this usage.33 The results of formal evaluations of this approach are awaited with interest. 3. Ensure that a skilled health provider with midwifery skills attend every birth: policies need to support the training, deployment and ongoing professional support of skilled personnel, especially in rural and underserved areas Home birth remains the strong preference, and often the only option, for many women in the developing world. A large proportion of these home deliveries takes place without skilled attendants. Provision of a health worker with midwifery skills at every birth, plus access to emergency hospital obstetric care, is considered the most crucial intervention for safe motherhood. The widespread training of traditional birth attendants (TBAs) in the 1980s and 1990s seems to have had limited impact on maternal mortality, and it therefore was recommended that that this strategy be replaced by the training of professional midwives.34 Indeed, a TBA in a home-birth situation will – in cases of, for example, obstructed labour, antepartum haemorrhage, transverse lie and eclampsia – have no tools to deal with these serious complications. To prevent or treat a case of PPH she would be able to administer misoprostol to the woman; it has been shown in The Gambia and Tanzania that TBAs are capable of so doing.35, 36 The resource implications of providing a professional midwife for each home birth are considerable. Assuming that a single midwife could assist in 100 births annually (also providing pre- and often neglected post-natal care), then 600,000 midwives will need to be trained to cover the 60 million deliveries currently unassisted by professional health workers. In addition to training, these midwives would also require salaries, housing and allowances for postings in rural areas, work opportunities for their spouses and educational facilities for their children.37 As with the TBA, the professional midwife would also need (the often lacking) continuing education and supervision and, if posted in the community, the possibility of referring and transporting patients to facilities with high-quality advanced obstetric care. Policies are urgently needed in many countries to support the training, deployment and ongoing professional support of skilled personnel. Those assisting births need also have the trust and respect of the community, and midwives from outside the area would have to be culturally sensitive. Providing a ‘professional midwife for all’ service should remain the goal, but bearing in mind that at present a TBA is the only help most pregnant women can count on at village level in many resource-poor settings, it is also pertinent to ask whether it is wise to deny TBAs access to tools that can help prevent and/or treat PPH. 4. Upgrade health facilities to ensure adequate transportation and communication structures, as well as the necessary supplies, drugs and equipment The technical evidence in support of a number of interventions for PPH is presented elsewhere in this series, and the scope for community-based distribution of misoprostol to women in the third trimester of pregnancy for use at the time of delivery has been mentioned above. It is appropriate to examine conventional interventions for PPH in the light of potential application in the developing world during transfer to a health facility, at health facilities able to offer basic emergency obstetric care, and at facilities offering comprehensive obstetric care. Transfer to health facilities The hazards of transferring patients to hospital during PPH or with a retained placenta were recognized in British clinical practice as a result of the Confidential Enquiries into Maternal Deaths introduced in the 1950s. This led to the development of ‘obstetric flying squads’, whose aim was to provide emergency care including manual removal of a retained placenta in the patient's home. This model became obsolete and was replaced with the ‘scoop and run’ approach following the deployment of paramedical ambulance crews able to site intravenous lines, institute volume replacement and oxytocic drug therapy during transfer to hospital. In developing countries, ambulance services are extremely limited or non-existent and, where they are present, do not, as a rule have the capacity to provide emergency supportive care during transfer. Thus, many women arrive at the hospital moribund and cannot be resuscitated. Where community-based midwives are providing skilled attendance at delivery and are equipped with intravenous fluids and oxytocic drugs, there is scope for them to undertake resuscitation and to accompany the patient to hospital. A potential problem is that for most community-based practitioners, the need to site an intravenous line will be an uncommon event and it is likely that even after skills training this competency, and the associated confidence, will be difficult to sustain. It is also impractical to maintain bimanual compression of the atonic uterus during transfer. However, the potential to administer repeat doses of oxytocic drugs when re-bleeding occurs during transfer might be of some value. The non-pneumatic anti-shock garment (NSAG) is a simple device, proposed as the immediate first-aid treatment for reversing hypovolaemic shock and decreasing blood loss secondary to obstetric haemorrhage by application of lower body counter pressure. Is also has the potential of keeping women alive during long journeys from home or basic obstetric care facilities to comprehensive emergency obstetric care (CEOC) facilities for definitive therapy. The garment is light weight and relatively inexpensive, as it can be reused at least 50 times. Unlike the pneumatic anti-shock trousers (PAST) and medical anti-shock trousers (MAST), there are no pumps, tubings or gauges to add to the complexity and risk of malfunction. Preliminary data indicate that women can remain stable for long periods while awaiting blood transfusion or on transit to a better-equipped facility.*38, *39, 40 The hydrostatic condom catheter has been described as an alternative to purpose-made balloon tamponade devices.41 This innovative approach from Bangladesh uses a sterile rubber catheter fitted with a condom as a tamponade device. The sterile catheter is inserted within the condom and tied near the mouth of the condom with silk thread and the outer end of the catheter is connected to a saline giving set. Vaginal bleeding is monitored and further inflation is stopped when bleeding ceases. The balloon is secured in place by use of a gauze roll placed in the vagina. As with purpose-made balloon tamponade devices, there are no randomized trial data and no data on use in pre-hospital emergency management. Where a skilled attendant is present, insertion of such a device might be sufficient to control bleeding and stabilize the patient for safer transfer to a health facility. This important potential intervention for pre-hospital use is urgently in need of research. Where the placenta is retained following a home birth, there is the possibility of oxytocin administration into the umbilical vein by a skilled attendant. Interpretation of the research evidence is challenging and it is important to stress that there are no studies in a community setting.42 Treatment of PPH at health facilities offering basic emergency obstetric care Health centres or small hospitals equipped and staffed to the ‘basic emergency obstetric care’ (BEOC) standard are expected to be able to provide emergency care up to and including manual removal of a retained placenta. In theory, they should therefore be capable of instituting therapy with intravenous fluids, oxytocic drugs and bimanual compression to control PPH. Such facilities are also responsible for undertaking a more formal diagnostic process, in particular identifying causes of PPH other than atony and responding appropriately; for example, suturing vaginal lacerations. In such facilities, the application of novel methods such as those discussed above is also very appropriate. Further referral to ‘comprehensive emergency obstetric care’ facilities will again require transport and the issues of logistics, cost and patient safety during transfer often present as much difficulty as transfer from home to basic health facility. Despite many ‘safe motherhood’ interventions over three decades to provide equipment and supply-chain logistics, the reality in many countries – as evidenced by facility surveys such as the Service Provision Assessments43 – is that many lack even basic equipment, such as sphygmomanometers, let alone essential drugs, and are understaffed or not staffed. The important policy issue for consideration in resource-poor settings is the extent to which BEOC facilities can or should be the focus for emergency PPH management, or whether their presence can be counterproductive, by introducing a further delay in patients receiving definitive care. There is a limit to what can be achieved in the absence of facilities for surgery and blood transfusion even when the notional staffing, equipment and drug supplies are in place. The appropriate pathway of care and referral will vary according to local conditions but needs to be clearly defined and well known within communities and among health professionals, to avoid confusion and life threatening delay. Treatment of PPH at comprehensive emergency obstetric care facilities The criteria for ‘comprehensive emergency obstetric care’ (CEOC) facility status include the ability to undertake surgery and blood transfusions, and these are therefore the locations for definitive treatment of PPH. The clinical skills and infrastructure should be sufficient for this, but in practice – as with BEOC facilities – there are often serious limitations to what can be offered to very sick patients. In developed-country settings, the clinical response to major PPH is usually rapid and sufficient to prevent organ damage and secondary complications such as coagulation failure, sepsis or adult respiratory distress syndrome. By contrast, in poor countries the response to a seriously ill patient is likely to be incremental as resources allow, with a much greater probability of complications. The antenatal health status of the mother is also likely to predispose to complications, in particular where severe anaemia, hypertensive disease and HIV infection are present. Thus, the clinical approach needs to be as aggressive as resources allow, with an early call for blood donors, other blood products where available, close monitoring of vital signs and urine output, and early consideration of surgical intervention where the immediate response is not favourable and bleeding continues. Balloon tamponade – as discussed above – merits early consideration, before proceeding to laparotomy for placement of compression sutures, then stepwise devascularization of the uterus and/or internal iliac artery ligation and hysterectomy. The incidence of emergency hysterectomy in the developing world is not known with certainty, and subtotal may be preferred to total hysterectomy. Irrespective of the type of procedure and country setting, there is a strong association with high maternal morbidity44, no doubt reflecting the patient's condition prior to surgery. Therefore, these patients require very close post-operative monitoring and correction of associated organ dysfunction in an intensive care setting where feasible. 5. Engage specialist obstetricians to contribute to the training and support of service initiatives, including ‘task shifting’ In the public health arena, specialist obstetricians have sometimes been seen as part of the problem rather than the solution, with their tendency to migrate to Western countries or gravitate towards private practice in urban areas rather than to service in district hospitals or health facilities in rural areas. It is unrealistic to anticipate the underlying economic and lifestyle drivers to change substantially through terms and conditions of government service, but there are ways of involving specialists through participation in national obstetric and gynaecological societies. An example is the set of projects currently sponsored by the International Federation of Gynecology and Obstetrics (FIGO), which places a strong emphasis on team working between midwives and obstetricians to achieve maternal health objectives.45 Another important leadership contribution that specialists can make is to set and advocate for standards of professional and ethical care in hospitals: sadly, sloppy and abusive behaviour by health staff is a significant deterrent to women accessing care in health facilities.46, *47 Specialists in developing countries are often involved in medical student or postgraduate training and represent role models for the next generation of practitioners. Finally, a current emphasis in health policy and planning is ‘task shifting’, meaning both the planned delegation of tasks hitherto undertaken by doctors to non-medical health professionals, such as midwives and clinical officers, and also the delegation of tasks hitherto undertaken by healthcare professionals to non-professional cadres. This model has been well developed in respect of HIV/AIDS treatment and care and is now under active discussion as a way forward for other health problems including maternity care.48 There is excellent evidence that assistant medical officers can provide a high standard of emergency obstetric care, and tend to remain in post in health facilities, in contrast to medical graduates.49 These approaches to the staffing of maternity services need the active participation and support of specialists to ensure that necessary training and ongoing support are provided throughout the health system. Summary The contribution of PPH to the global burden of maternal mortality is substantial. The challenges are to construct and sustain a functional health system in resource-poor settings, where socio-cultural and economic factors are major barriers to accessing obstetric care. Where in place, the health system needs to be rendered functional through training, supplies and communication up the referral chain. Specific clinical interventions for PPH, such as balloon tamponade, shock pants and uterine compression sutures, need to be tested properly in resource-poor settings at different levels of the health system and with different cadres of staff to inform policy on their role in reducing maternal mortality. Conflict of interest None declared. Practice points•Maternal education on the use of obstetric services is crucial. •Financial barriers to accessing obstetric care can be of great importance. •Community educators can play an important role in increasing facility-based deliveries. •The appropriate pathway of care and referral in the case of PPH will vary according to local conditions but needs to be clearly defined and well known within communities and among health professionals. •Non-physician healthcare providers can provide a high standard of emergency obstetric care. Research agenda•There is a need for contextually relevant evidence of the specific socio-cultural dynamics that are operating in particular regional settings. •Effective and sustainable methods of targeting financial assistance on poor women to access maternal health care are required. •Misoprostol should be distributed safely to women in the third trimester of pregnancy, to enable self-treatment in the absence of skilled assistance. •Is the non-pneumatic anti-shock garment (NSAG) effective as a first-aid treatment for reversing hypovolaemic shock and decreasing blood loss secondary to obstetric haemorrhage? •The role of balloon tamponade devices, as well as of the hydrostatic condom catheter in stopping bleeding in pre-hospital and hospital settings, require investigation. References 1. 1Hill K, Thomas K, AbouZahr C, et al. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007;370:1311–1319. Abstract | Full Text |
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*48. 48.WHO . http://www.who.int/healthsystems/task_shifting/en/2008;. *49. 49.Pereira C, Cumbi A, Malalane R, et al. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG. 2007;. Secretariat of His Highness the Aga Khan, Gouvieux, France; and Visiting Professor in Community Health Sciences, Aga Khan University, Karachi, Pakistan Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya  Corresponding author. Secretariat of His Highness the Aga Khan, Aiglemont, 60270 Gouvieux, France. Tel.: +33 344 583 555; Fax: +33 344 580 918.
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