Inability to predict postpartum hemorrhage: insights from Egyptian intervention data

<p>Abstract</p> <p>Background</p> <p>Knowledge on how well we can predict primary postpartum hemorrhage (PPH) can help policy makers and health providers design current delivery protocols and PPH case management. The purpose of this paper is to identify risk factors and determine predictive probabilities of those risk factors for primary PPH among women expecting singleton vaginal deliveries in Egypt.</p> <p>Methods</p> <p>From a prospective cohort study, 2510 pregnant women were recruited over a six-month period in Egypt in 2004. PPH was defined as blood loss ≥ 500 ml. Measures of blood loss were made every 20 minutes for the first 4 hours after delivery using a calibrated under the buttocks drape. Using all variables available in the patients' charts, we divided them in ante-partum and intra-partum factors. We employed logistic regression to analyze socio-demographic, medical and past obstetric history, and labor and delivery outcomes as potential PPH risk factors. Post-model predicted probabilities were estimated using the identified risk factors.</p> <p>Results</p> <p>We found a total of 93 cases of primary PPH. In multivariate models, ante-partum hemoglobin, history of previous PPH, labor augmentation and prolonged labor were significantly associated with PPH. Post model probability estimates showed that even among women with three or more risk factors, PPH could only be predicted in 10% of the cases.</p> <p>Conclusions</p> <p>The predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.</p

Contraceptive Use among Women Seeking Repeat Abortion in Addis Ababa, Ethiopia

Limited access to modern contraceptives in populations that desire smaller families can lead to repeat unintended pregnancy and repeat abortions. We conducted an analysis of the medical records of 1,200 women seeking abortion-related services in public and private facilities in Addis Ababa, Ethiopia from October 2008 to February 2009. We examined the characteristics of initial and repeat abortion clients including prior contraceptive use and subsequent method selection. The incidence of repeat abortion was 30%. Compared with women seeking their first abortion, significantly more repeat abortion clients had ever used contraceptives and they were nearly twice as likely to leave the facility with a method. However, repeat abortion clients were significantly more likely to have ever used short-term reversible methods and to choose short-term methods post-abortion. Contraceptive counseling services for repeat abortion clients’ should address reasons for previous contraceptive failure, discontinuation, or non-use. Post-abortion family planning services should be strengthened to help decrease repeat abortion. Keywords: abortion, repeat abortion, contraception, urban, Ethiopia (Afr J Reprod Health 2013; 17[4]: 56-65

Is attendant at delivery associated with the use of interventions to prevent postpartum hemorrhage at home births? The case of Bangladesh.

BackgroundHemorrhage 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.MethodsData 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.ResultsOverall, 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.ConclusionFindings 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

Is attendant at delivery associated with the use of interventions to prevent postpartum hemorrhage at home births? The case of Bangladesh

BackgroundHemorrhage 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.MethodsData 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.ResultsOverall, 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.ConclusionFindings 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

Factors Associated with Choice of Post-Abortion Contraception in Addis Ababa, Ethiopia

The high demand for abortion related services in Addis Ababa, Ethiopia indicates a reliance on abortion to control fertility and highlights an opportunity to increase access to contraceptives and improve post-abortion care. We analyzed the medical records of 1,200 women seeking abortion related services. Logistic regression was used to determine factors associated with use of modern or long-acting contraceptive post-abortion. Multivariate results illustrate that women aged 40-44, students, employed women, receipt of services in private clinics, number of children, and number of previous abortions were significantly associated with the odds of adopting any modern contraceptive post-abortion. The odds of choosing a long-active contraceptive method were significantly and positively associated with being age 25-29, attaining secondary or higher education, and number of children. Improved services and information along with reliable access to modern and long-acting contraceptives can reduce the need to use abortion to control fertility among women in Addis. (Afr J Reprod Health 2011; 15[3]: 55-62).La demande augment ée des services relatifs à l&apos;avortement à Addis Abéba, Ethiopie, montre une indépendance de l&apos;avortement pour contrôler la fertilité et souligne une opportunité pour augmenter l&apos;accès aux contraceptifs et améliorer les soins du post-avortement. Nous avons analysé les dossiers des 1200 femmes qui recherchaient des services liés à l&apos;avortement. Nous nous sommes servis de la régression logistique pour déterminer les facteurs liés à l&apos;utilisation du contraceptif du post-avortement modern ou à action prolongée. Des résultats ont montré que les femmes âgées de 40-44 ans, les étudiantes, les femmes employées, fréquentation des cliniques privées pour les services, nombre d&apos;enfants et nombre d&apos;avortements antérieurs, ont été significativement liés à la possibilité d&apos;adopter n&apos;importe quel contraceptif du post-abortion modern. La possibilité de choisir une méthode contraceptive à action prolongée a été considérablement et positivement liée au fait d&apos;avoir 25-29 ans, ayant acquis l&apos;éducation du niveau secondaire ou tertiaire et le nombre d&apos;enfants. L&apos;on peut réduire le besoin de contrôler la fertilité chez les femmes à Addis si les services et l&apos;information ainsi que l&apos;accès fiable aux contraceptifs modernes et à action prolongée sont améliorés

Disponibilité de misoprostol dans la communauté : Est-il sans danger?

This paper evaluates the safety and acceptability of long-term community-based use of misoprostol for management of postpartum hemorrhage (PPH) in home-births, by comparing deliveries with and without misoprostol use in communities of Kigoma, Tanzania. We administered a standardized survey instrument to women who delivered between August 2004 and May 2007. 940 women completed questionnaires, corresponding to 950 deliveries. Findings showed that the majority of TBAs administered misoprostol at the correct time (76%). Receipt of three or five tablets was most commonly reported (47% and 43% respectively). Misoprostol users were significantly more likely to experience shivering, high temperature, nausea, and vomiting after delivery; adjustment for gynecological history and delivery characteristics revealed no significant differences in experience of symptoms. Misoprostol was highly acceptable to all women surveyed. Misoprostol at the community level is a safe intervention (Afr J Reprod Health 2009; 13[2]:117-128).Cet article évalue la sauveté et l’acceptabilité de l’emploi à long terme de misoprostol dans la communauté pour le traitement de l’hémorragie du post partum (HPP) dans les naissances à domicile, en comparant les accouchements avec et sans l’utilisation de misoprostol dans les communautés de Kigoma, Tanzamie. Nous avons administré un instrument d’enquête standardisé aux femmes qui ont accouché entre le mois d’août 2004 et mai 2007. 940 femmes ont rempli des questionnaires, ce qui correspondait à 950 accouchements. Les résultats ont montré que la majorité des sages-femmes traditionnelles (SFTs) ont administre misoprostol comme il faut (76%). Elles ont indiqué en général avoir reçu trois ou cinq comprimés (47% et 43% respectivement). Les utilisateurs de misoprostol avaient la possibilité de subir le frissonnement, la haute température, la nausée et le vomissement après l’accouchement ; l’ajustement pour l’histoire gynécologique et les caractéristiques de l’accouchement n’ont pas révélé des différences significatives quant aux symptômes. Misoprostol a été bien acceptable à toutes les femmes enquêtées. Misoprostol au niveau de la communauté est une intervention sans danger (Afr J Reprod Health 2009; 13[2]:117-128)

Prevention of postpartum hemorrhage: Options for home births in rural Ethiopia

This paper sought to determine the safety and feasibility of home-based prophylaxis of postpartum hemorrhage (PPH) with misoprostol, including assessment of the need for referrals and additional interventions. In rural Tigray, Ethiopia, traditional birth attendants (TBAs) in intervention areas were trained to administer 600mcg of oral misoprostol. In non-intervention areas women were referred to the nearest health facility. Of the 966 vaginal deliveries attended by TBAs, only 8.9% of those who took misoprostol prophylactically (n=485) needed additional intervention due to excessive bleeding compared to 18.9% of those who did not take misoprostol (n=481).The experience of symptoms among those who used misoprostol can be considered of minor relevance and self-contained. This study found that prophylactic use of misoprostol in home births is a safe and feasible intervention. Community health care workers trained in its use can correctly and effectively administer misoprostol and be a champion in reducing PPH morbidity and mortality (Afr J Reprod Health 2009; 13[2]:87-95)

Prevention of postpartum hemorrhage: Options for home births in rural Ethiopia

This paper sought to determine the safety and feasibility of home-based prophylaxis of postpartum hemorrhage (PPH) with misoprostol, including assessment of the need for referrals and additional interventions. In rural Tigray, Ethiopia, traditional birth attendants (TBAs) in intervention areas were trained to administer 600mcg of oral misoprostol. In non-intervention areas women were referred to the nearest health facility. Of the 966 vaginal deliveries attended by TBAs, only 8.9% of those who took misoprostol prophylactically (n=485) needed additional intervention due to excessive bleeding compared to 18.9% of those who did not take misoprostol (n=481).The experience of symptoms among those who used misoprostol can be considered of minor relevance and self-contained. This study found that prophylactic use of misoprostol in home births is a safe and feasible intervention. Community health care workers trained in its use can correctly and effectively administer misoprostol and be a champion in reducing PPH morbidity and mortality (Afr J Reprod Health 2009; 13[2]:87-95)

Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date

Abstract Background Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births. Methods We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events. Results Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries. Conclusions Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication