Particular Concerns in the Developing World
A major challenge to reducing the global burden of PPH is the failure to prevent PPH or rapidly connect patients to treatment in low-resource settings. A series of delays in receiving definitive PPH treatment is associated with much higher mortality rates in such settings. Long transport times from communities or primary healthcare facilities, lack of transport or fuel, shortage of skilled providers and lack of basic medical supplies (e.g., medications, intravenous fluids, safe blood) contribute to these delays. Strategies to reduce PPH in low-resource areas must emphasize community-level prevention and first-aid while broadly improving healthcare capacity and access, and will benefit from novel methods designed to overcome the specific challenges of this clinical context.
Prenatal evaluation of anemia is important globally; however, diagnosis and treatment of nutritional factors, hemoglobinopathy, malaria and helminth infection is even more important in low-resource countries due to the higher burden of anemia among this population.
Despite the fact that oxytocin is the recommended uterotonic for prevention and treatment of PPH, its availability in the developing world is limited due to the requirement for temperature-regulated storage and administration by skilled health provider. The WHO supports oral misoprostol (600 μg) for PPH prevention by community and lay health workers in resource-limited settings where oxytocin use is not feasible. FIGO also recommends community-based misoprostol distribution in conjunction with health worker training. Optimal strategies for community-level distribution of misoprostol for PPH prevention should be considered to maximize limited resources and handle potential side effects of misoprostol. A recent review of community-based distribution suggests that high coverage of universal primary prophylaxis can be achieved through home visit or community-based personnel distribution, with low incidence of erroneous administration. Evaluation of a secondary prevention strategy, selectively offering misoprostol to women who appear to be bleeding more than average, is underway and will inform service delivery programming on clinical outcomes, program feasibility, cost and acceptability of these two community models of PPH care.
Development of oxytocin in modes that can surmount low-resource delivery challenges in underway. Oxytocin in a Uniject system, an easy-to-use single-dose injection format, was considered safe and feasible for active management of the third stage of labor in Guatemala and Mali pilot evaluations.[107,109] A recent cluster-randomized trial of Uniject oxytocin administered by peripheral health workers without midwifery skills in Ghana reported a 51% reduction in postpartum blood loss ≤500 ml with no safety concerns, providing preliminary evidence that community health workers can safely administer injected oxytocin at home births in rural areas. Pharmaceutical development of powdered, heat-stable oxytocin that can be inhaled is also being developed for an aerosol delivery system to remove the need for cold supply chain, sterile conditions and trained health workers.
Community mobilization and engagement strategies play an important role in improving the success of PPH-prevention programs. Greater community ownership and support of projects has been achieved by establishing rapport with key opinion leaders, and involving community members in the design and implementation of project activities.[112,113] FIGO recommends that community members be taught home-based life-saving skills (HLBSS), community-based obstetric first aid including uterine massage and emergency preparedness. Field tests suggest that HBLSS may be a useful adjunct for a comprehensive PPH prevention and treatment program, and its utility around increasing community support for emergency preparedness is particularly important for ensuring women's access to healthcare where they have less decision-making power.
Several low-cost strategies have been devised to improve accurate blood loss estimation in low-resource settings. Prata et al. recognized the utility of using household items such as the 'kanga' cloth, a locally produced standard size cotton fabric, for postpartum blood loss assessment in Tanzania. Use of the kanga for recognizing excessive blood loss (soaking 2 kangas = PPH) enabled the development of community-level guidance for early recognition of PPH in Tanzania. This method may translate to similar items throughout the developing world (e.g., chitengis, saris, longis). A dedicated absorbent delivery mat, which holds a maximum of 500 ml of blood, and visually depicts quantity of blood loss has also been effectively used by traditional birth attendants to recognize PPH in Bangladesh (Figure 3). In 2006, Patel et al. validated blood measurement in an under-buttocks, plastic, closed-ended, calibrated blood-collection drape. Blood collection drapes (Figure 1) have subsequently been used in studies in sub-Saharan Africa, Asia and Latin America.[63,117]
Given the long delays women in low-resource settings often face obtaining transport, during transport and awaiting definitive treatment, the NASG described previously is particularly suited to these settings (Figure 4). A cluster randomized trial of the NASG applied at the primary healthcare level prior to transfer to the RH was recently completed and suggested a promising trend for mortality reduction. The NASG has been recommended as a temporizing measure for PPH by the WHO and FIGO, and is cost effective.[6,27,118]
While the IUB devices currently available are prohibitively expensive for use in low-resource areas, PATH is working to develop an affordable dedicated balloon tamponade. In the meantime, point-of-care assembly of a condom-catheter device is able to achieve the same objective at low cost using commonly available materials. Other low-cost technologies in development that may impact prevention and treatment of PPH include a novel blood pressure device equipped with traffic light early warning systems to indicate that a woman should be referred to care for hyper or hypotension.
Finally, one of the largest contributors to PPH and other causes of maternal mortality and morbidity in low-resource settings is the lack of skilled healthcare providers. Increased production of and ability to retain a well-educated health workforce is crucial, but a challenge for many countries. Recent global discussions have focused on task-shifting to provide a greater mix of skilled providers and thus broader access to skilled care and lifesaving procedures. The WHO has made recommendations on key maternal health capacities with respect to each particular cadre of healthcare worker and context including lay health workers, auxiliary nurses, auxiliary nurse midwives, nurses, associate clinicians, advanced level associate clinicians and non-specialist doctors. Countries should work to implement these recommendations into their health worker training programs and staffing.
Expert Rev of Obstet Gynecol. 2013;8(6):525-537. © 2013 Expert Reviews Ltd.