Postpartum Hemorrhage (PPH)
In 2012, the World Health Organization estimated that nearly 800 women die each day from complications of pregnancy and childbirth. One of the primary causes, postpartum hemorrhage—an excessive loss of blood after childbirth—is responsible for at least one quarter of all maternal deaths worldwide and nearly 60 percent of maternal deaths in the developing world.
Currently, Pathfinder is working in three countries—India, Nigeria, and Peru—directing projects aimed at reducing morbidity and mortality associated with postpartum hemorrhage. In each country, Pathfinder’s "Clinical and Community Action to Address Postpartum Hemorrhage" varies according to the particular cultural and social context. But in all three, the great majority of maternal deaths are preventable if women have access to and are welcomed by skilled providers in well-equipped facilities. Unfortunately, poverty, isolation, lack of knowledge, and access to a skilled provider or an equipped facility continue to pose serious barriers in many countries. While quality care must be made available and accessible as the key to attracting women for services, another challenge lies in educating communities about the risks, danger signs and where to go for help during pregnancy, delivery and during the postpartum period.
The Four Delays
Pathfinder works to address all "Four Delays" that often contribute to maternal mortality. Each delay must be addressed effectively to reduce maternal mortality.
The first delay is in the community when an expectant mother, her family, or a community birth attendant fail to recognize that the woman is in crisis, often because of excessive bleeding. It is difficult to know how much is too much, as some bleeding is normal during childbirth, without education.
The second delay is in deciding and taking steps to seek skilled obstetric care once an emergency complication is recognized. This decision may involve finding a means and the money for transportation, permission from a husband or other key decision-makers to seek care, and lack of faith in existing services or not knowing where to find skilled care. The woman and her caretakers may not be confident in the care she will receive or fear mistreatment by facility staff.
The third is a delay in reaching the appropriate facility, due to lack of money, transportation, distance, poor roads, bad weather, or lack of information.
The fourth delay occurs at the facility, which may be poorly staffed and equipped and unable or unwilling to treat the woman in a timely fashion. The family may not be able to pay for care or have cultural fears about donating needed blood. Blood shortages play a critical role in the fourth delay, as surgery may be postponed for many hours while a willing matched donor is sought or the appropriate blood type is sourced from a blood bank.
The four delays reflect the many cultural, economic, and infrastructure barriers to quality health care in poor, traditional communities. Postpartum hemorrhage, like many intransigent health challenges, cannot be addressed by clinical interventions alone.
The Clinical and community action to address postpartum hemorrhage
More than 50 percent of women in developing countries still give birth at home. The Pathfinder approach focuses on prevention and care at the community level as well as making sure women reach the appropriate higher level facilities where they can receive effective care for complications. This innovative methodology is the basis of the Pathfinder International model to address postpartum hemorrhage, known as "Clinical and Community Action to Address Postpartum Hemorrhage."
The model, recognized and praised in an external evaluation commissioned by the John D. and Catherine T. MacArthur Foundation, is made up of three elements:
1) Advocacy to Promote Government Support
Prior to and throughout the implementation of the postpartum hemorrhage project in a country, Pathfinder field staff engage with government officials, especially public health officials and other stakeholders, outlining the elements of the model and their rationale. With this groundwork, important laws and policies (such as approval for the use of misoprostol or the non-pneumatic anti-shock garment (NASG)) necessary for the project can be sanctioned prior to its launch. Government officials in all countries are involved with implementation from the beginning and throughout, a necessary step for fostering sustainability and taking the interventions to scale.
2) Clinical Interventions
Prevention of postpartum hemorrhage through the routine use of the active management of the third stage of labor (AMSTL). The three main steps of AMSTL include:
- Administration of a uterotonic drug (oxytocin, misoprostol, or ergometrine) to promote contraction of the uterus following delivery.
- Delivery of the placenta by controlled cord traction; and,
- Uterine massage to contract the uterus following the delivery of the placenta.
The Pathfinder model includes several additional steps to further prevent bleeding, such as putting the baby to breast, keeping the bladder empty, teaching the mother to massage her own uterus to keep it contracted, and several others. We refer to this expanded list as AMTSL Plus.
Identification of postpartum hemorrhage through standardized methods of estimation of blood loss and monitoring of clinical signs
Management of postpartum hemorrhage through identifying the cause of hemorrhage, replacing the fluids to prevent shock, using an appropriate uterotonic, applying the NASG when shock occurs, replacing blood and performing surgery.
3) Community Engagement
Pathfinder works with community members and leaders to do the following:
- Organize communities to develop their own shared emergency transportation solutions. Community engagement must also involve the development of blood banking or a network of willing donors in case of need. Work must also be done to improve the quality of available facilities and the skills and attitudes of providers.
- Mobilize communities to recognize the danger of postpartum hemorrhage and excessive blood loss, and actively engage in healthy behaviors.
- Empower families for safe delivery by having birth preparedness plans and encouraging antenatal clinic attendance
The model can also be applied to pre-eclampsia and the other major causes of maternal mortality.
Pathfinder works closely with the Peruvian Ministry of Health to improve mother and newborn health and reduce maternal mortality in La Libertad region of Peru.
Pathfinder builds on its successful CCA-PPH Plus model to address the two leading causes of maternal mortality: postpartum hemorrhage and pre-eclampsia/eclampsia.
This MacArthur Foundation-funded project focused on strengthening reproductive health care services and preventing post-partum hemorrhage among refugee and displaced persons camps in western Tanzania.
We believe change starts with expertly trained providers and pharmacies that never run out of supplies. It starts with open conversations among women, young people, men, religious leaders, mothers-in-law, policymakers, and others, joining to discuss their beliefs and remove barriers to their health and well-being. Our 2014 Annual Report shows a few highlights of how Pathfinder has served as a catalyst for change over the past year.
It was a matter of life and death for Jenelia, who lives in a remote mountain village in Haiti, the most dangerous place to give birth in the Western Hemisphere. This issue of Pathways explores how mobile technology is changing the way community health workers are delivering health services to women like Jenelia.
The purpose of the Working Paper Series is to disseminate work in progress by Pathfinder International staff on critical issues of population, reproductive health, and development.
In this edition of Pathways, we share stories from clients served by in our maternal health projects, with a focus on prevention of mother-to-child transmission of HIV and postpartum hemorrhage.
With the support of the MacArthur Foundation, since 2007 Pathfinder International has implemented the Continuum of Care: Addressing Postpartum Hemorrhage project to prevent and manage PPH in India and Nigeria.
Pathfinder's 2011 Annual Report, "Breaking Down Barriers," looks at the obstacles people face in accessing sexual and reproductive health care and what Pathfinder has done in the past year to break these barriers down.
Notwithstanding India's "rapid" economic growth, higher infant and maternal mortality rates are "robbing" Indian women and girls of their chances to make a contribution, National Commission for Women chief Mamata Sharma said today.
Last year, the WHO, in its latest recommendation on managing postpartum hemorrhage, endorsed the use of non-pneumatic anti-shock garments (NASGs) ‘as a temporising measure till appropriate care is available’ and suggested that national guidelines be reviewed to include NASGs as a low-tech first aid for postpartum hemorrhage.