Objective To evaluate the effectiveness and safety of an ultra-lowcost uterine balloon tamponade package (ESM-UBTTM) for facility-based management of uncontrolled postpartum haemorrhage (PPH) in Kenya, Sierra Leone, Senegal, and Nepal.Design Prospective multi-centre case series.Setting Facilities in resource-scarce areas of Kenya, Sierra Leone, Nepal, and Senegal.Population Women with uncontrolled postpartum haemorrhage in 307 facilities across the four countries.Methods A standardised ESM-UBT package was implemented in 307 facilities over 29 months (1 September 2012 to 1 February 2015. Data were collected via a multi-pronged approach including data card completion, chart reviews, and provider interviews. Beginning in August 2014, women who had previously undergone UBT placement were sought and queried regarding potential complications associated with UBT use.Main outcome measures All-cause survival, survival from PPH, and post-UBT use complications (surgery, hospitalisation, antibiotics for pelvic infection) associated with UBT use.Results 201 UBTs were placed for uncontrolled vaginal haemorrhage refractory to all other interventions. In all, 38% (71/ 188) of women were either unconscious or confused at the time of UBT insertion. All-cause survival was 95% (190/201). However, 98% (160/163) of women survived uncontrolled PPH if delivery occurred at an ESM-UBT online facility. One (1/151) potential UBT-associated complication (postpartum endometritis) was identified and two improvised UBTs were placed in women with a ruptured uterus.Conclusions These pilot data suggest that the ESM-UBT package is a clinically promising and safe method to arrest uncontrolled postpartum haemorrhage and save women's lives. The UBT was successfully placed by all levels of facility-based providers. Future studies are needed to further evaluate the effectiveness of ESM-UBT in low-resource settings.Keywords Maternal mortality, postpartum haemorrhage, uterine balloon tamponade. Please cite this paper as: Burke TF, Ahn R, Nelson BD, Hines R, Kamara J, Oguttu M, Dulo L, Achieng E, Achieng B, Natarajan A, Maua J, Kargbo SAS, Altawil Z, Tester K, de Redon E, Niang M, Abdalla K, Eckardt MJ. A postpartum haemorrhage package with condom uterine balloon tamponade: a prospective multi-centre case series in Kenya, Sierra Leone, Senegal, and Nepal. BJOG 2016;123:1532-1540

A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed.

(BJOG. 2016;123:1532–1540) Uncontrolled postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. Several interventions have been developed and studied to manage uncontrolled PPH. However, several of these are not available in resource-limited settings. The authors of this study have developed a PPH package that includes an ultra-low cost (<US$5) condom uterine balloon tamponade kit called Every Second Matters for Mothers and Babies TM-UBT (ESM-UBT). They had previously used the kit in the South Sudan. They undertook the current multicenter prospective trial in Kenya, Sierra Leone, Senegal, and Nepal to assess the efficacy and safety of the ESM-UBT pack.

Background Fever is an important vital sign and often the first one to be assessed in a sick child. In acutely ill children, caregivers are expected to monitor a child’s body temperature at home after an initial medical consult. Fever literacy of many caregivers is known to be poor, leading to fever phobia. In children with a serious illness, the responsibility of periodically monitoring temperature can add substantially to the already stressful experience of caring for a sick child. Objective The objective of this pilot study was to assess the feasibility of using the iThermonitor, an automated temperature measurement device, for continuous temperature monitoring in postoperative and postchemotherapy pediatric patients. Methods We recruited 25 patient-caregiver dyads from the Pediatric Surgery Department at the Massachusetts General Hospital (MGH) and the Pediatric Cancer Centers at the MGH and the Dana Farber Cancer Institute. Enrolled dyads were asked to use the iThermonitor device for continuous temperature monitoring over a 2-week period. Surveys were administered to caregivers at enrollment and at study closeout. Caregivers were also asked to complete a daily event-monitoring log. The Generalized Anxiety Disorder-7 item questionnaire was also used to assess caregiver anxiety at enrollment and closeout. Results Overall, 19 participant dyads completed the study. All 19 caregivers reported to have viewed temperature data on the study-provided iPad tablet at least once per day, and more than a third caregivers did so six or more times per day. Of all participants, 74% (14/19) reported experiencing an out-of-range temperature alert at least once during the study. Majority of caregivers reported that it was easy to learn how to use the device and that they felt confident about monitoring their child’s temperature with it. Only 21% (4/9) of caregivers reported concurrently using a device other than the iThermonitor to monitor their child’s temperature during the study. Continuous temperature monitoring was not associated with an increase in caregiver anxiety. Conclusions The study results reveal that the iThermonitor is a highly feasible and easy-to-use device for continuous temperature monitoring in pediatric oncology and surgery patients. Trial Registration ClinicalTrials.gov NCT02410252; https://clinicaltrials.gov/ct2/show/NCT02410252 (Archived by WebCite at http://www.webcitation.org/73LnO7hel)

Topic: Systems-based Practice T he large global anesthesia crisis is well recognized and most seriously affects low-resource countries and settings. Severe shortages of anesthetists/anesthesiologists cause surgical delays that increase maternal and neonatal morbidity and mortality. This review was performed to gain a more complete understanding of the individual components of the "anesthesia gap" that affect vital reproductive health surgeries and procedures in settings with limited resources.A systematic literature search was performed by the authors in MEDLINE, the Cochrane Library, CINAHL, EMBASE, and POPLINE and included all articles published before December 31, 2013. Randomized controlled trials, prospective and retrospective observational studies, case series, and reports that assessed the use of anesthesia in reproductive health procedures in resource-poor settings were eligible for inclusion.Fourteen reports met the inclusion criteria. The main factors for a lack of anesthesia services were a significant lack of infrastructure, equipment and supplies, and trained personnel. Poor health system design and lack of general community infrastructure hinder the development of functioning comprehensive emergency obstetric and newborn care facilities. Facilities must be equipped with an operating theater, adequate support staff, and the ability to perform blood transfusions and emergency anesthesia. In many lowresource countries, these components are simply not present. Even if sufficient equipment is available, lapses in electricity service or oxygen provision and sporadic running water often prevent the use of equipment. In Uganda, this was reported by 41% of anesthesia providers. One review of 132 facilities in 8 countries verified frequent interruption. Other problematic infrastructure components were lack of transportation and roads, poor community education and preparedness, and the multiple effects of poverty. Essential surgical equipment and supplies, equipment for airway management, antibiotics, and medications for intubation, anesthesia, and analgesia are frequently not available. Basic safety monitoring equipment is often in disrepair or unaffordable for these facilities. The most common types of anesthesia in poor settings are general anesthesia with halothane and ether, spinal anesthesia with bupivacaine, and dissociative anesthesia with ketamine. Often providers cannot offer spinal and general anesthesia at the same time because they lack medications and supplies. Anesthesia providers performing cesarean deliveries seem to prefer ketamine because of its high therapeutic index, safety, and lower cost. Indeed, reports conflict over the relative safety for general versus spinal anesthesia, with 1 survey suggesting that general anesthesia is associated with a higher death rate and spinal anesthesia in another. The lack of trained personnel is the third overriding problem. The poorest regions in the world have the lowest numbers of anesthesiologists and anesthetists. Contributing factors include politica...