BackgroundHemorrhage 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.MethodsWe 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.ResultsEighteen 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.ConclusionsCommunity-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.

BackgroundKnowledge 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.MethodsFrom 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.ResultsWe 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.ConclusionsThe predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.

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.

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