Maternal Health

Training Traditional Birth Attendants on the Use of Misoprostol and a Blood Measurement Tool to Prevent Postpartum Haemorrhage: Lessons Learnt from Bangladesh

A consensus emerged in the late 1990s among leaders in global maternal health that traditional birth attendants (TBAs) should no longer be trained in delivery skills and should instead be trained as promoters of facility-based care. Many TBAs continue to be trained in places where home deliveries are the norm and the potential impacts of this training are important to understand. The primary objective of this study was to gain a more nuanced understanding of the full impact of training TBAs to use misoprostol and a blood measurement tool (mat) for the prevention of postpartum haemorrhage (PPH) at home deliveries through the perspective of those involved in the project. This qualitative study, conducted between July 2009 and July 2010 in Bangladesh, was nested within larger operations research, testing the feasibility and acceptability of scaling up community-based provision of misoprostol and a blood measurement tool for prevention of PPH. A total of 87 in-depth interviews (IDIs) were conducted with TBAs, community health workers (CHWs), managers, and government-employed family welfare visitors (FWVs) at three time points during the study. Computer-assisted thematic data analysis was conducted using ATLAS.ti (version 5.2). Four primary themes emerged during the data analysis, which all highlight changes that occurred following the training. The first theme describes the perceived direct changes linked to the two new interventions. The following three themes describe the indirect changes that interviewees perceived: strengthened linkages between TBAs and the formal healthcare system; strengthened linkages between TBAs and the communities they serve; and improved quality of services/service utilization. The data indicate that training TBAs and CHW supervisors resulted in perceived broader and more nuanced changes than simply improvements in TBAs’ knowledge, attitudes, and practices. Acknowledgeing TBAs’ important role in the community and in home deliveries and integrating them into the formal healthcare system has the potential to result in changes similar to those seen in this study.

Do Economists Have Frequent Sex?

Last year a member of the World Bank professional staff gave a lecture on development in Africa on the UC Berkeley campus. His audience asked him about rapid population growth in that continent. He immediately dismissed the question, saying that population growth did not need any special attention. It would look after itself. He was voicing an uncritical interpretation of the demographic transition, a “theory” which has as much evidence to support it as the fictitious Da Vinci Code, and like the Da Vinci Code it remains perennially popular.

Criticism of misguided Chu et al. article

Chu, Brhlikova and Pollock’s article suggests the WHO rethink its decision to include misoprostol on the Essential Medi- cines List. Their paper is a sad example of workers in an elite setting advocating policies with the potential to endanger the lives of thousands of vulnerable women in low-resource settings.

Training traditional birth attendants to use misoprostol and an absorbent delivery mat in home births.

A 50-fold disparity in maternal mortality exists between high- and low-income countries, and in most contexts, the single most common cause of maternal death is postpartum hemorrhage (PPH). In Bangladesh, as in many other low-income countries, the majority of deliveries are conducted at home by traditional birth attendants (TBAs) or family members. In the absence of skilled birth attendants, training TBAs in the use of misoprostol and an absorbent delivery mat to measure postpartum blood loss may strengthen the ability of TBAs to manage PPH. These complementary interventions were tested in operations research among 77,337 home births in rural Bangladesh. The purpose of this study was to evaluate TBAs' knowledge acquisition, knowledge retention, and changes in attitudes and practices related to PPH management in home births after undergoing training on the use of misoprostol and the blood collection delivery mat. We conclude that the training was highly effective and that the two interventions were safely and correctly used by TBAs at home births. Data on TBA practices indicate adherence to protocol, and 18 months after the interventions were implemented, TBA knowledge retention remained high. This program strengthens the case for community-based use of misoprostol and warrants consideration of this intervention as a potential model for scale-up in settings where complete coverage of skilled birth attendants (SBAs) remains a distant goal.

Global warming and reproductive health

The largest absolute numbers of maternal deaths occur among the 40–50 million women who deliver annually without a skilled birth attendant. Most of these deaths occur in countries with a total fertility rate of greater than 4. The combination of global warming and rapid population growth in the Sahel and parts of the Middle East poses a serious threat to reproductive health and to food security. Poverty, lack of resources, and rapid population growth make it unlikely that most women in these countries will have access to skilled birth attendants or emergency obstetric care in the foreseeable future. Three strategies can be implemented to improve women’s health and reproductive rights in high-fertility, low-resource settings: (1) make family planning accessible and remove non-evidenced-based barriers to contraception; (2) scale up community distribution of misoprostol for prevention of postpartum hemorrhage and, where it is legal, for medical abortion; and (3) eliminate child marriage and invest in girls and young women, thereby reducing early childbearing.

A Woman Cannot Die from a Pregnancy She Does Not Have

The fifth Millennium Development Goal has brought critical attention to the unacceptably high burden of maternal mortality and the need to improve antenatal health care. However, many of the approaches to reducing maternal mortality (e.g., increasing the number of deliveries at health facilities with skilled attendants or improving access to emergency obstetric care) are complex and will take time to implement. In the meantime, maternal mortality can be reduced relatively inexpensively by preventing unwanted pregnancy through family planning. The decision to practice family planning is personal and private, and it need not require professionals or health clinics. Although inexpensive at the program level, however, family planning may be difficult for individuals to afford. Thus, women face barriers, including cost, lack of transportation and the fear of side effects (real or rumored). In developing countries, making contraceptives available and accessible may be the most important, cost-effective and easily accomplished primary health care goal. Reducing barriers to family planning may lessen the burden of maternal death in low-resource settings.

Where There Are (Few) Skilled Birth Attendants

Recent efforts to reduce maternal mortality in developing countries have focused primarily on two long-term aims: training and deploying skilled birth attendants and upgrading emergency obstetric care facilities. Given the future population-level benefits, strengthening of health systems makes excellent strategic sense but it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. There are currently 28 countries from four major regions in which fewer than half of all births are attended by skilled birth attendants. Sixty-nine percent of maternal deaths in these four regions can be attributed to these 28 countries, despite the fact that these countries only constitute 34% of the total population in these regions. Trends documenting the change in the proportion of births accompanied by a skilled attendant in these 28 countries over the last 15-20 years offer no indication that adequate change is imminent. To rapidly reduce maternal mortality in regions where births in the home without skilled birth attendants are common, governments and community-based organizations could implement a cost-effective, complementary strategy involving health workers who are likely to be present when births in the home take place. Training community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) will increase the chance that women in the lowest economic quintiles will also benefit from global safe motherhood efforts.

Setting priorities for safe motherhood interventions in resource-scarce settings

Objective: Guide policy-makers in prioritizing safe motherhood interventions.

Methods: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models.

Results: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph).

Avoidable maternal deaths: Three ways to help now

The current paper examines the realities of women delivering in resource-poor settings, and recommends cost-effective, scalable strategies for making these deliveries safer. Ninety-five percent of maternal deaths occur in poor settings, and the largest proportion of these deaths are women who deliver at home, far away from health care facilities, and without financial access to skilled providers. This situation will improve only when policymakers and programme planners refocus their attention on service delivery and financing interventions, with the potential to reach the largest portion of women living in places where mortality is the highest. We suggest three feasible interventions that can potentially minimise both demand and supply side problems of safe delivery: (1) misoprostol to treat postpartum haemorrhage, an easy to use and heat stable technology to reduce the leading cause of maternal deaths; (2) alternative providers, such as clinical officers, trained to offer emergency obstetric care services; (3) financing safe delivery through vouchers or other mechanisms that can be implemented in poor settings and made attractive to the donor community through output-based assistance (OBA).

Keywords: postpartum haemorrhage; maternal mortality; safe delivery; vouchers; misoprostol

Published In Global Public Health, Volume 4, Issue 6 November 2009 , pages 575 – 587

Maternal mortality: one death every 7 min

This comment in the explores the role of policy and research in using the prevention of postpartum hemorrhage and suggest a joint meeting by WHO and FIGO to revisit the 2009 statement by WHO which does not recommend the use of misoprostol at the community level.

The theoretical and political framing of the population factor in development

The silence about population growth in recent decades has hindered the ability of those concerned with ecological change, resource scarcity, health and educational systems, national security, and other global challenges to look with maximum objectivity at the problems they confront. Two central questions about population—(i) is population growth a problem? and (2) what causes fertility decline?—are often intertwined; if people think the second question implies possible coercion, or fear of upsetting cultures, they can be reluctant to talk about the first. The classic and economic theories explaining the demographic transition assume that couples want many children and they make decisions to have a smaller family when some socio-economic change occurs. However, there are numerous anomalies to this explanation. This paper suggests that the societal changes are neither necessary nor sufficient for family size to fall. Many barriers of non-evidence-based restrictive medical rules, cost, misinformation and social traditions exist between women and the fertility regulation methods and correct information they need to manage their family size. When these barriers are reduced, birth rates tend to decline. Many of the barriers reflect a patriarchal desire to control women, which can be largely explained by evolutionary biology. The theoretical explanations of fertility should (i) attach more weight to the many barriers to voluntary fertility regulation, (ii) recognize that a latent desire to control fertility may be far more prevalent among women than previously understood, and (iii) appreciate that women implicitly and rationally make benefit–cost analyses based on the information they have, wanting modern family planning only after they understand it is a safe option. Once it is understood that fertility can be lowered by purely voluntary means, comfort with talking about the population factor in development will rise.

Published in: Phil. Trans. R. Soc. B October 27, 2009 364:3101-3113;

Saving maternal lives in resource-poor settings: Facing reality

Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions.

Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted. Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of thes ewomen deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.

© 2008 Elsevier Ireland

published in Health Policy 2009