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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 12, Num. 2, 2008, pp. 7-9
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African Journal of Reproductive Health,
Vol. 12, No. 1, April
2008, pp. 7-9
Editorial
Preventing primary
postpartum hemorrhage in unskilled births in Africa
Idara Udofia1 and
Friday Okonofua2
1Department of Political Science and
Anthropology, Columbia University, New York, USA, and
2Editor, African Journal of Reproductive
Health
Code Number: rh08018
Available evidence indicates that Africa
accounts for the highest burden of maternal
mortality in the world. Primary postpartum
hemorrhage (PPH) accounts for an estimated
25% of maternal mortality, and is a major
cause of postpartum disability in
sub-Saharan Africa. PPH and maternal anemia
are also indirect contributors to maternal
deaths due to other causes. Thus, it is
conceivable that any intervention aimed at
preventing PPH will reduce maternal
mortality by more than one quarter in
sub-Saharan Africa. To
date, nearly 90% of PPH are due to inadequate uterine
contractions occurring at the time of delivery. The
routine adminis-tration of uterotonics followed by
controlled cord traction is the method recommended by
the International Federation of Obstetricians and
Gynecologists (FIGO) and the International Confederation
of Midwives (ICM) for the prevention of PPH1.
Uterotonics are also the mainstay of treatment of PPH
after it has occurred.
The
World Health Organization recommends the administration
of intravenous oxytocin and ergometrine as first and
second line uterotonics for the prevention and treatment
of PPH2.
However, these uterotonics can only be administered in
deliveries taken by skilled birth attendants in orthodox
health facilities. Since oxytocin and ergometrine
require parenteral administration, these
recommen-dations are futile when deliveries are carried
out by unskilled birth attendants.
There
in lies the problem in sub-Saharan Africa, where large
proportions of births occur at home or are attended by
unskilled traditional birth attendants. Nigeria and
Ethiopia, two densely populated countries in Africa with
the highest maternal mortality rates, also have between
50-60% of births either unattended or attended by
unskilled birth attendants. Indeed, several studies
conducted in locations across sub-Saharan Africa, have
identified delivery by unskilled providers as the most
important risk factor for PPH fatalities3,4.
During such births, women are unnecessarily exposed to
the risk of dying from PPH, in part because the two
recommended drugs cannot be administered by unskilled
providers to prevent or treat PPH.
One long term measure to address this problem is to increase
the proportion of births attended by skilled providers
in health facilities in Africa. However, within the
context of the developmental realities in many parts of
Africa, this will take several years to materialize in
the continent.
Thus, short and medium term measures must be identified to
rapidly redress the problem, and reduce the burden of
PPH-related maternal mortality in the continent. One
such measure is to increase access to misoprostol
tablets for women being attended at the time of delivery
by unskilled birth providers. Misoprostol is a powerful
uterotonic that has been recommended by the WHO as third
line medication for the prevention and treatment of PPH5.
Indeed, recent studies have shown that results obtained
with oral misoprostol when used for the prevention and
treatment of PPH are similar to those obtained with
intramuscular oxytocin6.
Misoprostol has the advantage that it is presented in tablet
forms and is active through several routes of
administration - oral, buccal, sub-lingual, vaginal and
rectal. This makes it ideally suited for use by
unskilled birth attendants. Furthermore, misoprostol is
relatively cheap as compared to ergometrine and oxytocin,
and is free from significant side effects.
Multiple studies reaffirm that unskilled birth attendants are
able to successfully use misoprostol for the prevention
and treatment of PPH. A community based study in Java,
Indonesia, has shown that oral misoprostol can be given
by unskilled birth attendants for the prevention and
treatment of PPH. After months of misoprostol use,
significant reduction in maternal mortality was observed
in the region, mainly due to the use of misoprostol for
prevention and treatment of PPH by unskilled providers7.
A similar study in rural Tanzania has shown tremendous
promise in reducing maternal mortality, when traditional
birth attendants are taught to administer oral
misoprostol for the prevention and treatment of PPH8.
An ongoing study in Benin City, Nigeria9 is
also providing evidence indicating that traditional
birth attendants can safely administer rectal
misoprostol for treatment of PPH. This later study
consists of two arms - an intervention group, where TBAs
are taught to administer 1000 micrograms of rectal
misoprostol for treatment of PPH, and a control group,
where TBAs are asked to do what they have always done to
treat PPH. TBAs in the two arms are then requested to
refer continuing PPH not amenable to treatment to
orthodox health facilities nearest to them. The results
from 350 patients enlisted in the study so far, have
shown a significant decline in PPH referrals to orthodox
health facilities in the intervention sites as compared
to the control sites. Thus, we believe that misoprostol
is an essential intervention that can be scaled up in
communities with high rates of unskilled birth
attendance for the prevention and treatment of PPH.
Misoprostol has now been registered for the prevention and
treatment of PPH in four African countries - Ethiopia,
Tanzania, Uganda and Nigeria - all burdened with high
rates of maternal mortality. However, registration
alone is insufficient to maximize the benefits of
misoprostol. In Nigeria, the uterotonic has yet to be
well advertised at national and sub-national levels,
with recent results of a community-based study showing
that less than 5% of primary health care workers in the
country have knowledge of the drug10.
Misoprostol is also presently not on the essential drug
list in Nigeria, and is therefore not on the public drug
purchasing list in the country.
A call
is being made for the promotion of misoprostol as an
interim measure for the prevention of PPH and related
mortality in African countries with high rates of
unskilled birth attendance. This should consist of
registration of misoprostol in countries where the drug
has not yet been registered, its inclusion in the
essential drug list of countries, dissemination of
misoprostol information, training of unskilled providers
on prevention and treatment of PPH, and measures to
increase the availability of misoprostol in public and
private health institutions in Africa. The long term
measure to reduce PPH is to increase the proportion of
pregnant women using skilled birth attendants and
orthodox health facilities at the time of delivery.
This can be achieved through formal and informal
education, and the socio-economic empowerment of women.
Reducing maternal mortality due to PPH in Africa is a
major priority and a developmental imperative and is one
of the most essential steps needed to achieve the MDG 5
in the continent.
References
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al. WHO multicentre randomized trial of misoprostol in
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- Okonofua FE, Prata
N, et al. Misoprostol administered by traditional birth
attendants for control of postpartum hemorrhage in
Nigeria. Study in Progress.
- Okonofua FE,
Otoide V, Udofia I, Imariagbe C. Knowledge and practice
of methods for prevention and treatment of primary
postpartum hemorrhage by primary health workers in rural
Nigeria. Public Health (Submitted for Publication).
Copyright 2008 - Women's
Health and Action Research Centre, Benin City, Nigeria
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