Pathfinder Continuum of Care for Addressing Post-Partum Hemorrhage (PPH) Dr. Abdelhadi Eltahir, MD, MPH, Senior Advisor for Maternal and Newborn Health, Pathfinder International Half a minute to: Recognize the main players of the Pathfinder Continuum of Care: Pathfinder PPH Team, MacArthur, Dr. Suellen Miller, ,Director, Safe Motherhood Program, University of California and Dr. Stacie Geller, University of Illinois Chicago. (Perhaps slide 2 may be better for recognition of the players other than PI. For instance, NASG and Suellen and Stacie and the Drape) POPPHI Working Group Meeting The George Washington University’s Marvin Center 800 21st St. NW, Washington, DC 20006 April 6, 2006

What is Pathfinder’s Continuum of Care for Addressing PPH? Pathfinder’s CC-PPH Project is: An Initiative funded by The MacArthur Foundation; Aiming to provide replicable model; Focusing on new technologies that have significant impact in prevention and treatment of PPH; Initially being implemented in Nigeria and India; and A collaboration with Local, State and Federal Gvt as well as Departments of Health (MOH)

The new technologies for the CC-PPH are: Active Management of Third Stage of Labor (AMTSL); Blood Collection Drape and other effective blood loss estimation methods; and Non-Pneumatic Anti-Shock Garment (NASG).

In Country Scale up and Expansion of the CC-PPH India and Nigeria together account for a significant number of the world’s maternal deaths. According to WHO, India has the highest absolute number of maternal deaths, accounting for 25% of all maternal deaths worldwide, and hemorrhage accounts for 30-38% of these maternal deaths.[1] Nigeria has the second largest number of women dying in pregnancy and childbirth. Yet at 800 deaths per 100,000 live births, Nigeria’s MMR is significantly higher than India’s at 300/100,000.2,4 Yet these national figures conceal extreme variations in health outcomes between states in both countries. [1] Registrar General of India. Sample Registration Survey: Maternal mortality in India, 1997-2003: trends, causes, and risk factors. New Delhi, India: 2006. Pathfinder is working in Tamil Nadu, where there is considerable government enthusiasm for integrating the NASG into the existing health care system. Pathfinder is providing technical assistance and training to the health providers and training institutions on the use (and procurement) of the NASG. (Tamil State GVT will purchase the NASG from their own funds) India accounts for 25% of all maternal deaths worldwide 4

Nigeria in Country Expansion of the CC-PPH In Nigeria: 31 Intervention facilities and 11 control sites in the 4 initial states India and Nigeria together account for a significant number of the world’s maternal deaths. According to WHO, India has the highest absolute number of maternal deaths, accounting for 25% of all maternal deaths worldwide, and hemorrhage accounts for 30-38% of these maternal deaths.[1] Nigeria has the second largest number of women dying in pregnancy and childbirth. Yet at 800 deaths per 100,000 live births, Nigeria’s MMR is significantly higher than India’s at 300/100,000.2,4 Yet these national figures conceal extreme variations in health outcomes between states in both countries. [1] Registrar General of India. Sample Registration Survey: Maternal mortality in India, 1997-2003: trends, causes, and risk factors. New Delhi, India: 2006. Nigeria second largest number of women dying in pregnancy and childbirth

Components of Continuum of Care (CC) for PPH Advocacy: to gain understanding and support for the CC Model with : Government officials in departments of health and family welfare; Community leaders Professional bodies such as FOGSI, SOGON, IMA and MWAN AMTSL for preventing PPH: Prophylactic use of standard oxytocics; Controlled Cord Traction (CCT); and Uterine Massage Advocacy: For instance in Nigeria: Advocacy carried out with all 4 SMOHs Collaboration with FMOH and other IPs Stakeholder meeting held with over 100 participants from 26 states and hosted by the Kaduna state Governor’s wife PAC developed and first meeting held, chaired by Katsina state Governor’s wife FOGSI = Federation of Obstetric and Gynecological Societies of India IMA = Indian Medical Association SOGON: the Society of Gynecology and Obstetrics of Nigeria (SOGON), NANNM: The National Association of Nigeria Nurses and Midwives, MWAN: The Medical Women Association of Nigeria. AMTSL: Use of oxytocin CCT: Controlled Cord Traction shorten the time of delivery of placenta with much less blood loss Uterine massage ensures that the blood has stopped. For instance, use of Misoprostol in treatment of PPH (sub-lingual and rectally). It effective. 6

Components of Continuum of Care (CC) for PPH (cont’d) 3. Early detection of hemorrhage: Blood Collection Drape and other effective blood loss estimation methods Early fluid & uterotonic treatment of PPH: To prevent hypovolemic shock Community organization of transport: For rapid referral and safe transfer of obstetric emergencies to facilities that can treat PPH and shock Advocacy: For instance in Nigeria: Advocacy carried out with all 4 SMOHs Collaboration with FMOH and other IPs Stakeholder meeting held with over 100 participants from 26 states and hosted by the Kaduna state Governor’s wife PAC developed and first meeting held, chaired by Katsina state Governor’s wife FOGSI = Federation of Obstetric and Gynecological Societies of India IMA = Indian Medical Association SOGON: the Society of Gynecology and Obstetrics of Nigeria (SOGON), NANNM: The National Association of Nigeria Nurses and Midwives, MWAN: The Medical Women Association of Nigeria. AMTSL: Use of oxytocin CCT: Controlled Cord Traction shorten the time of delivery of placenta with much less blood loss Uterine massage ensures that the blood has stopped. For instance, use of Misoprostol in treatment of PPH (sub-lingual and rectally). It effective.

Components of Continuum of Care for PPH (cont’d) 6. Anti-Shock Garment (NASG): To resuscitate and stabilize women in shock until comprehensive care for PPH and shock is available NASG is a temporary measure to stabilize a woman who is in shock until rapid replacement of blood volume and definitive treatment Estimates by Dr. Suellen Miller and Dr. Stacie Geller who, based on their research on the NASG could reduce 60% of PPH deaths among women who are hemorrhaging. In the first 3 month (Aug – Oct 2008) NASG was applied on 276 cases who were in Shock.

Components of Continuum of Care for PPH (cont’d) Nigerians providers are aware of the use and effect of the NASG. The GON is working towards providing more NASG as part of the routine Health services. 7. Treatment of shock with rapid replacement of blood volume

Country Lifetime Risk of Maternal Death—1 in Why focusing on PPH? PPH is the most serious complication during childbirth and it contributes by an average of 25% to the causes of maternal mortality. It can kill a woman within two hours. In many rural areas in the developing countries women can not make it to a health facility. The concept of Life Time Risk of Dying and the contrast between two worlds (in one) Source: WHO Maternal Mortality report, 2005 Country Lifetime Risk of Maternal Death—1 in Sierra Leone 8 Afghanistan 8 Nigeria 13 Australia 13,300 Ireland 47,600

Continuum of Care: National Champions and Opinion Leaders Brief Remarks on the leadership role of MacArthur President and Dr Habib (Recognition of other key champions)

National Champions: Establishment of Maternity Blood Transfusion Center Immediate Results: Easier access to blood transfusion Significant reduction (about 75%) in the waiting time from arrival of patient to receiving blood This is a replicable model that should be promoted A replicable model and initiative: In Mohamed Murtala Specialist Hospital (conducts about 13,000 deliveries per year) Dr. Saduki whose the Maternity Blood Transfusion Center named after, was the thinker and implementer. Being an Ob/GYN and fully aware of investing in the golden time when a woman is in shock, pursued the establishment of the Blood Transfusion Center from A to Z within the Continuum of Care Project in Nigeria. Prior to this Center – Nurse midwives, at the maternity mentioned that at times it takes up to 5 hours to obtain one pint (unit) of blood for a woman who is in shock, Because they have to take the blood fot G&X-Matching and send to a blood Bank about 20 min away, then they have to ask the relative to go that bank (if they are available). Now the Blood Transfusion center is within the vicinity of the Maternity ward and immediatel Blood Transfusion is a key and life saving component. Dr. Habibu Maternity Blood Transfusion Centre has reduced the Third Delay by about 80% … From an average of 5 to 7hours to less than an hour. WWW.Pathfind.org

Continuum of Care: Availability of Emergency Blood Comments on Availability of Emergency Blood in Nigeria and India

Pathfinder Assists Indian Institutions and National Champions in Implementing CC-PPH Rekha Masilamani, Country Representative, India Dr. M. Muthulaxmi Prof, and HOD In India there are a number of national champions who are key promoters for the CC-PPH Pathfinder distributes NASG and AMTSL Guidelines and Protocols in local languages to Teaching Hospitals and training institutions

Pathfinder Training AMTSL in India Delivery of the baby

Pathfinder Training AMTSL in India (cont’d) Pathfinder Trains Indian health care providers (doctors, nurses and midwives) on the CC-PPH Controlled Cord Traction

Pathfinder Training AMTSL in India (cont’d) Demonstration of Uterine Massage

Pathfinder Training Blood Collection Drape in India

The best outcome of the Continuum of Care: India and Nigeria Project These smiling faces of mothers and babies are happy Indian and Nigerian mothers who enjoyed the service of the continuum of care and delivered with minimum blood loss by AMTSL.

Who is The most important visitor to Hospital? “The patient is the most important visitor in the Hospital. We are dependent on him. He is the purpose of our work. He is our business. He is a human being and not a statistic or a clinical material, he has feelings, emotions, biases and wants” Who is The most important visitor to Hospital? Mahatma Gandhi

Further Readings and References Geller, S, Adams, MG, Miller, S, A Continuum of Care Model for Postpartum Hemorrhage, International Journal of Fertility & Women's Medicine, 52(2-3)97-105, 2008. Miller, S, Hamza, S, Bray E, Gipson R, Nada, K, Fathalla, M, Mourad, M. et al. First Aid for Obstetrical Hemorrhage: The Pilot Study of the Non-pneumatic Anti-Shock Garment (NASG) in Egypt. BJOG, 113(4): p. 424-9, 2006. Miller, S, Ojengbede A, Turan J, Ojengbede O, Butrick E, Hensleigh, P. Anti-Shock Garments for Obstetric Hemorrhage. Current Women’s Health Reviews, 3(1), 3-11, 2007. Pathfinder International, “Refusing to Accept Maternal Mortality” Pathways: A Publication of Pathfinder International; Spring 2009 WWW.Pathfind.org

Thank you for listening Please visit WWW.Pathfind.org