PPH Notes: Current Directions for the Change We Want to See
“A woman who is pregnant has one foot in the grave.” – local proverb, Chad.
On an early Saturday morning just over a month ago, I tuned in for a free online conference organized by midwifery students at Oregon Health Sciences University and by Johns Hopkins University School of Nursing. Cup of coffee in hand, my caffeinated eyes widened as I listened in on a topic most relevant to my own interests: postpartum hemorrhage (PPH).
Deborah Armbruster, the Senior Maternal Health Advisor for USAID, presented an illuminating seminar entitled (not as creatively), “Postpartum Hemorrhage.” Now, a month or so later, I sit wondering just how many people switched on a computer that early Saturday morning and dialed their brain waves to focus in on the current state of PPH. My attendance estimate falls at a meek few. So, I’ve decided to share a succinct summary of Ms. Armbruster’s detailed seminar.
- PPH is one of the most prevalent, direct killers of women, accounting for approximately 35% of maternal deaths worldwide.
- PPH is due primarily to uterine atony (70% to 90%), or insufficient uterine contraction soon after childbirth. Without contractions, the blood in the uterus does not clot. Instead, it gushes. Other causes of PPH include trauma, retained tissue (usually a piece of the placenta), and an inverted or ruptured uterus.
- 50% of women in the world are anemic. The “leeway” for blood loss in moderately to severely anemic women is nonexistent. Women with anemia often begin childbirth in a physically weakened state. They risk a greater chance of uterine atony and face grave circumstances if PPH occurs because their blood reserve is already so low.
- 2/3 of PPH cases cannot be predicted or detected by risk assessment.
So what do we do? If PPH cannot be detected, how can we prevent it? When PPH occurs, how do we stop it? Ms. Armbruster answered these questions in detail.
First, it is important to note that women giving birth in a healthcare facility or in the care of a doctor typically have access to resources (medications, skilled personnel, and surgical procedures) that can fully prevent and/or treat PPH. Surgical procedures, though more complicated and resource-demanding, are highly successful. However, many women in the world give birth not at healthcare facilities but in low-resource community settings. Ms. Armbruster addressed these settings specifically, as they are the places where the majority of PPH-caused morbidity and mortality occurs.
There are several proven, high-impact strategies that work in the community. Most common is the use of active management of the third stage of labor (AMTSL). Of the multiple interventions used during AMTSL, administration of an uterotonic (an agent that helps the uterus contract) represents the most effective component. Oxytocin remains the best-recommended uterotonic, though it requires more skill in its administration. AMTSL instructions generally include giving a uterotonic, preferably oxytocin, within one minute of childbirth, delivering the placenta via controlled traction on the umbilical cord and counter pressure to the uterus (optional), massaging the uterus after delivery of the placenta to ensure that the uterus is firm (optional), and palpitating the uterus before finally joining the mother and infant together. If performed correctly, AMTSL can reduce risk of PPH by 60%. There are plenty of pluses to AMTSL, especially its administration of oxytocin; however, like any drug, physical treatment, or intervention, there are downsides.
The oxytocin (or other uterotonic) may not have been stored at an adequate temperature or may be of poor quality. Healthcare practitioners may not have sufficient training. The gaps in healthcare during childbirth make for a long, ongoing list of potential setbacks. The change we must see in PPH prevention spans far beyond which “high-impact strategy” we choose. It involves training skilled birth attendants, gaining support from communities, healthcare policy makers, and governments, educating women about the care they need before, during, and after childbirth, and considering new strategies that require less resources and minimal expertise. Finally, it is essential to ensure that these ideas, strategies, and interventions are put to good use in a way that is sustainable as well as compassionate, respectful, and kind. Change is not always immediate. It’s progressive. (This idea certainly is not novel, but I feel it deserves repeated mention.)
Throughout the seminar, my eyes bulged as statistic after statistic cropped up on PowerPoint slides. Most were presented with hopeful rhetoric, yet I could not help but perceive the flip-side: these numbers show that the world still lacks a foolproof PPH treatment or prevention plan.
PPH prevention and treatment represents an exciting, inspiring, and progressing revolution in global health. This small piece of writing is just an introduction to the current literature and research, as well as a starting point from which I hope we can all continue conversation and cultivate new ideas for progressive change in decreasing the burden posed by PPH.
At the very beginning, I included a quote taken from Ms. Armbruster’s presentation. It is a local proverb in Chad: “A woman who is pregnant has one foot in the grave.” In some countries, the words “pregnancy” and “childbirth” evoke notions of “new beginnings,” “creation,” and “life.” To learn that these same words represent such dark expectations is heart-wrenching. But I do think there is room enough for hope within the striking progress made by technologies and strategies like oxytocin and AMTSL. We must keep pushing for safe, health-filled childbirths to ignite change in the way women, families, and communities experience and understand pregnancy and childbirth around the globe.