Postpartum Hemorrhage in Developing Countries: New Findings and Innovative Technologies

“Postpartum Hemorrhage: New Findings and Innovative Technologies” - 36th Annual Global Health Council Meeting Session Digest

This is a review of the following session held at the 2009 Global Health Council meeting last week. This was cross-posted from


Presenters Discuss: possible risk factors
for postpartum hemorrhage (PPH) and the impact of active management of
the third stage of labor and its components on postpartum blood loss
(Global: Egypt, Ecuador, Turkey, Burkina Faso and Turkey); a
demonstration project to assess feasibility, acceptability, and safety
of oxytocin in Uniject as a first step to introducing the device on a
national scale, and strategies for scaling up use of oxytocin-Uniject™
devices with time-temperature indicator (TTI) for the prevention of PPH
(Mali); techniques for estimating blood loss for the early and accurate
diagnosis of PPH and cost-effective and reliable techniques for
improved blood loss estimation in rural settings (India, Tanzania) and
the importance of obstetric hemorrhage as a cause of maternal mortality
and morbidity in low-resource settings, the potential contribution of
the non-pneumatic anti-shock harment (NASG) to reducing death and
disability from obstetric hemorrhage (Nigeria). 

The session was moderated by Suellen Miller of UCSF – who works on
NASG among other projects. The panelists, in order of presentation:

  • Jill Durocher – Gynuity Health Projects, Determinants of Postpartum Hemorrhage [AMTSL]
  • Stacie Geller, PhD – University of Illinois-Chicago, Accessible Techniques for Improved Estimation of Blood Loss [blood drape]
  • Dosu Ojengbede – University College Hospital, Ibadan, Nigeria,
    Non-pneumatic Anti-shock Garment’s Potential for Obstetric Hemorrhage
    in Africa for Improved Estimation of Blood Loss [NASG]
  • Susheela Engelbrecht, CNM – PATH, Implementation Challenges on a Larger Scale [Uniject+oxytocin]

If you think you don’t know enough about PPH, check out this wikipedia entry.

By this point in the conference, I’m sure I’ve exposed my biases-
I’m interested in exploring themes across projects, with a particular
emphasis on opportunities for innovation. This session was no
different. Two key themes emerged: (1) these innovations are not magic
bullets – larger supporting systems need to be in place for them to be
effective, and (2) there are opportunities for improving outcomes by
improving the usability of these products.

No magic bullets

Susheela Engelbrecht’s wording in reference to Uniject syringes
preloaded with oxytocin was a bit different: “It is a magic bullet, but
many other things need to be in place”. With the NASG, the technology
buys critical time but is not a “definitive treatment” alone – it still
requires patient monitoring, for which appropriate staffing and
essential drugs are essential. The multi-country AMTSL (active
management of the third stage of labor) study suggests that steps such
as controlled cord contraction and fundal massage are only effective in
the context of uterotonic drug administration.

Improving usability

The technological innovations presented all show significant
promise. The Nigeria study, using a pre/post intervention design,
showed a reduction in blood loss of 61% and a reduction in mortality of
60%. The morbidity numbers were too small to make any inferences. A
randomized controlled trial showed that, compared to a gold standard
measure, the blood drape (Geller) was 33% more accurate than visual

Uterotonic drugs were shown to play a critical role in AMTSL and the
Uniject+oxytocin solution allows administration at the point-of-care to
avoid many of the pitfalls associated with ampoule+oxytocin+syringe
administration; however, there are some outstanding issues with cost
and policy:

  • cost: the Uniject solution will “always” be more expensive, currently a bit less than US$1 based on an Argentine formulation
  • policy: at what levels of the health system should this be used? should it be used only for AMTSL or also for PPH?

As we begin to move toward scaling these technologies, it will be
important to understand how people will use (and misuse) these
technologies in environments that are not subject to the scrutiny of
research studies.

Some notes I jotted down about usability innovations and challenges from the talks:

  • The blood drape had the unanticipated benefit of keeping things
    clean (containing blood), from the perspectives of women, birth
    attendants, and families
  • The original blood drape showed quantities (cc) of blood using a
    numerical scale, but a later version simply used a yellow line (alert)
    and red line (action) to identify risk level
  • For the blood drape, the alert and action values were not based on
    WHO standards, which are designed for equipped, clinical settings, but
    were calibrated based on data from deliveries in rural India (e.g. WHO
    standard was 500cc for alert, and the value used with the blood drape
    was 350cc)
  • Birth attendants and families using the blood drape for home
    deliveries on the floor came up with the idea of propping up the
    mother’s head with a dupatta to encourage the blood to flow into the
  • The blood drape must be placed under the women after birth, so that it doesn’t accumulate amniotic fluid (this is after all postpartum hemorrhaging)
  • With NASG the challenges include washing (decontaminating), drying,
    and folding – if this isn’t done in time, the benefit of the garment
    may be lost for the next patient – whether it is sent somewhere for
    decontamination or if it is done locally
  • The Uniject+oxytocin solution requires more space in the cold chain
    since the syringe and packaging takes up more space than standard
    ampoules for the same volume
  • With Uniject+oxytocin, some women though they were receiving a
    contraceptive injection against their will since their prior experience
    with pre-loaded syringes was with Depo-Provera
  • “Training was a non-issue” with Uniject+oxytocin. Those who read
    the instructions felt as comfortable as those who were trained by

During the Q&A there was one more. Professor Ojengbede mentioned
a case where a woman wore the NASG for four days in order to wait for a
blood transfusion. As soon as the bleeding stopped, she continued to
wear the garment and walked around the ward. In response to a question
about complications from wearing such a garment, the team indicated
that there were no cases of deep vein thrombosis or pulmonary embolism.
Note: the Nigeria study will soon be published in the Journal of
Obstetrics and Gynecology.