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Researchers explore new model of care for management of postpartum hemorrhage

“A new model of care can provide policymakers with a feasible and practical way to address the prevention and treatment of postpartum hemorrhage at the community level,” an international group of researchers said as their study is published in print format in the British Journal of Obstetrics and Gynaecology.

The article describes a community trial implemented by a team from India and the USA that compared two approaches to the management of postpartum hemorrhage – the leading complication of childbirth that causes approximately a quarter of all maternal deaths each year.

The study compared the current standard, ‘universal prophylaxis’ – a commonly-advocated community approach for reducing postpartum hemorrhage whereby every woman is administered a preventive uterotonic medicine to contract the uterus – to a novel approach, ‘secondary prevention/early treatment’ – where only the small proportion of women who bleed more than average are offered a treatment dose of misoprostol.

While it is known that universal prophylaxis can lower blood loss, it is less clear if this strategy saves lives. Even with prophylaxis up to 16% of women will still experience postpartum hemorrhage and may require immediate care.

“It is imperative to create options to manage postpartum hemorrhage wherever women deliver, including the lowest levels of the health system”, the authors said. “We wanted to examine a model of postpartum hemorrhage care that was simple, effective and sustainable.” This innovative early treatment approach has the potential to medicate fewer women, expose fewer women to side effects, improve acceptability, and reduce costs.

The study, conducted over a 2.5-year period (2011-2014) in a predominantly rural district of southern India, included over 3000 women who delivered vaginally with an Auxiliary Nurse Midwife (ANM) at home or in a health sub-center, the lowest health post level. ANMs were randomly assigned to administer misoprostol using either one of the two approaches.

Results show that the secondary prevention approach medicated substantially fewer women (4.7% versus 99.7%), who experienced significantly fewer side effects. There were no statistical differences in post-delivery hemoglobin levels, rate of postpartum hemorrhage, and rate of transfer to higher level facilities.

The authors conclude that this new research shows secondary prevention/early treatment to be a feasible non-inferior alternative strategy to universally medicating all women who deliver with prophylaxis. The approach has the potential for being more acceptable, cost-effective and sustainable, with the additional potential to equip community-level providers with a timely strategy to manage bleeding before it reaches the point of an emergency.

A similar trial, expected to end in early 2016, is underway in Egypt where blood loss is being estimated using locally available and inexpensive blood absorption pads commonly used in delivery.

The authors said: “In our opinion, this new early treatment approach is an important step towards a more strategic placement of misoprostol for managing postpartum hemorrhage along the continuum of care.”