Latest report: prevention and treatment of postpartum haemorrhage” by WHO 2012

Latest publication on “WHO recommendations for the prevention and treatment of postpartum haemorrhage” by WHO, 2012.

Every minute around the world 380 women become pregnant,

190 women face unplanned or unwanted pregnancies,

110 women experience pregnancy related complications,

40 women have unsafe abortions,

1 woman dies.”

The World Health Organization states that every minute, at least one woman dies from complications related to pregnancy or childbirth – that means 529 000 women a year. Unavailable, inaccessible, unaffordable, or poor quality care is fundamentally responsible.

Find the latest recommendations below.
The report in its guideline development method, section of the report reads out as follows: “The scientific evidence for the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. For each of the previous WHO recommendations on PPH (2007 and 2009) and for all the newly-added questions, evidence profiles were prepared based on 22 up-to-date systematic reviews. The revised and new recommendations were developed and adopted by an international group of experts who participated in the WHO Technical Consultation on the Prevention and Treatment of PPH, held in Montreux, Switzerland, 6–8 March 2012. The WHO Technical Consultation adopted 32 recommendations and these are shown in Boxes A, B and C. For each recommendation, the quality of the supporting evidence is graded as ‘very low’, ‘low’, ‘moderate’ or ‘high’………………”
Box A: Recommendations for the prevention of PPH
1. The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births. (Strong recommendation, moderate-quality evidence)
2. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. (Strong recommendation, moderate-quality evidence)
3. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 μg) is recommended. (Strong recommendation, moderate quality evidence)
4. In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 μg PO) by community health care workers and lay health workers is recommended for the prevention of PPH. (Strong recommendation, moderate quality evidence)
5. In settings where skilled birth attendants are available, CCT is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important (Weak recommendation, 
6. In settings where skilled birth attendants are unavailable, CCT is not recommended. (Strong recommendation, moderate-quality evidence)
7. Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care. (Strong recommendation, moderatequality evidence)
8. Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation. (Strong recommendation, moderate-quality evidence)
9. Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin. (Weak recommendation, low-quality evidence)
10. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. (Strong recommendation, very-low-quality evidence)
11. Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in caesarean section. (Strong recommendation, moderate-quality evidence)
12. Controlled cord traction is the recommended method for removal of the placenta in caesarean section. (Strong recommendation, moderate-quality evidence)
Box B: Recommendations for the treatment of PPH
13. Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH. (Strong recommendation, moderate-quality evidence)
14. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 μg) is recommended. (Strong recommendation, low-quality evidence)
15. The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous fluid resuscitation of women with PPH. (Strong recommendation, low-quality evidence)
16. The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly due to trauma. (Weak recommendation, moderate-quality evidence)
17. Uterine massage is recommended for the treatment of PPH. (Strong recommendation, verylow- quality evidence)
18. If women do not respond to treatment using uterotonics, or if uterotonics are unavailable, the use of intrauterine balloon tamponade is recommended for the treatment of PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
19. If other measures have failed and if the necessary resources are available, the use of uterine artery embolization is recommended as a treatment for PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
20. If bleeding does not stop in spite of treatment using uterotonics and other available conservative interventions (e.g. uterine massage, balloon tamponade), the use of surgical interventions is recommended. (Strong recommendation, very-low-quality evidence)
21. The use of bimanual uterine compression is recommended as a temporizing measure until appropriate care is available for the treatment of PPH due to uterine atony after vaginal delivery. (Weak recommendation, very-low-quality evidence)
22. The use of external aortic compression for the treatment of PPH due to uterine atony after vaginal birth is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, very-low-quality evidence)
23. The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, low-quality evidence)
24. The use of uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal birth. (Weak recommendation, very-low-quality evidence)
25. If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in combination with controlled cord traction is recommended. (Weak recommendation, very-low-quality evidence)
26. The use of ergometrine for the management of retained placenta is not recommended as this may cause tetanic uterine contractions which may delay the expulsion of the placenta. (Weak recommendation, very-low-quality evidence)
27. The use of prostaglandin E2 alpha (dinoprostone or sulprostone) for the management of retained placenta is not recommended. (Weak recommendation, very-low-quality evidence)
28. A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised. (Weak recommendation, very-low-quality evidence)
Box – C: Organisation of Care
29. The use of formal protocols by health facilities for the prevention and treatment of PPH is recommended. (Weak recommendation, moderate-quality evidence)
30. The use of formal protocols for referral of women to a higher level of care is recommended for health facilities. (Weak recommendation, very-low-quality evidence)
31. The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes. (Weak recommendation, very-low-quality evidence)
32. Monitoring the use of uterotonics after birth for the prevention of PPH is recommended as a process indicator for programmatic evaluation. (Weak recommendation, very-low-quality evidence)

BBC Provides Horrific Testimonies on Forced Sterilization in Uzbekistan

April 12, 2012 –

The BBC has a horrifying new report on the forced sterilization of women in Uzbekistan.

Stories have been leaking out for years about doctors secretly performing hysterectomies on women who have given birth in hospitals. The surgeries are described as “voluntary,” but has reported how increasing numbers of women are choosing to give birth at home, fearing doctors will tie up their fallopian tubes or cut out their uteri without their consent.

The UN Committee Against Torture and the US State Department have both expressed concern. Nevertheless, it appears Tashkent is issuing doctors quotas for the procedures.

“Every year we are presented with a plan. Every doctor is told how many women we are expected to give contraception to; how many women are to be sterilized,” a gynecologist from Tashkent told the BBC’s Natalia Antelava.

Several doctors I spoke to say that in the last two years there has been a dramatic increase in Caesarean sections, which provide surgeons with an easy opportunity to sterilize the mother. These doctors dispute official statements that only 6.8% of women give birth through C-sections.

“Rules on Caesareans used to be very strict, but now I believe 80% of women give birth through C-sections. This makes it very easy to perform a sterilization and tie the fallopian tubes,” says a chief surgeon at a hospital near the capital, Tashkent.

One local expert estimated tens of thousands of forced sterilizations have happened in the past few years across Central Asia’s most populous nation, a vast country of, officially, 28 million.

Adolat comes from Uzbekistan, where life centers around children and a big family is the definition of personal success. Adolat thinks of herself as a failure.

“What am I after what happened to me?” she says as her hand strokes her daughter’s hair – the girl whose birth changed Adolat’s life.

“I always dreamed of having four – two daughters and two sons – but after my second daughter I couldn’t get pregnant,” she says.

She went to see a doctor and found out that she had been sterilized after giving birth to her daughter by Caesarean section.

“I was shocked. I cried and asked: ‘But why? How could they do this?’ The doctor said, ‘That’s the law in Uzbekistan.'”

One mother of three describes regular visits from a nurse warning her to get a free hysterectomy before the state starts charging. “Another mother says she experienced months of mysterious pain and heavy bleeding following the birth of her son. Then she had an ultrasound check and discovered that her uterus had been removed,” the report said.

Why? Some observers believe Tashkent is obsessed with statistics. Unhappy that maternal mortality rates place the country between Palestine and Botswana (Central Asians dread being compared to Africans), officials seem to see sterilizations as a way to improve their rankings.

“It’s a simple formula – less women give birth, less of them die,” said one surgeon.

The result is that this helps the country to improve its ranking in international league tables for maternal and infant mortality.

“Uzbekistan seems to be obsessed with numbers and international rankings,” says Steve Swerdlow, Central Asia director at Human Rights Watch.

“I think it’s typical of dictatorships that need to construct a narrative built on something other than the truth.”

The government denies women are being sterilized by force and says Uzbekistan should be considered a role model for maternal health.

Listen to BBC Radio Program


How Biriya delivered safely

Kounteya Sinha | February 11, 2012

A unique project in MP ensures that even women who live in remote tribal villages are only a phone call away from safe childbirth.

ON HAND: Call centre numbers for Janani Express are plastered on the walls of village homes

Scenario 1

Time: 1. 40 am February 6

Deepak Tiwari, posted at Mandla district hospital’s 24X7 call centre, receives a call informing him that Biriyabai from the tribal village of Sarra has gone into labour. He immediately dispatches an ambulance. At 2. 30 am, Biriya arrives at the Nainpur community health centre (CHC), 32 km from her home, and safely delivers a baby girl.

Scenario 2

Time: 1. 05 am February 4

Shiv Kali Maravi from Bamnigaon is in labour. Her family calls Rameshwar Khudape who is now manning the same call center. An ambulance is dispatched. At 2. 16 am, the patient reaches the CHC at Niwas, 33 km away. Soon after, Maravi gives birth to a baby boy.

While new born babies continue to die in hospitals across West Bengal – a tragedy that chief minister Mamata Banerjee calls “fictional, ” drama of a different kind is being played out in Madhya Padesh’s remote villages – one that can teach Banerjee a lot.
A fleet of 669 ambulances and 176 staffers in 48 call centres across 50 districts of Madhya Pradesh are working 24×7 to maximise institutional deliveries in distant tribal villages of the state. Jointly run by the state government in association with Unicef, Janani Express is now a major success story in the field of public health. The results talk for themselves.

More than 7, 00, 000 pregnant women have been transported free of charge across the state between January 2008 and December 11, 2011. Fewer children in the state are now being delivered outside hospitals. While the number of Janani Express beneficiaries was 2, 691 in 2007, it has steadily increased to 23, 545 in 2008, 35, 076 in 2009 and over 1. 7 lakh in 2010. In 2011, 4. 81 lakh pregnant women have delivered in hospital settings while 10, 000 new born children have benefited from it.
Each district in the state now has a call centre with a dedicated phone number. Around 22 vehicles are placed at different delivery points. “Somebody in a village has to have a phone. A single call now ensures a mother’s safety, ” says Dr Gagan Gupta, Unicef health specialist.

The infant mortality rate in Madhya Pradesh saw a fall of five points in 2010 – from 67 per 1, 000 to 62 per 1, 000 – the highest such fall recorded in the state. This is also the most dramatic fall documented in a year in the last decade, according to the registrar general’s latest data. “The analysis of two pilot call centres from Guna and Shivpuri for 50, 000 pregnant women transported from 2008-2011 revealed that half of the beneficiaries belonged to scheduled castes and tribes and half of the women were transported in the night hours between 8 pm and 8 am. In addition, 90 per cent of patients were transported within two hours of a call to a health facility, ” says Dr Gupta.

So how did the scheme start? In order to promote institutional delivery of children, the Union health ministry started the Janani Surakhsha Yojna (JSY) scheme which entitled all wouldbe mothers to free delivery, including a Caesarean section, in hospitals. They would be entitled to free transport from their homes to government health facilities and between facilities in case they are referred on account of complications. They would also be offered free drop back to their homes soon after.

This initiative was estimated to benefit more than one crore would-be mothers and newborns every year in both urban and rural areas. Under the scheme, accredited social health activists (ASHAs) were given Rs 250 as transportation charge for bringing pregnant women on the verge of delivering to the closest health facility. But an analysis showed that the lack of organised transport in the hinterland meant that it was hard for ASHAs to reach pregnant women to health facilities in time. Often they would be transported in lorries and on bike pillions.

Using a public-private partnership model, MP then decided to tie up with a private transport company – chosen through a tender – to start the Janani Express. “The cost of hiring of the vehicles is met from the Rs 250 marked for transportation under JSY funds. These funds are pooled based on number of institutional deliveries and provided to chief medical officers to make payments to the hired agency, ” says Dr Gupta.

The first call centre was set up in Guna in 2006. Each centre is manned by four people. Says Tania Goldner, chief of UNICEF Madhya Pradesh of the project: “Such 24×7 call centres, the Janani Express, strengthening of health sub-centres and cash linked maternity benefits, are part of the continuum of care for pregnant women and contributed to a significant increase in institutional deliveries in MP and progressive decrease of the maternal mortality ratio for the state. ”

Dr Archana Mishra, deputy director, maternal health at that state directorate of health services, says the state is committed towards reduction of high maternal mortality rate and maternal deaths caused by the shortage of referral transport facilities.
“The scheme is providing free referral transport facilities to pregnant women coming for delivery. Nearly 50 per cent of pregnant women going for institutional delivery are availing the free services under the scheme. These facilities are available to both the mother and the new born after discharge from the government health institutions, ” says Dr Mishra.

Assam launches scheme for pregnant mothers

pregnancy test - negative

pregnancy test - negative (Photo credit: slayerphoto)

Assam launches scheme for pregnant mothers

Under the scheme all pregnant women are entitled to free delivery — including caesarean section —in public health institutions of the state
Submitted on 01/31/2012

Guwahati: Union Health and Family Welfare Minister Ghulam Nabi Azad on Monday launched an Assam government scheme entitling all pregnant women to free delivery — including caesarean section —in public health institutions.

The “Janani Sishu Suraksha Karyakram (JSSK)” also provides for free transport from home to institution, between facilities in case of a referral and a drop back home.

Azad also launched 23 mobile medical units (MMUs) for the 23 sub-divisions in the state, reports IANS.


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