Management Of Postpartum Hemorrhage Research Articles

Recognition and Management of Postpartum Hemorrhage

Abstract Postpartum hemorrhage (PPH) is an obstetric emergency and refers to excessive blood loss after birth. Loss of blood volume and oxygen-carrying capacity may lead to maternal hypovolemia and hypotension resulting in tissue hypoxia, the onset of anaerobic metabolism, and multiorgan failure. If timely and appropriate action is not taken, cardiac arrest and maternal death may occur. If the amount of blood loss exceeds 500 mL following a vaginal birth or 1000 mL during or following a cesarean section, it is termed PPH. Similar to any other surgical hemorrhage, PPH is classified into primary PPH (occurs within 24 hours of birth) or secondary PPH (between 24 hours and 12 weeks postpartum). PPH is a major contributor to maternal deaths worldwide, and it is estimated that a person dies because of PPH approximately every 5 minutes. Therefore, measures should be directed at prevention and early detection of PPH with prompt management. The prevalence of PPH varies globally and is influenced by location, socioeconomic factors, and the availability and quality of health care. The World Health Organization reported that PPH accounts for a quarter of global maternal deaths. The Mothers and Babies Reducing Risks through Audits and Confidential Enquiries report from the United Kingdom (2023) highlighted that despite rare mortality due to hemorrhage, the number of people dying of obstetric hemorrhage is not decreasing, particularly among people with abnormally invasive placentation. Additionally, substandard care was found to be responsible for more than 50% of deaths due to PPH in the United Kingdom. Therefore, it is vital that adequate healthcare infrastructure, trained and competent healthcare professionals, and immediate access to resources, interventions, and multidisciplinary teams are essential both in well-resourced and resource-restrained healthcare systems. Healthcare professionals must identify the potential risk factors for PPH and initiate preventive measures whenever possible. Additionally, they must respond swiftly if PPH occurs and ensure a multidisciplinary, multilayered approach for a synchronized response to optimize outcomes. This review article emphasizes the etiopathogenesis, diagnosis, and management of PPH based on current scientific evidence as well as international best practice recommendations.

Cervical clamping: An innovative adjunct for management of postpartum haemorrhage

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Traditional methods for acute management, such as uterotonics, uterine massage, and surgical interventions, may prove insufficient, prompting the search for alternative techniques. This article reviews the innovative use of cervical clamping as an adjunct to the critical first line care of patients with PPH, evaluating its efficacy, safety, and potential future implications1. The review highlights how mechanical pressure to the cervix may facilitate innate physiological reflexes to improve uterine contraction, promising a noninvasive alternative to control severe obstetric bleeding. The findings suggest that cervical clamping could be particularly beneficial in resource-limited settings where pharmacological and advanced surgical options are not readily available2.

Effectiveness of Telemedicine and Remote Monitoring in Reducing Postpartum Hemorrhage Rates: A Meta-Analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) with limited access to healthcare. Telemedicine and remote monitoring technologies offer potential solutions for early detection and management of PPH. This meta-analysis aimed to evaluate the effectiveness of these technologies in reducing PPH rates. A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted for studies published between 2013 and 2024 investigating the impact of telemedicine and remote monitoring interventions on PPH rates. Randomized controlled trials (RCTs) and observational studies with a control group were included. The primary outcome was the incidence of PPH (blood loss ≥500 ml after vaginal delivery or ≥1000 ml after cesarean delivery). Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Publication bias was assessed using funnel plot asymmetry and Egger's test. Six studies involving 4200 women met the inclusion criteria. The pooled analysis demonstrated a statistically significant reduction in PPH rates in the intervention groups compared to the control groups (RR 0.56; 95% CI 0.47-0.67; p<0.00001). The funnel plot was symmetrical, and Egger's test was not statistically significant (p=0.45), suggesting no evidence of publication bias. Telemedicine and remote monitoring interventions are associated with a significant reduction in PPH rates. These findings support the integration of these technologies into postpartum care to improve maternal outcomes, particularly in resource-constrained settings.

Bibliometric Analysis of Risk Factors Contributing to Maternal Mortality: Trends and Research Directions

ABSTRACT Maternal mortality remains a significant global health challenge, with high maternal mortality rates in many parts of the world being a key indicator of disparities in maternal health care. While great efforts have been made to reduce these mortality rates, the various contributing risk factors remain a major focus of efforts. This study aimed to conduct a bibliometric analysis of the scientific literature addressing risk factors contributing to maternal mortality over the period 2017 to 2024. In this study, data was obtained from 50 relevant articles retrieved from Google Scholar using Publish or Perish software. The articles were filtered based on relevance and analyzed in depth. The data collected included information on publication year, country of origin, publisher, number of citations, and article type. To generate a comprehensive bibliometric map, VOSviewer was used with the parameters of occurrence of at least 4 and 19 terms, as well as network visualization, overlay, and density. The analysis showed that research on maternal mortality has consistently focused on various risk factors and aspects of maternal health, with a significant emphasis on factors related to pregnancy complications, postnatal care, and socioeconomic health conditions. Developed countries such as the United States are often the primary location of research, indicating a high concentration of studies in these countries. In addition, the research highlighted consistent attention to the importance of adequate health care and specific health issues faced by pregnant women. The analysis also revealed that key themes in the current literature include the management of postpartum hemorrhage, postpartum infections, and the influence of socio-economic factors on maternal health. This study provides valuable insights into current research directions and trends in maternal health and underscores the importance of continuing to identify and mitigate risk factors that contribute to maternal mortality. The findings are expected to guide the development of more effective interventions and health policy strategies that can reduce maternal mortality globally and improve maternal health outcomes worldwide. Keywords: Maternal Mortality, Risk Factors, Bibliometric Analysis, Healthcare Interventions, Research Trends

Postpartum Hemorrhage Management in Canadian Emergency Nursing Practice

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality globally, claiming approximately 70,000 lives annually. Despite preventive efforts, high-income countries, including Canada, have reported increasing rates of PPH. The rising incidence and associated complications indicate improved emergency nursing practices in managing PPH are needed. Methods: PPH guidelines from the Society of Obstetricians and Gynecologists of Canada, Federation of International Gynecologists and Obstetricians, and the Canadian Association of Perinatal, and Women’s Health Nurses were compared to National Emergency Nurses Association guidelines. The competencies, medications, and obstetric maneuvers for PPH that may be relevant to emergency nurses were extracted and categorized for the emergency nursing HIRAID (History & Red flags, Assessment, Interventions, & Diagnosis) framework. Findings/Results: We found 13 discrete skills across the PPH guideline recommendations that are applicable to emergency nurses. There is near perfect overlap in medical recommendations, but gaps exist between FIGO and SOGC guidelines and NENA and CAPWHN guidelines. There are SOGC and FIGO guidelines that apply to emergency nurses that are not addressed in NENA guidelines, Discussion: There was significant overlap on treatment recommendations from maternal health bodies such as uterotonic drugs, hemorrhage control, and hemostatic resuscitation. There were significant gaps in NENA recommendations. Conclusion: The comparison of PPH guidelines highlights where NENA guidelines need further detail. These skills are particularly significant for providing nursing care in rural and remote areas. Standardized protocols for PPH management, interprofessional collaboration, and regular competency assessments are included in most guidelines but are conspicuously absent for emergency nurses. To address the gap, NENA could integrate national emergency nursing PPH competencies standards or develop recommendations for the care of maternal emergencies.

Efficacy of Intrauterine Condom Balloon in the Treatment of Atonic Postpartum Hemorrhage

Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, particularly in cases of uterine atony. Effective management is crucial to prevent severe complications and improve maternal outcomes. Intrauterine balloon tamponade techniques, such as the use of a condom balloon tamponade (CBT), have gained attention for their potential to control bleeding quickly and safely. This study aimed to assess the efficacy of intrauterine condom balloons in the treatment of atonic postpartum hemorrhage. Methods: This study is a prospective observational study conducted to assess the efficacy of intrauterine condom balloon tamponade (CBT) in the management of atonic postpartum hemorrhage (PPH). The study was carried out at the Department of Obstetrics and Gynecology in Dhaka Medical College Hospital, from January 2007 to December 2007. A total of 50 patients were selected by a purposive sampling technique. All collected data were analyzed using SPSS software (version 25.0). For continuous variables (e.g., blood loss, time to hemostasis), comparisons between groups (e.g., successful vs. unsuccessful tamponade cases) were performed using the Student’s t-test. For categorical outcomes, the Chi-square test was used to compare proportions. A p-value of < 0.05 was considered statistically significant. Result: Intrauterine condom balloon tamponade (CBT) effectively managed atonic postpartum hemorrhage in 50 participants, achieving an 84% cessation of bleeding within 30 minutes. The average saline volume used was 500 mL, with a notable 16% of cases requiring additional surgical interventions, primarily hysterectomy. Blood transfusion was necessary for 68% of participants, with higher transfusion needs in cases of failed CBT. Maternal complications were minimal, with 8% experiencing postpartum fever and 4% developing uterine infections. The mean hospital stay was 5.0 days, with 40% staying longer than 5 days, reflecting the need for ongoing ..........

Prevention of intrauterine balloon displacement in patients with postpartum hemorrhage: A narrative review.

Postpartum hemorrhage (PPH) remains a significant complication of pregnancy globally, with uterine atony accounting for the great majority of cases. Second-line hemostatic strategies such as uterine balloon tamponade play a crucial role in managing refractory hemorrhage. Despite its effectiveness, the phenomenon of balloon displacement poses a challenge to PPH management, often leading to treatment failure. Various techniques have been proposed to address this issue, including vaginal packing, cervical cerclage, fixation to the abdominal wall, holding the cervix with ring forceps, and suspending the balloon with cervical sutures. Each method has its advantages and limitations, influencing its suitability in different clinical scenarios. Understanding these techniques may be useful to optimize and improve the management of PPH and maternal outcomes. This review provides a comprehensive summary of these strategies, their mechanisms, and their clinical implications, aiming to guide healthcare providers in choosing the most appropriate approach for individual cases of PPH.

Comprehensive Literature Review of the use of The Bakri Balloon for Managing Postpartum Hemorrhage

Postpartum hemorrhage (PPH) remains a significant cause of maternal mortality and morbidity worldwide. It is defined as excessive bleeding, typically more than 500 ml of blood loss within the first 24 hours after childbirth. The Bakri Balloon technique has emerged as a promising solution for managing PPH, offering a minimally invasive approach to achieving hemostasis and preventing the need for more invasive surgical procedures. Aims: The aim of this paper review is to provide an overview of the effectiveness of intrauterine balloon tamponade in managing PPH. Methods: We conducted this paper review by selecting articles, retrospective cohort studies and reviews from clinical trials from PubMed. Results: Numerous studies have shown high success rates of treating PPH using The Bakri Balloon intrauterine tamponade. Conclusions: The Bakri Balloon intrauterine tamponade is an effective method in the management of primary postpartum hemorrhage.

The SYNAPPH Study: Uterine Synechiae Prevalence After a Postpartum Hemorrhage, a Pilot Study

Study ObjectiveTo prospectively assess the prevalence of intrauterine synechia following medically treated postpartum hemorrhage (PPH) and to evaluate the association between synechiae formation and PPH management techniques. DesignA prospective observational cohort study. SettingAngers University Hospital. ParticipantsA total of 83 women presenting with medically treated PPH from January to December 2021 were included in the study. InterventionDiagnostic hysteroscopy was performed twelve weeks postpartum to assess for the presence of uterine synechiae. Detailed data on PPH management techniques were collected for analysis. Measurements and Main ResultsThe majority of participants were primiparous and had undergone vaginal delivery. Only 7% required intrauterine balloon tamponade (IUBT), and 4% underwent uterine artery embolization. Uterine synechiae were identified in 20 women during diagnostic hysteroscopy, yielding a prevalence of 24% at 12 weeks postpartum; all classified as type I according to the ESGE classification system. IUBT was used in 15% of women with synechiae compared to 5% in the nonsynechiae group, although this difference was not statistically significant (OR 3.52, 95% CI 0.65–19.10, p = .123). Multivariate analysis identified second manual uterine examination (OR 5.00, 95% CI 1.50–16.66, p = .009) and bimanual uterine massage (OR 3.50, 95% CI 1.12–10.09, p = .020) as independent risk factors for synechiae formation. ConclusionThis is the first study to evaluate the risk of intrauterine synechiae following medically treated PPH. Mild uterine synechiae were observed in one in four women in the cohort. The need for a second manual uterine examination and bimanual uterine massage were significantly associated with the development of synechiae. Further research is warranted to explore the long-term clinical consequences, including fertility outcomes, and to determine the potential role of diagnostic hysteroscopy in postpartum follow-up after PPH. SummationThe study prospectively investigates the prevalence of uterine synechiae following nonsurgical postpartum hemorrhage, revealing a 24% occurrence, with second manual uterine examination and bimanual massage identified as independent risk factors.

Effect of WHO Guideline on Nurses’ Knowledge Regarding Prevention and Management of Postpartum Hemorrhage

Effect of WHO Guideline on Nurses’ Knowledge Regarding Prevention and Management of Postpartum Hemorrhage

Efficacy of B-Lynch Compression Suture for Control of Primary Post-Partum Hemorrhage

OBJECTIVES This study aimed to evaluate the efficiency of the B-Lynch compression suture for primary post-partum hemorrhage control. METHODOLOGY It is a prospective cross-sectional study performed for two years, i.e., 1 November 2021 to 31 October 2023, at the Department of Obstetrics and Gynaecology in a tertiary care hospital. This study included 65 study cases out of 23,964 with primary post-partum hemorrhage (PPH) due to uterine atony during cesarean delivery not responding to pharmacological treatment and was managed by applying B-Lynch compression sutures. The amount of blood loss, demographic characteristics, birth weight of babies, causative factors, and other related complications were studied in such selected cases. RESULTSB-Lynch compression suture presented a success rate of 97% in the present study. 52% had blood loss of 1000-1500ml, 29% had loss between 1501-2000ml and 18% had 2001-2500ml blood loss. 6% had wound gaping, 10.7% had a fever, and 8% had more than seven days stay in hospital, and wound infections were noted. CONCLUSION Our study concluded that the B-Lynch compression suture had a success rate of 97% in the management of primary post-partum hemorrhage, with few post-operative complications. The current research demonstrates the efficacy of B-Lynch as a lifesaving, easy, effectual technique that avoids hysterectomy and thus avoids heavy blood loss.

High-Fidelity Environment Effect on Early Postpartum Haemorrhage Management

Objective: In order to compare outcomes of a simulation of early postpartum haemorrhage management through a medium-fidelity mannequin in a high-fidelity environment before clinical practicums with those after clinical practicums in nursing students. Methods: This quasi-experimental study was performed on second-year nursing students (n=61). After the simulation, the students were asked to perform postpartum haemorrhage control in clinical practicums. Data were collected with the State-Trait Anxiety Inventory, Student Satisfaction and Self-Confidence in Learning Scale, Educational Practices Questionnaire, and Student Self-Evaluation Form. Results: The mean satisfaction, self-confidence, and Educational Practices Questionnaire scores after the simulation were high. The mean scores for feeling competent in involution, haemorrhage control, fundus massage, perineal care, andestablishing appropriate communication with patients and their relatives were 19.18±5.70 after the simulation and 23.83±5,03 after the clinical practicums. Conclusion: The medium-fidelity simulation in a high-fidelity environment of early postpartum haemorrhage management enhanced the students’ learning satisfaction and self-confidence. This helped them to feel more competent in the clinical practicums.

Integrating Heat-Stable Carbetocin and Tranexamic Acid for Prevention and Management of Postpartum Hemorrhage in Sub-Saharan Africa: A Five-Country Pilot Implementation Study

Background and Objective Globally, postpartum hemorrhage (PPH) remains the most common direct cause of maternal mortality. This study evaluated the feasibility and acceptability of introducing heat-stable carbetocin (HSC) for PPH prevention and tranexamic acid (TXA) for PPH treatment in five Sub-Saharan African countries following recent World Health Organization (WHO) recommendations. This study also assessed healthcare providers’ (HCPs’) favorability toward using these medicines. Methods We conducted a mixed methods pilot implementation study in selected facilities across Burkina Faso, Ethiopia, Ghana, Sierra Leone, and Uganda between May and December 2022. We compared baseline data obtained from patient registers with data collected during implementation on the safe and appropriate use of HSC and TXA using descriptive statistics. HCP responses were analyzed qualitatively using a thematic analysis. Results Following training, HSC was administered prophylactically in 11,329 (92.4%) of 12,262 deliveries in all study facilities which received a uteorotonic for PPH prevention during implementation and was used safely and appropriately. TXA administration for PPH treatment was done safely, appropriately, and within the WHO-recommended time. No adverse events were reported throughout the study. HCPs overall showed high confidence in, and favorability toward, using both medicines. Conclusion and Global Health Implications Our study demonstrated that HSC and TXA can be safely and appropriately implemented in primary and tertiary facilities, and their introduction is feasible and acceptable from the perspective of HCPs. A holistic approach to training and regular supportive supervision is needed to ensure the continued safe use of these new and lesser-utilized PPH medicines. Dedicated training is required to improve the documentation of patient charts on PPH care. Introducing these medicines holds promise for improving PPH care in low- and middle-income countries, including by addressing suboptimal efficacy due to cold chain system challenges.

Postpartum Hemorrhage in Humanitarian Settings: Implementation Insights from Using Heat-Stable Carbetocin and Tranexamic Acid

Background and Objective Maternal mortality, largely due to postpartum hemorrhage (PPH), remains high in resource-limited and crisis-affected settings, where heat-stable carbetocin (HSC) and tranexamic acid (TXA) offer promise for PPH prevention and treatment but lack evidence. This study, implemented in basic maternity facilities within humanitarian settings, explores healthcare providers’ perspectives on an HSC and TXA-inclusive PPH intervention package and related operational challenges and facilitators. Methods Based on semi-structured interview guides and using thematic analysis, this qualitative research, through 13 focus group discussions and individual interviews, investigated the perspectives of 64 healthcare staff (mostly midwives) from eight basic emergency obstetric care facilities in South Sudanese and Ugandan settings hosting large numbers of forcibly displaced populations. The PPH intervention package comprised refresher training, an online provider community, PPH readiness kits, alarm bells, and displayed algorithms. Results Findings from both countries converged, highlighting providers’ positive views on HSC and TXA. HSC effectiveness in preventing bleeding was acknowledged, bolstering staff’s confidence in its use. TXA was perceived as effective although providers reported having less experience with it due to the limited number of PPH cases. Enabling factors included the ease of administration, practical training, endorsement by national and local authorities, and the absence of a cold chain requirement. Appreciation was given to the WhatsApp community of practice as it facilitated knowledge exchange, quality improvement projects that enhanced PPH diagnosis, and innovative tools like wall clocks to record the timing of clinical actions and bells to call for assistance. Challenges included confusion between new and existing medications and record systems that inadequately capture HSC, TXA, and other PPH indicators. Conclusion and Global Health Implications HSC and TXA integrated into a PPH intervention package were overall positively valued by providers in humanitarian settings. Continued education and support are crucial. Addressing challenges like medication confusion underscores the need for ongoing education and clear guidelines for the use of HSC, TXA, oxytocin, and other drugs for PPH prevention and treatment. Our findings stress the importance of a comprehensive strategy to overcome health system barriers in PPH management, potentially improving maternal health outcomes in resource-limited and fragile contexts, with broader global implications.

Special Collection: Implementation Research Evidence for Prevention and Treatment of Postpartum Hemorrhage in High-Burden Low- and Middle-Income Countries

Postpartum hemorrhage (PPH), defined as a blood loss of 500 mL or more within 24 hours after birth, remains the leading cause of maternal mortality globally, accounting for over 20% of all maternal deaths. The burden of mortality from PPH is predominantly in low- and middle-income countries and demands coordinated accelerated efforts from the global maternal health community to meet the Sustainable Development 3 maternal health target by 2030. The International Journal of Maternal and Child Health and AIDS and the Concept Foundation are proud to present this Special Collection demonstrating the evidence for introducing heat-stable carbetocin and tranexamic acid, showcasing the feasibility and acceptability of their utilization for PPH prevention and management in resource-limited high-burden settings.

Prehospital Management of Postpartum Hemorrhage-A National, Cross-Sectional Study in Norway.

Postpartum hemorrhage (PPH) is a critical birth complication, and is stated by the World Health Organization (WHO) as among the five most frequent causes of death during pregnancy. External aortic compression (EAC) is recommended by the WHO as an intervention to achieve temporary bleeding control. An increasing number of births outside hospital underlines the importance of competence in handling potential birth complications, such as PPH. The aim of this study was to assess prehospital personnel's education, training, knowledge, and experiences regarding PPH and EAC across Norway. Prehospital personnel were invited to respond to a questionnaire through social media. Questions included those on education, training, knowledge, and experience regarding PPH and EAC. The Statistical Package for the Social Sciences (SPSS) version 28 was used to analyze the data, using descriptive statistics. Over a two-month period, 211 prehospital personnel responded to the questionnaire, of whom 55.5% were male. The respondents had an average of 10.3 years of prehospital experience. About half of the respondents had received education (48.6%) and training (62.4%) in PPH management. Still, 95.7 percent reported a need for more education and training. On knowledge questions, only half of the responses were correct (43.7% to 60.5%). Only 21 percent of the respondents had experienced patients with PPH, and of these only 3.8 percent had used EAC. Bimanual uterine compression was the most frequent intervention used (62.5%) across hospital trusts. Even if prehospital personnel receive education and training in the management of PPH and EAC, almost all report needing more. The results indicate a national variation, which may be discussed as to whether it is appropriate.

Thromboelastography as an early prediction method for hypofibrinogenemia in emergency department patients with primary postpartum hemorrhage

BackgroundTimely and accurate assessment of coagulopathy is crucial for the management of primary postpartum hemorrhage (PPH). Thromboelastography (TEG) provides a comprehensive assessment of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. This study aimed to evaluate the role of TEG in predicting hypofibrinogenemia in emergency department (ED) patients with primary PPH.MethodsWe conducted a retrospective observational study in the ED of a university-affiliated tertiary hospital between November 2015 and August 2023. TEG was performed upon admission. The cutoff value for hypofibrinogenemia was 200 mg/dL. The primary outcome was the presence of hypofibrinogenemia.ResultsAmong the 174 patients, 73 (42.0%) had hypofibrinogenemia. The need for massive transfusion was higher in the hypofibrinogenemia group (37.0% vs. 5.0%, p < 0.001). Among the TEG parameters, all values were significantly different between the groups, except for lysis after 30 min, suggesting a tendency toward hypocoagulability. Multivariable analysis revealed that the alpha angle (odds ratio (OR) 0.924, 95% confidence interval (CI) 0.876–0.978) and maximum amplitude (MA) (OR 0.867, 95% CI 0.801–0.938) were independently associated with hypofibrinogenemia. The optimal cutoff values for the alpha angle and maximum amplitude (MA) for hypofibrinogenemia were 63.8 degrees and 56.1 mm, respectively.ConclusionPoint-of-care TEG could be a valuable tool for the early identification of hypofibrinogenemia in ED patients with primary PPH.

Suggested Interdisciplinary Approach for Managing Postpartum Haemorrhage Caused by Uterine Atony-A Call for Updated Guidelines

Postpartum Hemorrhage (PPH) is a significant cause of maternal morbidity and mortality, often exacerbated by inadequate adherence to established guidelines. This article examines the critical role of uterine atony and explores the impact of factors such as inaccurate blood loss estimation and hematological complications. It critiques the existing clinical guidelines for insufficiently addressing the role of hematologists and proposes the integration of early assessment techniques, including viscoelastic hemostatic assays and targeted fibrinogen replacement, to more effectively manage coagulopathy. The article also highlights recent advancements, such as the Alma device, and advocates for a multidisciplinary approach that includes both obstetricians and hematologists to enhance PPH management and improve patient outcomes.

Development and Piloting of Implementation Strategies to Support Delivery of a Clinical Intervention for Postpartum Hemorrhage in Four sub-Saharan Africa Countries.

Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania. Implementation strategy development: We triangulated findings from qualitative interviews, surveys and a qualitative evidence synthesis to identify current PPH care practices and influences on future intervention implementation. We mapped influences using implementation science frameworks to identify candidate implementation strategies before presenting these at stakeholder consultation and design workshops to discuss feasibility, acceptability, and local adaptations. Piloting: The intervention and implementation strategies were piloted in 12 health facilities (3 per country) over 3 months. Interviews (n=58), case report forms (n=1,269), and direct observations (18 vaginal births, 7 PPHs) were used to assess feasibility, acceptability, and fidelity. Implementation strategy development: Key influences included shortages of drugs, supplies, and staff, limited in-service training, and perceived benefits of the intervention (e.g., more accurate PPH detection and reduced PPH mortality). Proposed implementation strategies included a PPH trolley, on-site simulation-based training, champions, and audit and feedback. Country-specific adaptations included merging the E-MOTIVE intervention with national maternal health trainings, adapting local PPH protocols, and PPH trollies depending on staff needs. Piloting: Intervention and implementation strategy fidelity differed within and across countries. Calibrated drapes resulted in earlier and more accurate PPH detection but were not consistently used at the start. Implementation strategies were feasible to deliver; however, some instances of limited use were observed (e.g., PPH trolley and skills practice after training). Systematic intervention development, piloting, and process evaluation helped identify initial challenges related to intervention fidelity, which were addressed ahead of a larger-scale effectiveness evaluation. This has helped maximize the internal validity of the trial.

The cost-effectiveness of preventing, diagnosing, and treating postpartum haemorrhage: A systematic review of economic evaluations.

Postpartum haemorrhage (PPH) is an obstetric emergency. While PPH-related deaths are relatively rare in high-resource settings, PPH continues to be the leading cause of maternal mortality in limited-resource settings. We undertook a systematic review to identify, assess, and synthesise cost-effectiveness evidence on postpartum interventions to prevent, diagnose, or treat PPH. This systematic review was prospectively registered on PROSPERO (CRD42023438424). We searched Medline, Embase, NHS Economic Evaluation Database (NHS EED), EconLit, CINAHL, Emcare, Web of Science, and Global Index Medicus between 22 June 2023 and 11 July 2024 with no date or language limitations. Full economic evaluations of any postpartum intervention for prevention, detection, or management of PPH were eligible. Study screening, data extraction, and quality assessments (using the CHEC-E tool) were undertaken independently by at least 2 reviewers. We developed narrative syntheses of available evidence for each intervention. From 3,993 citations, 56 studies were included: 33 studies of preventative interventions, 1 study assessed a diagnostic method, 17 studies of treatment interventions, 1 study comparing prevention and treatment, and 4 studies assessed care bundles. Twenty-four studies were conducted in high-income countries, 22 in upper or lower middle-income countries, 3 in low-income countries, and 7 studies involved countries of multiple income levels. Study settings, methods, and findings varied considerably. Interventions with the most consistent findings were the use of tranexamic acid for PPH treatment and using care bundles. In both cases, multiple studies predicted these interventions would either result in better health outcomes and cost savings, or better health outcomes at acceptable costs. Limitations for this review include that no ideal setting was chosen, and therefore, a transferability assessment was not undertaken. In addition, some sources of study uncertainty, such as effectiveness parameters, were interrogated to a greater degree than other sources of uncertainty. In this systematic review, we extracted, critically appraised, and summarised the cost-effectiveness evidence from 56 studies across 16 different interventions for the prevention, diagnosis, and treatment of PPH. Both the use of tranexamic acid as part of PPH treatment, and the use of comprehensive PPH bundles for prevention, diagnosis, and treatment have supportive cost-effectiveness evidence across a range of settings. More studies utilizing best practice principles are required to make stronger conclusions on which interventions provide the best value. Several high-priority interventions recommended by World Health Organization (WHO) such as administering additional uterotonics, non-pneumatic anti-shock garment, or uterine balloon tamponade (UBT) for PPH management require robust economic evaluations across high-, middle-, and low-resource settings.