Simple Tools to Reduce Postpartum Hemorrhage Deaths

Too often, giving birth is dangerous, and the most common cause of maternal mortality – postpartum hemorrhage (PPH), or excessive bleeding after childbirth – is largely preventable. The clinical best practices to prevent and manage PPH seem simple enough: administer oxytocin immediately after delivery; monitor frequently to detect any bleeding early; manage the source of the bleeding accordingly; and if the provider cannot stop the bleeding, promptly refer the patient to a higher-level facility for surgery or a blood transfusion.

When compliance with these best practices falls short, a common strategy used to improve health workers’ decision-making and adherence is to provide more training. However, simply giving people access to more information rarely changes behavior, and these trainings typically do not consider the extremely resource and time constrained environment that they often work in. For health workers in many contexts, like rural Madagascar, following PPH best practices is far from simple.

What prevents providers from following best practices?

For the past year, as part of the USAID-funded Breakthrough RESEARCH project led by the Population Council, we at ideas42 have learned about the extraordinary constraints that Malagasy health workers must face to save mothers’ lives. Basic care facilities are often only staffed by a midwife, who is responsible for myriad tasks, from delivering babies to treating malaria, administering child vaccinations, and more. To serve more of the population, many facilities are remote, sometimes accessible only by canoe when roads are washed out, and there is no one else available to give guidance or a helping hand if complications arise. Babies are often born at night, making it impossible for a health worker to sleep (affecting her ability to stay alert and do her job during the day) if she follows the monitoring protocol to regularly check the mother for bleeding. Facilities often have no running water or electricity, so working alone at night is even more difficult—it’s hard to deliver a baby or check for bleeding with just a cellphone’s flashlight.

Since referrals to better-equipped facilities are difficult and often impossible, and the conditions of health posts are such that management of PPH is difficult, prevention is of utmost importance. Administering oxytocin immediately after the birth of a baby  cuts the likelihood of PPH in half, which makes it the single most important best practice.

Why don’t health workers always administer oxytocin immediately after a delivery?

We spoke with health workers to understand their constraints and design solutions that might work for them. We found that they underestimate the likelihood and consequences of PPH, and as a result, prioritize other concerns. Even though PPH is the most common cause of death for women giving birth, it’s still rare, and rural health workers who deliver only a few babies per week are unlikely to encounter it often.

Real-time tools to address health workers’ challenges and save lives

One of the solutions we developed is a low power electronic timer that gives immediate feedback on the timeliness of oxytocin administration. As soon as the baby is born, the health worker can hit a large button to start a timer that counts down and beeps as 60 seconds approaches. The lunchbox-sized device is mounted on the wall so it can be hit with an elbow instead of soiled hands. The device also has the added benefit of freezing the timestamp at birth so it can be accurately recorded later—an incentive to use the timer, as it removes a reported burden of having to remember the time of birth for paperwork.

We also designed a glow-in-the-dark poster with simple illustrations of how to stop bleeding, based on cause, because when PPH occurs it’s hard for health workers to remember the specific details of their training in the urgent moment, and they have nobody to ask for help.

The last tool is a set of seven lanyard badges for assigning tasks – like “emotional support,” “torch bearer,” or “bleeding monitor” – to the people who go with a pregnant woman to the facility. In Madagascar, it is customary for relatives, neighbors, and other community members to attend deliveries to show their support and help laboring women reach the facility. The crowd of attendees at a delivery can be overwhelming for a provider; as one health worker explained, “[the badges] would be useful because lots of family come and don’t know what to do, and think someone else is going to do something so they don’t do it themselves.” The badges help by relieving health workers of some non-technical tasks while also making the attendees feel valued and important—a win-win.