clove and Postpartum-Hemorrhage

Postpartum hemorrhage (PPH) is the leading direct cause of maternal deaths worldwide, and women in low-income countries are at particularly high risk of dying from PPH-related consequences. Most deaths can be avoided through consistent provider adherence to prevention protocols and timely, appropriate management, yet providers do not consistently adhere to these best practices. USING BEHAVIORAL DESIGN TO DEVELOP SOLUTIONS TO IMPROVE PROVIDER CARE: We applied the behavioral design methodology to identify behavioral drivers, develop solutions, and build a program theory of change. Implementation research was conducted to understand the adoption, desirability, feasibility, and appropriateness of the solutions and explore suggestive findings related to impact. Data were collected through observation and in-depth interviews. Solutions developed included: (1) a timer to remind providers of the 1-minute window to administer oxytocin; (2) a glow-in-the-dark poster illustrating a simplified algorithm for PPH management; (3) badges to assign family members tasks to support providers during labor and delivery; and (4) a risk visualization exercise. Clinical mentors introduced the solutions during facility visits, and providers received orientation using videos. Solutions were piloted in 10 rural facilities in southeastern Madagascar during November-December 2020.. Providers reported high adoption of the timers and task badges during routine deliveries. They remarked on the desirability and appropriateness of the timer, task badges, and algorithm poster, as well as the value of the cocreation process. Adoption of the timer solution shows promise in having a potential positive impact on increasing the awareness of and adherence to timely oxytocin administration.. This work highlights the promise of applying behavioral science to identify underlying drivers of gaps in clinical practice and to develop innovative and desirable solutions to address them.

Topics: Behavioral Sciences; Female; Humans; Madagascar; Maternal Health Services; Oxytocin; Postpartum Hemorrhage; Pregnancy

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers' consistent following of PPH best practices in Madagascar.. In June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts.. We identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers' perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making.. Our study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.

Topics: Adult; Attitude of Health Personnel; Critical Pathways; Female; Guideline Adherence; Humans; Madagascar; Maternal Health Services; Maternal Mortality; Midwifery; Patient Preference; Postpartum Hemorrhage; Pregnancy; Qualitative Research; Risk Management; Social Perception; Time-to-Treatment

Pharmaceutical uterotonics are effective for preventing postpartum hemorrhage and complications related to unsafe abortion. In Madagascar, however, traditional birth attendants (Matrones) commonly administer medicinal teas for uterotonic purposes. Little is known about Matrone practices and how they might coincide with efforts to increase uterotonic coverage. The aims of this study were to: 1) identify indications for presumed uterotonic plant use by Matrones, 2) explore uterotonic practices at the village level, and 3) describe the response of health practitioners to village-level uterotonic practices.. Twelve in-depth interviews with health practitioners, Matrones and community agents were conducted in local dialect. All interviews were audio-recorded, transcribed, and translated into English for analysis using Atlas.ti. Medicinal plant specimens were also collected and analyzed for the presence of uterotonic peptides.. While Matrones reported to offer specific teas for uterotonic purposes, health practitioners discussed providing emergency care for women with complications associated with use of specific teas. Complications included retained placenta, hypertonic uterus, hemorrhage and sepsis. Chemical analysis indicated the presence of cysteine-rich peptides in the Dantoroa/Denturus plant used in some Matrones' teas.. The presence of uterotonic peptides in one plant used by Matrones may indicate that Matrones intend to administer uterotonics for safer childbirth. This finding, combined with practitioner reports of complications related to some medicinal teas, points to a need for availability of an evidence-based uterotonic at the village level, namely, misoprostol pills or oxytocin in the form of uniject.

Topics: Adult; Cysteine; Delivery, Obstetric; Female; Humans; Madagascar; Midwifery; Oxytocics; Plants, Medicinal; Postpartum Hemorrhage; Pregnancy; Teas, Medicinal

In Madagascar, where more than half of women give birth without skilled attendants, quality improvement of health services may ameliorate community perception of facility-based delivery care, thereby increasing the skilled birth attendance rate. For women who do deliver in a facility, a higher quality of services will lead to better outcomes, moving the country closer to reaching Millennium Development Goals 4 and 5. To guide the quality improvement processes at health facilities in Madagascar, this study assessed the quality of care at facilities with respect to interventions addressing the main causes of maternal and newborn complications with a focus on postpartum hemorrhage (PPH) and pre-eclampia/eclampsia (PE/E).. The study targeted all health facilities with a high volume of deliveries through inventories of medications and material, interviews with health providers, and observations of routine care and complicated cases. A total of 36 health facilities were included in the study, and interviews were carried out with 139 providers. Observations were made of 323 antenatal consultations and 347 labor and delivery clients, including 255 observations of the first stage of labor and 288 at the second or third stages.. The main challenges to providing high-quality services as revealed by the inventory are the low availability of clinical protocols and guidelines for providers, and syringes, needles, and IV infusion sets to give uterotonics. Also, communication equipment and emergency transport were available in half of facilities, and a safe water source within 500 meters was available in only 67%. Regarding provider knowledge as measured by the interviews, the strongest areas of knowledge were detection of lacerations and conducting a physical examination; the weakest were on management of uterine atony or of retained placenta, stabilizing the mother with magnesium sulphate and anti-hypertensives, initial steps in management of severe PE, management of convulsions, and essential equipment and supplies needed. Technical support or supervision of providers was often nonexistent or inadequate. Some aspects of the observed care were of moderately high quality, such as infection prevention and provision of prophylactic oxytocin. However, compliance with all elements of the active management of the third stage of labor (i.e., oxytocin within one minute of delivery, controlled cord traction, and uterine massage after delivery of the placenta) occurred in only 13% of observed deliveries. In only 48% of observed antenatal care consultations was blood pressure measured using correct technique, and in only 29% did the provider perform or refer the pregnant woman for proteinuria screening. During cases of postpartum hemorrhage management, manual removal of placenta (MRP) was attempted in five cases but in none was it carried out according to the guidelines. In several cases of severe pre-eclampsia and one case of eclampsia, magnesium sulphate, the drug of choice, was not given.. Overall, quality improvement is urgently needed to provide prophylactic oxytocin to all women within one minute of delivery, and to supply magnesium sulphate to all maternities for treatment of severe PE/E, among other interventions. To build on existing favorable policies to improve maternal and newborn health care in Madagascar, quality improvement efforts should target provider and facility readiness. In addition, national guidelines and protocols need to be updated and operationalized according to an appropriate national strategy that includes a budgeted action plan, follow-up, and performance-based recognition of providers and facilities. A national strategy is critical to ensure that all partners in the health system support it. An increase in the government's participation in funding for health (more than 12%, per the Abuja recommendation) would facilitate this program. Provider competencies can be maintained through regular practice with low-cost anatomical simulators and through use of regular updates and reminders to providers on clinical protocols via cell phones. In addition, accountability can be promoted by an adequate health management information system that collects data on the main causes of maternal and neonatal deaths, adequate supply at facilities of oxytocin, magnesium sulphate and other lifesaving drugs, and routine presentation of this information in regional and national fora.

Topics: Cross-Sectional Studies; Eclampsia; Female; Hospitals; Humans; Madagascar; Postpartum Hemorrhage; Pre-Eclampsia; Pregnancy; Quality of Health Care