Blami Dao

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial

BACKGROUND Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin. METHODS In this double-blind, non-inferiority trial, 31 055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Vietnam (two secondary-level and three tertiary-level facilities). 809 (3%) women were diagnosed with post-partum haemorrhage and were randomly assigned to receive 800 mug misoprostol (n=407) or 40 IU intravenous oxytocin (n=402). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS All randomly assigned participants were analysed. Active bleeding was controlled within 20 min after initial treatment for 363 (89%) women given misoprostol and 360 (90%) given oxytocin (relative risk [RR] 0.99, 95% CI 0.95-1.04; crude difference 0.4%, 95% CI -3.9 to 4.6). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) women receiving misoprostol and 123 (31%) receiving oxytocin (RR 1.12, 95% CI 0.92-1.37). Shivering (152 [37%] vs 59 [15%]; RR 2.54, 95% CI 1.95-3.32) and fever (88 [22%] vs 59 [15%]; 1.47, 1.09-1.99) were significantly more common with misoprostol than with oxytocin. Six women had hysterectomies and two women died. INTERPRETATION Misoprostol is clinically equivalent to oxytocin when used to stop excessive post-partum bleeding suspected to be due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour.

Essential basic and emergency obstetric and newborn care: From education and training to service delivery and quality of care

Approximately 15% of expected births worldwide will result in life‐threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource‐poor settings. Providers have been educated to deliver high‐impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre‐eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiegos programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high‐quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency‐based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale‐up of high impact evidence‐based maternal and newborn interventions in low‐resource settings.

Sublingual misoprostol versus standard surgical care for treatment of incomplete abortion in five sub-Saharan African countries

BackgroundIn low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC) services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful.MethodsA total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation.ResultsBoth misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%). Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92). Both tolerability of side effects and women’s satisfaction were similar in the two study arms.ConclusionMisoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability.Trial registrationThis study has been registered at clinicaltrials.gov as NCT00466999 and NCT01539408

Oral misoprostol as first-line care for incomplete abortion in Burkina Faso

To explore 400‐μg sublingual misoprostol as primary treatment in lower‐level facilities with no previous experience providing postabortion care.

Clinical articleOral misoprostol as first-line care for incomplete abortion in Burkina Faso

To explore 400‐μg sublingual misoprostol as primary treatment in lower‐level facilities with no previous experience providing postabortion care.

Preparing the next generation of maternal and newborn health leaders: The maternal and newborn health champions initiatives

A champion in health care can be defined as any health professional who has the requisite knowledge and skills in a relevant health field, who is respected by his/her peers and supported by his/her supervisors, and who takes the lead to promote or introduce evidence‐based interventions to improve the quality of care. Jhpiego used a common approach during two distinct initiatives to identify individuals in Africa, Asia, and Latin America and the Caribbean whose expertise in their clinical service area and whose leadership capacity could be strengthened to enable them to serve as champions for maternal and newborn health (MNH). These champions have gone on to contribute to the improvement of MNH in their respective countries and regions. The lessons learned from this approach are shared so they can be used by other organizations to design leadership development strategies for MNH in low‐resource countries.

Advancing implementation in maternal and newborn health: Two decades of experience

arshad Sanghvi, Jeffrey Michael Smith, Koki Agarwal, Blami Dao, onald Magarick Jhpiego In the past 15 years, Jhpiego has had the privilege of working with governments and other partners to implement interventions for maternal and newborn health (MNH) in nearly 40 countries. This Supplement to the International Journal of Gynecology and Obstetrics (IJGO) is our attempt to share our analysis and learning from those experiences as the global health community looks toward 2030 and beyond, and to ensure that implementation challenges, aswell as the resources required to address them, are an important part of the post-MillenniumDevelopment Goals conversation. The new global paradigm for MNH envisioned by the UN Secretary General’s Sustainable Development Goals and the Global Strategy for Women’s, Children’s, and Adolescents’ Health aims to bring evidencebased MNH interventions to national scale, setting ambitious targets to reach the unreached in every country and end all preventable deaths among women and children. Scale is not only about what works; it is about how to make that which has been proven to work in small, controlled areas apply equally well across all contexts. So wemust ask ourselves: What does it take for health systems to reach every woman, every child, everywhere, every time? The answer to this classic implementation science question is difficult to quantify, but we do have some evidence, and as with any scientific inquiry, we should startwith the evidence thatwe have. The papers in the Supplement have beenwritten by and for implementers, describing in detail what has been accomplished and highlighting lessons about what did and did not work. The lessons themselves will not be new to anyone who has worked in MNH as long as we have, but we believe that their thoughtful analysis and collective and inductive presentation is a unique illustration of the complexity of achieving—and then reinforcing—implementation results. Implementation science for MNH has a long road ahead. The papers in the first section directly confront the “how” of implementation. Even if we have all the right interventions, we need political commitment and partnerships to bring those interventions to populations in need. Sometimes these elements are beyond the control of implementers owing to contextual factors and prioritizations inherent in real-world public health environments, but there are common principles that can help navigate politics and partnerships more strategically and systematically to reach goals more rapidly and with longer-lasting efforts. We should not, however, sacrifice quality for speed; quality improvement, particularly the linkages between quality and health outcomes, remains a critical but under-funded area of our work. The second section examines the “who” of implementation, documenting ways to empower all cadres of frontline health workers with appropriate competencies to deliver evidence-based interventions, wherever women and children need them. It is our belief that those