Preventing primary postpartum hemorrhage in unskilled births in Africa.

Available evidence indicates that Africa accounts for the highest burden of maternal mortality in the world. Primary postpartum hemorrhage (PPH) accounts for an estimated 25% of maternal mortality, and is a major cause of postpartum disability in sub-Saharan Africa. PPH and maternal anemia are also indirect contributors to maternal deaths due to other causes. Thus, it is conceivable that any intervention aimed at preventing PPH will reduce maternal mortality by more than one quarter in sub-Saharan Africa. To date, nearly 90% of PPH are due to inadequate uterine contractions occurring at the time of delivery. The routine administration of uterotonics followed by controlled cord traction is the method recommended by the International Federation of Obstetricians and Gynecologists (FIGO) and the International Confederation of Midwives (ICM) for the prevention of PPH. Uterotonics are also the mainstay of treatment of PPH after it has occurred. The World Health Organization recommends the administration of intravenous oxytocin and ergometrine as first and second line uterotonics for the prevention and treatment of PPH. However, these uterotonics can only be administered in deliveries taken by skilled birth attendants in orthodox health facilities. Since oxytocin and ergometrine require parenteral administration, these recommendations are futile when deliveries are carried out by unskilled birth attendants. There in lies the problem in sub-Saharan Africa, where large proportions of births occur at home or are attended by unskilled traditional birth attendants. Nigeria and Ethiopia, two densely populated countries in Africa with the highest maternal mortality rates, also have between 50-60% of births either unattended or attended by unskilled birth attendants. Indeed, several studies conducted in locations across sub-Saharan Africa, have identified delivery by unskilled providers as the most important risk factor for PPH fatalities. During such births, women are unnecessarily exposed to the risk of dying from PPH, in part because the two recommended drugs cannot be administered Preventing primary postpartum hemorrhage in unskilled births in Africa