How Niger halved maternal mortality caused by postpartum hemorrhage

Niger’s adoption of an innovative three-step treatment protocol has cut deaths from postpartum hemorrhaging (PPH) by more than half, saving thousands of lives.

Postpartum hemorrhage is the leading cause of maternal mortality around the world and remains stubbornly high in low- and middle-income countries. It is responsible for the deaths of more than a quarter of the nearly 300,000 women who die each year in childbirth.

But a new three-step protocol implemented in Niger offers hope that even in the most severely resource constrained settings, maternal mortality can be reduced. In fact, the low-cost, three-step treatment protocol has reduced Niger’s maternal mortality rate from PPH to roughly the same rate found within the United States. It achieved this impact within six months of implementation and has maintained the impact for more than six years.

To help health providers in identifying women in need of the protocol, researchers recommend that the wrap-around garment worn by the woman be placed under her immediately after birth. A small experiment indicates that a fully soaked wrap in Niger contains about 500mL of blood. If the garment is blood soaked, she is to receive the three-step treatment as follows.

First, administration of misoprostol to decrease bleeding. If bleeding continues, a health care worker inserts and inflates a condom tamponade attached to a catheter into the woman’s uterus. The third step is wrapping the woman in an anti-shock garment and providing the woman with critical blood transfusions. This process has proven effective in preventing the deaths of 1,417 Nigerien women over a six-year research period from 2015 to 2020, according to recently published research in The Lancet.

Each of these three treatments had been shown to be effective when used alone. What’s new is their use in combination. The researchers, writing in February’s issue of the Lancet, recommended that, “Niger's strategy should be replicated in other low-income and perhaps middle-income countries.”

If it proves as impactful in other geographies, as seems likely, the authors called on UN agencies, the international community and the manufacturers of misoprostol and non-inflatable anti-shock garments, to rapidly scale global production.

Exemplars News spoke with one of the authors of the study, Dr. Zeidou Alassoum, Resident Technical Advisor in Niger for the NGO Health and Development International, which helped pioneer the innovative treatment, about how it works.

What was the origin of the PPH treatment program?

Dr. Alassoum: The origin was a pilot project for the prevention of maternal deaths and obstetric fistula in five rural communes at the district level in the west of the country, in the Tera district of the Tillaberi region. The project started in 2008 with the aim of reducing maternal deaths due to prolonged labor by 75% and fistula cases following childbirth by 50%.

These objectives were quickly achieved. PPH appeared to be the main cause of maternal mortality in the zone. Despite the fact that misoprostol is not officially authorized by the WHO for community use, health authorities [in Niger] allowed us in 2010 to experiment with this treatment at the community level to treat PPH. The results were impressive – a 75% reduction in PPH deaths after three years.

Dr. Alassoum: In Niger, it was regularly reported that 29% of maternal mortality was attributable to PPH and the overall maternal mortality ratio was around 535 deaths per 100,000 live births. At the same time, we took part in the the FIGO World Congress that was held in Rome in 2012 and misoprostol combined with Non-pneumatic Anti-Shock Garments (NASGs) – which we call anti-shock clothing or pants – and Uterine Balloon Tamponades (UBTs) were presented as a scientifically proven means to efficiently fight against PPH.

As a result of the above and knowing that a significant reduction in PPH mortality would have a definite impact on overall maternal mortality, we designed this program in conjunction with the Ministry of Health.

Are any of these three treatments new?

Dr. Alassoum: All the components can be considered new. Firstly, for misoprostol, it was only in 2012 that the WHO recommended its use for both the prevention and treatment of PPH. As for NASG and uterine tamponades, they had been researched but not, to our knowledge, used in large-scale programs.

How long have they been available? Have they been used widely in Niger previously?

Dr. Alassoum: In Niger, only misoprostol had been used, based on research findings, in post-abortion care or during cesarean section procedures to prevent post-operative bleeding.

What was the process of scaling up throughout the country and how successful has this been?

Dr. Alassoum: Niger went directly from the pilot to a country-wide program. However, the national program is not a community program like the pilot project. Firstly, it was a question of placing misoprostol in all health facilities in the country to compensate for the absence of oxytocin, or its poor quality, due to insufficient cold chain, as part of active management of the third period of childbirth for the prevention of immediate post-partum bleeding. Secondly, instead of community-based approach, a preventative dose [of misoprostol] is given during the prenatal consultation to each woman who is in the seventh, eight, or ninth month of pregnancy, while asking her to return to give birth at the center and bring the tablets with her.

Who thought to combine them and why?

Dr. Alassoum: The combination of these three elements of prevention and management of PPH was an idea of the NGO Health and Development International, which submitted it to the Ministry of Health, and together it was agreed to design and implement the program.

Can you speak to the ability of lower-level facilities to implement these interventions? What challenges have these faced and how were these overcome?

Dr. Alassoum: All levels of care (including first contact) have been trained and are competent to implement all components of the program. The only real challenge was the reluctance of staff to give women a preventive dose that they must bring back to the center when they come to give birth, but that they must swallow immediately after the baby is discharged in case the delivery arrives along the way.

The reason for this reluctance is that it could encourage women to give birth at home. But the argument that shifts this reluctance is that no matter what we do, those women who plan to give birth at home will do so. In addition, after 60 years of independence, about 60% of women give birth at home, so what is the lesser risk with which we are faced?

How difficult is it to provide these three treatments in combination in a resource-poor setting? Are the supplies readily available? How affordable are these treatments?

Dr. Alassoum: Misoprostol and NASG are ordered externally at affordable costs due to large quantities – about 22 US cents for 1cp of misoprostol including shipping and about US$40 for a NASG. For the uterine tamponade kit, the constituent elements can be collected locally and the total cost is about US$5.

Could you speak to the efficacy of these interventions compared to the more resource-intensive interventions such as blood transfusions or uterotonics?

Dr. Alassoum: Misoprostol is also a uterotonic that is as effective as oxytocin but which has the advantage of not requiring a cold chain. The first element that counts for effectiveness is that the intervention increases the chances of preventing PPH, thereby reducing the need for transfusion. Also, the use of anti-shock pants makes it possible to stabilize the patient in her condition throughout the evacuation transport, and thus, minimize the risk of death.

What is the potential impact? Is this a strategy that you think should be adopted by similar settings with high mortality due to PPH?

Dr. Alassoum: PPH occurs in most countries, and particularly in developing regions in Africa, Asia, and South America, and is the leading cause of maternal mortality. The potential impact of this intervention for us is the possibility that countries which have the challenge of [reducing their MMR as laid out in] the SDGs can replicate and/or adapt it to their own context in order to relegate PPH to a much lower rank among the causes of maternal mortality and, consequently, reduce the maternal mortality ratio.

Are there any other promising low-cost interventions aimed at improving maternal health outcomes that you’d like to share?

Dr. Alassoum: In my opinion, three important strategies can break the routine of programs and policies that states pursue today, and very often without much success, from the MDGs to the SDGs.

The first is a strategy of mobilizing community-added value to complement the efforts of state services. It makes it possible to better diagnose the demand for health care and services to adapt them to the proposed offer, but also to create the conditions for the full involvement of communities in the implementation of the offer.

The second is a strategy of gender and empathy, which consists of getting a large majority of men to adhere to the fact that the last day of pregnancy is their responsibility so they can have in place all the conditions for women to benefit from the assistance of health professionals.

The third is a strategy of filling the void created by the absence of midwives or female staff in first-level care facilities. The formula is the one we have been using for more than 10 years in 26 rural health centers. It consists of recruiting women from the community and putting them in rapid training at the State School of Public Health and transferring each of them to the health center of their community. They can conduct a correct prenatal consultation with full ability to identify the danger signs of pregnancy and refer the patients, if necessary. They are also able to conduct a normal delivery with full ability to identify the danger signs of childbirth and refer, if necessary. We call them assistant midwives. The financial compensation is about 4 or 5 times lower than that a midwife or nurse.