Scenario of Maternal Mortality by Obstetric Hemorrhage
Obstetric hemorrhage is one of the leading causes of preventable maternal deaths in
the world. There are 14 million cases of postpartum hemorrhage and 140 thousand related
deaths annually worldwide.[1] There is also a large contingent of women who survive a postpartum hemorrhage event
with related reproductive and emotional consequences. Postpartum hemorrhage stands
out as the second major cause of maternal deaths in Brazil.[2] However, it continues to be a leading cause of numerous preventable maternal deaths
in many areas of the country, especially the countryside and the Amazon region, where
there is a low density of health care facilities, fewer health care professionals,
and an inefficient logistic network for quickly obtaining blood supply.
Maternal mortality is an indicator of a population's living conditions and health
care, and it also reflects the human development of a country. Almost all maternal
deaths occur in developing countries. Low instruction levels, inadequate nutrition
conditions, insufficient social support, and lack of access to health care are strongly
associated with maternal deaths. In addition, maternal mortality is an indicator of
inequity between the richest and the poorest, and it also reveals gender inequalities
within a society. Given this scenario, the acceleration of maternal mortality reduction
was established as one of the priority global targets in the United Nation's Sustainable
Development Goals.[3] The reduction in maternal morbidity and mortality has been widely sought, but despite
ongoing efforts, the current results are still disappointing.
Zero maternal deaths by hemorrhage in the Americas
Zero Maternal Deaths by Hemorrhage (0MMxH) in the Americas is a project of the Pan
American Health Organization/World Health Organization (PAHO/WHO) and its Latin American
Center for Perinatology, Women and Reproductive Health (CLAP/SMR). This center is
dedicated to the prevention of obstetric hemorrhage. The initiative aims to strengthen
health care systems, eliminate barriers to access to health care, qualify health care
professionals to deal with obstetric hemorrhage, and ensure the availability of the
medical supplies and equipment needed to deal with severe forms of postpartum hemorrhage.
It also seeks to empower women, so that they can fully acknowledge their rights and
preferences. The initiative has the additional objective of mobilizing governments,
the civil society and communities, wherever it goes. The project has been successfully
implemented in the Americas and the Caribbean since 2014.
Zero Maternal Deaths by Hemorrhage in Brazil
Considering the experiences outlined before, PAHO/WHO and CLAP/SMR proposed that the
Brazilian Ministry of Health develop this initiative as a strategy to accelerate the
reduction of severe maternal morbidity and mortality related to obstetric hemorrhage,
since postpartum hemorrhage is an important cause of maternal deaths in the country,
especially in areas with low density of health care units and health care professionals.
The decision to introduce 0MMxH in the country was made jointly by the Ministry of
Health, through its Women's Health General Coordination, PAHO/WHO Brazil, and CLAP/SMR.
The program was based on the belief that increasing the competencies of health care
professionals may give them the technical skills to handle obstetric hemorrhagic emergencies,
and that the ministry needs to provide close guidance and technical support to local
health authorities in states and cities.
Phases of zero maternal deaths by hemorrhage in Brazil
Because of Brazil's large territory, it was initially decided to implement 0MMxH in
some priority areas of the country. A technical evaluation of the maternal mortality
ratio and the causes of maternal mortality was carried out for the Brazilian states
for the period between 2010 and 2014. This evaluation was carried out by the Ministry
of Health, with the support of the Technical Unit of Family, Gender and Life Course
- PAHO/WHO Brazil. Based on this assessment, eight priority states for launching 0MMxH
in Brazil were identified: Piauí, Maranhão, Pará, Tocantins, Bahia, Ceará, Minas Gerais
and Rio Grande do Sul.
The first phase of 0MMxH began with conversations among the Brazilian Federation of
Gynecology and Obstetrics Associations, the Ministry of Health and PAHO/WHO Brazil.
These conversations led to an agreement to hold two initial 0MMxH implementation workshops.
They were held in Brasília in September 2015, and were coordinated by CLAP/SMR, PAHO/WHO,
and the Ministry of Health. Health care professionals from obstetric care units in
the eight priority states were trained by international instructors from the Latin
American Federation of Societies of Obstetrics and Gynecology.
Because of the experiences in the first workshops, and because of certain specific
needs of Brazil, it was concluded that the original initiative should be adapted to
national demands. Subsequently, PAHO/WHO and the Ministry of Health, with the technical
support of CLAP/SMR, began to work on the customization of the strategy. During 2016,
physicians and nurses from various parts of Brazil worked together to craft a specific
format for a workshop to meet the expectations of Brazilian health care professionals.
The outcome of this joint effort was the production of a course with theoretical and
practical activities, called “Prevention and Obstetric Management of Postpartum Hemorrhage”.
The second phase of 0MMxH in Brazil was carried out with technical meetings involving
the Ministry of Health, PAHO/WHO and the health secretariats from the priority states.
The purpose of these meetings with local health authorities and health care professionals
was to make a plan for the implementation of 0MMxH in each region. In addition, these
local meetings brought together local stakeholders, such as city and state health
managers, health care professionals, workers involved in the transportation of patients,
and those involved in blood supply services to develop a joint plan of actions aiming
to reduce maternal mortality by obstetric hemorrhage in the states. These action plans
usually included the development of postpartum hemorrhage management protocols, the
improvement of health care systems, seeking the establishment of referral networks,
and strategies for the allocation and use of non-pneumatic anti-shock garments.
The third phase of the strategy consisted of training sessions for health care professionals
from the priority states. In these workshops, the health care professionals were trained
to prevent postpartum hemorrhage and to manage obstetric hemorrhage with powerful
tools that were used during field simulation procedures. The effects of the training
reverberated around the country. This led other Brazilian states, through their state
health secretariats, to carry out these courses on their own, with the collaboration
of local stakeholders such as obstetric and gynecological associations, nursing associations,
and universities.
Finally, the fourth phase of 0MMxH in Brazil consisted of monitoring of competency-building
among health care professionals, and implementation of a CLAP/SMR instrument that
allows the evaluation of the essential conditions for hospital obstetric services.
Advances achieved by zero maternal deaths by hemorrhage in Brazil
Zero Maternal Deaths by Hemorrhage was only recently introduced in Brazil. However,
the initiative has produced relevant and positive results since its implementation:
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√ It has promoted dialogue among health care professionals and healthcare managers,
which has led to the development of interventions to reduce maternal morbidity and
mortality due to postpartum hemorrhage.
-
√ It has stimulated multidisciplinary teamwork and highlighted the role of pregnant
women and their relatives during antenatal, labor, delivery and postpartum care.
-
√ It has garnered the support and engagement of medical and nursing associations,
as well as universities, for the dissemination of 0MMxH around the country.
-
√ It has been able to insert the theme of 0MMxH into major medical and nursing events,
such as regional and national congresses.
-
√ To date, more than 500 health care professionals have been trained on the prevention
and management of postpartum hemorrhage through 0MMxH.
-
√ It has introduced new low-cost technologies for postpartum hemorrhage care in several
regions, such as: non-pneumatic anti-shock garments, handcrafted intrauterine hemostatic
balloons, and obstetric hemorrhage toolkits. These help obstetrical health care providers,
hospitals and their managers develop work processes within their facilities for the
timely recognition of, and well-organized responses to, obstetrical hemorrhage situations.
-
√ It has produced, through joint efforts by highly qualified and experienced professionals,
evidence-based practice documents that guide obstetric hemorrhage prevention and management
in health care services in Brazil.
Final Considerations
Future plans for 0MMxH in Brazil are to include other states and regions of the country
into the initiative, under close monitoring by the Ministry of Health, local state
governments, medical and nursing professionals, universities, and civil society itself.
The main mission of 0MMxH is to contribute to the improvement of obstetrical care
quality in Brazil, and to raise the awareness that all people, in the positions or
roles they already have within society, are responsible for preventing maternal deaths.
Finally, within the framework of the Sustainable Development Goals, the needs of all
pregnant women should be met during pregnancy and the puerperium, and none of them
should die due to preventable causes.
