Continuum of Care: Addressing Postpartum Hemorrhage in India and Nigeria

Vidhya Kumawat, 29-year-old woman arrived at the hospital in Udaipur, in critical condition. Earlier that night, at a private hospital close to her home, Vidhya delivered her third child, but there were complications; she began to hemorrhage.

Though the medical staff at the private hospital was not trained to treat postpartum hemorrhage, they recognized Vidya’s dire condition and advised her husband, Suresh, to get her to a higher level facility for treatment.

Across 50 kilometers, Vidhya’s condition worsened. By 4 AM, when she finally arrived at RNT Medical College Hospital in Udaipur, she had lost a significant amount of blood. Her blood pressure had plunged, so the hospital staff wasted no time.

Within twenty minutes, the trained team at Zanana hospital applied an NASG and wheeled Vidhya into the operating room. They performed a hysterectomy and gave her five units of blood, donated by her husband and extended family.

Following surgery, Vidhya’s condition stabilized, and the staff was able to remove the NASG. In time, she was able to return to her village. She was able to return to her family and to a life she came so close to losing.

With funding from the John D. and Catherine T. MacArthur Foundation, Pathfinder worked to reduce India and Nigeria's maternal mortality and morbidity rates caused by postpartum hemorrhage.

The first phase of the project incorporated the three components of the Clinical and Community Action to Prevent Postpartum Hemorrhage: advocacy to promote government support, clinical interventions, and community engagement. In more extreme cases of shock resulting from severe postpartum hemorrhage, the non-pneumatic anti-shock garment (NASG) was used.

The NASG is a groundbreaking technology that evolved from a suit originally developed by NASA. The garment works to reverse life-threatening shock in women with severe postpartum bleeding until she can be transported to a high-level facility for treatment.

The project extended from the community, where women are most likely to give birth at home or community health centers, to higher level facilities where women can receive care for complications.

In Nigeria, the project was implemented in 60 health facilities in seven states, and in India, the RAKSHA (Sanskrit for "protection") project was implemented in four states including Bihar, Maharashtra, Rajasthan, and Tamil Nadu.

"Provider after provider reported seeing fewer cases of postpartum hemorrhage during facility deliveries, with some facilities not ever needing to use the anti-shock garment.  . . .  The data being collected in these facilities confirmed the providers' reporters: the incidence of postpartum hemorrhage in the program facilities is on a downward trend.
--- 2013 summary report commissioned by the MacArthur Foundation

In both Nigeria and India, the projects improved linkages between communities and health facilities by supporting the establishment of community-organized emergency transport systems and by pooling funds for emergencies. These systems are used to transport women to facilities for obstetric emergencies. Pathfinder also trained providers, mentored supervisors, and led facility upgrades to equip staff with delivery, surgical, and infection prevention materials. In Nigeria, Pathfinder provided an alternate source of running water.

Pathfinder’s project in India focused on building partnerships, supporting and strengthening existing health systems, and promoting the presence of skilled birth providers during delivery at all levels. The project successfully brought birth preparedness and complication readiness planning to thousands of women and families to address and prevent postpartum hemorrhage and pre-eclampsia.

An independent evaluation and report commissioned by the MacArthur Foundation in 2013 recognizes Pathfinder’s Continuum of Care approach and its ability to strengthen health systems and reduce rates of postpartum hemorrhage in project facilities.

“[The Clinical and Community Action to Address Postpartum Hemorrhage model] gives providers tools to use at each stage of need, from prevention to treatment. Although most of the interventions included in this continuum of care model are not new approaches, Pathfinder's packaging of the full range of interventions to address the problem of postpartum hemorrhage…was unique and we believe was what made a difference."

According to the report, another crucial part of the model’s success lies in the introduction of accountability and Pathfinder’s emphasis on monitoring and evaluation to promote program improvement. The report additionally recognizes Pathfinder’s strong advocacy efforts championing the coordinated approach to care in meetings with government officials, local leaders, organizations, and professional societies.

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