=By ‘Sanmi Falobi=

“From the evidence available, 28% of all maternal death in Nigeria is caused by excessive bleeding after child birth. 28% means that in almost every four women, one of them die as a result of Postpartum Hemorrhage and that is something that needs attention in terms of addressing maternal deaths in Nigeria”.

Maternal mortality and consequential social dysfunction
Sitting with a forlorn face and wondering what the future now holds, Mr. James Ogbe’s* life has not been the same following the sudden death of his wife as a result of post-delivery bleeding she experienced few hours after the birth of their second child. With a six year old girl and the new baby to now take care of, James Ogbe is not only mourning the untimely death of a loving wife, but also faced with the task of taking care of his two young children alone.
“How do I live on with life now? Where do I start from”, he said, with a voice laden with sadness. Why did she have to die? Please take away the baby, give me my wife back. Please give me my wife back!”, he demanded, expecting an answer from the nurse, that Saturday morning, minutes after he was told that his wife had died.

“I don’t want this baby, just give me my wife. Please give me my wife”, he repeated, with eyes fixed on the walls, above the nurse who was carrying his new-born baby. As he looks on at the wall vaguely, droplet of tears streams down his face. “Please give me my wife”, he muttered again and again, as a family member and another, a member of his church, rally round to hush him from further lamentations.

‘When she delivered, there were no issues at all. The labour period didn’t take long and the delivery was also normal. There’s wasn’t any much anxiety throughout it all. We had talked for some minutes after giving birth and we were even already hoping she would be discharged by the next morning”, Ogbe recounted.

“The next thing I heard later was that she was bleeding and that she needed extra blood as she had used three pints already. I was told that she may need a fourth one, so I had to go in an ambulance from the General Hospital, Ijaiye to Island Hospital, Lagos to get extra blood as their stock was already exhausted. By the time I came back with the blood, they told me she had died” Ogbe explained.

“How can she die from bleeding? Somebody that was okay and I saw and spoke with? I got the blood she needed, yet she still bled and died, why? How?”, he asked, lamenting.

Now, months later, with wife buried and family support rendered, the reality of the loss of a dear wife and the challenge in taking care of two little kids has gradually re-shaped the horizon for James Ogbe. Though the support from family, relatives and church members had helped in gradually and slowly dissipating the grief, there yet remain an un-answered question in the heart of James Ogbe and many others, relating to the circumstances that led to his wife bleeding to death after what seems to be a successful delivery of his second child.

“We picked that hospital because it was one of the best general hospital in Lagos. Why things twisted is still a mystery, and I wake up everyday seeking for answers”, he notes, as he tries to pick up his life again, each day driving home the reality that he has become a widower at just 36!

Understanding Postpartum Hemorrhage
James Ogbe’s questions may remain un-answered, as it is with many Postpartum Hemorrhage deaths in Nigeria. According to a 2016 report by the International Journal of Women’s Health (IJWH), post child-birth bleeding, medical known as Primary Postpartum Hemorrhage (PPH) is defined as blood loss from the genital tract of 500 mL or more following a normal vaginal delivery or 1,000 mL or more following a cesarean section within 24 hours of birth.

Giving a more simplified definition, the World Health Organization (WHO) in its June 15, 2017 recommendations on the World Maternal Antifibrinolytic (WOMAN) Trial on Prevention and Treatment of Postpartum Hemorrhage, defined PPH as a blood loss of 500 ml or more within 24 hours after birth. It noted that PPH is the leading cause of maternal mortality in low-income countries, and the primary cause of nearly one quarter of all maternal deaths globally. It was stated that most deaths resulting from PPH occur during the first 24 hours after birth. Interestingly, the WHO report also pointed out that the majority of PPH death could be avoided through the use of prophylactic uterotonic during the third stage of labour and by timely and appropriate management.

In Nigeria, an organization established as a response to the rising maternal morbidity and mortality rates in the country, the Community Health and Research Initiative (CHR) also shares the same concerns with the WHO, that timely and appropriate attention to post-delivery bleeding is critically important, especially because PPH occurs without warning, and a woman with severe PPH can bleed to death within a few hours if not rapidly and adequately treated.

As part of advocacy efforts to address the mortality resulting from PPH, an advocacy brief by CHR, titled, ‘simple facts about postpartum hemorrhage’ notes that the main cause of PPH is the failure of the uterus to contract after childbirth due to a number of reasons including lacerations in the birth canal, uterine rupture, retained placenta tissue and blood coagulation disorders. The document however noted that, “PPH can be prevented through the provision of appropriate medication and the administration of a class of medicines called uterotonics”. According to the advocacy brief, “postpartum hemorrhage death could be prevented if all women were given a high quality uterotonic immediately after delivery.”

The challenges in using Oxytocin in PPH prevention
Giving an insight about PPH, Dr. Musa Mohammed Bello, a Consultant Public Health Physician and member board of trustees of CHR, explained that Postpartum Hemorrhage which literally means excessive bleeding after child-birth is a condition that is very common among women and child delivery in Nigeria.

“We all know that in developing countries like Nigeria, maternal mortality or death of women during pregnancy, child birth or after child birth is very common, especially in Africa”, he said.

He further pointed out that though PPH deaths are easily preventable by the administration of an uterotonic drug, which helps to stop a woman from bleeding after child birth, he however emphasized that the conditions of storage and handling of the drug matters.

“Actually there are drugs that are supposed to be used to prevent Postpartum Hemorrhage. These drugs are very good, and they have been experimented and recommended to be used. These drugs have an umbrella name called uterotonic, which means group of drugs that causes contractions of the uterus of the womb after child birth. There are many of them, for example, there is Oxytocin injection, there is Egometrine injection, and there is Misoprostol tablet”, he explained.

“Out of these, Oxytocin is the most preferred first line drug of choice, but there is an issue with it in that it requires maintenance of content; you need to store it in a cold compartment between a temperature of 2 to 8 degrees Celsius for it to remain effective, but unfortunately, in developing countries like ours, we have problem with power so maintaining the content, refrigerating because of electricity problem is usually difficult, so these drugs are not performing the functions we expect them to perform, because of the heat nature”, he added.

Expatiating, he said: “So you find out that a woman has delivered, she’s bleeding and they gave her Oxytocin injection 3-4 times and it’s still not working because it has lost what we call efficacy due to temperature effect”.

Also giving credence on the need for a proper policy framework for the procurement and distribution of essential drugs, the National Chairman of the Association of Community Pharmacists of Nigeria (ACPN), Comrade Samuel Adekola, a pharmacist by profession, noted that despite all the effort to reduce maternal mortality in Nigeria, a critical mass of women still die with PPH being one of the leading causes of such deaths. While agreeing that Oxytocin as a first choice of drugs could be used to manage the situation, he however pointed out that for oxytocin to be effective, it must be stored at a specified temperature at all times.

“Oxytocin is the preferred first line drug of choice for the treatment of PPH. However it is the drug that has peculiarity in terms of transportation and storage, as it has to be stored between 2 and 8 degree Celsius. The drug has to be in a cold storage system at all times for it to remain effective. This is the challenge because of our environment, we have the problem of light and the problem of infrastructure. The fridge for storing a vaccine like oxytocin is not available in many places and where it is available, there may be no electricity to power them and yet people still give the drug, because it is there in the store”, he noted.
“Unfortunately, there is no means of knowing whether the temperature and the environment have affected it (Oxytocin), so they still give it because it is there in the store, irrespective of whether the condition of storage is as prescribed”, he pointed out.

“It is this challenge of the storage of Oxytocin that has given rise to research and development to another variety known as Carbetocin, which has been tested and proven and is now the drug being advocated, for the treatment of Postpartum Hemorrhage”, he added.

From Oxytocin to Carbetocin, hope rises
It would be recalled that sequel to the need to address the challenges associated with the use of Oxytocin in humid regions, the Word Health Organization (WHO) in June 2018 announced the report of a study on the formulation of a new drug for the treatment of postpartum hemorrhage in low and middle-income countries. In the study, published in the New England Journal of Medicine, an alternative drug – heat-stable Carbetocin – was recommended to be as safe and effective as Oxytocin in preventing postpartum hemorrhage.
“This new formulation of Carbetocin does not require refrigeration and retains its efficacy for at least 3 years stored at 30 degrees Celsius and 75% relative humidity”, a portion of the study stated.

The clinical trial, the largest of its kind, studied close to 30 000 women who gave birth vaginally in 10 countries: Argentina, Egypt, India, Kenya, Nigeria, Singapore, South Africa, Thailand, Uganda and the United Kingdom.

“The development of a drug to prevent postpartum hemorrhage that continues to remain effective in hot and humid conditions is very good news for the millions of women who give birth in parts of the world without access to reliable refrigeration,” Dr. Metin Gülmezoglu of the Department of Reproductive Health and Research at WHO, had said.

Acknowledging the WHO report, Comrade Adekola notes that Carbetocin has the advantage that it does not require any special condition other than keeping it at the normal room temperature. So it is a good alternative for effective treatment of PPH.

“This drug has been tested and would soon be released by WHO as the first line choice for the treatment of PPH. It is an injectable like Oxytocin, and also heat stable.
“We are calling on government at the national, state and local level to make this drug available, as it has the advantage that it can be stored at room temperature and there are no environmental factors affecting it like Oxytocin. Government should therefore do what they need to do to make this drug available so that every pregnant woman can have access to this drug, when the need arises”, he added.

Meanwhile and in the same vein, Dr. Aminu Magashi Garba, Coordinator, Africa Health Budget Network, Abuja is urging for a multi-stakeholders involvement in mitigating maternal mortalities in Nigeria.

“From the evidence available, 28% of all maternal death in Nigeria is caused by excessive bleeding after child birth. 28% means that in almost every four women, one of them die as a result of Postpartum Hemorrhage and that is something that needs attention in terms of addressing maternal deaths in Nigeria”, Dr. Magashi Garba noted.

“One thing we advocate for is that the government has to put money down in purchasing quality drugs that will stop bleeding after child birth. Quality drugs is beyond just buying a drug but also involve the process of transportation and the storage of such drugs. Government, in ensuring the quality of drugs must also put into consideration the conditions of storage and distribution process. So in the situation now that government cannot do that, we are in support of the alternate drug called Carbetocin which can be under normal room temperature for up to three years and is also an injectable that is effective like oxytocin”, he said.

Forging a common front through advocacy
Working in collaboration with CHR, Dr. Magashi Garba noted that the CHR and partner organizations are already undertaking a number of advocacy initiatives to rally stakeholders support involving the media, civil society as well as government agencies, especially relating to health matters, on measures to mitigate maternal mortality in Nigeria.

“As an organization, we are focusing on advocacy to the key stakeholders that we believe take decisions relating to procurement, storage and distribution of drugs; those that take decision concerning the type of drugs that should be in our essential drug list that need to be put at federal and state level for procurement and then those who are the key frontline health workers that needs to be sensitized on the use of this new drug, Carbetocin in the treatment of PPH.

‘We need to sensitize our people and involve all stakeholders about the burden of postpartum hemorrhage and maternal mortality so that all women delivering in the health facility will receive the care they are supposed to receive’ he added.

The need for enabling policy framework

Meanwhile, it is a welcome development to note that the Nigeria Health Ministry has also endorsed the WHO formulation of Carbetocin as effective as oxytocin, for the prevention of excessive bleeding. According to the Nigerian minister of health, Professor Isaac Oyewole, speaking at a health forum on eradication of Polio, in Kano, the WHO recommended heat-stable formulation of Carbetocin, is a ‘welcome development, and capable of lowering incidence of death among Nigerian women during childbirth.’

This statement by the Minister, it is hoped, will translate to a policy that aids pregnant women to better cope with post child-birth bleeding issues through an effective drug administration mechanism that ensures the provision and use of Carbetocin as a key essential drug for the treatment of postpartum hemorrhage in Nigeria.

However, though Carbetocin, manufactured by Ferring Pharmaceuticals is available in Canada, the United Kingdom and many other countries, there is still the need to have some advocacy in creating the enabling policy framework to list it as an essential drug in the treatment of PPH in Nigeria and many other Africa countries.

Though, human error sometimes may contribute to mortalities, an effective drug administration mechanism, would certainly help reduce maternal mortality and save pregnant women from dying, thereby eliminating the social dysfunction associated with the such deaths during child-birth; either as a mother, or as a wife.

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*Editor’s note: *James Ogbe is herein used as a pseudo name.

Image credits: Wendy Marijnissen, 100huntley, babycenter.com

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