1. Postpartum Hemorrhage in Sudan:
Magnitude and implications
By:
Dr: Waled Amen Mohammed
Dr. Dina Sami Khalifa
Geneva Foundation for Medical
Education and Research
GFMER Sudan 2012
Forum No: ( 1 )

2. Name of presenter
Name Position Institution
Waled Amen Mohammed Head, Community Health UMST
Nursing
Name of contributors
Name Position Institution
Waled Amen Mohammed Head, Community Health UMST
Nursing
Dina Sami Khalifa Epidemiologist Ahfad University for
Women

3. Content of the presentation
• Background
• Definition of PPH
• Etiology : 4Ts
• Contribution of PPH in MMR in Sudan
• Factors that put Sudanese women at added risk
• Protocols and guidelines for management of PPH (FIGO)
• Benefits of effective prevention and treatment of PPH
• Sudan health Policy implications on PPH
• Problem In Sudan
• Success stories for combating PPH from developing
countries
• Recommendations for PPH prevention and management
in Sudan
• Conclusion

4. Background
 Despite efforts and activities, maternal mortality rate is still high
in developing countries (WHO, 2007).
 MMR in Sudan is (1107 in 2006 and 750 in 2010) ¹
 Three quarters of maternal deaths occur during delivery and
immediate postpartum period. ²
¹ SHHS, 2006 &SHHSII, 2010
² Abdel-Tawab N, El-Rabbat M, 2010.

5. Definition of PPH
WHO defines PPH as:
Primary PPH: bleeding from the genital tract in excess
to 500 ml in the first 24 hours after delivery
Secondary PPH: bleeding from the genital tract in
excess to 500 ml in the after 24 hours after delivery
till end of puerperium. (WHO, 1989).

6. Etiology : 4Ts
Tone : Uterine atony
Trauma : Uterine, cervical or vaginal lacerations
Tissue : Retained placental tissue
Thrombin : Coagulopathy
 delay in recognition & referral  Maternal Near Miss or
Mortality

7. Contribution of PPH in MMR in
Sudan
Out of 535164 live births in 2010, 957 were maternal
deaths.¹
Out of 957 maternal deaths, 806 cases (84.2%) occurred
in health facilities, while 151 cases (15.8%) occurred at
community settings.¹
Maternal death from obstetric hemorrhage affects 225
cases (25.1%), PPH is 183 (81.4%).¹
¹ (FMoH, Sudan, 2010).

8. Contribution of PPH in MMR in
Sudan
• Study conducted in Kassala State-Eastern Sudan to
assess MMR found that the case fatality rate of PPH is
2.6%).¹
Proper management of PPH reduction of 25% of
MM in Sudan  i.e. reduce more than 90,000
deaths/year
¹ Mohammed AA, 2009

9. Factors that put Sudanese women
at added risk:
• Home deliveries by Village Midwives (VMWs) and
Traditional Birth Attendants (TBA)  79 %. ¹
• High unmet need for family planning  29%. ¹
• Anaemia (nutritional, malaria)
• Early marriage
• FGM and de-infibulation
• Routine episiotomy performed as standard
¹ (SHHS II 2010)

10. Protocols and guidelines for
management of PPH (FIGO):
• Prevention  Utero-tonic drugs + Active Management of
Third Stage of Labour (AMTSL)
• Treatment  Utero-tonic drugs +/- Blood transfusion +/-
Surgical interference;

11. Protocols and guidelines for
management of PPH (FIGO):
• Currently no standard protocol and guidelines in FMoH for
management of PPH had been implemented.
• All protocols require highly skilled birth attendants at level
of Health facility
• Both accurate knowledge about AMTSL and its correct use
remains low in developing countries.

12. Benefits of effective prevention
and treatment of PPH ¹
• Less maternal deaths
• Fewer admissions to intensive care unit
• Less blood loss
• Less use of blood transfusion
• Less use of additional utero-tonics
• Less postpartum anemia
• Earlier establishment of breastfeeding
• Less anemia in infancy
¹ WHO Recommendations, 2007.

13. Sudan health Policy implications on
PPH:
• RH Policy encourages home delivery for low risk
women; PPH can happen in low risk pregnancy
• Village Midwives are not empowered by policy
makers to deal with emergency cases and use of
active management of third stage of labour (use of
oxytocine).

14. Sudan health Policy implications on
PPH:
• Low quality of health services and inequity in
distribution; delay in referral and delay in proper
management at health facilities are key reasons
for high PPH mortality.

15. Problem In Sudan:
• Women are delivering at home (79%)  Village
Midwives not equipped with prevention
mechanisms  Policy does not support VMWs to
perform PPH prevention and treatment  late
recognition of PPH late referral to health facilities
( delay in decision making/inequity in distribution of
Emergency & Comprehensive facilities) delay in
service and/or inappropriate management low
availability of drugs/blood banks  exacerbation of
haemorrhage  Maternal Death.

16. Success stories for combating PPH
from developing countries:
1. Anti Shock devices (Life-wrap suit): to treat
PPH. Evidence so far; decrease fatality in PPH
cases by 69% in Egypt, Nigeria, Zambia &
Zimbabwe. Stabilizes bleeding at community
till referral to an EmOC facility.

17. 2. Misoprestol (at the community level):
For preventing PPH, oral misoprostol (600 mcg)
and for treatment sublingual (800 mcg) can be
safely and effectively administered by lower-
level health providers. Trails proved
effectiveness & acceptability of drug by
women in (Burkina Faso, Ecuador, Egypt,
Turkey, and Vietnam)

18. Misoprestol (at the community level):
Cheap
Needs no refrigeration
Oral and needs no injection
VMW can easily be trained to administer it.
Its a good solution for low income settings.

19. Recommendations for PPH prevention
and management in Sudan:
• Setting specific standard guidelines and protocols for
PPH prevention and treatment AT FACILITY &
COMMUNITY level with massive dissemination and
implementation.
• Targeted and evidence based capacity building of
VMW SKILLED birth attendants

20. • Community awareness raising for recognition of
danger signs during and after delivery.
• Introduction of effective evidence based
interventions that help in reduction of the impact of
PPH ( e.g. uterotonic drugs by VMWs)

21. • Developing countries experiences for prevention and
treatment of PPH should be analysed and studied and then
modified for national application.
• Focusing on Health services providers (VMWs) to raise
community awareness.

22. CONCLUSION
• Postpartum hemorrhage is still one of the leading causes of
maternal near miss & maternal mortality in Sudan.
• Sudanese women are at higher risk for postpartum
hemorrhage due to many social determinants.
• There are no standard guidelines for prevention and
treatment for PPH in Sudan.

23. References
• WHO. Reducing the Global Burden: Postpartum Haemorrhage. A n e w s Le t t e r o f Wo r l d w i d e A c t i v i t y. 2007.
• Abdel-Tawab N, El-Rabbat M. Maternal and Neonatal Health Services in SUDAN: Results of a Situation Analysis. Sudan;
2010.
• World Health Organization. The prevention and management of postpartum haemorrhage. Report of a technical working
group of the WHO. Geneva: WHO; 1989 Contract No.: Document Number|.
• Federal Ministry of Health-Sudan. National Maternal Death Review report Khartoum: Federal Ministry of Health-Sudan;
2010 Contract No.: Document Number|.
• Mohammed AA. Postpartum haemorrhage, hospital experience in high maternal. World Congress of Gynaecology &
Obstetrics International Federation of Gynecology & Obstetrics and South African Obstetrical & Gynaecological Society of 4-
9 October 2009; 2009; Cape Town- South Africa. Researchgate; 2009.
• Miller S, Ojengbede O, Turan JM, Morhason-Bello IO, Martin HB, Nsima D. A comparative study of the non-pneumatic anti-
shock garment for the treatment of obstetric hemorrhage in Nigeria. Int J Gynaecol Obstet. Volume 107, Issue 2, Pages 121-
125 (November 2009) PubMed PMID: 19628207
• A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. Int J
Gynaecol Obstet. 2010 Jan 21. [Epub ahead of print] PubMed PMID: 20096836

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25. Thank you