Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study

Abstract

Background Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics. Methods The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women’s report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use. Results Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7–99.8%). Survey-report underestimated coverage (79.5 to 91.7%). “Don’t know” replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the “right time” (1 min) and 69.8% within 3 min. Women’s report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording. Conclusions Routine registers have potential to track uterotonic coverage – register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

“…These findings highlight an urgent requirement for improved evidence to support an expanded typology of respectful care that intentionally includes newborns [19], and highlights the importance of disaggregating data by mode of birth. This was a recurrent theme across the EN-BIRTH study [49][50][51][52].…”

Barriers and enablers to routine register data collection for newborns and mothers: EN-BIRTH multi-country validation study

“…The qualitative data analysis presented in this paper identified common barriers and enablers for labour ward register recording across all indicators, using health worker and data collector responses together. Indicatorspecific mixed-methods linked analyses will be presented in other linked papers to further explore subthemes and differences between cadres [57][58][59][60][61][62]. It was beyond the scope of this study for the EN-BIRTH data collectors to directly observe or measure the detailed process of register filling (e.g.…”

Count every newborn: EN-BIRTH study improving facility-based coverage and quality measurement in routine information systems

“…Quality of care had many gaps compared to global standards, notably regarding timing of care. For example, although provision of uterotonics to prevent postpartum hemorrhage was universally high across all five hospitals, the observational data showed that overall only 16% of women received uterotonics within 1 min after birth [18]. Regarding neonatal resuscitation, most non-breathing newborns were observed to receive bag-mask-ventilation, but overall only 1% within the recommended 1 min after birth [21].…”

“…This supplement starts with three papers on measurement systems covering: EN-BIRTH electronic data collection [15], survey-report for validity of 33 indicators [16], and barriers/enablers to recording in routine registers [17]. Subsequent papers detail findings for the following maternal and newborn coverage indicators: uterotonics to prevent postpartum haemorrhage [18], immediate newborn care including breastfeeding practices [19], chlorhexidine for umbilical cord care [20], neonatal resuscitation [21], KMC [22], neonatal infection antibiotic management [23]. Two papers assess validity and data quality for the outcomes of birthweight [24] and stillbirth [25].…”

“…Routine hospital registers had high validity for most clinical interventions assessed in at least one hospital, provided the register design included the indicator. regarding uterotonics for prevention of postpartum hemorrhage, chlorhexidine cord application, and have potential for neonatal bag-and-mask resuscitation [18,20,21]. Design of registers is critical for improving reporting accuracy, even the labour ward register designs varied across the three countries.…”