Perceptions and management of postpartum haemorrhage among remote communities in Lao PDR.

INTRODUCTION: In Lao People's Democratic Republic, despite a policy to provide free maternal health services in healthcare facilities, many rural women continue to deliver at home, without a skilled birth attendant. These women are at high risk of postpartum haemorrhage, the leading cause of maternal mortality in the country. While women in remote areas continue to be unable to access facility-based birthing, interventions to reduce postpartum haemorrhage are a priority. This requires an understanding of how women and their families recognise and manage postpartum haemorrhage in home births. The purpose of this study was to understand community perceptions and management of postpartum bleeding during home births in remote Lao communities. METHODS: Five focus group discussions with a total of 34 women and their support networks were conducted in five remote communities in Oudomxay, a province with high rates of maternal mortality. Villages were selected with district health officials based on (1) known cases of postpartum haemorrhage, (2) travel time from the provincial capital (2-4 hours), (3) distance to the district health service (>4 km), and (4) population (50-150 people), with the five selected villages being the farthest from the district health service. The focus group discussions were complemented by qualitative, community-based key informant interviews (n=9). All interviews were conducted in Lao, English or the ethnic language most suitable for the sample and simultaneously translated by native speakers. All transcripts were translated into English, back translated and checked against interview recordings. The qualitative data were coded into key themes while moving between the data and the coded extracts. Interpretation of the data themes and coding was an ongoing process with codes and themes checked by the research team. RESULTS: Women described postpartum bleeding as a normal, necessary cleansing process. Some women felt it was critical in order to expel 'bad blood' and restore the mother to good health. Participants were able to describe late symptoms of postpartum haemorrhage but did not describe any methods to accurately estimate the amount of blood loss that required intervention. Traditional remedies were the first courses of action, potentially delaying treatment at a healthcare facility. When asked about the acceptability of taking oral medication immediately following home births to prevent postpartum haemorrhage, most women felt it would be acceptable provided it would not stop normal bleeding, and its usage, benefits and side-effects were clearly explained. CONCLUSION: While women continue to home birth in remote communities without skilled birth attendants, an informed understanding of traditional management of postpartum haemorrhage can assist in designing culturally responsive interventions. To support a reduction in morbidity and mortality from postpartum haemorrhage, tailored interventions are needed to raise awareness among women and their families to reduce delays in seeking health care. Women felt it would be acceptable to take oral medication to prevent postpartum haemorrhage. As such, community-based distribution of misoprostol that can be administered by lay people would provide an effective and acceptable prevention strategy. Other strategies should include promoting birthing plans, delivery by skilled birth attendants and early initiation of breastfeeding.

Preparedness for threat of chikungunya in the pacific.

Chikungunya virus (CHIKV) caused significant outbreaks of illness during 2005-2007 in the Indian Ocean region. Chikungunya outbreaks have also occurred in the Pacific region, including in Papua New Guinea in 2012; New Caledonia in April 2013; and Yap State, Federated States of Micronesia, in August 2013. CHIKV is a threat in the Pacific, and the risk for further spread is high, given several similarities between the Pacific and Indian Ocean chikungunya outbreaks. Island health care systems have difficulties coping with high caseloads, which highlights the need for early multidisciplinary preparedness. The Pacific Public Health Surveillance Network has developed several strategies focusing on surveillance, case management, vector control, laboratory confirmation, and communication. The management of this CHIKV threat will likely have broad implications for global public health.

Working together to address disability in a culturally-appropriate and sustainable manner.

PURPOSE: Disability has an enormous impact throughout the world. An increasing amount of important disability research and practice is being undertaken in low-income settings; however, success and sustainability of programmes in these contexts can often be challenging. We share lessons from our experiences. METHOD: We reviewed past literature and international consensus statements relating to disability and development practice. We then held several face to face and email discussions to document the key lessons we have learnt from working in this context. We report on these in this paper. RESULTS: The key lessons are to invest adequate time and develop trusting relationships, undertake sufficient consultation and collaboration, include and empower persons with disability, and view capacity building as a two-way process. CONCLUSIONS: Improving the lives of persons with disability in development contexts is likely to be best achieved through processes that are inclusive, owned and driven by local communities.

Misoprostol for the prevention of postpartum hemorrhage during home births in rural Lao PDR: establishing a pilot program for community distribution.

PURPOSE: The purpose of this study was to gather the necessary data to support the design and implementation of a pilot program for women who are unable to deliver in a healthcare facility in the Lao People's Democratic Republic (PDR), by using community distribution of misoprostol to prevent postpartum hemorrhage (PPH). The study builds on an earlier research that demonstrated both support and need for community-based distribution of misoprostol in Lao PDR. METHODS: This qualitative study identified acceptability of misoprostol and healthcare system needs at varying levels to effectively distribute misoprostol to women with limited access to facility-based birthing. Interviews (n=25) were undertaken with stakeholders at the central, provincial, and district levels and with community members in five rural communities in Oudomxay, a province with high rates of maternal mortality. Focus group discussions (n=5) were undertaken in each community. RESULTS: Respondents agreed that PPH was the major cause of preventable maternal mortality with community distribution of misoprostol an acceptable and feasible interim preventative solution. Strong leadership, training, and community mobilization were identified as critical success factors. While several participants preferred midwives to distribute misoprostol, given the limited availability of midwives, there was a general agreement that village health workers or other lower level workers could safely administer misoprostol. Many key stakeholders, including women themselves, considered that these community-level staff may be able to provide misoprostol to women for self-administration, as long as appropriate education on its use was included. The collected data also helped identify appropriate educational messages and key indicators for monitoring and evaluation for a pilot program. CONCLUSION: The findings strengthen the case for a pilot program of community distribution of misoprostol to prevent PPH in remote communities where women have limited access to a health facility and highlight the key areas of consideration in developing such a program.

Stakeholder Analysis of Community Distribution of Misoprostol in Lao PDR: A Qualitative Study.

BACKGROUND: Globally, significant progress has been made in reducing maternal mortality, yet in many low-resource contexts it remains unacceptably high. Many of these deaths are due to postpartum haemorrhage and are preventable with access to essential obstetric care. Where there are barriers to access, maternal deaths could be prevented if community-level misoprostol was available. The purpose of this study was to explore perceptions of stakeholders regarding misoprostol use in the Lao People's Democratic Republic, a setting with high maternal mortality. METHODS: Semi-structured interviews were conducted with 35 stakeholders in the capital, Vientiane and in one northern province identified as a site for a possible intervention. The sample included international and national stakeholders involved in policy-making and providing maternal and reproductive health services. FINDINGS: Most stakeholders supported a pilot program for community distribution of misoprostol but levels of awareness of the drug's use in preventing postpartum haemorrhage and level of influence over policy direction varied considerably. Some international organizations, all identified as powerful in influencing policy, were ambivalent about the use of community distribution of misoprostol. Concerns related to the capacity of village health workers or lay people to safely administer misoprostol, whether its distribution would undermine efforts to improve access to safe delivery services and active management of the third stage of labour, the ease with which prescription drugs can be bought over the counter, and technical, logistical, and financial constraints. CONCLUSION: Access to appropriate oxytocic drugs is a matter of health equity. In settings without access to essential obstetrical care, misoprostol represents a viable solution for the prevention of postpartum haemorrhage. Understanding stakeholders' perspectives and their legitimate concerns on misoprostol can inform interventions in order to assuage these concerns and enable disadvantaged women to access misoprostol and its potentially life-saving benefits.

Geographical origin of post-landmine injury malaria infections.

OBJECTIVE: In Cambodia, a highly landmine-contaminated country with endemic malaria, symptomatic falciparum malaria has been observed in patients presenting with traumatic landmine injuries. Because a link between recrudescence of symptomatic Plasmodium falciparum malaria and severe trauma is well established, we explored whether a link could be demonstrated between the geolocation of landmine amputations and malaria cases. METHOD: Landmine amputation data in Cambodia (2005-2008) were compared with predicted measures of malaria endemicity. Data of injuries that had resulted in amputation were plotted over a surface of P falciparum parasite rates. RESULTS: No statistically significant correlation was found, possibly because the P falciparum endemicity surface was drawn from a model-based geostatistical prediction of infection prevalence and did not distinguish cases of recrudescence. The implication of this finding is that where symptomatic falciparum malaria has been observed in patients with landmine injuries, the cases were likely to be reactivated falciparum infections and not new cases. CONCLUSIONS: Further research is needed to understand the relationship between P falciparum and trauma. To distinguish P falciparum recrudescence from new cases, a prospective registry is needed. Also, practitioners need to be aware of the possibility of post-injury malaria recrudescence in complex emergencies.