2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Design and Implementation of a Didactic Curriculum in a Large Neonatal-Perinatal Medicine Fellowship Program: A Single-center Experience.

OBJECTIVE: Although the Accreditation Council for Graduate Medical Education and American Board of Pediatrics (ABP) provide regulations and guidance on fellowship didactic education, each program establishes their own didactic schedules to address these learning needs. Wide variation exists in content, educators, amount of protected educational time, and the format for didactic lectures. This inconsistency can contribute to fellow dissatisfaction, a perceived poor learning experience, and poor attendance. Our objective was to create a Neonatal-Perinatal Medicine (NPM) fellow curriculum based on adult learning theory utilizing fellow input to improve the perceived fellow experience. STUDY DESIGN: A needs assessment of current NPM fellows at Cincinnati Children's Hospital was conducted to guide the development of a new curriculum. Fellow perception of educational experience and board preparedness before and after introduction of the new curriculum was collected. Study period was from October 2018 to July 2021. RESULTS: One hundred percent of the fellows responded to the needs assessment survey. A response rate of 100 and 87.5% were noted on mid-curriculum survey and postcurriculum survey, respectively. Key themes identified and incorporated into the curriculum included schedule structure, content, and delivery mode. A new didactic curriculum implementing a consistent schedule of shorter lectures grouped by organ system targeting ABP core content was created. After curriculum implementation, fellows had higher self-perception of board preparedness, and overall improved satisfaction. CONCLUSION: Our positive experience in implementing this curriculum provides a framework for individual programs to implement similar curricula, and could be utilized to aid in development of national NPM curricula. KEY POINTS: · Fellowship didactic education varies significantly resulting in learner dissatisfaction and poor attendance.. · Widespread need to restructure didactic curricula exists.. · Our study provides a framework for future curricula..

Telementoring initiative for newborn care providers in Kenya, Pakistan and Tanzania.

OBJECTIVES: To support governments' efforts at neonatal mortality reduction, UNICEF and the American Academy of Pediatrics launched a telementoring project in Kenya, Pakistan and Tanzania. METHODS: In Fall 2019, an individualised 12-session telementoring curriculum was created for East Africa and Pakistan after site visits that included care assessment, patient data review and discussion with faculty and staff. After the programme, participants, administrators and UNICEF staff were surveyed and participated in focus group discussions. RESULTS: Participants felt the programme improved knowledge and newborn care. Qualitative analysis found three common themes of successful telementoring: local buy-in, use of existing training or clinical improvement structures, and consideration of technology needs. CONCLUSIONS: Telementoring has potential as a powerful tool in newborn education. It offers more flexibility and easier access than in-person sessions. This project has the potential for scale-up, particularly when physical distancing and travel restrictions are the norm.

Adaptation of Essential Care for Every Baby educational program to improve infant outcomes in the context of Zika.

BACKGROUND: The outbreak and ongoing transmission of Zika virus provided an opportunity to strengthen essential newborn care and early childhood development systems through collaboration with the US Agency for International Development Applying Science to Strengthen and Improve Systems (USAID ASSIST). The objective was to create a system of sustainable training dissemination which improves newborn care-related quality indicators in the context of Zika. METHODS: From 2018-19, USAID ASSIST supported a series of technical assistance visits by the American Academy of Pediatrics (AAP) in four Caribbean countries to strengthen the clinical capacity in care of children potentially affected by Zika through dissemination of Essential Care for Every Baby (ECEB), teaching QI methodology, coaching visits, and development of clinical care guidelines. ECEB was adapted to emphasize physical exam findings related to Zika. The first series of workshops were facilitated by AAP technical advisors and the second series were facilitated by the newly trained local champions. Quality of care was monitored with performance indicators at 134 health facilities. RESULTS: A repeated measures (pre-post) ANOVA was conducted, revealing significant pre-post knowledge gains [F(1) = 197.9, p < 0.001] on knowledge check scores. Certain performance indicators related to ECEB practices demonstrated significant changes and midline shift on the run chart in four countries. CONCLUSION: ECEB can be adapted to incorporate important local practices, causes of neonatal morbidity and mortality, and differing healthcare system structures, which, as one part of a larger technical assistance package, leads to improved performance of health systems.

Timing of Antenatal Steroid Administration and Effects on the Newborn Infant: A Retrospective Study.

OBJECTIVE: The timing of antenatal steroids (ANS) on short- and long-term effects on newborn infants was evaluated. STUDY DESIGN: This study was conducted at the University of Cincinnati Medical Center Level-III Neonatal Intensive Care Unit by reviewing the medical records of all women with history of ANS exposure from January 2015 to December 2018. We compared outcomes of newborns delivered within the ideal therapeutic window of 24 hours to 7 days (within window [WW]) after administration to those exposed and delivered outside the therapeutic window (outside window primary group [OWP]). Outcomes included anthropometrics, blood sugars, thyroid hormone profile, and neonatal morbidities. RESULTS: A total of 669 patients were identified as having received at least two doses of ANS. Two-thirds of them delivered within the ideal therapeutic window. Significant differences were found in anthroprometrics including lower birth weight, shorter length, and smaller head circumferences in those born within the window compared with those outside the window. Derangements in glucose homeostasis requiring treatment and elevations of thyroid stimulating hormone (TSH) were seen in infants born outside the ideal therapeutic window compared with those born within the therapeutic window. No differences were found in neonatal morbidities including severe intraventricular hemorrhage (sIVH), necrotizing enterocolitis (NEC), need for resuscitation, exogenous surfactant administration, continuous positive airway pressure (CPAP), mechanical ventilation, bronchopulmonary dysplasia (BPD), or periventricular leukomalacia (PVL). After controlling for selected covariates, only birth length was different between the groups. CONCLUSION: Effects on anthropometrics, glucose homeostasis, and thyroid function support the need to develop new or refine existing risk stratification systems to time the administration of antenatal steroids. Better targeting of women and fetuses may confer the benefits of systemic corticosteroids while mitigating the risks of adverse effects. KEY POINTS: · The timing of antenatal steroids on short and long-term effects on newborn infants was evaluated.. · Differences were found in anthroprometrics, glucoses, and thyroid function.. · No differences were found in neonatal morbidities..

The NRP 8th Edition: Innovation in Education.

BACKGROUND: Approximately 10% of newborns need assistance at birth, and an evidence-based, timely, and coordinated response is critical to optimal outcome. The Neonatal Resuscitation Program® (NRP®) is the training and education standard in the United States for healthcare professionals who manage newborns in the hospital. This article summarizes the development of evidence-based resuscitation science, changes in the NRP 8th edition educational methodologies, and several significant practice changes made for educational efficiency and patient safety. EVIDENCE ACQUISITION: The NRP 8th edition is informed by multiple systematic reviews of emerging science conducted by the International Liaison Committee on Resuscitation (ILCOR), which culminates in consensus documents on resuscitation science. The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) used these recommendations to develop the most recent neonatal resuscitation guidelines for North America. These guidelines inform the NRP 8th edition practice recommendations. RESULTS: The most recent CoSTR (Consensus on Science with Treatment Recommendations) summary and AAP/AHA guidelines for neonatal resuscitation yielded no major changes in practice. However, scientific research over the past 5 years resulted in new and higher grades of evidence to support previous recommendations. The NRP Steering Committee revised several practices in the interest of patient safety and educational efficiency. IMPLICATIONS FOR PRACTICE: The NRP 8th edition materials were released in June 2021 and must be in use by January 1, 2022. In the new ILCOR evidence review format, CoSTR scientific reviews and statements are published continuously instead of every 5 years; however, future editions of NRP will be released every 5 years unless there is compelling evidence that mandates an earlier change.

The NRP 8th Edition: Innovation in Education.

The American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program® (NRP®) 8th-Edition materials were released in June 2021 and must be in use by January 1, 2022. Ongoing international review and consensus of resuscitation science since 2015 has yielded no major changes in practice. However, the NRP Steering Committee revised several practices in the interest of patient safety and educational efficiency. The NRP 8th Edition offers NRP Essentials and NRP Advanced levels of learning and 2 recommended Provider Course formats. In most hospitals, NRP Essentials and NRP Advanced will be taught using instructor-led Provider Courses. Resuscitation Quality Improvement® (RQI® for NRP®), a self-directed learning program that uses low-dose, high-frequency quarterly learning and skills sessions, may be used in hospitals that already use RQI for life support education.

Behind the Scenes: Publishing in the Maternal and Child Health Journal.

The Editors of the Maternal and Child Health Journal offer an inside look at publishing in the journal, including advice for potential authors and reviewers.

Neonatal resuscitation in global health settings: an examination of the past to prepare for the future.

As rates of childhood mortality decline, neonatal deaths account for nearly half of under-5 deaths worldwide. Intrapartum-related events (birth asphyxia) contribute to approximately one-quarter of neonatal deaths, many of which can be prevented by simple resuscitation and newborn care interventions. This paper reviews various lines of research that have influenced the global neonatal resuscitation landscape. A brief situational analysis of asphyxia-related newborn mortality in low-resource settings is linked to renewed efforts to reduce neonatal mortality in the Every Newborn Action Plan. Possible solutions to gaps in care are identified. Building on international scientific evidence, tests of educational efficacy, and community-based trials established the feasibility and effectiveness of training in resource-limited settings and identified successful implementation strategies. Implementation of neonatal resuscitation programs has been shown to decrease intrapartum stillbirth rates and early neonatal mortality. Challenges remain with respect to provider competencies, coverage, and quality of interventions. The combination of resuscitation science, strategies to increase educational effectiveness, and implemention of interventions with high coverage and quality has resulted in reduced rates of asphyxia-related neonatal mortality. Further efforts to improve coverage and implementation of neonatal resuscitation will be necessary to meet the 2035 goal of eliminating preventable newborn deaths.

County-level Variation in Infant Mortality Reporting at Early Previable Gestational Ages.

BACKGROUND: Infant mortality rate (IMR), or number of infant deaths per 1000 livebirths, varies widely across the US While fetal deaths are not included in this measure, reported infant deaths do include those delivered at previable gestations, or ≤20 weeks gestation. Variation in reporting of these events may have a significant impact on IMR estimates. METHODS: This retrospective analysis used US National Center for Health Statistics 2007-2013 data from 2391 US counties. Counties were categorised by US region, demographic characteristics, and state-level fetal death reporting requirements. County percentage of fetal deaths among all 17-20 week fetal and infant deaths was evaluated using multivariable linear regression. County-level characteristics were then included in multivariable linear regression to determine the associated change in county IMR. RESULTS: County percentage of deaths at 17-20 weeks reported as fetal ranged from 0% to 100% (mean 63.7%). Every 1 point increase in this percentage was associated with a 0.02 point decrease in county IMR (95% confidence interval (CI) 0.02, 0.03). When county IMRs were recalculated holding the percentage of fetal vs. infant deaths at 17-20 weeks constant at 63.7%, results suggest that the predicted gap in county IMR between Northeast and Midwest regions would narrow by 0.45 points. CONCLUSIONS: Variable reporting of previable fetal and infant deaths may compromise the validity of county IMR comparisons. Improved consistency and accuracy of fetal and infant death reporting is warranted.

Using quality improvement to decrease birth asphyxia rates after 'Helping Babies Breathe' training in Kenya.

AIM: The Helping Babies Breathe (HBB) programme is known to decrease neonatal mortality in low-resource settings but gaps in care still exist. This study describes the use of quality improvement to sustain gains in birth asphyxia-related mortality after HBB. METHODS: Tenwek Hospital, a rural referral hospital in Kenya, identified high rates of birth asphyxia (BA). They developed a goal to decrease the suspected hypoxic-ischaemic encephalopathy (SHIE) rate by 50% within six months after HBB. Rapid cycles of change were used to test interventions including training, retention and engagement for staff/trainees and improved data collection. Run charts followed the rate over time, and chi-square analysis was used. RESULTS: Ninety-six providers received HBB from September to November 2014. Over 4000 delivery records were reviewed. Ten months of baseline data showed a median SHIE rate of 14.7/1000 live births (LB) with wide variability. Ten months post-HBB, the SHIE rate decreased by 53% to 7.1/1000 LB (p = 0.01). SHIE rates increased after initial decline; investigation determined that half the trained midwives had been transferred. Presenting data to administration resulted in staff retention. Rates have after remained above goal with narrowing control limits. CONCLUSION: Focused quality improvement can sustain and advance gains in neonatal outcomes post-HBB training.

Interventions to reduce neonatal mortality: a mathematical model to evaluate impact of interventions in sub-Saharan Africa.

AIM: To determine which interventions would have the greatest impact on reducing neonatal mortality in sub-Saharan Africa in 2012. METHODS: We used MANDATE, a mathematical model, to evaluate scenarios for the impact of available interventions on neonatal deaths from primary causes, including: (i) for birth asphyxia - obstetric care preventing intrapartum asphyxia, newborn resuscitation and treatment of asphyxiated infants; (ii) for preterm birth - corticosteroids, oxygen, continuous positive air pressure and surfactant; and, (iii) for serious newborn infection - clean delivery, chlorhexidine cord care and antibiotics. RESULTS: Reductions in infection-related mortality have occurred. Between 80 and 90% of deaths currently occurring from infections and asphyxia can be averted from available interventions, as can 58% of mortality from preterm birth. More than 200 000 neonatal deaths can each be averted from asphyxia, preterm birth and infections. Using available interventions, more than 80% of the neonatal deaths occurring today could be prevented in sub-Saharan Africa. CONCLUSION: Reducing neonatal deaths from asphyxia require improvements in infrastructure and obstetric care to manage maternal conditions such as obstructed labour and preeclampsia. Reducing deaths from preterm birth would also necessitate improved infrastructure and training for preterm infant care. Reducing infection-related mortality requires less infrastructure and lower-level providers.

Antenatal corticosteroids beyond 34 weeks gestation: What do we do now?

The practice of antenatal corticosteroid administration in pregnancies of 24-34 weeks of gestation that are at risk of preterm delivery was adopted over 20 years after the first randomized clinical trial in humans. It is biologically plausible that antenatal corticosteroid in pregnancies beyond 34 weeks of gestation would reduce rates of respiratory morbidity and neonatal intensive care admission. Mostly guided by the results of a large multicenter randomized trial of antenatal corticosteroid in late preterm infants, the Antenatal Late Preterm Steroids Trial, the American Congress of Obstetricians and Gynecologists has released a practice advisory that the "administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days." However, many unanswered questions about the risks and benefits of antenatal corticosteroids in this population remain and should be considered with the adoption of this treatment recommendation. This review of the literature indicates that the greatest effect is in the reduction of transient tachypnea of the newborn infant, which is a mostly self-limited condition. This benefit must be weighed against unanticipated outcomes, such as neonatal hypoglycemia, and unknowns about long-term neurodevelopmental follow up and metabolic risks. Amelioration of respiratory morbidity in late preterm infants does not preclude these infants from having other complications that are related to prematurity that require intensive care. Other possible morbidities of prematurity may be magnified if these babies no longer have respiratory symptoms. Conversely, if these late preterm babies no longer exhibit respiratory symptoms and "look good," they may be discharged before other morbidities of prematurity have resolved and be at risk for readmission. Furthermore, it is also important to ensure that unintended consequences are avoided to achieve a minor benefit. Some of these consequences may include treatment with multiple steroid courses or "treatment creep" in women at 34 to <37 weeks of gestation who do not meet the inclusion/exclusion criteria of the Antenatal Late Preterm Steroids Trial, particularly when a high percentage of women do not receive antenatal corticosteroid within 7 days of delivery. Finally, we believe that caution should be exercised before wide-scale universal adoption of antenatal corticosteroid for pregnancies that are at risk of preterm birth at 34 to <37 weeks of gestation, when it is unclear whether there are long-term effects. For a more balanced rationale for the decision to use antenatal corticosteroid treatment in pregnancies at >34 weeks of gestation, we urge for ongoing research into the risks and benefits of antenatal corticosteroid use in preterm infants overall, for better prediction of preterm birth so that antenatal corticosteroid can be administered within the ideal time frame, and for long-term neurodevelopmental follow-up of the participants in the large randomized Antenatal Late Preterm Steroids Trial.

Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time?

BACKGROUND: The first minutes after birth are critical to reducing neonatal mortality. Helping Babies Breathe (HBB) is a simulation-based neonatal resuscitation program for low resource settings. We studied the impact of initial HBB training followed by refresher training on the knowledge and skills of the birth attendants in facilities. METHODS: We conducted HBB trainings in 71 facilities in the NICHD Global Network research sites (Nagpur and Belgaum, India and Eldoret, Kenya), with a 6:1 ratio of facility trainees to Master Trainers (MT). Because of staff turnover, some birth attendants (BA) were trained as they joined the delivery room staff, after the initial training was completed (catch-up initial training). We compared pass rates for skills and knowledge pre- and post- initial HBB training and following refresher training among active BAs. An Objective Structured Clinical Examination (OSCE) B tested resuscitation skill retention by comparing post-initial training performance with pre-refresher training performance. We identified factors associated with loss of skills in pre-refresher training performance using multivariable logistic regression analysis. Daily bag and mask ventilation practice, equipment checks and supportive supervision were stressed as part of training. RESULTS: One hundred five MT (1.6 MT per facility) conducted initial and refresher HBB trainings for 835 BAs; 76% had no prior resuscitation training. Initial training improved knowledge and skills: the pass percentage for knowledge tests improved from 74 to 99% (p < 0.001). Only 5% could ventilate a newborn mannequin correctly before initial training but 97% passed the post-initial ventilation training test (p < 0.0001) and 99% passed the OSCE B resuscitation evaluation. During pre-refresher training evaluation, a mean of 6.7 (SD 2.49) months after the initial training, 99% passed the knowledge test, but the successful completion rate fell to 81% for the OSCE B resuscitation skills test. Characteristics associated with deterioration of resuscitation skills were BAs from tertiary care facilities, no prior resuscitation training, and the timing of training (initial vs. catch-up training). CONCLUSIONS: HBB training significantly improved neonatal resuscitation knowledge and skills. However, skills declined more than knowledge over time. Ongoing skills practice and monitoring, more frequent retesting, and refresher trainings are needed to maintain neonatal resuscitation skills. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01681017 ; 04 September 2012, retrospectively registered.

Antenatal exposure to sulindac and risk of necrotizing enterocolitis.

OBJECTIVE: Most studies of tocolytics are underpowered to assess drug effects on rare adverse neonatal outcomes. Our aim was to optimize statistical power to assess the influence of sulindac on the rare but severe outcome of necrotizing enterocolitis (NEC) by performing a case-control study. STUDY DESIGN: A priori sample size of 78 in each group was estimated to detect a 2.5-fold increase in nonsteroidal antiinflammatory drug exposure in NEC cases. Maternal-neonatal charts were reviewed from 2007 through 2012 to yield 110 NEC cases: 68 patients with confirmed NEC by Bell's stage II criteria, and 42 with suspected NEC. Cases and controls (N = 131, matched according to gestational age at delivery, plurality, and delivery date) were compared in rates of antenatal exposures to nonsteroidal antiinflammatory drugs, other tocolytics, and maternal-neonatal characteristics and complications. RESULTS: Cases and controls were delivered at a mean of 28 weeks. Approximately 52% of the total cohort received tocolytics (26% indomethacin, 15% sulindac, 32% calcium channel blockers, 32% beta-sympathomimetics), with no differences in frequency of use between cases and controls. While there was no difference in indomethacin exposure between cases and controls, antenatal exposure to sulindac was independently associated with increased risk of NEC (adjusted odds ratio, 5.33; 95% confidence interval, 1.38-20.57; P = .02), even after adjustment for other factors significantly associated with NEC. CONCLUSION: Our data demonstrate an adverse association of sulindac with NEC. These findings deserve further investigation and using sulindac as a tocolytic agent requires caution.

Reducing maternal mortality from preeclampsia and eclampsia in low-resource countries--what should work?

OBJECTIVE: Preeclampsia/eclampsia (PE/E) remains a major cause of maternal death in low-income countries. We evaluated interventions to reduce PE/E-related maternal mortality in sub-Saharan Africa. DESIGN: Mathematical model to assess impact of interventions on PE/E-related maternal morbidity and mortality. SETTING: Sub-Saharan Africa countries. POPULATION: Pregnant women in sub-Saharan Africa in 2012. METHODS: A systematic literature review populated a decision-tree mathematical model with interventions to diagnose, prevent, and treat women with PE/E. The impact of increased use of interventions [diagnostics, transfer to a hospital, magnesium sulfate (MgSO4 ) use, cesarean section/labor induction] on PE/E-related maternal mortality was analyzed. MAIN OUTCOME MEASURES: Prevalence of PE/E and PE/E-associated maternal mortality rates in sub-Saharan Africa. RESULTS: Without interventions, an estimated 20 570 PE/E-associated deaths would have occurred in sub-Saharan Africa in 2012. With current low rates of diagnosis, MgSO4 use, transfers and cesarean section/induction rates, about 17 520 maternal deaths were associated with PE/E in 2012. Higher use of MgSO4 would have prevented about 610 deaths. With high diagnostic levels, MgSO4 use, transfer and cesarean section/induction, mortality was reduced to 3750 annual deaths, saving about 13 770 maternal lives. If all MgSO4 use was removed from the model, 4060 maternal deaths would occur, increasing maternal deaths by only 310. CONCLUSIONS: In sub-Saharan Africa, our model suggests that increasing use of PE/E diagnostics, transfer to higher levels of care and increased hospitalization with cesarean section/induction of labor would substantially reduce maternal mortality from PE/E. Increasing use of MgSO4 would have a smaller impact on maternal mortality.

Resuscitation and Obstetrical Care to Reduce Intrapartum-Related Neonatal Deaths: A MANDATE Study.

To evaluate the impact of neonatal resuscitation and basic obstetric care on intrapartum-related neonatal mortality in low and middle-income countries, using the mathematical model, Maternal and Neonatal Directed Assessment of Technology (MANDATE). Using MANDATE, we evaluated the impact of interventions for intrapartum-related events causing birth asphyxia (basic neonatal resuscitation, advanced neonatal care, increasing facility birth, and emergency obstetric care) when implemented in home, clinic, and hospital settings of sub-Saharan African and India for 2008. Total intrapartum-related neonatal mortality (IRNM) was acute neonatal deaths from intrapartum-related events plus late neonatal deaths from ongoing intrapartum-related injury. Introducing basic neonatal resuscitation in all settings had a large impact on decreasing IRNM. Increasing facility births and scaling up emergency obstetric care in clinics and hospitals also had a large impact on decreasing IRNM. Increasing prevalence and utilization of advanced neonatal care in hospital settings had limited impact on IRNM. The greatest improvement in IRNM was seen with widespread advanced neonatal care and basic neonatal resuscitation, scaled-up emergency obstetric care in clinics and hospitals, and increased facility deliveries, resulting in an estimated decrease in IRNM to 2.0 per 1,000 live births in India and 2.5 per 1,000 live births in sub-Saharan Africa. With more deliveries occurring in clinics and hospitals, the scale-up of obstetric care can have a greater effect than if modeled individually. Use of MANDATE enables health leaders to direct resources towards interventions that could prevent intrapartum-related deaths. A lack of widespread implementation of basic neonatal resuscitation, increased facility births, and emergency obstetric care are missed opportunities to save newborn lives.

Tranexamic acid to reduce postpartum hemorrhage: A MANDATE systematic review and analyses of impact on maternal mortality.

OBJECTIVE: Postpartum hemorrhage (PPH) is a major cause of maternal mortality, with almost 300,000 cases and ~72,000 PPH deaths annually in sub-Saharan Africa. Novel prevention methods practical in community settings are required. Tranexamic acid, a drug to reduce bleeding during surgical cases including postpartum bleeding, is potentially suitable for community settings. Thus, we sought to determine the impact of tranexamic acid on PPH-related maternal mortality in sub-Saharan Africa. STUDY DESIGN: We created a mathematical model to determine the impact of interventions on PPH-related maternal mortality. The model was populated with baseline birth rates and mortality estimates based on a review of current interventions for PPH in sub-Saharan Africa. Based on a systematic review of literature on tranexamic acid, we assumed 30% efficacy of tranexamic acid to reduce PPH; the model assessed prophylactic and treatment tranexamic acid use, for deliveries at homes, clinics, and hospitals. RESULTS: With tranexamic acid only in the hospitals, less than 2% of the PPH mortality would be reduced. However, if tranexamic acid were available in the home and clinic settings for PPH prophylaxis and treatment, a nearly 30% reduction (nearly 22,000 deaths per year) in PPH mortality is possible. CONCLUSION: These analyses point to the importance of preventive and treatment interventions compatible with home and clinic use, especially for sub-Saharan Africa, where the majority of births occur at home or community health clinics. Given its feasibility to be given in the home, tranexamic acid has potential to save many lives.