Maternal mortality by socio-demographic characteristics and cause of death in South Africa: 2007-2015.

BACKGROUND: South Africa's maternal mortality ratio remains high although it has substantially declined in the past few years. Numerous studies undertaken in South Africa on maternal mortality have not paid much attention to how the causes are distributed in different socio-demographic groups. This study assesses and analyses the causes of maternal mortality according to sociodemographic factors in South Africa. METHODS: The causes of maternal deaths were assessed with respect to age, province, place of death, occupation, education and marital status. Data were obtained from the vital registration database of Statistics South Africa. About 14,892 maternal deaths of women from 9 to 55 years of age were analysed using frequency tables, cross-tabulations and logistic regression. Maternal mortality ratio (MMR), by year, age group, and province for the years 2007-2015 was calculated. RESULTS: The 2007-2015 MMR was 139.3 deaths per 100,000 live births (10,687,687 total live births). The year 2009 had the highest MMR during this period. Specific province MMR for three triennia (2007-2009; 2010-2012; 2013-2015) shows that the Free State province had the highest MMR (297.9/100000 live births; 214.6/100000 live births; 159/100000 live births) throughout this period. MMR increased with age. Although the contribution of the direct causes of death (10603) was more than double the contribution of indirect causes (4289) maternal mortality showed a steady decline during this period. CONCLUSIONS: The study shows evidence of variations in the causes of death among different socio-demographic subgroups. These variations indicate that more attention has to be given to the role played by socio-demographic factors in maternal mortality.

Pregnancy-Related Acute Kidney Injury in Preeclampsia: Risk Factors and Renal Outcomes.

Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 µmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6-11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8-2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21-4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.

Changing the conversation: applying a health equity framework to maternal mortality reviews.

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: A before-and-after observational study.

BACKGROUND: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies. OBJECTIVES: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme. METHODS: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and a before-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures. RESULTS: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts. CONCLUSIONS: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths.

Deaths preventable by actions of the Unified Health System in the population of the Brazilian Southeast Region. / Mortes evitáveis por ações do Sistema Único de Saúde na população da Região Sudeste do Brasil.

This paper aims to analyze the mortality trend in the population aged 5-69 years residing in the Southeast and Federal Units (UF), using the "Brazilian List of Preventable Deaths Causes". An ecological study on time series of the standardized mortality rate from preventable and non-preventable causes, with adjustments for ill-defined causes and underreporting of notified deaths, from 2000 to 2013. A declining mortality rate from preventable (2.4% per year) and non-preventable causes (1.5% per year) was found in the population aged 5-69 years living in the Southeast in the period 2000-2013. A drop in all groups of preventable deaths causes and stability in the maternal death causes was observed. Deaths from noncommunicable diseases fell 2.7% annually and were higher in the age group of 60-69 years in 2013 (211.8/100,000 inhabitants for deaths from ischemic heart disease, 146.3/100,000 inhabitants for cerebrovascular diseases and 96.5/100,000 inhabitants for diabetes). The highest preventable death rates are from chronic noncommunicable diseases and external causes, both of which are sensitive to health promotion and intersectoral interventions, which reinforces the need for integrated health policies.

O objetivo deste artigo é analisar a tendência da mortalidade na população de 5 a 69 anos, residente na região Sudeste e Unidades Federadas (UF), utilizando-se a "Lista Brasileira de Causas de Mortes Evitáveis". Estudo ecológico de séries temporais da taxa de mortalidade padronizada por causas evitáveis e não evitáveis, com correções para as causas mal definidas e o sub-registro de óbitos informados, no período de 2000 a 2013. Evidenciou-se o declínio da taxa de mortalidade na população de 5 a 69 anos residente na região Sudeste por causas evitáveis (2,4% ao ano) e não evitáveis (1,5% ao ano) no período 2000-2013. Houve queda em todos os grupos de causas de mortes evitáveis e estabilidade nas causas de morte materna. As mortes por doenças não transmissíveis reduziram 2,7% ao ano e foram mais elevadas na faixa etária de 60 a 69 anos em 2013 (211,8/100.000 hab. para as mortes por doenças isquêmicas do coração; 146,3/100.000 hab. para as doenças cerebrovasculares; e 96,5/100.000 hab. para diabetes). As taxas de mortes evitáveis mais elevadas são por doenças crônicas não transmissíveis e causas externas, ambas sensíveis às intervenções de promoção da saúde e intersetoriais, o que reforça a necessidade de políticas de saúde integradas.

Mortes evitáveis por ações do Sistema Único de Saúde na população da Região Sudeste do Brasil / Deaths preventable by actions of the Unified Health System in the population of the Brazilian Southeast Region

Resumo O objetivo deste artigo é analisar a tendência da mortalidade na população de 5 a 69 anos, residente na região Sudeste e Unidades Federadas (UF), utilizando-se a "Lista Brasileira de Causas de Mortes Evitáveis". Estudo ecológico de séries temporais da taxa de mortalidade padronizada por causas evitáveis e não evitáveis, com correções para as causas mal definidas e o sub-registro de óbitos informados, no período de 2000 a 2013. Evidenciou-se o declínio da taxa de mortalidade na população de 5 a 69 anos residente na região Sudeste por causas evitáveis (2,4% ao ano) e não evitáveis (1,5% ao ano) no período 2000-2013. Houve queda em todos os grupos de causas de mortes evitáveis e estabilidade nas causas de morte materna. As mortes por doenças não transmissíveis reduziram 2,7% ao ano e foram mais elevadas na faixa etária de 60 a 69 anos em 2013 (211,8/100.000 hab. para as mortes por doenças isquêmicas do coração; 146,3/100.000 hab. para as doenças cerebrovasculares; e 96,5/100.000 hab. para diabetes). As taxas de mortes evitáveis mais elevadas são por doenças crônicas não transmissíveis e causas externas, ambas sensíveis às intervenções de promoção da saúde e intersetoriais, o que reforça a necessidade de políticas de saúde integradas.

Abstract This paper aims to analyze the mortality trend in the population aged 5-69 years residing in the Southeast and Federal Units (UF), using the "Brazilian List of Preventable Deaths Causes". An ecological study on time series of the standardized mortality rate from preventable and non-preventable causes, with adjustments for ill-defined causes and underreporting of notified deaths, from 2000 to 2013. A declining mortality rate from preventable (2.4% per year) and non-preventable causes (1.5% per year) was found in the population aged 5-69 years living in the Southeast in the period 2000-2013. A drop in all groups of preventable deaths causes and stability in the maternal death causes was observed. Deaths from noncommunicable diseases fell 2.7% annually and were higher in the age group of 60-69 years in 2013 (211.8/100,000 inhabitants for deaths from ischemic heart disease, 146.3/100,000 inhabitants for cerebrovascular diseases and 96.5/100,000 inhabitants for diabetes). The highest preventable death rates are from chronic noncommunicable diseases and external causes, both of which are sensitive to health promotion and intersectoral interventions, which reinforces the need for integrated health policies.

Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria.

BACKGROUND: Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review. METHODS: We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study. RESULTS: Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses. CONCLUSION: We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

Epidemiological analysis of maternal deaths in Hunan province in China between 2009 and 2014.

BACKGROUND: The control of maternal deaths continues to be a significant public health issue and commands an enormous amount of attention, especially under the future family planning policy. Here, we describe the epidemiology and trends of maternal deaths in Hunan province, and give several policy implications. METHODS: Maternal deaths in Hunan province between 2009 and 2014 were retrospectively reviewed and analyzed. Cochran-Armitage trend test was used to assess the time trends of maternal mortality rates. Binary logistic regression analyses were undertaken to identify the factors that were associated with unavoidable maternal deaths. RESULTS: In total, there were 987 maternal deaths, with the overall MMR declining by 45.24%. The most common causes of maternal death during this period were pregnancy complications (28.37%), obstetric hemorrhage (25.33%), and amniotic fluid embolism (15.70%). Obstetric hemorrhage (28.14%) was higher in rural areas, while pregnancy complications were higher (29.27%) in urban areas. In all, 627 (63.5%) deaths were avoidable. The risk factors associated with unavoidable maternal deaths was above 35 years (aOR = 1.80 95%CI: 1.27-2.55), without prenatal examination (aOR = 8.97 95%CI: 1.11-7.78), low household incomes (aOR = 1.15 95%CI: 1.02-1.29), without adopting the new way to deliver (aOR = 5.15 95%CI: 3.20-8.31), and death location (aOR = 1.09 95%CI: 1.02-1.18). The most frequent and important factors associated with avoidable deaths was improper knowledge and skills of the county medical institutions. CONCLUSIONS: Moderate progress was made in reducing the MMR in Hunan province. The government should aim to improve the basic midwifery skills in rural areas and the obstetric emergency rescue service for critically ill pregnant women in urban areas, and strengthen training to improve knowledge and skills in medical institutions in counties.

Underlying determinants of maternal mortality in a rural South African population with high HIV prevalence (2000-2014): A population-based cohort analysis.

INTRODUCTION: Maternal mortality is one of the significant health indicators of any country and it's a frequent subject in many global heath discussions. Even though the global trends have shown a decrease on maternal mortality, many countries in sub-Saharan Africa failed to achieve the MDG 5 target in 2015.There is no specific single solution for reducing maternal mortality but there is unanimity that a reliable health system with skilled personal is vital for addressing maternal mortality. This study therefore seeks to identify the risk factors for maternal mortality in typical rural sub-Saharan African countries. METHOD: A longitudinal population based cohort study was conducted using data from 2000-2014 in Africa Health Research Institute (AHRI).The Cox regression method was used to assess the influence of selected risk factors using the Mosley-Chen model on maternal mortality. A total of 20701 women aged 15-49 years were included in the study. RESULTS: The study found 212 maternal deaths from 32,620 live births with a maternal mortality ratio (MMR) of 650 per 100,000 live births. The main causes of death were Communicable diseases (38.2%), Aids and TB (31%) and Unknown causes (11.8%). An increased risk of death was identified on, poor wealth index (HR 3.92[1.01, 15.3]), period of death 2000-2006(HR32.1 [3.79, 71.5]) and number of deliveries (6.76[2.70, 16.9]) were associated with a high risk of maternal mortality after adjusting for other independent variables included in the study. CONCLUSION: Socio-economic status, number of deliveries and period of death were found to be associated with maternal death in rural South Africa.

Reducing late maternal death due to cardiovascular disease - A pragmatic pilot study.

BACKGROUND: Late maternal mortality (up-to 1-year postpartum) is poorly reported globally and is commonly due to cardiovascular disease (CVD). We investigated targeted interventions aiming at reducing peripartum heart failure admission and late maternal death. METHODS AND RESULTS: Prospective single-centre study of 269 peripartum women presenting with CVD in pregnancy, or within 6-months postpartum. Both cardiac disease maternity (CDM) Group-I and Group-II were treated by a dedicated cardiac-obstetric team. CDM Group-II received additional interventions: 1. Early (2-6 weeks) postpartum follow-up at the CDM clinic and immediate referral to dedicated CVD specialist clinics. 2. Beta-blocker therapy was continued in women with LVEF<45% while pregnant, or immediately started postpartum. Of 269 consecutive women (mean age 28.6 ±â€¯5.9), 213 presented prepartum, 22% in NYHA groups III-IV and 79% in modified WHO groups III-IV. Patients were diagnosed with congenital heart disease (30%), valvular heart disease (25%) and cardiomyopathy (31%). The groups were similar in age, diagnosis, NYHA, modified WHO, BP and HIV, but Group-II had a higher rate of previously known CVD (p < 0.001) and a lower rate of being nulliparous (p < 0.0005). Of Group-I patients 9 died within the 12-month follow-up period versus one death in Group-II (p = 0.047). Heart failure leading to admission was 32% in Group-I versus 14% in Group-II (p = 0.0008), with Group-II having a higher beta-blocker use peripartum (p = 0.009). Perinatal mortality rate was 22/1000 live births with no differences between groups. CONCLUSION: Early follow-up in a dedicated CDM clinic with targeted pharmacological interventions led to a significant reduction in peripartum heart failure admission and mortality.

Impact of relaxation of the one-child policy on maternal mortality in Guangzhou, China.

OBJECTIVE: To assess the impact of the one-child policy in China on maternal mortality. METHODS: The present retrospective study included maternal death data from Guangdong, China, from January 1, 2006, to December 31, 2015; data from 2013 were excluded because they were not available. Maternal deaths were divided into legal and illegal pregnancies based on adherence to the one-child policy. The maternal mortality ratio (MMR) was compared between the groups, temporal trends in the MMR were examined, and comparisons were made of the causes of death and access to maternity care. RESULTS: The final analysis included 847 520 live deliveries and 383 maternal deaths. The MMR among legal pregnancies declined moderately from 18.5 deaths per 100 000 live deliveries in 2006 to 12.2 deaths per 100 000 live deliveries in 2015 (P=0.029), whereas the MMR among illegal pregnancies declined dramatically from 1268.4 deaths per 100 000 live deliveries to 177.5 deaths per 100 000 live deliveries (P<0.001). The proportion of avoidable maternal deaths decreased and access to quality maternity care improved among illegal pregnancies during the study period. CONCLUSIONS: Maternal mortality among illegal pregnancies declined with relaxation of the one-child policy in China.

Systematic review of obstetric care from a women-centered perspective in Nigeria since 2000.

BACKGROUND: A women-centered approach can improve the quality of patient care. OBJECTIVE: To review issues in the provision of obstetric care from a patient-centered care perspective in Nigeria. SEARCH STRATEGY: Using terms related to maternal and perinatal mortality, in combination with "Nigeria", MEDLINE, Embase, CINAHL, Web of Knowledge, and African Journal Online were searched, between December 1, 2013 and January 31, 2014, for articles in any language. SELECTION CRITERIA: Articles published in a Nigerian setting after 2000 that investigated causes of and circumstance surrounding maternal deaths and complications, or clinical practice related to maternal care were included. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers using a standardized abstraction form and were analyzed from a patient-centered perspective. MAIN RESULTS: The analysis included 57 studies. Clandestine induced abortions, lack of prenatal care, delays in seeking care, and the use of spiritual churches for delivery were found to contribute to adverse pregnancy outcomes. CONCLUSIONS: Healthcare systems respond inadequately to patients' needs in terms of abortion care, information sharing, transitioning between prenatal and obstetric care, and patients' non-medical needs. Data from clinician-led maternal death audits provided insights into how women-centered care can be provided; nonetheless, more-focused studies from a primarily patient-centered perspective are warranted.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

OBJECTIVE: To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. METHODS: We conducted a repeated cross-sectional study using the 2006-2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. FINDINGS: A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. CONCLUSION: The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Trends in maternal mortality in the United States.

Maternal mortality is a major global concern. Although a notable decline in maternal mortality in the United States occurred during the mid-20th century, this progress stalled during the late 20th century. Furthermore, maternal mortality rates have increased during the early 21st century. Around the year 2000 the maternal mortality rate began to rise and has since nearly doubled. Given that at least half of maternal deaths in the U.S. are preventable, the rise in maternal deaths in the U.S. is historic and worrisome. This overview will try to provide a context for understanding the problem of this rise in maternal mortality in the U.S. by briefly discussing how maternal mortality rates are reported from National Vital Statistics data and from a National Surveillance system. Trends and causes of maternal deaths and the difficulty with interpreting these trends will be discussed.

Maternal Deaths Account for a Small Proportion of the Total Deaths Among Reproductive Age Women.

BACKGROUND: For more than 30 years, the focus for women's health in low- and middle-income countries has been on reductions in maternal mortality. This perception was reinforced by the choice of the maternal mortality ratio as the primary indicator for women's health in the Millennium Development Goals. This analysis provides a more objective view by comparing the relative magnitudes of mortality among reproductive age women during pregnancy and the 6-week postpartum period versus other periods during this age range. MATERIALS AND METHODS: Data were aggregated from 38 countries in three regions with Demographic and Health Surveys that contained a maternal mortality module and were conducted in the prior 10 years to derive the proportion of total mortality ascribed to maternal mortality (proportion maternal [PM]) among women 15-49 years of age in 5-year age groups by country, region, and human immunodeficiency virus (HIV) prevalence. Estimates of maternal and nonmaternal deaths were based on the sisterhood method. Age-adjusted PM ranged from 5.7% in Swaziland to 41.7% in Timor-Leste. Regional averages were 14.3% in Latin America and the Caribbean, 24.2% in Asia, and 19.8% in sub-Saharan Africa (SSA). The age-specific pattern of PM showed an increasing trend into the mid-30s followed by a decline. The age-adjusted PM for each country in SSA stratified by HIV prevalence showed an inverse relationship between HIV prevalence and PM with countries with high and low HIV at the lower and upper ends of the PM distribution, respectively. CONCLUSIONS: Maternal deaths account for only 6%-40% of all deaths occurring among reproductive age women in a selection of low- and middle-income countries. Although a continued focus and push to reduce maternal mortality is warranted, attention to other causes of death and health issues for women of reproductive age is clearly needed. Research on the causes of death among women and prevention and treatment policies that provide health, education, and nutrition services to women need to be a priority.

Oxytocin--ensuring appropriate use and balancing efficacy with safety.

Maternal deaths due to haemorrhage continue to increase in South Africa (SA). It appears that oxytocin and other uterotonics are not being used optimally, even though they are an essential part of managing maternal haemorrhage. Oxytocin should be administered to every mother delivering in SA. Awareness is required of the side-effects that can occur and the appropriate measures to avoid harm from these. Second-line uterotonics should also be available and utilised in conjunction with mechanical and surgical means to arrest haemorrhage in women who continue to bleed after the appropriate administration of oxytocin.