Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa.

Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

Outcomes of self-induced late pregnancy termination in women presenting to a tertiary hospital in the Eastern Cape Province, South Africa.

BACKGROUND: Little is known about the outcomes of self-induced pregnancy termination after 24 weeks' gestation, as previous studies have concentrated on outcomes before 24 weeks. OBJECTIVES: To investigate the gestational age, misoprostol dosage, source of information on misoprostol, reasons for termination and outcomes of self-induced pregnancy termination after 24 weeks' gestation. METHODS: A quantitative, retrospective case series observational research design was utilised. Paediatric case summaries and the Perinatal Problem Identification Programme were used to collect data. Cases of self-induced pregnancy termination using misoprostol after 24 weeks' gestation treated at a tertiary hospital in the Eastern Cape Province, South Africa, during the period 1 July 2011 - 1 January 2012 were identified and included in the study. Frequencies and proportions were used to analyse data. RESULTS: Eighteen known cases of self-induced pregnancy termination using misoprostol after 24 weeks' gestation were treated at the hospital during the 6-month study period. Misoprostol doses ranged from 400 to 1 200 µg. Birth weight was <500 g in 1 case (6%), 500 - 1499 g in 12 (67%), 1 500 - 1 999 g in 2 (11%), >2 500 g in 1 (6%) and unknown in 1 (6%). Eleven of the babies (67%) were born alive and 5 (28%) were stillborn (1 further stillbirth (6%) was classified as an abortion, <500 g). One baby (6%) survived, and in 1 case (6%) the pregnancy continued. Eight of the 10 neonatal deaths were early and 2 were late. The major cause of neonatal death was hyaline membrane disease (n=8, 44%). Other causes were hypoxia (n=2), septicaemia (n=2), necrotising enterocolitis (n=2), pulmonary haemorrhage (n=2) and intraventricular haemorrhage (n=2). More than one cause applied in some cases. The maternal complications were manual removal of the placenta (n=2, 11%), ruptured uterus (n=1, 6%), and anaemia with blood transfusion (n=1, 6%). CONCLUSIONS: Self-administration of misoprostol to induce pregnancy termination after 24 weeks' gestation contributes to preterm births and perinatal morbidity and mortality. The findings of this study show that there is a need to educate women on the perinatal and maternal risks associated with self-induced pregnancy termination at a late stage of gestation, availability of safe options for pregnancy termination, and contraceptive use and adherence. Healthcare workers need to be sensitive to the possibility that cases of apparent spontaneous preterm labour or birth may have been self-induced.