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.

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.