Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Dr. Grethe Heitmann and Dr. Justus Hofmeyr.

Task Force Synthesis Citation

Shahaed H, Subic AM, Carlson JN, Douma M, Djarv T, Kule A, Hofmeyr GJ, Kishibe T, Aronsson A, Heitmann G, Thommesen T, Orkin A on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.

Lay provider administration of interventions for the treatment of post-partum hemorrhage: a scoping review.[Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, date. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process for the production of a Consensus on Science with Treatment Recommendations (CoSTR) started with a scoping review of interventions used by lay providers to treat post-partum hemorrhage. This search was conducted at the Temerty Faculty of Medicine and the Dalla Lana School of Public Health at the University of Toronto in Ontario, Canada with involvement of clinical content experts. Evidence for literature was sought and considered by the First Aid Task Force.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: First aid or emergency care administered by a lay provider to anyone experiencing post-partum hemorrhage.

Intervention: emergency care provided by a lay provider when someone is experiencing post-partum hemorrhage. Interventions that are classified as emergency care include those that fall within the following two categories:

Physical Interventions: Examples of physical interventions administered by a lay provider including external uterine massage, bimanual compression, aortic compression, anti-shock garment, manual removal of placenta, or manual removal of clots

Medications/Pharmaceuticals: Examples of medical interventions administered by a lay provider included iron supplementation, prostaglandin E1/misoprostol or any other drug that may be accessible without intervention from a medical professional.

Excluded interventions include those that require hospital/clinic support through medical professionals such as a blood transfusion, or any invasive surgical intervention such as curettage, uterine or pelvic artery ligation, uterine tamponade, or hysterectomy.

Comparators: No intervention

Outcomes: Any clinical outcome

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Grey literature including social media, non-peer reviewed studies, unpublished studies, case reports, conference abstracts and trial protocols were eligible for inclusion.

Timeframe: All years. Literature updated to October 22, 2024.

Search Strategies

Articles for review were obtained by searching all OVID Medline, EBM Reviews – Cochrane Central Register of Controlled Trials, CINAHL Complete (EBSCO), and Embase Classic + Embase for all entries from database inception to March 2024 (last searched on March 25, 2024).

Articles were searched using key terms including “Community Health Workers,” “Lay,” “Developing Countries,” and “Postpartum Hemorrhage” including their MESH terms and Embase exploded terms.

Records were downloaded and imported into Covidence. A total of 3539 studies were added to title and abstract screening after 19 duplicate records were removed. Following this, 102 studies underwent full-text review. Additional studies were identified through searching the reference lists of the included studies and conducting a grey literature search with key terms. Fourteen studies were then selected for data extraction.

The initial search was rerun to include articles published from March 25^th, 2024, to October 22, 2024. A total of 188 studies were added to title and abstract screening after 12 duplicate records were removed. Studies were screened by a single reviewer on October 22, 2024, and two additional papers were identified (Fobo 2024, 9; Nabatanzi 2024, 349) and incorporated into this narrative review.

Inclusion and Exclusion criteria

Population:

• Inclusion Criteria: Women suffering from post-partum hemorrhage
• Exclusion Criteria: None

Intervention:

• Inclusion Criteria:
  • Any emergency care provided by a lay provider for the treatment of PPH
    • Physical Interventions: Examples of physical interventions administered by a lay provider included external uterine massage, bimanual compression, aortic compression, anti-shock garment, manual removal of placenta, or manual removal of clots
    • Medications/Pharmaceuticals: Examples of medical interventions administered by a lay provider included iron supplementation, prostaglandin E1/misoprostol or any other drug that may be accessible without intervention from a medical professional.
• Exclusion Criteria: Excluded interventions included those describe measures for preventing PPH by a lay provider, and interventions that require hospital/clinic support through medical professionals such as a blood transfusion, or any invasive surgical intervention such as curettage, uterine or pelvic artery ligation, uterine tamponade, or a hysterectomy.

Comparators:

• Inclusion Criteria: No Intervention
• Exclusion Criteria: N/A

Outcomes:

• Inclusion Criteria: Any clinical outcome
• Exclusion Criteria: N/A

Study Designs:

• Inclusion Criteria: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Grey literature including social media, non-peer reviewed studies, unpublished studies, case reports, conference abstracts and trial protocols were eligible for inclusion.
• Exclusion Criteria: Non-systematic review articles were excluded.

Data Tables:

Prisma: FA7337 PRISMA Interventions used by Lay Providers during Post

Data: FA7337 PPH interventions Appendix 1 PPH Scoping Review summary tables

Task Force Insights

1. Why this topic was reviewed.

Post-partum hemorrhage (PPH) occurs when an individual loses 500mL of blood post vaginal birth or 1000 mL of blood post cesarian section. PPH is the leading cause of maternal mortality and morbidity worldwide, particularly in low-income countries with limited resources. (WHO 2012, 1). Approximately 14 million women each year experience PPH, resulting in 70,000 maternal deaths globally. Those who do survive often face life-long reproductive challenges (WHO 2022, 1). Early recognition and prompt treatment have the ability to prevent many deaths and long term health challenges (Likis 2015, 1). Much of the current literature focuses on interventions and strategies for treating PPH employed in hospital by skilled health professionals. Through this scoping review, we aimed to examine interventions for treating PPH conducted out of hospital settings by lay providers.

This topic was prioritized due to the high prevalence of PPH worldwide and the significant number of preventable deaths because of PPH. It has previously not been reviewed by ILCOR and no clear recommendations for lay providers have been made for PPH treatment.

2. Narrative summary of evidence identified

This scoping review included 16 studies of various types including 1 text and opinion article (Rodgers 2012, 56), 2 observational training and/or performance assessments (Andreatta 2012, 371; Candidori 2024, 104223) 5 qualitative studies (Collins 2016, 69; Fobo 2024, 9; Hose 2020, 5436; Nelson 2013, 27; Ononge 2016, 211), 3 cross-sectional studies (Bräuer 2015, 105; Nabatanzi 2024, 349; Prata 2009, 117), 2 guidelines (Lalonde 2012 108; Nyasulu 2010, 98), 2 non-randomized experimental trials (Mary 2021, 118, Prata 2005, 51), and 1 randomized control trial (Abbas 2019, 290). The interventions employed in these studies were primarily targeted towards traditional birth attendants (TBAs) including unskilled TBAs and TBAs with minimal training, volunteers, mothers themselves, and their supports, such as family members.

Three main interventions were discussed in the 14 included studies: the importance of uterine compression, highlighted by seven studies (Abbas 2019, 290; Andreatta 2012, 371; Bräuer 2015, 105; Hose 2020, 5436; Lalonde 2012, 108; Nelson 2013, 27; Nyasulu 2010, 98; Ononge 2016, 211); prompt referral to a healthcare facility, discussed in eight studies (Bräuer 2015, 105; Fobo 2024, 9; Nelson 2013, 27; Nyasulu 2010, 98; Ononge 2016, 211; Mary 2021, 118; Prata 2009, 117; Prata 2005, 51); and the use of misoprostol, mentioned by six studies (Abbas 2019, 290; Lalonde 2012, 108; Nyasulu 2010, 98; Mary 2021, 118; Prata 2009, 117; Prata 2005, 51). Uterine fundal massage was described as a technique performed after expulsion of the placenta involving massaging the uterine fundus through the abdomen until uterine contraction, and constant assessment of the contracted uterus through palpation to determine if repeat massage is necessary (Lalonde 2012, 108). Misoprostol administration varied amongst studies with some administering the misoprostol rectally (Prata 2009, 117; Prata 2005, 51), and others administering it orally (Abbas 2019, 290; Mary 2021, 118). The dosage of misoprostol given also varied and ranged from 400 – 1000mcg (Abbas 2019, 290; Lalonde 2012, 108; Nyasulu 2010, 98; Mary 2021, 118; Prata 2009, 117; Prata 2005, 51). Of the six studies, one study was a double blind RCT which showed no statistically significant difference in clinical outcomes (drop in hemoglobin of 20 g/L or more, referral, transfer, additional interventions, and acceptability of the medication) between the intervention group using misoprostol and the control group which did not (Abbas 2019, 290). Three studies commented on misoprostol’s overall efficacy and acceptability by patients while also discussing common adverse effects experienced by patients, including shivering, high temperature, nausea and vomiting (Abbas 2019, 290; Mary 2021, 118; Prata 2009, 117; Prata 2005, 51). The remaining two studies were guidelines encouraging the use of misoprostol (Lalonde 2012, 108; Nyasulu 2010, 98).

At least two studies discussed the use of oxytocin by lay provider (Bräuer 2015, 105; Lalonde 2012, 108; Nyasulu 2010, 98), ergotamine/ergometrine (Bräuer 2015, 105; Lalonde 2012, 108; Ononge 2016, 211), controlled cord traction (Hose 2020, 5436) and an intrauterine balloon tamponade device for lay provider use (Nelson 2013, 27; Candidori 2024, 104223). Three studies also noted the importance of education and adequate monitoring (Lalonde 2012, 108; Nyasulu 2010, 98; Mary 2021, 118). All medications were administered orally, rectally, or intramuscularly and therefore considered to be compatible with existing first aid practices. Oxytocin was noted to be an innovative intervention that had potential for widespread use amongst lay providers if placed in a “Uniject” autoinjector device, allowing it to remain cool (Bräuer 2015, 105; Lalonde 2012, 108; Nyasulu 2010, 98). Ergotamine/ergometrine was kept and used by TBAs of various levels of education in lay settings (Bräuer 2015, 105; Ononge 2016, 211) and was further recommended for intramuscular delivery in low-resource settings (Lalonde 2012, 108). While controlled cord traction was not recommended for use by unskilled birth attendants in at least two included studies (Lalonde 2012, 108; Nyasulu 2010, 98), in lower resource settings, some unskilled providers applied cord contraction in the absence of skilled birth attendants (Hose 2020, 5436). The use of uterine balloon tamponade was found to be effective and simple to use by community providers in one study (Nelson 2013, 27) and was compared to a new medical device called BAMBI (Balloon Against Maternal Bleeding) in a second study (Candidori 2024, 104223). Although we excluded studies on conventional uterine balloon tamponade, we included these studies because they were specifically about the lay provision of uterine tamponade as either adapted uterine balloon tamponades, or as innovative devices useable by non-skilled providers. As such, the usability of the BAMBI device for non-medical users was found to be significantly higher when compared to a traditional condom balloon tamponade device (Candidori 2024, 104223. The importance of PPH awareness for birth attendants, mothers, and their supports, during and after PPH was also emphasized throughout all studies. Two studies specifically referenced a Home-Based Life-Saving Skills Program that would be beneficial for families (Lalonde 2012, 108; Nyasulu 2010, 98).

The use of a non-pneumatic anti-shock garment was highlighted by two studies (Lalonde 2012, 108; Rodgers 2012, 56). These garments are conventionally used only in healthcare facilities but were described as having high potential for application by lay providers. They consist of a lower body suit that forces blood back to the vital organs (heart, brain and lungs) while reducing blood loss and maintaining blood pressure (Lalonde 2012, 108; Rodgers 2012, 56).

There were several other practices that were highlighted in individual studies, such as the use of aortic compression during PPH (Lalonde 2012, 108), application of heat or cold (Bräuer 2015, 105; Hose 2020, 5436), consumption of cold liquids (Hose 2020, 5436; Ononge 2016, 211), changing the mother’s position (Bräuer 2015, 105), and the use of herbal medicine (Ononge 2016, 211). At least six studies discussed herbal medicine (Bräuer 2015, 105; Collins 2016, 69; Fobo 2024, 9; Hose 2020, 5436; Nabatanzi 2024, 349; Ononge 2016, 211), most often in the form of teas to respond to PPH. Most of these studies came from rural or lower-resource communities where the aim of the study was to better understand the traditional practices used to manage PPH. When interviewing more skilled providers in these studies, herbal medicine was noted to be discouraged during training sessions and its use was noted to be decreasing (Ononge 2016, 211). Skilled providers also noted that herbal medicine and traditional uterotonic teas sometimes brought on unintended adverse effects (Ononge 2016, 211).

3. Narrative Reporting of the task force discussions

The Task Force discussed the following concepts:

• The PPH is associated with substantial global morbidity and mortality.
• That most birth attendants globally are untrained or trained to level that would align with a “first aid provider” outside of the birthing or obstetrical domain.
• That PPH has, in part, been excluded from the conventional corpus of first aid knowledge and practice (such as ILCOR’s own first aid content) for reasons related to the history of first aid, and that this may serve to compound gender-based health inequities. Incorporating PPH into first aid science may help to correct this.
• That determining the difference between preventing and treating PPH can be difficult, especially when interventions used for prevention and treatment are often the same (e.g. manual external uterine massage, oxytocin).
• That the research arising from this scoping review covers a very wide range of responses and may be well suited for first aid practice, but not well suited for inclusion in standard course-based or general first aid education.

Knowledge Gaps

• Most studies were qualitative and retrospective in nature, resulting in an overall low quality of evidence.
• Only one RCT (Abbas 2019, 290) was performed and only evaluated the efficacy of misoprostol.
• Only short-term survival and outcomes were evaluated, long-term follow-up was not done for most studies
• Overall, there is limited literature that exists on this topic
• Lay providers and their competencies varied between studies from skilled and unskilled traditional birth attendants to community providers, to mothers themselves and family
• Sample sizes greatly varied between studies, from 12 to 4008. Most studies had a smaller sample size.
• There was a small portion of studies on preventive measures which were not included, due to the inclusion criteria of the review. These studies were also mostly qualitative.

References

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