Country Experiences: Niger

Why try a standardized approach to PPH Treatment in Niger?

To save lives, prevent suffering, and save money for the inhabitants.[i]

Niger’s Ministry of Health launched its Initiative to Prevent Women from Bleeding to Death at Childbirth using proven, low-tech, low-cost, new technologies combined in an innovative way because, if nothing is done, roughly 10% of women the world over bleed severely, and up to 18% bleed enough at childbirth to meet the criterion for PPH.1,[ii],[iii] Also, in most settings, PPH is the main cause of maternal mortality.[iv]

Prevention in a hot climate without reliable refrigeration uses misoprostol costing < $1 USD, immediately after birth. This reduces the occurrence of excessive bleeding by over 70%.[v]

3-Step Treatment is given to those who bleed too much anyway (≥500 ml.), as is seen when a traditionally used cloth becomes soaked with blood. The 3-Step Treatment is:

1) Give the woman a treatment-dose (800 mcg) of misoprostol.  If the bleeding does not stop within 25 minutes, then proceed to step 2.

2) Place a Condom Tamponade – a condom tied onto a catheter, inserted into the bleeding uterus – and inflate with 300-500 ml of water. If that does not stop the bleeding within 6-12 minutes, proceed to step 3.

3) Apply a non-pneumatic anti-shock garment (NASG) and get her directly to surgery at a pre-defined “definitive treatment hospital” where an obstetrician is available to do specialized procedures such as B-Lynch sutures, artery ligation, etc, even if far away.   Note: Antibiotics are in each tamponade kit to protect against infection because we insert clean but unsterile equipment into her uterus.

At their 3rd trimester prenatal consultation, each woman gets a prevention dose of misoprostol with instructions on when and how to use it, given in case she does not make it to the health center in time. However, she is encouraged to give birth in a health setting and bring the dose with her.

This 3-Step Treatment is by health workers, who receive training and supplies.

Niger is the first country in the world to take such ambitious steps aiming to halve PPH mortality nationwide. This cost about $700,000 to put in place nationwide for a population of 17.8 million in 2014, including the baseline survey. Cash benefits for the population are roughly estimated to be on the order of 12 times greater than the annual cost. This includes benefits from deaths averted, and loss of income from severe anemia in PPH survivors, using half of WHO’s 6-month Burden of Diseases estimate for the duration of income-loss from severe anemia. We used $1/day as the estimated income for the population of Niger.

What counts most is, of course, people’s lives. The women themselves and children who can have their mother survive to be with them as they grow up! Averted loss is also nice.

Can a standardized approach to PPH Prevention and Treatment succeed in Niger, a country at the bottom of the UN’s Human Development Index? [vi]

Niger’s standardized approach to PPH Treatment (and Prevention) has been published, together with its scientific basis. Analysis of its impact is in the process of being published in a peer-reviewed medical article, as must be done if one is to have scientific credibility.

Meanwhile, here are a couple of anecdotes.

PLEASE NOTE: A story or two does not constitute scientific evidence by any means! And these anecdotes do not constitute “publication” of whether Niger’s standardized approach to PPH Treatment is working, or not.

The waking of a doctor

Shortly after the country started putting in place its PPH Prevention and Treatment Initiative, the medical director for one of Niger’s eight regions called the capital to “complain.” Why? He had been woken by his telephone at 5 in the morning – not a typical experience for upper-level administrators in any country’s health system!

A doctor in his region was so excited by the following experience that he could not resist phoning his boss to share the good news: At 02:00 in the night, a woman gave birth at his health center and began bleeding furiously. By chance, just a few days earlier he had been trained but was (wrongly) not given necessary supplies for the new PPH Initiative.

Remembering his training, he dug around to find a condom somewhere. He found some string, a catheter, and a large syringe. He tied the condom to the catheter, inserted it into the woman’s uterus, inflated the condom with water through the catheter as he had practiced on a simulator just a few days before. The bleeding stopped almost immediately!

The midwife’s uterus

A midwife was herself giving birth to her first child, at the hospital where she works. All went well with the mother and child until the baby was born. Then she started to bleed. Massively. The maternity staff and the on-duty doctor rushed her toward the operating theater, where he intended to do a hysterectomy to save her life.

Problem: arriving, they discovered the operating theatre was busy! Somebody was already on the table, undergoing surgery.

In desperation, hoping to keep her alive until the surgery became freed-up, the doctor who had recently been trained in Niger’s standardized approach to PPH Treatment inserted a Condom-Tamponade, right there in the hallway. The bleeding stopped. Her life and her uterus, both were saved that night!





Copyright Credit:   Grandmother with twins. © Dr. Zeidou Alassoum

Copyright Credit:   Fig. 1 and Fig. 2 are from Seim AR, Alassoum Z, Lalonde AB, Souley I. An Integrating Model for Rapid Reduction of Maternal Mortality Due to Primary Postpartum Haemorrhage – Novel Use of the Catalyst Approach to Public Health. Afr J Reprod Health 2019; 23[2]: 18-26. DOI: 10.29063/ajrh2019/v23i2.2

[i] Seim AR, Alassoum Z, Lalonde AB, Souley I. An Integrating Model for Rapid Reduction of Maternal Mortality Due to Primary Postpartum Haemorrhage – Novel Use of the Catalyst Approach to Public Health. Afr J Reprod Health 2019; 23[2]: 18-26. DOI: 10.29063/ajrh2019/v23i2.2

[ii] AbouZahr C. Global burden of maternal death and disability. Br Med Bull. 2003: 67: 1-11.

[iii] El-Rafaey H, Rodeck C. Post-partum hemorrhage: definitions, medical and surgical management. A time for a change. Br Med Bull. 2003; 67: 205-17.

[iv] World Health Organization. Trends in maternal mortality: 1990 to 2015 estimates by WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Geneva: WHO; 2015. 93 p.

[v] Bellad MB, Tara D, Ganachari MS, Mallapur MD, Goudar SS, Kodkany BS, et al. “Prevention of postpartum hemorrhage with sublingual misoprostol or oxytocin: a double‐blind randomized controlled trial.” BJOG. 2012; 119.8: 975-86. doi:10.1111/j.1471-0528.2012.03341.x

[vi] UNDP. Human Development Report 2019. See p. 303.