Table Of Contents
Supplies & Supply Chains
When many more women choose to give birth at health facilities instead of at home, the demand to increase the supplies to health centers and hospitals increase. Many countries struggle to meet this increased need for supplies, both for normal deliveries and for complications.
To improve the prevention and treatment of PPH, only 2-3 specific drugs, and 2 specific devices are necessary. These are:
- Uterotonics (for routine prevention, and for treatment of PPH). Preferably at least 2 different uterotonics.
- Tranexamic acid (TXA), injectable
- IV crystalloids (IV fluid, “drip”)
- Uterine balloon tamponade (UBT)
- Non-pneumatic anti-shock garment( NASG)
One could expand the list to include more general supplies, like blood pressure machines, hemoglobin measurement devices, detergents, and disinfectants, or gloves. And of course, similar shortlists can be made for other common, often life threatening maternal and child conditions.
To get these quite cheap and simple items reliably in place in a health center, hospital or private facility, a number of very important steps need to be given attention.
For drugs, the Essential Drug List (EML) is a key document. All the drugs listed above need to be included in the EML, with the right indications, in order to enable national procurement and distribution. Countries typically use the World Health Organization (WHO) Essential Medicine List as they update their own. A close collaboration between the national MNCH program and the Essential Drugs department is essential.
The national guidelines (for PPH, and other MNCH care) need to clearly reflect the drugs and devices that are needed for control of PPH, or other conditions. For devices, similar rules may apply – the public health sector will not import devices that have not been officially approved. Also here, the decision to procure can be based on WHO recommendation, and after that the product approval may be based on e.g. manufacturers' compliance to either WHO prequalification technical requirements, European directives and regulations (CE marking), U.S. regulations (FDA approval), or other e.g. national regulatory authority's quality requirements.
National level “procurement” means finding the “best buy” globally in order to buy the drugs and devices. The national organization for procurement of drugs and devices, often a part of the ministry of health, will agree at a high level with other parts of the ministry of health on what needs to be procured, and ensure that the purchase is financed and imported to the country. National procurement processes are often obliged to follow international bidding rules, since some funding may come from the UN system, including World Bank contributions. Such rules may require several international tenders, from different suppliers. All in all, such processes may result in a lead time from requests from the public health field, to actual supply of the drug/device in the periphery, of 12-24 months. National programs, therefore, need to have close links with procurement processes.
National distribution and storage is another important step. How do drugs and devices get from the port of entry to the health center or hospital? Most countries have a national storage facility, often in the capital. Many countries also have regional and/or provincial deposits from which supplies are requested according to local routines, through appropriate channels and by designated people.
Monitoring local availability is a fundamental stepthat is being facilitated by Logistics Management Information Systems (LMIS) that are operated through computers, special software, and the internet.
If the Ministry of Health/national distribution system knows what is available on the shelves of hospitals and health centers, key drugs and devices can be given priority, avoiding shorter or longer gaps of the absolutely fundamental, life-saving tools in the periphery.
In the private sector, procurement, ordering, and distribution is more varied from country to country. One important conclusion, however, is that many private providers will wish to follow the public sector, using the routines and devices/drugs that are standard in the public sector – or if possible improve on those. Establishing “standard treatment”, including for PPH, in the public sector is thus important, in order to influence the private sector. Such processes are made easier by the fact that many providers in the private sector also work in the public sector.
Uterotonics are absolutely necessary and life-saving in maternal care, and must always be available. The most common uterotonic is IV oxytocin, which is used for induction of labour, augmentation of labour, for Active Management of Third Stage of Labor (AMTSL), and for treatment of PPH. This drug is heat sensitive and deteriorates when kept for long periods outside a refrigerator. Some countries fail to keep it in the cold chain, so oxytocin supplies reaching a health center may already be inactive. Fake and low-quality drugs are also a problem. Ensuring a safe and reliable supply is important. Recently, heat-stable carbetocin has emerged as a good alternative for prevention of PPH. (It cannot be used for induction or augmentation; and is not yet recommended for treatment of PPH). Oral misoprostol is an alternative for both AMTSL and treatment of PPH (if the woman is not in shock and unable to take the oral pill). An ampoule of oxytocin costs around 25-30 US cents.
Tranexamic acid (TXA) in itself reduces maternal deaths by 30% in women with PPH. It is thus an important drug that should be given via IV to all women with PPH as soon as possible after the diagnosis of PPH. If the woman keeps bleeding, it should be repeated once. One ampoule costs around 1.5 USD on the global market. In many countries, it is still not available everywhere where women give birth, and doctors and midwives should probably raise their voices (in their professional societies, and in dialogue with their MoH and partner organizations) to make it a standard treatment for PPH.
Uterine balloon tamponade (UBT) is like the above two drugs used to stop PPH in both high-, middle- and low-income countries. The two most affordable, and scientifically proven devices are the ESM-UBT and the Ellavi balloon from Sinapi. The “Every Second Matters UBT” (ESM-UBT) costs around 4 USD and is assembled in a clean assembly unit from already existing devices (a special urinary catheter with a Luer-lock valve inserted; a condom; a piece of string, syringe and instruction). It has recently been approved by the FDA. The Ellavi device, costing around 12 USD, in a closed system combines the UBT with a plastic bag for the fluid, enabling the adjustment of the intrauterine pressure by raising the fluid bag. It is sold by Sinapi at http://ellavi.com/contact
The non-pneumatic anti-shock garment (NASG) is the only item among the above PPH tools that is regularly reused. The device is sold e.g. by Maternova, VIA global and UNFPA and UNICEF supply catalogs at around 40-95 USD, and can be used at least 100 times. Careful disinfection, washing and drying, plus clean storage, ensures a long life-span for the device.
Importantly, both UNICEF and UNFPA are currently increasing their support to improved PPH control. In any low- and middle-income country, it is important to contact the respective national UNICEF and UNFPA offices to discuss how they can support actions to improve the supply chain of the critical tools above.
In addition, the non-profit Reproductive Health Supplies Coalition is helping to support improved national supply chains for maternal health, including on PPH tools. They can be reached at www.rhsupplies.org
For further guidance on introducing new PPH medicines and supplies into a country, please refer to USAID & SIAPS “Guidance for Planning the Introduction of New Reproductive, Maternal, Newborn, and Child Health Medicines and Supplies.”