Transforming postpartum hemorrhage treatment with Uterine Balloon Tamponade
By Pauline Achieng Tom
Lilian Achieng Omondi, 28, from Kosinyo village in Siaya County experienced excessive bleeding throughout her first two pregnancies which would stop upon receiving an oxytocin injection.
However, during her most recent birth, the bleeding would not stop despite receiving the same injection leading her to lose consciousness.
Lilian was suffering from postpartum hemorrhage (PPH) which contributes to 287,000 deaths in Kenya alone. This is 34 percent of overall maternal deaths.
To plug the existing gaps in PPH care in Kenya, Kisumu Medical and Education Trust (KMET) a Non-governmental Organization in Kenya, assembles and distributes a Uterine Balloon tamponade (UBT) to stop excessive bleeding, the kit which is usually used after all other measures have failed has proven to be a lifesaver, especially for Lilian.
“I experienced heavy bleeding and the injection (oxytocin) did not help this time. It started with very painful labor that lasted about five hours I saw my baby, breastfed her, and immediately I became unconscious,” she recalls
At Akala Health Centre, in Siaya County, Achieng regained her consciousness after the doctor had used a UBT kit on her to stop the bleeding.
The kit consists of a pair of condoms, a silicon catheter, a string, two data cards, a referral card, and a 60ml syringe.
“When I woke up, I noticed something strange in my body. The doctor was removing some water from my body using a syringe. It was not painful. At this time, I had gained consciousness and the bleeding had stopped,” she explains.
PPH is an obstetric emergency usually indicated by persistent severe blood loss of more than 500ml for vaginal delivery or 1,000ml of blood for a cesarian section within the first 24 hours following childbirth.
According to Liddy Dulo, coordinator of innovative programs at KMET the kit is easy to use and can be used by any skilled healthcare provider once trained.
“The way the UBT works to stop bleeding is by exerting pressure in the uterus, normally when a mother delivers naturally once the baby and placenta are delivered the uterus contracts, failure to the mother starts bleeding excessively,” Dulo said.
The UBT kit is an effective device that national and county health services can use to avert deaths and disability arising from uncontrolled uterine bleeding after childbirth when other interventions are unavailable or fail.
“When after use of misoprostol and an oxytocin injection still don’t stop the bleeding use of UBT can avert certain death, disability or hysterectomy,” she adds.
In 2012, KMET and Massachusetts General Hospital introduced the use of UBT in Kenya at very low costs, the kit was dubbed ‘Every Second Matters for Mothers and Babies – Uterine Balloon Tamponade’ (ESM-UBT).
“We did a small in-country research just to prove the concept and we were supported by Massachusetts General Hospital(MGH) and Harvard University. We piloted in 12 private facilities where we provided the UBT, we trained and monitored the facilities and collected data,” explained Ms. Liddy.
World Health Organization recommends the use of UBT as a feasible measure in treatment of PPH in order to avoid surgery or as a temporizing measure while awaiting transfer to a higher-level facility.
Currently, KMET and MGH have rolled out the ESM-UBT to over 1,300 facilities in 23 counties and Over 6,600 health workers across the country have received training on the use of ESM-UBT and the clinical management of PPH as recommended by the WHO, an estimated 3000 lives saved through the use of ESM-UBT.
The training done on how to use ESM-UBT is extensive and covers the clinical management of PPH as recommended by the WHO
“Before we employ the UBT we have to make sure all products of conception(tissues)are removed, presence of any placenta, membrane or blood clot will result in continuous bleeding,” Ms. Liddy reiterates.
There are a few predisposing factors that can lead to PPH, over -distention of the uterus due to multiple pregnancies-twins, triplets or big babies, Polyhydramnios which is the excessive accumulation of fluid in the uterus, retained placenta after delivery, prolonged labor, anemia, prior history of PPH or trauma due to episiotomy.
Surgery as a PPH intervention is considered to be radical since hysterectomy (total removal of the uterus) can cause disability to young women which would have happened to Melisa Akinyi 17 from Kakamega county.
Despite receiving the first lines of treatment she still kept bleeding heavily, Her Nurse Lilian Musalia received a distress message from her colleague at midnight saying “I feel like screaming, I have a mother with PPH and I am all alone with the watchman.” She rushed to her aid.
Melisa Akinyi had received 40 units of oxytocin, a first line treatment for PPH but was still actively bleeding. “I left for the hospital on foot when I got there her bed was soaked in blood and my colleague looked dazed by the unfolding events. I knew we had to act fast. ”Musalia recalls.
after performing a uterine massage and examining for vaginal tears Ms. Musalia came to the conclusion that this was a case of PPH.
“I knew UBT was the only solution. We had two UBTs in the drawer in the maternity room so I began assembling one. I inserted the balloon and miraculously the bleeding stopped after filling it with only one liter of water,” recounts Lilian.
Once Melisa was stable, she was referred to Mukumu Mission Hospital where she was transfused with two units of blood the UBT was removed at 6am and the bleeding had completely stopped.
Reiterating how useful UBT is as a tool in saving women lives from death and preventing hysterectomy KMET’s Liddy Dulo who was once a Practicing Nurse and a midwife, notes that teenage girls are prone to PPH and radical interventions like surgery may expose them to disabilities at such a young age.
“We find that teen moms are prone to PPH because they’re still very young. So, if you do a hysterectomy, you remove the uterus of a 13,14, or 16-year-old girl, that’s their first pregnancy When she’s of age, she’s getting married, and she would like to have another baby.
“Apart from societal stigma from the African culture, the loss of a uterus can also cause a lot of hormonal imbalances, because you will remove even the tubes, the use of UBT can help a woman reserve her uterus,” Dulo stated.
KMET is able to keep the price of the UBT kit so low due to the fact that most of its components a locally sourced and assembled for free, the UBT kit is KShs 1000 and it comes with a booklet of instructions.
When assembling the kit KMET has a program dubbed ‘Woman to Woman’ where young women who study at KMET donate their time to assemble the UBT kit.
“We have these young girls who had to drop out of school due to teen pregnancy we take them in for technical training for hairdressing, tailoring, and cooking so we nicknamed this program woman to woman since they are ladies preparing these kits to save another woman’s life, we train them on assembling them.”
One of the major challenges when treating PPH, especially in Kenya is the lack of first line drugs, according to a study done by the Ministry of Health and WHO (Stock Measure Evaluation, 2017), about 25 per cent of health facilities in Mandera, Busia and Kisumu counties did not have oxytocin and misoprostol in stock, others did not have refrigeration needed to store the drugs, this prompted KMET to introduce the bundle approach.
This approach was introduced in 2019, it involves a bundle of interventions put together and it entails the standard intervention protocol of PPH treatment using drugs and Tranexamic acid, UBT, and antishock garment used to reverse shock caused by excessive blood loss, as well as non-clinical approaches like teamwork, communication, network integration, leadership, and overall facility readiness, all these interventions together will work concurrently to save the life of a mother.
Financial constraints are another major challenge for health facilities to overcome when acquiring UBT kits, therefore to help ease this constraint KMET through networking advocated for the UBT kit to be part of the government’s essential commodities list.
“We have come a long way with the government to get the UBT kit enlisted before we could go train and tell them to go buy and they would depend on the little non-farm money with which they can only use for commodities on the government’s essential list”
Despite all the efforts undertaken some facilities still don’t prioritize the acquisition of UBT with some communities being hesitant about the use of condoms because of religious reasons.
“A few believe that a condom is just for sex but I can see with a lot of enlightenment people are changing their opinion reasoning that if it can save a woman then its acceptable.”
Low awareness level among healthcare workers on the use of UBT also impedes its adoption and uptake.
“We still have to go through health facilities management teams and sensitize them on the importance of UBT, however being health providers, they understand easily the need for UBT especially since it is included in Emergency obstetric care (EmOC) as basic essential maternal complication management,” Dulo said.
Another critical issue in the implementation of UBT has been the challenge of staff retention, as certain healthcare facilities that have received the necessary training continue to face high staff turnover rates.
“We are now encouraging facility training so that everybody is brought on board and trained on the management of PPH, we plan on using ongoing programs like EmOC.”
Ms. Liddy Dulo insists that maternal mortality is preventable stating,” pregnancy should not be a death sentence.”
This story was first published in Health Business