Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study

Abstract

Background: Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics.

Methods: The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women's report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use.

Results: Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7-99.8%). Survey-report underestimated coverage (79.5 to 91.7%). "Don't know" replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the "right time" (1 min) and 69.8% within 3 min. Women's report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording.

Conclusions: Routine registers have potential to track uterotonic coverage - register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.

Keywords: Birth; Coverage; Health management systems; Hospital records; Maternal; Postpartum haemorrhage; Survey; Uterotonics; Validity.

Fig. 1

Uterotonics: validation design, EN-BIRTH study. EN-BIRTH validation Design comparing observation gold standard with register-recorded and women’s report on exit survey. EN-BIRTH data collection tools (observation checklist, register data extraction tool and exit-interview survey tool) are published separately [15, 29]

Fig. 2

Flow diagram for uterotonic cases, EN-BIRTH study (n = 23,015)

Fig. 3

Coverage rates for uterotonic administration measured by observation, register and exit-survey (95% CI), EN-BIRTH study (n = 23,015). n = 23,015 observer assessed births; 20,632 women with survey-reported births & 14,221 with register records, (noting that for validity analysis, n = all register data from Tanzania + revised register data from Bangladesh) [28]. BD = Bangladesh, NP = Nepal, TZ = Tanzania. Pokhara, Nepal has no register column for recording uterotonics (n = 6838). *Pooled using random effects

Fig. 4

‘Don’t Know’ replies for exit-survey reported uterotonic provision, EN-BIRTH study (n = 20,632) *individually weighted mean. Cut-off ranges adapted from WHO Data Quality Review, Module 2 "Desk review of data quality” [33]

Fig. 5

Hospital register design and completion for uterotonics by site, EN-BIRTH study (n = 14,211). Register Recorded n = 14,221 (for validity analysis n = all register data from Tanzania + revised register data from Bangladesh) [28]. ~ Revised Register design, further details available in Additional file 4. *Completeness calculations are “not possible” for Bangladesh registers as the instructions state leave blank if intervention/practice is not done. Cut-off ranges adapted from WHO Data Quality Review, Module 2 “Desk review of data quality” [33]

Fig. 6

Gap analysis for uterotonic coverage and quality, EN-BIRTH study. N = 23,015 observer assessed births: 20,632 survey reported births and 14,221 register recorded (all cases in Tanzania and those from revised register data from Bangladesh) BD = Bangladesh, NP = Nepal, TZ = Tanzania

Fig. 7

Timing of oxytocin administration, EN-BIRTH study (n = 22,121). N = 22,121 (women observer-assessed to receive oxytocin from 0 to 30 min after birth). BD = Bangladesh, NP = Nepal, TZ = Tanzania

Fig. 8

Barriers and enablers to routine register recording of uterotonic administration, EN-BIRTH study. This Figure illustrates the overall barriers and enablers to facility based data collection identified by EN-BIRTH participants [32]. The bold text are the issues specific to uterotonics administration. The transition from red to green is a reminder that most factors identified by participants could serve as either a barrier or enabling factor depending on the facility-level resources and management