Intervention 6: Birth Preparedness

Birth Preparedness

Birth preparedness: Since it is impossible to predict who will have an obstetric emergency, it is important that pregnant women and their families are prepared for the various scenarios that might arise at the time of delivery. As part of a birth plan, families should decide where to give birth (preferably at the health facility), identify transport to the health facility, organise the supplies they will need for the delivery and decide what they will do in an emergency. It is safest for all women to deliver with an SbA in a health facility. This message is always reinforced as part of the 7-11 strategy. In cases where a family cannot or chooses not to deliver in a facility, it is even more important that they are prepared for a safe home birth and have contingency plans and resources in the event of an emergency. A good birth plan will reduce confusion at the time of delivery.

As part of the 7-11 strategy, women and their families are informed about the health risks and benefits, including the social benefits, of healthy timing and spacing of pregnancies, and are provided with information regarding the birth spacing methods available to them.

Definition:

Birthing and emergency plans are in place and the family understands, recognizes and acts quickly if complications arise in pregnancy, during labour and delivery or after the delivery. If approved in your country/context "safe motherhood tablets" (misoprostol) are in the pregnant woman's posession and are taken immediately after the birth of the baby to prevent a Postpartum Haemorrhage(PPH).

Target Behaviours:

Pregnant woman attends at least 4 antenatal visits and the 4th is in late pregnancy
Pregnant woman is tested for HIV, knows her HIV status so she can help protect her baby
Pregnant woman and her family consider giving birth in a facility with a skilled birth attendant
Household knows the location of the closest facility
Pregnant woman selects a birth companion to accompany her to the facility and stays to support her during labour and deliver
Household prepares by gathering clean birth supplies, pre arranges transport and saves money needed to pay for the delivery and any emergency care
Household prepares for care of other children whilst the mother is away
Pregnant woman receives "safe motherhood tablets" (misoprostol) at the 4th ANC visit, for from a CHW at a home visit in late pregnancy, and takes the tablets as soon as possible after the baby is born

Misoprostol for Prevention of Postpartum Haemorrhage

Haemorrhage is a leading cause of maternal death. Usually after the delivery of a baby active management of the third stage of labour (AMTSL) using oxytocin is recommended to prevent PPH (Post-Partum Haemmorhage). In 2012 WHO guidelines for the prevention of PPH recommended the administration of Misoprostol by community health workers (CHWs). Research has shown that community-based programs for prevention of PPH using misoprostol can achieve high distribution and coverage, particularly when CHWs visit homes.

Misoprostol is an important alternative for PPH in low-resource settings because...

Many women are delivering at home with no access to skilled birth attendants where oxytocin is unavailable
Misoprostol is in tablet form
Misoprostol does not require injection supplies, a skilled provider, or refrigeration
Misoprostol is safe and effective for preventing PPH

Currently...

Many governments have or are considering policy updates for use of misoprostol for prevention of PPH and distribution by CHWs and World Vision is well placed to support the Ministry of Health and development partners in the roll out and scale up of this intervention.

(Adapted from www.biomedcentral.com/1471-2393/13/44 and http://www.k4health.org/toolkits/postpartumhemorrhage/advance-distribution-misoprostol-program-resources)

Questions:

Why plan ahead for birth?

The more prepared families are for the birth and the new baby the more chance that the mother and the newborn baby will survive, especially if there is an unexpected emergency. It takes time to save up the money needed for the delivery and new baby. The family will need items like baby clothing, clean birth materials and mothers hygiene and it is best to keep them in a bag ready for the birth.

Costs for the delivery at the facility and for transport to and from, as well as for any emergency treatment, can be a lot of money for the family so saving up over the time of the pregnancy is advised. Mothers and babies can die whilst families look for money to pay for transport or unexpected emergency care.

What supplies are needed for a clean birth?

All births, whether they happen at home or in the health facility, need to be “clean” otherwise the mother and baby can become very sick from infection entering the birth canal or via the baby’s umbilical cord.

The birth needs to happen on a clean surface so a plastic sheet or mat is needed. The birth assistant must have clean hands before helping mother and baby, so soap and water is needed The birth attendant needs to be protected from infections like HIV so plastic gloves are needed and the umbilical cord must be kept clean so clean string for tying the umbilical cord and a clean blade for cutting the cord is needed.

All families are advised to have these supplies ready along with clothes for the mother and newborn baby and packed ready to take to the health facility when labour starts, or to use at a home birth.

What sort of complications can arise and when?

Only 15% of all pregnancies develop complications but if they do they can be very dangerous.  The most common complication is bleeding before or soon after the birth. Other problems can be convulsions, very high fever with severe pain after the birth. The newborn baby can become suddenly very sick with difficult breathing or fever.

Most deaths of mothers and newborn babies happen on the day of birth or in the first 3 days after the birth. Being prepared for complications means families can act quickly if needed. Delay in taking a sick mother and newborn to the facility can mean the difference between living and dying.

Why deliver in a health facility rather than at home?

The staff at the health facilities are trained to care for mothers and babies during the labour and delivery and they have the drugs and equipment ready for assisting the birth. Although most births go very smoothly occasionally there can be a complication and if this happens at home the time taken to get the mother to the health facility might be too long to help save her life. Planning to have the baby in the health facility means that if a complication does arise the health staff can give immediate emergency care or organize to transfer the mother to the referral hospital quickly.

What is a birth companion?

A birth companion is someone whom the woman has chosen to be with her during the labour and delivery in order to provide her with physical and emotional support. Having a birth companion during the labour and delivery, rather than labouring alone, can actually result in improved outcomes such as a shorter labour, improved early initiation of breastfeeding and care of the newborn! This is especially so if it is the first birth and best if the birth companion has learnt about best practices for pregnancy, labour, delivery and newborn care. The birth companion may have accompanied her to ANC or been present during home visits by a CHW.

The birth companion can be a friend, a traditional birth attendant (TBA), a mother or mother in law, a sister or other woman relative, or even her husband! The delivery room in the health facility requires enough space and privacy for the woman to have her birth companion with her.

What is a post-partum hemorrhage?

A post-partum hemorrhage (PPH) is heavy bleeding from the birth canal after the birth of the baby. There is always some blood loss after a delivery but if the blood soaks through clothes and runs into a pool under the bed it is too much. PPH is the most common complication and is the leading cause of mothers’ deaths in the world. A woman can die from a PPH in as little as 2 hours. A PPH can happen if the womb is tired after a long labour, if there is some damage to the birth canal or if the placenta has been retained (has not come out).

A PPH cannot be predicted and every mother, whether it is her first baby or 10th baby is at risk of a PPH.

PPH can be prevented by having medication immediately after the birth of the baby. This medication can be given as an injection by the skilled birth attendant or tablets if the birth occurs at home or the injection is not available.

How does the "safe motherhood tablets" (misoprostol) help prevent a PPH?

The safe motherhood tablets work by quickly making the womb strong again after the labour and birth of the baby. They help to push out the placenta after the birth of the baby and to stop further bleeding. The tablets are specially designed for those women who cannot reach a facility and the birth happens at home or if the health facility has no injections, or refrigeration to store the drug or lack skilled staff.

A CHW or TBA, who has been trained in administering safe motherhood tablets and is present at the birth, can give the tablets or the mother can take them herself.