Development, Field-Testing and Piloting of a refractory postpartum haemorrhage management package: the PPH ReAct (PPH Refractory Action) study

在资源匮乏的国家，每六分钟就有一名母亲在年富力强时因分娩后出血过多而死亡，往往会留下一个年轻的家庭。当一位母亲死于分娩时，她的婴儿活过第一个月的可能性不到20%。产后出血过多，或产后出血(PPH)，是全世界母亲死亡的最常见原因。有效的治疗可以为大多数女性止血。然而，尽管接受了“第一反应”治疗，但仍继续出血的患者被认为患有难治性产后出血，他们是死亡或遭受重大并发症的女性。我们已经为这些女性制定了一个临时管理方案，称为“PPH反应”方案。我们希望完善这一一揽子管理方案，为此制定一项实施战略，并对这些战略进行实地测试，最后在肯尼亚的5个卫生机构试行这一办法。世界卫生组织在2012年发布了《预防和治疗产后出血的建议》，为PPH的管理提供了循证的建议。然而，遵守这些建议目前受到一些挑战的限制。挑战和建议的解决方案1)尽管对PPH进行了“第一反应”治疗，许多妇女仍继续出血--&gt；解决方案：难治性PPH治疗方案2)用于难治性PPH管理的延迟或不一致的治疗--&gt；解决方案：难治性PPH管理(PPH反应)方案，它使用简化的方法和核对表，以确保一致和及时的评估和治疗。3)许多护理提供者和组织努力为患有难治性产后增生症的妇女提供有效的护理，尽管已经有了治疗方法--解决方案：更深入地了解挑战，以及利用行为科学框架改变医疗保健专业人员和组织的行为的战略。4)缺乏证据和信心，认为拟议的方法可以改善难治性PPH治疗的有效治疗方法的使用--解决方案：对难治性PPH治疗方案进行研究，以确保医疗保健专业人员和组织更多地使用挽救生命的治疗方法。这项研究可以产生必要的证据，使医疗从业者和政策制定者有信心实施和扩大该计划。5)有限的扩大和覆盖--&>解决方案：强大的合作伙伴的参与：世界卫生组织、Jhpiego、行为科学家、卫生部和概念基金会我们的目标是开发、改进和评估管理难治性PPH的有效方法。尽管付出了集中的努力，但PPH仍然是导致母亲在分娩过程中死亡或遭受重大并发症的主要原因。大多数患有PPH的妇女对最初的治疗有反应。然而，相当多的妇女不这样做，这些妇女遭受死亡或遭受重大并发症。有一个尚未得到满足的需求，即确定治疗难治性PPH的最佳方法。此外，一种管理方法只有在被广泛接受并在日常实践中使用时才能实现其预期目标；因此，有必要制定一项有意义的战略来实施这一方法。因此，我们建议制定、完善和试行棘手的PPH管理一揽子计划和实施战略。

Every six minutes a mother dies from excessive bleeding after childbirth in low-resource countries, in the prime of her life and often leaving behind a young family. When a mother dies in childbirth, her infant has less than a 20% chance of surviving past the first month. Excessive bleeding after childbirth, or postpartum haemorrhage (PPH), is the commonest reason why mothers die worldwide. Effective treatment can stop bleeding in most women. However, those who continue to bleed despite 'first response' treatment are thought to have refractory PPH and are the women who die or suffer major complications. We have developed a provisional management package for these women, called the 'PPH ReAct' package. We wish to refine this management package, develop an implementation strategy for this, field-test these and finally pilot the approach in 5 health facilities in Kenya. The WHO published "Recommendations for the Prevention and Treatment of Postpartum Hemorrhage" in 2012 to provide evidence-informed recommendations for managing PPH. However, adherence to these recommendations is currently limited by a number of challenges. Challenges and proposed solutions 1) Many women continue to bleed despite 'first response' management of PPH --> Solution: A refractory PPH treatment package 2) Delayed or inconsistent use of treatments for refractory PPH management --> Solution: A refractory PPH management (the PPH ReAct) package that uses simplified approaches and a checklist to ensure consistent and timely assessments and treatments. 3) Many care providers and organisations struggle to provide effective care for women with refractory PPH, despite treatments being available --> Solution: Deeper understanding of challenges, and a strategy for changing behaviours of healthcare professionals and organisations using behavioural science frameworks. 4) Lack of evidence and confidence that the proposed approach can improve usage of effective treatments for treatment of refractory PPH --> Solution: A study for the refractory PPH treatment package to ensure an increase usage of life-saving treatment by the healthcare professionals and organisations. This study could generate the necessary evidence that will give healthcare practitioners and policy makers the confidence to implement and scale-up the programme.5) Limited scale-up and coverage --> Solution: Engagement of strong partners: World Health Organisation, Jhpiego, Behavioural Scientists, Health Ministries and Concept FoundationOur aim is to develop, refine and evaluate an effective approach to managing refractory PPH. Despite concentrated efforts, PPH remains the leading cause why mothers die or suffer major complications during childbirth. Most women with PPH respond to initial treatments. However, a substantial number of women do not, and these are the women who suffer die or suffer major complications. There is an unmet need to define the optimal approach for managing refractory PPH. Furthermore, a management approach could achieve its intended goals only if it is widely accepted and used in everyday practice; thus a meaningful strategy for implementing this approach is necessary. We therefore propose the development, refinement and piloting of a refractory PPH management package and implementation strategy.