Questions/Answers

Postpartum hemorrhage (PPH) is a leading cause of birth related death around the world. It also affects postpartum mothers both physiologically and mentally such as inadequate lactation and depression. Health Region 3 is comprised of five provinces (Nakhonsawan, Phichit, Uthaithani, Chainat, and Kampheangphet). From 2005 to 2009, PPH rate in this region increased from 1.7 to 2.9 percent. The Regional Health Promotion Center 3 (HPC3) which is responsible for maternal care in this region, found that there were many methods to estimate postpartum blood loss in each hospital such as visual estimation, estimation from number of gauzes and clothing swabs used. Usually these methods are underestimated by around 50 percent and lead to delays in diagnosis of severe blood loss and also inappropriate treatment times. Maternal death frequently occurred in low socioeconomic women which had many effects to the child and their family thereafter. Regional Health Promotion Center 3 initiated the project to develop an accurate method to estimate blood loss after delivery which can be used simply and effectively for most hospital service units: The postpartum blood collection bag.

The postpartum blood loss collection bag was initiated to develop a low cost, accurate, simple to produce and use in all contexts of health service units.

Postpartum hemorrhage was a preventable cause of death of women which still occurred in every level of service unit. The availability of simple, low cost, accurate, and widely distributed health service technology will promote gender equality and provide affordable high quality healthcare for all women.

Even though the Maternal Mortality Rate (MMR) of Thailand was below the SDGs target in 2030, it affected the health and well-being of children in all aspect and their families. The development of blood loss collection bags aimed to reduce the preventable causes of mortality (target 3: good health and well-being and target 5: quality education) which many poor and vulnerable women face (target 1: no poverty), in order to improve the standard of care for various levels of health service units for the good health and well-being of children, women and their families.

Development of blood loss collection bags was initially used in Regional Health Promotion Center 3 (HPC 3), then by the advocacy to the policy decision administrator of Maternal and Child Health Board Region 3 which realized that maternal death still occurred in all 5 provinces of this region. They finally declared the policy to use blood loss collection bags in all labor rooms in this region. After that meetings and workshops were conducted to increase the capacity of all related personnel caring for pregnant women to effectively use these bags.

Health Region 3 located in the central part of Thailand, composed of 5 provinces (Nakhonsawan, Phichit, Uthai, Chainat, and Kampheangphet). Women of reproductive age numbered 420,654 people from the overall population of 2,216,116 (19.0%). This region is 300-400 kilometers (4 hours) from Bangkok. The distance from the remote community hospital to a provincial hospital is about 100 kilometers (1.5 hours). Early diagnosis and prompt treatment of PPH is crucial to the survival of patients especially within 30 minutes. After the policy for using blood loss collection bag in all deliveries, the PPH rate decreased from 1.9 to 1.1 percent from 2013 to 2015. This simple innovative technology lead to a decrease in healthcare costs such as treatment of complications, day of admission, opportunity costs and productivity of their families and the community.

The blood loss collection bag is made from 30 x 60-inch rectangular plastic bag, which could be easily found in the market, and Thai people uses it as common usage in Thailand. The plastic bag is split diagonally into a triangle shape. There was a volume scale of 300 milliliters of blood loss at the bottom end of the bag to warn of the urgent treatment of blood loss.

The blood loss collection bag was developed from the prototype of Siriraj Hospital which designed a pentagon shape and cost about 160 baht. HPC 3 then initiated an idea of using the rectangular plastic bag commonly used as a reservoir in the garbage bag in our hospital. Splitting into two triangle bags will have no residual plastic which was the advantage of this design. This saved money (around 30 baht) and support reducing waste and helping combat global warming.

Initially, there was no financial support needed for plastic bag. HPC3 used plastic bag, which was normally used in the hospital, and modified its shape. To retain the bag shape, HPC3 allocated budget to buy plastic bag sealer. The modified blood collection bag was put into gas sterilizer (14 baht/50 bags per time) and sterilized bag can be used before 6 months. After successful implementation in HPC3, the blood loss reduction bag was registered for petty patent in 2015. Then, this initiative was presented to the Maternal and Child Health Board of region 3 adopted and defined it as a policy to implement in all labor rooms in the region. Training (capacity building) was initiated for all levels of health personnel caring for intrapartum and postpartum women. Clinical practice guidelines for PPH was also developed to improve the quality of services, even in remote areas.

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This tool is presented in academic and public health forums as: (1). Poster presentation as an innovation in the 6th National Health Promotion and Environmental Health Conference, September 4-6, 2013, Bangkok, Thailand (2). Oral presentation “Quality of Labor room service” 7th National Maternal and Child Health Seminar. January 27-29, 2015, Bangkok, Thailand (3). Poster presentation in the Ministry of Public Health Academic Seminar, September 27, 2015, Nonthaburi, Thailand (4). Received the Thailand Public Service Awards 2017 in the category of Excellence Innovation Service.

After the policy of using blood collection bags during the delivery process of pregnant women in Health Region 3 and through the presentation in many academic meeting, there were 41 hospitals throughout the country that purchased the bags from our center. However, many hospitals could adapt and produce by themselves by using local materials and so did not need to purchase high cost medical products from foreign countries.

- The blood loss collection bag was introduced as national policy to define every hospital caring of pregnant women using it as a tool to prevent PPH and decrease MMR. - Clinical Practice Guideline for PPH-defined to use blood loss collecting bags during the process of delivery for early diagnosis and prompt treatment. - It is simply designed, low cost, do it yourself and made of a common material that is easily found in the market or community.

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The blood loss collection bag was accepted by regional maternal and child health boards to use as a tool to improve the quality of services, preventing PPH and decreasing MMR. Monthly maternal mortality rate was collected by labor room personnel and reported to their health area via Health Data Center. Satisfaction survey was collected from site visit in health region 3 only. The same set of questionnaire survey was sent to further area to get evaluation from the personnel in labor room as well. The evaluation of personnel satisfaction on bag usage was 88.16%, appropriate size of bag 88.16% and sensitivity to detect hemorrhage and initiate prompt treatment was 91.43%.

During the implementation period (2014-2017) the MMR showed a good trend as 3, 0, 1, 0 case per 100,000 live births respectively. The rates of PPH in the first 48 hours were 1.9, 1.7, 1.1 and 1.7 percent respectively during the same period.

Overall indicators used were the maternal mortality ratio during the first 42 days after delivery and postpartum hemorrhage in first 48 hours of more than 500 milliliters.

Prevention of PPH was advocated and mobilized through the network of partnerships and stakeholders. At the community level, groups of people and health volunteers were empowered to seek and provide primary care for all pregnant women in the village. Local administrative authorities and schools cooperate with government and private hospitals to provide integrated holistic care for pregnant women and their families in order to increase knowledge and health literacy on the risk of complicated pregnancies and delivery. Private manufacturers of blood loss collection bags (SA modern line companies) coordinated with the developing team to produce the most practical and low cost model. All health personnel and service units which use this bag will record and report the efficiency of the bag, also the levels of PPH and the results of management to policy level of the region and country.

Our success and what we have learned, was developed by knowledge management processes to solve problems and improve the efficiency of our routine work. Beginning from the patient care team (PCT), the obstetrics unit was concerned about PPH, the leading cause of maternal death. They coordinated with a multidisciplinary and partnership approach. The blood loss collection bag is one of the initiatives to prevent maternal death. This innovation is accessible since the cost is very cheap and it helps decreasing patient’s health care and financial burden in post-partum period. We finally realized that morbidity and mortality of pregnant women occurs not only in the labor room, but we had to cooperate with other stakeholders such as local administrative authorities, schools and the community to work together to promote protective factors, decrease risk factors of maternal death and ultimately raise the health literacy of the people and the community.