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I'm not an expert in this area, but it would seem that this study is an encouraging development in a very important area.

Over the research period in Niger, an estimated 1,417 fewer women died from bleeding after childbirth - known as postpartum haemorrhage (PPH) - than otherwise would have.

It also prevented tens of thousands of other women from experiencing abnormally high blood loss.

PPH now accounts for one in 10 of maternal deaths in Niger, whereas before the project began it accounted for more than three times that.

Summary of the Lancet article about the study:


Primary postpartum haemorrhage is the principal cause of birth-related maternal mortality in most settings and has remained persistently high in severely resource-constrained countries. We evaluate the impact of an intervention that aims to halve maternal mortality caused by primary postpartum haemorrhage within 2 years, nationwide in Niger.


In this 72-month longitudinal study, we analysed the effects of a primary postpartum haemorrhage intervention in hospitals and health centres in Niger, using data on maternal birth outcomes assessed and recorded by the facilities’ health professionals and reported once per month at the national level. Reported data were monitored, compiled, and analysed by a non-governmental organisation collaborating with the Ministry of Health. All births in all health facilities in which births occurred, nationwide, were included, with no exclusion criteria. After a preintervention survey, brief training, and supplies distribution, Niger implemented a nationwide primary postpartum haemorrhage prevention and three-step treatment strategy using misoprostol, followed if needed by an intrauterine condom tamponade, and a non-inflatable anti-shock garment, with a specific set of organisational public health tools, aiming to reduce primary postpartum haemorrhage mortality.


Among 5 382 488 expected births, 2 254 885 (41·9%) occurred in health facilities, of which information was available on 1 380 779 births from Jan 1, 2015, to Dec 31, 2020, with reporting increasing considerably over time. Primary postpartum mortality decreased from 82 (32·16%; 95% CI 25·58–39·92) of 255 health facility maternal deaths in the 2013 preintervention survey to 146 (9·53%; 8·05–11·21) of 1532 deaths among 343 668 births in 2020. Primary postpartum haemorrhage incidence varied between 1900 (2·10%; 2·01–2·20) of 90 453 births and 4758 (1·47%; 1·43–1·52) of 322 859 births during 2015–20, an annual trend of 0·98 (95% CI 0·97–0·99; p<0·0001).


Primary postpartum haemorrhage morbidity and mortality declined rapidly nationwide. Because each treatment technology that was used has shown some efficacy when used alone, a strategic combination of these treatments can reasonably attain outcomes of this magnitude. Niger's strategy warrants testing in other low-income and perhaps some middle-income settings.


The Government of Norway, the Government of Niger, the Kavli Trust (Kavlifondet), the InFiL Foundation, and individuals in Norway, the UK, and the USA.


For the French translation of the abstract see Supplementary Materials section.





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Thanks so much for flagging this - I had seen this on BBC but this has pushed me to follow up! Here's a bunch of not so ordered thoughts.  As background I'm a doctor who manages rural health centers, some of which deliver babies.

  1. The benefit claimed in this study is insane. A 50% drop in bloodloss related maternal mortality is beyond the pale of almost any recent medical intervention. It's important to remember though that this effect cannot be all be attributed t the nterventno is not only not a RCT, but there is no control group. Having a control group here was impossible for ethical reasonsbecause the intervention was already proven to have benefit

    There will have been other developments during the 5 years of the study that contributed to the 50% drop in maternal mortality, apart from their intervetions. As one concrete example according to the worldbank fertiility rates have reduced in NIger from 7.2 too 6.8 during the study period, which of itself will have reduced maternal mortality  by a small percentage. Also their statement "Niger has not seen changes in its population's socioeconomic status or infrastructure that could affect the results."  seems inaccurate as Niger's GDP has increased by about 15% in that time. 

    Also they claim that surrounding countrys' maternal mortality rate has not decreased in that time, which seems almost impossible given the trend of maternal mortality reducing (if at a far slower rate). For example below is modelling estimating that bordering country Niger's mortality rate reportedly dropped by around 15% during the study period. Of course data are limited.

    Modeled maternal mortality ratio from 2014 to 2023 in Mali, based on three different LiST projections


It however seems  likely their intervention had a big effect, but I feel like they could have put a bit more effort in achknowledging these confounders. EAs would conservatively and heavily discounted for these kind of things, but they barel acknowledged them in this study.

2. This intervention is probably very cost effective, while keeping in mind that they haven't accounted for other potential causes or discounted at all. From the study "the financial benefits to the population have been roughly estimated to be 5·7–7·8 times the annual running cost of the intervention, costing about US$37·94–27·73 per disability-adjusted life-year prevented (appendix pp 7, 17–24), more than Expanded Program on Immunization vaccination, but less than treating diarrhoea or acute respiratory illness in children younger than 5 years.". Seems pretty good. Also these kind of country AID funded programs usually have massively bloated costs. I'm sure many orgs could do it much cheaper, perhaps even at half the cost or less which leaves room for increased cost-effectveness.

3.This study will immediately change my practice. The main intervention, giving misoprostol after every delivery isn't standard practise in Uganda at the moment but is super easy and cheap to implement. Just making sure everyone uses misoprostl could potentially be an excitng intervention of EA level cost-effectiveness. I don't have the time but someone SHOULD look int ths.  This study will prompt me to start doing this within the next couple of months at the 5 health centers we manage which deliver (low numbers) of babies. 

Interested to hear more comments about this.

Just flagging that (in NZ at least), misoprostol is not given routinely for prevention of PPH. That's probably because there's access to IV oxytocin, so if you already have that in your practice then it's probably worse for patient outcomes to change to misoprostol.[1] If there's no access to IV oxytocin though, then misoprostol is recommended as second line recommendation by other bodies (FIGO 2022).

Alongside access to ecbolics, fairly simple things like active management of third stage of labour is probably pretty important in reducing PPH (my guess is the NNT of active management is probably comparable or lower than administering misoprostol for PPH prevention, though I'm less sure about the cost-effectiveness of scalable interventions in these areas).

  1. ^

    Note this also seems to be true for management of PPH.

Thanks so much for this Bruce - I had completely missed the fact that oxytocin was still clearly better - our faciities which deliver babies (apart from one) have fridges and already use that, although we don't have standard practice of using it for every delivery which we should! (We use for most). I know that's a bad miss by me. 

So it seems like if you have a fridge - Oxytocin (it's cheap anyway), and if not misoprostol.

Thanks so much again. In my defence I would have talked to the midwives and would have read guidelines before making that mistake anyway.

Thanks for sharing this! As someone who identifies as an EA, I feel that it's important to be familiar with a wide range of problems in the world, and this alerted me to a new one (and some amazing news!). 

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