Bleeding Adolescent Girls

                                 Girls and Women Endangered by Premature Births and Post-Partum Hemorrhage in Uganda

Simon Mugudde – MAKEXAFRICA – Jinja: Uganda has a high rate of preterm births, with 14% of babies being born before 37 weeks, and 13.6 per 1,000 live births. Preterm births are the leading cause of neonatal deaths, accounting for 28–31% of all neonatal deaths, and are directly responsible for 8/27 neonatal deaths per 1,000 live births. Approximately, 226,000 babies are born preterm each year, with 11,000 born before 28 weeks, and 5,700 impaired survivors.

Iron deficiency is the most common cause of anemia during pregnancy in Uganda, and is a risk factor for premature birth and infant mortality. In low- and middle-income countries, maternal anemia is responsible for 12% of low birth weight, 19% of preterm birth, and 18% of perinatal mortality. Other risk factors for anemia include: intestinal parasites and unprotected drinking water. Moderate and severe anemia can also be associated with maternal HIV infection, maternal blood transfusion, neonatal death, and decreased placental thickness. Red blood cell (RBC) transfusions are a key treatment for anemia of prematurity. RBCs stored for up to 42 days since donation are safe and effective for small volume transfusions. Other risk factors for premature births in Uganda include high rates of malaria transmission and adolescent births.

Post-Partum Hemorrhage (PPH) is the leading cause of maternal deaths in Uganda, accounting for 35% of all maternal deaths in the country, with an incidence of 9%. The soon-to-be released Uganda Clinical Guidelines, 2022, and the Essential Maternal and Newborn Clinical Care Guidelines, 2022, recommend Heat Stable Carbetocin (HSC), oxytocin or misoprostol for the prevention of PPH and oxytocin or Tranexamic Acid (TXA) for its management. One in three women have anemia in pregnancy. Risk of PPH when anemic is 50%. PPH Case fatality 2.3%, and PPH is responsible for 34% of all maternal deaths reviewed. Hemorrhage was the leading cause of death across all levels of health care with the biggest contribution at health center II and III levels.

Tranexamic acid is also included in the Essential Medicines and Health Supplies List for Uganda (EMHSLU) 2016. In Uganda, tranexamic acid is available as Transamin injection, Transamin 250 and 500mg tablets, Hemsamic 500mg tablets, Tranlok 500mg tablets and Tranlok injection. Tranexamic acid offers an additional benefit above and beyond what is being done for women already. Further, uterotonics, including oxytocin, are widely used in Uganda. In lower-level health facilities in Central Uganda, 97.4% of women received a uterotonic for the prevention of PPH, with oxytocin being most commonly used. Oxytocin is also widely available in the Ugandan public health sector, with 90% of public health facilities reporting its availability. However, the availability falls below the World Health Organization benchmark of 80% in private health facilities (52%) and non-government organizations (NGO) or faith-based institutions (63%). Similarly, while misoprostol is 88% available in public health facilities, it is only 50% and 55% available in private and NGO/faith-based facilities. Private medicine outlets, including pharmacies and drug shops, play a critical role in plugging such gaps in the public health supply chain. However, a study done in private medicine outlets across four districts in Uganda found oxytocin to be available in only 37% of the private outlets.

The Uganda National Drug Authority (NDA) drug register indicates that over ten brands of TXA and two brands of HSC are registered for use in the private sector in Uganda. Key players in the private sector include private importers and wholesale pharmacies, clinics and private hospitals. Procurement and distribution of medicines and supplies in public health facilities is handled by the National Medical Stores (NMS). Engagements with the MOH and the NMS indicate that plans for procurement of HSC and TXA for use in the public sector for financial year 2023-2024 are underway with support from the Government of Uganda and the United Nations Population Fund.