The Barriers to the Integration of the Uterine Balloon Tamponade into South Africa and Ghana's Health Systems for the Management of Postpartum Hemorrhage

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.

Dynamics of the Disk-Pendulum Coupled System With Vertical Excitation

This paper investigates the static and dynamic characteristics of the semi-elliptical rocking disk on which a pendulum pinned. This coupled system’s response is also analyzed analytically and numerically when a vertical harmonic excitation is applied to the bottom of the rocking disk. Lagrange’s Equation is used to derive the motion equations of the disk-pendulum coupled system. The second derivative test for the system’s potential energy shows how the location of the pendulum’s pivotal point affects the number and stability of equilibria, and the change of location presents different bifurcation diagrams for different geometries of the rocking disk. For both vertically excited and unforced cases, the coupled system shows chaos easily, but the proper chosen parameters can still help the system reach and keep the steady state. For the steady state of the vertically excited rocking disk without a pendulum, the variation of the excitation’s amplitude and frequency result in the hysteresis for the amplitude of the response. When a pendulum is pinned on the rocking disk, three major categories of steady states are presently in the numerical way.

In Whose Image: The Emergence, Development, and Challenge of African-American Evangelicalism

The current era of American Christianity marks the transition from a Western, white-dominated U.S. Evangelicalism to an ethnically diverse demographic for evangelicalism. Despite this increasing diversity, U.S. Evangelicalism has demonstrated a stubborn inability to address the entrenched assumption of white supremacy. The 1970s witnessed the rise in prominence of Evangelicalism in the United States. At the same time, the era witnessed a burgeoning movement of African-American evangelicals, who often experienced marginalization from the larger movement. What factors prevented the integration between two seemingly theologically compatible movements? How do these factors impact the challenge of integration and reconciliation in the changing demographic reality of early twenty-first Evangelicalism?

The question is examined through the unpacking of the diseased theological imagination rooted in U.S. Evangelicalism. The theological categories of Creation, Anthropology, Christology, Soteriology, and Ecclesiology are discussed to determine specific deficiencies that lead to assumptions of white supremacy. The larger history of U.S. Evangelicalism and the larger story of the African-American church are explored to provide a context for the unique expression of African-American evangelicalism in the last third of the twentieth century. Through the use of primary sources — personal interviews, archival documents, writings by principals, and private collection documents — the specific history of African-American evangelicals in the 1960s and 1970s is described. The stories of the National Black Evangelical Association, Tom Skinner, John Perkins, and Circle Church provide historical snapshots that illuminate the relationship between the larger U.S. Evangelical movement and African-American evangelicals.

Various attempts at integration and shared leadership were made in the 1970s as African-American evangelicals engaged with white Evangelical institutions. However, the failure of these attempts point to the challenges to diversity for U.S. Evangelicalism and the failure of the Evangelical theological imagination. The diseased theological imagination of U.S. Evangelical Christianity prevented engagement with the needed challenge of African American evangelicalism, resulting in dysfunctional racial dynamics evident in twenty-first century Evangelical Christianity. The historical problem of situating African American evangelicals reveals the theological problem of white supremacy in U.S. Evangelicalism.