Postpartum Haemorrhage

Placenta previa is the placement of the placenta in the inferior segment of the uterine cavity. This defective implantation of the placenta is in most cases due to a defective vascularization of the decidua. Multiparity, great mother’s age, previous abortions, previous caesarean section, multiple pregnancy, fetal abnormalities, leiomyoma uteri act., constitute some risk factors that favor the development of placenta previa. In report to the degree of coverage of the internal orifice of the uterus from placental tissue, placenta previa divided into: placenta previa totalis, placenta previa partialis, placenta previa marginalia and low-lying placenta. The dominant clinical signs are vaginal bleeding, which varies from light spotting to heavy bleeding that could seriously endanger the woman’s life. In diagnosing of placenta previa helpsymptoms and signs U/S examination is used for diagnosis with up to 95 percent accuracy. Placenta previa complications appear on 0.5% of all pregnancies. These complications can be; maternal and fetal. All these complications have an effect on the increase of maternal and fetal or neonatal mortality rate. We report a case of a 31-year-old woman admitted to our hospital in the department of Obstetrics and Gynecology with signs and symptoms of placenta previa. One day later, the patient gave birth by caesarean section to a healthy baby, but two hours later, the patient’s condition was complicated by postpartum hemorrhage (PPH). The diagnosis was based on symptoms and signs as continuous bleeding ‘ex utero’, clots in vagina, uterine atony, distended bladder, blood loss greater than 1,000 ml, there were signs of a clinically apparent shock. Using a conservative approach such as the application of uterotonic drugs and uterine massage, we managed to save the uterus of the patient.

Keywords: placenta previa, postpartum hemorrhage

To the Editor:
I have now delivered 550 consecutive births using
expedient delivery of the placenta and uterotonics when
needed according to Judy’s 3,4,5 minute protocol (1)
with no postpartum hemorrhage over 1,000 cc and only
3 over 500 cc. Blood loss less than 200 cc was estimated
and blood loss over 200 cc was measured in a
measuring cup. Among 550 births, the average maternal
age was 28.4 years, average birthweight 3,350 g,
average live birth order 3.4, and average blood loss of
129 cc during the first 2 hours postpartum. Among 104
primiparous births, the average maternal age was
23.8 years, the average birthweight 3,166 gm, and the
average blood loss of 150 cc during the first 2 hours
postpartum. While 95 percent of women needed no
uterotonics, 5 percent of women received one dose of
either intramuscular Pitocin or Methergine at 10 minutes
postpartum (largely primiparous or vaginal births
after a cesarean). Two women underwent manual
removal at 30 minutes postpartum. The protocol is as
follows:
Judy’s 3,4,5 protocol: At the 36-week prenatal visit,
the midwife squats in front of the client to teach and
demonstrate to her exactly how she will deliver her placenta
5 minutes after the birth. The client’s consent is
obtained.
Immediate continuous skin-to-skin contact with the
baby is initiated for the first 3 1⁄2 minutes postpartum.
The cord is cut at exactly 3 minutes postpartum while
the baby is in her mother’s arms. The midwife keeps
hands off the fundus and the cord. At 4 minutes: The
midwife assists or directs the mother, as necessary, into
a squatting position on the floor with both feet flat on
the floor or on the floor of an empty bathtub. The
mother hands over the baby to someone or baby waits
on the bed for 1 minute. The midwife encourages the
woman to push out the placenta without a contraction.
It is helpful to say things like: pushing out the placenta
prevents bleeding and that the placenta is right there,
ready to deliver. The woman is in a squatting position
while she pushes out and delivers the placenta. The
time of delivery is noted. Immediately after delivery of
the placenta, the mother is dressed with a sanitary pad,
assisted into the bed, and immediately given the baby.
The uterus is massaged once immediately to check for
clots.
If bleeding is above average during the next 5 minutes,
a shot of either 10 l Pitocin, 0.2 mg methergine
intramuscularly, or both is given at 10 minutes postpartum.
Early suckling at the breast is initiated, which
generally takes place between 10 and 45 minutes postpartum
depending on the baby.
The protocol prevents postpartum hemorrhage by
expediently delivering the placenta, which allows the
uterus to expediently contract, closing off the blood
vessels that cause postpartum hemorrhage from uterine
atony. It decreases the need for manual removal and
situates the mother/baby dyad on a clean dry bed at
5 minutes postpartum, which is conducive to bonding.
Two examples of Judy’s 3,4,5 protocol being performed
appear on YouTube. I would very much like to
hear from other practitioners who are willing to test
this protocol in their own practices.
Judy Slome Cohain, CNM
Private Practice, Alon Shvut, Israel
Address correspondence to Judy Slome Cohain, CNM;
email: [email protected]

Postpartum hemorrhage is a major cause of maternal mortality and morbidity. The purpose of this study is determine the effectiveness of uterine massage on uterus involution and lochia rubra in the first postpartum 24 hours after vaginal birth. This is an experimental clinic study and the study sample consisted of a total of 60 women 30 in the study group and another 30 in the control group. Those in the study group received uterine massage for 45 seconds in the first hour postpartum with 15-minute intervals and it was then continued for 45 seconds hourly until the 12 th hour postpartum. The findings were evaluated at the 24 th hour. The total amount of lochia in 24 hours for the women in the study group (117. .09 g) was less than the total amount of lochia obtained from the control group (147. .75 g.) and this finding was found to statistically significant (t=-2.826, p=0.007<0.05). Fundus height at the 24 th hour postpartum for the women in the study group (1. .20 cm) was lower than the umbilicus when compared to the fundus height of the women in the control group (1. .95 cm); however, no statistically significant difference was detected (F=1.997, SD=3, p=0.116>0.05). In conclusion, the total amount of lochia throughout the 24 hours postpartum after vaginal birth in the study group was lower than the total amount of lochia for the control group.

Parturition is considered a clean contaminated event. Problems following parturition such as retained placenta [1,2] , endometritis [3,4] and genital prolapse [5] have negative effects on the ovarian function of postpartum buffalo cows whereas problems such as metabolic disorders [6] and mastitis result in lowered overall production [7]. The immediate few days or weeks postpartum can be particularly problematic in cattle which readily develop diseases related to placental expulsion, metabolism, mammary glands and reproductive tract [8] and similar problems may appear in the buffalo. The complications of the reproductive tract during the postpartum period include hemorrhage, vulval hematoma, lacerations, reproductive organ (vagina, uterus) rupture, perineal injuries, distal displacement of pelvic organs (vagina, uterus, urinary bladder, perivaginal fat) and retained placenta [9] whereas those of metabolism include milk fever, hypophosphatemia and ketosis [10]. The complications of mammary gland include conditions such as udder edema, hemolactia, hypogalactia and mastitis [11]. Some of these problems can arise even after a normal parturition while others follow an abnormal parturition. Parturient injuries of the reproductive tract are less prevalent in the buffalo [9] probably due to a lower frequency of improper cervical dilation even in buffaloes suffering from dystocia [12,13]; the same is true for metabolic disorders [6,10] and mammary disorders [11]. Season affects the incidence of reproductive disorders [14] and similar effects are observed in relation to body weight changes at parturition (negative energy balance) [15] and agro-ecologic location [16]. There is a significant effect of management practices on the incidence of postpartum reproductive disorders [17]. Body condition score at calving can affect the incidence of calving disorders in buffaloes [18]. Pluriparous buffaloes with a medium condition score show the least incidence of disorders compared to thin and fat primiparous and pluriparous buffaloes. The period of calving and parity have a significant effect on postpartum complications such as pyometra and endometritis [19-21]. Similar effects of environmental temperature were recorded in the buffalo [22]. Different research analyses/surveys have mentioned the relative frequency of reproductive tract disorders during the postpartum period (Table 1) in buffaloes [20], however, disorders related to metabolism and the mammary gland are usually not mentioned in these reports. Table 1. Relative Incidence of Postpartum Disorders in Buffaloes in Different Studies

Background. Iron suplement programs, as an approach to overcoming anemia, indicate positive impact although many studies have also noted varying levels of success or even a failure. The known and commonly acknowledged side effect of iron supplements, such as constipation, causes a tendency for patients to stop consuming these supplements. Aim: To examine hemoglobin level and bowel movement differences resulting from an iron suplement program of the government program as well as consumption of the date fruits, and two common products freely available to the Indonesian consumers. Method. This study is a pilot randomized controlled trial with four groups consist of three treatment groups and one control group. Respondents were anemia adolescent girls with inclusive but not exclusive criteria. 40 respondents were selected using random permutated blocks. Intervention was done for 30 days with weekly assessments. Data analysis used Friedman Test, Wilcoxon Signed Rank and Multiple Linear Regression test. Results. There is a significant hemoglobin difference before and after intervention on the four groups. The differences seen in week 1, 2, 3, then tends to decline. Strong, significant correlation is found in treatment with hemoglobin and defecation duration (week 4) and bowel problems (week 2, 3, 4); feeding frequency and menstruation with hemoglobin (week 1); feeding frequency and defecation duration (week 2); water intake and defecation duration (week 4). Multiple linear regression analysis results in regression equation and participants' prediction towards dependent variables. There is a positive, significant relationship between treatment (week 2, 3) and bowel problems, water intake (week 4) and defecation duration. Conclusion. Dates can be used instead of iron tablets and 7dates can be used as a companion iron tablets.

This paper presents a physiologically based theory that describes, explains and predicts the mechanisms by which skin-to-skin contact and breastfeeding at birth may reduce the incidence of PPH (Key terms are defined in table 1).  The ideas for this theory have their roots in the practice, wide reading and writing of three authors of this paper.  The overall focus of this paper is on the neuro-hormonal control of the myometrium, including the regulation of uterine contraction and retraction that is essential to minimise blood loss in the 3rd and 4th stages of labour.  First, the background literature concerning the importance of the 3rd and 4th stages of labour is presented. Next, the structure and function of the myometrium is summarised.  Then, the functioning of the autonomic nervous system, as it relates to the uterus is described. Attention is then narrowed to the key neuro-hormonal factors, oxytocin and adrenaline/noradrenaline, which interact to affect the functioning of the uterus during the birthing process. The discussion section integrates this knowledge to explain and predict the physiological functioning of the uterus during 3rd and 4th stage labour both when skin-to-skin contact and breastfeeding occurs, and when they do not.

Introduction: Postpartum Hemorrhage (PPH) in Egypt Especially in Rural Area is still one of the main Causes Responsible For maternal morbidity and mortality. It still needs a radical Solution. Aim Of The Work: Evaluation of Lower Uterine Segment Post Partum Hemorrhage Management by Cervical suture, B-Lynch suture and Foley balloon and to evaluate the efficacy and safety of a novel cervical suturing technique. Patient&Methods: This study included 9860 patients in obstetric department for delivery in Banha teaching hospital. It include 30 pregnant women (primigravide and multigravide) in labour admitted to obstetric ward complaining of (PPH).This study was classified into 3 Groups .Group (I): Ten cases were managed by cervical suture in vaginal delivery with cervical tear and laceration. Group (II): Ten cases were managed by B-Lynch suture 7 of them delivered by CS & 3 of them delivered by vaginal delivery then hysterotomy was done to them. Group (III): Ten cases were managed by Foley balloon after vaginal delivery or caesarian section. Results: The mean (± SD) parity for PPH cases in this study was 1.53±1.13 times with a range of 0–7 times. The group representing primigravidas with postpartum hemorrhage was 43.3% of cases, while the group with parity ranging from 1– 4 was 50% of the PPH cases. Finally the group of cases with parity greater than 4 represented 6.7%. The treatment modalities for PPH applied in Banha teaching hospital included ecbolics, uterine massage and bimanual compression in all cases. Repair of trauma was applied in 33, 3%. Replacement with blood and blood products was done in cases with DIC which represented 3.3%, & hysterectomy was done in 3 cases as a last resort measure. Conclusion and Recommendation: The study added an evidence to confirm the world wide applicability of the cervical suturing as a method to improve the management of lower uterine segment PPH .The technique of that suture is easily learned and its popularization therefore, might be a must.

Commentary and hypothesis on paper . In this hypothesis, we propose that all women who have had previous caesarean sections should have a transvaginal scan examination between 6 and 8 weeks of gestation in any subsequent pregnancy. The purpose of this scan would be to identify the implantation site of the gestational sac. If the scan showed that the sac was implanted in the fundus, this should rule out the possibility of a scar pregnancy and the potential of placenta accreta in a woman with a previous scar. The other possibility is that of a low or isthmic gestational sac. This has a higher chance of adverse events, includ- ing miscarriage, scar pregnancy and placenta accreta. Women with a low gestational sac would be categorised as higher risk and require further evaluation and monitoring.

This paper aims to introduce the method for detection and classification of an abnormality of the brain region into infarct, haemorrhage. Initially, the image is pre-processed to remove film artifact, noise using morphological operations. And the brain image is cropped to eliminate the extra parts. Before the abnormality region (infarct, haemorrhage) is segmented, the image is pre-segmented. In this stage, the image is subdivided into four quadrants using split and merge technique to find the region that has the possibility for inclusion of abnormal areas. Thus, the unnecessary regions are no need to search and segment. This paper proposes pre-processing and pre-segmentation steps for the detection of abnormal region in the brain image. Then, abnormalities can be segmented by grouping homogeneous regions according to the predefined criteria. The accuracy of the segmentation results can be assessed by the specialist.

The prevalence of postpartum haemorrhage (PPH) in Jos, plateau state has not been well documented in recent times. This study was conducted to determine the prevalence of PPH among women who were delivered of their babies in Plateau Specialist Hospital between 2010 and 2012. A retrospective study was adopted and 4552 files of women that delivered in the hospital were reviewed. Findings revealed that 65 women were diagnosed with PPH and was common among women between 25 and 34 years of age.  Uterine laceration, uterine atony and retained products are the main causes of PPH in the study area. Further, the incidence of PPH was low as well as the overall prevalence in the three years considered. It was recommended that the current practices of active management be sustained and women between 25 and 34 years that come to deliver should be given special care.

KEYWORDS- Prevalence, Postpartum haemorrhage, Plateau State Specialist Hospital

The off-label use of the drug misoprostol has effectively turned homebirths in ‘resource-poor’ nations into unmarked and un-enunciated zones of experimentation. Misoprostol has become the public health solution in response to medico-humanitarian discourses that construct homebirths as responsible for high maternal mortality. In the absence of proper safety tests, advocating its routine administration against postpartum haemorrhage in homes around Pakistan functions to erase the distinction between service delivery projects and experimentation. Drawing on ethnographic research in Balochistan, I argue that promoting misoprostol in contexts of structural inequality, particularly where excessive artificial labour induction prevails, constitutes the enactment of a kind of ‘medical relativism’. This medical relativism entails an experimental practice that burdens poor women with undue risk as misoprostol becomes a substitute for required structural and economic transformation of Pakistan's healthcare system. Overall, the paper concludes, the contemporary faith in pharmaceuticals perpetuates a colonial governmentality of bodies, medicines, and healthcare.

Background: Obstetric fistula is a public health problem in the developing world. Surgical repair is the mainstay of treatment. Blood transfusion is not a common practice in fistula surgery. The study aims to determine the rate as well as the predisposing factors for blood transfusion among women who had fistula repair. Methodology: This was a hospital-based retrospective study carried out at the National Obstetric Fistula Centre, Abakaliki, Nigeria. Relevant information was obtained from the records of women who had fistula surgery from December 2008 to June 2014. The information was transferred into a proforma and presented in tables. Data was analysed using SPSS Version 20. The means were compared using the student's t-tests. A P-value of less than 0.05 was considered significant. Results: Out of 1728 women who had surgery for obstetric fistula, 26 were transfused peri-operatively giving a rate of 1.5%. Out of these, 25 (96.2%) presented with residual fistulae for repeat surgery. All the 26 (100%) women had complicated fistulae. The commonest types of fistulae among the women that were transfused were ureteric (19.5%), intracervical (19.5%) and juxtacervical (19.5%) fistulae. The mean estimated blood loss for women who had transabdominal repair was 539 ml while that for those who transvaginal repair was 494 ml. The difference was not statistically significant (t-value=0.7803, two-tailed p-value=0.4577). Conclusion: Peri-operative blood transfusion among women with obstetric fistula is an uncommon practice. It is more likely among women with residual fistulae undergoing repeat surgery, complicated fistulae and women with were ureteric, intracervical and juxtacervical fistulae.

Objective: To examine the effect of skin-to-skin contact and breastfeeding within 30 minutes of birth, on the rate of primary postpartum haemorrhage (PPH) in a sample of women who were at mixed-risk of PPH. Design: Retrospective cohort study Setting: Two obstetric units plus a freestanding birth centre in Australia. Participants: After excluding women (n=3671) who did not have opportunity for skin to skin and/or breastfeeding, I analysed deidentified birth records (n=7548) extracted from the electronic data base ObstetriX for the calendar years 2009 and 2010. Intervention: Skin and breastfeeding within 30 minutes of birth. Measures: Outcome measure was PPH i.e. blood loss of 500ml or more estimated at birth. Data was analysed using descriptive statistics and logistic regression (unadjusted and adjusted). Findings: After adjustment for covariates, women who had neither skin to skin contact nor breastfeeding were almost twice as likely to have a PPH compared to women who had both skin...

This narrative review discusses the history of the pathophysiologic principles and utilization of point-of-care (POC) viscoelastic tests (VETs) in the definition and treatment of postpartum hemorrhage (PPH). This paper addresses the epidemiology of PPH, describes the hemostatic changes that occur in pregnancy and in PPH, and demonstrates the utilization of viscoelastic testing in the identification and treatment of patients with PPH. Additionally, a description of rotational thromboelastometry (ROTEM) and thromboelastography (TEG), the two most commonly used VETs, is detailed in this paper. VETs have only recently been used to guide blood component therapy (BCT) in trauma in the last decade. The recent increased utilization of VETs to guide BCT in PPH is following a similar trend with a delay of ten years. In a similar fashion to the trauma literature, which expanded greatly within this last decade, the literature concerning the use of VETs in PPH has also increased in the last few years. However, because of differing pathophysiologies associated with the coagulopathy of PPH verses traumatic-induced coagulopathy (TIC), utilization of VETs has been more refined and focused on the VETs' capacity to determine low fibrinogen and to guide the utilization of blood components and prohemostatic agents. The identification and treatment of PPH depends on clinical parameters, conventional coagulation tests (CCTs) including Clauss fibrinogen, and VETs. Successful treatment of PPH will no doubt include utilization of all three strategies with an increasing utilization of VETs in the future.

This paper is about a drug called misoprostol and its controversial clinical and social lives. Though originally developed as a treatment for gastric ulcers, in the 1980s it developed an off-label reputation as an abortifacient. The drug’s association with clandestine abortion has profoundly shaped its social life as a marginal and suspect character in the realm of global maternal and reproductive health where it has the potential to prevent two major causes of maternal death – post partum haemorrhage and unsafe abortion.  The social life of misoprostol has also been shaped by the question of authoritative practice, that is, the question of who can deliver medicine. Both issues are about the specters of misuse of misoprostol: off-label, illegal, immoral, or by unlicensed providers.  In this paper I focus ethnographically on two women’s health NGOs that have been conducting clinical testing and advocacy for the use of misoprostol for reproductive indications in global maternal health settings.  Drawing on the notions of pharmaceutical activism and protocol feminism, I describe and analyze how the tools of evidence and authoritative practice are being re-assembled in new networks of expertise towards the social justice goals of life, access and dignity for women.

The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. This biologically based theory hypothesises that to achieve and maintain eutony and eulochia,...

This study sought to investigate the management and strategies utilized by nurses in the control of postpartum hemorrhage among pregnant women in UCTH. In order to successfully carry out the study, the following research questions and hypotheses were formulated. What is the proportion, proper management strategies   utilized and the causes of postpartum hemorrhage among pregnant women in UCTH? The research instruments used in collecting data for analysis was in parts, records from the hospital and a four point likert scale questionnaire which was administered on 57 nurses used as sample for the study. Their responses were analyzed using appropriate statistic and the following results were obtained. Only   12   cases   of   postpartum   hemorrhage   were recorded out of 1952 cases of labour registered in 2017 in UCTH. Management strategies utilized by the nurses in the control of postpartum haemorrhage in UCTH. Prolonged labour, disease conditions, multiparity with lax uterine muscle...

Background: Secondary Postpartum Haemorrhage (SPPH) refers to any abnormal vaginal bleeding between 24 hours to 6 weeks postpartum. SPPH is a relatively unexplored issue and there is limited evidence, especially regarding risk factors. The aim of this study was to identify risk factors for SPPH. Method: Patients readmitted with a diagnosis of SPPH between 2014 and 2018 at a tertiary hospital in Queensland, Australia were identified. These patients were compared with randomly selected controls that gave birth via vaginal delivery and caesarean section at the centre during the same time period. Logistic regression analyses were applied for categorical variables and T-test along for continuous variables. Results: 110 cases of SPPH were identified and 225 patients that did not have SPPH were randomly allocated as controls. Incomplete placenta (p=0.005), Antepartum Haemorrhage (APH) (p=<0.00), antepartum (p=0.004) anticoagulation, along with previous obstetric complications (p=0.036) were found to be statistically significant risk factors for SPPH. Previous obstetric complications include conditions such as primary PPH, gestational diabetes and pre-eclampsia. Demographic factors of age and ethnicity did not express any predisposition to SPPH along with other factors such as BMI, parity and plurality. The average estimated blood loss within 24 hours of delivery in the SPPH case group was 350ml and control group was 300ml (p=0.038). Conclusion: This study confirms that incomplete placenta, APH, antepartum anti-coagulation and previous obstetric complications are risk factors for secondary postpartum haemorrhage. Early identification of these risk factors could potentially prevent SPPH, allowing a safer postnatal journey for mothers.

Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack n...

Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack n...

Durable solutions for daunting problems in global health can be elusive. The global health literature tends to present aggregated data and highlight clinical outcomes but fails to describe the systems that buttress the interventions. The common idiom about "missing the forest for the trees" is apropos: by focusing on individual examples, we may miss the bigger picture. How implementation of policies and innovations plays out on the front lines of service delivery often goes uncommunicated. The Networks of Care scoping study takes a different approach, looking at diverse programs to seek out common patterns. Using the four domains of the Networks of Care framework to structure descriptions of six operational programs reveals commonalities in their designs and shows the utility of the framework's components. The commonalities increase our conviction that the framework can be used as a practical approach to strengthen service-level health systems. The case studies are followed by a commentary about the potential synergy of Networks of Care with Universal Health Coverage efforts, to deliver on the core promises to increase access and quality of care for all, especially the persistently underserved. These case studies help define a practical toolkit to promote enduring positive changes, forging a path for the Networks of Care framework to move anecdotes of individual successes to health policy and broader implementation, enabling global health practitioners at all levels to keep the big picture in focus while working toward ensuring healthy lives and well-being for all.