Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Haleema Shakur; Ian Roberts; Bukola Fawole; Rizwana Chaudhri; Mohamed El-Sheikh; Adesina Akintan; Zahida Qureshi; Hussein Kidanto; Bellington Vwalika; Abdulfetah Abdulkadir; Saturday Etuk; Shehla Noor; Etienne Asonganyi; Zarko Alfirevic; Danielle Beaumont; Carine Ronsmans; Sabaratnam Arulkumaran; Adrian Grant; Kaosar Afsana; Metin Gulmezoglu; Beverley Hunt; Oladapo Olayemi; Iain Chalmers; Pisake Lumbiganon; Gilda Piaggio; Tony Brady; Diana Elbourne; Eni Balogun; Tracey Pepple; Danielle Prowse; Nigel Quashi; Lin Barneston; Collette Barrow; Lisa Cook; Lauren Frimley; Daniel Gilbert; Catherine Gilliam; Rob Jackson; Taemi Kawahara; Hakim Miah; Sergey Kostrov; Maria Ramos; Phil Edwards; Tom Godec; Sumaya Huque; Olujide Okunade; Olusade Adetayo; Aasia Kayani; Kiran Javaid; Chrstine Biryabarema; Robert Tchounzou; Mohan Regmi; Kastriot Dallaku; Mateus Sahani; Sayeba Akhter; Nicolas Meda; Anthony Kwame Dah; Olufemi Odekunle; Oluwabusola Monehin; Austin Ojo; Grace Akinbinu; Ifeoma Offiah; Ubong Akpan; Uduak Udofia; Useneno Okon; Ezukwa Omoronyia; Okpe James; Nike Bello; Blessed Adeyemi; Chris Aimakhu; Olufemi Akinsanya; Bamidele Adeleye; Oluwaseun Adeyemi; Kayode Oluwatosin; Abiodun Aboyeji; Abiodun Adeniran; Adebayo Adewale; Noah Olaomo; Lawrence Omo-Aghoja; Emmanuel Okpako; Lucky Oyeye; Francis Alu; John Ogudu; Ezekiel Ladan; Ibrahim Habib; Babasola Okusanya; Olatunde Onafowokan; David Isah; Abalaka Aye; Felix Okogbo; Egbaname Aigere; Mark Ogbiti; Temitope Onile; Olaide Salau; Yinka Amode; Kamil Shoretire; Adebola Owodunni; Kehinde Ologunde; Akintunde Ayinde; Moses Alao; Olalekan Awonuga; Babatunde Awolaja; Omololu Adegbola; Fatimah Habeebu-Adeyemi; Adeyemi Okunowo; Hadiza Idris; Ola Okike; Nneka Madueke; Josiah Mutihir; Nankat Joseph; Babatunde Adebudo; Adeniyi Fasanu; Olugbenga Akintunde; Olufemi Abidoye; Owigho Opreh; Sophia Udonwa; Gladys Dibia; Simeon Bazuaye; Arafat Ifemeje; Aniefiok Umoiyoho; Emmanuel Inyang-Etoh; Sununu Yusuf; Kayode Olayinka; Babalola Adeyemi; Olusegun Ajenifuja; Umar Ibrahim; Yusuf Baffah Adamu; Oluwarotimi Akinola; Grace Adekola-Oni; Paul Kua; Roseline Iheagwam; Audu Idrisa; Ado Geidam; Andrea Jogo; Joseph Agulebe; Joseph Ikechebelu; Onyebuchi Udegbunam; Jacob Awoleke; Oluseyi Adelekan; Hajaratu Sulayman; Nkeiruka Ameh; Nurudeen Onaolapo; Affiss Adelodun; William Golit; Dachollom Audu; Adetunji Adeniji; Folasade Oyelade; Lamaran Dattijo; Palmer Henry; Olabisi Loto; Odidika Umeora; Abraham Onwe; Emily Nzeribe; Bartthy Okorochukwu; Augustine Adeniyi; Emmanuel Gbejegbe; Akpojaro Ikpen; Ikemefuna Nwosu; Abdulrasaq Sambo; Olubunmi Ladipo; Sola Abubakar; Ola Nene Okike; Enyinnaya Chikwendu Nduka; Eziamaka Pauline Ezenkwele; Daniel Onwusulu; Theresa Azonima Irinyenikan; Swati Singh; Amaitari Bariweni; Hadiza Galadanci; Peter Achara; Mohammed Gana; Kiran Jabeen; Ayesha Mobeen; Sadaf Mufti; Maliha Zafar; Basharat Ahmad; Maimoona Munawar; Jeharat Gul; Naseema Usman; Fehmida Shaheen; Mariam Tariq; Nadia Sadiq; Rabia Batool; Habiba Sharaf Ali; Manahil Jaffer; Asma Baloch; Noonari Mukhtiar; Tasneem Ashraf; Raheela Asmat; Salma Khudaidad; Ghazala Taj; Roshan Qazi; Saira Dars; Faryal Sardar; Sanobar Ashfaq; Saeeda Majeed; Sadaqat Jabeen; Rukhsana Karim; Farzana Burki; Syeda Rabia Bukhari; Fouzia Gul; Musarrat Jabeen; Akhtar Sherin; Qurratul Ain; Shahid Rao; Uzma Shaheen; Samina Manzoor; Shabeen Masood; Shabana Rizvi; Anita Ali; Abida Sajid; Aisha Iftikhar; Shazia Batool; Lubna Dar; Shahenzad Sohail; Shazia Rasul; Shamsa Humayun; Rashida Sultana; Sofia Manzoor; Syeda Mazhar; Afshan Batool; Asia Nazir; Nasira Tasnim; Hajira Masood; Razia Khero; Neelam Surhio; Samana Aleem; Naila Israr; Saba Javed; Lubna Bashir; Samina Iqbal; Faiza Aleem; Rubina Sohail; Saima Iqbal; Samina Dojki; Alia Bano; Naseem Saba; Maimoona Hafeez; Nishat Akram; Riffat Shaheen; Haleema Hashmi; Sharmeen Arshad; Rubina Hussain; Sadia Khan; Nighat Shaheen; Safia Khalil; Pushpa Sachdev; Gulfareen Arain; Amtullah Zarreen; Sara Saeed; Shamayela Hanif; Nabia Tariq; Mahwish Jamil; Shama Chaudhry; Hina Rajani; Tayyiba Wasim; Summera Aslam; Nilofar Mustafa; Huma Quddusi; Sajila Karim; Shazia Sultana; Misbah Harim; Mohd Chohan; Nabila Salman; Fareesa Waqar; Shamsunnisa Sadia; Lubna Kahloon; Shehla Manzoor; Samar Amin; Umbreen Akram; Ambreen Ikram; Samina Kausar; Tahira Batool; Brigadier Naila Tahir Kyani; Christine Biryabarema; Ruth Bulime; Regina Akello; Bernadette Nakawooya Lwasa; Joselyn Ayikoru; Christine Namulwasira; Patrick Komagum; Isabirye Rebecca; Nayiga Annet; Nakirigya Nuulu; Elizabeth Nionzima; Rose Bwotya; Margret Nankya; Sarah Babirye; Joseph Ngonzi; Cesar Sanchez; Nkonwa Innocent; Kusasira Anitah; Ayiko Jackson; Elizabeth Ndagire; Dominic Drametu; Grace Meregurwa; Francis Banya; Rita Atim; Uganda Martyrs; Emmanuel Byaruhanga; Hussein Iman; Vincent Oyiengo; Peninah Waigi; Rose Wangui; Faiza Nassir; Musimbi Soita; Rophina Msengeti; Zeinab Zubier; Hillary Mabeya; Antony Wanjala; Henry Mwangi; Brian Liyayi; Evelyn Muthoka; Alfred Osoti; Amos Otara; Veronicah Ongwae; Victor Wanjohi; Bonface Musila; Kubasu Wekesa; Alex Nyakundi Bosire; Alice Ntem; Angeline Njoache; Alice Ashu; Andre Simo; Dorothy Keka; Kenfack Bruno; Amadou Ndouoya; Martin Saadio; Mesack Tchana; Odel Gwan; Pauline Assomo; Venantius Mutsu; Nji Eric; Pascal Foumane; Philemon Nsem; Jeanne Fouedjio; Ymele Fouelifack; Pierre Marie Tebeu; Wisal Nabag; Riham Desougi; Hadia Mustafa; Huida Eltaib; Taha Umbeli; Khalid Elfadl; Murwan Ibrahim; Abdalla Mohammed; Awadia Ali; Somia Abdelrahiem; Mohammed Musa; Mahdi Bushra; Omer Babiker; Hala Abdullahi; Mohamed Ahmed; Duria Rayis; Saeed Abdelrahman Abdelgabar; Gillian Houghton; Andrew Sharpe; Jim Thornton; Nick Grace; Carys Smith; Kim Hinshaw; Dawn Edmundson; Paul Ayuk; Alison Bates; George Bugg; Joanne Wilkins; Clare Tower; Alysha Allibone; Ahmad Kazumari; Anna Danford; Matilda Ngarina; Muzdalifat Abeid; Khadija Mayumba; Magreth Zacharia; George Mtove; Leonard Madame; Anthony Massinde; Berno Mwambe; Sebastian Kitengile Ganyaka; Shyam Gupta; Rabindra Bhatt; Ajay Agrawal; Pramila Pradhan; Nikita Dhakal; Punita Yadav; Gyanendra Karki; Bhola Ram Shrestha; Mwansa Lubeya; Jane Mumba; Willies Silwimba; Isaiah Hansingo; Noojiri Bopili; Ziche Makukula; Alexander Kawimbe; Mwansa Ketty Lubeya; Willard Mtambo; Mathew Ng'ambi; Saimir Cenameri; Ilir Tasha; Aferdita Kruja; Besnik Brahimaj; Leon Kaza; Desire Tshombe; Elizabeth Buligho; Roger Paluku-Hamuli; Charles Kacha; Kato Faida; Badibanga Musau; Herman Kalyana; Phanny Simisi; Serge Mulyumba; Nzanzu Kikuhe Jason; Jean Robert Lubamba; Willis Missumba; Ferdousi Islam; Nazneen Begum; Ferdousi Chowdhury; Rokeya Begum; Farjana Basher; Nazlima Nargis; Abu Kholdun; Shahela Jesmin; Shrodha Paul; Hailemariam Segni; Getachew Ayana; William Haleke; Hassen Hussien; Fikre Geremew; Moussa Bambara; Adolphe Some; Amadou Ly; Roamba Pabakba; Horace Fletcher; Leslie Samuels; Henry Opare-Addo; Roderick Larsen-Reindorf; Kwadwo Nyarko-Jectey; Glen Mola; Malts Wai; Magdy El Rahman; Wafaa Basta; Hussein Khamis; Maria Fernanda Escobar; Liliana Vallecilla; Gabriel Essetchi Faye; Natl Coordinators

doi:10.1016/S0140-6736(17)30638-4

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Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

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Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Haleema Shakur, Ian Roberts, Bukola Fawole, Rizwana Chaudhri, Mohamed El-Sheikh, Adesina Akintan, Zahida Qureshi, Hussein Kidanto, Bellington Vwalika, Abdulfetah Abdulkadir, …

The Lancet (British edition), Vol.389(10084), pp.2105-2116

27/05/2017

DOI: https://doi.org/10.1016/S0140-6736(17)30638-4

PMCID: PMC5446563

PMID: 28456509

Abstract

General & Internal Medicine

Life Sciences & Biomedicine

Medicine, General & Internal

Science & Technology

Background 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. Methods 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 number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1.5%] of 10 036 patients vs 191 [1.9%] of 9985 in the placebo group, risk ratio [RR] 0.81, 95% CI 0.65-1.00; p=0.045), especially in women given treatment within 3 h of giving birth (89 [1.2%] in the tranexamic acid group vs 127 [1.7%] in the placebo group, RR 0.69, 95% CI 0.52-0.91; p=0.008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3.6%] patients in the tranexamic acid group vs 351 [3.5%] in the placebo group, RR 1.02, 95% CI 0.88-1.07; p=0.84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5.3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5.5%] in the placebo group, RR 0.97, 95% CI 0.87-1.09; p=0.65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation. Copyright (C) The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.

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Title: Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial
Creators - without role: Haleema Shakur
Ian Roberts
Bukola Fawole
Rizwana Chaudhri - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Mohamed El-Sheikh
Adesina Akintan - Mother & Child Hosp, Akure, Nigeria
Zahida Qureshi - University of Nairobi
Hussein Kidanto - Muhimbili Natl Hosp, Muhimbili, Tanzania
Bellington Vwalika - Univ Teaching Hosp Lusaka, Lusaka, Zambia
Abdulfetah Abdulkadir - Millennium Engineering and Integration
Saturday Etuk - University of Calabar
Shehla Noor
Etienne Asonganyi
Zarko Alfirevic - Liverpool Womens Hosp, Liverpool Womens NHS Fdn Trust, Liverpool, Merseyside, England
Danielle Beaumont
Carine Ronsmans
Sabaratnam Arulkumaran
Adrian Grant
Kaosar Afsana
Metin Gulmezoglu
Beverley Hunt
Oladapo Olayemi - Univ Coll Hosp, Ibadan, Nigeria
Ian Roberts
Iain Chalmers
Pisake Lumbiganon
Gilda Piaggio
Tony Brady
Haleema Shakur
Ian Roberts
Zarko Alfirevic
Diana Elbourne
Metin Gulmezoglu
Carine Ronsmans
Eni Balogun
Tracey Pepple
Danielle Prowse
Nigel Quashi
Lin Barneston
Collette Barrow
Danielle Beaumont
Lisa Cook
Lauren Frimley
Daniel Gilbert
Catherine Gilliam
Rob Jackson
Taemi Kawahara
Hakim Miah
Sergey Kostrov
Maria Ramos
Ian Roberts
Haleema Shakur
Phil Edwards
Tom Godec
Sumaya Huque
Bukola Fawole
Olujide Okunade
Olusade Adetayo
Rizwana Chaudhri
Aasia Kayani
Kiran Javaid
Bukola Fawole
Rizwana Chaudhri
Chrstine Biryabarema
Zahida Qureshi
Robert Tchounzou - Reg Hosp Limbe, Limbe, Cameroon
Mohamed El-Sheikh
Hussein Kidanto
Mohan Regmi - BP Koirala Inst Hlth Sci, Dharan, Nepal
Bellington Vwalika
Kastriot Dallaku - Obstet Gynaecol Univ Hosp K Gliozheni, Shkoder, Albania
Mateus Sahani - Birmingham Repertory Theatre
Sayeba Akhter - College Station Medical Center
Abdulfetah Abdulkadir
Nicolas Meda
Anthony Kwame Dah
Adesina Akintan
Olufemi Odekunle - Mother & Child Hosp, Akure, Nigeria
Oluwabusola Monehin - Mother & Child Hosp, Akure, Nigeria
Austin Ojo - Mother & Child Hosp, Akure, Nigeria
Grace Akinbinu - Mother & Child Hosp, Akure, Nigeria
Ifeoma Offiah - Mother & Child Hosp, Akure, Nigeria
Saturday Etuk
Ubong Akpan - University of Calabar
Uduak Udofia - University of Calabar
Useneno Okon - University of Calabar
Ezukwa Omoronyia - University of Calabar
Okpe James - University of Calabar
Oladapo Olayemi
Nike Bello - Univ Coll Hosp, Ibadan, Nigeria
Blessed Adeyemi - Univ Coll Hosp, Ibadan, Nigeria
Chris Aimakhu - Univ Coll Hosp, Ibadan, Nigeria
Olufemi Akinsanya - Fed Med Ctr Owo, Owo, Nigeria
Bamidele Adeleye - Fed Med Ctr Owo, Owo, Nigeria
Oluwaseun Adeyemi - Fed Med Ctr Owo, Owo, Nigeria
Kayode Oluwatosin - Fed Med Ctr Owo, Owo, Nigeria
Abiodun Aboyeji - University of Ilorin
Abiodun Adeniran - University of Ilorin
Adebayo Adewale - University of Ilorin
Noah Olaomo - University of Ilorin
Lawrence Omo-Aghoja - Delta State Univ, Teaching Hosp, Cleveland, MS 38733 USA
Emmanuel Okpako - Delta State Univ, Teaching Hosp, Cleveland, MS 38733 USA
Lucky Oyeye - Delta State Univ, Teaching Hosp, Cleveland, MS 38733 USA
Francis Alu - Maitama Dist Hosp, Abuja, Nigeria
John Ogudu - Maitama Dist Hosp, Abuja, Nigeria
Ezekiel Ladan - Maitama Dist Hosp, Abuja, Nigeria
Ibrahim Habib - Fed Med Ctr Katsina, Katsina, Nigeria
Babasola Okusanya - Federal Reserve
Olatunde Onafowokan - University of Abuja
David Isah - University of Abuja
Abalaka Aye - University of Abuja
Felix Okogbo - Irrua Specialist Teaching Hosp, Irrua, Nigeria
Egbaname Aigere - Irrua Specialist Teaching Hosp, Irrua, Nigeria
Mark Ogbiti - Irrua Specialist Teaching Hosp, Irrua, Nigeria
Temitope Onile - Fed Med Ctr Lokoja, Lokoja, Nigeria
Olaide Salau - Fed Med Ctr Lokoja, Lokoja, Nigeria
Yinka Amode - Fed Med Ctr Lokoja, Lokoja, Nigeria
Kamil Shoretire - Fed Med Ctr Gusau, Gusau, Nigeria
Adebola Owodunni - Fed Med Ctr Gusau, Gusau, Nigeria
Kehinde Ologunde - Fed Med Ctr Gusau, Gusau, Nigeria
Akintunde Ayinde - Adeoyo Matern Hosp, Ibadan, Nigeria
Moses Alao - Fed Med Ctr Abeokuta, Abeokuta, Nigeria
Olalekan Awonuga - Fed Med Ctr Abeokuta, Abeokuta, Nigeria
Babatunde Awolaja - Fed Med Ctr Abeokuta, Abeokuta, Nigeria
Omololu Adegbola - University of Lagos
Fatimah Habeebu-Adeyemi - University of Lagos
Adeyemi Okunowo - University of Lagos
Hadiza Idris - Nyanya Gen Hosp, Abuja, Nigeria
Ola Okike - Nyanya Gen Hosp, Abuja, Nigeria
Nneka Madueke - Nyanya Gen Hosp, Abuja, Nigeria
Josiah Mutihir - University of Jos
Nankat Joseph - University of Jos
Babatunde Adebudo - University of Jos
Adeniyi Fasanu - Ladoke Akintola University of Technology
Olugbenga Akintunde - Mother & Child Hosp, Akure, Nigeria
Olufemi Abidoye - Ladoke Akintola University of Technology
Owigho Opreh - Seventh Day Adventist Hosp, Bangalore, Karnataka, India
Sophia Udonwa - Seventh Day Adventist Hosp, Bangalore, Karnataka, India
Gladys Dibia - Seventh Day Adventist Hosp, Bangalore, Karnataka, India
Simeon Bazuaye - Lagos Isl Matern Hosp, Lagos, Nigeria
Arafat Ifemeje - Lagos Isl Matern Hosp, Lagos, Nigeria
Aniefiok Umoiyoho - University of Uyo
Emmanuel Inyang-Etoh - University of Uyo
Sununu Yusuf - Fed Med Ctr Birnin Kebbi, Birnin Kebbi, Nigeria
Kayode Olayinka - Fed Med Ctr Birnin Kebbi, Birnin Kebbi, Nigeria
Babalola Adeyemi - Obafemi Awolowo Univ, Teaching Hosp, Ife, Nigeria
Olusegun Ajenifuja - Obafemi Awolowo Univ, Teaching Hosp, Ife, Nigeria
Umar Ibrahim - Fed Med Ctr Azare, Bauchi, Nigeria
Yusuf Baffah Adamu - Fed Med Ctr Azare, Bauchi, Nigeria
Oluwarotimi Akinola - Lagos State University
Grace Adekola-Oni - Lagos State University
Paul Kua - Mécanique et Engrenage Moderne
Roseline Iheagwam - Mécanique et Engrenage Moderne
Audu Idrisa - University of Maiduguri
Ado Geidam - University of Maiduguri
Andrea Jogo - Fed Med Ctr Makurdi, Borno, Nigeria
Joseph Agulebe - Fed Med Ctr Makurdi, Borno, Nigeria
Joseph Ikechebelu - Nnamdi Azikiwe University
Onyebuchi Udegbunam - Nnamdi Azikiwe University
Jacob Awoleke - Ekiti State University
Oluseyi Adelekan - Ekiti State University
Hajaratu Sulayman - Ahmadu Bello University
Nkeiruka Ameh - Ahmadu Bello University
Nurudeen Onaolapo - Ajeromi Gen Hosp, Lagos, Nigeria
Affiss Adelodun - Ajeromi Gen Hosp, Lagos, Nigeria
William Golit - Plateau State Specialist Hosp, Jos, Nigeria
Dachollom Audu - Plateau State Specialist Hosp, Jos, Nigeria
Adetunji Adeniji - Technol Teaching Hosp, Ladoke Akintola Univ, Ogbomoso Site, Jos, Nigeria
Folasade Oyelade - Technol Teaching Hosp, Ladoke Akintola Univ, Ogbomoso Site, Jos, Nigeria
Lamaran Dattijo - Abubakar Tafawa Balewa University
Palmer Henry - Abubakar Tafawa Balewa University
Babalola Adeyemi
Olabisi Loto - Wesley Guild Hosp OAUTH, Oyo, Nigeria
Odidika Umeora - Fed Teaching Hosp Abakaliki, Abakaliki, Nigeria
Abraham Onwe - Fed Teaching Hosp Abakaliki, Abakaliki, Nigeria
Emily Nzeribe - Fed Med Ctr Owerri, Owerri, Nigeria
Bartthy Okorochukwu - Fed Med Ctr Owerri, Owerri, Nigeria
Augustine Adeniyi - Istituto di Ortofonologia
Emmanuel Gbejegbe - Kogi State Specialist Hosp, Lokoja, Nigeria
Akpojaro Ikpen - Kogi State Specialist Hosp, Lokoja, Nigeria
Ikemefuna Nwosu - Fed Med Ctr Bida, Bida, Nigeria
Abdulrasaq Sambo - Fed Med Ctr Bida, Bida, Nigeria
Olubunmi Ladipo - Natl Hosp Abuja, Abuja, Nigeria
Sola Abubakar - Technol Teaching Hosp, Ladoke Akintola Univ, Ogbomoso Site, Jos, Nigeria
Ola Nene Okike - Karshi Gen Hosp, Karshi, Nigeria
Enyinnaya Chikwendu Nduka - Fed Med Ctr Umuahia, Umuahia, Nigeria
Eziamaka Pauline Ezenkwele - University of Nigeria
Daniel Onwusulu - Fed Med Ctr Asaba, Asaba, Nigeria
Theresa Azonima Irinyenikan - State Specialist Hosp Akure, Akure, Nigeria
Swati Singh - Usmanu Danfodiyo University
Amaitari Bariweni - Fed Med Ctr Yenagoa, Yenagoa, Nigeria
Hadiza Galadanci - Aminu Kano Teaching Hosp, Aminu, Nigeria
Peter Achara - Fed Med Ctr Keffi, Keffi, Nigeria
Mohammed Gana - Gen Hosp Minna, Minna, Nigeria
Rizwana Chaudhri
Kiran Jabeen - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Ayesha Mobeen - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Sadaf Mufti - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Maliha Zafar - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Shehla Noor
Basharat Ahmad - Ayub Teaching Hosp, Rawalpindi, Pakistan
Maimoona Munawar - Ayub Teaching Hosp, Rawalpindi, Pakistan
Jeharat Gul - Ayub Teaching Hosp, Rawalpindi, Pakistan
Naseema Usman - Ayub Teaching Hosp, Rawalpindi, Pakistan
Fehmida Shaheen - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Mariam Tariq - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Nadia Sadiq - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Rabia Batool - Holy Family Hosp, Gyn & Obs Unit, Rawalpindi, Pakistan
Habiba Sharaf Ali - Ziauddin University
Manahil Jaffer - Ziauddin University
Asma Baloch - Ziauddin University
Noonari Mukhtiar - Ziauddin University
Tasneem Ashraf - College Station Medical Center
Raheela Asmat - College Station Medical Center
Salma Khudaidad - College Station Medical Center
Ghazala Taj - College Station Medical Center
Roshan Qazi - Liaquat Univ, Hosp LUMHS, Gynae Unit 1, Jamshoro, Pakistan
Saira Dars - Liaquat Univ, Hosp LUMHS, Gynae Unit 1, Jamshoro, Pakistan
Faryal Sardar - Liaquat Univ, Hosp LUMHS, Gynae Unit 1, Jamshoro, Pakistan
Sanobar Ashfaq - Liaquat Univ, Hosp LUMHS, Gynae Unit 1, Jamshoro, Pakistan
Saeeda Majeed - MED Institute
Sadaqat Jabeen - Lady Reading Hosp, Peshawar, Pakistan
Rukhsana Karim - Lady Reading Hosp, Peshawar, Pakistan
Farzana Burki - Lady Reading Hosp, Peshawar, Pakistan
Syeda Rabia Bukhari - Lady Reading Hosp, Peshawar, Pakistan
Fouzia Gul - Mécanique et Engrenage Moderne
Musarrat Jabeen - Mécanique et Engrenage Moderne
Akhtar Sherin - Mécanique et Engrenage Moderne
Qurratul Ain - Mécanique et Engrenage Moderne
Shahid Rao - Nishtar Hosp Unit III, Multan, Pakistan
Uzma Shaheen - Nishtar Hosp Unit III, Multan, Pakistan
Samina Manzoor - Nishtar Hosp Unit III, Multan, Pakistan
Shabeen Masood - Fatima Bai Hosp, Karachi, Pakistan
Shabana Rizvi - Fatima Bai Hosp, Karachi, Pakistan
Anita Ali - Fatima Bai Hosp, Karachi, Pakistan
Abida Sajid - Lady Aitchison Hosp, Lahore, Pakistan
Aisha Iftikhar - Lady Aitchison Hosp, Lahore, Pakistan
Shazia Batool - Lady Aitchison Hosp, Lahore, Pakistan
Lubna Dar - Shalamar Hosp, Lahore, Pakistan
Shahenzad Sohail - Shalamar Hosp, Lahore, Pakistan
Shazia Rasul - Shalamar Hosp, Lahore, Pakistan
Shamsa Humayun - Sir Ganga Ram Hosp Lahore, Lahore, Pakistan
Rashida Sultana - Sir Ganga Ram Hosp Lahore, Lahore, Pakistan
Sofia Manzoor - Sir Ganga Ram Hosp Lahore, Lahore, Pakistan
Syeda Mazhar
Afshan Batool
Asia Nazir
Nasira Tasnim - MCH Ctr PIMS, Obs & Gynae Unit 2, Islamabad, Pakistan
Hajira Masood - Nishtar Hosp Unit I, Multan, Pakistan
Razia Khero - College Station Medical Center
Neelam Surhio - College Station Medical Center
Samana Aleem - College Station Medical Center
Naila Israr - Fed Govt Serv Hosp FGSH Unit III, Islamabad, Pakistan
Saba Javed - Federal Reserve
Lubna Bashir - Fed Govt Serv Hosp FGSH Unit III, Islamabad, Pakistan
Samina Iqbal - Sobhraj Matern Hosp KMC, Karachi, Pakistan
Faiza Aleem - Sobhraj Matern Hosp KMC, Karachi, Pakistan
Rubina Sohail - Serv Hosp Lahore Unit II, Lahore, Pakistan
Saima Iqbal - Serv Hosp Lahore Unit II, Lahore, Pakistan
Samina Dojki - Patel Hosp, Karachi, Pakistan
Alia Bano - Patel Hosp, Karachi, Pakistan
Naseem Saba - Dera Ismail Khan Dist Teaching Hosp, Islamabad, Pakistan
Maimoona Hafeez - College Station Medical Center
Nishat Akram - College Station Medical Center
Naila Israr
Riffat Shaheen - Fed Govt Poly Clin FGPC, Hosp Unit 1, Islamabad, Pakistan
Haleema Hashmi - Liaquat Natl Hosp, Islamabad, Pakistan
Sharmeen Arshad - Liaquat Natl Hosp, Islamabad, Pakistan
Rubina Hussain - Ziauddin University
Sadia Khan - Ziauddin University
Nighat Shaheen - CGH Cantonment Gen Hosp, Rawalpindi, Pakistan
Safia Khalil - CGH Cantonment Gen Hosp, Rawalpindi, Pakistan
Pushpa Sachdev - Isra Univ Hosp, Sindh, Pakistan
Gulfareen Arain - Isra Univ Hosp, Sindh, Pakistan
Amtullah Zarreen - Jinnah Hosp Lahore, Lahore, Pakistan
Sara Saeed - Jinnah Hosp Lahore, Lahore, Pakistan
Shamayela Hanif - Mécanique et Engrenage Moderne
Nabia Tariq - Shifa Int Hosp, Islamabad, Pakistan
Mahwish Jamil - Shifa Int Hosp, Islamabad, Pakistan
Shama Chaudhry - Ziauddin University
Hina Rajani - Ziauddin University
Tayyiba Wasim - Serv Hosp, Lahore Unit 3, Lahore, Pakistan
Summera Aslam - Serv Hosp, Lahore Unit 3, Lahore, Pakistan
Nilofar Mustafa - Combined Mil Hosp CMH, Lahore, Pakistan
Huma Quddusi - Nishtar Hosp Unit II, Multan, Pakistan
Sajila Karim - Nishtar Hosp Unit II, Multan, Pakistan
Shazia Sultana - Ziauddin University
Misbah Harim - Ziauddin University
Mohd Chohan - Lady Willingdon Hosp, OBGYN Unit 2, Karachi, Pakistan
Nabila Salman - Nescom Hosp, Islamabad, Pakistan
Fareesa Waqar - Pakistan Railway Hosp, Multan, Pakistan
Shamsunnisa Sadia - Pakistan Railway Hosp, Multan, Pakistan
Lubna Kahloon - DHQ Hosp Rawalpindi, Rawalpindi, Pakistan
Shehla Manzoor - Ayub Teaching Hosp, Rawalpindi, Pakistan
Samar Amin - Mécanique et Engrenage Moderne
Umbreen Akram - Combined Mil Hosp CMH Kharian, Lahore, Pakistan
Ambreen Ikram - Mian Mohammad Trust Hosp, Faisalabad, Pakistan
Samina Kausar - College Station Medical Center
Tahira Batool - Gen Hosp, Kahota Res Lab KRL, Rawalpindi, Pakistan
Brigadier Naila Tahir Kyani - Mil Hosp MH Rawalpindi, Rawalpindi, Pakistan
Christine Biryabarema - Mulago Hosp, Kampala, Uganda
Ruth Bulime - Mulago Hosp, Kampala, Uganda
Regina Akello - Mulago Hosp, Kampala, Uganda
Bernadette Nakawooya Lwasa - Mulago Hosp, Kampala, Uganda
Joselyn Ayikoru - Mulago Hosp, Kampala, Uganda
Christine Namulwasira - Mulago Hosp, Kampala, Uganda
Patrick Komagum - Mubende Reg Referral Hosp, Mubende, Uganda
Isabirye Rebecca - Mubende Reg Referral Hosp, Mubende, Uganda
Nayiga Annet - Mubende Reg Referral Hosp, Mubende, Uganda
Nakirigya Nuulu - Mubende Reg Referral Hosp, Mubende, Uganda
Elizabeth Nionzima - St Francis Hosp Buluba, Kampala, Uganda
Rose Bwotya - St Francis Hosp Buluba, Kampala, Uganda
Margret Nankya - St Francis Hosp Buluba, Kampala, Uganda
Sarah Babirye - St Francis Hosp Buluba, Kampala, Uganda
Joseph Ngonzi - Mbarara Hosp, Mbarara, Uganda
Cesar Sanchez - Mbarara Hosp, Mbarara, Uganda
Nkonwa Innocent - Mbarara Hosp, Mbarara, Uganda
Kusasira Anitah - Mbarara Hosp, Mbarara, Uganda
Ayiko Jackson - Entebbe Gen Hosp, Entebbe, Uganda
Elizabeth Ndagire - Entebbe Gen Hosp, Entebbe, Uganda
Dominic Drametu - Adjumani Hosp, Adjumani, Uganda
Grace Meregurwa - Natural Resources Institute Finland
Francis Banya - Church Uganda Kisiizi Hosp, Kisiizi, Uganda
Rita Atim - Church Uganda Kisiizi Hosp, Kisiizi, Uganda
Uganda Martyrs
Emmanuel Byaruhanga - Ibanda Hosp, Martyrs, Uganda
Hussein Iman - Garissa Prov Gen Hosp, Garissa, Kenya
Vincent Oyiengo - Garissa Prov Gen Hosp, Garissa, Kenya
Peninah Waigi - Garissa Prov Gen Hosp, Garissa, Kenya
Rose Wangui - Garissa Prov Gen Hosp, Garissa, Kenya
Faiza Nassir - Coast Prov Gen Hosp, Mombasa, Kenya
Musimbi Soita - Coast Prov Gen Hosp, Mombasa, Kenya
Rophina Msengeti - Coast Prov Gen Hosp, Mombasa, Kenya
Zeinab Zubier - Coast Prov Gen Hosp, Mombasa, Kenya
Hillary Mabeya - Moi Teaching & Referral Hosp, Eldoret, Kenya
Antony Wanjala - Moi Teaching & Referral Hosp, Eldoret, Kenya
Henry Mwangi - Moi Teaching & Referral Hosp, Eldoret, Kenya
Brian Liyayi - AIC Kijabe Hosp, Kijabe, Kenya
Evelyn Muthoka - AIC Kijabe Hosp, Kijabe, Kenya
Alfred Osoti - AIC Kijabe Hosp, Kijabe, Kenya
Amos Otara - Nakuru Prov Gen Hosp, Nakuru, Kenya
Veronicah Ongwae - Nakuru Prov Gen Hosp, Nakuru, Kenya
Zahida Qureshi
Victor Wanjohi - University of Nairobi
Bonface Musila - Mwingi Dist Hosp, Mwingi, Kenya
Kubasu Wekesa - Bungoma Dist Hosp, Bungoma, Kenya
Alex Nyakundi Bosire - Nairobi Hosp, Nairobi, Kenya
Etienne Asonganyi
Alice Ntem - Kumba Dist Referral Hosp, Kumba, Cameroon
Angeline Njoache - Kumba Dist Referral Hosp, Kumba, Cameroon
Alice Ashu - Kumba Dist Referral Hosp, Kumba, Cameroon
Andre Simo - Reg Hosp Limbe, Limbe, Cameroon
Robert Tchounzou
Dorothy Keka - Reg Hosp Limbe, Limbe, Cameroon
Kenfack Bruno - Dschang Dist Hosp, Dschang, Cameroon
Amadou Ndouoya - Dschang Dist Hosp, Dschang, Cameroon
Martin Saadio - Dschang Dist Hosp, Dschang, Cameroon
Mesack Tchana - Hop Laquintinie Douala, Douala, Cameroon
Odel Gwan - Hop Laquintinie Douala, Douala, Cameroon
Pauline Assomo - Hop Laquintinie Douala, Douala, Cameroon
Venantius Mutsu - St Theresas Catholic Hosp, Kumba, Cameroon
Nji Eric - St Theresas Catholic Hosp, Kumba, Cameroon
Pascal Foumane - Yaounde Gynaecoobstet & Paediat Hosp, Yaounde, Cameroon
Philemon Nsem - Yaounde Gynaecoobstet & Paediat Hosp, Yaounde, Cameroon
Jeanne Fouedjio - Yaounde Cent Hosp, Yaounde, Cameroon
Ymele Fouelifack - Yaounde Cent Hosp, Yaounde, Cameroon
Pierre Marie Tebeu - Ctr Hosp & Univ Yaounde, Yaounde, Cameroon
Wisal Nabag - Khartoum North Teaching Hosp, Khartoum, Sudan
Riham Desougi - Khartoum North Teaching Hosp, Khartoum, Sudan
Hadia Mustafa - Khartoum North Teaching Hosp, Khartoum, Sudan
Huida Eltaib - Khartoum North Teaching Hosp, Khartoum, Sudan
Taha Umbeli - Omdurman Matern Hosp, Omdurman, Sudan
Khalid Elfadl - Omdurman Matern Hosp, Omdurman, Sudan
Murwan Ibrahim - Omdurman Matern Hosp, Omdurman, Sudan
Abdalla Mohammed - Kassala New Hosp Al Saudi, Al Saudi, Sudan
Awadia Ali - Kassala New Hosp Al Saudi, Al Saudi, Sudan
Somia Abdelrahiem - Wad Medani Teaching Hosp Obstet & Gynaecol, Wad Madani, Sudan
Mohammed Musa - Wad Medani Teaching Hosp Obstet & Gynaecol, Wad Madani, Sudan
Mahdi Bushra - Kosti Hosp, Kosti, Sudan
Omer Babiker - Kosti Hosp, Kosti, Sudan
Hala Abdullahi - Soba Univ Hosp, Soba, Sudan
Mohamed Ahmed - Soba Univ Hosp, Soba, Sudan
Duria Rayis - Khartoum Teaching Hosp, Khartoum, Sudan
Saeed Abdelrahman Abdelgabar - Elmek Nimir Univ Hosp, Elmek Nimir, Sudan
Zarko Alfirevic
Gillian Houghton - Liverpool Womens Hosp, Liverpool Womens NHS Fdn Trust, Liverpool, Merseyside, England
Andrew Sharpe - Liverpool Womens Hosp, Liverpool Womens NHS Fdn Trust, Liverpool, Merseyside, England
Jim Thornton - Nottingham Univ Hosp Trust, City Hosp Nottingham, Nottingham, England
Nick Grace - Nottingham Univ Hosp Trust, City Hosp Nottingham, Nottingham, England
Carys Smith - Nottingham Univ Hosp Trust, City Hosp Nottingham, Nottingham, England
Kim Hinshaw - Sunderland Royal Hosp, City Hosp Sunderland NHS Trust, Sunderland, Tyne & Wear, England
Dawn Edmundson - Sunderland Royal Hosp, City Hosp Sunderland NHS Trust, Sunderland, Tyne & Wear, England
Paul Ayuk - Newcastle Upon Tyne Hosp NHS Trust, Royal Victoria Infirm, Newcastle Upon Tyne, Tyne & Wear, England
Alison Bates - Newcastle Upon Tyne Hosp NHS Trust, Royal Victoria Infirm, Newcastle Upon Tyne, Tyne & Wear, England
George Bugg - College Station Medical Center
Joanne Wilkins - College Station Medical Center
Clare Tower - Cent Manchester Univ Hosp NHS Fdn Trust, St Marys Hosp, Manchester, Lancs, England
Alysha Allibone - Cent Manchester Univ Hosp NHS Fdn Trust, St Marys Hosp, Manchester, Lancs, England
Hussein Kidanto
Ahmad Kazumari - Muhimbili Natl Hosp, Muhimbili, Tanzania
Anna Danford - Muhimbili Natl Hosp, Muhimbili, Tanzania
Matilda Ngarina - Muhimbili Natl Hosp, Muhimbili, Tanzania
Muzdalifat Abeid - Temeke Municipal Hosp, Temeke, Tanzania
Khadija Mayumba - Temeke Municipal Hosp, Temeke, Tanzania
Magreth Zacharia - Temeke Municipal Hosp, Temeke, Tanzania
George Mtove - Hospitali Teule Muheza Designated Dist Hosp, Muheza, Tanzania
Leonard Madame - Hospitali Teule Muheza Designated Dist Hosp, Muheza, Tanzania
Anthony Massinde - College Station Medical Center
Berno Mwambe - College Station Medical Center
Sebastian Kitengile Ganyaka - Mwananyamala Municipal Hosp, Mwanza, Tanzania
Mohan Regmi
Shyam Gupta - BP Koirala Inst Hlth Sci, Dharan, Nepal
Rabindra Bhatt - BP Koirala Inst Hlth Sci, Dharan, Nepal
Ajay Agrawal - BP Koirala Inst Hlth Sci, Dharan, Nepal
Pramila Pradhan - College Station Medical Center
Nikita Dhakal - College Station Medical Center
Punita Yadav - College Station Medical Center
Gyanendra Karki - Birat Hosp & Res Ctr, Biratnagar, Nepal
Bhola Ram Shrestha - Mid Western Reg Hosp, Birendranagar, Nepal
Bellington Vwalika
Mwansa Lubeya - Univ Teaching Hosp Lusaka, Lusaka, Zambia
Jane Mumba - Univ Teaching Hosp Lusaka, Lusaka, Zambia
Willies Silwimba - Univ Teaching Hosp Lusaka, Lusaka, Zambia
Isaiah Hansingo - Livingstone Gen Hosp, Livingstone, Zambia
Noojiri Bopili - Livingstone Gen Hosp, Livingstone, Zambia
Ziche Makukula - St Francis Hosp Katete, Katete, Zambia
Alexander Kawimbe - Kabwe Gen Hosp, Kabwe, Zambia
Mwansa Ketty Lubeya - Kafue Dist Hosp, Kafue, Zambia
Willard Mtambo - Nashotah House Theological Seminary
Mathew Ng'ambi - Chipata Gen Hosp, Chipata, Zambia
Kastriot Dallaku
Saimir Cenameri - Obstet Gynaecol Univ Hosp K Gliozheni, Shkoder, Albania
Ilir Tasha - Obstet Gynaecol Univ Hosp K Gliozheni, Shkoder, Albania
Aferdita Kruja - Obstet Gynaecol Univ Hosp K Gliozheni, Shkoder, Albania
Besnik Brahimaj - Reg Hosp Fier, Fier, Albania
Leon Kaza - Lezha Reg Hosp, Lezha, Albania
Mateus Sahani
Desire Tshombe - Birmingham Repertory Theatre
Elizabeth Buligho - Birmingham Repertory Theatre
Roger Paluku-Hamuli - Birmingham Repertory Theatre
Charles Kacha - Birmingham Repertory Theatre
Kato Faida - CSR Carmel, Goma, DEM REP CONGO
Badibanga Musau - Birmingham Repertory Theatre
Herman Kalyana - Birmingham Repertory Theatre
Phanny Simisi - Birmingham Repertory Theatre
Serge Mulyumba - Birmingham Repertory Theatre
Nzanzu Kikuhe Jason - Birmingham Repertory Theatre
Jean Robert Lubamba - Notre Dame of Dadiangas University
Willis Missumba - Birmingham Repertory Theatre
Ferdousi Islam - College Station Medical Center
Nazneen Begum - College Station Medical Center
Sayeba Akhter
Ferdousi Chowdhury - College Station Medical Center
Rokeya Begum - College Station Medical Center
Farjana Basher - College Station Medical Center
Nazlima Nargis - Sina
Abu Kholdun - Sina
Shahela Jesmin - College Station Medical Center
Shrodha Paul - College Station Medical Center
Hailemariam Segni - Jimma University
Getachew Ayana - Jimma University
William Haleke - Jimma University
Abdulfetah Abdulkadir
Hassen Hussien - Millennium Engineering and Integration
Fikre Geremew - Millennium Engineering and Integration
Moussa Bambara - Ctr Hosp Univ Souro Sanou, Souro Sanou, Burkina Faso
Adolphe Some - Ctr Hosp Univ Souro Sanou, Souro Sanou, Burkina Faso
Amadou Ly - Ctr Hosp Univ Souro Sanou, Souro Sanou, Burkina Faso
Roamba Pabakba - Ctr Hosp Reg Dedougou, Dedougou, Burkina Faso
Horace Fletcher - Univ Hosp West Indies, Kingston, Jamaica
Leslie Samuels - Univ Hosp West Indies, Kingston, Jamaica
Henry Opare-Addo - Komfo Anokye Teaching Hosp, Kumasi, Ghana
Roderick Larsen-Reindorf - Komfo Anokye Teaching Hosp, Kumasi, Ghana
Kwadwo Nyarko-Jectey - Ashanti Mampong Municipal Hosp, Mampong, Ghana
Glen Mola
Malts Wai - Port Moresby Gen Hosp, Port Moresby, Papua N Guinea
Magdy El Rahman - Mataria Teaching Hosp, Cairo, Egypt
Wafaa Basta - Mataria Teaching Hosp, Cairo, Egypt
Hussein Khamis - Mataria Teaching Hosp, Cairo, Egypt
Maria Fernanda Escobar - Fdn Valle Lili, Cali, Colombia
Liliana Vallecilla - Fdn Valle Lili, Cali, Colombia
Gabriel Essetchi Faye - Hop Gen Abobo Nord, Abobo, Cote Ivoire
Natl Coordinators
Publication Details: The Lancet (British edition), Vol.389(10084), pp.2105-2116
Publisher: Elsevier
Number of pages: 12
Grant note: UK Department of Health; National Institutes of Health Research (NIHR) Pfizer Wellcome Trust London School of Hygiene AMP; Tropical Medicine Bill AMP; Melinda Gates Foundation; CGIAR
Identifiers: 9949794808331
Academic Unit: King Saud University; Princess Nourah bint Abdulrahman University
Language: English
Resource Type: Journal article