Community Level Use of Misoprostol for PPH Prevention

What works and what is next?

Nuriye Hodoglugil, MD, MA, DrPH VSI, Associate Medical Director

PPH management: from home to delivery room

Community-level Primary health center Hospital/ tertiary Misoprostol tablets Oxytocin in prefilled device Oxytocin/Ergometrine EmOC

CONTINUUM OF CARE

18 countries (and counting) have

demonstrated effective, feasible, safe, and acceptable community-based use of misoprostol through
research and/or implementation programs with different models of distribution

CBD: Reaching women where they are with misoprostol ( M )

Health Facility
M

CHW
M

ANC
M

CDK

Home
M

referral
M

PREGNANCY

CHW/ TBA/ ANM

DELIVERY

Community level use is effective in preventing PPH

Country PPH rate in control group (%) PPH rate with misoprostol (%) Source

INDIA
PAKISTAN

12.0
21.9

6.4
16.5

Derman et al., 2006

Mobeen et al., 2010

BANGLADESH

6.4

1.6

Nasreen et al., 2011

Community level use is feasible (e.g. Bangladesh)

6 Northwest Districts >77,000 women delivered 70% received CDK with misoprostol and Quaiyums mat >46,000 delivered at home >90% used misoprostol Tangail >19,000 women delivered 70% registered by community field workers >16,500 delivered at home 95% used misoprostol Coxs Bazar >19,000 women delivered 70% registered >17,400 delivered at home 95% used misoprostol

Community level use increases uterotonic coverage

Country Uterotonic coverage (before/control) Uterotonic coverage (after/intervention) Source

Nepal Afghanistan

12% 26%

74% (misoprostol 49%) 96 (misoprostol 67%)

Rajbhandari, 2010 Sanghvi, 2010

Community level distribution reaches the poor, the illiterate and the remote
NEPAL
Uterotonic coverage increased (from 12% to 74%): 12 times in the poorest vs. 3 times in the richest quintile 9 times among the most remote areas (>3 hours) vs. 5 times among women living closer to a facility (<1 hour)

Community level distribution is safe and acceptable

AFGHANISTAN
Of the 1,421 women in the intervention group who took misoprostol, 100% correctly took it after birth; including 20 women with twin pregnancies 92% of women said they would use misoprostol in their next pregnancy

Women understand the message

Importance of facility delivery and birth preparedness The risk of excessive bleeding and dying during delivery How to use misoprostol correctly

Community level use has additional benefits for women and families
s

Source: Prevention of postpartum hemorrhage at home birth: A program Implementation Guide. USAID/ACCESS 2009.

Moving to national expansion: All births are covered with a uterotonic

Transition & National Expansion

Diffusion Innovation

Rwanda Zimbabwe South Sudan

Ghana Kenya Tanzania

Mozambique

Nigeria Ethiopia Tanzania

Bangladesh Nepal Afghanistan

Issues to consider for nationwide expansion

Funding for national expansion A more systematic approach to scale-up: Scale-able intervention strategies Cost benefit analysis Standard monitoring for safety, inappropriate use, etc. Lessons learned from other community based distribution programs (misoprostol, FP, PMTCT, etc.) Consistent supply of good quality products Implications of simplified AMTSL for home deliveries?

potential impact
In a 10 year periodThe combined use of oxytocin and misoprostol, where oxytocin is the first-line intervention for institutional deliveries and misoprostol for home deliveries, could prevent 41 million PPH cases and save 1.4 million lives.

Source: Seligman, B and Xingzhu L., 2006. Economic Assessment of Interventions for Reducing Postpartum Hemorrhage in Developing countries.

Countdown to 2015 for Maternal Health:

Skilled birth attendant coverage was the least equitable intervention & Community-based interventions were more equally distributed than those delivered in health facilities.

Misoprostol use at the community level is an important tool to address inequity and reach MDG 5
(Source: Barros AJD et al., Equity in maternal, newborn and child health interventions in Countdown to 2015: A retrospective of survey data from 54 countries. Lancet, 31 March 2012)

Thank you!
nuriye@vsinnovations.org

www.vsinnovations.org

Parking lot

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VSI Operations Research in Africa: Misoprostol for PPH Prevention

Country Distribution model/Level of provider Enrollment n

Ethiopia Ghana Kenya Madagascar Mozambique Nigeria Tanzania Zambia

TBA, health extension workers ANC ANC, community midwives ANC, public community health centers ANC, TBA TBA, community drug keepers ANC ANC

2,580 6,650 3,800 950 3,800 1,800 12,500 5,500

WHO and use of misoprostol for PPH prevention Included in the WHO Model List of Essential Medicines (May 2011) Misoprostol is moved from Complementary to Core List [N]ew evidence submitted showed that misoprostol can be safely administered to women to prevent PPH by traditional birth attendants or assistants trained to use the products at home deliveries.

in Asia deliver without a skilled attendant

44% of women

20