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Community Level Use ofMisoprostol for PPH
Prevention
What works and what is next?
Nuriye Hodoglugil, MD, MA, DrPH
VSI, Associate Medical Director
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PPH management: from home todelivery room
CONTINUUMOFCARE
Misoprostol tablets
Oxytocin in prefilled device
Oxytocin/Ergometrine
EmOC
Community-level Primary health center Hospital/ tertiary
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18 countries (and counting) have
demonstrated effective, feasible, safe, andacceptable community-based use of misoprostol through
research and/or implementation programs with differentmodels of distribution
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DELIVERYPREGNANCY
CBD: Reaching women wherethey are
HealthFacility
Home
CHW
CHW/TBA/ANM
CDK
ANC
referral
M
M
M
M
with misoprostol ( )
M
M
M
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Community leveluse is effective in
preventing PPH
Country PPH rate in
control group(%)
PPH rate with
misoprostol(%)
Source
INDIA 12.0 6.4 Derman et al., 2006
PAKISTAN 21.9 16.5 Mobeen et al., 2010
BANGLADESH 6.4 1.6 Nasreen et al., 2011
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Community level use isfeasible (e.g. Bangladesh)
6 NorthwestDistricts
>77,000 womendelivered
70% receivedCDK withmisoprostol andQuaiyums mat
>46,000 deliveredat home
>90% usedmisoprostol
Tangail
>19,000 womendelivered
70% registeredby communityfield workers
>16,500 deliveredat home
95% usedmisoprostol
Coxs Bazar
>19,000 womendelivered
70% registered
>17,400 deliveredat home
95% usedmisoprostol
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Community leveluse increases
uterotonic coverage
CountryUterotoniccoverage
(before/control)
Uterotoniccoverage
(after/intervention)Source
Nepal 12% 74%(misoprostol 49%)
Rajbhandari, 2010
Afghanistan 26% 96(misoprostol 67%)
Sanghvi, 2010
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Community leveldistribution reaches the
poor, the illiterate andthe remote
NEPAL
Uterotonic coverage increased (from 12% to 74%):
12 times in the poorest vs. 3 times in the richestquintile
9 times among the most remote areas (>3 hours)vs. 5 times among women living closer to afacility (
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Community leveldistribution is safe and
acceptable
AFGHANISTAN
Of the 1,421 women in the intervention group whotook misoprostol, 100% correctly took it after birth;including 20 women with twin pregnancies
92% of women said they would use misoprostol intheir next pregnancy
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Womenunderstand the
message
Importance of facilitydelivery and birth
preparednessThe risk of excessivebleeding and dyingduring delivery
How to usemisoprostol correctly
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Community level use has additionalbenefits for women and families
s
Source: Prevention of postpartum hemorrhage at home birth: A program
Implementation Guide. USAID/ACCESS 2009.
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Moving to national expansion: All birthsare covered with a uterotonic
Innovation
RwandaZimbabwe
South Sudan
Diffusion
Transition &National
Expansion
Ghana
KenyaTanzania
Mozambique
Bangladesh
Nepal
Afghanistan
NigeriaEthiopia
Tanzania
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Issues to consider fornationwide 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 distributionprograms (misoprostol, FP, PMTCT, etc.)
Consistent supply of good quality products
Implications of simplified AMTSL for home deliveries?
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potential impact
In a 10 year periodThe combined use ofoxytocin 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.
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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.
(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)
Misoprostol use at the community level is
an important tool to address inequity andreach MDG 5
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Thank [email protected]
www.vsinnovations.org
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Parking lot
17
VSI Operations Research in Africa:
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VSI Operations Research in Africa:Misoprostol for PPH Prevention
Country Distribution model/Level of
provider
Enrollment n
Ethiopia TBA, health extension workers 2,580
Ghana ANC 6,650
Kenya ANC, community midwives 3,800
Madagascar ANC, public community healthcenters
950
Mozambique ANC, TBA 3,800
Nigeria TBA, community drug keepers 1,800
Tanzania ANC 12,500
Zambia ANC 5,500
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WHO and use of misoprostol for PPHprevention
Included in the WHO Model List of EssentialMedicines (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 birthattendants or assistants trained to use theproducts at home deliveries.
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in Asia deliver without a skilled attendant44% of women
20
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