hodoglugil_experience with community level use of misoprostol in asia

8/2/2019 Hodoglugil_Experience With Community Level Use of Misoprostol in Asia

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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


2/20

PPH management: from home todelivery room

CONTINUUMOFCARE

Misoprostol tablets

Oxytocin in prefilled device

Oxytocin/Ergometrine

EmOC

Community-level Primary health center Hospital/ tertiary


3/20

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


4/20

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


70% registeredby communityfield workers


95% usedmisoprostol

Coxs Bazar


70% registered


95% usedmisoprostol


7/20

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


11/20

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


19/20

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.


20/20

in Asia deliver without a skilled attendant44% of women

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hodoglugil_experience with community level use of misoprostol in asia

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