September 2013

 

           

Introducing Misoprostol for the Management of Postpartum Hemorrhage in Zimbabwe

FINAL REPORT

 

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Zimbabwe  Ministry  of  Health  and  Child  Care  Through  the  combined  efforts  of  the  government,  organizations,  communities  and  individuals,  the  Government  of  Zimbabwe  aims  to  provide  the  highest  possible  level  of  health  and  quality  of  life  for  all  its  citizens,  and  to  support  their  full  participation  in  the  socio-­‐economic  development  of  the  country.  This  vision  requires  that  every  Zimbabwean  have  access  to  comprehensive  and  effective  health  services.  The  mission  of  the  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  to  provide,  administer,  coordinate,  promote  and  advocate  for  the  provision  of  quality  health  services  and  care  to  Zimbabweans  while  maximizing  the  use  of  available  resources.  

Venture  Strategies  Innovations  (VSI)    VSI  is  a  California-­‐based  nonprofit  organization  committed  to  improving  women  and  girl's  health  in  developing  countries  by  creating  access  to  effective  and  affordable  technologies  on  a  large  scale.  VSI  connects  women  with  life-­‐saving  medicines  and  services  by  engaging  governments  and  partners  to  achieve  regulatory  approval  of  quality  products  and  integrating  them  into  national  policies  and  practices.  

 

Zimbabwe  Ministry  of  Health  and  Child  Care  The  Permanent  Secretary  Kaguvi  Building,  4th  Floor  Central  Avenue  (Between  4th  and  5th  Street)  Harare,  Zimbabwe  Telephone:  +263-­‐4-­‐798537-­‐60  Website:  http://www.mohcw.gov.zw    Venture  Strategies  Innovations  19200  Von  Karman  Avenue,  Suite  400  Irvine,  California  92612    USA  Telephone:  +1  949  622  5515  Website:  www.vsinnovations.org        

 

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Acknowledgements

Zimbabwe  Ministry  of  Health  and  Child  Care:  Dr.  Bernard  Madzima,  Director,  Maternal  and  Child  Health  Ms.  Margaret  Nyandoro,  Deputy  Director,  Director  of  Reproductive  Health    Principal  Investigators:  Dr.  Tsungai  Chipato,  University  of  Zimbabwe  Dr.  Partson  Zvandasara,  University  of  Zimbabwe  Dr.  Velda  Mushangwe,  University  of  Zimbabwe    VSI  program  team:  Ndola  Prata,  Medical  Director  Nuriye  Nalan  Sahin  Hodoglugil,  Associate  Medical  Director  Katharine  Rivett,  Program  Manager  Engeline  Mawere,  Regional  Program  Officer  Molly  Moran,  Monitoring  and  Evaluation  Specialist  Alice  Mpete,  Nurse  Administrator  Allison  Boiles,  Communications  Specialist    This  project  could  not  have  been  completed  without  the  contributions  of  the  expert  staff  and  colleagues  at  the  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  and  Venture  Strategies  Innovations  (VSI),  whose  dedication  to  this  operations  research  and  invaluable  contributions  to  its  development  led  to  its  successful  implementation.  The  operations  research  benefitted  from  the  participation  of  the  district  officials,  who  contributed  to  supportive  supervision  and  monitoring  of  operations  research  activities.  The  operations  research  also  benefitted  from  the  participation  of  community  leaders  and  other  community  members  who  led  and  participated  in  community  awareness  activities.  Tarra  McNally,  former  VSI  Country  Representative,  initiated  the  preliminary  work  on  this  operations  research,  and  oversaw  the  activities  until  July  2013  and  Melody  Liu  provided  data  management  support  until  August  2013.  Debbie  Koh  provided  programmatic  support  until  January  2013.  Most  importantly,  VSI  would  like  to  thank  all  of  the  women  who  participated  in  this  operations  research.              

 

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Executive Summary

The  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  committed  to  preventing  maternal  mortality  and  morbidity  due  to  postpartum  hemorrhage  by  ensuring  that  women  have  access  to  essential  medicines  at  the  time  of  delivery.  Postpartum  hemorrhage  (PPH)  is  the  most  common  cause  of  maternal  mortality  globally,  leading  to  a  woman’s  death  every  seven  minutes.  In  Zimbabwe,  14%  of  all  maternal  deaths  are  due  to  PPH.  Ensuring  prompt  access  to  high-­‐quality  prevention  and  treatment  of  PPH  for  all  women  who  deliver  is  an  essential  strategy  to  combat  PPH-­‐related  morbidity  and  mortality  and  to  make  progress  toward  reaching  Millennium  Development  Goal  5,  the  reduction  of  maternal  mortality  by  three-­‐quarters  by  2015.    Misoprostol,  an  effective,  safe,  low-­‐cost  and  heat  stable  uterotonic  in  tablet  form,  is  recommended  by  the  World  Health  Organization  (WHO)  for  both  PPH  prevention  and  treatment.  The  ZMoHCC  aims  to  increase  the  availability  of  misoprostol  throughout  the  country,  with  the  ultimate  goal  of  ensuring  that  every  Zimbabwean  woman  has  access  to  a  uterotonic  drug  at  the  time  of  delivery.    Based  on  recent  evidence,  the  WHO  identified  the  use  of  uterotonics  as  the  key  intervention  in  the  active  management  of  third  stage  of  labor  (AMTSL)  package,  and  recommends  that  all  women  giving  birth  should  be  offered  uterotonics  for  the  prevention  of  PPH.  Oxytocin  is  recommended  as  the  uterotonic  drug  of  choice,  for  the  prevention  and  treatment  of  PPH,  and  misoprostol  is  recommended  in  settings  where  oxytocin  is  unavailable  or  cannot  be  safely  used.  Misoprostol  is  included  in  the  WHO  Model  List  of  Essential  Medicines  for  PPH  prevention;  as  well  as  in  the  Priority  Life-­‐saving  Medicines  for  Women  and  Children.    Furthermore,  it  is  included  in  the  life-­‐saving  commodities  list  for  PPH  prevention  by  the  United  Nations’  Commission  on  Life-­‐saving  Commodities  for  Women  and  Children,  whose  goal  is  to  increase  the  supply  and  use  of  essential  commodities.        The  ZMoHCC  and  Venture  Strategies  Innovations  (VSI),  a  U.S.  based  non-­‐profit  organization  with  operations  in  Harare,  collaborated  to  conduct  operations  research  (OR)  to  provide  evidence  on  the  feasibility  and  effectiveness  of  integrating  misoprostol  for  PPH  prevention  and  treatment  for  use  at  all  levels  of  health  facilities,  when  oxytocin  is  not  available  or  cannot  be  safely  used.    The  ZMoHCC’s  and  VSI’s  joint  OR  was  conducted  in  68  health  facilities  in  four  districts  of  Zimbabwe.  The  OR  sites  included  a)  provincial  hospitals,  b)  district  hospitals,  c)  mission  hospitals,  d)  rural  hospitals  and  e)  rural  health  centers  (RHCs).  A  training  of  trainers  was  conducted  for  40  senior  doctors  and  nurses,  followed  by  cascade  trainings  for  135  providers  (primary  care  nurses,  nurses  and  midwives)  from  all  sites.  Facility  services  from  September  2011  to  February  2012  were  reviewed  to  provide  a  baseline  facility  assessment.  Operations  research  was  conducted  from  January  2013  to  June  2013,  during  which  misoprostol  was  available  for  women  at  these  facilities.      A  baseline  facility  assessment  was  conducted  at  the  68  facilities  prior  to  the  introduction  of  misoprostol.  Staff  were  interviewed  and  records  for  services  provided  from  September  2011  to  February  2012  were  reviewed  to  collect  information  on  the  number  of  deliveries,  PPH  management  practices,  drug  supplies,  staffing,  and  facility  infrastructure.  During  the  OR,  which  refers  to  the  period  from  January  to  June  2013  where  misoprostol  was  made  available  at  all  facilities,  PPH  management  practices  were  monitored  for  six  months.  Focus  group  discussions  were  held  with  Village  Health  Workers  to  identify  a  tool  for  measuring  blood  loss  during  home  deliveries,  and  a  community  education  campaign  was  conducted  with  their  help  on  topics  that  included  birth  

 

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preparedness,  the  importance  of  a  facility  delivery,  how  to  recognize  signs  of  excessive  bleeding,  and  the  availability  of  drugs  to  prevent  bleeding  at  facilities.  These  messages  were  incorporated  into  routine  antenatal  care  (ANC)  education  sessions  and  community  meetings,  and  presented  on  a  poster  that  was  displayed  in  key  community  sites.    While  oxytocin  was  available  at  over  90%  of  the  facilities  at  the  time  of  the  baseline  assessment,  over  half  of  the  facilities  (61%)  reported  having  had  a  stock-­‐out  in  the  past  six  months.  The  mean  duration  of  stock-­‐outs  was  highest  at  RHCs  (52  days)  and  mission  hospitals  (14  days).  Only  the  provincial  hospital  did  not  report  a  stock-­‐out  in  that  period.    A  total  of  8,258  deliveries  were  recorded  at  the  OR  facilities  from  January  to  June  2013.  Of  those,  259  were  caesarean  sections,  and  528  women  delivered  at  home  or  on  the  way  to  the  hospital,  which  left  a  total  of  7,400  vaginal  deliveries  at  the  facilities  in  the  OR  districts.  Place  of  delivery  was  not  recorded  for  71  women.  Over  one-­‐fourth  (n=2,147)  of  vaginal  facility  deliveries  for  which  facility  level  data  was  available  took  place  at  the  RHCs,  with  another  ten  percent  (n=730)  at  the  rural  hospitals.  Almost  one-­‐third  took  place  at  a  district  hospital  (n=2,308),  while  approximately  15%  each  took  place  at  the  mission  hospitals  (n=1,064)  and  the  provincial  hospital  (n=1,134).    Near  universal  uterotonic  coverage  for  PPH  prevention  at  facility  deliveries  (99%)  was  achieved  during  the  OR.  Misoprostol  contributed  to  this  high  coverage.  Of  the  women  who  delivered  at  a  facility  for  whom  district  and  uterotonic  for  PPH  prevention  were  recorded,  88%  received  oxytocin,  9%  received  misoprostol,  3%  received  ergometrine  and  1%  received  no  uterotonic.  In  terms  of  uterotonic  coverage  for  all  births,  the  impact  was  greatest  at  the  RHCs  and  rural  hospitals  where  baseline  coverage  rates  were  lowest.  At  RHCs,  coverage  increased  from  81%  to  97%,  while  at  rural  hospitals,  it  rose  from  78%  to  99%.  Where  uterotonic  coverage  was  high  at  baseline  (for  mission,  district  and  provincial  hospitals  at  99%  to  100%),  the  coverage  was  unchanged.      The  use  of  misoprostol  for  PPH  prevention  during  the  OR  was  higher  at  the  RHCs  and  rural  hospitals  than  at  the  other  types  of  facilities.  Over  the  six  months,  at  RHCs,  21%  of  maternity  cases  that  were  vaginal  deliveries  and  for  whom  uterotonic  data  was  available  were  given  misoprostol  for  PPH  prevention.  At  rural  hospitals,  the  corresponding  figure  was  16%.        Training  and  instruction  on  dose  and  route  of  administration  were  given  to  health  providers  during  the  OR  training  sessions,  at  supervisory  visits,  and  via  misoprostol  regimen  cards.  Provider  adherence  to  instructions  was  high.  A  correct  regimen  of  600mcg  orally  was  administered  to  all  women  with  a  vaginal  delivery  for  whom  data  was  recorded.    A  total  of  259  PPH  cases  among  women  with  vaginal  deliveries,  for  whom  data  was  available  on  treatment  and  facility  level,  were  recorded  at  the  OR  sites  from  January  to  June  2013.  Overall,  10%  were  treated  with  misoprostol.  Misoprostol  played  the  greatest  role  in  PPH  treatment  at  the  RHCs  and  rural  hospitals.  Over  40%  of  the  total  number  of  PPH  cases  were  treated  at  these  two  levels  of  facilities.  At  RHCs,  19%  (n=15)  of  the  PPH  cases  were  treated  with  misoprostol;  over  one-­‐fourth  (27%;  n=6)  of  the  PPH  cases  at  the  rural  hospitals  were  treated  with  misoprostol.  The  availability  of  misoprostol  played  a  significant  role  in  the  treatment  of  women  suffering  from  PPH,  particularly  women  living  in  rural  areas  who  would  have  had  more  difficulty  reaching  a  referral  hospital  in  an  urban  area  in  a  timely  fashion.      

 

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The  OR  provides  strong  evidence  of  the  role  that  misoprostol  can  play  in  the  management  of  PPH,  particularly  at  RHCs  and  at  rural  hospitals,  where  maintaining  a  regular  supply  of  oxytocin  under  optimal  conditions  can  present  greater  challenges.  Providers  at  these  lower-­‐level  facilities  were  able  to  correctly  administer  misoprostol  for  PPH  prevention  and  treatment.  The  addition  of  misoprostol  expands  uterotonic  coverage,  especially  to  more  rural  women,  reducing  the  risk  of  PPH.  Ultimately,  the  burden  on  referral  hospitals  of  providing  PPH  treatment  to  large  numbers  of  women  will  be  reduced.  Most  importantly,  misoprostol  can  contribute  to  preventing  the  unnecessary  loss  of  women’s  lives  from  postpartum  hemorrhage.    The  following  recommendations  on  opportunities  to  strengthen  PPH  management  services  in  Zimbabwe  are  based  on  the  results  of  the  OR  and  lessons  learned  by  the  ZMoHCC  and  providers  during  project  implementation.  Consequently,  a  number  of  the  recommendations  encompass  issues  related  to  scaling  up  PPH  management  services  in  Zimbabwe  that  are  not  specifically  tied  to  data  from  the  OR.  

1. Integrate  misoprostol  as  an  additional  uterotonic  for  PPH  management  at  all  health  facilities  that  conduct  deliveries  in  Zimbabwe.  

2. Ensure  that  RHCs  and  rural  hospitals  can  manage  PPH  in  order  to  decrease  costs,  both  to  women  and  to  the  health  system,  of  managing  complicated  PPH  cases  at  higher  level  facilities.  

3. Disseminate  and  implement  the  BEmOC  guidelines,  to  ensure  that  providers  can  correctly  implement  PPH  management  and  referrals  according  to  protocols.    

4. Provide  training  and  job  aids  on  the  use  of  misoprostol  for  PPH  management,  following  the  service  delivery  protocols,  to  all  maternity  service  providers,  including  physicians,  midwives,  nurses,  primary  care  nurses,  and  nurse  aides.    

5. Incorporate  training  on  misoprostol  in  PPH  management  into  the  pre-­‐service  curricula  of  the  medical,  nursing,  and  midwifery  schools.  

6. Increase  community  awareness  through  appropriate  interventions  to  ensure  uterotonic  coverage  for  all  women  giving  birth.  

7. Register  misoprostol  for  obstetric  uses  in  Zimbabwe,  as  an  important  first  step  to  ensure  the  ongoing  supply  of  a  high  quality  product.    

8. Adopt  and  implement  procedures  for  the  ordering  and  distribution  of  misoprostol  to  ensure  its  availability  for  PPH  management  in  all  levels  of  health  facilities,  with  special  attention  to  ensuring  stocks  in  rural  facilities  where  the  need  is  most  often  unmet  

           

 

 

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Acronyms and Local Terms

AMTSL   Active  Management  of  the  Third  Stage  of  Labor  

ANC   Antenatal  Care  

IEC   Information,  education  and  communication    

M&E     Monitoring  and  Evaluation  

MOH   Ministry  of  Health  

MTWG   Misoprostol  Technical  Working  Group  

PCN   Primary  Care  Nurse  

PPH   Postpartum  hemorrhage  

RHC   Rural  Health  Center  

TOT   Training  of  trainers  

VHW   Village  Health  Workers  

VSI   Venture  Strategies  Innovations  

WHO   World  Health  Organization  

ZMoHCC   Zimbabwe  Ministry  of  Health  and  Child  Care  

 

 

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Table of Contents

Acknowledgements  ................................................................................................................................  ii  

Executive  Summary  ...............................................................................................................................  iii  

Acronyms  and  Local  Terms  ....................................................................................................................  vi  

Table  of  Contents  .................................................................................................................................  vii  

List  of  Boxes,  Tables  and  Figures  .........................................................................................................  viii  

1.  Introduction  .......................................................................................................................................  1  

2.  Goal  and  Objectives  ...........................................................................................................................  2  

3.  Background  ........................................................................................................................................  3  3.1  Maternal  health  services  in  Zimbabwe  .......................................................................................  3  3.2  Maternal  health  and  postpartum  hemorrhage  in  Zimbabwe  .....................................................  4  3.3  Misoprostol  for  the  management  of  postpartum  hemorrhage  ..................................................  5  3.4  Policies  and  regulations  enabling  the  use  of  misoprostol  in  Zimbabwe  .....................................  6  3.5  Rationale  for  introducing  misoprostol  for  PPH  prevention  and  treatment  at  all  levels  of  health  facilities  .............................................................................................................................................  6  

4.  Operations  Research  Components  ....................................................................................................  6  

5.    Methods  ............................................................................................................................................  7  5.1  Participating  districts  ...................................................................................................................  7  5.2  Participating  facilities  ..................................................................................................................  8  5.3  Service  delivery  and  referral  protocols  for  PPH  prevention  and  treatment  ................................  9  5.4  Health  provider  training  ............................................................................................................  11  5.5  Generating  community  awareness  ...........................................................................................  12  5.6  Monitoring  and  evaluation  of  the  operations  research  ............................................................  13  5.7  Data  collection  tools,  data  management  and  data  analysis  ......................................................  14  

6.  Operations  Research  Implementation  Timeline  ..............................................................................  16  

7.  Results  .............................................................................................................................................  16  7.1  Findings  from  baseline  facility  assessment  ...............................................................................  17  7.2  Operations  research  findings:  PPH  prevention  .........................................................................  19  7.3  Operations  research  findings:  PPH  cases  ..................................................................................  24  7.4  Maternal  deaths  ........................................................................................................................  26  7.5  Community  awareness  ..............................................................................................................  26  7.6  Provider  perspectives  on  introduction  of  misoprostol  for  PPH  prevention  and  treatment  ......  29  

8.  Discussion  and  Conclusions  .............................................................................................................  31  

9.  Programmatic  Recommendations  ...................................................................................................  34  

10.  References  .....................................................................................................................................  37  Appendix  A:  MIsoprostol  Regimens,  Pocket  Reference  for  Clinicians  .................................................  39  Appendix  B:  Contraceptive  Guide,  Pocket  Reference  for  Clinicians  ....................................................  40  Appendix  C:  Uterotonics  for  PPH  Prevention,  Pocket  Reference  for  Clinicians  ...................................  41  Appendix  D:  Poster  for  PPH  Prevention  ..............................................................................................  42      

 

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List of Boxes, Tables and Figures

Box  1:  WHO  2012  recommendations  for  PPH  prevention  and  treatment  ............................................  2  Box  2:  Perspectives  from  providers  .....................................................................................................  31    Table  1:  Provider  cadres  involved  in  delivering  maternal  health  services  .............................................  4  Table  2:  Socio-­‐demographic  characteristics  of  participating  districts  ...................................................  7  Table  3:  Description  of  levels  of  health  facilities,  services  provided  and  staffing  .................................  9  Table  4:  Distribution  of  health  facilities  which  participated  in  operations  research  by  district  ............  9  Table  5:  Providers  trained  for  the  operations  research,  by  cadre  and  district  ....................................  12  Table  6:  Distribution  of  deliveries  according  to  type  and  place  of  delivery  by  district  ........................  17  Table  7:  Some  characteristics  of  the  OR  facilities  according  to  facility  level  at  baseline  .....................  18  Table  8:  Average  number  of  staff  according  to  cadre  and  facility  level  at  baseline  ............................  18  Table  9:  Oxytocin  availability  and  stock  outs  according  to  facility  level  at  baseline  ...........................  19  Table  10:  Uterotonic  used  for  PPH  prevention  among  women  who  had  a  vaginal  delivery  at  a  facility  

according  to  district  ....................................................................................................................  20  Table  11:  Uterotonic  used  for  PPH  prevention  among  women  who  had  a  vaginal  delivery  at  a  facility  

according  to  facility  level  ............................................................................................................  21  Table  12:  Reported  PPH  cases  among  women  with  facility  or  home  vaginal  deliveries  according  to  

facility  level  and  type  of  uterotonic  used  for  treatment  of  PPH  .................................................  25  Table  13:  Comparison  of  PPH  cases  recorded  for  all  facility  deliveries,  over  6  months,  at  baseline  and  

during  the  OR,  by  the  level  of  facility  ..........................................................................................  26  Table  14:  Socio-­‐demographic  characteristics  of  village  health  workers  who  participated  in  FGDs  ....  27  Table  15:  Selected  characteristics  of  providers  who  responded  to  the  survey  ...................................  30  

Figure  1:  Estimates  of  the  maternal  mortality  ratio  in  Zimbabwe  between  1994  and  2011  .................  4  Figure  2:  Health  facilities  that  participated  in  the  operations  research  in  the  four  districts  in  

Zimbabwe  .....................................................................................................................................  8  Figure  3:  Service  delivery  and  referral  protocols  for  PPH  prevention  and  treatment,  based  on  the  

level  of  facility  and  availability  of  uterotonics  ............................................................................  11  Figure  4:  Data  flow  and  management  .................................................................................................  14  Figure  5:  Flow  chart  illustrating  women  delivering  in  the  four  operations  research  districts,  their  

place  of  delivery  and  type  of  delivery  .........................................................................................  17  Figure  6:  Flow  chart  illustrating  women  delivering  at  a  facility  during  the  operations  research  and  the  

uterotonic  they  received  for  PPH  prevention  .............................................................................  19  Figure  7:  Proportion  of  facility  deliveries  receiving  a  uterotonic  for  PPH  prevention,  at  baseline  and  

during  the  operations  research  ...................................................................................................  21  Figure  8:  Total  uterotonic  coverage  at  facility  deliveries  during  the  operations  research  ..................  22  Figure  9:  Trends  in  cumulative  number  of  women  receiving  misoprostol  for  PPH  prevention  

according  to  facility  level  ............................................................................................................  22  Figure  10:  Trends  in  the  uterotonic  used  for  PPH  prevention  for  vaginal  deliveries  at  rural  health  

centers  ........................................................................................................................................  23  Figure  11:  Trends  in  the  uterotonic  used  for  PPH  prevention  for  vaginal  deliveries  at  rural  hospitals  23  Figure  12:  Flow  chart  illustrating  location  of  delivery,  type  of  delivery  and  the  number  of  women  

who  were  reported  to  develop  PPH  ...........................................................................................  24  Figure  13:  Cumulative  number  of  people  reached  with  community  awareness  messages,  by  

facilitator  and  month  ..................................................................................................................  29  Figure  14:  Provider  views  on  misoprostol  training,  use  and  access    ...................................................  30

 

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1. Introduction

The  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  is  deeply  committed  to  improving  maternal  health  in  Zimbabwe  and  to  increasing  access  to  essential  drugs  and  services.  With  a  population  of  12.4  million,  Zimbabwe  has  been  facing  severe  economic  challenges,  which  have  adversely  affected  maternal  health  outcomes  (United  Nations  Development  Program  and  the  Government  of  Zimbabwe,  2010).  From  2000  to  20008,  Zimbabwe’s  GDP  shrunk  by  an  estimated  40%  (United  Nations  Development  Program  and  Government  of  Zimbabwe,  2010).  The  proportion  of  the  population  living  below  the  Total  Consumption  Poverty  Line  (TCPL),  which  is  the  minimum  expenditure  needed  to  buy  a  basic  basket  of  items  for  subsistence,  was  72%  in  2003  and  this  percentage  is  estimated  to  have  increased  as  a  result  of  the  economic  crisis  of  2008  (United  Nations  Development  Program  and  the  Government  of  Zimbabwe,  2010).  As  the  economy  has  worsened,  so  has  access  to  and  delivery  of  maternal  health  services,  resulting  in  a  high  maternal  mortality  ratio  (MMR).    Most  recent  estimates  report  the  MMR  at  960  maternal  deaths  per  100,000  live  births  (Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012).    Based  on  the  1994  MMR  estimate  of  283  per  100,000  live  births,  there  was  a  300%  increase  over  fifteen  years  (Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.,  1995).        The  Zimbabwe  Ministry  of  Health  and  Child  Care’s  commitment  to  improving  maternal  health  in  Zimbabwe  is  outlined  clearly  in  their  National  Maternal  and  Neonatal  Health  Roadmap  2007-­‐2015,  where  they  lay  out  evidence-­‐based  strategies  for  reversing  the  decline  in  maternal  health,  a  key  pillar  of  which  is  the  procurement  and  distribution  of  essential  maternal  health  commodities  (ZMoHCW,  2007a).    Globally,  postpartum  hemorrhage  (PPH)  is  the  most  common  cause  of  maternal  deaths;  one  woman  dies  from  PPH  every  seven  minutes  (Potts  et  al.,  2010).  PPH  can  also  cause  long-­‐term  severe  morbidities,  including  severe  anemia  (Abou-­‐Zahr,  2003).    In  Zimbabwe,  PPH  is  the  primary  obstetric  cause  of  maternal  death.    According  to  the  2007  Maternal  and  Perinatal  Mortality  Study,  PPH  accounted  for  14%  of  maternal  deaths  (ZMoHCW,  2007b).  The  use  of  uterotonic  drugs  in  the  active  management  of  the  third  stage  of  labor  (AMTSL)  is  the  recommended  strategy  to  reduce  blood  loss  along  with  additional  treatments  or  interventions.    AMTSL  has  traditionally  included:  administration  of  a  uterotonic  drug,  controlled  cord  traction,  and  uterine  massage.  The  World  Health  Organization  (WHO)  estimates  that  the  correct  use  of  ATMTSL  would  prevent  60%  of  PPH  cases  (WHO,  2006).    Recent  evidence  suggests  that  within  the  AMSTL  package,  it  is  the  administration  of  a  uterotonic  drug  that  has  the  greatest  effect  on  preventing  PPH  (Aflaifel  and  Weeks,  2012).      Oxytocin  is  recommended  by  the  WHO  as  the  first-­‐line  uterotonic  drug  for  PPH  prevention  and  treatment  (WHO,  2012).  This  recommendation  has  been  included  in  the  recently  revised  Basic  Emergency  Obstetric  and  Newborn  Care  Training  Manuals  (Zimbabwe  Ministry  of  Health  and  Child  Welfare,  2012).  However,  ensuring  that  all  women  delivering  in  a  health  facility  have  access  to  oxytocin  has  been  a  challenge,  both  globally  and  in  Zimbabwe,  because  of  frequent  stock-­‐outs  and  quality  issues  related  in  part  to  the  cold  chain  requirements  (UN  Commission  Implementation  Planning  Meeting,  2012).    To  ensure  the  availability  of  a  recommended  uterotonic  for  all  women  seeking  maternity  care  at  government  health  facilities,  the  ZMoHCC  aimed  to  make  misoprostol  available  for  PPH  prevention  and  treatment,  to  be  used  when  oxytocin  cannot  be  administered.    Registering  the  drug  for  PPH  prevention  and  treatment  in  Zimbabwe  will  allow  for  misoprostol  to  be  marketed  for  these  indications  and  will  ensure  that  an  insert  with  proper  dosages  and  instructions  

 

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for  providers  and  pharmacists  is  included  with  the  drug,  as  well  as  ensure  that  product  quality  is  monitored  by  a  drug  regulatory  board.  The  Medical  Research  Council  of  Zimbabwe  (MRCZ)  requested  that  operations  research  (OR)  be  conducted  prior  to  drug  registration,  to  demonstrate  the  feasibility  and  effectiveness  of  introducing  misoprostol  for  PPH  prevention  and  treatment.  In  response  to  this  request,  the  Zimbabwe  Ministry  of  Health  and  Child  Care  (ZMoHCC)  collaborated  with  Venture  Strategies  Innovations  (VSI),  a  US-­‐based  nonprofit  organization,  to  conduct  OR  to  support  the  introduction  of  misoprostol  as  an  additional  uterotonic  for  the  management  of  postpartum  hemorrhage  at  all  health  facility  levels.      Box  1:  WHO  2012  recommendations  for  PPH  prevention  and  treatment  

 This  report  describes  the  OR  on  the  introduction  of  misoprostol  by  the  ZMoHCC  conducted  with  the  support  of  VSI  in  four  districts  of  Zimbabwe.      

2. Goal and Objectives

The  main  goal  of  this  OR  was  to  assess  the  feasibility  and  effectiveness  of  introducing  misoprostol  for  the  prevention  and  treatment  of  PPH  at  all  levels  of  the  health  care  system.    The  specific  objectives  were:  

• Determine  whether  introducing  misoprostol  as  an  additional  uterotonic  available  at  all  health  facility  levels  increases  the  proportion  of  women  with  facility-­‐based  vaginal  births  who  receive  a  uterotonic  from  skilled  providers  immediately  after  delivery;  

• Assess  the  acceptability  of  the  introduction  of  misoprostol  for  the  management  of  PPH  among  health  providers  at  all  levels  of  health  facilities;  

• Identify  a  culturally-­‐appropriate  method  for  measuring  postpartum  blood  loss,  in  order  for  communities  to  assess  when  a  woman  has  lost  too  much  blood  after  delivery,  is  facing  a  life-­‐threatening  emergency,  and  requires  immediate  referral  to  a  health  facility;    

• Generate  evidence  to  inform  future  policy  on  the  use  of  misoprostol  for  PPH  management  and  provide  guidance  on  scaling  up  misoprostol  use  for  PPH  management  at  the  national  level.  

PPH  Prevention:  

1. The  use  of  uterotonics  for  the  prevention  of  PPH  during  the  third  stage  of  labor  is  recommended  for  all  births.    

2.  Oxytocin  (10  IU,  IV/IM)  is  the  recommended  uterotonic  drug  for  the  prevention  of  PPH.  3. In  settings  where  oxytocin  is  unavailable,  the  use  of  other  injectable  uterotonics  (e.g.  

ergometrine/methylergometrine  or  the  fixed  drug  combination  of  oxytocin  and  ergometrine)  or  oral  misoprostol  (600  mcg)  is  recommended.    

4. In  settings  where  skilled  birth  attendants  are  not  present  and  oxytocin  is  unavailable,  the  administration  of  misoprostol  (600  mcg  PO)  by  community  health  care  workers  and  lay  health  workers  is  recommended  for  the  prevention  of  PPH.    

 

PPH  Treatment:  1. Intravenous  oxytocin  is  the  recommended  uterotonic  drug  for  the  treatment  of  PPH.    2. If  intravenous  oxytocin  is  unavailable,  or  if  the  bleeding  does  not  respond  to  oxytocin,  

the  use  of  intravenous  ergometrine,  oxytocin-­‐ergometrine  fixed  dose,  or  a  prostaglandin  drug  (including  sublingual  misoprostol,  800  mcg)  is  recommended.    

 

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3. Background

3.1 MATERNAL HEALTH SERVICES IN ZIMBABWE Ensuring  that  high  quality  maternal  health  services  are  available  at  all  levels  of  the  health  care  system  is  a  key  goal  of  the  ZMoHCC.  About  two  thirds  (65%)  of  Zimbabwean  births  occur  in  health  facilities,  primarily  in  public  sector  facilities.  Home  births  are  three  times  more  common  in  rural  areas  (42%)  than  in  urban  areas  (14%)  (Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012).  To  encourage  facility  deliveries  and  ensure  that  women  living  in  rural  areas  have  a  safe  place  to  stay  in  the  weeks  before  giving  birth,  UNFPA  has  been  working  with  the  ZMoHCC  to  refurbish  105  maternity  waiting  homes  (UNFPA,  2013).      However,  even  when  women  reach  a  health  facility  for  delivery,  supply-­‐side  barriers  affect  timely  provision  of  quality  emergency  obstetric  care  resulting  in  key  constraints  to  reducing  maternal  mortality  (Knight,  2013).  As  of  2010  80%  of  public  sector  midwifery  posts  were  vacant  in  Zimbabwe  (United  Nations  Development  Program  and  Government  of  Zimbabwe,  2010).  Additionally,  the  National  Pharmaceutical  Company  (NatPharm)  of  Zimbabwe,  which  is  the  national  drug  procurement  and  distribution  body  for  all  government  hospitals  and  clinics,  has  experienced  a  sharp  decrease  in  funding  over  the  past  two  decades,  leading  to  a  lack  of  procurement  of  essential  pharmaceuticals  (United  Nations  Industrial  Development  Organization,  2011).      The  key  cadres  of  health  providers  who  are  responsible  for  delivering  maternal  health  services  are  summarized  in  Table  1  below.  It  is  noteworthy  that  the  ZMoHCC  and  Zimbabwe  Nursing  Council  have  trained  over  4,000  Primary  Care  Nurses  (PCNs)  since  2004,  in  large  part,  to  ensure  that  basic  emergency  obstetric  and  neonatal  care  (BEmONC)  is  available  at  rural  health  centers  (RHCs).  Over  95%  of  PCN  posts  are  currently  filled  (Taylor,  Gomez  et  al.,  2010).  Pre-­‐service  training  for  PCNs  includes  a  six-­‐week  rotation  in  obstetrics;  however,  the  lack  of  supervision  and  poor  working  conditions  mean  PCNs  graduate  and  function  with  limited  experience  and  confidence  (Taylor  et  al.,  2010).  Human  resources  for  health  remain  a  challenge  in  Zimbabwe,  and  according  to  the  National  Health  Strategy:  2009  to  2013,  in  public  sector  facilities  doctor  vacancy  is  69%,  midwife  vacancy  is  over  78%  and  nursing  tutor  vacancy  is  62%  (ZMoHCW,  2009).    Given  this  shortage  of  doctors  and  midwives,  ensuring  that  PCNs  are  able  to  effectively  deliver  basic  emergency  obstetric  and  neonatal  care  (BEmONC)  is  a  strategic  goal  of  the  ZMoHCC.  

 

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Table  1:  Provider  cadres  involved  in  delivering  maternal  health  services*  

Title   Training  and  current  practice  

Medical  Doctors   General  practitioners  provide  maternal  health  services  at  the  district  level.  General  Registered  Nurses  (GRNs)   GRNs  have  three  years  of  training  prior  to  service.  

Midwives  Midwives  have  one  additional  year  training  post  nursing  diploma.  Midwives  formerly  staffed  rural  health  centers  and  district  hospitals,  but  most  midwife  positions  are  now  vacant.  

Clinical  Officers  GRN  /midwives  who  receive  18  months  additional  training  including  surgery  such  as  cesarean  sections.  Ideally  posted  at  district  hospitals,  but  there  are  very  few  occupied  posts  at  this  time.  

Primary  Care  Nurses  (PCNs)  

This  second-­‐level  nursing  cadre  was  revived  and  renamed  in  2003  to  fill  the  staffing  gap  at  the  primary  health  care  level.  PCNs  are  professional  nurses  who  are  trained  for  18  months  to  provide  ANC,  normal  delivery  care,  identification  and  referral  of  obstetric  complications,  postnatal  care,  family  planning  and  integrated  management  of  childhood  illness.    Each  RHC  is  staffed  by  1-­‐2  PCNs.    

Nurse  Aides  Nurse  aides  were  general  hands  who  were  promoted  to  the  position  of  nurse  aide.  They  received  training  from  a  GRN  or  PCN  on  the  job.  Nurse  aides  are  not  allowed  to  administer  injections.    

*Adapted  from  Taylor  et  al.  (2010).  Maternal  and  Child  Health  Integrated  Program:  Zimbabwe  Situation.  

3.2 MATERNAL HEALTH AND POSTPARTUM HEMORRHAGE IN ZIMBABWE The  impact  of  political,  economic,  and  environmental  factors  on  maternal  health  in  Zimbabwe  has  been  particularly  notable,  and  Zimbabwe’s  MMR  has  increased  significantly  since  1994  (Figure  1).  According  to  Millennium  Development  Goal  (MDG)  5,  which  aims  to  reduce  the  maternal  mortality  ratio  by  75%  by  2015,  Zimbabwe’s  target  is  to  reach  an  MMR  of  174  (United  Nations  Development  Program  and  Government  of  Zimbabwe,  2010).  This  is  considered  to  be  unattainable  based  on  recent  trends  and  the  current  MMR  of  960.      

Figure  1:  Estimates  of  the  maternal  mortality  ratio  in  Zimbabwe  between  1994  and  2011  

 ¹Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.  1995.  Zimbabwe  Demographic  and  Health  Survey,  1994.  Calverton,  Maryland:  Central  Statistical  Office  and  Macro  International  Inc.  ²Central  Statistical  Office  [Zimbabwe]  and  Macro  International  Inc.  2000.  Zimbabwe  Demographic  and  Health  Survey  1999.  Calverton,  Maryland:  Central  Statistical  Office  and  Macro  International  Inc.  ³WHO/UNICEF/UNFPA  and  The  World  Bank.  Maternal  mortality  in  2005.  Estimates  developed  by  WHO,  UNICEF,  UNFPA  and  the  World  Bank.  Geneva:  World  Health  Organisation;  2007.  ⁴Central  Statistical  Office  (CSO)  [Zimbabwe]  and  Macro  International  Inc.  2007.  Zimbabwe  Demographic  and  Health  Survey  2005-­‐06.  Calverton,  Maryland:  CSO  and  Macro  International  Inc.  ⁵Zimbabwe  Ministry  of  Health  and  Child  Welfare.    Maternal  and  Perinatal  Mortality  Study.  Ministry  of  Health  and  Child  Welfare  [Zimbabwe],  2007.  ⁶Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International.  2012.  Zimbabwe  Demographic  and  Health  Survey  2010-­‐11.  Calverton,  Maryland:  ZIMSTAT  and  ICF  International  Inc.  

283  

695  

880  

555  

725  

960  

0  

200  

400  

600  

800  

1000  

1200  

1994¹   1999²   2005³   �2005-­‐06⁴   2007⁵   �2010-­‐11⁶  

    1994¹   1999²   2005³  �2005-­‐06⁴  

2007⁵  �2010-­‐11⁶  

 

5  

The  primary  obstetric  causes  of  maternal  death  in  Zimbabwe,  as  reported  in  the  2007  Maternal  and  Perinatal  Mortality  Study,  were  PPH  (18.6%),  pregnancy  induced  hypertension/eclampsia  (15.7%),  sepsis  (12.3%),  and  abortion-­‐related  causes  (2.6%)  (ZMoHCW,    2007b).  Active  Management  of  the  Third  Staqe  of  Labor  (AMTSL)  shortens  the  third  stage  of  labor,  and  is  an  important  preventive  measure  for  PPH  (Gulmezoglu  et  al.,  2012).  According  to  the  most  recent  evidence  on  the  AMTSL,  WHO  recommends  the  use  of  uterotonics  as  the  main  intervention  within  the  active  management  of  third  stage  of  labor  package  (WHO,  2012).  As  most  deaths  from  PPH  occur  in  the  first  24  hours  after  birth  (WHO,  2012),  it  is  very  important  that  both  preventative  and  therapeutic  measures  are  available  during  labor  and  delivery  to  prevent  mortality  due  to  PPH.      Oxytocin,  the  recommended  uterotonic  drug  to  prevent  and  treat  PPH,  is  an  injectable  uterotonic  and  requires  a  reliable  cold  chain.  It  is  reported  that  oxytocin  loses  effectiveness  after  three  months  of  being  stored  at  temperatures  higher  than  30  degrees  Celcius  (Wilson  et  al.,  2012).  In  the  case  of  Zimbabwe,  the  stock  outs  in  facilities,  as  well  as  lack  of  a  continuous  and  reliable  cold  chain  system  specifically  for  oxytocin,  could  possibly  be  interfering  with  both  the  availability  and  efficacy  of  oxytocin.    It  is  reported  that  providers  at  lower-­‐level  facilities  often  use  their  vaccine  refrigerators  to  store  their  oxytocin.  In  addition,  even  when  oxytocin  is  refrigerated,  the  unreliable  power  supply,  and  frequent  power  shortages  experienced  in  health  facilities  (World  Bank,  2012)  threaten  its  stability,  thus  affecting  its  efficacy.  Providers  will  not  know  if  their  oxytocin  is  still  potent  without  the  time-­‐temperature  indicator  (TTI)  on  the  product  package  or  if  the  storage  temperature  has  not  been  carefully  tracked  (PATH,  2010).  Further,  oxytocin  is  administered  using  a  disposable  syringe  and  needle,  which  necessitates  that  the  provider  attending  the  delivery  be  trained  and  authorized  to  administer  injections.  However,  the  reality  is  that  when  PCNs  are  not  present  at  the  facility,  nurse  aids  -­‐  who  are  not  authorized  to  provide  injections  –  may  be  the  only  trained  providers  available  to  attend  deliveries.    The  introduction  of  misoprostol  can  help  to  mitigate  these  challenges.  

3.3 MISOPROSTOL FOR THE MANAGEMENT OF POSTPARTUM HEMORRHAGE Where  oxytocin  is  unavailable  or  cannot  be  safely  used  because  of  lack  of  refrigeration,  as  there  is  a  lack  of  essential  supplies  such  as  syringes,  or  trained  personnel  to  administer  injections,  misoprostol  can  be  used  effectively  for  the  management  of  PPH  (Geller  et  al.,  2006).    Misoprostol  is  a  prostaglandin  analogue  in  tablet  form  that  has  been  recognized  by  the  international  community  for  its  potential  to  reduce  PPH  in  resource-­‐poor  settings  due  to  its  relative  efficacy,  ease  of  administration,  and  stability  in  field  conditions  (Derman  et  al.,  2006;  Alfirevic  et  al.,  2007).  It  has  been  shown  to  be  effective  in  reducing  the  risk  of  PPH  by  between  24%  (Mobeen  et  al.,  2011)  and  47%  (Derman  et  al.,  2006).      Based  on  recent  evidence,  the  WHO  identified  the  use  of  uterotonics  as  the  key  intervention  within  the  AMTSL  package,  and  recommends  that  all  women  giving  birth  should  be  offered  uterotonics  for  the  prevention  of  PPH  (WHO,  2012).  Oxytocin  is  recommended  as  the  uterotonic  drug  of  choice  for  the  prevention  and  treatment  of  PPH,  and  misoprostol  is  recommended  in  settings  where  oxytocin  is  unavailable  or  cannot  be  safely  used  (WHO,  2012).  Misoprostol  is  included  in  the  WHO  Model  List  of  Essential  Medicines  (WHO,  2011b)  for  PPH  prevention;  as  well  as  in  the  Priority  Life-­‐saving  Medicines  for  Women  and  Children  (WHO,  2011a).    Furthermore,  it  is  included  in  the  life-­‐saving  commodities  list  for  PPH  prevention  by  the  United  Nations’  Commission  on  Life-­‐saving  Commodities  for  Women  and  Children  (UN  Commissioner’s  Report,  2012),  whose  goal  is  to  increase  the  supply  and  use  of  essential  commodities.  In  addition,  the  World  Health  Organization  recommends  that  if  oxytocin  is  

 

6  

unavailable,  or  if  the  bleeding  does  not  respond  to  oxytocin,  800  mcg  sublingual  misoprostol  is  a  recommended  treatment  regimen  (WHO,  2012).  

3.4 POLICIES AND REGULATIONS ENABLING THE USE OF MISOPROSTOL IN ZIMBABWE As  a  result  of  the  strong  evidence  on  the  safety  and  efficacy  of  misoprostol  for  PPH  management  in  numerous  countries  and  the  effectiveness  of  misoprostol  in  resource-­‐constrained  settings,  the  ZMoHCC  supports  expanding  access  to  misoprostol  in  Zimbabwe.  Led  by  the  ZMoHCC,  a  Misoprostol  Technical  Working  Group  (MTWG)  was  formed  in  January  2011  to  include  the  Zimbabwe  Confederation  of  Midwives  (ZICOM)  and  the  Zimbabwe  Society  of  Obstetricians  and  Gynaecologists  (ZSOG).    The  primary  purpose  of  the  MTWG  was  to  provide  input  on  the  OR  protocols.  Through  the  work  of  the  MTWG  hosted  within  the  ZMoHCC,  misoprostol  is  included  in  the  2011  Essential  Drugs  List  of  Zimbabwe  (EDLIZ)  for  obstetric  indications.  The  maternal  health  indications  for  which  misoprostol  is  included  in  the  EDLIZ  are:  prevention  and  treatment  of  PPH,  induction  of  labor,  pregnancy  termination,  intrauterine  fetal  death,  missed  abortion,  and  treatment  of  incomplete  abortion  and  miscarriage  (The  National  Medicine  and  Therapeutics  Policy  Advisory  Committee  [NMTPAC],  ZMoHCW,  et  al.,  2011).  The  most  up-­‐to-­‐date  information  on  the  use  of  misoprostol  for  PPH  prevention  and  treatment  is  included  in  the  most  recently  revised  Basic  Emergency  Obstetric  and  Newborn  Care  Training  Manuals  (ZMoHCW,  2012).  With  support  from  the  ZMoHCC,  Pharmaceutical  and  Chemical  Distributors,  a  Harare-­‐based  distributor,  submitted  an  amendment  to  the  Medicines  Control  Authority  of  Zimbabwe  (MCAZ)  to  include  all  obstetric  indications  in  the  current  registered  product,  Cipla’s  Misoprost  200®.  

3.5 RATIONALE FOR INTRODUCING MISOPROSTOL FOR PPH PREVENTION AND TREATMENT AT ALL LEVELS OF HEALTH FACILITIES Given  the  benefits  and  additional  uterotonic  coverage  misoprostol  can  bring  through  addressing  some  of  the  shortcomings  discussed  above,  the  OR  integrated  misoprostol  at  all  levels  of  health  facilities  for  the  management  of  PPH.  Making  misoprostol  available  at  all  facilities  to  be  used  by  providers  trained  in  its  use  was  hypothesized  to  increase  overall  uterotonic  coverage  for  PPH  prevention,  as  well  as  to  provide  an  additional  option  for  treatment  of  PPH  where  oxytocin  is  not  available.      

4. Operations Research Components

In  January  2013,  the  ZMoHCC,  with  the  support  of  VSI,  launched  the  OR  to  introduce  misoprostol  for  the  management  of  PPH  at  all  levels  of  the  healthcare  system.      The  OR  included  four  main  components:  

1) Development  of  protocols  for  PPH  management  service  delivery:  Service  delivery  and  referral  protocols  were  developed  by  the  MTWG  that  outlined  the  uterotonics  to  be  used  -­‐  including  misoprostol-­‐  along  with  the  steps  and  referral  chains  for  PPH  prevention  and  treatment.      

2) Training  of  service  providers:    Two  providers  from  each  of  the  OR  facilities  that  attend  deliveries  were  trained  on  the  use  of  misoprostol  for  PPH  prevention  and  treatment  and  the  new  service  delivery  protocols.  The  two  providers  were  tasked  with  sharing  the  knowledge  and  information  they  received  with  all  other  providers  attending  deliveries  at  their  facilities,  referred  to  as  “feedback”  training.  This  type  of  training  is  commonly  used  in  Zimbabwe.    

 

7  

3) Community  awareness:  A  community  awareness  campaign  was  conducted  by  health  providers  at  the  facilities,  village  health  workers  (VHWs),  and  OR  staff  to  provide  information  on  the  importance  of  birth  preparedness  and  delivering  in  a  facility,  the  availability  of  drugs  that  can  prevent  bleeding  at  facilities,  safe  delivery  practices  and  how  to  recognize  excessive  bleeding  at  delivery.    

4) Monitoring  and  evaluation:  Data  were  collected  on  facility  deliveries  for  uterotonic  use  and  coverage,  PPH  treatment,  referrals,  as  well  as  community  awareness  activities,  and  provider  perspectives  on  the  introduction  of  misoprostol.  Supportive  supervision  was  conducted  throughout  the  OR  to  identify  and  resolve  challenges  with  program  implementation  and  data  collection.  

5. Methods

5.1 PARTICIPATING DISTRICTS The  Misoprostol  Technical  Working  Group  (MTWG)  identified  four  of  Zimbabwe’s  59  districts,  located  in  three  of  the  country’s  eight  provinces,  for  participation  in  the  OR.  These  districts  were:  Mutare,  Chimanimani,  Matobo  and  Umguza.  Mutare  and  Chimanimani  are  located  in  Manicaland  Province  in  eastern  Zimbabwe.  Umguza  and  Matobo  districts,  both  of  which  are  in  southern  Zimbabwe,  are  located  in  Matebeleland  North  and  Matebeleland  South  Provinces,  respectively  (Figure  2).  The  districts  were  purposively  selected  by  the  MTWG  with  the  aim  of  reflecting  the  country’s  diversity  in  terms  of  geographical  location,  resources,  and  political  affiliation.  All  of  the  four  districts  had  high  MMRs  and  relatively  poor  obstetric  services,  thus  making  the  OR  relevant.  Capturing  this  diversity  was  intended  to  help  identify  the  different  challenges  of  introducing  misoprostol  across  a  variety  of  settings  and  provide  more  comprehensive  insight  into  how  the  ZMoHCC  could  scale  up  the  introduction  of  misoprostol  for  PPH  management  nationally.  Socio-­‐demographic  characteristics  of  participating  districts  are  presented  in  Table  2.  

Table  2:  Socio-­‐demographic  characteristics  of  participating  districts    

  Mutare   Chimanimani   Umguza   Matobo  Population   434,379   136,055   81,781   110,266  Total  fertility  rate(a)   4.8   4.8   4.1   4.2  Percentage  Delivered  in  Health  Facility  (a)   60.9%   60.9%   63.5%   69.3%  Median  Years  of  Education  Completed  (Women)  (a)   8.7   8.7   7.2   8.3  Median  Years  of  Education  Completed  (Men)  (a)   9.8   9.8   7.1   7.9  Literacy  (Women)  (a)   94.4%   94.4%   87.9%   92.9%  Literacy  (Men)  (a)   96.0%   96.0%   83.5%   91.5%  Health  Insurance  Coverage  (Women)  (a)   4.7%   4.7%   3.0%   4.7%  Health  Insurance  Coverage  (Men)  (a)   9.6%   9.6%   4.2%   7.4%  Wealth  quintile(a)          

Lowest   17.5%   17.5%   61.0%   26.8%  Second   21.5%   21.5%   13.5%   23.2%  Middle   29.2%   29.2%   8.6%   26.7%  Fourth   20.4%   20.4%   8.5%   17.3%  Highest   11.3%   11.3%   8.3%   6.1%  

(a) Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International,  2012  

 

 

 

8  

Figure  2:  Health  facilities  that  participated  in  the  operations  research  in  the  four  districts  in  Zimbabwe  

5.2 PARTICIPATING FACILITIES The  health  care  system  in  Zimbabwe  operates  on  four  levels,  from  the  primary  to  the  specialist/referral  level:  rural  health  center  (RHC),  district-­‐level  hospital,  provincial  hospital,  and  central  hospital  with  some  variations  (clinics,  maternity  hospitals,  mission  hospitals,  and  rural  hospitals)  depending  on  the  district  (Table  3).  The  referral  system  is  hierarchical  with  increasingly  complex  cases  referred  to  higher-­‐level  facilities.  In  urban  catchment  areas  (e.g.,  Harare,  Bulawayo),  RHCs  can  refer  patients  directly  to  the  central  hospitals.    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUTARE DISTRICT!Pop. = 434,379!

Rural Health Center = 20!Rural/Mission Hospital = 3!

District Hospital = 1!Provincial Hospital = 1!

CHIMANIMANI DISTRICT!Pop. = 136,055!

Rural Health Center = 15!Rural/Mission Hospital = 5!

District Hospital = 0!Provincial Hospital = 0!

MATOBO DISTRICT!Pop. = 110,266!

Rural Health Center = 8!Rural/Mission Hospital = 4!

District Hospital = 1!Provincial Hospital = 0!

UMGUZA DISTRICT !Pop. = 81,781!

Rural Health Center = 8!Rural/Mission Hospital = 1!

District Hospital = 1 Provincial Hospital = 0!

HARARE!

 

9  

Table  3:  Description  of  levels  of  health  facilities,  services  provided  and  staffing*  

Level  of  facility     Services  Provided   Staffing  

Central  Hospital     Specialty  services  and  management  of  complicated  cases    

• Obstetricians,  gynecologists,  neonatologists,  pediatricians,  pediatric  surgeons  

• Midwives,  General  Registered  Nurses  (GRNs)  and  State  Certified  Maternity  Nurses  (SCMNs)  

Provincial  hospitals   Management  of  complicated  cases  

• Obstetricians,  gynecologists,  neonatologists,  pediatricians,  anesthetists  

• Midwives,  GRNs  and  SCMNs  

District  /mission  hospitals      

• Basic  Emergency  Obstetric  and  Neonatal  Care  (BEmONC)  and  Comprehensive  Emergency  Obstetric  and  Neonatal  Care  (CEmONC)    

• Long-­‐acting  and  permanent  contraceptive  methods    

• Supervision  of  lower  levels:  rural  health  centers  and  Village  Health  Workers  

• District  medical  officer,  MDs  • Clinical  officers  • Midwives,  GRNs,  nurse  anesthetists  • Pharmacists  

Clinics/Rural  Health  Centers  

• Antenatal  care  (ANC)  • Basic  delivery  care  including  ENC;  Basic  

Emergency  Obstetric  and  Neonatal  Care  (BEmONC)  

• Family  planning  

• Sometimes  a  midwife  or  GRN  • SCMN/SCN  • Primary  Care  Nurses  • Nurse  aides  

Village  Health  Workers    

• Immunization;  health  promotion  • Family  planning:  counseling,  resupplies  

and  referrals    

1  VHW  per  100  families  

*Adapted  from:  Taylor,  P.,  P.  Gomez,  et  al.  (2010).  Maternal  and  Child  Health  Integrated  Program:  Zimbabwe  Situation.   With  the  exception  of  Mutare  district,  all  health  facilities  in  the  four  districts  that  conducted  deliveries  participated  in  the  OR,  which  added  up  to  a  total  of  68  facilities  (Table  4).  In  Mutare  District,  only  25  of  the  50  eligible  facilities  could  participate  due  to  budgetary  constraints,  which  limited  monitoring  and  supportive  supervision  activities  to  25  facilities  per  district.  The  25  facilities  that  participated  from  Mutare  district  were  selected  by  district  officials  to  include  a  mixture  of  facility  levels  and  rural  and  urban  facilities.  The  three  urban  health  centers  from  Mutare  that  participated  in  the  OR  are  grouped  with  the  RHCs  for  the  purposes  of  analysis  in  this  report.    

Table  4:  Distribution  of  health  facilities  which  participated  in  operations  research  by  district  

Facility  Level    Participating  District  

Mutare   Chimanimani   Umguza   Matobo   Total  Rural  Health  Center*   20   15   8   8   51  Rural/Mission  Hospital   3   5   1   4   13  District  Hospital   1   0   1   1   3  Provincial  Hospital   1   0   0   0   1  TOTAL   25   20   10   13   68  *Three  urban  health  centers  in  Mutare  District  are  included  in  the  “Rural  Health  Center”  category    

5.3 SERVICE DELIVERY AND REFERRAL PROTOCOLS FOR PPH PREVENTION AND TREATMENT 5.3.1 PPH Prevention Service Delivery and Referral Protocol Women  who  delivered  at  a  health  facility  were  given  oxytocin  (10  IU,  IM)  as  the  first-­‐line  uterotonic  for  PPH  prevention;  misoprostol  (600  mcg,  oral)  was  given  if  oxytocin  was  not  available  (Figure  3).  

 

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Women  were  instructed  during  ANC,  in  both  individual  and  group  sessions,  to  go  to  the  nearest  health  facility  in  the  case  that  they  delivered  at  home  and  experienced  excessive  bleeding.    5.3.2 PPH Treatment Service Delivery and Referral Protocol The  PPH  treatment  protocols  by  facility  level  developed  for  the  OR  were  as  follows;  they  were  applied  the  same,  regardless  of  PPH  prevention  status,  or  the  drugs  used  for  prophylaxis  :      

• Rural  Health  Centers:    Routine  treatment  of  PPH  prior  to  the  OR  included  the  use  of  only  injectable  uterotonics,  with  oxytocin  and/or  ergometrine.  During  the  OR,  misoprostol  (800  mcg  sublingual)  was  integrated  as  an  additional  treatment  option  for  PPH,  in  cases  where  oxytocin  was  not  available  or  failed  as  a  prevention  method  or  the  provider  assisting  the  delivery  was  not  authorized  to  administer  an  injection,  such  as  in  the  absence  of  a  PCN  at  the  time  of  delivery.    If  a  woman  continued  to  bleed  after  being  treated  with  any  uterotonic,  or  experienced  deterioration  in  vital  signs  (blood  pressure  or  pulse),  she  was  referred  to  a  district  hospital.  

• District  Hospitals:    Misoprostol  (800  mcg  sublingual)  was  integrated  as  an  additional  treatment  option  for  PPH  at  the  level  of  district  hospitals,  of  which  some  had  the  capacity  for  further  surgical  interventions  for  PPH  treatment  depending  on  the  skill  sets  of  the  attending  doctors.  If  a  woman’s  condition  deteriorated  or  if  she  required  a  surgical  intervention  that  was  not  available  at  the  district  hospital,  she  was  referred  to  a  provincial  or  central  hospital.    

• Provincial/Central  Hospitals:  All  methods  of  PPH  treatment,  including  injectable  uterotonics  and  surgical  care  as  needed,  were  available  at  this  level.  Misoprostol  was  integrated  as  an  additional  treatment  option  in  cases  of  oxytocin  stock-­‐outs,  or  in  addition  to  oxytocin  as  needed.  

 

 

11  

Figure  3:  Service  delivery  and  referral  protocols  for  PPH  prevention  and  treatment,  based  on  the  level  of  facility  and  availability  of  uterotonics*  

5.4 HEALTH PROVIDER TRAINING Trainings  on  misoprostol  for  PPH  management  covered  the  following  topics:  maternal  mortality  and  the  role  of  PPH;  misoprostol  use  for  PPH  management;  evidence  and  policies  in  support  of  using  misoprostol;  components  of  AMTSL;  and  postpartum  contraceptive  counseling.  Additionally,  providers  were  trained  in  how  to  complete  the  OR  data  collection  tools.  Three  pocket  guides  were  developed  for  the  OR:  one  for  misoprostol  regimens,  one  for  postpartum  contraception,  and  one  for  all  uterotonic  regimens.  One  copy  of  each  guide  was  distributed  to  each  participating  facility  (Appendix  A-­‐C).      A  four-­‐day  workshop  to  train  the  trainers  was  conducted  in  Harare  in  February  2012  for  40  senior-­‐level  service  providers  (doctors,  nurses  and  midwives),  district  pharmacists  and  reproductive  health  officers  (RHOs)1  from  the  four  OR  districts.  As  the  data  collection  did  not  start  until  January  2013,  additional  refresher  trainings  were  held  in  December  2012  for  the  40  providers  who  had  attended  the  initial  training  of  trainers  (TOT).  The  senior  refresher  trainings  were  held  to  review  the  materials  that  had  initially  been  presented  in  February,  as  well  as  the  final  OR  protocols  and  data  collection  tools.    The  district  nursing  officers  and  community  sisters  (senior  district  nurses  who  supervise  the  RHCs)  from  each  OR  district  selected  the  providers  who  would  participate  in  the  cascade  trainings.  In  most  cases,  RHCs  were  staffed  by  two  nurses  (typically  PCNs),  both  of  whom  participated  in  the  OR  training.  At  district  and  provincial  hospitals,  nurses  who  worked  in  the  labor  ward  participated  in  the  

1  A  reproductive  health  officer  is  the  midwife  or  doctor  at  the  provincial  level  who  is  responsible  for  managing  reproductive  health  services.  

!Oxytocin infusion, 40 units at

30-40 drops/minute!!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV*!

!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!!SURGICAL INTERVENTION, IF NECESSARY AND AVAILABLE!!

!!!

!!!!

Oxytocin, 10 units IM!!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV*!

!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!

!!!!

!!!!

!!!

Oxytocin infusion, 40 units at 30-40 drops/minute!

!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV!!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!

!SURGICAL INTERVENTION IF

NECESSARY!!!!

!!

Bleeds > 500 ml (PPH)!

!Perceived PPH!

!!

Bleeds > 500 ml (PPH)!

!!

Bleeds > 500 ml (PPH)!

Provincial/Central Hospitals!District Hospital!Home! Rural Health Center!

!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!

10 IU oxytocin, IM !If oxytocin NOT available!600 mcg misoprostol oral!

10 IU oxytocin, IM !If oxytocin NOT available!600 mcg misoprostol oral!

Self refer to health facility, treatment according to

facility guidelines!

No uterotonic!

!!!!!!!!!!!!!!!!!!!!

10 IU oxytocin, IM!If oxytocin NOT available, !600 mcg misoprostol oral!

Refer if woman continues to bleed or has a

deterioration in vital signs ! *Facility treatment regimens are the same for all women with PPH, regardless of what, if any, uterotonic was used for PPH prevention!

PREVENTION !!!!TREATMENT!

Refer if woman requires a surgical intervention not available at the district

hospital!

 

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training.  Trainers  conducted  cascade  trainings  in  December  2012  in  Bulawayo  and  Mutare,  where  two  providers  from  each  of  the  OR  facilities  participated.  In  total,  135  providers  were  trained,  50  from  Mutare  District,  40  from  Chimanimani  District,  25  from  Matobo  District,  and  20  from  Umguza  District  (Table  5).  These  135  providers  were  evaluated  at  the  end  of  the  training  with  standardized  knowledge  and  skills  assessment  tools.  Providers  who  attended  the  cascade  trainings  were  tasked  with  sharing  “feedback”  to  other  providers  who  were  not  at  the  training,  but  who  assist  in  deliveries  at  their  respective  facilities.  Providers  who  received  this  “feedback”  were  not  assessed  using  the  standardized  knowledge  and  skills  assessment  tools.    Table  5:  Providers  trained  for  the  operations  research,  by  cadre  and  district  

  Mutare   Chimanimani   Matobo   Umguza  Provincial  and  

central  hospital  health  officers  

Total  

Training  of  trainers  (TOT)   5   5   5   5   20   40  

Cascade  trainings   50   40   25   20   -­‐-­‐-­‐   135  

Primary  Care  Nurse   20   22   12   12   -­‐-­‐   66  

Nurse   25   12   3   4   -­‐-­‐   44  Midwife   4   6   8   4   -­‐-­‐   22  Sister  in  Charge   1     2     -­‐-­‐   3  

TOTAL   55   45   30   25   20   175    During  the  supportive  supervision,  data  collection  tools  were  reviewed  and  OR  protocols  were  reviewed  and  reinforced  with  providers,  to  ensure  that  all  providers  who  were  attending  deliveries  were  informed  about  the  OR  and  the  use  of  misoprostol  according  to  protocols.  

5.5 GENERATING COMMUNITY AWARENESS A  community  education  campaign  was  conducted  to  educate  women  and  the  community  about  birth  preparedness,  the  importance  of  delivering  in  a  facility,  the  availability  of  drugs  to  prevent  bleeding  at  health  facilities,  safe  delivery  practices,  and  how  to  recognize  excessive  bleeding.    Awareness-­‐raising  activities  included  the  following:  

a. Education  Sessions  during  antenatal  care  (ANC):  Women  were  given  information  during  routine  ANC  visits  about  the  importance  of  birth  preparedness,  delivering  in  a  health  facility  and  attending  ANC  throughout  pregnancy.    Women  were  informed  that  effective  drugs  to  help  prevent  and  stop  bleeding  after  childbirth  were  available  at  the  health  facility.    Women  were  also  educated  about  how  to  recognize  the  need  for  referral  if  they  had  excessive  bleeding  after  a  home  delivery.      

b. Community  meetings:  Operations  research  staff  and  VHWs  held  general  sensitization  meetings  at  the  village  level  to  educate  communities  about  the  above  messages.    

c. Print:  A  general  information  poster  about  the  importance  of  delivering  in  a  health  facility  and  how  to  prevent  excessive  bleeding  after  childbirth  was  developed  and  displayed  in  key  places  in  the  community  and  at  health  facilities  (e.g.  waiting  areas)  (Appendix  D).  

5.5.1 Focus Group Discussions with Vil lage Health Workers If  a  woman  has  the  possibility  to  deliver  at  home,  it  is  critical  that  she  and  her  family  understand  when  she  has  bled  too  much  and  must  be  immediately  taken  to  a  health  facility  to  stop  her  bleeding.  Focus  group  discussions  (FGDs)  were  held  with  VHWs  in  two  districts  to  identify  appropriate  local  

 

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methods  for  measuring  blood  loss  at  delivery.  The  discussions  were  held  to  provide  information  on  local  practices  at  home  births,  including  what  (if  anything)  VHWs  were  currently  using  to  collect  and  measure  blood  loss  after  delivery.  The  objective  was  to  identify  an  easily  accessible  method  for  measuring  postpartum  blood  loss,  and  to  establish  a  threshold  for  excessive  bleeding  (defined  as  bleeding  in  excess  of  500  ml)  using  that  method.  The  focus  groups  identified  using  a  zambia  (a  local  cloth  that  all  women  own)  as  the  best  method  to  measure  blood  loss  after  home  deliveries,  with  two  soaked  zambias  signifying  that  a  woman  had  bled  excessively.    This  method  was  then  shared  as  a  key  message  of  the  community  education  campaign  so  that  women  and  communities  could  better  understand  when  a  woman  had  bled  too  much  after  delivery  and  should  be  immediately  referred  to  a  health  facility.    Operations  research  staff  members  conducted  two  focus  group  discussions  with  VHWs  in  November  and  December  2012.  The  district  nursing  officers  (DNOs)  from  each  district  were  asked  to  select  VHWs  for  participation  to  ensure  that  some  who  participated  had  experience  with  home  deliveries.  The  DNOs  contacted  each  selected  VHW  and  invited  them  to  participate,  explaining  that  their  responses  would  be  confidential.  Participating  VHWs  were  reimbursed  for  their  transportation  costs  and  were  also  given  a  $10  allowance  for  the  day  (the  amount  paid  by  other  international  NGOs  for  VHW  participation),  as  well  as  $10  for  meals.      The  focus  group  discussions  were  held  in  two  locations.  The  first  was  in  the  city  of  Mutare  in  Mutare  District,  in  the  conference  room  of  a  district  hospital.  The  other  was  in  Umguza  District  in  a  central  town  hall  near  Nyamandlovu.  Both  locations  were  easily  accessible  by  bus  for  the  FGD  participants.      Each  group  was  led  by  a  facilitator  who  spoke  the  group’s  primary  language  (Shona  in  Mutare  District  and  Ndebele  in  Umguza  District).  Each  facilitator  was  a  Community  Health  Nurse  with  experience  conducting  FGDs  and  working  with  VHWs  to  ensure  that  she  was  viewed  by  VHWs  as  a  trusted  person.  District  nursing  officers  selected  the  facilitators.  They  were  trained  by  VSI  staff  to  use  a  discussion  guide  that  was  prepared  by  VSI’s  Monitoring  and  Evaluation  team.  The  guide  was  composed  of  ten  open-­‐ended  questions,  each  of  which  had  between  four  to  five  sub-­‐questions.  A  VSI  staff  member  recorded  the  focus  group  discussions  using  a  digital  voice  recorder  (DVR).    

5.6 MONITORING AND EVALUATION OF THE OPERATIONS RESEARCH VSI,  in  collaboration  with  the  ZMoHCC,  developed  data  collection  tools  for  the  OR  (see  Section  5.7  Data  Collection  Tools,  Data  Management  and  Data  Analysis).  Baseline  data  was  collected  for  the  time  period  September  2011  to  February  2012  in  order  to  assess  current  PPH  management  practices.  The  OR  was  implemented  from  January  2013  to  June  2013.  During  the  period  of  the  OR,  service  delivery  data  on  PPH  management  practices  were  collected  on  a  monthly  basis  by  OR  staff.  Data  on  community  education  sessions  and  provider  perspectives  on  misoprostol  were  also  collected.      Monitoring  and  evaluation  (M&E)  activities  were  undertaken  by  OR  staff  hired  expressly  for  the  OR.  Additionally,  VSI’s  Zimbabwe  Program  Officer  provided  oversight  to  all  M&E  activities  and,  in  coordination  with  high-­‐level  officials  from  the  ZMoHCC,  conducted  targeted  supportive  supervision  to  facilities  that  were  encountering  challenges  during  the  OR.    Supportive Supervision Regular  monthly  visits  by  OR  monitoring  staff  took  place  in  order  to  assess  the  status  of  the  OR  and  to  provide  supportive  supervision  to  health  providers  and  other  facility  staff.  OR  monitoring  staff  

 

14  

ensured  that  providers  were  following  the  correct  clinical  protocols  that  had  been  laid  out  for  the  OR.    If  there  were  protocol  violations,  they  worked  with  providers  to  ensure  that  they  understood  how  to  correct  them.  They  also  reviewed  all  data  collection  tools,  confirming  that  forms  were  being  filled  out  correctly  and  that  there  were  no  additional  issues  to  be  addressed  or  need  to  retrain  providers.  In  addition  to  quantitative  data  collected  with  the  monitoring  and  evaluation  tools,  OR  staff  also  collected  qualitative  information  from  providers  and  district  supervisors  about  the  OR  to  monitor  the  fidelity  of  implementation  and  to  ensure  timely  identification  of  challenges.  

5.7 DATA COLLECTION TOOLS, DATA MANAGEMENT AND DATA ANALYSIS The  ZMoHCC  and  VSI  collaboratively  developed  data  collection  tools  for  the  OR.  The  tools  included  the  Facility  Assessment  Tool;  Monthly  Facility  Form;  Community  Education  Logbook;  updated  Delivery  Registry;  Maternity  Record  Form;    and  Provider  Survey.  The  data  flow  for  each  tool  is  represented  in  Figure  4.    Figure  4:  Data  flow  and  management  

   Facility Assessment Tool Baseline  data  from  the  68  facilities  participating  in  the  OR  was  collected  by  OR  monitoring  staff  in  August  2012  prior  to  the  initiation  of  any  OR  program  components.  The  baseline  gathered  information  on  current  PPH  management  practices,  delivery  costs  and  available  equipment.  The  data  was  gathered  using  the  Facility  Assessment  Tool  developed  for  the  OR.  OR  staff  completed  a  Facility  Assessment  Tool  at  each  of  the  68  OR  facilities.  These  tools  were  then  mailed  to  VSI’s  M&E  team  in  Irvine,  CA,  where  they  were  entered  into  Microsoft  Excel  and  then  exported  into  Stata/SE  12  (StataCorp  2011)  for  analysis.    

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15  

Monthly Facil ity Form OR  staff  used  a  Monthly  Facility  Form  to  record  key  service  delivery  indicators,  misoprostol  stock,  and  challenges  or  questions  that  providers  brought  up  during  monitoring  visits.  Monthly  Facility  Forms  were  completed  during  the  OR  by  OR  monitoring  staff  during  their  monthly  supervisory  visits.  The  OR  monitoring  staff  then  entered  the  forms  into  an  Excel  spreadsheet  and  emailed  them  to  the  VSI  Zimbabwe  Program  Officer  in  Harare,  as  well  as  to  VSI’s  M&E  team  in  Irvine,  CA.   Revised Delivery Registry and Maternity Record Form All  health  facilities  in  Zimbabwe  conducting  deliveries  currently  keep  a  Delivery  Registry  to  record      information  about  each  woman  admitted  for  delivery,  as  well  as  women  who  delivered  at  home  and  came  to  the  facility  for  emergency  or  postnatal  care.  This  registry  was  slightly  revised  for  the  OR  to  capture  information  on  the  uterotonic  used  for  PPH  treatment  as  well  as  whether  a  woman  measured  blood  loss  at  a  home  delivery  before  coming  to  the  facility.  Health  providers  at  the  OR  facilities  completed  the  Delivery  Registry  for  every  woman  who  delivered  at  the  health  facility  and  for  women  who  delivered  at  home  and  came  to  the  facility  for  a  postnatal  visit.  OR  monitoring  staff  copied  data  from  the  Delivery  Registries  to  the  Maternity  Record  Form  during  monthly  site  visits.  The  VSI  Data  Manager  in  Harare  entered  these  data  into  a  central  database  using  Epi  Info  3.5.4.  The  database  was  analyzed  by  VSI  staff  in  Irvine,  Ca.  using  Stata/SE  12  (StataCorp  2011).      Community Education Logbook A  Community  Education  Logbook  was  completed  by  providers,  VHWs,  and  OR  monitoring  staff  to  capture  the  number  of  community  educations  sessions  they  led,  the  date  of  the  education  sessions,  and  how  many  community  members  were  involved.  Health  providers  at  OR  sites  and  VHWs  completed  the  Community  Education  Logbook  when  they  held  education  sessions  about  misoprostol.  VHW  logbooks  were  deposited  at  the  OR  sites.  OR  monitoring  staff  collected  the  logbooks  and  mailed  them  to  the  VSI  Zimbabwe  Program  Officer  in  Harare,  who  mailed  them  to  VSI’s  M&E  team  in  Irvine,  CA.  Data  from  the  Community  Education  Logbooks  were  entered  into  Microsoft  Excel  and  analyzed  by  VSI’s  M&E  team  using  Stata/SE  12  (StataCorp  2011).   Provider Survey All  providers  who  participated  in  the  OR  and  were  trained  on  the  appropriate  use  of  misoprostol  for  PPH  were  asked  to  complete  a  short  self-­‐administered  survey  to  share  their  perspectives  on  the  program,  their  level  of  acceptability  with  misoprostol  for  PPH  management,  their  level  of  satisfaction  using  misoprostol,  challenges  they  experienced,  and  any  other  relevant  experiences  with  using  misoprostol  for  PPH  management.    In  May  and  June,  2013,  OR  monitoring  staff  distributed  and  collected  the  surveys  as  part  of  their  routine  supervisory  visits.    Providers  completed  the  surveys  in  private  and  returned  them  to  the  monitor  in  a  sealed  envelope;  they  took  an  average  of  less  than  15  minutes  to  complete.  The  OR  monitoring  staff  left  a  copy  of  the  survey  and  an  envelope  if  one  of  the  providers  was  not  present  during  the  visit;  the  provider  then  completed  the  survey  and  returned  it  to  the  OR  monitoring  staff  member  at  the  next  visit.    The  completed  Provider  Surveys  were  collected  by  OR  monitoring  staff  and  mailed  to  the  VSI  Data  Manager  in  Harare.  The  VSI  Data  Manager  in  Harare  then  entered  the  data  using  Epi  Info  3.5.4.  This  database  was  analyzed  by  the  VSI  M&E  team  in  Irvine,  CA  using  Stata/SE  12  (StataCorp  2011).    Final  data  analysis  for  this  report  was  conducted  by  VSI’s  M&E  team  in  August  2013.  The  final  technical  report  was  written  by  VSI’s  M&E  team  in  September  2013  in  Irvine,  CA.      

 

16  

6. Operations Research Implementation Timeline

All  of  the  OR  activities,  including  the  preparatory  phase,  implementation,  data  collection  and  analysis,  took  place  between  2010  and  2013.  The  ZMoHCC  and  VSI  were  responsible  for  the  ongoing  management  and  oversight  of  the  OR  activities.  A  formal,  full  assessment  of  the  capacity  of  stakeholders  to  register  and  introduce  misoprostol  into  the  health  system  was  conducted  in  November  2010.    During  this  assessment,  VSI  staff  met  with  representatives  from  the  ZMoHCC  and  the  National  Pharmaceutical  Company  of  Zimbabwe  (Natpharm),  and  various  maternal  health  stakeholders.        In  February  2012,  VSI  conducted  a  training  of  trainers  (TOT),  which  was  followed  by  the  cascade  training  and  a  senior  refresher  training  of  providers  in  December  2012.  In  July  and  August  2012,  the  ZMoHCC  and  VSI  staff  conducted  facility  assessments  at  all  facilities  in  the  four  OR  districts  to  gather  baseline  information  about  resources,  staffing  and  current  PPH  management  practices.  The  protocol  for  the  operations  research  was  approved  by  the  Medical  Research  Council  of  Zimbabwe  (MRCZ),  the  Medicines  Control  Authority  of  Zimbabwe  (MCAZ)  and  the  Joint  Research  Ethics  Committee  (JRECH)  in  November  2012.    Provision  of  services  with  misoprostol  was  initiated  only  after  ensuring  that  facilities  had  the  required  supplies.  For  this  reason,  implementation  started  at  different  times  in  the  different  districts.  Implementation  began  between  January  and  February  2013.      At  the  end  of  March  2013,  MCAZ  and  MRCZ  conducted  facility  site  visits  to  check  for  protocol  compliance  and  regulation  of  misoprostol  by  pharmacists  and  providers.  US-­‐based  VSI  staff  conducted  a  monitoring  and  evaluation  visit  in  April  2013,  during  which  time  they  visited  33  facilities  across  all  four  districts  (eight  in  Mutare,  eight  in  Chimanimani,  eight  in  Matobo  and  nine  in  Umguza).      At  the  beginning  of  June  2013  VSI  replaced  all  current  misoprostol  stock  in  the  OR  facilities  with  new  stock  to  enable  the  facilities  to  continue  to  offer  misoprostol  for  PPH  management  throughout  the  OR,  until  the  ZMoHCC  restocks  them  through  Natpharm.    Operations  research  implementation  ended  at  the  end  of  June  2013.  During  the  two  months  that  followed,  VSI  staff  cleaned  and  analyzed  OR  data  and  wrote  the  final  report.

7. Results

The  final  sample  used  for  data  analysis  captured  information  on  a  total  of  8,258  women  who  either  delivered  or  received  postnatal  service  immediately  after  delivery  in  an  OR  facility  between  January  and  June  2013  (Figure  5).      Of  the  8,258  women  in  the  Delivery  Registries,  data  was  missing  on  the  location  of  delivery  for  71  women.  Of  the  remaining  8,187  women  for  whom  place  of  delivery  was  recorded,  94%  (n=7,659)  delivered  at  a  facility,  while  6%  (n=510)  delivered  at  home  and  0.2%  (n=18)  delivered  on  the  way  to  a  facility.  Of  the  women  who  delivered  at  a  facility,  97%  (n=7,400)  had  vaginal  deliveries,  while  3%  (n=259)  had  cesarean  sections.        

 

17  

Figure  5:  Flow  chart  illustrating  women  delivering  in  the  four  operations  research  districts,  their  place  of  delivery  and  type  of  delivery  (January  –  June  2013)  

 District  level  differences  were  observed  for  the  location  and  type  of  delivery  (Table  6).  While  Mutare  district  had  the  highest  proportion  of  facility  deliveries  (95%)  and  cesarean  sections  (5%),  Umguza  district  had  the  highest  proportion  of  home  deliveries  (17%),  followed  by  Chimanimani  district  (9%).    Table  6:  Distribution  of  deliveries  according  to  type  and  place  of  delivery  by  district    (January  –  June  2013)  

  Chimanimani  (n=1,676)  

Matobo  (n=734)  

Mutare  (n=5,327)  

Umguza  (n=447)  

Total*                          (n=8,184)  

Facility   1,523  (90.9%)  

681  (92.8%)  

5,081  (95.4%)  

372  (83.2%)  

7,657    (93.6%)  

Vaginal  deliveries     1,513  (99.3%)  

678  (99.6%)  

4,835  (95.2%)  

372  (100%)  

7,398  (96.6%)  

Caesarean  section   10  (0.7%)  

3  (0.4%)  

246  (4.8%)   0   259  

(3.4%)  

Home   149  (8.9%)  

53  (7.2%)  

232  (4.4%)  

75  (16.8%)  

509  (6.2%)  

On  the  way  to  the  facility  

4  (0.2%)  

0  (0%)  

14  (0.3%)  

0  (0%)  

18  (0.2%)  

*Of  the  8,258  women  whose  deliveries  were  recorded  during  the  OR,  54  women  had  missing  information  on  place  of  delivery,  three  women  had  missing  district  information  and  17  women  were  missing  both  characteristics.  

7.1 FINDINGS FROM BASELINE FACILITY ASSESSMENT Table  7  summarizes  some  of  the  basic  findings  from  the  baseline  assessment,  in  relation  to  infrastructure  characteristics  of  the  facilities,  as  well  as  their  staffing  and  supplies.    During  the  assessment,  nearly  40%  of  the  RHCs  reported  not  having  electricity  or  a  power  source,  which  is  essential  to  refrigerate  oxytocin  as  described  in  the  earlier  sections  (Table  7).  In  addition,  with  the  exception  of  the  provincial  hospital  in  Mutare,  monthly  power  outages  were  reported  at  all  facility  levels.      Around  two-­‐thirds  of  rural,  mission  and  district  hospitals  had  a  maternity  waiting  home,  as  opposed  to  only  37%  of  RHCs.  Provincial  and  mission  hospitals  had  the  highest  mean  number  of  beds  in  their  maternity  wards  (n=30  and  n=18,  respectively),  while  RHCs  had  the  lowest  (n=4).  When  the  data  for  the  51  health  centers  was  further  disaggregated  into  48  rural  and  3  urban  health  centers,  the  mean  number  of  beds  in  maternity  wards  for  RHCs  was  three,  while  the  mean  number  of  beds  for  urban  health  centers  was  twelve  (data  not  shown).    

All  Women  n  =  8,258  

Women  who  delivered  at  a  facility  n  =  7,659  

Vaginal  Delivery  n  =  7,400  

Cesarean  seccon    n  =  259  

Women  who  delivered  at  home  n  =  510  

Vaginal  Delivery  n=  510  

Women  who  delivered  on  the  way  to  a  facility  

n  =  18  

Vaginal  Delivery  n  =  18  

Place  of  delivery  not  recorded  n  =  71  

 

18  

Table  7:  Some  characteristics  of  the  OR  facilities  according  to  facility  level  at  baseline    (September  2011  –  February  2012)  

 

Rural  Health  Center  (n=51)  

Rural  Hospital  

(n=8)  

Mission  Hospital  

(n=5)  

District  Hospital  

(n=3)  

Provincial  Hospital  

(n=1)  

Total  (n=68)  

Facility  has  electricity/power   31  (60.8%)  

8  (100.0%)  

4  (80.0%)  

3    (100.0%)  

1    (100.0%)  

47    (69.1%)  

Mean  number  of  days  per      month  facilities  reported  experiencing  power  outages  

8.7   6.1   3.7   4.8   0   7.7  

Facility  has  a  maternity  waiting  home  

19  (37.3%)  

5  (62.5%)  

3  (60.0%)  

2    (66.7%)   0   29    

(42.7%)  Mean  number  of  beds  in  maternity  ward  (min;  max)  

3.5  (0;  23)  

9.4  (5;  14)  

17.6  (2;  27)  

9.3  (1;  21)   30   5.9  

(0;  30)    The  cadre  and  number  of  staff  varied  by  facility  level.  There  were  an  average  of  two  PCNs  at  each  RHC,  five  at  rural  hospitals  and  seven  at  mission  hospitals  (Table  8).    Very  few  doctors  were  reported  at  any  facility  level  other  than  the  provincial  hospital,  which  reported  15  doctors  on  staff.  When  the  data  on  health  centers  was  further  disaggregated  into  rural  and  urban  health  centers,  the  most  notable  change  was  in  the  number  of  midwives  recorded  as  working  at  the  facilities.  Rural  health  centers  reported  an  average  of  0.4  midwives  (ranging  from  0  to  4),  while  the  three  urban  health  centers  that  participated  in  the  OR  reported  an  average  of  11  midwives  (ranging  from  one  to  18)  (data  not  shown).    Table  8:  Average  number  of  staff  according  to  cadre  and  facility  level  at  baseline    (September  2011  –  February  2012)  

 Rural  Health  

Center  (n=51)  

Rural  Hospital  (n=8)  

Mission  Hospital  

(n=5)  

District  Hospital  

(n=3)  

Provincial  Hospital  

 (n=1)  Primary  care  nurses      (min;  max)  

1.8    (0;  5)  

5.3    (1;  13)  

7.2  (0;  24)   0   0  

Nurses        (min;  max)  

1.1    (0;  15)  

6.8  (2;  16)  

5.0    (1;  17)  

6.7    (3;  11)   235  

Midwives        (min;  max)  

1.0  (0;  18)  

1.5  (0;  4)  

3.6  (0;  9)  

5  (4;  6)   24  

Clinical  Officers        (min;  max)  

0.1  (0;  1)   0   0.2  

(0;  1)   0   0  

Doctors      (min;  max)  

0.1    (0;  2)  

0.3    (0;  2)  

1  (0;  3)  

1.3  (1;  2)   15  

 While  oxytocin  was  available  at  over  90%  of  the  facilities  at  the  time  of  the  baseline  assessment,  over  half  of  the  facilities  (61%)  reported  having  had  a  stock-­‐out  in  the  past  six  months  (Table  9).  The  mean  duration  of  stock-­‐outs  was  highest  at  RHCs  (52  days)  and  mission  hospitals  (14  days).  Only  the  provincial  hospital  did  not  report  a  stock-­‐out  of  oxytocin  in  that  period.  When  the  data  for  health  centers  was  further  disaggregated  into  rural  and  urban  health  centers,  the  mean  duration  of  oxytocin  stock-­‐outs  was  less  at  the  three  urban  health  centers  (11  days)  when  compared  to  RHCs  (57  days)  (data  not  shown).      

 

19  

Table  9:  Oxytocin  availability  and  stock  outs  according  to  facility  level  at  baseline    (September  2011  –  February  2012)  

 

Rural  Health  Center  (n=51)  

Rural  Hospital  

(n=8)  

Mission  Hospital  

(n=5)  

District  Hospital  

(n=3)  

Provincial  Hospital  

(n=1)  

Total  (n=68)  

Oxytocin  stocked  at  facility  

47  (92.2%)  

7  (87.5%)  

4  (80.0%)  

3    (100.0%)  

1    (100.0%)  

62    (91.2%)  

Oxytocin  stock-­‐outs  occurred  in  last  6  months  

29  (61.7%)  

4  (57.1%)  

3  (75.0%)  

2    (66.7%)   0   38    

(61.3%)  

Mean  duration  of  oxytocin  stock-­‐outs  in  days  (min;  max)    

52.0  (0;  240)  

7.7  (2;  14)  

14.3  (6;  30)  

8  (2;  14)  

 N/A  

42.2  (0;  240)  

 Only  four  facilities  reported  offering  blood  transfusions  at  baseline  (one  mission  hospital,  one  rural  hospital,  one  district  hospital  and  the  provincial  hospital)  (data  not  shown).  It  is  important  to  note  that  the  cost  of  blood  transfusions  can  be  very  high;  based  on  interviews  with  providers  at  the  provincial  hospital,  blood  transfusions  could  cost  as  much  as  $273.    

7.2 OPERATIONS RESEARCH FINDINGS: PPH PREVENTION  One  key  objective  of  the  OR  was  to  increase  uterotonic  coverage  at  the  third  stage  of  labor  at  facility  deliveries.    Figure  6  illustrates  the  number  of  women  who  delivered  at  a  facility  during  the  OR,  and  the  type  of  uterotonic  they  received  for  PPH  prevention.  For  women  who  had  vaginal  deliveries  and  for  whom  uterotonic  information  was  recorded,  the  majority  received  oxytocin  (88%),  followed  by  misoprostol  (9%)  and  ergometrine  (3%).  Overall,  only  1%  of  women  who  delivered  at  a  facility  (n=82)  did  not  receive  any  uterotonic.  Of  the  259  women  who  had  a  cesarean  section,  almost  all  (n=258)  were  given  oxytocin,  and  one  was  given  ergometrine.      Figure  6:  Flow  chart  illustrating  women  delivering  at  a  facility  during  the  operations  research  and  the  uterotonic  they  received  for  PPH  prevention  (January  –  June  2013)  

Of  the  528  women  who  delivered  at  home  or  on  the  way  to  the  health  facility,  only  214  women  (41%)  received  a  uterotonic  for  PPH  prevention  once  they  arrived  at  the  facility.  A  total  of  307  women  (58%)  who  delivered  at  home  were  recorded  as  receiving  no  uterotonic,  and  uterotonic  data  was  missing  for  seven  women.    The  majority  of  the  214  women  who  received  a  uterotonic  were  

Women  who  delivered  at  a  facility  n  =  7,659  

Vaginal  Delivery  n  =  7,400  

Oxytocin  n  =  6,492  

Misoprostol  n  =  625  

Ergometrine  n  =  195  

No  uterotonic  n  =  82  

Uterotonic  informacon  not  recorded  

n  =  6  

Cesarean  seccon    n  =  259  

Oxytocin  n  =  258  

Ergometrine  n  =  1  

 

20  

administered  oxytocin  (n=143;  67%),  while  37  received  misoprostol  (17%)  and  34  received  ergometrine  (16%)  (data  not  shown).      The  type  of  uterotonic  administered  for  PPH  prevention  varied  by  district  (Table  10).  Among  women  who  had  vaginal  deliveries  and  for  whom  data  was  recorded  on  uterotonic  and  district  (n=7,392),  Umguza  had  the  highest  proportion  of  deliveries  receiving  oxytocin  (94%),  followed  by  Mutare  district  (91%).  Chimanimani  and  Matobo  districts  reported  use  of  misoprostol  for  PPH  prevention  for  slightly  over  10%  of  all  deliveries  (11%  and  12%  respectively).  Very  low  rates  of  ergometrine  were  recorded  in  every  district  except  for  Chimanimani,  where  10%  of  deliveries  received  ergometrine.    Misoprostol  and  oxytocin  was  supplied  regularly  to  OR  districts  during  data  collection,  and  Chimanimani  district  was  the  only  district  during  the  OR  to  report  two  oxytocin  stock-­‐outs;  one  in  February  2012  and  another  in  May  2012  (data  not  shown).      Table  10:  Uterotonic  used  for  PPH  prevention  among  women  who  had  a  vaginal  delivery  at  a  facility  according  to  district  (January  –  June  2013)  

  Chimanimani  (n=1,512)  

Matobo  (n=678)  

Mutare  (n=4,833)  

Umguza  (n=369)  

Total*      (n=7,392)  

Oxytocin   1,166  (77.1%)  

596  (87.9%)  

4,382  (90.7%)  

348  (94.3%)  

6,492  (87.8%)  

Misoprostol   160  (10.6%)  

80  (11.8%)  

366  (7.6%)  

19  (5.2%)  

625  (8.5%)  

Ergometrine   150  (9.9%)  

1  (0.2%)  

42  (0.9%)  

1  (0.3%)  

194  (2.6%)  

No  uterotonic   36  (2.4%)  

1  (0.2%)  

43  (0.9%)  

1  (0.3%)  

81  (1.1%)  

Total  women  receiving  a  uterotonic  for  PPH  prevention  

1,476  (97.6%)  

677  (99.9%)  

4,790  (99.1%)  

368  (99.7%)  

7,311  (98.9%)  

*Of  the  total  7,400  women  who  had  a  vaginal  delivery,  information  was  missing  on  district  for  two  women,  and  on  uterotonic  used  for  6  women.      Uterotonic  administered  for  PPH  prevention  amongst  women  who  had  vaginal  deliveries  also  varied  by  facility  level  (Table  11).  Overall,  RHCs  (including  the  three  urban  health  centers)  reported  the  highest  level  of  usage  of  misoprostol  for  PPH  prevention,  for  approximately  one-­‐fifth  (21  %)  of  all  vaginal  deliveries  (for  which  data  was  available  on  the  facility  level  and  uterotonic  used).  When  further  analysis  was  conducted  to  disaggregate  the  RHCs  from  the  3  urban  health  centers,  the  role  of  misoprostol  for  PPH  prevention  was  even  higher,  with  28%  of  deliveries  at  RHCs  receiving  misoprostol,  as  compared  to  0.4%  (n=2)    at  urban  health  centers  (data  not  shown).  At  rural  hospitals,  misoprostol  was  used  for  PPH  prevention  for  16%  of  deliveries.  At  the  mission,  district,  and  provincial  hospitals,  the  majority  of  women  (ranging  from  92%  -­‐  99%)  received  oxytocin,  while  misoprostol  use  for  PPH  prevention  was  minimal.  The  highest  number  of  women  receiving  no  uterotonic  (n=61)  delivered  at  RHCs.    

 

 

21  

Table  11:  Uterotonic  used  for  PPH  prevention  among  women  who  had  a  vaginal  delivery  at  a  facility  according  to  facility  level  (January  –  June  2013)  

 

Rural  Health  Center  

(n=2,147)  

Rural  Hospital  (n=730)  

Mission  Hospital    (n=1,064)  

District  Hospital  (n=2,308)  

Provincial  Hospital  (n=1,134)  

Total*      (n=7,383)  

Oxytocin   1,515  (70.6%)  

584  (80.0%)  

976  (91.7%)  

2,292  (99.3%)  

1,120  (98.8%)  

6,487  (87.9%)  

Misoprostol   451  (21.0%)  

114  (15.6%)  

41  (3.9%)  

12  (0.5%)  

3  (0.3%)  

621  (8.4%)  

Ergometrine   120  (5.6%)  

24  (3.3%)  

39  (3.7%)  

1  (0.0%)  

9  (0.8%)  

193  (2.6%)  

No  uterotonic     61  (2.8%)  

8  (1.1%)  

8  (0.8%)  

3  (0.1%)  

2  (0.2%)  

82  (1.1%)  

Total  women  receiving  a  uterotonic  for  PPH  prevention  

2,086  (97.2%)  

722  (98.9%)  

1,056  (99.2%)  

2,305  (99.9%)  

1,132  (99.8%)  

7,301  (98.9%)  

*  Of  the  total  7,400  women  who  had  a  vaginal  delivery,  11  women  were  missing  facility  level  information,  five  were  missing  method  of  PPH  prevention,  and  one  woman  was  missing  both  facility  level  information  and  method  of  PPH  prevention.    Uterotonic  coverage  at  facility  deliveries  increased  at  RHCs  and  rural  hospitals  after  the  inclusion  of  misoprostol  during  the  OR  (Figure  7).  Rural  health  centers  saw  a  16%  increase  in  uterotonic  coverage  from  the  baseline  assessment,  where  81%  of  deliveries  received  a  uterotonic,  to  97%  coverage  during  the  OR.    At  rural  hospitals,  uterotonic  coverage  increased  from  78%  at  baseline  to  99%  during  the  OR.  Where  uterotonic  coverage  was  high  at  baseline  (99%  to  100%  at  mission,  district  and  provincial  hospitals),  the  coverage  remained  stable.  While  the  numbers  of  deliveries  recorded  at  district  and  provincial  hospitals  varied  between  the  baseline  assessment  and  the  OR,  the  uterotonic  coverage  recorded  at  these  facility  levels  remained  high  throughout  both  periods.      

Figure  7:  Proportion  of  facility  deliveries  receiving  a  uterotonic  for  PPH  prevention,  at  baseline  and  during  the  operations  research*  

*Of  the  total  7,659  women  who  had  a  vaginal  delivery  during  the  OR,  11  women  were  missing  facility  level  information,  five  were  missing  method  of  PPH  prevention,  and  one  woman  was  missing  both  facility  level  information  and  method  of  PPH  prevention.  

81%   78%  

96%  100%   100%  

92%  97%   99%   99%   100%   100%   99%  

50%  

60%  

70%  

80%  

90%  

100%  

Uterotonic  coverage  at  Rural  Health  Centers    

Uterotonic  coverage  at  

Rural  Hospitals  

Uterotonic  coverage  at                  Mission  Hospitals  

Uterotonic  coverage  at  District  Hospitals  

Uterotonic  coverage  at  Provincial    Hospital  

Total  uterotonic  coverage  

Baseline  (Sept  2011-­‐Feb  2012)   Operacons  Research  (Jan-­‐June  2013)  

 

22  

 Near  universal  uterotonic  coverage  (99%)  for  PPH  prevention  at  facility  deliveries  was  achieved  during  the  OR,  which  was  a  substantial  increase  from  92%  uterotonic  coverage  at  baseline.  Misoprostol  contributed  to  this  high  coverage  (Figure  8).     Figure  8:  Total  uterotonic  coverage  at  facility  deliveries  during  the  operations  research    (January  –  June  2013)  

 The  majority  of  women  who  received  misoprostol  for  PPH  prevention  delivered  at  RHCs.  Misoprostol  use  at  RHCs  increased  fourfold  between  January  and  May  (Figure  9).   Figure  9:  Trends  in  cumulative  number  of  women  receiving  misoprostol  for  PPH  prevention  according  to  facility  level  (January  -­‐  June  2013)  

  When  uterotonic  use  data  was  analyzed  to  identify  trends  during  the  OR,  it  was  found  that  oxytocin  use  for  PPH  prevention  at  RHCs  ranged  from  61%  to  82%  (Figure  10).  On  the  other  hand,  the  proportion  of  misoprostol  use  for  PPH  prevention  at  RHC  deliveries  was  approximately  9%  in  January,  increased  to  30%  in  March,  and  stabilized  between  22-­‐26%  for  the  following  three  months  of  data  collection.  Misoprostol  contributed  significantly  to  increasing  uterotonic  coverage  at  RHCs.            

Received a uterotonic!

Did not receive a uterotonic!

!"#

$$"#

0  

100  

200  

300  

400  

500  

January   February   March   April   May   June  

Cumulac

ve  num

ber  o

f  wom

en  

District  Hospital   Mission  Hospital   Provincial  Hospital  

Rural  Health  Center   Rural  Hospital  

 

23  

Figure  10:  Trends  in  the  uterotonic  used  for  PPH  prevention  for  vaginal  deliveries  at  rural  health  centers  (January  –  June  2013)  

*  Of  the  2,148  women  who  delivered  at  a  rural  health  center  and  had  a  vaginal  delivery,  one  woman  is  missing  PPH  prevention  method  information  and  eleven  are  missing  moth  information.    Misoprostol  also  contributed  to  increasing  uterotonic  coverage  at  rural  hospitals  (Figure  11).  The  highest  proportion  of  misoprostol  use  at  rural  hospitals  was  seen  in  February  (25%)  and  April  (19%).With  the  addition  of  misoprostol,  the  proportion  of  women  receiving  no  uterotonic  remained  extremely  low  throughout  the  OR,  and  during  the  last  month  of  the  OR  all  women  having  a  vaginal  delivery  at  rural  hospitals  received  a  uterotonic  for  PPH  prevention.      Figure  11:  Trends  in  the  uterotonic  used  for  PPH  prevention  for  vaginal  deliveries  at  rural  hospitals  (January  –  June  2013)*  

*  Of  the  730  women  who  delivered  at  a  rural  hospital  and  had  a  vaginal  delivery,  nine  women  are  missing  PPH  prevention  method  information,  two  are  missing  month  information,  and  one  woman  is  missing  both.  

74%  82%  

67%   73%   67%   61%  

9%  10%  

30%   22%  26%  

26%  

10%  7%   2%   3%   6%  

8%  7%   1%   1%   2%   1%   5%  

0%  

20%  

40%  

60%  

80%  

100%  

January  (n=336)  

February  (n=270)  

March  (n=326)  

April  (n=436)  

May        (n=498)  

June  (n=270)  

Oxytocin   Misoprostol   Ergometrine   No  uterotonic  

77%   71%  87%  

77%   79%  90%  

14%   25%  

12%  19%   14%  

9%  8%   1%   4%   5%  1%  3%   1%   2%  

0%  

20%  

40%  

60%  

80%  

100%  

January                      (n=132)  

February          (n=126)  

March          (n=137)  

April              (n=109)  

May              (n=123)  

June                  (n=101)  

Oxytocin   Misoprostol   Ergometrine   No  uterotonic  

 

24  

 Among  the  625  women  who  were  administered  misoprostol  for  PPH  during  the  OR,  data  on  misoprostol  route  and  dosage  was  available  for  591  and  606  women,  respectively.    For  all  women  for  whom  the  route  and/or  dosage  was  recorded,  correct  route  (oral)  and  correct  dose  (600  mcg)  of  misoprostol  was  used  (data  not  shown).  

7.3 OPERATIONS RESEARCH FINDINGS: PPH CASES During  the  OR,  PPH  was  diagnosed  through  visual  estimation  of  blood  loss,  for  which  providers  were  trained  to  strengthen  their  observational  skills  to  improve  estimations.    There  were  a  total  of  244  PPH  cases  reported  during  the  OR  for  vaginal  deliveries  at  facilities,  and  the  proportion  of  women  reported  to  develop  PPH  varied  by  the  type  of  uterotonic  they  received  for  PPH  prevention  (Figure  12).  Reported  PPH  cases  at  vaginal  facility  deliveries  ranged  from  3%  for  women  who  had  received  oxytocin  to  4%  for  women  who  had  received  misoprostol  or  ergometrine.      Figure  12:  Flow  chart  illustrating  location  of  delivery,  type  of  delivery  and  the  number  of  women  who  were  reported  to  develop  PPH  (June  –  January  2013)  

Treatment  methods  for  reported  PPH  cases  varied  by  facility  level  (Table  12).  Of  the  241  PPH  cases  after  a  facility  delivery  (for  women  for  whom  data  was  recorded  for  facility  level  and  uterotonic  for  PPH  treatment),  the  majority  (86%)  were  treated  with  oxytocin,  followed  by  misoprostol  (10%)  and  ergometrine  (3%).      Misoprostol  had  the  greatest  influence  at  RHCs  and  rural  hospitals,  where  it  was  used  to  treat  19%  and  27%  of  reported  PPH  cases,  respectively.  The  uterotonic  used  for  PPH  treatment  was  not  recorded  for  three  women  who  developed  PPH  at  a  facility  delivery.      

Women  who  delivered  at  a  facility  

n  =  7,659    

Vaginal  Delivery  n  =  7,394  

Oxytocin  n  =  6,492  

PPH  Cases  n  =  209  

Misoprostol  n  =  625  

PPH  Cases    n  =  24  

Ergometrine  n  =  195  

PPH  Cases  n  =  8  

No  Uterotonic  n  =  82  

PPH  Cases  n  =  3    

Cesarean  seccon  n  =  259  

Oxytocin    n  =  258  

PPH  Cases  n  =  6  

Ergometrine  n  =  1  

Uterotonic  informacon  not  

recorded  n  =  6  

Women  who  delivered  at  home  or  

on  the  way  to  a  facility    N  =  528  

Vaginal  Delivery  N  =  521  

Oxytocin  n  =  143  

PPH  Cases  n  =  5  

Misoprostol  n  =  37  

PPH  Cases  n  =  1  

Ergometrine  n  =  34  

PPH  Cases  n  =  1  

No  Uterotonic  n  =  307  

PPH  Cases  n  =  11  

Uterotonic  informacon  not  

recorded  N  =  7    

 

25  

Of  the  528  women  who  delivered  at  home  or  on  the  way  to  the  facility,  a  total  of  18  women  (4%)  were  recorded  as  experiencing  PPH.  Of  these  18    women,  11  (  61%)  were  not  recorded  as  receiving  a  uterotonic,  while  five  received  oxytocin,  one  received  misoprostol  and  one  received  ergometrine  when  they  arrived  at  the  facility.    Table  12:  Reported  PPH  cases*  among  women  with  facility  or  home  vaginal  deliveries  according  to  facility  level  and  type  of  uterotonic  used  for  treatment  of  PPH  (January  –  June  2013)  

 Rural  

Health  Center  

Rural  Hospital  

Mission  Hospital  

District  Hospital  

Provincial  Hospital   Total  

PPH  cases  reported  at  facility  deliveries**   79   22   38   80   22   241  

Uterotonic  used  for  PPH  treatment  

Oxytocin   56  (70.9%)  

15  (68.2%)  

35  (92.1%)  

80  (94.1%)  

22  (100%)  

208  (86.3%)  

Misoprostol   15  (19.0%)  

6  (27.3%)  

2  (5.3%)  

0  (0%)   0   23  

(9.5%)  

Ergometrine   6  (7.6%)  

1  (4.6%)  

0  (0%)   0   0   7  

(2.9%)  

Not  recorded   2  (2.5%)  

0  (0%)  

1  (2.6%)  

0  (0%)   0   3  

(1.2%)  PPH  cases  reported  for  home  deliveries   9   2   1   5   1   18  

Uterotonic  used  for  PPH  treatment  

Oxytocin   3  (33.3%)  

1  (50.0%)   0   0   1  

(100%)  5  

(27.8%)  

Misoprostol   0   0   0   1  (20.0%)   0   1  

(5.6%)  

Ergometrine   1  (11.1%)   0   0   0   0   1  

(5.6%)  

Not  recorded                         5  (55.6%)  

1  (50.0%)  

1  (100%)  

4  (80.0%)   0   11  

(61.1%)  *PPH  was  diagnosed  through  visual  estimation  of  blood  loss.  **For  the  244  women  who  had  vaginal  facility  deliveries  and  developed  PPH,  two  women  were  missing  facility  level  information  and  one  woman  was  missing  PPH  treatment  method.          When  the  proportion  of  all  PPH  cases  among  facility  deliveries  (including  vaginal  deliveries  and  cesarean  sections,  due  to  the  fact  that  the  baseline  data  did  not  distinguish  between  type  of  delivery  for  PPH  cases)  were  compared  between  the  baseline  data  and  the  OR  data,  a  total  of  249  PPH  cases  were  reported  during  the  OR  (accounting  for  3%  of  all  facility  deliveries),  as  compared  to  173  PPH  cases  at  baseline  (2%  of  all  facility  deliveries)  (Table  13).  The  difference  was  not  statistically  significant.        

 

26  

Table  13:  Comparison  of  PPH  cases  recorded  for  all  facility  deliveries,  over  6  months,  at  baseline  and  during  the  OR,  by  the  level  of  facility  (January  –  June  2013)  

 

Rural  Health  Center  

(n=2,824)  

Rural  Hospital  (n=764)  

Mission  Hospital  (n=1,066)  

District  Hospital  (n=1,486)  

Provincial  Hospital  (n=3,411)  

Total  (n=9,551)  

Baseline    (September  2011  –  February  2012)  

19  (0.7%)  

9  (1.2%)  

125  (11.7%)  

10    (0.7%)  

10    (0.3%)  

173    (1.8%)  

 

Rural  Health  Center  

(n=2,070)  

Rural  Hospital  (n=710)  

Mission  Hospital  (n=1,038)  

District  Hospital  (n=2,228)  

Provincial  Hospital  (n=1,352)  

Total*  (n=7,647)  

Operations  research  (January  –  June  2013)  

79  (3.7%)  

22  (3.0%)  

39  (3.6%)  

83  (3.6%)  

26  (1.9%)  

249  (3.3%)  

*Of  the  252  women  who  developed  PPH  at  a  facility  delivery  (either  after  a  vaginal  or  caesarean  section  delivery)  there  were  three  women  missing  information  on  facility  level.  

7.4 MATERNAL DEATHS There  were  two  maternal  deaths  due  to  PPH  reported  in  the  four  districts  during  the  operations  research.  Neither  woman  was  given  misoprostol  for  PPH  prevention  or  PPH  treatment.  

7.5 COMMUNITY AWARENESS    Focus Group Discussions with Vil lage Health Workers A  total  of  21  women  (nine  in  Umguza  and  12  in  Mutare)  attended  the  two  FGDs.  Table  14  presents  the  socio-­‐demographic  characteristics  of  the  women  who  participated  in  FGD.    

 

27  

Table  14:  Socio-­‐demographic  characteristics  of  village  health  workers  who  participated  in  FGDs  

  Total  (n=21)  Mean  age    (min;  max)  

46.6  (26;  70)    

Religion    

Methodist   2  (9.5%)  

Seventh  Day  Adventist   4  (19.0%)  

Catholic   2  (9.5%)  

Pentacostal   8  (38.1%)  

Anglican   3  (14.3%)  

Apostolic   2  (9.5%)  

Marital  status    

Married   11  (52.4%)  

Single   2  (9.5%)  

Widowed   8  (38.1%)  

Employment  status    

Village  Health  Worker   21  (100.0%)  

Mean  years  working  as  a  VHW  (min;  max)   8.9    (0.5;  20)  

Traditional  Birth  Attendant  (TBA)   8  (38.1%)  

Mean  years  working  as  a  TBA  (min;  max)   9.5    (4;  20)  

Experience  at  home  deliveries    

Ever  assisted  with  home  deliveries   10  (47.6%)  

Mean  number  home  deliveries  assisted  during  their  lifetime  (min;  max)  

35.6    (1;  234)  

 The  majority  of  VHWs  that  participated  in  the  FGD  understood  the  risks  of  delivering  at  home,  citing  that  they  did  not  have  the  skills  nor  equipment  to  handle  complicated  deliveries.  Despite  this,  they  felt  that  there  are  many  reasons  why  women  in  Zimbabwe  continue  to  deliver  at  home.  These  reasons  included  negative  perceptions  about  delivering  at  a  facility,  e.g.  fear  of  exposing  their  poverty,  (for  example,  some  women  do  not  have  enough  money  to  buy  clothes  for  their  newborn,  and  may  have  to  use  jerseys  instead);  fear  of  exposing  infidelity;  unmarried  teenagers  worrying  about  being  asked  questions  about  their  boyfriends;  a  preference  for  traditional  birth  attendants  (TBAs);  unwillingness  to  undergo  HIV  testing;  fear  of  having  a  caesarean  section;  and  some  access  issues  such  as  distance  to  health  facilities  and  lack  of  transport.      Five  VHWs  in  the  FGDs  had  direct  experience  in  assisting  a  delivery  where  a  women  bled  excessively,  and  three  of  these  five  VHWs  had  experienced  the  death  of  a  woman  from  PPH.  Searching  for  transport  for  women  who  developed  PPH  was  agreed  to  be  a  key  challenge  at  home  deliveries,  and  based  on  the  cases  described,  either  a  tractor  or  a  wheelbarrow  was  used  for  transport  to  a  health  facility.  Religious  influence  was  highlighted  as  a  factor  in  terms  of  women’s  response  to  PPH.    For  

 

28  

example,  it  was  reported  that  in  the  case  of  Apostolic  women  that  suffered  from  excessive  bleeding,  they  would  not  go  or  be  taken  to  a  health  facility,  and  were  sometimes  prevented  by  their  husbands  from  seeking  care  at  a  facility.  Two  women  reported  that  if  a  woman  needed  to  get  to  a  health  facility  during  a  home  delivery,  it  was  the  sabhuku  (a  village  headman  who  answers  to  the  village  chief)  who  mobilized  funds  and  resources  to  get  the  woman  to  a  facility.    Participants  said  that  there  were  no  “home  remedies”  for  managing  PPH,  but  they  cited  practices  such  as:  1)  giving  sugar  and  salt  water  as  a  hydrating  solution;  2)  rubbing  the  woman’s  stomach;  and  3)  laying  her  on  a  sand  bed  so  that  the  woman  would  not  be  disturbed  by  how  much  she  was  bleeding.  Recognizing  excessive  bleeding  at  a  home  delivery  was  universally  agreed  to  be  difficult.  While  participants  said  that  there  were  certain  “signs”  that  a  woman  had  too  much  bleeding  (sweating,  weakness,  dizziness,  fainting),  the  signs  were  often  detected  too  late  to  help  the  woman.      The  participants  had  a  number  of  ideas  for  measuring  blood  loss  at  home  deliveries,  including  the  use  of  “cotton”  (although  they  felt  many  poor  women  would  not  have  cotton  available),  old  linen,  a  bed  sheet,  or  a  “zambia,”  a  local  cloth  that  all  women  own.  The  focus  group  facilitators  then  explained  that  using  a  “zambia”  to  measure  excessive  blood  loss  at  home  deliveries  is  a  method  that  has  been  used  in  a  number  of  other  countries  (Tanzania,  Zambia,  and  Mozambique).  The  facilitators  demonstrated  how  two  zambias  could  be  used  to  soak  up  500  mls  of  liquid,  which  is  the  amount  of  blood  loss  that  defines  PPH.  The  participants  all  felt  that  this  method  was  very  effective  in  demonstrating  how  much  blood  loss  was  excessive,  and  they  thought  that  the  method  would  be  culturally  acceptable  to  women  and  families  in  their  communities.  They  suggested  relaying  information  about  this  blood  loss  measurement  tool  to  women  through  community  demonstrations,  home  visits  to  pregnant  women,  group  education  sessions,  community  workshops  and  dramas  using  “community  lead  mothers.”  They  also  recommended  involving  mothers-­‐in-­‐law,  village  headmen  and  “krawl”  heads  in  community  education  efforts.    Community Education Sessions Community  education  sessions  held  during  the  OR  incorporated  messages  from  the  key  findings  from  the  FGDs.  Based  on  feedback  from  the  FGDs,  a  variety  of  information  channels  were  used  to  disseminate  community  education  information,  including  community  demonstrations  and  dramas,  home  visits  to  pregnant  women,  group  education  sessions  at  health  facilities  and  community  dramas.  Local  stakeholders  (village  headmen,  “krawl”  heads,  mothers-­‐in-­‐law)  were  also  involved  in  relaying  messages  about  safe  delivery.    The  key  messages  of  the  community  education  sessions,  some  of  which  were  based  on  findings  from  the  FGDs,  included:    1)  measuring  blood  loss  at  home  deliveries  with  two  zambias  as  a  culturally  acceptable  means  of  blood  loss  measurement;  2)  demonstrations  of  this  method  of  blood  loss  measurement  for  women  and  their  families  to  know  when  a  woman  has  bled  too  much  at  a  home  delivery;  3)  the  importance  of  birth  preparedness  and  delivering  in  a  health  facility;  and,  4)  safe  delivery  practices.  These  key  messages  were  shared  with  OR  staff,  providers  and  VHWs,  who  incorporated  messages  into  their  education  sessions  and  worked  to  involve  local  stakeholders  in  the  community  education  campaign.    A  total  of  364  sessions  were  conducted  and  17,134  community  members  were  reached  with  messages  during  the  course  of  the  OR  (Figure  13).  The  vast  majority  of  education  sessions,  both  at  the  facilities  and  in  the  communities,  were  group  sessions.  The  number  of  education  sessions  led  by  

 

29  

health  providers  increased  steadily  during  the  OR.  Health  providers  led  the  majority  of  the  sessions  (54%)  and  VHWs  led  19%  of  the  sessions.    

Figure  13:  Cumulative  number  of  people  reached  with  community  awareness  messages,  by  facilitator  and  month  (January  –  June  2013)  

During  the  OR,  100  women  reported  that  they  experienced  excessive  bleeding  at  a  home  delivery  and  then  self-­‐transferred  to  a  health  facility.  Of  those,  only  15  women  (15%)  reported  to  a  provider  that  they  measured  blood  loss  at  a  home  delivery  before  coming  to  the  health  facility;  two  of  them  reported  using  a  zambia  to  measure  blood  loss  at  a  home  delivery.    

7.6 PROVIDER PERSPECTIVES ON INTRODUCTION OF MISOPROSTOL FOR PPH PREVENTION AND TREATMENT Providers  who  had  either  been  trained  at  the  cascade  trainings  or  received  feedback  from  their  colleagues  about  their  trainings  were  invited  to  complete  a  Provider  Survey.  During  the  last  two  months  of  the  project,  OR  monitoring  staff  visited  each  facility  and  explained  to  providers  the  purpose  of  the  Provider  Survey,  which  was  to  gather  provider  perspectives  on  using  misoprostol  for  PPH  prevention  and  treatment.  OR  monitoring  staff  left  Provider  Surveys  at  the  facility  and  asked  that  staff  member(s)  who  had  received  training  on  using  misoprostol  for  PPH  prevention  and  treatment  complete  the  survey,  which  they  would  then  pick  up  at  their  supportive  supervision  visit  the  following  month.    In  total,  76  surveys  were  completed  and  at  least  one  provider  from  each  OR  facility  completed  a  survey.  Table  15  presents  characteristics  of  providers  who  responded  to  the  survey.        

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%"&'8

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30  

Table  15:  Selected  characteristics  of  providers  who  responded  to  the  survey  

Level  of  facility  where  provider  works  (n=76)  

Rural  Health  Center   52  (68.4%)  

Mission/Rural  Hospital   18  (23.7%)  

District  Hospital   5  (6.6%)  

Provincial  Hospital   1  (1.3%)  

Location  of  primary  work  site  (n=76)  

Rural   71  (93.4%)  

Urban   5  (6.6%)  

Age  (n=74)*  

Mean  age  (min;  max)   38  (27;59)  

Sex  (n=75)**  

Male   25  (32.9%)  

Female   50  (65.8%)  

*Missing  data  on  age  for  two  respondents.  **Missing  data  on  sex  for  one  respondent.    Almost  all  (96%)  respondents  recommended  the  use  of  misoprostol  to  other  providers  for  PPH  prevention  and  treatment  (Figure  14).  The  larger  majority  (99%)  stated  that  it  was  easy  to  learn  to  use  misoprostol  for  PPH  management.  However,  over  half  of  the  providers  agreed  or  strongly  agreed  that  they  needed  more  training  to  be  confident  in  using  misoprostol  for  PPH  prevention  and  treatment.      Figure  14:  Provider  views  on  misoprostol  training,  use  and  access  (n=76)  

*Proportion  of  providers  who  checked  “agree”  or  “strongly  agree”  on  the  survey  for  these  items.  

96%  

55%  

53%  

99%  

86%  

96%  

0%   20%   40%   60%   80%   100%  

"I  am  able  to  access  misoprostol  when  I  need  to  use  it  for  prevencon  and/or  treatment  of  

PPH"  

“I  feel  that  I  need  more  training  to  be  confident  in  using  misoprostol  for  PPH  

treatment”  

“I  feel  that  I  need  more  training  to  be  confident  in  using  misoprostol  for  PPH  

prevencon”  

"It  was  easy  to  learn  how  to  use  misoprostol  for  PPH  management."  

“The  training  I  received  made  me  confident  in  using  misoprostol  for  PPH  management.”  

“I  would  recommend  the  use  of  misoprostol  for  prevencon  and  treatment  of  PPH  to  other  

qualified  health  care  providers”  

Misoprostol  Use  

Misoprostol  Training

Misoprostol  Access

 

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Three  themes  emerged  from  the  comments  and  recommendations  provided  by  the  respondents.  These  themes  included  misoprostol  availability,  the  effectiveness  of  misoprostol  administration,  and  the  need  for  additional  training.  Some  of  the  respondents  mentioned  that  misoprostol  should  be  accessible  at  all  times  and  that  health  facilities  should  be  stocked  with  the  drug  on  a  continuous  basis.  Many  of  the  respondents  also  mentioned  the  effectiveness  of  misoprostol  and  its  ease  of  use  in  treating  PPH.  Some  of  the  respondents  noted  that  the  side  effects  associated  with  misoprostol  are  rarely  experienced  and  that  the  administration  of  misoprostol  helps  curb  costs  by  avoiding  referrals.  The  primary  theme  that  emerged  was  the  need  for  additional  training.  Many  respondents  expressed  the  need  for  additional  training  on  PPH  management  with  misoprostol  for  nurses  and  other  health  care  workers  such  as  nurse  aides.    Some  of  the  respondents  also  mentioned  that  they  would  feel  more  confident  using  misoprostol  for  PPH  management  with  additional  training.  Respondents  also  felt  that  VHWs  should  receive  additional  training  on  educating  women  about  the  availability  of  misoprostol  for  PPH  management.    Box  2:  Perspectives  from  providers  

8. Discussion and Conclusions

INTRODUCING MISOPROSTOL INTO THE MIX OF AVAILABLE UTEROTONICS FOR PPH PREVENTION CONTRIBUTES TO NEAR UNIVERSAL COVERAGE AT RURAL HEALTH CENTERS AND RURAL HOSPITALS This  OR  generated  sufficient  evidence  to  inform  the  scale-­‐up  of  PPH  management  with  misoprostol  in  Zimbabwe.    Misoprostol  effectively  compensated  for  the  lack  of  availability  of  other  uterotonics  for  PPH  prevention  at  rural  facilities,  increasing  coverage  at  RHCs  from  81%  to  97%  and  at  rural  hospitals  from  78%  to  99%.  Despite  the  fact  that  the  uterotonic  is  the  most  critical  component  of  AMTSL,  uterotonic  coverage  at  facility  deliveries  varies  widely,  globally.  A  survey  done  in    15  tertiary  obstetric  centers  around  the  world  found  that  administration  of  a  uterotonic  occurred  in  only  44%  of  vaginal  deliveries,  making  it  the  least  used  component  of  AMTSL  (Festin  et  al.,  2003).  While  data  from  the  OR  in  Zimbabwe  revealed  high  rates  of  oxytocic  use  at  tertiary  facilities  (district  and  provincial  hospitals),  uterotonic  use  at  RHCs  and  rural  hospitals  was  found  to  be  much  lower  at  baseline  (81%  and  78%,  respectively).  Including  misoprostol  as  an  additional  uterotonic  for  PPH  prevention  resulted  in  almost  universal  (99%)  uterotonic  coverage  at  all  facility  deliveries  during  the  OR,  an  increase  from  92%  at  baseline.    

 “Misoprostol  was  useful  in  our  setting  as  we  sometimes  are  short  of  oxytocin.  Although  we  didn’t  have  PPH  patients  we  feel  that  could  have  handled  it  well.”  Primary  Care  Nurse,  Chimanimani  District      

“Misoprostol  can  be  safely  used  by  non-­‐qualified  personnel  who  cannot  give  injectables.”  Primary  Care  Nurse,  Mutare  District      

“Misoprostol  was  easy  to  administer  and  no  problems  were  encountered  in  using  the  drug.  We  recommend  the  use  of  it  at  areas  like  outreach  points  so  as  to  assist  the  hard  to  reach  clients.”  Midwife,  Mutare  District      “Misoprostol  is  useful  in  rural  setting.  It  cuts  costs  and  it’s  not  refrigerated.”  Primary  Care  Nurse

 

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MISOPROSTOL MADE THE GREATEST CONTRIBUTION TO INCREASING UTEROTONIC COVERAGE AT RURAL HEALTH CENTERS AND RURAL HOSPITALS During  the  six  months  of  OR,  at  RHCs,  21%  (n=451)  of  vaginal  deliveries  for  whom  uterotonic  data  was  available  received  misoprostol  for  PPH  prevention.  At  rural  hospitals,  the  corresponding  figure  was  16%  (n=114).  Without  the  availability  of  misoprostol  in  these  facilities,  these  women  may  not  have  received  a  uterotonic  for  PPH  prevention.      Even  when  oxytocin  is  available  as  the  drug  of  choice  for  PPH  management,  the  additional  availability  of  misoprostol  at  RHCs  and  rural  hospitals  will  help  to  overcome  possible  challenges  with  oxytocin,  which  can  include  a  lack  of  ideal  storage  conditions,  stock  outs,  or  shortage  of  providers  who  are  authorized  to  administer  injections.  Baseline  data  revealed  that  RHCs  and  rural  hospitals  are  vulnerable  to  oxytocin  stock-­‐outs,  with  approximately  three-­‐fifths  of  these  facilities  reporting  at  least  one  oxytocin  stock-­‐out  in  the  last  six  months.  Refrigeration  is  recommended  for  the  storage  of  oxytocin  to  ensure  its  stability  (Hogerzeil  et  al.  1993);  however,  the  need  to  refrigerate  oxytocin  can  compromise  its  availability.  In  surveys  from  11  sub-­‐Saharan  African  countries,  only  28%  of  health  facilities  reported  reliable  electricity  supplies  (Adair-­‐Rohani  et  al.,  2013).    Nearly  40%  of  the  RHCs  in  the  OR  reported  at  baseline  not  having  electricity  or  a  power  source,  which  is  essential  to  refrigerate  oxytocin  and  ensure  the  stability  of  the  drug,  especially  when  stored  for  over  a  few  months.  Misoprostol  provides  a  safe,  effective  and  low-­‐cost  alternative  to  oxytocin  when  the  oxytocin  supply  is  interrupted,  storage  conditions  are  not  maintained,  or  syringes  or  staff  trained  and  authorized  to  administer  oxytocin  are  not  available.    

RURAL WOMEN, WHO ARE MOST LIKELY TO CONFRONT BARRIERS RELATED TO COST, LACK OF TRANSPORT AND CULTURAL BARRIERS THAT LIMIT THEIR ACCESS TO TIMELY MATERNITY SERVICES, BENEFITTED MOST FROM THE AVAILABILITY OF MISOPROSTOL FOR PPH TREATMENT Almost  two-­‐fifths  of  deliveries  during  the  OR  took  place  at  RHCs  and  rural  hospitals,  which  serve  primarily  rural  populations.  Increasing  the  capacity  of  the  staff  at  these  facilities  to  manage  PPH  is  essential.  District  and  provincial  hospitals  are  mainly  located  in  major  urban  settings,  making  it  difficult  for  rural  women  to  access  them.  Ensuring  universal  administration  of  a  uterotonic  at  all  levels  of  facility  deliveries  will  lead  to  a  decrease  in  PPH  cases.  Prompt  treatment  of  PPH,  when  it  does  occur,  will  help  prevent  maternal  mortality  and  morbidity.  Providing  treatment  options  at  rural  facilities  is  extremely  important  because  if  a  woman  delivers  at  a  rural  facility  and  has  to  be  transferred  to  a  tertiary  facility,  the  woman  faces  numerous  barriers  to  accessing  care.  Qualitative  data  from  providers  at  the  provincial  hospital  revealed  that  blood  transfusions  for  women  cost  $273,  and  that  if  a  woman  is  unable  to  pay  this  amount  up-­‐front,  she  will  not  receive  the  transfusion.  Efforts  are  currently  underway  in  Zimbabwe  to  decrease  the  costs  of  managing  PPH  for  women;  for  example,  UNFPA  is  subsidizing  a  voucher  program  to  allow  equitable  access  to  blood  transfusion  (Taylor  et  al.,  2010).  Enabling  RHCs  and  rural  hospitals  to  effectively  manage  PPH  will  contribute  to  decreasing  the  number  of  women  who  have  to  be  transferred  to  higher-­‐level  district  and  provincial  hospitals  for  PPH  treatment.  This  will  decrease  both  costs  to  the  women  (in  terms  of  transport  and  paying  for  blood  transfusions),  as  well  as  costs  to  the  health  system  (physician  time  to  treat  PPH  cases  at  the  higher-­‐level  facilities,  decrease  in  bed  occupancy,  etc.).    

 

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MISOPROSTOL CAN BE ADMINISTERED CORRECTLY AND SAFELY FOR THE PREVENTION OF PPH AT ALL FACILITY LEVELS Provider  adherence  to  correct  dosage  protocols  was  extremely  high,  and  a  correct  regimen  of  600  mcg  of  oral  misoprostol  was  administered  to  all  women  with  a  facility  vaginal  delivery  for  whom  data  was  recorded.  Providers  received  training  on  dose  and  route  of  administration  at  the  cascade  trainings,  supervisory  visits,  and  they  also  had  access  to  this  information  on  the  misoprostol  regimens  dosage  cards.    

INCLUDING AN INDICATOR FOR UTEROTONIC USED FOR PPH TREATEMENT CONTRIBUTES TO HIGH-QUALITY DATA COLLECTION ON PPH MANAGEMENT  Monitoring  the  use  of  uterotonics  for  the  prevention  of  PPH  is  recommended  as  a  process  indicator  for  programmatic  evaluation,  and  the  suggested  Prophylactic  Uterotonic  Coverage  Indicator  is  calculated  as  the  number  of  women  receiving  prophylactic  uterotonic  drugs  after  birth  divided  by  all  women  giving  birth  (WHO,  2012).  While  the  Delivery  Registry  used  by  the  ZMoHCC  collects  data  on  prophylactic  uterotonic  use,  the  revised  Delivery  Registry  used  for  the  OR  added  a  column  to  collect  data  on  1)  whether  a  woman  developed  PPH  and  2)  what  uterotonic  was  given  for  PPH  treatment.  Despite  the  fact  that  PPH  is  relatively  rare,  it  is  important  to  document  PPH  cases,  as  well  as  their  treatment,  in  order  to  ensure  that  proper  PPH  management  protocols  are  being  followed.  Consequently,  the  continued  use  of  the  revised  Delivery  Registry  may  allow  the  ZMoHCC  to  better  capture  data  on  PPH  management  practices.  Additionally,  as  providers  during  the  OR  were  trained  to  visually  estimate  blood  loss  to  diagnose  PPH,  it  is  plausible  that  they  diagnosed  more  PPH  cases.  As  the  ZMoHCC  plans  to  continue  training  providers  on  PPH  management  with  misoprostol,  it  can  be  expected  that  providers  will  continue  to  see  an  increase  in  PPH  diagnoses,  and  it  will  be  increasingly  important  to  accurately  capture  PPH  management  practices.    

A CULTURALLY APPROPRIATE METHOD FOR MEASURING POSTPARTUM BLOOD LOSS WAS IDENTIFIED Focus  group  discussions  with  VHWs  identified  a  culturally  acceptable  method  for  measuring  blood  loss  at  home  deliveries.  Two  soaked  zambias,  a  widely  available  local  cloth  in  Zimbabwe,  were  identified  as  a  threshold  for  when  a  woman  had  experienced  excessive  bleeding  and  needed  to  go  to  a  health  facility  for  emergency  treatment.  Using  a  local  cloth,  similar  to  a  zambia,  to  measure  excessive  blood  loss  at  home  deliveries  has  been  piloted  in  other  countries  (Prata  et  al.,  2012)  and  data  from  the  literature  suggests  that  increasing  community  knowledge  about  how  to  identify  excessive  bleeding  after  childbirth  can  increase  the  proportion  of  women  who  self-­‐refer  to  a  facility  after  developing  PPH  at  a  home  delivery.    

PROVIDERS AND VILLAGE HEALTH WORKERS INTEGRATED MESSAGES ABOUT THE IMPORTANCE OF FACILITY DELIVERIES, THE AVAILABILITY OF DRUGS AT THE FACILITY TO PREVENT BLEEDING, AND HOW TO RECOGNIZE EXCESSIVE BLOOD LOSS, INTO THEIR EXISTING EDUCATIONAL ACTIVITIES Community  sensitization  activities  were  an  important  component  of  the  OR,  and  17,134  community  members  were  reached  with  messages  about  the  importance  of  facility  deliveries,  misoprostol,  and  how  to  recognize  excessive  blood  loss  at  delivery.  Health  providers  led  the  majority  of  education  sessions  (54%),  indicating  that  providers  are  able  to  incorporate  messages  about  misoprostol  into  already-­‐existing  education  sessions.  Village  health  workers  led  19%  of  the  sessions.  However,  it  is  important  to  note  that  the  population  of  the  four  OR  districts  was  762,481,  meaning  that  only  2%  of  the  population  was  reached  with  these  messages.  As  the  ZMoHCC  works  to  ensure  that  all  women  

 

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deliver  in  a  health  facility,  it  will  be  increasingly  important  to  continue  to  educate  communities  on  the  importance  of  delivering  in  a  health  facility  and  that  drugs  are  available  at  facilities  to  prevent  bleeding  during  childbirth.  Simultaneously,  it  will  be  critical  to  ensure  that  communities  understand  how  to  recognize  excessive  blood  loss  after  delivery.      During  the  OR,  100  women  reported  that  they  experienced  excessive  bleeding  at  a  home  delivery,  and  then  self-­‐referred  to  a  facility  for  treatment.  Only  15  of  these  women  reported  to  a  provider  that  they  measured  blood  loss  at  a  home  delivery  before  coming  to  the  health  facility;  two  of  these  women  reported  that  they  used  a  zambia  to  measure  blood  loss  at  a  home  delivery.  While  this  number  is  very  small,  not  all  women  who  had  home  deliveries  were  captured  in  the  Delivery  Registry.  Thus,  there  may  have  been  women  who  delivered  at  home  and  used  a  zambia  to  measure  blood  loss,  for  whom  data  was  not  captured  during  the  OR.  With  6%  of  recorded  deliveries  during  the  OR  taking  place  at  home,  it  is  necessary  to  ensure  that  these  women  have  the  knowledge  to  know  when  they  are  bleeding  excessively  and  must  go  to  a  health  facility  for  treatment.   UTEROTONIC COVERAGE WAS LOWEST IN WOMEN WHO DELIVERED AT HOME During  the  OR,  data  on  home  deliveries  was  captured  in  the  Delivery  Registry  for  women  who  delivered  at  home  and  then  came  to  a  facility  immediately  after  delivery  for  postnatal  care.  The  registries,  as  such,  did  not  capture  the  totality  of  home  deliveries,  as  many  women  who  deliver  at  home  do  not  immediately  come  to  a  facility  afterwards.  Despite  this,  home  delivery  rates  were  relatively  high  in  some  districts  during  the  OR:  17%  of  recorded  deliveries  in  Umguza  district  and  9%  of  recorded  deliveries  in  Chimanimani  district  took  place  at  home.  For  women  who  were  recorded  as  delivering  at  home  and  for  whom  uterotonic  data  was  recorded,  only  41%  (n=214)  were  recorded  as  receiving  a  uterotonic  for  PPH  prevention  when  they  reached  a  facility.      PROVIDERS FIND MISOPROSTOL HIGHLY ACCEPTABLE, BUT RECOMMEND ADDITIONAL TRAINING  Over  half  of  respondents  to  the  Provider  Survey  agreed  or  strongly  agreed  that  they  need  more  training  to  be  confident  in  using  misoprostol  for  PPH  prevention  (53%)  and  treatment  (55%).  As  providers  are  regularly  relocated  to  new  facilities,  some  providers  initially  trained  at  the  cascade  trainings  moved  to  different  facilities  during  the  OR.  It  is  important  to  ensure  that  all  of  the  providers  providing  delivery  services  are  formally  trained  with  standardized  knowledge  and  skill  assessment  tools  on  the  appropriate  use  of  misoprostol  for  PPH  management.    

9. Programmatic Recommendations

The  following  recommendations  are  based  both  on  the  results  of  the  OR  as  well  as  lessons  learned  by  the  ZMoHCC  and  providers  in  terms  of  what  is  needed  to  strengthen  PPH  management  in  Zimbabwe.  As  such,  the  following  recommendations  go  beyond  the  results  presented  in  this  report,  and  encompass  larger  programmatic  priorities  in  the  country.  

INTEGRATE MISOPROSTOL AS AN ADDITIONAL UTEROTONIC FOR PPH MANAGEMENT AT ALL HEALTH FACILITIES THAT CONDUCT DELIVERIES IN ZIMBABWE Misoprostol  provided  critical  uterotonic  coverage  to  women  delivering  at  RHCs  and  rural  hospitals.  Misoprostol  should  continue  to  be  supplied  to  all  health  facilities  in  Zimbabwe  that  conduct  

 

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deliveries  to  ensure  that  all  women  delivering  in  facilities  receive  a  uterotonic,  whether  they  deliver  in  a  rural  or  urban  location.  

ENSURE THAT RURAL HEALTH CENTERS AND RURAL HOSPITALS CAN MANAGE PPH IN ORDER TO DECREASE COSTS, BOTH TO WOMEN AND TO THE HEALTH SYSTEM, OF MANAGING COMPLICATED PPH CASES AT HIGHER LEVEL FACILTIES If  a  woman  delivers  at  a  rural  facility,  develops  PPH,  and  has  to  be  transferred  to  a  higher-­‐level  facility,  she  faces  numerous  challenges:  cost  of  transport  to  the  referral  facility;  the  time  it  will  take  to  get  to  the  referral  facility  (particularly  given  that  the  average  time  from  development  of  PPH  to  death  is  two  hours);  and  high  costs  of  blood  transfusions  at  referral  facility.  Consequently,  ensuring  that  rural  women  can  receive  high  quality  maternity  care  at  rural  health  facilities  is  essential  to  achieving  the  ZMoHCC’s  goal  of  achieving  health  equity.    

DISSEMINATE AND IMPLEMENT THE BEMOC GUIDELINES, TO ENSURE THAT PROVIDERS CAN CORRECTLY IMPLEMENT PPH MANAGEMENT AND REFERRALS ACCORDING TO PROTOCOLS The  BeMOC  Guidelines  are  currently  not  printed  in  Zimbabwe,  and  there  is  a  need  for  providers  to  be  uniformly  educated  on  correct  PPH  management  protocols.  The  BeMOC  guidelines  should  be  printed  and  disseminated  to  all  facilities  conducing  deliveries.  Supportive  supervision  should  also  be  provided  to  ensure  that  providers  are  correctly  implementing  the  protocols.  

PROVIDE TRAINING AND JOB AIDS ON THE USE OF MISOPROSTOL FOR PPH MANAGEMENT, FOLLOWING THE SERVICE DELIVERY PROTOCOLS, TO ALL MATERNITY SERVICE PROVIDERS INCLUDING PHYSICIANS, MIDWIVES, NURSES, PRIMARY CARE NURSES, AND NURSE AIDES It  is  important  to  keep  service  providers’  skills  and  knowledge  up  to  date,  and  certain  components  of  providers’  training  need  to  be  reinforced  to  assure  that  the  protocol  and  reporting  system  are  followed  correctly.  Supplying  providers  with  job  aids  and  reference  materials  at  health  facilities  will  improve  the  quality  of  PPH  management  services.  The  misoprostol  regimen  cards  developed  for  the  OR  should  continue  to  be  used  as  additional  providers  are  trained  on  using  misoprostol  for  PPH  management.      The  high  turnover  of  staff,  as  well  as  other  job  responsibilities  that  the  providers  need  to  fulfill  can  make  it  challenging  to  ensure  that  a  facility  has  trained  providers  available  at  all  times  to  manage  PPH.    Training  all  providers  who  attend  deliveries,  including  nurse  aides,  was  suggested  during  the  interviews  with  the  providers.  Nurse  aides  were  not  a  part  of  the  cascade  trainings  for  the  OR,  as  attending  deliveries  is  not  included  in  their  job  description.  However,  in  reality,  when  PCNs  were  not  available  at  RHCs  to  attend  deliveries,  nurse  aides  managed  the  deliveries  as  the  only  available  facility  staff.    As  nurse  aides  currently  are  not  authorized  to  administer  injections,  misoprostol  fills  a  critical  gap  in  the  maternity  care  that  they  can  provide.  

INCORPORATE TRAINING ON MISOPROSTOL FOR PPH MANAGEMENT INTO THE PRE-SERVICE CURRICULA OF THE MEDICAL, NURSING, AND MIDWIFERY SCHOOLS In  order  to  ensure  the  sustainable  dissemination  of  correct  and  updated  clinical  protocols  and  guidelines,  training  on  misoprostol  for  PPH  management  should  be  incorporated  into  the  pre-­‐service  curricula  of  all  medical,  nursing  and  midwifery  schools  in  Zimbabwe.  

 

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INCREASE COMMUNITY AWARENESS THROUGH APPROPRIATE INTERVENTIONS TO ENSURE UTEROTONIC COVERAGE FOR ALL WOMEN GIVING BIRTH Engage  providers,  VHWs,  district  health  staff,  and  local  administrators  in  additional  community  awareness  activities  to  raise  awareness  of  the  importance  of  facility  deliveries,  the  availability  of  drugs  at  facilities  to  prevent  bleeding,  and  how  to  recognize  excessive  blood  loss  at  delivery.    

REGISTER MISOPROSTOL FOR OBSTETRIC USES IN ZIMBABWE, AS AN IMPORTANT FIRST STEP TO ENSURE THE ONGOING SUPPLY OF A HIGH QUALITY PRODUCT Registration,  the  process  by  which  a  drug  is  approved  by  a  regulatory  agency  for  importation,  distribution  and  marketing  for  a  specific  medical  indication,  is  a  key  strategy  for  improving  access  to  misoprostol.    Registration  is  important  because  it  allows  for  the  drug  to  be  marketed  for  approved  indications  and  to  ensure  that  an  insert  with  proper  dosages  and  instructions  for  providers  and  pharmacists  is  included  with  the  product.  It  ensures  that  oversight  is  provided  by  a  drug  regulatory  board  which  oversees  product  quality.  It  will  be  important  both  to  ensure  that  a  misoprostol  product  is  registered  for  PPH  prevention  and  treatment  and  that  procedures  are  in  place  for  ongoing  procurement,  in  order  to  ensure  the  availability  of  misoprostol  for  PPH  at  all  levels  of  the  health  care  system.  

ADOPT AND IMPLEMENT PROCEDURES FOR THE ORDERING AND DISTRIBUTION OF MISOPROSTOL TO ENSURE ITS AVAILABILITY FOR PPH MANAGEMENT IN ALL LEVELS OF HEALTH FACILITIES, WITH SPECIAL ATTENTION TO ENSURING STOCKS IN RURAL FACILITIES WHERE THE NEED IS MOST OFTEN UNMET As  misoprostol  for  PPH  management  is  expanded  in  Zimbabwe,  procedures  should  be  put  in  place  to  ensure  that  stock-­‐outs  do  not  occur,  particularly  at  the  RHCs  and  rural  hospitals,  where  misoprostol  had  the  greatest  impact  on  increasing  uterotonic  coverage.      

 

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APPENDIX A: MISOPROSTOL REGIMENS, POCKET REFERENCE FOR CLINICIANS

CERVICAL RIPENINGDose Route Instructions

400 mcg Vaginal or sublingual Give 3 hours before the procedure.

INTRAUTERINE FETAL DEATHReduce doses in women with not use with previous cesarean section.

Dose Route Instructions13-17 weeks200 mcg Vaginal Every 6 hours, maximum 4 doses.18-26 weeks100 mcg Vaginal Every 6 hours, maximum 4 doses.>26 weeks25 mcg Vaginal Every 6 hours.OR25 mcg Oral Every 2 hours.

MEDICATION ABORTIONUse as permitted within the country’s legal framework.

RegimenMEDICATION ABORTION WITH MIFEPRISTONE AND MISOPROSTOLUp to 9 weeks gestationMifepristone 200 mg oral followed 24 to 48 hours later by misoprostol 800 mcg vaginal, sublingual or buccal. For oral route, 400 mcg misoprostol can be used up to 7 weeks of gestation.9-12 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vagi-nal. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.12-24 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vaginal or 400 mcg oral. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.Dose Route InstructionsMEDICATION ABORTION WITH MISOPROSTOL ONLYUp to 12 weeks gestation

800 mcg Vaginal or sublingual Every 3 hours, maximum 3 doses.

12-24 weeks gestation

400 mcg Vaginal or sublingual Every 3 hours, maximum 5 doses.

 

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APPENDIX B: CONTRACEPTIVE GUIDE, POCKET REFERENCE FOR CLINICIANS

Adapted from: MAQ Exchange: Contraceptive Technology Update

Contraceptive Guide for POSTPARTUM SERVICESPocket Reference for Clinicians

DELIVERY

Condoms/SpermicidesIntrauterine Device (IUD)a

Tubal Ligation

Lactational Amenorrhea Methodb

ALL WOMEN

BREAST-FEEDING WOMEN

NON-BREAST-FEEDING WOMEN

Combined Oral or Injectable Contraceptives (COCs/CICs)c

48 HOURS

3 WEEKS

4 WEEKS

6 WEEKS

6 MONTHS

9 MONTHS

Diaphragm/Cervical Cap

Male Sterilization

Progestin-only Pills or InjectablesCombined Oral or Injectable Contraceptivesc

Progestin-only Pills or Injectables

Emergency Contraception

aIf delivery is in a health care facility, IUD can be inserted immediately postpartum (within 48 hrs).

cDuring the first 6 months postpartum, COCs/CICs may affect the quantity of breastmilk and the healthy growth of the infant. However, if no other methods are available or acceptable, a woman may use COCs/CICs starting 6 weeks postpartum.

bNatural family planning (NFP) may be harder for breastfeeding women as reduced ovarian function makes fertility signs more difficult to interpret. As a result, NFP can require prolonged periods of abstinence during breastfeeding.

 

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APPENDIX C: UTEROTONICS FOR PPH PREVENTION, POCKET REFERENCE FOR CLINICIANS

MISOPROSTOL

Rural Health Centers: 10 IU intramuscularly (IM)

800 mcg sublingual

ERGOMETRINE0.5 mg IM or intravenously (IV)*Contraindicated when used with certain HIV drugs including HIV protase inhibitor, efavirenz, or delavirdine.

District/Provincial/Central Hospitals: Oxytocin infusion, 40 IU at 30-40 drops per minute

Uterotonics forPostpartum Hemorrhage TREATMENT*

Pocket Reference for Clinicians

*The regimens listed here are from the Zimbabwe PPH treatment protocol developed for operations research.

OXYTOCIN

 

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APPENDIX D: POSTER FOR PPH PREVENTION

I delivered ata health facility.”

Prevent excessive bleedingafter chilbirth

“I made the Right Choice.“I made the Right Choice.