misoprostol delivers_roy_5.3.12
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Misoprostol Delivers!The use of misoprostol in the prevention of postpartum hemorrhage (PPH) in Doti
District, Nepal
Implementation and data collection CARE Nepal CRADLE TeamStatistics by Noor Tirmizi and Kristen Yee
Outline
• Background
Results from Feasibility Study
• Results from Case Control Study on Effectiveness• Methods• Results
• Descriptive statistics• Bivariate analysis• Logistic regression
• Limitations• Conclusions
• Blanket pilot program initiated in Dec 2010 in Doti
• Hilly, mountainous region, 768 sq miles
• Aimed to Provide misoprostol (600μg) to every pregnant women in 8th month of pregnancy
• Training of HWs/FCHV and drug supply facilitated by CARE
• Monitoring and supervision of rollout done by MoH in partnership with CARE
Background: Misoprostol in Doti District, Nepal
Operations Research Study
To determine• feasibility • acceptability • safety
of community-based distribution of misoprostol by community volunteers under government service towards the prevention of postpartum hemorrhage (PPH) in pregnant women
4
OR – Feasibility Study
Objectives of the study: • To explore the utilization pattern of Misoprostol in Doti district
during delivery.• To find out results of Misoprostl and list side
effects/complicatins seen.
Study Design • A cross section study on feasibility of Misoprostol by Recently
Delivered Women (RDW)
Sample Size for the study• 15/ 50 VDCs randomly selected. (1) all the FCHVs of those VDC
interviewed (2) Recently delivered women (3) Similarly HW and HWIC wherever available in these 15 VDCs interviewed.
Study Setting & Design
Data Collection • Quantitative collected from the interview of RDW• Qualitative collected using IDI and FGDs of FCHVs, HWs, HFICs
Data processing and analysis• Data collection tools were coded and analyzed in SPSS• FGDs/IDIs were transcribed and analyzed using content analysis
approach
Duration of Data Collection• August 2011 for both qualitative and quantitative data
Antenatal & Health Education Characteristics
Cases (N=55) Controls (N=290)
Variable Freq Percent Freq Freq Percent
FreqANC < 4
visits16 28.6 99 34.1
4 visits 39 71.4 191 65.9
Any counseling on BPP by FCHV
No 19 34.5 67 23.1
Yes 36 65.5 223 76.9
BPP counseling by FCHV in 8th month of pregnancy
No 43 78.2 185 63.8
Yes 12 21.8 105 36.2
Delivery Characteristics
Cases (N=55) Controls (N=290)
Variable Freq Percent Freq Freq Percent
Freq
Place of delivery Home 55 100.0 286 98.6
Cowshed 0 0.0 2 0.7
Road 0 0.0 2 0.7
HW attended delivery
No 36 64.7 143 49.2
Yes 19 35.3 147 50.8
Source of Information
Knowledge on MSC Percent (n=169)
Heard about MSC from:
FCHV 72.2
VHW/MCHW/ANM 17.8
Doctors/HA/AHW 8.9
OR - The Numbers Game
345 Women Interviewed
173 Received Misoprostol
169 took the correct dose
Feasibility• 49% Illiterate• 40% Dalits• 95% women had FCHV < 30 minute walk
Safety• 88% knew correct timing.• Common Side Effects vomit, diarrhea, shivering• 95% knew advice to go to HF if bleeding persists
Acceptability: 99.4% of users would recommend MSC to their friends and relatives
FGD/IDI Findings
1) MCHW/ANM• Interview with nursing staffs revealed that FCHVs were capable for
distribution of MSC and counseling on its usage to mothers.
2) HF- Incharge• HF in-charges were confident about knowledge of FCHVs on MSC; dose,
time to take, side effects and its return and their ability to distribute the tablets.
3) FCHV • FCHV reported that they gave the tablets only after enough counseling on
the dose, time and its general side effects to the mothers.
Some of the more aware mothers came to ask for the tablets at last months of the pregnancy.
Objectives:• Determine the odds of misoprostol ingestion based on receipt of pills • Determine the odds of postpartum hemorrhage based on correct
ingestion of misoprostol (600μg taken orally immediately following childbirth)
Definition:• PPH – MOH definition – 2 half meter cloths completely soaked with
blood during delivery.
Cases = RDW women who experienced PPH (n=55)
Controls = RDW women who did not experience PPH (n=290)
Study on Effectiveness of Misoprostol
Binary Logistic Regression Results Effectiveness of MSC reducing PPH
Variable Reduction in PPH CI
Exp (β)Age
(15-24) yrs of age25 yrs or older
1.57 0.85 2.79
Ingestion of misoprostol (600 μg)Yes
0.46* 0.25 0.86
Receipt of Counseling on BPP by FCHV in 8th month of last pregnancy 0.53** 0.27 1.07
Binary Logistic Regression Results—Factors Affecting Ingestion of MSC
Variable MSC Ingestion CIExp (β)
Age(15-24) yrs of age25 yrs or older
0.95 0.60 1.48
Literacy
Literate 1.43 0.91 2.26
ANC Visits
Did complete 4 visits 1.78* 1.13 2.81
Continued Counseling Did not receive any counseling
1.43 0.85 2.40
Cross Tables to Explain Reasons for Non-use
Variable
AccessDid not take MSC following
childbirthN (%)
Did take immediately following childbirth
N (%)
Got MSC tablets during pregnancy
67 (40.9) 97 (59.1)
Knowledge: Reasons for taking MSC
Stop PPH, Prevent Death, help uterus contraction & placenta expulsion
114 (54) 95 (45.0)
Knowledge on Correct Dose of MSC
Knowledge on dose Incorrect dose N (%)
Correct dose N (%)
Reasons for taking MSC
Stop PPH & Prevent Death 15 (8.8) 155 (91.2)
Counseling
Did receive counseling by FCHV 129 (49.8) 130 (50.2)
Limitations
Data collection• Cross-sectional analysis• Self-report of misoprostol ingestion and PPH
Data analysis• Sample size (N=345)• Proxy measures limit interpretation
Key Findings
• Women who completed four antenatal visits had 1.78 the odds of taking misoprostol correctly relative to those women who did not complete four antenatal visits
• Women who took misoprostol were associated with a 53% decrease in the risk of postpartum hemorrhage
Examples from Literature
• BRAC’s maternal, neonatal and child health program in rural northern Bangladesh 2008-2010
• Successfully provided misoprostol (400μg) to mothers under direct supervision of CHW
• Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)• Provides basic package of interventions to mother and child within first 48
hours of newborn’s life. Misoprostol part of maternal intervention
• The Center for Health Innovations’ Venture Strategies Innovation (VSI)• Improve misoprostol availability• Work with ministries of health to incorporate misoprostol into national
guidelines and promote task-shifting and training• Multi-country initiative, more policy level focus
Conclusions
National Policy Level• Pilot program initiated by the Government of Nepal and CARE was successful.
CARE worked with other partners/stakeholders and FHD to prepare guidelines for a national program on Misoprostol use. It is a part of SMH program in Nepal and is included in the EDL.
• Program has now been scaled up to function on a national level
• Study findings are consistent with existing literature• Misoprostol as a tool in the reduction of postpartum hemorrhage• Feasibility and acceptability of misoprotol use and dissemination of the
community level• this study adds to existing evidence in demonstrating that in one of the most
remote regions of Nepal (hills and mountains), community-level distribution of misoprostol is possible
References
• GULMEZOGLU, A. M., VILLAR, J., NGOC, N. T., PIAGGIO, G., CARROLI, G., ADETORO, L., ABDEL-ALEEM, H., CHENG, L., HOFMEYR, G., LUMBIGANON, P., UNGER, C., PRENDIVILLE, W., PINOL, A., ELBOURNE, D., EL-REFAEY, H. & SCHULZ, K. 2001. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet, 358, 689-95.
• HASHIMA, E. N., NAHAR, S., AL MAMUN, M., AFSANA, K. & BYASS, P. 2011. Oral misoprostol for preventing postpartum haemorrhage in home births in rural Bangladesh: how effective is it? Glob Health Action, 4.
• HOFMEYR, G. J., GULMEZOGLU, A. M., NOVIKOVA, N., LINDER, V., FERREIRA, S. & PIAGGIO, G. 2009. Misoprostol to prevent and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related effects. Bull World Health Organ, 87, 666-77.
• PRATA, N., GESSESSEW, A., ABRAHA, A. K., HOLSTON, M. & POTTS, M. 2009. Prevention of postpartum hemorrhage: options for home births in rural Ethiopia. Afr J Reprod Health, 13, 87-95.
• RAJBHANDARI, S., HODGINS, S., SANGHVI, H., MCPHERSON, R., PRADHAN, Y. V. & BAQUI, A. H. 2010. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J GynaecolObstet, 108, 282-8.
• HASHIMA, E. N., NAHAR, S., AL MAMUN, M., AFSANA, K. & BYASS, P. 2011. Oral misoprostol for preventing postpartum haemorrhage in home births in rural Bangladesh: how effective is it? Glob Health Action, 4.
• HOFMEYR, G. J., GULMEZOGLU, A. M., NOVIKOVA, N., LINDER, V., FERREIRA, S. & PIAGGIO, G. 2009. Misoprostol to prevent and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related effects. Bull World Health Organ, 87, 666-77.
• Maternal and Neonatal Health. Preventing Postpartum Hemorrhage: A community-based approach proves effective in rural Indonesia. Baltimore, USA: MNH Program, 2004.
• PRATA, N., GESSESSEW, A., ABRAHA, A. K., HOLSTON, M. & POTTS, M. 2009. Prevention of postpartum hemorrhage: options for home births in rural Ethiopia. Afr J Reprod Health, 13, 87-95.
• RAJBHANDARI, S., HODGINS, S., SANGHVI, H., MCPHERSON, R., PRADHAN, Y. V. & BAQUI, A. H. 2010. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J GynaecolObstet, 108, 282-8.
• WORLD HEALTH ORGANIZATION. 2007. WHO recommendations for the prevention of postpartum haemorrhage. Geneva, 14-15.