Protecting mothers from PPH at home births with misoprostol:

From national advocacy to community-based distribution

Alisha Ann Graves, MPHSenior Program Manager, VSI

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VSI’s approach

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The case of misoprostol

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Misoprostol is capable of curbing maternal mortality due to postpartum hemorrhage & unsafe abortion

• Effective, evidence-based intervention• Heat-stable, low-cost, generic tablets • Simple to administer without skilled attendance

Ideal in low-resource settings & supported by international health organizations

Key agencies have recognized the role of misoprostol in different settings to avoid maternal mortality

FIGO/ ICM 2006 Call to Action

“the different setting where women give birth…require different strategies to prevent and treat PPH.”

“…in home births without a skilled attendant, misoprostol may be the only technology available to control PPH.”

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Global Policy (cont.)WHO Recommendations on the Prevention of PPH (2007)

“In the absence of AMTSL, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker* trained in its use for prevention of PPH”*auxiliary nurse-midwives, community midwives, village midwives, and health visitors—if they have been specially trained, qualify

UpdateWHO added misoprostol to its Model List of Essential Medicines for prevention of PPH (May 2011, unedited report)-was previously included for treatment of incomplete abortion

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*Misoprostol may or may not be registered for gastric ulcers

Registered for postpartum hemorrhage (PPH) and treatment of incomplete abortion*

Registered for PPH and other ob/gyn indication*

Registered for PPH*

Registered for another ob/gyn indication (not PPH)

Registered for gastric ulcers only

2004 misoprostol registration status (Approximated)

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*Misoprostol may or may not be registered for gastric ulcers

Registered for postpartum hemorrhage (PPH) & treatment of incomplete abortion*

Registered for PPH and other ob/gyn indication*

Registered for PPH*

Registered for another ob/gyn indication, not PPH*

Registered for gastric ulcers only

2010 misoprostol registration statusLast updated: August 2010

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Government policies set level of access guidelines and public sector procurement

Misoprostol for PPHEssential Drugs List National Clinical Guidelines

EthiopiaTanzaniaZambia

Sudan (South)Kenya

Nigeria

EthiopiaNigeria

Tanzania & ZanzibarUgandaZambiaGhanaKenya

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Preventing PPH at home-births in Tanzaniathrough antenatal care (ANC) distribution of misoprostol

• Goal: Assess the feasibility, safety, program effectiveness, and acceptability of distribution of misoprostol through ANC visits

• Conducted in four districts of Tanzania (January - December 2009)

• Collaborating Institutions:

OPERATION RESEARCH

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Enrollment and ANC/Delivery Characteristics

Enrollment• ANC Attendance = 12,892• Enrollment = 12,511 (97%)• Postpartum Interview = 6,735 (54% of enrolled)

ANC/Delivery Characteristics• Average number of ANC visits = 3.0• ANC attendance > 32 weeks = 44%• Health facility delivery = 67%

Components of the ANC Distribution Program

Community Awareness Campaign on Birth Preparedness

and PPH Prevention•Radio•Community meetings with CORPs and TBAs•Posters and Pamphlets

Focused ANC with Misoprostol Distribution

•ANC Visit•Education Session on PPH and Misoprostol•Misoprostol Distribution at > 32 weeks gestation

Reduce PPH at Home Births

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No uterotonic9%

Injection41%

Misoprostol at health facility

23%

Misoprostol at home27%

Green color = Birth protected from PPH by use of uterotonic after delivery

n= 6,735

Program EffectivenessBirths Protected from PPH

SafetyCorrect Use of Misoprostol

Almost all 1,826 women who took misoprostol at home reported using the drug correctly:

– Correct dose (3 tablets)= 99.5%– Correct route (oral) = 98%

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Women’s Acceptability

Would recommend misoprostol to a friend

Would use misoprostol in a

subsequent pregnancy

Would purchase misoprostol

0%10%20%30%40%50%60%70%80%90%

100% 99% 98% 96%96% 95% 93%

Took misoprostol (n=3,370)Did not take misoprostol (n=3,365)

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ConclusionsIntegration of misoprostol into existing ANC Services is: • Feasible– Reach of community awareness campaign to almost all women– High enrollment and misoprostol distribution to eligible clients

• Safe– All women used misoprostol correctly at home births– Low report of postpartum symptoms

• Effective– High comprehension of key community awareness messages– 88% coverage of misoprostol at home births

• Acceptable– Women feel more secure and protected from PPH

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Select Policy Implications

• Scale-up within Tanzania and beyond• Consider other mechanisms of misoprostol

distribution for self-administration• Misoprostol should be available in all delivery

rooms

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Thank youAlisha Ann Gravesagraves@vsinnovations.org

Stay connected!www.vsinnovations.org