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NEPAL: A Pioneer in Community-Based Distribution of Misoprostol
for Prevention of PPH at Homebirth
Dr. Naresh P KC
Ministry of Health and
Population, NepalMay 2012
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2
Haemorrhage
24%
Eclampsia
21%
Abortion
7%
Heart disease
7%
Obstructed Labour
6%
Anaemia
4%
Gastroenteritis
4%
Puerperal sepsis
5%
Other direct
6%
Other indirect
16%
Sources: Nepal Demographic and Health Surveys, 2006, 2011; MaternalMortality and Morbidity Survey 2008/09
PPH 17%
MNH Situation in Nepal• Maternal Mortality Ratio one
of the highest in South EastAsia: 281/100,000
• Hemorrhage (APH, PPH)leading cause of maternaldeath
• Deliveries by Skilled BirthAttendants increasing but stilllow
• 19% in 2006
• 36% in 2011
• Low uterotonic coverage
(Oxytocin or Misoprostol)
• Low SBA retention in remote
areas
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Basic research Introduction
and pilot
Influential evidence
Policy considerations
RegionalRCTshowingefficacy
Professionalexperience andhospital datasuggesting high riskfor PPH
Jan 2004: NepalGoN committedto pilot followingBangkokworkshop
Apr 2004: Discussionwith professionalorganizations, SafeMotherhood Sub-Committee
Sept 2004:Formation of TechnicalAdvisoryCommittee
Feb 2005:NHRCapproval forpilot
1 year: evidence topilot
Preliminary Work for Pilot
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Pilot in Context
• First priority was to increase skilledattendance at birth and
institutional deliveries through:
– Health facility upgrades
– Emphasis on AMTSL at healthfacilities
– SBA in-service training
– Maternity incentive scheme
• Misoprostol distribution by FCHVsfor prevention of PPH at home
birth within a broader community
approaches
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Health workers/
Health facilitiesFCHV
Woman & newborn
• FCHVs and HWs work closely for promotion of ANC, Institutional
delivery and PNC. They have key role in:•
Promotion of ANC, institutional delivery and PNC, self-care, hygiene, Essential Newborn Care
• Use of iron/folate, deworming tablets, TT, post-natal Vitamin A•
Birth preparedness (money, transport, SBA and blood)
•Identification of danger signs (pregnancy, delivery and post-natal) and referral
• At 8th month, FCHVs distributes Misoprostol. During PNC home visits
confirms use and retrieves if unused
Community Service Delivery System
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Areas Antenatal Delivery Post-natalAssess Danger signs and referral Danger signs and
referral
•Danger signs and referral
(including neonates)
•Birth weight
Counsel
•Birth preparedness and
complication readiness•Danger signs/refer
•Seeking care, TT & anti-
helminthic Rx
• Misoprostol
•Danger signs and
referral
•Promotion of institutional
deliveries
•Essential newborn
care
•ENC
•Exclusive breast feeding•PNC (rest, food, hygiene,
etc.)
•Family Planning
Distribute•Iron/folate•Misoprostol
•BPP action card
•Iron/folate
•Post-natal Vit A
Document Pregnancy registration Pregnancy outcomes
Key Roles of FCHVs
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Results of Misoprostol Pilot in
Banke District, 2005-2007
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Timing of Misoprostol Use
0
86
14
0
20
40
60
80
100
before the delivery
of the baby
afer the delivery of
the babybut before
the delivery of the
placenta
afer the delivery of
both baby and
placenta
P e r c e n
t
Source: Follow-up survey 2007
Used appropriately
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Symptoms Reported
2218.5
3.4
9
26.3
27
6.29.4
1.3
7
15.1
0
10
20
30
40
50
60
70
80
90
100
D i z z y
S h i v e r i n g
N a u s e a
F e v e
r
L o o s e
m o t i o n
H e a d a c h e
P e r c e n t
Used MSC Not used MSC
Source: Follow up survey 2007
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Uterotonic Coverage
Baseline Endline
0
20
40
60
80
100
Misoprostol
Inj. Oxytocin
Source: Follow up survey 2007
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Use of Skilled Birth Attendant
Associated with increased SBA use
Source: NFHP survey
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Conclusion: Pilot Success in Banke
• Significant increase of uterotonic coverage
• High coverage in governmentsystem with mobilization of FCHVs
• Adverse effects were not asignificant problem
• Misoprostol can and shouldbe implemented with effortsto increase Skilled BirthAttendants use
• High degree of correct use,efficacy and safety
• Suggestive to scale-up inother districts
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Expansion from Pilot
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Progression to scale
Pilot National level scale-up
Influential evidence
Policy considerations
Regional
RCT usedforadvocacy
Pilot results
used todemonstratefeasibility
Mar 2010:Nepal countryteam committedfor nationallevel expansionof MSC
(ReconveningBKK conference)
April/May 2010: Sharing andadvocacy at thenational level
June 2010:MOHP approvedfor nationallevel expansion
July 2010:Developedimplementationguidelines
6 months: pilotresults to scale-
up
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Current GON Approach to PPH Prevention
Prevention of PPH
Active Management of Third
Stage of Labor (AMTSL)
Use of Misoprostol at home
birth
Use of uterotonicdrugs: Inj.
Oxytocin within aminute after
delivery of baby
Controlledcord
traction
Uterinemassage
Use of uterotonic drug: TabMisoprostol (600 mcg) after
delivery of a baby
Only trained health workers can do
AMTSL
Feasible in community
settings
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Central Region
Eastern Region
Mid-Western Region
Far-Western Region
Western Region
Humla
Darchula
Baitadi
Dadeldhura
Kanchanpur
Kailali
Doti
Bajhang
Bajura
Achham
Bardiya
Mugu
Dolpa
Mustang
Manang
Rasuwa
Kalikot
Dailekh
Surkhet
Jumla
Jajarkot
Banke
Rukum
Salyan
Dang
Rolpa
Pyuthan
Myagdi
Baglung
Gulmi
Kapilvastu
Kaski
Syangha
Rupandehi
Palpa
Lamjung
Tanahu
Gorkha
Chitwan
Dhading
Nuwakot
Makwanpur
Nawalparasi
P a r s a
B a r a
R a u t a h a t *
Taplejung
SolukhumbuSankhuwasava
Sindhupalchowk
S a r l a h i
M a h
o t t a r i
D h a
n u s h a
Siraha
SaptariSunsari
Sindhuli
Kavre
Dolakha
Ramechhap
Okhaldhunga
Udayapur
Morang Jhapa
Ilam
KhotangBhojpur
Dhankuta
K
L
B
N
Districts with Misoprostol
• GoN is committed to increase uterotonic coverage (GON
expanding the intervention and purchasing Misoprostol)
• Priority is AMTSL during deliveries at health facilities
• Misoprostol national level scale-up focusing in remote areas.
Pilot – 2005
Expansion – 2009/10
Expansion – 2010/11
Plan for Expansion – 2011/12
Legend
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Major Inputs for Program Scale-up
• Training
• Review/refresher meetings
• Logistic support
• Monitoring
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Uterotonic Coverage(in selected program districts)
26
50
1427 33
4327
36
59
44
22
5250
56
5628
34
0
20
40
60
80
100
120
Misoprostol coverage HW/HF delivery
Source: District HMIS, 2011/12
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•
National context: Urgent need toreduce MMR due to PPH
• Realistic piloting under MoHPsystem
• Rapid move from pilot to scale-
up (<2 years)
• Consensus and support from allstakeholders (including NepalSociety of Ob/Gyns) for scale-up
•Nepal is pioneer in successfulimplementation of Misoprostoland has been a subject of globalinterest
Conclusions
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• Distribution of misoprostol,ensuring availability andtransportation
• Collection of reports from
grassroots level• Program expansion/coverage only
in partners supported districtslimiting the expansion in priority
districts• Ensuring the quality of training to
FCHVs
Challenges
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Thank You
Implementing Partners• Government of Nepal (FHD lead)
• Partners• USAID/NFHP II and its partners
• UNICEF• CARE Nepal
• Rural Health Development Program(RHDP)/SDC
• Health Right International
• Nepal Society of Obstetricians andGynaecologists (NESOG)
• One Heart Worldwide (planning to supportin expansion)
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