Postpartum Hemorrhage Prevention and Treatment in Africa: Using Misoprostol at Community Level

Ndola Prata, MD, MSc

Africa Regional Meeting on Interventions for Impact in Essential Obstetric and

Newborn CareAddis Ababa, EthiopiaFebruary 21-25, 2011

9/28/10

Rational for community-level prevention and treatment of PPH with misoprostol

Disparities in maternal indicators: – MMR – Skilled assistance during delivery – Access to EmOC – Access and usefulness of ANC

There is an imperative need to address home births with quality interventions

Interventions & Technologies for PPH ManagementIntervention/ Technology Location Where it is Used Level of Provider

Home based life saving skills Household Minimally trained

Conventional Injectable Uterotonics

Facility Household

Skilledskilled

Misoprostol FacilityHousehold

Skilled Minimally trained & Self Administration

Oxytocin-Uniject FacilityHousehold (?)

SkilledMinimally trained

Anti-shock Garment FacilityHousehold (for application only)

SkilledMinimally trained (for application only)

IV fluids and Blood Facility Skilled

Balloon/condom Catheter Facility Highly skilled

Surgical interventions Facility Highly skilled

WHEN AND HOW DO WE REACH THE WOMAN?

4

DELIVERYDELIVERYPREGNANCYPREGNANCY

ANC Health Facility

Home

TBA

PPH Prevention

DELIVERYDELIVERYPREGNANCYPREGNANCY

ANC Health Facility

Home

Community Health Worker

TBA

M

M

M

PPH Prevention: Misoprostol the “game changer”

Options to Prevent PPH using Misoprotsol at Community Level

• During pregnancy– ANC– Community health worker– Safe delivery kits– Pharmacies; chemical sellers; community drug

keepers; patent medicine vendor

• At Home Delivery– Community health worker– Traditional birth attendant

PPH Prevention at the Community Level

8

MadagascarPrimary health centers 1& 2

ZambiaANC Distribution

MozambiqueTBA & ANC Distribution

TanzaniaANC Distribution

GhanaANC Distribution

NigeriaTBAs & Community Gatekeepers

UgandaHealth Centers 3 & 4

BangladeshTBA & ANC Distribution in safe delivery kits

KenyaANC Distribution

EthiopiaHEW

NepalPharmacies/Social Marketing

Indonesia (not shown)

Community health volunteers

AfghanistanCommunity health volunteers

PakistanLady health visitors

Distribution of Misoprostol for PPH Prevention through Antenatal Care (ANC)

Community Awareness Campaign on Birth

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

Misoprostol Distribution at ANC•ANC Visit•Education Session on PPH and Misoprostol•Misoprostol Distribution

Reduce PPH at Home Births

9

Misoprostol distribution at ANC increased the number of births protected from PPH in Kenya

N=2,890

Community distribution of misoprostol increased the number of births protected from PPH in Zaria, Nigeria

PPH Treatment at Home Births

Critical Considerations:

– Who is present at birth?

– How will women/family get the drug?

– When is the drug administered? How is PPH identified?

– Route of administration?

TBA Treatment of PPH with Misoprostol Reduced the Need for Referrals and Interventions

25

2 1

19 19

95

0

20

40

60

80

100

PPH Overall Referrals Required Additional Interventions (of those

with PPH)

%

Intervention (n=454) Control (n=395)

Prata, Mbaruku, et al. International Journal of Gynecology and Obstetrics (2005) 90,51-55. 13

14

Use and Effectiveness of Misoprostol for Treatment of PPH at Community level

Women with perceived PPH (2 kangas soaked with blood) (N=239)

Women offered misoprostol for treatment(N=171)

71.5%

Women received misoprostol for treatment(N=164)

95.9%

Women who took misoprostol and needed to be transferred for additional interventions

(N=3)1.8%

Strategies for Community level use of MisoprostolProgramatic & Implementation level

• Know the community• Effective awareness

campaign• Integrate misoprostol

distribution into existing community-based maternal health interventions

• Improve services in delivery rooms

Strategies for Community level use of MisoprostolPolicy Level

• Commitment to protect all deliveries from PPH wherever they occur

• Allocation of human and financial resources• Scale up interventions• Work towards a comprehensive package of

maternal health services that includes community-based distribution of misoprostol

Thank You