PPH Prevention through platform of antenatal care

Albert Kitumbo, MDIfakara Health Institute

Rationale for ANC Distribution of Misoprostol for Prevention of PPH

• PPH is the leading cause of maternal death • Misoprostol has been shown to be safe for

preventing PPH at home deliveries• In Tanzania:– 94% of women attend at least one antenatal care visit

(ANC) during their pregnancy– 53% of women deliver outside of facilities

By educating women and distributing misoprostol during ANC visits, women who deliver at home will

have access to this life-saving technology

Operations Research: Testing the ANC Distribution Model

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

• Conducted in 4 districts of Tanzania between January and December 2009

• Collaborating Institutions: Ifakara Health Institute; Venture Strategies Innovations; Bixby Center at the University of California, Berkeley

Provide evidence that: • Women can safely self-

administer misoprostol for prevention of PPH at home births

• ANC visits are a feasible and effective means of distributing misoprostol for PPH prevention to women

• Women and communities find misoprostol to be acceptable

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

Community Awareness Campaign

Key messages:– Promote attendance at

ANC throughout pregnancy– Importance of delivering in

a health facility– Plan early for a safe

delivery– PPH consequences & blood

loss measurement with the kanga

– Misoprostol is available at ANC once a woman is 32 weeks pregnant

Focused ANC with Misoprostol Distribution

• Educate all women coming to ANC about safe delivery and PPH prevention

• Screen women for eligibility to receive misoprostol

• Distribute misoprostol to eligible women > 32 weeks gestation

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%

FeasibilityCoverage of Community Awareness Campaign

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Program EffectivenessComprehension of Campaign Messages

PPH Information Misoprostol Information

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10Green color = Birth protected from PPH by use of uterotonic after delivery

n= 6,735

Program EffectivenessBirths Protected from PPH

Program EffectivenessUse of Misoprostol by Location of Delivery

Green color = Birth protected from PPH by use of uterotonic after delivery11

Need for Additional Interventions after Home Birth

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

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Conclusions

Integration 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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Limitations and Challenges

• Women returning for an ANC visit after 32 weeks gestation is lower than anticipated– Greater effort to encourage women to return to

the health facility– In the future, consider lowering the gestational

age requirement to receive misoprostol

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Policy Implications• Other countries with similarly high rates of ANC and lower

rates of facility delivery should consider ANC distribution to protect women who deliver at home

• All ANC providers should be trained to distribute misoprostol at ANC – bring the program to scale

• Gestational age limitations decrease coverage – consider lower or removing

• Scale up the community awareness campaign to increase knowledge of key messages

• Consider other mechanisms of misoprostol distribution for self-administration

• Misoprostol should be available in all delivery rooms