Preventing - The Bixby Center for Population, Health, and...

P r e v e n t i n g PostPartum hemorrhage at t h e c o m m u n i t y l e v e la compendium of oper at ions research

2 Preventing PostPartum hemorrhage at the community leveli Preventing PostPartum hemorrhage at the community level

authors:

ndola Prata, medical Director

martine m. holston, Director of research and implementation

eDitor:

amy a. grossman, technical advisor, communications

citation:

venture strategies innovations. Preventing Postpartum hemorrhage

at the community level: a compendium of operations research. irvine:

vsi, 2013.

19200 von Karman avenue, suite 400

irvine, california 92612 usa

tel +1 949 622 5515

PhotograPhy:

Cover:

VSI/Emma Nesper Holm ©2010

This page

VSI/Marko Balenovic ©2012

Opposite page

VSI/Videocam Productions ©2011

a comPendium of oPerations research 3

c ontents

acKnoWleDgements

acronyms

eXecutive summary

i. introDuction

ii. vsi oPerations research moDel

iii. country Program summaries

BANGLADESH

GHANA

KENYA

MOZAMBIQUE

NIGERIA

TANZANIA

ZAMBIA

iv. cross-cutting results anD Factors For success

reFerences

iii

iv

v

1

3

9

10

12

14

16

18

20

22

24

33

a comPendium of oPerations research i i

VSI wishes to acknowledge Katharine Allen and Laura Spautz in helping to draft this report, and the valuable contributions of the expert staff and colleagues at the following implementing partner organizations and government institutions: Asso-ciação Moçambicana de Obstetras e Ginecologis-tas; Bixby Center for Population, Health and Sus-tainability, School of Public Health, University of California, Berkeley; Ghana Health Services; Ifak-ara Health Institute; International Centre for Diar-rhoeal Disease Research, Bangladesh; Ministry of Health, Mozambique; Ministry of Health, Zambia; Ministry of Public Health and Sanitation, Kenya; Population and Reproductive Health Partnership at Ahmadu Bello University; and Rangpur Dinajpur Rural Services Bangladesh. PSI in Kenya, Mozam-bique and Tanzania; Society for Family Health in Zambia; and DKT, Mozambique also deserve rec-ognition for their support of information, educa-tion and communication material development in each country.

VSI also acknowledges the significant efforts of the field teams in each country, including the numerous district-level coordinators, supervisors, health management teams, nurses, midwives, com-munity health workers and traditional birth atten-dants, without whom the operations research could not have been executed, or the women in the project districts so expertly served.

The guidance and contributions of several indi-viduals in the development and/or implementation of the operations research program in each country warrants specific acknowledgement:

Bangladesh: M. Abdul Quaiyum, Salima Rah-man, Mohsina Begum, Ashrafi Jahan Azmi and Arshadul Islam ghana: Gloria Quansah Asare and the Technical Advisory Group, Kwame Amponsa-Achiano, Bernard E.K. Vikpeh-Lartey and Bibiana Irene BangpuoriKenya: Joseph G. Karanja, Zahida Qureshi,Josephine Kibaru, Isaac Bashir, Shiprhah Kuria and Catharine KamauMozaMBique: Cassimo Bique, Veronica de Deus, Ernestina Maia and Momade Bay Ustanigeria: Clara Ladi Ejembi, Oladapo Shittu, and the Executive Committee of the Population and Re-productive Health Partnership, Venture Strategies for Health and Development and His Royal Highness, Emir of ZazzauTanzania: Godfrey Mbaruku, Albert Kitumbo, Selamani Mbuyita, Idda Kinyonge, Felix Lubuga, Hadija Kweka, Abdallah Mkopi and Silas Temu zaMBia: Reuben Mbewe, Mary Nambao, Her Excel-lency Christine Kaseba-Sata and Rabecca Kalwani

In closing, VSI is grateful for the participation and trust of the women and their communities in the operations research districts in Bangladesh (Dinajpur, Kurigram, Lalmonirhat, Nilphamari, Panchagarh and Thakurgaon), Ghana (Birim South, Komenda-Edina-Eguafo-Abirem, Sene and Upper Manya Krobo), Kenya (Maragua and Kitui), Mozambique (Chokwé, Namacurra, Nacala-Porto and Nacala-a-Velha), Nigeria (Dakace, Hayin Ojo, Tsi-biri, Yakawada and Unguwan Godo), Tanzania (Kigoma, Kilombero, Ulanga and Rufigi) and Zambia (Kalomo, Kapiri Mposhi, Masaiti, Mungwi and Petauke).

ACKNOWLED GEMENTS

i i i Preventing PostPartum hemorrhage at the community level


acronyms

anC Antenatal careCdK Clean delivery kitChV Community Health VolunteerChW Community Health WorkerCorPs Community-oriented Resource PersonshiV Human Immunodeficiency VirusiCCdr,B International Centre for Diarrhoeal Disease Research, BangladeshKaP Knowledge, attitudes and practicesKeea Komenda-Edina-Eguafo-Abirem districtMdg Millennium Development GoalM&e Monitoring and EvaluationMMr Maternal Mortality Rationgo Non-governmental organizationor Operations researchPPh Postpartum hemorrhagePrhP Population and Reproductive Health Partnership rdrs Rangpur Dinajpur Rural ServicessMag Safe Motherhood Action GroupTBa Traditional Birth AttendantVsi Venture Strategies InnovationsWho World Health Organization

a comPendium of oPerations research i v

6 Preventing PostPartum hemorrhage at the community level

Despite remarkable progress toward improved maternal health, most developing countries are not on track to meet the fifth Millennium Development Goal to significantly reduce maternal mortality by 2015 (World Health Organization, 2012a). Postpar-tum hemorrhage (PPH) remains the leading direct cause of maternal deaths despite being preventable with the use of a uterotonic drug immediately after birth. Misoprostol has emerged as an effective and safe uterotonic that is especially suited for home births, which is where the majority of women in de-veloping countries deliver. These home deliveries place women at a high risk for PPH and subsequent death. However, limited evidence exists on the ef-fectiveness of service delivery models to distribute misoprostol for PPH prevention at home births de-spite international recognition of its potential in community settings.

In response to this knowledge gap, the non-profit women’s health organization, Venture Strategies Innovations (VSI) worked on a series of independent operations research programs across seven countries in Africa and Asia. Between 2008 and 2012, VSI, in collaboration with local and in-ternational partner and research organizations, conducted operations research to determine the feasibility, acceptability, and program effective-ness of misoprostol use to prevent PPH at the community level.

VSI designed a unified approach for these programs, which was then adapted to each country and its unique sociocultural context and development needs. The operations research model consisted of a misoprostol dis-tribution strategy, either through antenatal care visits or via traditional birth attendants, and a community aware-ness campaign to highlight the importance of delivering in a health facility, the danger of PPH and the correct use of misoprostol. Based on the analysis of program results, several important cross-country findings were observed:

• Community-level distribution of misoprostol reaches women;

• Protection from PPH can be significantly in-creased through community-level distribution of misoprostol;

• Women can use misoprostol correctly during home births and experience minimal, self-limiting side effects; and

• Women view misoprostol as beneficial and would use it in a subsequent pregnancy or recommend it to a friend.

Additionally, this compendium identifies several facilitating factors that contributed to program success that can increase the likelihood of effective scale-up on a national level: strong government support; high levels of antenatal care coverage; the identification of local methods to measure blood loss; and the adapt-ability of program methods to the local context.

EXECUTIVE SUMMARY

v Preventing PostPartum hemorrhage at the community level


H O M E B I RT H S A N D M AT E R N A L M O RTA L I T Y

In developing countries maternal mortality re-mains a significant problem that is concentrated pre-dominately among the poor (Ronsmans and Graham, 2006). Countries where most women deliver outside of a health facility have the highest rates of maternal mor-tality. In sub-Saharan Africa and South Asia, where the majority of maternal deaths are concentrated, only 7 to 22% of women in the poorest wealth quintiles deliver in a facility (Ronsmans and Graham, 2006; Montagu et al., 2011). This means that most women, and the vast majority of poor women, give birth at home and more often than not, these home deliveries are unattended by a skilled provider (Montagu et al., 2011). If the fifth Millennium Development Goal (MDG 5) to signifi-cantly reduce the maternal mortality ratio (MMR) is to be achieved, then interventions must address the fact that many women are delivering at home and without a skilled attendant (Ronsmans and Graham, 2006).

P O S T P A RT U M H E M O R R H A G EGlobally, the leading obstetric cause of maternal

deaths is postpartum hemorrhage (Hogan et al., 2010), commonly defined as blood loss of 500 ml or more within 24 hours after delivery (World Health Organi-zation (WHO), 2012b). However, postpartum hemor-rhage (PPH) is both preventable and treatable.

The use of a uterotonic drug immediately after birth is one of the most effective interventions to prevent PPH (WHO, 2012b). Currently, oxytocin is the recom-mended uterotonic drug of choice for preventing and treating PPH, and is administered by a skilled provid-er. The Uniject™ auto-disable injection system devel-oped by the US-based non-governmental organization, PATH, might be a future solution to allow for oxytocin to be used during home births; however, it is still in

the early stages of use and distribution (Althabe et al., 2011). Consequently, the vast majority of poor women in developing countries give birth at home without ac-cess to injectable uterotonics and as a result they re-main at a high risk of complications from PPH and subsequent death (Montagu et al., 2011; Prata et al., 2011; Ronsmans and Graham, 2006).

M I S O P R O S T O L F O R P R E V E N T I O N O F P P H

Misoprostol is a globally recognized alternative utero-tonic for the prevention of PPH (Lalonde, 2012; WHO, 2012b; United Nations, 2012). As an effective uterotonic with an excellent safety profile, misoprostol has been in-creasingly used in obstetrical and gynecological practice (Derman et al., 2006; Alfirevic et al., 2007) and in 2011 was added to WHO’s Model List of Essential Medicines for PPH prevention (WHO, 2012c). Unlike oxytocin, which in its current formulation must be refrigerated and delivered via injection by a skilled provider, miso-prostol tablets are administered orally, are inexpensive and easy to store (Parsons et al., 2007; Derman et al., 2006; Prata et al., 2006). When used during home deliv-eries, where no other medicine is available, misoprostol is shown to decrease the risk of PPH from 24% (Mobeen et al., 2011) to 47% (Derman et al., 2006).

I . INTRODUCTION

In sub-Saharan Africa and South Asia most women give birth at home. More often than not these births are unattended by a skilled provider, like this recent delivery in Ghana. Photography: VSI/Emma Nesper Holm ©2012

globally, the leading obstetric c ause of maternal deaths is Post-Partum hemorrhage.


Misoprostol tablets are ideally suited for PPH preven-tion at home births and in resource-poor settings. In its 2012 “Recommendations Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting,” WHO rec-ommends administration of misoprostol by community and lay health workers for PPH prevention at home deliv-eries when oxytocin is unavailable (WHO, 2012d). Howev-er, a limited body of evidence exists on the effectiveness of service delivery models to distribute misoprostol for PPH prevention at home births despite international recogni-tion of its potential in community settings (Mobeen et al., 2011; Prata et al., 2009; Diadhiou et al., 2011; Sanghvi et al. 2010; Rajbhandari et al., 2010, Smith et al., 2013).

M I S O P RO S TO L D I S T R I B U T I O NAT T H E C O M M U N I T Y L E V E L

In response to a knowledge gap on misoprostol use at the community level for PPH prevention, VSI collaborated on a series of independent operations research programs across seven African and Asian countries. This research was further motivated by a strong desire from these coun-tries’ governments to address high maternal mortality ra-tios and accelerate progress toward MDG 5, and with an understanding that most maternal deaths occur at home.

Between 2008 and 2012, VSI, in collaboration with lo-cal and international partner organizations and research institutions, conducted operations research programs to evaluate the feasibility, acceptability, safety and program effectiveness of misoprostol use to prevent PPH at the community level. While early programs provided proof of concept, later programs served as pilots to demon-strate feasibility in the local context for implementation and subsequent policy development. Each program was adapted to the local setting while a standard approach was employed across all countries. This compendium summarizes VSI’s study findings.

O P E R AT I O N R E S E A R C H C O M P E N D I U M O V E R V I E W

This compendium provides a systematic review of VSI’s operations research on community-level use of misoprostol in resource-constrained settings. The compendium includes:

Section II: Operations research (OR) model overview that describes the basic components of VSI’s OR model for implementing distribution of miso-prostol for community-level prevention of PPH in ru-ral, low-resource settings.

Section III: Country program summaries that provide specifics of how the OR model was adapted to individual country settings.

Section IV: Cross cutting results that sum-marize important findings shared across countries and highlight best practices and key factors for program success.

Developed with policy makers, stakeholders and researchers in mind, the goal of this compendium is to contribute to the growing evidence base on the community-level use of misoprostol to prevent PPH, including advanced provision of misoprostol to pregnant women. The findings highlighted in this compendium demonstrate that misoprostol distri-bution at the community level is a safe, acceptable, feasible and effective way to reduce PPH in resource-poor settings.

Misoprostol tablets are a WHO-endorsed essential medicine for the prevention of postpartum hemorrhage. Photography: VSI/Marko Balenovic, ©2012.

in randomized control trials, miso-prostol was shown to decrease the risk of pph from 24% to nearly 50% in home deliveries.


This section outlines the basic components of VSI’s operations research (OR) model for imple-menting distribution of misoprostol for commu-nity-level prevention of postpartum hemorrhage (PPH) (Figure 1). While this general model ap-plies to all of VSI’s OR programs, each program was tailored to the specific needs and context of the country (see Section IV).

1 . P L A N N I N Ga. Collaboration with partners: Within each

country, VSI collaborated with government ministries of health, non-governmental organizations (NGOs) and other partners such as health institutes, profes-sional obstetrician and gynecologist associations, social marketers and local universities with a share goal of improving maternal health outcomes. For sev-eral programs, VSI partnered with the Bixby Center for Population, Health and Sustainability at the Uni-versity of California, Berkeley. By utilizing existing partnerships, infrastructure, markets and distribution networks, the organization built on the strength of es-tablished resources and capacities within each country.

VSI places great value on engaging stakeholders to gain buy-in for future policy decisions related to wide-scale adoption of safe motherhood programs. Securing governmental commitment and support is key to suc-cessfully launching and scaling-up projects and pro-

grams. As such, each operations research program was designed to answer specific policy and programmatic questions to facilitate subsequent policy developments related to PPH prevention in the country and enable its broader adoption outside of the pilot districts.

b. Formative research: Prior to the design of the operations research model, VSI assessed community Knowledge, Attitudes and Practices (KAP) related to

labor, delivery and blood loss. Information obtained from KAP assessments was crucial to the research design, including identifying potential opportunities for awareness creation and the ability to introduce a medicine in the context of traditional birthing prac-tices. Identification of blood loss measurement tools that are culturally appropriate and context-specific was also an important outcome. Through discussions with local experts and using qualitative research tech-niques such as focus groups with traditional birth at-tendants (TBAs), a locally used method for identifying excessive blood loss was established (see Text Box 1, page 4). This method was then used in all education activities to inform women and communities how to identify PPH and when to refer a woman for life-saving interventions.

c. Analysis of health care access and utiliza-tion patterns: In program districts, VSI analyzed health care access and utilization patterns to identify

I I . VS I OP ERATIONS RESEARCH MODEL

1. P l a n n i n ga. Collaboration with Partnersb. Formative Researchc. analysis of Health Care access and Utilization Patternsd. Community Engagement

f igure 1

VSI OperatIOnS reSearch MOdel fOr cOMMunIty-leVel MISOprOStOl dIStrIbutIOn

2. I m p l e m e n tat I o na. Community awareness Campaignb. misoprostol Distributionc. Data Collectiond. Data entry and management

3. Assessing progressa. supportive supervisionb. Final Technical reportc. Disseminate results


appropriate distribution mechanisms for misoprostol tablets and ways to educate women that capitalized on existing health care infrastructure and established health-seeking behaviors. VSI worked to integrate the new PPH-prevention intervention into the existing health care system and to strengthen monitoring and evaluation activities of maternal health programs.

Researchers selected program sites in consultation with local governments based upon their stated objec-tives and programmatic needs, or to prioritize certain target populations. For example, program sites were selected based on their geographic remoteness, the presence of existing NGOs or complementary commu-nity-level safe motherhood programs, or because they were priority areas identified by the government.

d. Community engagement: Since the Alma Ata Declaration in 1978, community engagement and empowerment have gained wide acceptance as criti-cal tools for strengthening health systems, addressing inequities and increasing demand for essential health

services (WHO, 1978). Informed and mobilized com-munities have played an important role, for example, in fostering acceptance of and demand for maternal health services across the continuum of care from home to health facility. Given the particular empha-sis on women who deliver at home, these operations research programs included the voices of local village leaders, informal and formal community groups, and religious organizations during the planning phase; this helped ensure community acceptance of the program and bolstered local awareness of the health issue under study. Partnerships with local leaders, health workers and NGOs active in the area meant women could be reached by people whom they knew and trusted.

2 . I M P L E M E N TAT I O N a. Community awareness campaign: A com-

munity awareness campaign on birth preparedness and PPH prevention was an essential component of VSI’s OR programs. The campaigns utilized a mix of

in tanzania, the kanga is a colorful cloth of standard dimen-sion that is worn commonly by women as a sarong, head wrap or a baby carrier. through focus group discussions and in-depth interviews, researchers found that traditional birth attendants typically place a kanga under a woman’s buttocks immediately after delivery and when two kangas are soaked with blood they measure slightly more than 500 ml, the standard definition of PPh (Who, 1990; Prata etal., 2005).

this finding prompted research in other countries, where re-searchers found similar garments used during delivery to collect blood loss that were then calibrated to be used as a threshold for identifying PPh and a cue to refer women who bled exces-sively (e.g., one capulana in mozambique, two chitenges in Zambia, or one lesso in Kenya). Photography: VSI/Sameer Kermalli ©2011

text box 1

MEASURINGPOSTPARTUM BLOOD LOSS WITH THE kanga


Pictorial

instructions

• Local artists created pictorial images to illustrate the correct use of misoprostol and

warning messages indicating when to refer for excessive bleeding.

• Used for educational materials, such as pamphlets and posters.

• Women always received a pamphlet with pictorial instructions when they were given misoprostol.

inFormational

Posters

• Described misoprostol and where it could be obtained—designed for each program.

• Presented one or more of the community awareness campaign’s key messages.

• Displayed in prominent locations at clinics (e.g., waiting areas) and in central

community locations (e.g., market or village well).

Facility-BaseD

eDucational

sessions

• Conducted by providers during ANC visits on birth preparedness and PPH prevention.

• Targeted pregnant women, and often held in a group setting to enable more participation.

• Women were encouraged to bring their partner of family member(s) with them.

community-level

aWareness

meetings

• Conducted by community leaders, TBAs and other community-based health promoters

(e.g., community health workers, safe motherhood group, etc.).

• Included as part of larger, general community meetings or held separately as a focused

topic, such as at a women’s group meetings.

home visits • TBAs or community-based health promoters visited women in their homes.

• Conducted education sessions with pregnant women, using pamphlets or other pictorial

materials.

raDio sPots • Scripted to highlight the campaign’s key messages.

• Aired to reinforce the need for birth preparedness and use of misoprostol for PPH.

f igure 2

I n f o r m at I o n , E d u c at I o n ,a n d c o m m u n I c at I o n S t r at E g I E SProjects used one or more of the following strategies to educate women and communities

information, education and communication (IEC) strategies to bolster safe delivery practices, reinforce the importance of delivering in a facility and in-crease women’s knowledge of PPH and misoprostol use for PPH prevention. The community awareness campaigns in all the OR programs focused on four key messages:• Message 1: The importance of delivering at a

health facility;• Message 2: Birth preparedness and early planning

for a safe delivery;• Message 3: PPH identification, consequences and

recognition using the identified postpartum blood loss measurement method (e.g., kanga in Tanzania); and

• Message 4: The importance of misoprostol in the prevention of PPH in home births.

Programs used one or more of the following approaches to educate women and communities: pictorial instructions, informational posters, facil-ity-based educational sessions, community-level awareness meetings, home visits and radio spots (Figure 2).

b. Misoprostol Distribution: While a standard dose of misoprostol was used in all countries (three tablets equaling 600 mcg), each program had a miso-prostol distribution strategy tailored to the local con-text. In any of the following distribution strategies, misoprostol was distributed either as tablets alone or


included in the contents of a clean delivery kit. Strate-gies are described in Figure 3 (page 7) and variations are described in the country program summaries in Section III (page 9).

Antenatal Care (ANC): Across all African countries, 69% of pregnant women have at least one ANC visit, which presents a valuable point-of-con-tact with expectant mothers. In countries with high ANC attendance, distributing misoprostol during ANC visits capitalizes on women’s existing health-seeking behavior and has the potential to reach the majority of pregnant women, regardless of where they deliver.

Traditional Birth Attendants: A TBA has been defined as a person who assists mothers during child-birth and initially acquired her skills by delivering ba-bies herself or through apprenticeship to other TBAs (WHO, 1992). In settings where reaching women dur-ing pregnancy is challenging (e.g., low rate of ANC at-tendance) and TBAs attend many home deliveries, they can be a means to reach women who are delivering at home who might not have other contact with the for-mal health care system.

c. Data collection at sites: Data were collect-ed using a standard questionnaire for a period of six months to over a year; collection methods varied across programs and included the point of distribution, the time of delivery and/or during follow up postnatal care (Figure 4, page 8).

d. Data entry and management: Data entry was performed under the supervision of the local implementing partner and verified by VSI Moni-toring and Evaluation (M&E) staff who conducted the analysis.

3 . A S S E S S I N G P R O G R E S S A N D S H A R I N G R E S U LT S

a. Supportive supervision: Program manage-ment conducted monthly or bi-monthly supervisory visits during program implementation and addressed implementation challenges as they arose. Any ad-verse effects were documented and addressed. The VSI M&E staff conducted one or more visits to each study site to confirm that the program was being

Traditional Birth Attendant (TBA), Mozambique. Photography: VSI/Natalie Williams © 2010


implemented according to protocol and to facilitate any necessary changes.

b. Final technical report: VSI produced a comprehensive report on each operations research program. These included background on PPH and the history of misoprostol in the study country, methodology, results, conclusions and recommen-dations for future actions. For purposes of describ-ing the OR results, VSI used the SAFE model:

Safety: Correct use of misoprostol; i.e., taking 600

mcg misoprostol orally immediately after delivery.Acceptability: Willingness to use misoprostol

in the future, recommend it to a friend, or pay for the tablets.

Feasibility: Coverage of misoprostol distri-bution or the proportion of the target population reached through the distribution mechanism (i.e., proportion of all women attending ANC who were enrolled and given misoprostol to take home).

Effectiveness: Births protected from PPH, i.e.,

f igure 3

A N C A N D T B A C O M P O N E N T SO F M I S O P RO S TO L D I S T R I B U T I O N

A N C D I S T R I B U T I O N T B A D I S T R I B U T I O N

Educationall women receiving anc attended an educational session that focused on the campaign’s four key messages.

EnrollmEntEnrollment periods varied across programs from first contact during pregnancy to the 3rd trimester. in some programs, enroll-ment included signing a written informed consent form.

ScrEEningProviders screened for patient eligibility. cri-teria included gestational age, being chronic disease free, and the determination that a complicated delivery was not anticipated.

miSoProStol diStributionEnrolled, eligible women were given three tablets of misoprostol. a pictorial brochure was included. the provider reviewed these instructions with each woman.

TrainingTBa training sessions included a review of clean delivery practices and study procedures.

EnrollmEnTTBas enrolled women at delivery, ensuring they were in a relatively comfortable condition (sporadic contractions). Women in the second stage of labor (fully dilated with very short intervals between contractions) were ineligible for enrollment in the study.

ScrEEningTBas were trained to assess women and determine if they were eligible. Screening criteria included absence of chronic diseases.

adminiSTEr miSoproSTolTBas administered 600 mcg of oral misopro-stol to women after delivery, after confirming that there were no other babies in the womb.

idEnTify ThE nEEd for rEfErral TBas were trained to measure postpartum blood loss using the blood loss collection method identified for the project.


f igure 4

data c o l l e c t i o n m e t h o d s

the proportion of all births where a uterotonic was used for PPH prevention.

c. Dissemination of results to stakeholders and governments: At the completion of each re-search program, VSI convened a stakeholders’ meet-ing to disseminate results at the national level and,

where possible, the district level; drafted a final tech-nical report and policy brief; and presented results at international meetings and conferences. Additional operations research results have been published in peer-reviewed journals (Prata et al., 2012a; Prata et al., 2012b; Smith et al., 2013).

Point of Distribution

Data collected at the time of service or misoprostol distribution and could include

socio-demographic information, AnC information, gestational age, misoprostol distribu-

tion, and reasons for not accepting misoprostol.

Time of Delivery

Data collected by research staff and included uterotonic use, symptoms experienced, com-

plications experienced, referral, and condition at discharge.

Follow Up

Routine postnatal visit: In some projects, data collection was included at the time of the

post-birth service. Information collected on location of delivery, uterotonic use, and refer-

ral and whether additional interventions were needed.

Postpartum interview: Conducted by research staff when women either returned for post-

natal care or were contacted though active follow-up. Data collected on ppH knowledge,

views of and experience with misoprostol, delivery details (location, attendant, and type of

uterotonic given), referral and interventions needed, symptoms experienced and accept-

ability of misoprostol.


VSI’s operations research (OR) model was applied in seven African and Asian countries. While a unified approach was developed, its operationalization was specific to each country and its unique sociocultural context and development needs. The primary goal of each OR endeavor was to increase uterotonic cover-age at delivery and to prevent postpartum hemorrhage (PPH). A set of common objectives was employed and included the following:

• To assess whether distribution of misoprostol dur-ing antenatal care (ANC) visits or at home delivery with a traditional birth attendant (TBA) were feasible mechanisms to reach women who deliver at home.

• To determine if misoprostol distribution during pregnancy via ANC or at delivery with a TBA is ef-fective in increasing protection from PPH among women who deliver at home through increased use of uterotonic drugs at delivery.

• To provide necessary evidence that women can

safely self-administer misoprostol for prevention of PPH at home births after being educated on and receiving the drug at ANC visits or from a TBA.

• To determine whether women find misoprostol to be an acceptable means of preventing PPH at home births.

• To generate evidence for the national scale-up of misoprostol distribution strategies.

The following section provides a country-by-country overview of each operations research program. Each country brief highlights the local context, research partners and elements of the misoprostol distribu-tion strategy and community awareness campaigns. Additionally, information is provided on data collec-tion methods and key findings and conclusions from each program. For more program-specific details, the full technical reports are available by request at [email protected].

I I I . COUNTRY PROGRAM SUMMARIES

ghana nigeria

Kenya

tanZania

moZamBiQue

ZamBia

BanglaDesh

A S I A

A f r i c A


bangladeshC O N T E X T :

• Maternal mortality ratio (MMR): 194 deaths per 100,000 live births (National Institute of Popula-tion Research and Training (NIPORT), 2011).

• 77% of births occur at home and 27% of births are at-tended by a skilled birth attendant (NIPORT, 2011).

• 54% of women receive ANC from medically trained providers (NIPORT, 2012).

R E S E A R C H P A RT N E R S :• The International Centre for Diarrhoeal Disease

Research, Bangladesh (ICDDR,B)• Bixby Center for Population, Health and Sustain-

ability – University of California, Berkeley• Rangpur Dinajpur Rural Services (RDRS),

Bangladesh

M I S O P R O S T O LD I S T R I B U T I O N S T R AT E G Y :

• ANC distribution: Misoprostol was included in a clean delivery kit (CDK), and offered to women at ANC if they were 32 weeks or greater gestation.

• Birth attendant: An RDRS trained birth atten-dant provided a CDK during a home delivery and assisted with using its contents.

C O M M U N I T YA W A R E N E S S C A M P A I G N :

• Community health workers (CHWs) conducted health education sessions during ANC visits.

• Pregnant women were encouraged to bring rela-tives (in-laws and husbands) to ANC visits to par-ticipate in the education sessions.

S C A L I N G U P O F M I S O P R O S T O L F O R P R E V E N T I O NO F P O S T P A R T U M H E M O R R H A G EI N 2 9 U p a z i l a s ( 2 0 0 9 - 2 0 1 1 )

Dhaka

1

2 4

35

6

29 upazilas (sub-districts) in the six northwestern districts of Bangladesh: Panchagarh (1), thakurgaon (2), Dinajpur (3), nilphamari (4), lalmonirhat (5) and Kurigram (6). Population: 90,65,626. ProJect Districts capital


bangladesh

• Blood loss measurement tool: A delivery mat de-signed by a scientist at ICDDR,B (Prata et al., 2012b). When placed under a woman in labor, it can only ab-sorb up to 500 ml of blood. If there is additional blood that is not absorbed by the mat, it indicates PPH.

D ATA C O L L E C T I O NA N D E V A L U AT I O N :

• Point of distribution: 77,337 women were en-rolled and delivered during the program period; information was collected during ANC visits and a post-delivery check-up.

• Postpartum interviews: 3,016 (4%) of those who were enrolled and delivered during the pro-gram period were randomly selected for active follow-up (every 20th woman).

• Verbal autopsies: Using a standardized ver-bal autopsy questionnaire, 113 deaths during the program period were documented.

K E Y F I N D I N G S A N D C O N C L U S I O N S :

• Of the women who delivered during the program, 70% received a CDK during pregnancy or at deliv-ery, demonstrating that distributing CDKs through these channels is a feasible way to reach a large number of women. Most of the women who did not receive a CDK during pregnancy delivered with an RDRS birth attendant (73%), highlighting the im-portance of equipping them with CDKs to ensure misoprostol is on-hand to prevent PPH.

• Of the women who received a CDK, 96% were pro-tected from PPH either by using misoprostol at home, or by delivering at a health facility or with a skilled provider. Misoprostol used at home deliveries and distributed through CDKs increased protected births in the program by 60%.

• Almost all of the 1,893 women who used miso-

prostol at home and participated in the postpartum interviews reported using the drug correctly (96%), taking the correct dose at the right time.

• Over 98% of women who took misoprostol consid-ered it useful and would recommend it to a friend.

• Almost all women who received a CDK used Quai-yum’s mat to estimate blood loss at delivery (96%). Most women who used the mat said they found it useful and would use it again in their next delivery (87%). This is evidence that Quaiyum’s mat is a fea-sible and acceptable means of assessing postpartum blood loss in Bangladesh, improving recognition of PPH and facilitating a timely referral to prevent delays in seeking care.

• Fewer than 1% of women experienced retained pla-centa, eclampsia or tears. Two and three percent of women experienced prolonged labor and obstruct-ed labor, respectively. Only 2% of women needed to be referred during labor, delivery or postpartum.

• Perceived PPH occurred in fewer than 1% of deliveries, regardless of whether the woman used misoprostol, delivered in a health facility or with a skilled provider, or if she delivered at home and did not use misopro-stol. This rate is much lower than expected based on other studies on maternal health in Bangladesh

• A total of 113 deaths were reported in the study areas during the program time period. Eclampsia accounted for the largest proportion of deaths followed by PPH, bleeding-related causes and other direct causes. Thir-ty-seven fewer deaths were observed than expected in this program using the most recent MMR estimate.

• The results from this program and other PPH pre-vention programs were shared during a national dissemination meeting in June 2011, where the scale-up of misoprostol for PPH prevention was of-ficially recommended. It is currently being imple-mented throughout the country.

IncludIng mIsoprostol In the [clean delIvery kIt] Is a good thIng. pregnant women are comIng to the clInIc because they have heard about the new cdk and mIsoprostol, whereas before, tbas had to motIvate mothers to come to anc. now mothers are comIng on theIr own and askIng for the new cdk.”

—Community Health Worker, Nilphamari


ghana

C O N T E X T :• MMR: 350 deaths per 100,000 live births

(WHO, 2012a).• 24% of maternal deaths are due to hemorrhage

and 42% of women deliver at home (Ghana Statistical Service (GSS), 2009).

• 95% of women attend at least one ANC visit with a healthcare professional (GSS, 2009).

• Program launched to meet government calls to demonstrate the feasibility of PPH prevention using misoprostol in the Ghanaian context.

R E S E A R C H P A RT N E R :• Ghana Health Services


• ANC distribution: Women were offered miso-prostol during ANC visits once they had reached 12 weeks gestation.

C O M M U N I T YA W A R E N E S S C A M P A I G N : TBAs conducted awareness meetings with community leaders and women’s groups. They also conducted one-on-one information sessions with pregnant women.

• Community health volunteers (CHVs) dissemi-nated messages about birth preparedness and misoprostol use.

• Queen Mothers (traditional female community leaders) participated in community sensitiza-tion efforts due to their substantial community influence.

• Durbars (local community meetings) were orga-nized by TBAs, CHVs and District Health Man-agement Teams and brought together community members to share messages about misoprostol and its availability in health facilities.

• Megaphone announcements were made in local markets and radio spots were broadcast.

D I S T R I B U T I O N O F M I S O P RO S TO L AT A N T E N ATA L C A R E V I S I T S F O R P R E V E N T I O N O F P O S T PA RT U M H E M O R R H AG E ( 2 0 0 9 - 2 0 1 2 )

Four districts: Birim south and upper manya Krobo, Komenda-edina-eguafo-abirem (Keea) and sene. Population: 405,890. ProJect Districts capital

sene

accra

uPPer manya KroBo

Birim south

Keea



• Point of distribution: Providers registered 11,328 women during ANC; 47% (5,345) of these women formally enrolled in the program.

• Postnatal follow-up: Providers interviewed 68% of enrolled women during routine postnatal care visits.


• Approximately 93% of women who delivered at home and returned for postnatal care used misoprostol at delivery. Without the availabil-ity of misoprostol, these women would not have had protection from PPH.

• For those women who accepted misoprostol at ANC, reported use was very high and correct, with 99% of women reporting at their postnatal visit that they correctly used the drug.

• Of the women who took misoprostol home from ANC and did not use it at a home delivery, the vast majority (83%) returned the misoprostol to a facility, as they had been instructed to do by the ANC provider who initially gave them the tablets. The proportion returning misoprostol was also high among facility deliveries, with 92% of the women who delivered at a facility and did not use misoprostol returning the drug.

• Over 300 TBAs and 200 CHVs educated women about the use of misoprostol and safe delivery in this program. During supervisory visits, TBAs and CHVs reported that women and community members responded positively to their messages, and that women appreciated having messages about safe motherhood brought to them by fellow members of their community.

• Two maternal deaths were reported during the program period. Further inquiry was conduct-ed into the cause of the death and both were found to be unrelated to the program or to tak-ing misoprostol. No referrals were made during the program.

• During the course of the program, the misopro-stol tablets were recalled due to quality issues and replaced with another brand of misoprostol tablets. This recall took place in July and August 2011, and all tablets were replaced by September 1, 2011. Data were analyzed for Phase 1 (April- August 2011) and Phase 2 (September 2011-Jan-uary 2012) taking into account the drug recall process. This had negative effects on program enrollment, which was significantly lower dur-ing the recall months.

• The results from this program were shared during a national dissemination meeting in March 2012, where the scale-up of this program was officially recommended.

Many of the woMen who coMe to antenatal [care] are froM far away and they cannot go to the health center to deliver. Maybe if they try, they will deliver in the car. if there is no car to go, they cannot walk. the Misoprostol is helping theM a lot, and it is also helping us because there are fewer coMplications.”

—Community Health Nurse, Birim South District


C O N T E X T :• MMR: 488 deaths per 100,000 live births

(Kenya National Bureau of Statistics (KNBS) and ICF Macro, 2010).

• 56% of Kenyan women give birth at home, with-out access to emergency obstetric care services. In rural areas this is higher (63%), with similar rates of women delivering without a skilled birth atten-dant (KNBS and ICF Macro, 2010).

• 92% of women utilize ANC during their pregnancy (KNBS and ICF Macro, 2010).

R E S E A R C H P A RT N E R S :• The Division of Reproductive Health, Ministry of

Health and Sanitation• Kenya Obstetrical and Gynaecological Society


• ANC distribution: In both program districts, ANC providers distributed misoprostol during routine visits.

• Community midwife distribution: In Mara-gua district, women received misoprostol during a home delivery with a community midwife.


• Posters and pamphlets were available and distrib-uted in the communities through ANC facilities and by CHWs.

• CHWs conducted group and one-on-one meet-ings with community members. These meetings reinforced ANC messages, including information about safe delivery, PPH and misoprostol, and encouraged women to attend ANC and deliver at health facilities.

• Two radio scripts in local dialects were aired.

• Blood loss measurement tool: The lesso is a pre-cut rectangular piece of brightly colored fabric worn by local women; one lesso com-pletely soaked with liquid equals approximately 500 ml.

Kenyamaragua

Kituinairobi

I N T R O D U C T I O N O F M I S O P R O S T O LF O R P R E V E N T I O NO F P O S T P A R T U MH E M O R R H A G E A TT H E C O M M U N I T YL E V E L ( 2 0 0 9 - 2 0 1 1 )

two districts: Kitui and maragua. Population: 1,000,000. ProJect Districts capital


Most of the Mothers went to deliver at hospital, and those who delivered at hoMe used [Miso] and it helped theM.”

—Community health worker, Maragua district

Kitui


• Points of distribution: Service delivery data collected on 3,844 women, either during ANC or at delivery with a community midwife.

• Postnatal follow-up: 75% of enrolled women were interviewed after delivery during routine postnatal care.


• Women attending ANC enrolled in the program and took misoprostol home at high rates. Miso-prostol was distributed to over 98% of women at-tending ANC.

• 95% of home deliveries were covered by misopro-stol. These deliveries would not have received any uterotonic protection against PPH if misoprostol had not been available.

• Uterotonic coverage for all women for whom there is postpartum data was very high, regard-less of location of delivery. The majority of wom-en who delivered in facilities received oxytocin at the time of delivery (89% of facility deliveries). The availability of misoprostol covered an addi-tional 10% of facility deliveries.

• Community midwives in Maragua District were an additional health resource for women in areas where the community midwives oper-ate private clinics and provide ANC services.

Community midwives also provided skilled attendance for home deliveries to women in remote areas. All deliveries attended by com-munity midwives in this program were protect-ed from PPH by either misoprostol or oxytocin.

• Over 3,000 CHWs educated women and com-munity members on birth preparedness, risks of PPH, and PPH prevention with misoprostol in this program. CHWs served an essential func-tion of generating awareness about the program and reinforcing the messages of ANC providers According to the CHWs, women and communi-ties responded to their sessions with overwhelm-ing positivity.

• Women who used misoprostol at home and at fa-cility deliveries self-reported very few experiences of excessive bleeding or the need for referral and additional interventions. Of the 1,084 women who delivered at home and used misoprostol, only two women self-reported experiencing ex-cessive bleeding and neither woman required ad-ditional interventions or referral.

• Reports of postpartum symptoms among women who used misoprostol were very low, with over 90% of women reporting having experienced no symptoms.

• Correct use of misoprostol at home births was nearly universal (97%); women who took miso-prostol at home demonstrated their ability to use it safely and effectively.


C O M M U N I T Y- B A S E DP R E V E N T I O N

O F P O S T P A R T U M H E M O R R H A G E

W I T H M I S O P R O S T O L ( 2 0 0 9 - 2 0 1 1 )

moZambiQue C O N T E X T :

• MMR: 490 per 100,000 live births (WHO, 2012a).

• 85% of women attend at least one ANC visit on average, but provincial variance exists (Instituto Nacional de Estatistica, 2005). • Program implemented in response to the

Ministry of Health’s request for research to dem-onstrate the effectiveness of misoprostol at the community level in Mozambique.

R E S E A R C H P A RT N E R S :• Associação Moçambicana de Obstetras e

Ginecologistas • Bixby Center for Population, Health and

Sustainability – University of California, Berkeley• Population Services International – Mozambique


Each site used a different strategy, depending on its level of ANC coverage:

• High ANC coverage site (Chokwe): Miso-

prostol distributed to women at 28 weeks gesta-tion or greater, coinciding with their eligibility to receive niverapine to prevent mother-to-child HIV transmission.

• Low ANC coverage site (Namacurra): Miso-prostol distributed at delivery by TBA.

• Average ANC cover site (Nacala-Porto/Na-cala-a-Velha): Misoprostol distributed at ANC visits to women at 28 weeks gestation or greater and by TBAs at delivery.


• Promotional posters, informational pamphlets and educational flip books distributed.

• TBA meetings with community leaders, women’s groups and one-on-one with pregnant women in villages.

• TBAs spoke in churches after sermons to reach both women and men with birth preparedness messages.

• Blood loss measurement tool: A pre-cut piece of cloth of standard size which women wear as a skirt,

three sites: chokwe, namacurra, and nacala-Porto/nacala-a-velha. Population: 1,000,000. ProJect Districts capital

nacala-Porto/nacala-a-velha

maputo

namacurra

choKWe


shawl, head wrap or strap to carry a baby. One capaluna soaked with blood is equivalent to 600 ml of fluid.


• Points of distribution: 11,927 women were reached through ANCs and TBAs.

ANC: 5,771 women attended ANC in Chokwe and Nacala-Porto/Nacala-a-Velha.

TBA: 4,511 women were assisted in delivery in Namacurra and Nacala-Porto/Nacala-a-Velha.

• Postpartum interviews: Providers inter-viewed 6,758 participants who delivered at health facilities when the participant returned to a health facility for routine postnatal care, or through active follow-up.


• Recall of community awareness messages about ex-cessive bleeding and misoprostol was high among all women who completed a postpartum interview. Most women mentioned identifying excessive bleeding us-ing the capulana, demonstrating that the capulana is a feasible and acceptable tool for assessing blood loss at the community level. Regardless of where the woman was offered misoprostol, ANC providers and health facilities were mentioned most often as sourc-es of information about PPH and misoprostol.

• 92% of women in Chokwé and 97% in Nacala-Porto/Nacala-a-Velha whose ANC records were analyzed took misoprostol home.

• Both ANC and TBA distribution resulted in pro-tected births at virtually all home deliveries in the postpartum interview sample. In Chokwé, 99% of the women delivering at home used the misopro-stol they had received at ANC.

• TBAs used misoprostol in all of the deliveries they attended in Namacurra. In Nacala-Porto/Nacala-a-Velha, ANC distribution was complemented by TBA distribution of misoprostol. TBAs gave miso-prostol at delivery to the 5% of women delivering at home who did not receive misoprostol at ANC, resulting in over 99% of home births in the post-partum sample protected from PPH.

• Virtually all the women who received misoprostol at ANC correctly self-administered the drug af-ter delivering at home (99%). Additionally, most women delivering with TBAs in Namacurra and Nacala-Porto/Nacala-a-Velha also reported tak-ing the correct dose at the correct time at a home delivery (99%). These results demonstrate that women and TBAs can safely use misoprostol at home deliveries once educated about the drug.

• Acceptability of misoprostol was very high among both misoprostol users and non-users across all three sites. 96% of women who used misoprostol reported that they would recom-mend misoprostol to a friend or use it in a sub-sequent pregnancy.

• There were no bleeding-related referrals, nor were there any referrals due to use of misoprostol in the postpartum interview sample. No maternal deaths were reported.

For those that deliver at home, misoprostol saves lives.”—Nurse, Chokwe


C O N T E X T :• MMR: 630 per 100,000 live births, which is one

of the world’s highest (WHO, 2012a).• 65% of deliveries take place at home without

trained health professionals (National Population Commission, 2009).

• Program implemented to address the Ministry of Health’s request for local evidence on the use of misoprostol by non-skilled providers.

R E S E A R C H P A RT N E R S :• Population and Reproductive Health Partnership

(PRHP) of Ahmadu University, Zaria, Nigeria• Bixby Center for Population, Health and Sustain-

ability – University of California, Berkeley• Venture Strategies for Health and Development


• Misoprostol distributed by community drug keep-ers to TBAs and pregnant women or members of their households. Tablets made available during the last months of pregnancy.


• Fact sheets for health providers and drug keep-ers, posters, head coverings (hijabs) and kettles (butas) inscribed with instructions for misopro-stol use, audio-taped dramas distributed on CD and tape, illustrated booklets for non-literate audiences, interpersonal communications by TBAs and community-oriented resource per-sons (CORPS).

• Blood loss measurement tools: The moda, a cap used locally for fetching water, and a two-yard cotton wrapper. Each holds 500 ml of liq-uid when filled or soaked.


• Points of distribution: Through TBAs and community drug keepers, 1,875 women received misoprostol and provided intake data.

• Postpartum interviews: Completed for 96% of enrolled women via active follow-up.

nigeria

P R E V E N T I O N O F P O S T PA RT U M H E M O R R H A G E AT H O M E B I RT H S I N F I V E C O M M U N I T I E S A R O U N D Z A R I A , K A D U N A ( 2 0 0 8 - 2 0 1 0 )

KaDuna

abuja

Zaria

Five communities around Zaria in the northern part of Kaduna state: hayin ojo, Dakace, tsibiri, yakawada and ungawan. estimated Population: 21,000. ProJect state capital town


KaDuna • Maternal mortality audit: Doctors on the research team investigated all cases of maternal mortality that occurred in the study communities during the program period.


• After delivery, most women reported having re-ceived information about bleeding (88%). Overall, TBAs were the most frequently reported source of information about PPH (77%), followed by mid-wives (52%) and health facilities (49%). The infor-mation, education and communication campaign was successful in reaching targeted women with the message about misoprostol for PPH. 88% of women reported knowing about misoprostol for PPH, with the main source of information about misoprostol being the TBA (85%).

• Across all communities, TBAs and CORPs were effective in reaching pregnant women with mes-sages about PPH and misoprostol; TBAs were very effective in accessing the drug using the com-munity drug keepers. 84% of enrolled women re-ceived misoprostol to use in case they delivered at home. TBAs and CORPs proved critical resources for the intervention’s success and were effective community agents for interpersonal messages to women and men.

• The use of misoprostol for PPH prevention at home births was the most important contributor

to births protected against PPH. The percentage of women who received injectable uterotonics is very low in these communities (4%). With misoprostol available at the community level, 79% of the wom-en enrolled in the program were protected against PPH who otherwise would not have been. With the use of misoprostol at home births where TBAs were able to provide the uterotonic at time of de-livery, a total of 83% of deliveries were protected. This demonstrates the importance of an interven-tion for home births in communities where most of the deliveries take place at home.

• Among women who used misoprostol for PPH prevention, 98% reported using the correct dose and 88% reported correctly taking misoprostol orally immediately after delivery of the child. This further confirms that community-level use of misoprostol can be done safely and correctly.

• Acceptability was extremely high in all communi-ties. 95% of women said they would take misopro-stol in a future pregnancy and 96% would recom-mend it to a friend.

• Bleeding-related problems that developed during home births were successfully treated at home. Among those who took misoprostol at home, only one woman required additional interventions, was taken to the facility and died of bleeding- related complications. Two additional PPH- related maternal deaths were recorded among women who did not take misoprostol.

I had nIghtmares whIle I was pregnant because I feared bleedIng.

I am grateful for mIsoprostol for protectIng me.”—Mother who experienced PPH in a previous delivery, Hayin Ojo, Nigeria


tanZaniaC O N T E X T :

• MMR: 460 deaths per 100,000 live births (WHO, 2012a).

• 50% of deliveries take place in a health facility (National Bureau of Statistics (NBS) Tanzania and ICF Macro, 2010).

• 96% of women receive ANC from a health profes-sional once during pregnancy (NBS Tanzania and ICF Macro, 2010).

• Tanzanian Ministry of Health and Social Welfare recommended an operations research program to demonstrate that misoprostol distribution at ANC can address PPH.

R E S E A R C H P A RT N E R S :• Ifakara Health Institute - Tanzania• Bixby Center for Population, Health and Sustain-

ability - University of California, Berkeley


• ANC distribution: Misoprostol provided oncea woman reached 32 weeks gestation.


• Pictorial pamphlets, general awareness posters, informational posters, radio, community meet-ings and home visits by TBAs and CHWs.

PREVENTION OF POSTPARTUM HEMORRHAGE AT HOME BIRTHS: MISOPROSTOL DISTRIBUTION DURING ANTENATAL CARE VISITS (2008-2011)

Four districts: Kigoma urban, Kilombero, ulanga and rufiji. Population: 1,007,237. ProJect Districts capital town

ruFiJi

Dar es salaam

ulanga

KilomBero

KigomaurBan


• Blood measurement tool: Kanga, a bright-colored cloth worn by Tanzanian women as sa-rongs and shawls. Placed under a woman’s but-tocks during delivery, two standard-sized kangas when soaked with blood contain slightly more than 500 ml of blood.


• Point of distribution: Data were collectedat every ANC visit of the 12,511 womenenrolled.

• Postpartum interviews: A postpartum inter-view questionnaire was administered to 6,735 women (54% of enrolled) either by providers for all women returning for a routine postnatal care visit or by research assistants through active follow-up of women who did not return for post-natal care.


• The multi-faceted community awareness cam-paign was successful in reaching 96% of women who participated in the postpartum interview. Most (84%) said they identified excessive bleed-ing using the kanga method. Midwives and fa-cility-based education were reported as the most important sources of information for women’s awareness of PPH and misoprostol (85-94% across districts).

• Only 44% of enrolled women returned for an ANC visit after reaching 32 weeks gestation, limiting

the number of women who were given the drug to take home. The variation in the range of ANC attendance after 32 weeks gestation across dis-tricts – 38% to 59% – indicate that it is important to consider individual characteristics of districts in scale-up strategies. Therefore, the 32-week gestation restriction resulted in fewer women be-ing reached with the drug.

• Misoprostol played a vital role in protecting births from PPH both at home and in facilities: 91% of the 6,735 women who participated in the postpartum interview received a uterotonic at delivery (27% used misoprostol at home; 73% received a uterotonic at a health facility).

• Of the women in the postpartum interview sam-ple who delivered at home, 88% used misoprostol after delivery. Without misoprostol, no uteroton-ic would have been used and these births would have been at high risk for PPH.

• The safety of misoprostol distributed at ANC for PPH prevention at home births was well demon-strated. All women who took misoprostol at home said they took the drug correctly (dose and route). Thirty women reported requiring referral for bleeding-related causes and no maternal deaths were reported.

• Most of the women who took misoprostol home from ANC used it at delivery (96% in the post-partum interview sample). Almost all wom-en who used misoprostol would recommend it to a friend (99%) or use it in a subsequent pregnancy (98%).

When We had miso[prostol] We had no cases of postpartum hem-orrhage arriving at our health center. since the project ended, We are seeing cases again.”

—Nurse, Health Center, Ulanga District


ZambiaC O N T E X T :

• MMR: 603 per 100,000 live births (Hogan et al., 2010).• 47% of Zambian women deliver with a trained

professional and 52% deliver at home; in rural ar-eas up to 67% of deliveries occur at home (Central Statistical Office (CSO), 2009).

• 94% of women attend at least one ANC visit with a skilled provider (CSO, 2009).

R E S E A R C H P A RT N E R S :• Ministry of Health, Zambia• Bixby Center for Population, Health and Sustain-

ability – University of California, Berkeley


• ANC distribution: Misoprostol was distributed to women during routine ANC visits.


• Radio adverts, posters and pamphlets, and one-on-one educational sessions were used.

• Safe Motherhood Action Groups (SMAGs) brought the campaign’s messages into the com-munity. SMAGs are community organizations af-filiated with certain health centers.

• SMAGs conducted community meetings and educa-tional sessions on the key messages comprising the program’s awareness campaign.


• Point of distribution: 5,574 women attended ANC during the program period.

• Postpartum survey: A separate evaluation was carried out after the program period and included

M I S O P RO S TO L D I S T R I B U T I O N AT A N T E N ATA L

C A R E V I S I T S F O R T H E P R E V E N T I O N

O F P O S T PA RT U M H E M O R R H A G E ( 2 0 0 8 - 2 0 1 0 )

Five districts: Kapiri mposhi, Petauke, Kalomo, mungwi and masaiti. Population: 199,645. ProJect Districts capital

Kalomo

lusaka

KaPiri mPoshi

masaiti

mungWi

PetauKe


two control districts where misoprostol was not available during the program period. 1,989 wom-en completed the survey and 53% were from the intervention districts.

• Verbal autopsies: Four deaths were recorded in the intervention areas during the program period.


• 94% of women who attended ANC in the interven-tion areas received misoprostol.

• Uterotonic coverage was greater in the interven-tion areas than in the control areas, both at home births and at facility births. Almost half of the women delivering at home in the intervention areas were protected from PPH with misopro-stol (49%); fewer than 1% of women in control areas reported uterotonic use at home deliveries. In addition, having misoprostol available at fa-cilities meant that an additional 20% of women in intervention areas were protected from PPH with a uterotonic. While 66% of women in inter-vention areas received some type of uterotonic regardless of their location of delivery, only 20% of women in control areas received a uterotonic at delivery for prevention of PPH.

• Distributing misoprostol through ANC did not lead to more women delivering at home in the intervention areas. In fact, significantly more women in interven-tion areas where misoprostol was available delivered at facilities when compared to control areas. Since an important component of this pilot project was facil-ity- and community-based education on birth pre-paredness and PPH prevention, the higher rate of facility delivery seen in the intervention areas could be the result of additional messages on the safety of delivering in the facility, as promoted by ANC provid-ers and SMAGs.

• Knowledge about misoprostol was high in interven-tion areas. Health facilities and ANC providers were the most frequently cited sources of information on PPH and misoprostol by women in the intervention areas. While all women attending ANC in interven-tion areas should have received information on PPH and misoprostol, the importance that participants placed on the health facility for this information demonstrates the vital role health facilities and their staff play in educating women.

• 33% of women in the intervention area recognized SMAGs as important sources of information about misoprostol. The inclusion of SMAGs in this program was instrumental in raising initial awareness about PPH and misoprostol among women and communi-ties, as well as for reiterating messages heard at ANC and other health facilities.

• Correct use of misoprostol by women who delivered at home was very high, with 88% of women taking it immediately after delivery and orally, and over 80% reporting that they took the proper prevention dose of three tablets.

• Acceptability of misoprostol was extremely high among women in intervention areas. The majority of women would recommend the drug to a friend (88%), use it in a subsequent delivery (90%), or be willing to purchase the drug (80%).

• Bleeding-related referrals were lower in the inter-vention areas where misoprostol was available for home and facility deliveries (39% versus 55% of total referrals). This may be a result of the role of misoprostol in reducing excessive bleeding at deliv-ery as well as the subsequent need for referrals.

• Four maternal deaths were recorded in the inter-vention areas and six in the control. Most of the ma-ternal deaths in control areas were bleeding-related, compared with no bleeding-related deaths in the intervention areas.

As men, we Are the grAvediggers in our communities. since this [misoprostol] project cAme, we hAve not dug Any grAves for our women.”

—Safe Motherhood Action Group volunteer, Kapiri Mposhi, Zambia


IV. CROSS-CUT TING RESULTS AND FACTORS FOR SUC CESS

This section highlights important results across the seven countries that participated in VSI’s operations research (OR) between 2008 and 2012.

The main findings are:Feasibility: Community-level distribution of

misoprostol and messages reach women.Effectiveness: Protection from postpartum hem-

orrhage (PPH) can be significantly increased through

community-level distribution of misoprostol.Safety: Women can use misoprostol correctly

during home births and experience expected, but self-limiting side effects.

Acceptability: Women view misoprostol as ben-eficial and would use it in a subsequent pregnancy or recommend it to a friend.

Photography:, clockwise from top: VSI/Videocam Productions © 2011, VSI/Shirine Mohagheghpour © 2010, VSI/Emma Nesper Holm © 2012


F E A S I B I L I T YDistribution of misoprostol at the community level reaches women:

• Across all seven countries, the vast majority of wom-en eligible to receive misoprostol took the tablets home from antenatal care (ANC) visits or received it from a traditional birth assistant (TBA).

• Coverage of misoprostol distribution to preg-nant women ranged from almost 70% of those enrolled and eligible to receive misoprostol in

Bangladesh to over 99% in Ghana (Figure 5). • These results show that for countries with high

rates of ANC coverage, the distribution of miso-prostol to women via ANC visits is a successful method of getting misoprostol into the hands of pregnant women.

• In regions where ANC coverage is low, such as Nigeria and certain health districts in Mozam-bique, the use of TBAs to distribute misoprostol is an effective alternative.

F igure 5

D I S T R I B U T I O N O f m I S O p RO S TO l Ta B l e T STO e l I g I B l e wO m e N ac RO S S a l l c O U N T R I e S

*

Bangladeshn=77363

Ghanan=5345

Kenyan=3812

Mozambiquen=4292n=2441

Nigerian=1875

Tanzanian=5507

Zambian=5574

0 20% 40% 60% 80% 100%

99.4%

98.4%

98.4%

100%

83.6%

96.8%

94%

69.4%

n= Number of eligible women % Eligible women receiving misoprostol during ANC visit % Eligible women receiving misoprostol via a TBA Includes Namcurra district only, where TBA-only distribution occurred*


E F F E C T I V E N E S SProtection from PPH can be significantly in-creased through community-level distribution of misoprostol:

• Among the women who received misoprostol during ANC or from a TBA and subsequently delivered at home, over 80% used the drug correctly (correct dose, route and timing) during their home delivery.

• This ranged from 79% in Nigeria to over 99% in Mozambique (Figure 6), demon-strating that uterotonic coverage can be effectively increased via community-level distribution of misoprostol.

• When women are offered misoprostol, they will subsequently use it when delivering at home, which translates into more women being protected from PPH.

F igure 6

M i s o p ro s to l u s e d u r i n g h o M e d e l i v e r i e s ac ro s s a l l c o u n t r i e s

Bangladeshn=53897

Ghanan=1261

Kenyan=1142

Mozambiquen=2353

Nigerian=1421

Tanzanian=1827

Zambian=281

86 .4%

93.1%

94.9%

99.4%

79%

88%

82.9%

percentage of women who used misoprostol during a home deliveryEach symbol represents 10%


• Examining all deliveries captured by follow-up shows that community-level distribution of misoprostol, combined with an aggressive community awareness campaign, leads to an overall increase in uterotonic coverage.

• Results show that more than 60% of all births were protected from PPH. These pro-tected births were the result of either miso-prostol use during a home birth or deliv-ery at a health facility. For the purposes of the OR, a birth was considered “protected” from PPH if misoprostol was available at a home delivery or if the woman delivered at a health facility (Figure 7).

• In most countries, such as Mozambique and

Nigeria, misoprostol use during home births helped protect more than 50% of women from PPH. In Nigeria, this figure approached 83% of women who delivered during the program period.

• For other countries, such as Ghana, Kenya and Tanzania, health facility deliveries pro-tected more than 50% of births. This under-scores the effectiveness of campaign messages that encouraged facility deliveries and the im-portance of continuing to encourage women to deliver in a health facility. Moreover, use of misoprostol can protect women both at home and in health facilities as a back-up uterotonic.

F igure 7

misoprostol and uterotonic use by location of delivery across all countries

0% 20% 40% 60% 80% 100%

22% 32% 10% 23%

Bangladeshn=77363

Ghanan=3499

Kenyan=2890

Mozambiquen=9093

Nigerian=1710

Tanzanian=6735

Zambian=1047

30%10%

36% 64% 3%

40% 57% 1% 2%

0.1%53% 47%

83% 22%

4%5%63%27%

n= Number of deliveries captured via follow-up Misoprostol used during home birth Uterotonic received at health facility birth No uterotonic received at health facility birth No uterotonic received at home birth


S A F E T YWomen can use misoprostol correctly and experience self-limiting side effects:

• The efficacy of misoprostol and subsequent protection from PPH is dependent upon correct use: taking a three-tablet (600 mcg) dose orally immediately after delivery of the baby and be-fore the placenta delivers.

• Across all seven countries, the vast majority of women correctly used misoprostol (Table 1). Percentages of correct use were routinely 90% or higher and ranged from 88% in Nigeria to over 98% in Tanzania, illustrating that miso-prostol can be correctly used during at home births, ensuring PPH protection.

• In general, the limited number of women who incor-rectly used misoprostol either did not take the full dose (three tablets) or took the tablets at the incorrect time, but never before the delivery of the baby.

• Across all seven countries, the side effects asso-

ciated with misoprostol use were limited both in

type and severity.

• According to self-reports, the majority of women

in most countries experienced no side effects with

misoprostol use, which ranged from 48% in Zam-

bia to 95% in Ghana (Figure 8, page 29).

• Among women who did experience side effects,

the most common symptoms reported were shiv-

ering, nausea and a rise in body temperature.

• These findings are consistent with other published lit-

erature on the side effects of misoprostol use, which

show shivering and pyrexia (increased body tem-

perature) to be associated with the drug (Prata et al., 2009a; Hashima et al., 2011; Sheldon et al., 2012).

• These side effects remained short in duration and tolerable, suggesting that misoprostol remains a safe uterotonic agent, especially in resource-poor settings.

Bangladesh

n=1893

Ghana

n=1413

Kenya

n=1084

Mozambique

n=1846

Nigeria

n=1422

Tanzania

n=1826

Zambia

n=233

DOSE

Three tablets(correct dose)

96.7% 100% 99.9% 99.7% 97.5% 99.5% 80.3%

TIMING

Immediately afterdelivery, beforeplacenta was delivered(correct timing)

99.8% 99.7% 100% N/A N/A N/A 88.0%

ROUTE

Oral (correct route) N/A 100% 96.7% 99.6% N/A 98.1% 87.6%

Correct use of misoprostol (correct,does, timing, route)

96.4% 99.3% 96.6% N/A 87.5%* 98.1%** N/A

* Correct timing and route, only ** Correct route and dose, only

Table 1

CORRECT USE OF MISOPROSTOL AT HOME DELIVERYACROSS ALL STUDY COUnTRIES


A C C E P TA B I L I T Y Women view misoprostol as beneficial:

• Women reported an extremely high level of satis-faction with misoprostol.

• In the countries where these data were collected, almost all women would use misoprostol again in a subsequent pregnancy. This ranged from almost 90% of women in Zambia to 98% in Tanzania (Table 2).

• Women would also recommend misoprostol to a friend, while most would be willing to purchase misoprostol for future use.

• High levels of acceptability were seen across a diverse population of women in terms of geo-graphic location and socio-demographic char-acteristics suggesting that the drug has a wide base for use.

Bangladeshn= 2011

Ghanan= 1413

Kenyan= 1323

Mozambiquen= 6681

Nigerian= 1425

Tanzanian= 3370

Zambian= 1047

0 20% 40% 60% 80% 100%

42%

11.1%

74.6%

17.4%

4.6%

73.7%

9.9%

47.8%

31.7%

88.2%

6.2%

3.1%

78%

17.5%

6.6%

94.8%

3.5%

0.5%

90%

6%

None Shivering Rise in body temperature Percentage totals may exceed 100, as women may have reported experiencing multiple symptoms.

F igure 8

Self-reported Side effectS of miSoproStol uSerS*

*


Bangladesh

n=53897

Ghana

n=N/A

Kenya

n=N/A

Mozambique

n=6681

Nigeria

n=1796

Tanzania

n=3370

Zambia

n=1047

Would use misoprotol in a subsequent pregnancy

N/A N/A N/A 96.9% 95.4% 98.0% 89.7%

Would recommendmisoprostol toa friend

99.3% N/A N/A 97.9% 95.7% 98.0% 88.1%

Would purchasemisoprostol

86.9% N/A N/A 71.9% 95.3% 95.6% 80.1%

Table 2

ACCEPTABILITY OF MISOPROSTOLACROSS ALL STUDY COUNTRIESPerceptions from participating women

text box 2

IMPACT ON FACILITY DELIVERIES OF MISOPROSTOL DISTRIBUTION

an often-cited concern regarding the advanced provision of misoprostol to expectant moth-ers is that it will deter facility births. however, findings from vsi’s operations research corrobo-rate other studies, which show that programs to increase access to misoprostol can effectively complement efforts to increase facility birth (rajbhandari etal., 2010; sanghvi etal., 2010).

in Zambia, vsi monitored control areas where misoprostol was not made available. Distrib-uting misoprostol through anc did not lead to more women delivering at home in the inter-vention areas. significantly more women in intervention areas where misoprostol was available reported delivering in a facility compared to control areas (54% vs. 40%). this suggests that distributing misoprostol at anc visits did not encourage more women to deliver at home.

Photography: VSI/Alice Cartwright ©2010


S U M M A RYThe results from these studies contribute to a

growing body of evidence that community-level dis-tribution and use of misoprostol is feasible and effec-tive. Distribution through ANC visits and at delivery with TBAs has the potential to increase the number of women who receive a uterotonic drug for preven-tion of PPH at delivery. Moreover, the majority of women used the drug correctly after a home birth for PPH prevention, while symptoms associated with misoprostol use were within the normal range, self-limiting and overall did not necessitate further in-tervention. Additionally, misoprostol was extremely acceptable to women across all programs. Nearly all women stated they would recommend misoprostol, take it again in a subsequent pregnancy, and would be willing to pay for the drug.

In 2012, new global recommendations emerged to guide countries as they consider introducing or scaling-up misoprostol for PPH prevention. In light of the published evidence, the World Health Orga-nization (WHO) supports the use of misoprostol for PPH prevention by community health care workers and lay health workers in settings where skilled birth attendants are not present and oxytocin is unavail-able (WHO, 2012d). Moreover, new guidance on health worker roles to optimize maternal and neo-natal health recommends community and lay health worker administration of misoprostol to prevent PPH at delivery, where oxytocin is unavailable. The OR described herein present alternate distribution mechanisms, including advanced provision to preg-nant women, and can help advance the field with regard to the role of community lay health workers and healthcare workers to achieve equitable access to misoprostol amongst the most vulnerable and hardest to reach women.

Several facilitating factors were common across the operations research programs. By highlighting these factors, it is hoped that future successes may be realized through the effective scale-up of PPH

prevention projects with misoprostol.• Strong governmental support

Across almost all seven countries, national

and local government agencies strongly sup-ported each program. Not only did most coun-tries actively seek evidence to support the use of misoprostol, many governmental agencies partnered with VSI to implement each pro-gram. Additionally, several countries had previously integrated misoprostol into their obstetric and gynecologic treatment standards and national essential medicines list, but de-sired evidence on feasibility of misoprostol distribution and suggested guidelines on levels of access. This high-level support proved cru-cial for both planning and successful program implementation.

• High levels of ANC coverageRates of ANC attendance of at least one visit

during pregnancy were high across all countries. This enabled the distribution of misoprostol at ANC both practical and feasible. It also allowed distribution to be carried out in a medi-cal setting with educational sessions on how to correctly use misoprostol. This suggests that such a distribution method will work in other African and Southeast Asian countries with similar levels of ANC coverage.

• Local methods to measure blood lossKey to these programs was the integration

and use of local methods to measure blood loss after birth (e.g., the kanga, lesso, Quaiyum’s mat, etc). This reduced the amount of new learning or new tools that were introduced with each program. Instead, each program built upon existing methods to measure blood loss and identify PPH. Moreover, it helped in terms of the programs’ feasibility and ac-ceptance among providers and the women participants.

• Adaptability of program methods to local context

While VSI employed a standardized approach across all seven countries, every program was tailored to the particular needs and context of each country. For example, specific methods of misoprostol distribution varied by


country and were adapted to the local cultural setting. In Bangladesh, misoprostol was included in clean delivery kits, which were distributed to pregnant women during home-based ANC visits; in Mozambique, misoprostol tablets were distrib-uted during ANC visits or via TBAs at delivery; and in Nigeria distribution was through TBAs at delivery and community drug keepers. These findings highlight the need to customize distribu-tion methods and illustrate that such distribution is feasible when properly designed.

Just as misoprostol distribution was customized to suit local needs and cultural considerations, the outreach methods for the community awareness

campaign were similarly developed. For example, in Bangladesh small health education sessions were held with families of pregnant women, while in Tan-zania a wider approach that included radio adverts and pamphlet distribution was employed to comple-ment additional one-on-one educational sessions. These campaigns contributed to the overall effec-tiveness of misoprostol distribution by increasing women’s awareness of birth complications, reinforc-ing the importance of delivering in a health facility, and encouraging the use of misoprostol after deliv-ery. The combination of misoprostol distribution and community awareness campaigns resulted in more than 60% of all births during the operations research being protected from PPH.


alFirevic Z, Blum J, Walraven g, WeeKs a & WiniKoFF B. 2007. Preven-

tion of postpartum hemorrhage with misoprostol. Int JGynaecolObstet, 99

suppl 2:s198-201.

althaBe F, maZZoni a, caFFerata ml, giBBons l, KarolinsKi a, arm-

Bruster D, BueKens P & BeliZan Jm. 2011. using uniject to increase the

use of prophylactic oxytocin for management of the third stage of labor in

latin america. IntJGynaecolObstet, 114:184-9.

central statistical oFFice (cso), m. o. h. m., troPical Diseases

research centre, university oF ZamBia, anD macro interna-

tional inc, 2009. Zambia Demographic and health survey 2007. calver-

ton, mD: cso and macro international.

Derman rJ, KoDKany Bs, gouDar ss, geller se, naiK va, BellaD mB,

PatteD ss, Patel a, eDlavitch sa, hartWell t, chaKraBorty h &

moss n. 2006. oral misoprostol in preventing postpartum haemorrhage in

resource-poor communities: a randomised controlled trial. Lancet, 368:1248-53.

DiaDhiou m, Dieng t, ortiZ c, mall i, Dione D & sloan nl. 2011.

introduction of misoprostol for prevention of postpartum hemorrhage at the

community level in senegal. IntJGynaecolObstet, 115:251-5.

ghana statistical service (gss), g. h. s. g. a. m. i. 2009. ghana Demo-

graphic and health survey 2008. accra, ghana: gss, ghana health service

(ghs) and macro international.

hashima en, 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? GlobHealthAction, 4.

hogan mc, Foreman KJ, naghavi m, ahn sy, Wang m, maKela sm,

loPeZ aD, loZano r & murray cJ. 2010. maternal mortality for 181

countries, 1980-2008: a systematic analysis of progress towards millennium

Development goal 5. Lancet, 375:1609-23.

instituto nacional De estatIstica, m. r. D. s. D., measure Dhs+/orc

macro, 2005. mocambique inquerito Demografico e da saude 2003. maputo.

Kenya national Bureau oF statistics (KnBs) & icF macro 2010.

Kenya Demographic and health survey 2008- 09. calverton, mD: KnBs and

icF macro.

lalonDe a. 2012. Prevention and treatment of postpartum hemorrhage in

low-resource settings. IntJGynaecolObstet, 117:108-18.

moBeen n, Durocher J, ZuBeri n, Jahan n, Blum J, Wasim s, Wal-

raven g & hatcher J. 2011. administration of misoprostol by trained tra-

ditional birth attendants to prevent postpartum haemorrhage in homebirths

in Pakistan: a randomised placebo-controlled trial. BJOG, 118:353-61.

montagu D, yamey g, visconti a, harDing a & yoong J. 2011. Where

do poor women in developing countries give birth? a multi-country analysis

of demographic and health survey data. PLoSOne, 6, e17155.

national Bureau oF statistics (nBs) tanZania anD icF macro

2010. tanzania Demographic and health survey 2010 Preliminary report. Dar

es-salaam, tanzania: tBs and icF macro.

national institute oF PoPulation research anD training

(niPort), m. e., university oF north carolina – chaPel hill,

icDDr,B, 2011. Bangladesh maternal mortality and health care survey 2010:

summary of Key findings and implications.

national institute oF PoPulation research anD training,

m. a. a., measure Dhs, 2012. BanglaDesh DemograPhic anD

health survey 2011 Preliminary rePort. Dhaka.

national PoPulation commission 2009. measure Dhs, icF macro ni-

geria Demographic and health survey 2008 Preliminary report. abuja, nigeria.

Parsons sm, Walley rl, crane Jm, mattheWs K & hutchens D. 2007.

rectal misoprostol versus oxytocin in the management of the third stage of

labour. JObstetGynaecolCan, 29:711-8.

Prata n, gessesseW a, aBraha aK, holston m & Potts m. 2009a. Pre-

vention of postpartum hemorrhage: options for home births in rural ethiopia.

AfrJReprodHealth, 13:87-95.

Prata n, hamZa s, gyPson r, naDa K, vahiDnia F & Potts m. 2006.

misoprostol and active management of the third stage of labor. IntJGynaecol

Obstet, 94, 149-55.

Prata n, mBaruKu g & camPBell m. 2005. using the kanga to measure

postpartum blood loss. IntJGynaecolObstet, 89, 49-50.

Prata n, mBaruKu g, grossman aa, holston m & hsieh K. 2009.

community-based availability of misoprostol: is it safe? Afr JReprodHealth,

13, 117-28.

Prata n, Passano P, roWen t, Bell s, Walsh J & Potts m. 2011. Where

there are (few) skilled birth attendants. JHealthPopulNutr, 29, 81-91.

Prata n, eJemBi c, Fraser a, shittu o, minKler m. 2012a. community

mobilization to reduce postpartum hemorrhage in home births in northern

nigeria. SocSciMed, 74(8):1288-96

Prata n, Quaiyum ma, Passano P, Bell s, Bohl DD, etal. 2012b. training

traditional birth attendants to use misoprostol and an absorbent delivery mat

at home births. SocSciMed, 75(11): 2021-7.

raJBhanDari s, hoDgins s, sanghvi h, mcPherson r, PraDhan

yv & BaQui ah. 2010. expanding uterotonic protection following childbirth

through community-based distribution of misoprostol: operations research

study in nepal. IntJGynaecolObstet, 108: 282-8.

ronsmans c & graham WJ. 2006. maternal mortality: who, when, where,

and why. Lancet, 368: 1189-200.

sanghvi h, ansari n, Prata n, giBson h, ehsan at & smith Jm. 2010.

Prevention of postpartum hemorrhage at home birth in afghanistan. IntJGyn-

aecolObstet, 108: 276-81.

shelDon Wr, Blum J, Durocher J & WiniKoFF B. 2012. misoprostol for

the prevention and treatment of postpartum hemorrhage. ExpertOpinInvestig

Drugs, 21, 235-50.

smith Jm, guBin r, holston mm & Prata n. misoprostol for postaprtum

hemorrhage prevention at home birth: an integrative review of global imple-

mentation to date. BMCPregnancyandChildbirth 2013, 13:44

uniteD nations 2012. un commission on life-saving commodities for

Women and children: commissoner’s report. new york: united nations.

WorlD health organiZation 1978. Declaration of alma-ata interna-

tional conference on Primary health care. conference on Primary health

care, 6-12 september, 1978 1978 alma-ata, ussr. alma-ata: World health

organization.

WorlD health organiZation 1990. the Prevention and manage-

ment of Postpartum haemorrhage. report of a technical Working group. .

geneva: Who.

WorlD health organiZation 1992. traditional Birth attendants: a

Who/unFPa/uniceF Joint statement. geneva: World health organization.

WorlD health organiZation 2012a. trends in maternal mortality, 1990-

2010. Who, uniceF, unFPa and the World Bank estimates. geneva.

WorlD health organiZation 2012b. Who recommendations for the

prevention and treatment of postpartum haemorrhage. geneva: Who.

WorlD health organiZation 2012c. the selection and use of essential

medicines: report of the Who expert committee, march 2011. WHOtechni-

calreportseries. geneva: Who.

WorlD health organiZation 2012d. Who recommendations opti-

mizing health worker roles to improve access to key maternal and newborn

health interventions through task shifting. geneva: Who.

References

VSI is a tax-exempt501(c)(3) nonprofit organization incorporated in the State of California.

vsi northern california 2115 milvia street, suite 4aberkeley, california 94704 usa

vsi rwandagrand Pension Plaza, 3rd floorKiyovu, Kigali, rwanda

vsi ethiopiaKirkos sub city 01/19addis ababa, ethiopia

vsi Zimbabwe20 cleveland road, milton Parkharare, Zimbabwe

contact information vsinnovations.org

vsi southern california (hQ)19200 von Karman avenue, suite 400 • irvine, california 92612 usatel +1 949 622 5515 • fax +1 949 622 5516

Photography: VSI/Natalie Williams © 2010

Preventing - The Bixby Center for Population, Health, and...

Documents

Transcript of Preventing - The Bixby Center for Population, Health, and...