Prevention of Postpartum Haemorrhage (An Integrated Approach)

Implementing an integrated approach to prevent postpartum haemorrhage, leading cause of maternal death in developing countries, can reduce maternal mortality drastically. The integrated approach consists of: improving the quality of practice of AMTSL at health facilities and use of Misoprostol in home deliveries.

1. An Integrated Approach For Prevention of PPH Akmal Samsor December, 2011.

2. Outline Maternal Mortality Causes of Maternal Mortality Prevention of PPH at Health Facility Prevention PPH at Home Births A world FREE from PPH mortality

3. Leading Causes of Maternal Death Cause of death Developed countries Africa Asia LAC Hemorrhage 13% 34% 31% 21% Hypertensive disorders 16% 9% 9% 26% Sepsis/infections 2% 10% 12% 8% Abortion 8% 4% 8% 12% Obstructed labor 0% 4% 9% 13% Anemia 0% 4% 13% 0% HIV/AIDS 0% 6% 0% 0% Source: Khan et al, WHO analysis of causes of maternal death: a systematic review, The Lancet, March 28, 2006 -- % rounded

4. Source: Adapted from " WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, vol 367, April 1, 2006.

5. Skilled Care During Delivery (AMSTL)

6. 7 Preventing PPH in Births Attended Skilled Providers Physiologic management Active management OR and 95% CI Bristol Trial 152/849 (17.9%) 50/846 (5.9%) 3.13 (95% CI 2.3 - 4.2) Hinchingbrooke Trial 126/764 (16.5%) 51/748 (6.8%)  2·42 (95% CI 1·78-3·30) p<0·0001 Prendiville et al 1988, Rogers et al 1998.

7. Niger: Reduction in Post-partum Hemorrhage 8 USAID HEALTH CARE IMPROVEMENT PROJECT

8. USAID HEALTH CARE IMPROVEMENT PROJECT 9

9. Deliveries Attended by SBAs

10. “ A woman who is pregnant has one foot in the grave” . . . Local Proverb, Chad

11. Parent Death & Child Survival in Bangladesh Cumulative probability of survival of child to age 10 years Father alive: 88.6% Father dead: 89.3% Mother alive: 88.9% Mother dead: 23.8% Ronsmans LANCET 2010

12. “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Albert Einstein

13. New Thinking : Community Based Prevention of PPH

14. Components of Community Based Prevention of PPH BCC component : Counseling pregnant women on BP & CR Danger sings of pregnancy Importance of presence of SBA during delivery Misoprostol ( use & side effects) Enabling environment component : Distribution of Misoprostol at 8 th month of pregnancy Improving the quality of AMSTL (SBM-R) Community mobilization to strengthen emergency transportation services

15. Implementation

16. Implementation

17. Evidence from community based PPH prevention Indonesia Safety : No women took medication at wrong time Acceptability : women who used medication said they would recommend it and purchase the drug for future births Feasibility : Community volunteers successfully offered information about PPH and safely distributed the medication Effectiveness : the combination of skilled providers using oxytocin and community distribution of misoprostol allowed 94% coverage with PPH prevention method In partnership with Depkes , POGI, IBI & supported by USAID through the MNH program

18. Evidence from community based PPH prevention Afghanistan Safety : 100% took correctly after birth including 22 sets of twins Acceptability : 92% said they would recommend it and purchase the drug for future births Feasibility : Community volunteers successfully offered information about PPH and safely distributed the medication Effectiveness : the combination of skilled providers using oxytocin and community distribution of misoprostol allowed 93% coverage with PPH prevention method Sanghvi, et al. 2009.

19. Evidence from community based PPH prevention “Our wives will not die anymore because of bleeding, if they take this drug after birth of the baby and before expulsion of Baar ( placenta). We must support and encourage you. Thank you for distributing the drug to our district.” (A community leader, Afghanistan)

20. Evidence from community based PPH prevention 18,761 pregnant women were dispensed misoprostol by FCHVs with no significant adverse events or misuse or incorrect use Proportion of deliveries protected by a uterotonic rose from 10.4% to 72.5%; largest gains were among the poor, illiterate and those living in remote areas Institutional deliveries increased from 9.9% to 16.0% MMR among 13,969 misoprostol users was 72/100,000; significantly lower than among non-users (304/100,000), as well as the national level of 281/100,000 Rajbhandari, Hodgins, Sanghvi, IJGO march 2010

21. Evidence from community based PPH prevention 1620 women, placebo-controlled trial Misoprostol: oral, stable, positive safety profile—can be used in the absence of a skilled birth attendant Misoprostol associated with Reduction in PPH (12% to 6.4%; p<0.0001) Reduction in acute severe PPH (1.2% to 0.2%; p<0.0001) Decrease in mean PP blood loss (262.3 to 214.3ml; p<0.0001) Transitory chills and fever Source: Derman, et al, Oral misoprostol in preventing postpartum hemorrhage in resource-poor communities: A randomized controlled trial, The Lancet, Oct. 7, 2006.

22. Global Policy Change “ After consideration of the evidence for efficacy and safety , the Committee decided to add misoprostol to the List, for the prevention of PPH in settings where parenteral uterotonics are not available or feasible”. World Health Organization, 18th expert committee on the selection and use of essential medicines ( 21 to 25 March 2011 Accra, Ghana).

23. Vision for the future “ A world FREE from PPH mortality”. World Map in Proportion to Maternal Mortality

24. Integration: AMTSL & CB prevention of PPH Integration will enable the facility based and community based health care providers to deliver quality health services; Team formation : SBAs and CHWs Provide CHWs better leadership (SBA Vs CHS) SBAs better linked with the communities Fallow up of the MCH services clients (ANC, PNC, FP) Better tracking of the commodities (misoprostol, FP pills)

25. Integration: AMTSL & CB prevention of PPH (cont …) Improved Quality of counseling: SBAs no longer doing the routine BP & CR counseling CHWs totally responsible for BP & CR counseling SBA asking each women visiting the health facility targeted questions about BP & CR Danger sings of pregnancy ? Diet during pregnancy ? TT vaccination and why? Provide feedback to the visiting women Quality of counseling (inquiring Vs providing) Quality of counseling (listening Vs talking)

26. Currently how counseling is done ? IEC is the duty of every health worker CHW is counseling (??) a client SBA is counseling(??) a client The only time that a woman get a better counseling is, during the supervisory visits (?) (filling the checklist) Client just listens and providers talks (75% Vs 25%) No mechanism to check the quality of counseling within system only checklists (fear)

27. Collaboration: AMTSL & CB prevention of PPH Collaboration will enable different partners to deliver health services at a larger scale Effectiveness = Quality * Coverage Remaining focused by delivering quality services to achieve our goals ( Facility based Vs Community based services/ Facility based and Community based services)

28. Collaboration: AMTSL & CB prevention of PPH Making this world FREE from PPH mortality ? Can I do it ? “ NO !” But Why ? Change your question. OK Can We? Yes, We can.

29. This in not a Mission Impossible

30. Thank you Comments/Questions ?