Making her Journey Safe: Preventing Postpartum Hemorrhage at Homebirth

Publication date: 2008

1 Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Making Her Journey Safe: Preventing Postpartum Hemorrhage at Homebirth Harshad Sanghvi Vice President & Medical Director, Jhpiego 2 Perspectives on scale up ƒ Innovations to address different components of problem ƒ Building global, regional and in-country consensus − FIGO-ICM − WHO − Regional conferences ƒ Developing in-country − champions, capability, experience ƒ Achieving coverage ƒ Ensuring coverage of rural and most vulnerable 3 Preventing Mortality from PPH ƒ We know what to do: − AMTSL integrated within skilled care at birth − CBD of uterotonic (misoprostol) within an integrated community package of care − Basic EmOC that is delivered as close to births as possible − Timely access to comprehensive EmOC ƒ Big gaps exist between Knowing what to do & Consistent utilization of what is known 4 Ethiopia AMTSL: Missing the opportunity to maximize on a cost effective intervention ƒ Practice of AMTSL: 29% of facility births ƒ Use of uterotonic only: 100% ƒ Oxytocin 68%, ƒ 28% Ergometrine (mostly after placenta), ƒ 1% both ƒ Most Ergometrine stored inappropriately ƒ Harmful practices in third stage in more than 1/3 of facility births. Facility based management and community perceptions of PPH, Ethiopia 2006 5 Availability of Selected Drugs in Birthing Areas in Health Facilities: Tanzania 64 70 69 17 75 85 18 5 57 13 3 9 68 4 0 10 20 30 40 50 60 70 80 90 MgS o4 Diaz epa m Hyd rala zine Calc ium Gl oxy toci n Erg om etrin e Mis opro stol Hospitals HC/D EmOC situation analysis 2006 6 Creating Champions: Maternal and Newborn Regional Expert Program ƒ 43 regional experts from 18 countries providing technical leadership in 48 countries ƒ developing the next generation of regional experts (now 320+) from additional 48 countries ƒ Leading the Development of a large number of in- country trainers and service providers ƒ Scaling up adoption of evidence based practices 2 7 Bangladesh: Scaling up use of AMTSL Advocacy for AMTSL Learning AMTSL Learning AMTSL Post training development of Actions 8 Bangladesh: Evaluating Impact Evaluation visits to 48 sites within 6 months of training Evaluation conducted by change management team: MNH regional experts: 3 Obstetricians, 3 Midwives, I anesthetist ƒ 93% of all cases (1870 births) in month prior to visit had AMTSL. ƒ Reduction in cases of PPH (2.8% vs 7.8% in previous year) ƒ No PPH related deaths from any of 48 sites. 9 Nigeria: Integrated Household to Hospital Continuum: Put simply……. Decreased Maternal and Newborn Mortality Increased Use of EmONC and Postpartum FP Improved Supply (SBMR) Increased Demand (BCC/CM) 10 Deliveries by SBAs and Use of Partograph 0 500 1000 1500 2000 2500 3000 3500 4000 4500 Oct-Dec, 2006 Jan-March, 2007 April-June, 2007 July-September, 2007 Quarter N um be r Deliveries by SBAs Use of Partograph Deliveries –Partograph use Number of Newborn receiving Essential Newborn Care 58 1846 3771 50 550 1050 1550 2050 2550 3050 3550 4050 Oct-Dec, 2006 Jan-March, 2007 April-June, 2007 July- September, 2007 Quarter N um be r Essential Care Essential newborn care Number Receiving Postnatal Care within 3 days of deliveries 1 43 259 0 50 100 150 200 250 300 Oct-Dec, 2006 Jan-March, 2007 April-June, 2007 July-September, 2007 Quarter N um be r Postnatal Care An FGD session with older women ACCESS-Nigeria 11 ACCESS-Nigeria: Deliveries by SBA and Use of AMTSL ANC by SBAs Target Attained Oct-Dec, 2006 2500 4887 Jan-March, 2007 5000 6598 April-June, 2007 7000 9278 July-September, 2007 9000 12570 Del by SBAs Oct-Dec, 2006 500 564 Jan-March, 2007 500 635 April-June, 2007 600 2517 July-September, 2007 2500 3969 Deliveries by SBAs AMTSL Oct-Dec, 2006 564 0 Jan-Mar, 2007 635 97 April-June, 2007 2517 2240 July-Sept, 2007 3969 3950 Oct-Dec, 2007 3590 3966 Jan-Mar, 2008 5746 5268 Target Attained Oct-Dec, 2006 2500 1480 Jan-March, 2007 2500 783 April-June, 2007 1500 1713 July-September, 2007 2000 2516 0 1000 2000 3000 4000 5000 6000 Number of Women Oct-Dec, 2006 Jan-Mar, 2007 April- June, 2007 July-Sept, 2007 Oct-Dec, 2007 Jan-Mar, 2008 Quarter and Year Women Delivering with SBAs and Receiving AMTSL Deliveries by SBAs AMTSL 12 Seeking Solutions for Births That Occur Without Skilled Care ƒ We cannot predict PPH on the basis of risk factors. ƒ In most ountries fewer than 50% births are attended by a “skilled” attendant. ƒ Once severe PPH occurs, death follows very rapidly ƒ Timely referral and transport to facilities is not easily available or affordable ƒ Availability of emergency obstetric care services is grossly limited. 3 13 A Randomized PlaceboA Randomized Placebo--Controlled Trial of Oral Misoprostol 600 mcg Controlled Trial of Oral Misoprostol 600 mcg for Prevention of PPH at Four Primary Health Center Areas of for Prevention of PPH at Four Primary Health Center Areas of Belgaum District, Karnataka IndiaBelgaum District, Karnataka India 0.20 (0.04, 0.91) 0.53 (0.39, 0.74) Relative Risk (95% CI) 10010 (1.2) 2 (0.2) Severe Postpartum Hemorrhage (blood loss ≥ 1,000 ml) 1897 (12.0) 53 (6.5) Postpartum Hemorrhage (blood loss ≥ 500 ml) NNTPlacebo (N=808) N (%) Misoprostol (N= 812*) N (%) Primary Outcome Gouder et al Lancet 2007 14 WHO Recommendations for the Prevention of PPH (WHO 2007) 7. In the absence of AMTSL, should uterotonics be used alone for prevention of PPH? Recommendation: ƒ In the absence of AMTSL, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH (strong recommendation, moderate quality evidence) The complex and thorough process of evaluating evidence and gaining consensus for global guidelines on PPH has now been adopted by WHO for all guidelines 15 Indonesia: evidence from community based PPH prevention programs Indonesia ƒSafety: No women took medication at wrong time ƒAcceptability: women who used medication said they would recommend it and purchase the drug for future births ƒFeasibility: Community volunteers successfully offered information about PPH and safely distributed the medication ƒEffectiveness: 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 Sanghvi et al 2004 Indonesia: Photo by Harshad Sanghvi CBD misoprostol is now being introduced in 7 provinces in Indonesia with access and UNICEF support 16 Afghanistan: High Coverage Is Possible Even in Difficult Areas Estimates of eligible women based on CSO 2006 data, 3.7% CBR. Target eligible population is 2334. over 10 months Intervention areas  (June 2006 ‐ August 2007) 0 10 20 30 40 50 60 70 80 90 100 Jun e Jul y Au gu st Se pt em be r Oc tob er No ve mb er De ce mb er Jan ua ry feb ru ary Ma rch Ap ril Ma y Jun e Jul y Au gu st % given misoprostol % reached with message % took misoprostol Steady coverage though out by CHW even when external monitoring reduced during winter 17 Afghanistan: Near Universal Coverage with Uterotonic is possible 3.8% 74.3% Did not use any uterotonic Intervention (2039) 26.5% 25.7% Received injection only : presumed oxytocin 96.2 %25.7%Used any uterotonic 67% 0 Used misoprostol only Control (1148) Uterotonic drugs National TAG, have reviewed results in January 2008 and are pursuing inclusion in Basic Health Care Package 18 Nepal: Integrating into Female Community Health Volunteer program: NFHP, Nepal 29 10 45 28 maternal deaths NN mortality (/1000 LB) pre post expected (NDHS 06) observed Intervention : FCHV makes Household level : Antenatal contact • for health education, • assessment • dispensing of medications (Iron, misoprostol) Early post-natal home visit to • assess and educate • dispense and document • recover unused misoprostol 100% 66% 64% Expected pregnancies 16,500 Reached by intervention10,964 Received misoprostol With health worker No health worker, took misoprostol no HW, no misoprostol 61% ?% Received PPH protection 22% 39% 5% Nepal TAG approved scale up and is program incorporated in current years budget planning 4 19 FOGSI-Macarthur-Jhpiego National EmOC program, India: Working towards standards, FRUs in Surat, India 0 10 20 30 40 50 60 70 80 90 ANC L& D PAC Facility D & S Baseline first visit second visit Baselines are self assessments, first assessment was at 2 months after training, second 6 months 20 Midwifery schools in Afghanistan: Scaling up through Midwifery education 21 Trend in Percentage of Standards Achieved by Programs 2004 - 2006 41% 62% 58% 33% 86% 69% 83% 66% 57% 83% 81% 80% 67% 78% 64% 92% 81% 90% 88% 93% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Balkh HIS Hirat HIS Kabul HIS Nangarhar HIS Kandahar I HS IHS Sites % o f a ch ie ve d st an da rd s Baseline 1st Assesment 2nd Assesment Non-binding Assesment Binding Assesment Accreditation Threshold 22Scaling up through strategic partnerships 23Scaling up through strategic partnerships 24 Take Home Message: Creating Change ƒ Implementers must perceive a benefit ƒ Someone they trust believes the change can work in their setting (early adaptors or Champions) ƒ They feel they can adapt the practice to their setting ƒ Managers (e.g. investors) feel they can try it at low risk ƒ Some “quick wins” are seen in the early stages 5 25 Contacts ƒ ACCESS: ƒ Patricia Gomez ƒ Emmanuel Otolorin ƒ Afghanistan SSMP: ƒ Nasratullah Ansari: ƒ NFHP: ƒ Steve Hodgins: ƒ Venture Strategies: ƒ Ndola Prata: ƒ UNICEF-Indonesia ƒ Zulkarnain : ƒ JHPIEGO: ƒ Harshad Sanghvi “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) District Shura (council) meeting

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