Misoprostol for the prevention of post-partum haemorrhage in Mozambique: An analysis of the interface between human rights, maternal health and development

Background: Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly. Methods: A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique’s misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained. Results: Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control. Conclusions: Applying a rights-based approach to the Mozambican misoprostol program is helpful in contextualising and informing the practical changes needed to improve access to misoprostol as an essential medicine, and in turn, preventing PPH. This study adds to the evidence of the interconnection between human rights, health and development and the importance of integrating the concepts to ensure women’s rights are prioritized within health service delivery. This paper presents an analysis of the early expansion phase of the scale-up of Mozambique’s misoprostol program in two provinces through the lens of a Tarantola and colleagues’ human rights, health and development framework [20, 21] (see Fig. 1). This qualitative study had two main components. The first was a policy document review to describe the human rights, health, and development context in Mozambique. The second was a thematic analysis of qualitative primary data from a program evaluation of misoprostol for the prevention of PPH. The health, human rights and development framework was used to identify three examples from the primary data which describes where rights might have been infringed. A document review of misoprostol program and policy documentation in Mozambique was undertaken with the goal of identifying the key documents most salient to health and reproductive rights. These documents were initially accessed through a grey literature search online, using a combination of key words in English and Portuguese including “health”, “development” AND/OR “human rights” in “Mozambique”. We then triangulated our grey literature search with the MoH and program partners through the course of the study. Core documents included the National PPH Strategy; The National Health Sector Strategic Plan 2015–2019; the National Plan for Health and Human Resource Development; Demographic and Health Surveys (2011 & 2015); the international human rights treaties Mozambique has signed and ratified; the UNDP Human Development Index; and gender equity publications and policy areas related to health and development at the national, regional and organisational levels. Forward snowballing of references and suggestions from the MoH and program partners were used to locate additional documents and literature. A thematic analysis of the documents was undertaken under the Framework’s central tenents of human rights, health and development [20]. Qualitative data from semi-structured interviews and focus group discussions were collected in 2017 as part of a larger evaluation of the scale-up of misoprostol for the prevention of PPH in two provinces in Mozambique [22]. The broader study aimed to a) uderstand TBA’s roles and perceptions on the distribution of misoprostol; b) explore the views of women who had used misoprostol; c) identify facilitators and barriers to the early expansion of the misoprostol program for the prevention of PPH at the community level; and d) examine coverage and utilisation of misoprostol in the two provinces. Study interview guides for stakeholders and health staff were developed using existing tools relevant to this study [23, 24]. Questions focussed on the process of scale-up including barriers and enablers; dissemination and advocacy; organizational inputs; finances/mobilization of resources; and monitoring and evaluation. CHWs and TBAs were interviewed about their use and understanding of misoprostol and the barriers and enablers to the misoprostol program. Women who used misoprostol were asked questions about their experience receiving and using the medication. Purposive sampling was used to select the research participants based on consultation with key stakeholders in the program, assistance from district health staff, community health workers, and women who used misoprostol. MNCH stakeholders were interviewed based on their involvement in the misoprostol program. Details of recruitment and data collection procedures are documented elsewhere [22, 25]. In total, focus group discussions and semi-structured key informant interviews were undertaken with: Most interviews and FGDs were conducted in local language or where appropriate, Portuguese. Interviews averaged 45 min and were recorded with participant permission. MNCH stakeholder interviews took place in Maputo city, Inhambane and Nampula Provinces at the participant’s office or convenient alternative. Team members debriefed daily to record observations and context. Recruitment and data collection procedures are elaborated elsewhere [22, 25]. Two international and three local research assistants collected data. Research assistants received training on qualitative data collection and research ethics. Interviews, field notes and recordings were translated and transcribed in Portuguese by Mozambicans who spoke local dialects, and then translated into English. Data quality checks from Portuguese to English were undertaken by KH and JH by listening to the interview recording in Portuguese alongside the Portuguese transcripts and English translation. Nvivo (v.11) software was used to undertake the analysis. The first author read all interviews and documents twice to become familiar with the data. All data were deductively coded by the first author according to the underpinning constructs of the framework [20]. The second round of coding was inductive and resulted in the emergence of additional themes. The analysis was cross-checked with co-authors to ensure interpretation of meaning was accurate. Ethical clearance was obtained from the Human Research Ethics Committee at Charles Darwin University, Australia (HREC 2015–2445) and the Mozambican National Bioethics Committee and MoH (105/CNBS/2016). All participants were informed of the study purpose, potential risks and benefits, after which written informed consent was obtained. All participants were given the right to refuse or withdraw at any point; none did so.