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Background: A postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia. Advance distribution of misoprostol was offered during antenatal care (ANC) and home visits. Feasibility, acceptability, effectiveness of distribution mechanisms and uterotonic coverage were evaluated.Methods: Eight facilities were strengthened to provide PPH prevention with oxytocin, PPH management and advance distribution of misoprostol during ANC. Trained traditional midwives (TTMs) as volunteer community health workers (CHWs) provided education to pregnant women, and district reproductive health supervisors (DRHSs) distributed misoprostol during home visits. Data were collected through facility and DRHS registers. Postpartum interviews were conducted with a sample of 550 women who received advance distribution of misoprostol on place of delivery, knowledge, misoprostol use, and satisfaction.Results: There were 1826 estimated deliveries during the seven-month implementation period. A total of 980 women (53.7%) were enrolled and provided misoprostol, primarily through ANC (78.2%). Uterotonic coverage rate of all deliveries was 53.5%, based on 97.7% oxytocin use at recorded facility vaginal births and 24.9% misoprostol use at home births. Among 550 women interviewed postpartum, 87.7% of those who received misoprostol and had a home birth took the drug. Sixty-three percent (63.0%) took it at the correct time, and 54.0% experienced at least one minor side effect. No serious adverse events reported among enrolled women. Facility-based deliveries appeared to increase during the program.Conclusions: The program was moderately effective at achieving high uterotonic coverage of all births. Coverage of home births was low despite the use of two channels of advance distribution of misoprostol. Although ANC reached a greater proportion of women in late pregnancy than home visits, 46.3% of expected deliveries did not receive education or advance distribution of misoprostol. A revised community-based strategy is needed to increase advance distribution rates and misoprostol coverage rates for home births. Misoprostol for PPH prevention appears acceptable to women in Liberia. Correct timing of misoprostol self-administration needs improved emphasis during counseling and education. © 2014 Smith et al.; licensee BioMed Central Ltd.
To reduce mortality from PPH the Liberia Ministry of Health and Social Welfare (MOHSW) is implementing two concurrent strategies to increase uterotonic coverage. The first aims to increase use of active management of the third stage of labor (AMTSL) at institutional deliveries, with a focus on the provision of oxytocin as part of active management. The second is to study counseling of pregnant women either during ANC or home visits by a health worker and the advance distribution of misoprostol to those women late in pregnancy for use at home births. Both interventions were implemented simultaneously in two districts of Grand Bassa County in 2012 and 2013. District #3 and Campwood districts were selected for this evaluation based on Ministry of Health and Social Welfare (MOHSW) priorities, compelling public health need, interest of the district leadership and existing program funding support from USAID. Because pregnant women from Campwood district often seek services in Fenutoli of neighboring Bong County and vice versa, the Fenutoli population and clinic were included in the Campwood parameters in Table 1. Population and maternal health parameters for district #3 and Campwood District, Liberia a2011 population projection (MOHSW). bbased on the crude birth rate of 45.0 (MOHSW). cNational level (LDHS 2013). dNational level (LDHS 2007) 2013 data not yet available. This project was approved by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health, U.S.A (IRB00004451) and the Liberian Institute for Biomedical Research/National Health Science Research Ethics Committee (ref EC/LIBR/012/021) in October 2012. The study was implemented as a longitudinal observational study to assess the ability to achieve high coverage within the target population of the use of a uterotonic immediately following birth. The intervention involved activities at the health facility, community and household levels by MOHSW staff and unpaid community volunteers. Program implementation was preceded by a design phase wherein the Ministry carefully considered the benefits and limitations of a specific intervention to reduce postpartum hemorrhage at home birth. The research questions were: 1) if ANC visits were a feasible and effective mechanism for providing birth preparedness and complication readiness (BP/CR) counseling and distributing misoprostol during pregnancy for PPH prevention to women who deliver at home; 2) whether trained District Reproductive Health Supervisors (DRHSs) could effectively provide counseling on BP/CR and distribute misoprostol to women during home visits; 3) whether the two strategies together could achieve high coverage of uterotonic use for PPH prevention either at facility or home births; 4) whether misoprostol use would be acceptable to women for PPH prevention; and 5) whether advance distribution of misoprostol would affect facility birth rates. Preparatory activities took place from August to November 2012, and training was conducted in December 2012. Counseling by health workers and distribution of misoprostol started in December 2012 and continued for seven months through June 2013. Approximately 1826 pregnant women age 15–49 were expected to be enrolled, based on the national crude birth rate of 45.0 births per 1000 population, the total population for the two districts and the seven-month period of observation. It was expected that the majority of women would be reached through ANC, and that the remainder would be identified through community mapping by trained traditional midwives (TTMs) and targeted for home visits by the DRHSs. TTMs were trained to identify and educate pregnant woman about misoprostol, but not to distribute the drug. The PPH prevention program was designed by the MOHSW with the technical assistance of Jhpiego through the Maternal and Child Health Integrated Program (MCHIP). It was implemented by the Grand Bassa County Health Team in Liberia, with technical guidance from Family Health Division of the MOHSW and MCHIP staff. As misoprostol was not available in Liberia, Venture Strategies Innovations provided the misoprostol and ensured its appropriate importation and entry into the regular national commodity distribution system of the Liberian National Drug Service (NDS). Based on evidence from other PPH prevention studies, a dose of 600 mcg (three tablets, each 200 mcg) misoprostol tablets taken orally was chosen. Facility-based care at eight of nine health facilities was strengthened by training the providers who offer ANC, delivery services and postnatal care. Health care providers who attend deliveries were trained on AMTSL, especially the administration of oxytocin for the prevention of PPH, and the management of PPH among women who took with misoprostol at home. Training used competency-based methods, and all providers were competent at the conclusion of the training, as measured by objective skill assessment tools. For the advance distribution intervention, health care workers at facilities were trained to provide the following during ANC: provision of specific messages on BP/CR and the risks of PPH; identification and consenting of eligible women; counseling on the use of misoprostol; and advance distribution of misoprostol to women at or after 32 weeks of pregnancy for self-administration following home birth. For prevention of PPH at home birth, DRHSs were trained in counseling and advance distribution of misoprostol. DRHSs are certified/registered midwives who work at hospitals and health clinics and conduct outreach in communities and women’s homes. They supervise other staff, including TTMs. DRHSs were trained to identify, with the help of the TTMs, women who had not completed the recommended ANC visits, to obtain oral consent, and to counsel them on BP/CR and the importance of facility-based delivery. If the woman was at eight months of pregnancy, the DRHS would provide a dose of misoprostol for the woman/family to hold until the time of delivery, with instructions to take the medication immediately following the birth of the baby (with confirmation of no undiagnosed second twin) and before the delivery of the placenta. TTMs, MOHSW-recognized volunteer CHWs, were trained in community mapping to identify all pregnant women in their community and to hold community sensitization activities. TTMs counseled women late in pregnancy using pictorial cards on the importance of ANC, birth preparedness, facility-based birth and appropriate preparation for birth; the danger signs of pregnancy, especially PPH; and the use of misoprostol for PPH prevention. TTMs did not distribute the misoprostol, but reinforced the messages about misoprostol obtained either from the clinics or the DRHS. All participants were trained in record keeping and data recording, using specific data collection tools designed according to their corresponding role. Counseling by all providers was facilitated by specifically designed, nationally appropriate pictorial message cards. The educational messages to women regarding misoprostol were to: store it in a safe place until the time of delivery; never take the medication prior to the birth of the baby; ensure that the TTM check for the presence of a second baby immediately following delivery at home; and swallow the three tablets with water immediately after the delivery of the baby and before the delivery of the placenta. Women were advised about transient side effects and the possibility of continued bleeding, even if the medication was taken correctly. In the face of persistent side effects or continued bleeding, women were advised to go to a facility. If women chose delivery in a facility, they were instructed to bring their misoprostol, which would be returned to the provider who would destroy it and administer oxytocin. Women who consumed the medication at home were instructed to bring the empty blister packets with them to the health facility during their postpartum visit and newborn’s first immunization visit. Misoprostol was obtained from Cipla Pharmaceuticals (India) in four-tablet strips. Once the medication arrived in country and was entered into the NDS system, it was repackaged by the county pharmaceutical system before distribution to the health facilities and DRHSs. Repackaging involved cutting the four-tablet strips into three-tablet strips and placing them in a small sachet with an instruction card for use. Pregnant women who consented and met all of the following eligibility criteria were provided with misoprostol: aged 15 years or older; had reached 32 weeks gestation or greater; had no known history of allergy to prostaglandins; and had not previously had a cesarean section. Women who had or developed a chronic disease over the course of her pregnancy (such as cardiac disease, diabetes, pregnancy-related hypertension or any other high-risk condition) were not eligible to receive misoprostol. These women were strongly encouraged to deliver in a facility and informed about risks involved in delivery without skilled attendance. Data on misoprostol distribution were collected at health facilities using modified ANC registers and at home by DRHSs using a Community Register for Recording Counseling and a Misoprostol Distribution and Delivery Information register. Data were tallied monthly in Monthly Misoprostol Consumption Log Books. Data on facility-based deliveries and any complications were extracted from the Labor and Delivery Registers. Data on home births were reported by TTMs to the health facility and others were captured during postpartum or first immunization visits. If women experienced a severe adverse event or were referred to another facility due to severe complications, providers recorded data using the Health Facility Admission Form. Baseline and prospective data on ANC visits and numbers of deliveries at the facility were collected from routine reporting into the Health Management Information System (HMIS). Among the women who were enrolled and received advance distribution of misoprostol, 550 were randomly selected from the ANC and DRHS registers for a follow-up interview postpartum. The sample was arrived by using Epi Info 7 StatCalc using estimated PPH prevalence at 20% at 95% confidence interval and design effect of 2. Using this calculation, 500 interviews were required, and 10% additional interviews were added to account for no-responses. The group that received misoprostol from DRHS was oversampled to allow for better understanding of the role that cadre played in the education of women and provision of misoprostol and messages. Postpartum interviews were intended to be conducted by the DRHSs, but it was determined not to be feasible during implementation due to the small number of DRHS and their broad array of responsibilities. MCHIP hired dedicated interviewers and trained them to go to the houses of the selected women to administer the questionnaire. All data collection forms were manually reviewed for completion and accuracy by the MCHIP office in Liberia. The MCHIP Liberia and Washington teams assisted with data entry and analysis using Microsoft Access. Initial analysis was performed in Washington, DC using Stata 10.0 (Stata Corp, College Station, TX, USA). A trend analysis was conducted on AMTSL data to examine the proportion of women with vaginal births receiving a uterotonic, as well as the numbers of ANC visits and births at facilities from baseline to the end of the program. The misoprostol distribution analysis included summary statistics of distribution and cross-tabulation of key outcome indicators. Results were summarized using frequency distributions and cross tabulations.
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