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Background: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. Methods: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. Results: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. Conclusion: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.
We used a mixed-methods approach to assess the implementation of the early expansion phase of scaling up misoprostol in 2 provinces in Mozambique. The objectives of this study were to: (1) identify facilitators and barriers to the early expansion of the misoprostol program for the prevention of PPH at the community level, and (2) examine coverage and use of misoprostol in the 2 provinces. The qualitative component of the study applied a phenomenological approach to understand the experiences of those involved in Mozambique’s misoprostol program. Phenomenology is an interpretive approach based on the lived experiences of people who participated in the phenomenon.38 Data were collected between February and October 2017 in Maputo City and in 2 districts in Inhambane province and 3 districts in Nampula province. These provinces were chosen due to geographic region—Inhambane is located in the southern region, and Nampula in the northern region of the country. Inhambane province initiated implementation in 2015, whereas Nampula, one of the provinces selected during the second phase of expansion, commenced implementation in 2016. Districts were chosen based on inclusion in the misoprostol program, geographic accessibility, and discussions with provincial and district health authorities. One-to-one, semistructured qualitative interviews were conducted with (1) MNCH national, provincial, and district stakeholders with experience working on the misoprostol program; (2) health staff (MNCH nurses and midwives, medical chiefs, hospital directors, pharmacists, and health technicians); and (3) CHWs (referred to as Agentes Polivalentes Elementares in Mozambique) and TBAs. In addition, focus group discussions were conducted separately with CHWs and TBAs. The ExpandNet/WHO framework and the document entitled 20 Questions for Developing a Scale-up Case Study30 were used to assist in the design of the interview guides for stakeholder and health staff interviews. Focus group discussion questions for CHWs and TBAs focused on the use and understanding of the medication and barriers and facilitators to the misoprostol program. The interview and focus group discussion guides were revised with input from the MOH and local research assistants to ensure questions could be understood in the local language and were relevant to the context. Participants were recruited via purposive sampling based on advice from key stakeholders in the program and assistance from district health staff and CHWs. We applied the phenomenological approach and interviewed a relatively varied sample of participants engaged in various aspects of the program. We sought to gain a range of experiences rather than selecting an established number of participants. We contacted 18 MNCH stakeholders via email or phone to arrange interviews. Interviews with 19 health staff were organized with assistance from district health authorities who called the health facility in advance. Fifteen of the stakeholders and all of the health staff contacted agreed to be interviewed. CHWs and TBAs were selected with assistance from the district MNCH coordinator who contacted the CHWs and asked them to come to the health facility for the interview. Where possible, the research team would drive to meet the CHW or TBA at their home or in the community to conduct the interview. In total, we interviewed 15 CHWs and coordinators and 15 TBAs. Three CHWs and 4 TBAs who were contacted were not available to attend an interview due to prior commitments. Additionally, we conducted 4 FGDs with TBAs in Nampula province and 1 FGD with CHWs in each province. Interviews were conducted in English, Portuguese, and local languages where appropriate. The first and second authors conducted the stakeholder interviews. One international and 3 local research assistants trained in qualitative data collection methods and ethical protocols conducted interviews and focus group discussions at the health facility and in the field. Interviews were recorded with permission, transcribed and translated verbatim into Portuguese, and then translated to English. Participant numbers were determined based on obtaining thematic saturation. National policy and planning documents were analyzed alongside notes and observations from a 2017 national MOH MNCH workshop, which included a review of the misoprostol program. Notes, policy documents, and qualitative interviews were coded and analyzed using NVivo 11 software. Quantitative data were provided by the provincial health directors at a national MNCH workshop. These data were analyzed to estimate coverage of and access to misoprostol in Inhambane and Nampula provinces from January through September 2017. We present descriptive statistics in the results. The resulting indicators are not based on directly reported data, but primarily based on calculated, indirect data estimates leading to some imprecision. We organized the data according to the ExpandNet/WHO framework’s planning and management categories. Categories of the planning phase included: the environment, the innovation, the user organization, and the resource team. Management of scale-up was coded into the 5 strategic choice areas of the ExpandNet/WHO framework in the following categories: type of scale-up; dissemination and advocacy; organizational process; costs/mobilization of resources; and monitoring and evaluation. We also referenced the 20 Questions for Developing a Scale-Up Case Study30 in coding the transcripts into the planning and management categories. Results were further categorized as facilitators and barriers to scale up, or both. Finally, we included an additional category to report outcomes, including coverage and uptake, to assess progress of the expansion phase. Outcomes were coded into access, utilization, and logistics systems. We defined access as the number of women who delivered with a TBA and received the drug or who received it in advance during an antenatal care visit, as a proportion of the estimated number of expected home births in the catchment area. Utilization was defined as the number of women who used misoprostol (i.e., unreturned doses of misoprostol) as a proportion of the estimated number of expected home births in the catchment area. Ethical clearance was obtained from the Human Research Ethics Committee at Charles Darwin University, Australia (HREC 2015–2445), the Mozambican National Bioethics Committee, and the MOH. All participants provided informed consent and none requested to be withdrawn from the study.
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