Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Implementing best practices postpartum hemorrhage_Alisha Graves_10.14.11

1,350 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Implementing best practices postpartum hemorrhage_Alisha Graves_10.14.11

  1. 1. Misoprostol for PPH: Overcoming Challenges Alisha Graves, MPH Senior Programs Manager CORE Group Conference Washington, DC October 13-14, 2011
  2. 2. VSI’s approach November 30, 2010
  3. 3. <ul><li>Hormone-like substance </li></ul><ul><li>Uterotonic: Contracts the uterus, ripens the cervix </li></ul><ul><li>Approved by the FDA in 1984 (Cytotec) for the prevention of peptic ulcer during NSAID treatment </li></ul>What is Misoprostol?
  4. 4. The case of misoprostol Misoprostol is capable of curbing maternal mortality due to postpartum hemorrhage & unsafe abortion <ul><li>Effective, evidence-based intervention </li></ul><ul><li>Heat-stable, low-cost, generic tablets </li></ul><ul><li>Simple to administer without skilled attendance </li></ul>Ideal in low-resource settings & supported by international health organizations
  5. 5. Improving community-based drug provision <ul><li>“ Interpretation Community provision of misoprostol and antibiotics to reduce maternal deaths from post-partum haemorrhage and sepsis could be a highly effective addition to health-facility strengthening in Africa. Investigation of such interventions is urgently needed to establish the risks, benefits, and challenges of widespread implementation.” </li></ul><ul><li>Source: Pagel et al. Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model. The Lancet, 2009. </li></ul>
  6. 6. Challenges and solutions for large-scale implementation
  7. 7. Challenge #1: Political sensitivity <ul><li>Objections! </li></ul><ul><ul><li>Abortion </li></ul></ul><ul><ul><li>promoting home births </li></ul></ul><ul><ul><li>inferior to oxytocin </li></ul></ul><ul><ul><li>working with TBAs </li></ul></ul><ul><li>Identify and support local experts and advocates </li></ul><ul><li>scientific evidence & global policies support its use </li></ul><ul><li>www.vsinnovations.org offers resources to help you prepare an advocacy toolkit </li></ul>
  8. 8. Overcoming Political Sensitivities Global Policies and Scientific Evidence <ul><li>WHO added misoprostol to its Model Essential Medicines List for Treatment of Incomplete Abortion & PPH prevention ( WHO, 2009; 2011) </li></ul><ul><li>Misoprostol reduced PPH by half (RR=0.53), when compared to not using anything in community settings in India ( Derman et al.Lancet, 2006) </li></ul><ul><li>Community based distribution of misoprostol was found to be safe, effective and acceptable in both Afghanistan and Nepal ( Sanghvi et al. IJGO, 2010; Rajbhandari et al. IJGO, 2010) </li></ul><ul><li>A recent study from Bangladesh reported 81% protection against primary PPH when used in community settings (Hashima-E-Nasreen et al., Global Health Action 2011) </li></ul>
  9. 9. Challenge #2: Barriers to Access on a National Level <ul><li>Institutionalization </li></ul><ul><li>Registration </li></ul><ul><li>Addition to national essential medicines list </li></ul><ul><li>National guidelines and job aids </li></ul><ul><li>Public procurement and distribution </li></ul><ul><li>National curricula </li></ul>
  10. 10. Global Misoprostol Registration by Indication NEPAL INDIA TANZANIA & ZANZIBAR NIGERIA * Misoprostol may or may not be registered for gastric ulcers Registered for postpartum hemorrhage (PPH) & treatment of incomplete abortion* Registered for PPH and other ob/gyn indication* Registered for PPH* Registered for another ob/gyn indication, not PPH* Registered for gastric ulcers only BANGLADESH ZAMBIA UGANDA SUDAN GHANA KENYA Last updated: August 2011 SOMALILAND MOZAMBIQUE PAKISTAN SIERRA LEONE MALAWI ETHIOPIA
  11. 11. Challenge #3: Barriers to Access on a Local Level <ul><li>Lack of trained providers </li></ul><ul><ul><li>Antenatal care distribution </li></ul></ul><ul><ul><li>Community health workers </li></ul></ul><ul><ul><li>Traditional birth attendants </li></ul></ul><ul><li>Rural environments </li></ul><ul><ul><li>Public and private sectors, including pharmacists & drug sellers </li></ul></ul><ul><ul><li>Local implementers </li></ul></ul><ul><ul><li>Social marketing </li></ul></ul><ul><ul><li>Demand generation </li></ul></ul>
  12. 12. Community Awareness Campaign on Birth Preparedness and PPH Prevention <ul><li>Key messages: </li></ul><ul><li>Promote attendance at ANC throughout pregnancy </li></ul><ul><li>Importance of delivering in a health facility </li></ul><ul><li>Plan early for a safe delivery </li></ul><ul><li>PPH consequences & blood loss measurement </li></ul><ul><li>Misoprostol is available at ANC </li></ul>
  13. 13. 17 Feb 2010
  14. 14. 17 Feb 2010
  15. 15. Other challenges (perceived & real!) <ul><li>Programming for prevention vs treatment </li></ul><ul><li>Estimating blood loss </li></ul><ul><li>Cost </li></ul><ul><li>Safety, eg use for other indications </li></ul>
  16. 16. “ As men, we are the gravediggers in our communities. Since this project came, we have not dug any graves for our women.” - Safe Motherhood Action Group member, Kapiri Mposhi, Zambia “ I had nightmares while I was pregnant because I feared bleeding. I am grateful for misoprostol for protecting me.” - Mother with previous PPH, Hayin Ojo, Nigeria “ Thank you to those who have provided us with this drug. You have given us pride.” - Antenatal care provider, Masaiti, Zambia Thank You
  17. 17. Community mobilization involves the delivery of clear messages through local groups
  18. 18. Summary of Strategies for Community-based Distribution of Misoprostol <ul><li>Treatment </li></ul><ul><li>TBA recognition of PPH and treatment with misoprostol </li></ul><ul><li>Prevention </li></ul><ul><li>ANC distribution </li></ul><ul><li>HEWs trained in PPH management at health post and home births in collaboration with TBAs and other CHWs </li></ul><ul><li>TBA distribution of misoprostol at delivery for PPH prevention </li></ul><ul><li>Private sector </li></ul><ul><li>Hybrid Models: ANC + TBA </li></ul>
  19. 19. Regimens for Misoprostol Indications INDICATION REGIMEN Postpartum hemorrhage prevention 600 mcg, oral Postpartum hemorrhage treatment 1000 mcg, rectal 800 mcg ,sublingual Treatment of incomplete abortion & miscarriage 600 mcg, oral 400 mcg, sublingual Treatment of missed abortion 800 mcg, vaginal 600 mcg, sublingual Labor Induction (live fetus > 24 weeks) 25µg Vaginal (q 4 hrs, max 6 doses) , or 50µg Oral (q 4 hrs, max 6 doses) , or 20µg Oral solution* (q 2 hrs, max 12 doses) Intrauterine Fetal Death (13-17 weeks) (18-26 weeks) (27+ weeks) 200 mcg, vaginal (q 6 hours, max 4 doses) 100 mcg, vaginal (q 6 hours, max 4 doses) 25-50 mcg vaginal (q 4 hours, max 6 doses) Pregnancy termination (36-48 hours after 200 mg mifepristone) (<12 weeks) 800 mcg vaginal 400 mcg oral Pregnancy termination (alone) (<12 weeks) 800 mcg, vaginal (q 6,12 or 24 hours for 3 doses) 800 mcg, sublingual (q 3 hours for 3 doses)

×