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Implementing best practices postpartum hemorrhage_Alisha Graves_10.14.11


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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> 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)