Based on low number of health facilities and health providers in Nepal, especially in Doti District, which is in the mountainous Far Western Region, MoH decided to pilot Provide misoprostol to women late in pregnancy, to be taken immediately after delivery, for births not attended by a skilled providerSystem was MoH’sSee operations research paper p.4 seems pills were distributed from Dec 2010-April 2011. Started community-level distribution in Dec (what does this mean??) and then stopped in April w/ pills expired in June and the government failed to renew stocks Provided to women in the last yr of the project, would have liked to have paid more attn to it, but couldn’t for this reason
Focus on ingestion of MSC and PPH today; feasibility and acceptability was done by CARE Nepal team
Restricted to Doti District, Far Western RegionPlains study done, but none done in the hills and mountains, roads poor, few health facilities, few health workers, would this still work here? Self-report of ingestion of matrusurakshachakki – translates to maternal protection tablets and PPHSurvey pilot tested in Khrisain VDC, which was not selected in the randomized process-definition of PPH was soaked pads (-same named as used in Rajbhandari study
Nepal family health program – miso coverage 53% (estimated pregnancies = 16000, received MSC 11685, 53% of these took miso)
Descriptive statistics presented in operations research report by field team in Nepal; I will show you relevant stats for our purposes hereThis is subsequent analysis of data. Objectives here were:
Proxy – i.e. use of receipt of counseling at 8M rather than knowing exact time point when women were given pills.
Some studies show a reduction in risk of PPH as high as 79%FCHV one – possible misclassification/missed cases. FCHVs are often present at ANC visits, when women don’t come for ANC visit, FCHVs go to them at home. Could be that this question wasn’t clear.
BRAC – paper is among those I sent you when I was doing the lit reviewhttp://www.nursing.emory.edu/manhep/index.htmlhttp://healthmarketinnovations.org/program/venture-strategies-innovations-vsi
Misoprostol Delivers!The use of misoprostol in the preventionof postpartum hemorrhage (PPH) in Doti District, NepalImplementation and data collection CARE Nepal CRADLE TeamStatistics by Noor Tirmizi and Kristen Yee
Outline• Background Results from Feasibility Study• Results from Case Control Study on Effectiveness• Methods• Results • Descriptive statistics • Bivariate analysis • Logistic regression• Limitations• Conclusions
Background: Misoprostol in Doti District, Nepal • Blanket pilot program initiated in Dec 2010 in Doti • Hilly, mountainous region, 768 sq miles • Aimed to Provide misoprostol (600μg) to every pregnant women in 8th month of pregnancy • Training of HWs/FCHV and drug supply facilitated by CARE • Monitoring and supervision of rollout done by MoH in partnership with CARE
Operations Research StudyTo determine• feasibility• acceptability• safety of community-based distribution of misoprostol by community volunteers under government service towards the prevention of postpartum hemorrhage (PPH) in pregnant women3
OR – Feasibility StudyObjectives of the study:• To explore the utilization pattern of Misoprostol in Doti district during delivery.• To find out results of Misoprostl and list side effects/complicatins seen.Study Design• A cross section study on feasibility of Misoprostol by Recently Delivered Women (RDW)Sample Size for the study• 15/ 50 VDCs randomly selected. (1) all the FCHVs of those VDC interviewed (2) Recently delivered women (3) Similarly HW and HWIC wherever available in these 15 VDCs interviewed.
Study Setting & Design Data Collection• Quantitative collected from the interview of RDW• Qualitative collected using IDI and FGDs of FCHVs, HWs, HFICsData processing and analysis• Data collection tools were coded and analyzed in SPSS• FGDs/IDIs were transcribed and analyzed using content analysis approachDuration of Data Collection• August 2011 for both qualitative and quantitative data
Antenatal & Health Education Characteristics Cases (N=55) Controls (N=290) Percent Percent Variable Freq Freq Freq FreqANC <4 16 28.6 99 34.1 visits 4 visits 39 71.4 191 65.9Any counseling on No 19 34.5 67 23.1BPP by FCHV Yes 36 65.5 223 76.9BPP counseling by No 43 78.2 185 63.8FCHV in 8th monthof pregnancy Yes 12 21.8 105 36.2
Source of InformationKnowledge on MSC Percent (n=169)Heard about MSC from:FCHV 72.2VHW/MCHW/ANM 17.8Doctors/HA/AHW 8.9
OR - The Numbers GameFeasibility• 49% Illiterate• 40% Dalits 345 Women Interviewed• 95% women hadFCHV < 30 minutewalk 173 Received MisoprostolSafety• 88% knew correct timing.• Common Side Effects 169 took the correct vomit, diarrhea, shivering dose• 95% knew advice to go to HFif bleeding persists Acceptability: 99.4% of users would recommend MSC to their friends and relatives
FGD/IDI Findings1) MCHW/ANM• Interview with nursing staffs revealed that FCHVs were capable for distribution of MSC and counseling on its usage to mothers.2) HF- Incharge• HF in-charges were confident about knowledge of FCHVs on MSC; dose, time to take, side effects and its return and their ability to distribute the tablets.3) FCHV• FCHV reported that they gave the tablets only after enough counseling on the dose, time and its general side effects to the mothers. Some of the more aware mothers came to ask for the tablets at last months of the pregnancy.
Study on Effectiveness of MisoprostolObjectives:• Determine the odds of misoprostol ingestion based on receipt of pills• Determine the odds of postpartum hemorrhage based on correct ingestion of misoprostol (600μg taken orally immediately following childbirth)Definition:• PPH – MOH definition – 2 half meter cloths completely soaked with blood during delivery.Cases = RDW women who experienced PPH (n=55)Controls = RDW women who did not experience PPH (n=290)
Binary Logistic Regression Results Effectiveness of MSC reducing PPHVariable Reduction in PPH CI Exp (β)Age (15-24) yrs of age 1.57 0.85 2.79 25 yrs or olderIngestion of misoprostol (600 μg) 0.46* 0.25 0.86YesReceipt of Counseling on BPP by FCHVin 8th month of last pregnancy 0.53** 0.27 1.07
Binary Logistic Regression Results—FactorsAffecting Ingestion of MSCVariable MSC Ingestion CI Exp (β)Age (15-24) yrs of age 0.95 0.60 1.48 25 yrs or olderLiteracy Literate 1.43 0.91 2.26ANC Visits Did complete 4 visits 1.78* 1.13 2.81Continued Counseling Did not receive any 1.43 0.85 2.40 counseling
Cross Tables to Explain Reasons for Non-useVariable Did not take MSC following Did take immediatelyAccess childbirth following childbirth N (%) N (%)Got MSC tablets during 67 (40.9) 97 (59.1)pregnancyKnowledge: Reasons fortaking MSCStop PPH, Prevent Death,help uterus contraction & 114 (54) 95 (45.0)placenta expulsion
Knowledge on Correct Dose of MSCKnowledge on dose Incorrect dose Correct dose N (%) N (%)Reasons for taking MSCStop PPH & Prevent Death 15 (8.8) 155 (91.2)CounselingDid receive counseling by FCHV 129 (49.8) 130 (50.2)
LimitationsData collection• Cross-sectional analysis• Self-report of misoprostol ingestion and PPHData analysis• Sample size (N=345)• Proxy measures limit interpretation
Key Findings• Women who completed four antenatal visits had 1.78 the odds of taking misoprostol correctly relative to those women who did not complete four antenatal visits• Women who took misoprostol were associated with a 53% decrease in the risk of postpartum hemorrhage
Examples from Literature• BRAC’s maternal, neonatal and child health program in rural northern Bangladesh 2008-2010 • Successfully provided misoprostol (400μg) to mothers under direct supervision of CHW• Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) • Provides basic package of interventions to mother and child within first 48 hours of newborn’s life. Misoprostol part of maternal intervention• The Center for Health Innovations’ Venture Strategies Innovation (VSI) • Improve misoprostol availability • Work with ministries of health to incorporate misoprostol into national guidelines and promote task-shifting and training • Multi-country initiative, more policy level focus
ConclusionsNational Policy Level• Pilot program initiated by the Government of Nepal and CARE was successful. CARE worked with other partners/stakeholders and FHD to prepare guidelines for a national program on Misoprostol use. It is a part of SMH program in Nepal and is included in the EDL. • Program has now been scaled up to function on a national level• Study findings are consistent with existing literature • Misoprostol as a tool in the reduction of postpartum hemorrhage • Feasibility and acceptability of misoprotol use and dissemination of the community level • this study adds to existing evidence in demonstrating that in one of the most remote regions of Nepal (hills and mountains), community-level distribution of misoprostol is possible
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