Bangladesh Program for the Prevention of Postpartum Hemorrhage: Implementation Experiences

Dr. S. A. J. M. Musa
Director PHC, & LD, MNCAH, DGHS

Dr. Mohammad Sharif

Director MCH, & LD, MCRAH, DGFP

Dr. Abu Jamil Faisel

Project Director, Mayer Hashi project & Country Representative EngenderHealth Bangladesh

Presentation Outline
Government policies and plans to address PPH prevention: a two pronged approach:
AMTSL: Assessment, interventions, implementation challenges Misoprostol: Major milestones, pilots, lessons learned, national scale-up, implementation challenges

PPH Prevention Approaches

The government emphasizes the use of community skilled birth attendants (CSBAs) for home births and the development of a midwifery cadre to increase skilled attendance at facilities In addition, the government initiated other policies for addressing maternal mortality such as demand side financing (DSF), health insurance schemes, community level use of MgSO4 in a loading dose for prevention of PE/E etc. The Ministry of Health and Family Welfare proposes a two-pronged approach for PPH prevention:

1. Active management of the third stage of labor (AMTSL) at the facility level
2. Community-based distribution and use of Misoprostol
(Ref: GOB OPs on MNCH)

1. Active Management of the Third Stage of Labor

Active management of third stage of labor (AMTSL) - a proven simple effective intervention (WHO, ICM/FIGO, 2006) Three components:
10 I.U Injection Oxytocin ( intramuscular) within one minute after delivery of baby Control Cord Traction (CCT) Uterine Massage after delivery of placenta

2008 AMTSL Assessment Key Findings

Proportion of Deliveries where AMTSL is Correctly Practiced
96.9

100 90 80 70 60 50 40 30 20 10 0
25.7 19 16 44.5 61.5 83

Uterotonic drug at any stage

Uterotonic drug at third stage of labor (correct stage) Uterotonic drug at third stage and immediately after delivery of baby (correct stage & timing) Uterotonic drug at 3rd stage, after delivery of baby, 10 IU (with correct dose) Uterotonic drug, 3rd stage, after delivery of baby, 10 IU, IM (correct dose & route) Correct use of uterotonic drug+controlled cord traction Correct use of uterotonic drug, CCT, uterine massage

Post Assessment Interventions

AMTSL training conducted for doctors and nurses in 25 out of 64 districts (by Mayer Hashi in 21 districts) Trained maternity care service providers started practicing their newly learned AMTSL skills Supervision and coaching with DGFP and DGHS Information on AMTSL practices collected through monthly reports Post-training AMTSL practice increased from 16% to 85% Incidence of PPH in monitored facilities declined drastically by more than 75% Mayer Hashi is working with DGHS and DGFP on improving Oxytocin storage in facilities and warehouses

AMTSL Implementation Challenges

Ensuring country-wide training and supervision of providers
Ensuring correct and consistent use of AMTSL in the facilities Maintaining the cold chain for oxytocin Inclusion of AMTSL in the GOB reporting system and consistent reporting. Low institutional delivery rate

Shortage of skilled providers

Limited availability of facilities that offer 24/7 delivery services

2. Misoprostol
Misoprostol is a uterotonic increasingly used in clinical and home settings to prevent and manage PPH. Misoprostol tablets are inexpensive, easy to store, stable under field conditions and have an excellent safety profile.

FIGO and ICM jointly recommend that in home births without a skilled attendant, misoprostol may be an appropriate technology for controlling PPH (ICM/FIGO, 2006)
WHO recommends misoprostol for the prevention of PPH where oxytocin is not available or cannot be safely used (WHO, 2011)

Misoprostol introduction: Major Milestones

Establishment of the National PPH Prevention Task Force, Secretariat at EngenderHealth (October 2006)
Some NGOs started using misoprostol in their working areas (urban and rural). Approval of misoprostol for prevention of PPH by the Directorate General of Drug Administration and its inclusion in the updated essential drug list (May 2008) Approval of the piloting of community-based distribution of misoprostol using fieldworkers (August 2008) Agreement and approval of the effective misoprostol dose for preventing PPH for national use400 mcg (March 2010) Approval of the scale-up plan for misoprostol by the National Technical Committee (NTC) of Directorate General of Family Planning (DGFP) (May 2010) Approval of the national scale-up plan developed with Mayer Hashi technical assistance (September 2010)

Misoprostol use in two pilot districts with Mayer Hashi TA

District Number of

pregnant women registered

Number of Number of Number of women who took Misoprostol women women delivered delivered at home

Tangail 22,050* Coxs Bazar

19,066 19,188

16,513 17,477

15,605 (95%) 16,689 (95%)

25,320

*in both districts 70% of pregnant women were registered by the fieldworkers

National Scale-Up
Incorporated misoprostol into the Health, Population and Nutrition Sector Development Program (HPNSDP) 2011 2016 and respective Operational Plans of DGHS and DGFP
Allocated budget in the Operational Plans for implementation of scale-up

Phase-wise scale-up has started since July 2011 in 4 Districts

Developed implementation modalities for both DGFP and DGHS. DGFP is using their field workers (FWAs) for distribution of the tablets to the pregnant women around 32 weeks of gestation. DGHS is using the Community Clinics and other facilities (e.g. UHCs) to distribute the tablets to the pregnant women when they come for their last ANC visit A misoprostol card was introduced to avoid duplication of distribution Implementation guidelines/circulars were sent out to DGFP and DGHS field staff

National Scale-Up (2)

Tested training and BCC materials approved by DGFP and DGHS were handed over to them DGFP and DGHS will continue to receive TA from Mayer Hashi and other partners to strengthen misoprostol program at the community level Efforts are underway to institutionalize Maternal Death Audits (verbal autopsy) as part of maternal mortality reduction efforts DGFP has incorporated misoprostol in their record keeping and reporting system. DGHS is in the process of doing the same

Lessons Learned from NGO & Pilot programs

Misoprostol can be effectively distributed through trained and supervised fieldworkers
One-day training was found to be sufficient for the fieldworkers Service provider attendance is not required during misoprostol use, and wellcounseled women themselves can correctly use Misoprostol to prevent PPH Misoprostol can reduce PPH compared to previous delivery, as reported by the clients Delivery attendants need to be educated on misoprostol benefits, so they will not prevent women from using the tablets A few women in the pilots reported minor misoprostol-induced side effects The distribution of misoprostol after 32 weeks pregnancy is advisable

Close collaboration with the government, through implementation of pilots and provision of scientific evidence and continuous technical assistance, increases the chances of developing scalable programs

Misoprostol implementation challenges

Reaching and registering all pregnant women for misoprostol distribution
Distribution of Misoprostol tablets to all registered pregnant women Raising community awareness about Misoprostol use and removing myths and misperceptions about delivery and PPH

Preventing inappropriate use of Misoprostol

Raising community awareness regarding facility delivery and use of SBAs Ensuring the accuracy and consistency of information provided through the governments cascade training Ensuring a continuous supply of Misoprostol Ensuring consistent monitoring, supervision, and follow-up of the PPH prevention interventions Ensuring reporting of the PPH prevention interventions through the governments management information system

Thank You