NEPAL: A Pioneer in CommunityBased Distribution of Misoprostol for Prevention of PPH at Homebirth

Dr. Naresh P KC Ministry of Health and Population, Nepal May 2012

MNH Situation in Nepal

Maternal Mortality Ratio one
of the highest in South East Asia: 281/100,000

Deliveries by Skilled Birth

19% in 2006 36% in 2011

Hemorrhage (APH, PPH) leading cause of maternal death

Puerperal sepsis 5%
Gastroenteritis 4%

Other indirect 16%

Haemorrhage 24%

Other direct 6%

PPH 17%

Attendants increasing but still low

Anaemia 4%

Eclampsia 21%

Low uterotonic coverage (Oxytocin or Misoprostol) Low SBA retention in remote areas

Obstructed Labour 6% Heart disease 7%

Abortion 7%

Sources: Nepal Demographic and Health Surveys, 2006, 2011; Maternal Mortality and Morbidity Survey 2008/09

Preliminary Work for Pilot

Jan 2004: Nepal GoN committed to pilot following Bangkok workshop Policy considerations Apr 2004: Discussion with professional organizations, Safe Motherhood SubCommittee 1 year: evidence to pilot Professional experience and hospital data suggesting high risk for PPH Influential evidence Sept 2004: Formation of Technical Advisory Committee Feb 2005: NHRC approval for pilot

Basic research
Regional RCT showing efficacy

Introduction and pilot

Pilot in Context
First priority was to increase skilled attendance at birth and institutional deliveries through:
Health facility upgrades Emphasis on AMTSL at health facilities SBA in-service training Maternity incentive scheme

Misoprostol distribution by FCHVs for prevention of PPH at home birth within a broader community approaches

Community Service Delivery System

Health workers/ Health facilities FCHV

Woman & newborn

FCHVs and HWs work closely for promotion of ANC, Institutional

delivery and PNC. They have key role in:

Promotion of ANC, institutional delivery and PNC, self-care, hygiene, Essential Newborn Care Use of iron/folate, deworming tablets, TT, post-natal Vitamin A Birth preparedness (money, transport, SBA and blood) Identification of danger signs (pregnancy, delivery and post-natal) and referral

At 8th month, FCHVs distributes Misoprostol. During PNC home visits confirms use and retrieves if unused

Key Roles of FCHVs

Areas Antenatal
Assess Danger signs and referral

Delivery
Danger signs and referral
Danger signs and referral Promotion of institutional deliveries Essential newborn care

Post-natal
Danger signs and referral (including neonates) Birth weight
ENC Exclusive breast feeding PNC (rest, food, hygiene, etc.) Family Planning Iron/folate Post-natal Vit A

Counsel

Birth preparedness and complication readiness Danger signs/refer Seeking care, TT & antihelminthic Rx Misoprostol Iron/folate Misoprostol BPP action card

Distribute

Document

Pregnancy registration

Pregnancy outcomes

Results of Misoprostol Pilot in Banke District, 2005-2007

Timing of Misoprostol Use

Used appropriately

100 80 60 40 20 0

86

Percent

14 0

before the delivery of the baby

afer the delivery of the babybut before the delivery of the placenta

afer the delivery of both baby and placenta

Source: Follow-up survey 2007

Symptoms Reported
100 90 80 70 60 50 40 30 20 10 0
27 22 18.5 15.1 3.4 6.2 9 9.4 2 1.3 6.3 7

Percent

Used MSC

Not used MSC

Source: Follow up survey 2007

Headache

Shivering

Nausea

Loose motion

Dizzy

Fever

Uterotonic Coverage
100 80

60

40

20

0 Baseline Misoprostol Inj. Oxytocin

Source: Follow up survey 2007

Endline

Use of Skilled Birth Attendant

Associated with increased SBA use

Source: NFHP survey

Conclusion: Pilot Success in Banke

Significant increase of
uterotonic coverage High coverage in government system with mobilization of FCHVs Adverse effects were not a significant problem Misoprostol can and should be implemented with efforts to increase Skilled Birth Attendants use High degree of correct use, efficacy and safety Suggestive to scale-up in other districts

Expansion from Pilot

Policy considerations Mar 2010: Nepal country team committed for national level expansion of MSC (Reconvening BKK conference) Pilot Regional RCT used for advocacy April/May 2010: Sharing and advocacy at the national level June 2010: MOHP approved for national level expansion July 2010: Developed implementation guidelines

6 months: pilot results to scaleup Pilot results used to demonstrate feasibility Influential evidence

National level scale-up

Progression to scale

Current GON Approach to PPH Prevention

Prevention of PPH
Active Management of Third Stage of Labor (AMTSL) Use of Misoprostol at home birth

Use of uterotonic drugs: Inj. Oxytocin within a minute after delivery of baby

Controlled cord traction

Uterine massage

Use of uterotonic drug: Tab Misoprostol (600 mcg) after delivery of a baby

Only trained health workers can do AMTSL

Feasible in community settings

Districts with Misoprostol

Far-Western Region
Humla Darchula Bajhang Baitadi Bajura Jumla Achham Kalikot Dolpa Mustang Kanchanpur Kailali Rukum Surkhet Bardiya Salyan Rolpa Banke Dang Palpa Kapilvastu Rupandehi Nawalparasi Chitwan Makwanpur L Ramechhap Parsa Sindhuli Rautahat* Bara Okhaldhunga Khotang Sarlahi Dhanusha Mahottari Udayapur Siraha Saptari Sunsari Morang Jhapa Bhojpur Dhankuta Baglung Myagdi Kaski Lamjung Rasuwa Pyuthan Gulmi Syangha Tanahu Nuwakot Sindhupalchowk Dolakha Dhading K B Kavre Gorkha Manang Dailekh Jajarkot Mugu

N
Mid-Western Region

Dadeldhura Doti

Western Region

Central Region

Eastern Region
Solukhumbu Sankhuwasava Taplejung

Legend
Pilot 2005 Expansion 2009/10 Expansion 2010/11 Plan for Expansion 2011/12

Ilam

GoN is committed to increase uterotonic coverage (GON expanding the intervention and purchasing Misoprostol) Priority is AMTSL during deliveries at health facilities Misoprostol national level scale-up focusing in remote areas.

Major Inputs for Program Scale-up

Training Review/refresher meetings Logistic support Monitoring

Uterotonic Coverage (in selected program districts)

120 100 80 44 60 40 20 50 26 22 14 27 33 59 43 27 36 52 50 56 56 34

28

Misoprostol coverage

HW/HF delivery
Source: District HMIS, 2011/12

Conclusions
National context: Urgent need to reduce MMR due to PPH Realistic piloting under MoHP system Rapid move from pilot to scaleup (<2 years) Consensus and support from all stakeholders (including Nepal Society of Ob/Gyns) for scale-up Nepal is pioneer in successful implementation of Misoprostol and has been a subject of global interest

Challenges
Distribution of misoprostol, ensuring availability and transportation Collection of reports from grassroots level Program expansion/coverage only in partners supported districts limiting the expansion in priority districts Ensuring the quality of training to FCHVs

Thank You
Implementing Partners Government of Nepal (FHD lead) Partners
USAID/NFHP II and its partners UNICEF CARE Nepal Rural Health Development Program (RHDP)/SDC Health Right International Nepal Society of Obstetricians and Gynaecologists (NESOG) One Heart Worldwide (planning to support in expansion)