1. Prevention of Postpartum Hemorrhage (PPH) in South Sudan: Increasing Access to Evidence-based Interventions Jeffrey M. Smith, MD, MPH South Sudan PPH Team Results Dissemination Meeting, Juba, South Sudan 15 May 2013

2. Presentation Objectives Learning Phase: 1.Describe the design 2.Review the questions identified and the findings Expansion Phase: 3.Discuss next steps for expansion of PPH reduction activities

3. Strategies for Prevention of PPH Counseling and Misoprostol Distribution at home by HHP Home visit Education Session on PPH and Misoprostol Advanced distribution of misoprostol Counseling and Misoprostol Distribution at home by HHP Home visit Education Session on PPH and Misoprostol Advanced distribution of misoprostol Counseling and Misoprostol Distribution at ANC ANC Visit Education Session on PPH and Misoprostol Advanced distribution of misoprostol Counseling and Misoprostol Distribution at ANC ANC Visit Education Session on PPH and Misoprostol Advanced distribution of misoprostol PREVENTION OF PPH AMTSL (with oxytocin or misoprostol) at health facility

4. Learning Phase Objectives 1.Assess if ANC visits by trained professionals is an effective mechanism for advanced distribution of misoprostol for PPH prevention to women who deliver at home 2.Assess if home visits by HHPs for counseling on BP/CR and advanced distribution of misoprostol is effective for PPH prevention for women who deliver at home 3.Assess the coverage and use of misoprostol for home births 4.Determine if misoprostol is acceptable to South Sudanese women for PPH prevention 5.Measure whether a strategy of advanced distribution impacts the proportion of deliveries conducted in a health facility 4

5. Study area: expected numbers 5 Mundri EastMvoloTotal Population52,79952,597105,396 # of expected births (annual) 1, 8481, 8413,689 #of villages in each county 142135 # and type of facilities 4 PHCCs 10 PHCUs 1 hospital 2 PHCCs 8 PHCUs 6 PHCCs 18 PHCUs 1 hospital # of HHPs126144270 # of health workers 6361124

6. Design  To reach 1,660 pregnant women with misoprostol Through HHP home visits Or through ANC (after 32 weeks) Recruited/consented pregnant women living in Mundri East and Mvolo, who are: –Above age 15 years –32 weeks gestation or greater –Have no known history of allergy to prostaglandins –Have no previous Caesarean section –Have no known chronic disease or condition (e.g., cardiac disease, diabetes, etc) 6

7. Design  SBAs/CMWs/MCHWs & HHPs were trained to:  Provide birth preparedness / complication readiness (BP/CR) education including PPH risk  Advanced distribution of misoprostol (three 200- μg tablets) late in pregnancy (at/after 32 weeks)  Conduct postnatal care follow-up interview at facilities or at home to: collect information on experience / complications and retrieve empty or unused misoprostol packets. 7

8. Timeline 20122013 AprMayJuneJulyAugSep Oct NovDecJanFebMarAprMay Oct Submitted a research design to MoH and JHU for approval Preparatory activities Training of Health workers and HHPs in counseling and PPH Prevention Training of ANC providers (SBA and MCHWs) in AMTSL Implementation & intensive monitoring Data Analysis and Sharing Learning

9. Findings: Mundri East  2 counties selected for implementation;  Mundri East has completed data collection  Mvolo data collection on-going  15 health facilities engaged  1 hospital, 4 PHCCs, 10 PHCUs  25 ANC providers trained for misoprostol education and advanced distribution  15 SBAs + 4 CMWs trained on AMTSL  135 HHPs trained: counseling and misoprostol advanced distribution during home visits 9

10. Findings: Summary It was feasible to implement a combined PPH prevention intervention of improving services at health facilities and a community focus to reach women who are unable to deliver at health facilities in a rural county of South Sudan.  Prior to the intervention, there was limited use of a uterotonic for PPH prevention in the hospital and no use in health centers. 10

11. Findings: Side effects and complications 11  Minor side effects:  85% of women interviewed who took misoprostol experienced a minor side effect  Serious adverse events:  None among participants  Maternal deaths  2 women, not enrolled in study One woman with triplets (VBx2, C/S), died due to postpartum haemorrhage and DIC One woman died as a result of suspected domestic violence

12. Question #1: Are ANC visits by trained providers effective for distributing misoprostol for PPH prevention to women who deliver at home?  Overall distribution rate for intervention = 85%  85% of expected deliveries were counseled and provided medication  HHPs achieved greater distribution  Provided 4 out of 5 women counseling and advanced distribution of misoprostol during home visits.  ANC distribution was less effective  Reached a smaller percentage of the women than through HHP home visits.  ANC complemented HHP efforts  Helped achievement of high rate of distribution. 12

13. Findings: Distribution 13 enrolled 924 = anticipated births

14. Question #2: Are home visits by HHPs for counseling on BP/CR and advanced distribution of misoprostol is effective for PPH prevention for women who deliver at home?  Both HHPs and health care providers were effective at misoprostol-related education and advanced distribution.  Women who were surveyed (n=511) had high knowledge on BP/CR  Arranging transportation and saving money for delivery  Danger signs during pregnancy  Misoprostol  Timing and number of pills  Surveyed women had lower knowledge on:  Signs of excessive bleeding  3 or more side effects of misoprostol 14

15. Women’s knowledge by counseling source 15

16. Question #3: What coverage and use of misoprostol for home births can be achieved?  Use of misoprostol for home births high  99% of women having a home birth in Mundri East and had misoprostol reported taking it. 16

17. Overall uterotonic coverage: 94% Uterotonic Coverage of Expected Deliveries 17

18. Question #4: Is misoprostol acceptable to South Sudanese women for PPH prevention?  Misoprostol is acceptable to South Sudanese women for PPH prevention.  Even though most women (85%) surveyed experienced side effects  About 9 of 10 women said they:  Were satisfied with misoprostol (87%)  Would recommend it to a friend ( 94%)  Would pay 5 SSP for the medicine ( 92%)  Would take it for the next delivery (99%) 18

19. Question #5: What proportion of deliveries were conducted by trained attendants at health facility?  SSHHS 2010 (national 11.5%)  SHTP II: ~15% facility birth (2012)  87% of deliveries given a uterotonic for PPH prevention  3-fold increase in deliveries from Q1 2012 to Q1 2013  No reduction in facility births after start of intervention 19  43% of deliveries at a health facility Intervention start: September 2012

20. Other findings 20  97% of providers and HHPs had correct knowledge about misoprostol  95% of them were satisfied with the training provided  No stockouts of misoprostol reported  No leakage of misoprostol from the program  For two months, two PHCCs were not able to properly store oxytocin due to refrigerator failure

21. Lessons learned  Ministry of Health leadership and the Technical Advisory Group helped to guide the program implementation and monitored its progress.  The role of a champion was critical to advance both the community and facility components. 21

22. Lessons learned: Facility-level  In the absence of oxytocin, misoprostol can be provided at health facility.  2 PHCCs used misoprostol as alternative to oxytocin when the cold chain system not working  MCHWs can use misoprostol for prevention of PPH  Lack of cold chain system in some facilities (broken fridges) 22

23. Lessons learned: Community-level  HHPs are highly motivated  HHPs’ lack of reading/writing didn’t limit program  Supportive supervision for HHPs is inadequate as facility supervisors do not have time to supervise  Intervention modified so that HHPs came to facility on a regular / monthly basis for supervision and restock of miso  A maternal death audit process was introduced to capture cause of death for enrolled clients.  Strengthening maternal death audits will help to understand cause of death and delays for decision- making for seeking care 23

24. Status in Mvolo (May 2013)  Data collection on going  Data analysis to follow  1 Maternal Death  1 case due to retained placenta Counselled but delivered before HHP could enroll in program. HHP Administered misoprostol in face of retained placenta but unsuccessful. Considered by IRB to be non-serious non-compliance 24

25. MVOLO COUNTY NumberPercentage Estimated deliveries (6 mo)921 Pregnant women identified49253% Received PPH Prevention package of counseling and misoprostol Facility0 HHPs only278100% Place of delivery Health facility9625.6% Home26574.4% Coverage Rate: Health facility (oxytocin)96100% Home (misoprostol)263*99% * 1 delivered away from home and didn’t bring miso with her; 1 husband threw the drug away as he was not counseled Mvolo: Distribution and coverage

26. Mvolo: Implementation Observations  Inadequate supervision due to absence of focal person at program initiation and acting staff had other responsibilities.  Transition from SC to NPA caused a gap in PPH activites.  The CHD remained supportive throughout

27. Key findings  94% of births protected from postpartum haemorrhage  99% of women who had misoprostol and delivered at home, took the misoprostol  No women took the drug prior to delivery  Facility birth rate increased 27

28. Discussion and next steps  Approve PPH clinical guidelines  Revise program implementation package  Training materials  Communication materials  Strengthen educational messages  Strategically expand program in 2 states and beyond. 28

29. Thank you! 29