1. Postpartum Hemorrhage Prevention and Treatment in Africa: Using Misoprostol at Community Level Ndola Prata, MD, MSc Africa Regional Meeting on Interventions for Impact in Essential Obstetric and Newborn Care Addis Ababa, Ethiopia February 21-25, 2011 9/28/10

2. Rational for community-level prevention and treatment of PPH with misoprostol Disparities in maternal indicators: – MMR – Skilled assistance during delivery – Access to EmOC – Access and usefulness of ANC There is an imperative need to address home births with quality interventions

3. Interventions & Technologies for PPH Management Intervention/ TechnologyLocation Where it is UsedLevel of Provider Home based life saving skillsHouseholdMinimally trained Conventional Injectable Uterotonics Facility Household Skilled skilled MisoprostolFacility Household Skilled Minimally trained & Self Administration Oxytocin-UnijectFacility Household (?) Skilled Minimally trained Anti-shock GarmentFacility Household ( for application only ) Skilled Minimally trained ( for application only ) IV fluids and BloodFacilitySkilled Balloon/condom CatheterFacilityHighly skilled Surgical interventionsFacilityHighly skilled

4. WHEN AND HOW DO WE REACH THE WOMAN? 4

5. DELIVERY PREGNANCY ANCHealth Facility Home TBA PPH Prevention

6. DELIVERY PREGNANCY ANCHealth Facility Home Community Health Worker TBA M M M PPH Prevention: Misoprostol the “game changer”

7. Options to Prevent PPH using Misoprotsol at Community Level During pregnancy – ANC – Community health worker – Safe delivery kits – Pharmacies; chemical sellers; community drug keepers; patent medicine vendor At Home Delivery – Community health worker – Traditional birth attendant

8. PPH Prevention at the Community Level 8 Madagascar Primary health centers 1& 2 Zambia ANC Distribution Mozambique TBA & ANC Distribution Tanzania ANC Distribution Ghana ANC Distribution Nigeria TBAs & Community Gatekeepers Uganda Health Centers 3 & 4 Bangladesh TBA & ANC Distribution in safe delivery kits Kenya ANC Distribution Ethiopia HEW Nepal Pharmacies/ Social Marketing Indonesia (not shown) Community health volunteers Afghanistan Community health volunteers Pakistan Lady health visitors

9. Distribution of Misoprostol for PPH Prevention through Antenatal Care (ANC) Community Awareness Campaign on Birth Preparedness & PPH Prevention Radio Community meetings with CORPs and TBAs Posters and Pamphlets Misoprostol Distribution at ANC ANC Visit Education Session on PPH and Misoprostol Misoprostol Distribution Reduce PPH at Home Births 9

10. Misoprostol distribution at ANC increased the number of births protected from PPH in Kenya N=2,890

11. Community distribution of misoprostol increased the number of births protected from PPH in Zaria, Nigeria

12. PPH Treatment at Home Births Critical Considerations: – Who is present at birth? – How will women/family get the drug? – When is the drug administered? How is PPH identified? – Route of administration?

13. TBA Treatment of PPH with Misoprostol Reduced the Need for Referrals and Interventions Prata, Mbaruku, et al. International Journal of Gynecology and Obstetrics (2005) 90,51-55. 13

14. 14 Use and Effectiveness of Misoprostol for Treatment of PPH at Community level Women with perceived PPH (2 kangas soaked with blood) (N=239) Women offered misoprostol for treatment (N=171) 71.5% Women received misoprostol for treatment (N=164) 95.9% Women who took misoprostol and needed to be transferred for additional interventions (N=3) 1.8%

15. Strategies for Community level use of Misoprostol Programatic & Implementation level Know the community Effective awareness campaign Integrate misoprostol distribution into existing community- based maternal health interventions Improve services in delivery rooms

16. Strategies for Community level use of Misoprostol Policy Level Commitment to protect all deliveries from PPH wherever they occur Allocation of human and financial resources Scale up interventions Work towards a comprehensive package of maternal health services that includes community-based distribution of misoprostol

17. Thank You