1. Dr. Nowrozy Kamar Jahan Team Leader (PPH Prevention) Mayer Hashi (Smiling Mother) Project EngenderHealth Bangladesh Community-based PPH Prevention in Bangladesh : Scaling up Misoprostol Distribution and Use

2. Background BMHSMMS-2001  MMR 320/100,000 live births ( BMHSMMS-2001 ) BMHSMMS-2001  Estimated number of live births: 3.8 million/year ( BMHSMMS-2001 )  Annual number of maternal deaths:12,000  85% of deliveries occur at home ( BDHS 2007 )

3.  National PPH Prevention Task Force (October, 2006)  Misoprostol tablets approved for PPH prevention (May, 2008)  Guideline on Misoprostol use for PPH prevention (May, 2008)  Misoprostol Use Phase 1 Implementation plan for piloting Misoprostol distribution and use (August 2008) Major Milestones for PPH Prevention

4.  First pilot at Tangail district ( Nov,08 - June, 09) –Total population of eight sub-districts: 2.4 million –Est. total # of pregnant women: 21,178  Formal evaluation of the Tangail pilot (October, 2009)  2 nd pilot at Cox’s Bazar ( Nov,09 -June, 2010) –Total population of five sub-districts: 1.3 Million –Est. total # of pregnant women: 13,031 Community-level PPH Prevention Activities

5. District planning and orientation meeting Misoprostol training for GOB and NGO fieldworkers and supervisors Orientation sessions for facility-based service providers Repackaging of Misoprostol tablets Development of BCC materials Activities undertaken in Tangail District

6. BCC Materials on Use of Misoprostol

7. Activities undertaken in Tangail district (Cont’d)  Identification and registration of pregnant women  Counseling of pregnant women, birth attendants and family members  Distribution of Misoprostol tablets  Follow-up of women after delivery

8. Summary Findings -Tangail Summary Overview of Project Monitoring Data Common reasons for not taking Misoprostol: Women with severe anemia believed that they did not have sufficient blood to loose. Women who left the working area after registration forgot to take drug with them. Women who delivered alone at home forgot to take the drug. Some women were prevented by TBAs or village doctors from taking the tablets.

9. Summary Findings - Tangail (cont’d) Side effects, referred cases and maternal death  0.4% (39) registered pregnant women suffered from minor side effects (fever, shivering)  0.3% (25) registered pregnant women suffered from complications and were referred to a hospital  Eight maternal deaths during the pilot period in the project area

10. Summary Findings - Cox’s Bazar  During the period of November, 09- January, 2010 –8,201 pregnant women registered –3,213 registered pregnant women received Misoprostol tablets –1,214 registered pregnant women delivered at home –1,147 (94%) pregnant women who delivered at home used Misoprostol

11. Scaling up Misoprostol Use Best Practice  The evaluation showed that Misoprostol can be safely distributed by the trained GOB and NGO field workers  The 2 Pilots created demand for Misoprostol interventions in other areas  Four large International organizations have started to implement programs  The Ministry of Health and Family Welfare has shown interest in scaling up the community based distribution and use of Misoprostol throughout the country

12. Challenges  To scale-up Misoprostol for PPH prevention, the following elements need to be addressed: –National dose for Misoprostol –Including Misoprostol tablets in the GOB logistics distribution system –Training and orientation through the government operational plan –Marketing of Misoprostol for PPH prevention in a special packet –Incorporation of Misoprostol reporting system in GOB MIS system