Improving Maternal Health: PREVENTING POST-PARTUM HEMORRHAGE IN RURAL ZAMBIA

Although maternal mortality rates are declining in Zambia, they remain unnecessarily high. An estimated 591 women die due to complications related to pregnancy and/or childbearing for every 100,000 births in Zambia1 – a rate which is more than 70 times higher than the United States. Post-partum hemorrhage (PPH) is a leading cause of maternal mortality in Zambia, accounting for 34 percent of all maternal deaths according to one study.2 Factors contributing to maternal mortality in Zambia include high rates of unattended births, geographic and transportation barriers to accessing health facilities, and shortages of trained health personnel as well as essential drugs and medical supplies. In Zambia, all of these factors are exacerbated in rural areas where rates of home deliveries are higher (71 percent of all rural births occur at home)3 and access to trained providers as well as essential supplies are more limited. Only 41 percent of health facilities had oxytocin4 in-stock according to SFH monitoring visits conducted before misoprostol distribution for PPH prevention efforts began in early 2009.

SFH/PSI RESPONDSIn support of the Zambian Ministry of Health’s (MOH) Millennium De-velopment Goal of reducing mater-nal mortality by three-quarters, SFH/PSI aims to prevent 200,000 cases of PPH in Zambia between 2009 and 2013 by improving access to miso-prostol5 in rural settings where ac-cess to skilled providers and oxytocin are limited. Toward this goal, SFH/PSI distributes and promotes correct use of misoprostol for PPH preven-tion to pregnant women in ten dis-tricts selected in consultation with the MOH based on high reported rates of home deliveries: Mumbwa, Mwense, Kazungula, Chienge, Chongwe, Ka-fue, Mongu, Senanga, Luangwa and Lufwanyama.6 Since March 2009, SFH/PSI has implemented the fol-lowing program strategies to reduce maternal mortality in Zambia:

. Distribution of misoprostol to 205 government health facilities in 10 rural districts.

. Training of health facility staff as well as influential community members in 10 rural districts to promote the correct use of misoprostol for PPH prevention. In one district (Lufwanyama), the MOH approved SFH to work with trained traditional birth attendants (TBAs) to distribute misoprostol. In the remaining nine districts, SFH/PSI trains facility-based health workers to distribute three tablets (200 micrograms each) of misoprostol to every pregnant woman during routine prenatal care.

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Women are asked to bring the tablets with them when re-turning to a facility to deliver. In case they are unable to deliver at a facility, they are instructed how to correctly use the drug following a home delivery.

. Development of heavily illustrated, local language materi-als to promote correct use of misoprostol for PPH pre-vention, including a ‘Take Action Safe Delivery’ card and a counseling fl ipchart for distribution/use during prenatal care.

. Development of an over-branded (MisoSafe) social mar-keting misoprostol product with heavily illustrated insert to explain correct use, approved by the Zambian Pharma-ceutical Regulatory Authority in May 2010.

. Quarterly monitoring visits by a trained midwife to partici-pating facilities.

. In-depth interviews with women who received misoprostol during prenatal care and subsequently delivered either at a facility or at home.

RESULTS During the fi rst 12 months of implementation, SFH/PSI achieved the following:

. We distributed 196,140 tablets to health facilities in the participating districts during the fi rst 12 months. During the same time period, providers and TBAs distributed 93,945 tablets to 31,315 pregnant women.

. Trained 673 facility-based providers and 279 commu-nity volunteers (including Safe Motherhood Action Group members) to promote safe motherhood behaviors, includ-ing early and regular prenatal care and use of misoprostol to prevent PPH following home deliveries.

In-depth interviews conducted in December 2009 among 24 women who received misoprostol from a provider trained by SFH/PSI and subsequently delivered either at a facility or at home, suggest that pre-natal care is an appropriate mecha-nism for distributing misoprostol in settings where rates of prenatal care are high and home-based deliveries are high. Rural Zambian women who received misoprostol from a facil-ity-based provider or a TBA reported that they:

:: Understood how and why to take misoprostol fol-lowing a home-delivery to prevent PPH

‘Take Action Safe Delivery’ card

Misoprostol is available and free at your nearest rural health centre

• Every pregnant woman should attend an Antenatal Clinic with one of her family members.

• Make sure a pregnant woman gives birth in a health facility.• If a pregnant woman gives birth at home, she should swallow three Mis-

oprostol tablets immediately after giving birth.• If bleeding becomes excessive (two chitenges soaked with blood) she

should be taken to the nearest health facility for examination and treat-ment.

Misoprostol prevents excessive bleeding after childbirth

Misoprostol poster from SFH/PSI Zambia

“I asked if I had to take the drug when labor pains started and I was told, ‘no.’ I only take the drug after giving birth because if you take the drug dur-ing labor you will have killed the child as the drug is very reactive.” 37-year-old mother of seven children, Chongwe district

:: Stored it carefully at home until delivery time“I put [the tablets] in a plastic paper and put the plastic in a bag and then put the bag in the same bin in fear of the children picking it up. Then I locked the bin up.” 25-year-old mother of three children, Lufwanyama district

:: Discussed misoprostol for PPH prevention with spouses, mo-thers and friends

“I told my husband about it all – ‘at the clinic we have been given a drug to take right after delivery, so please remind me when the labor pains start so that I do not forget to carry it with me to the clinic,’ I told him.” 38-year-old mother of five children, Mwense district

“I told people at home, my mother and my husband about [misoprostol.] When [my friends] would come for pre-natal we would discuss and we would remind each other to collect the drug from the nurse.” 22-year-old mother of three children, Chongwe district

:: Perceived quicker recovery and safer delivery compared to previous births

“What used to happen before was not good because sometimes it was not easy to get to the hospital...so we were forced to use our hands to pull out [the placenta] which was dangerous because there was a possibility that there would be some things remaining inside the womb. Now, when I had this baby I had no problems after taking Misoprostol. It just took a minute and the placenta came out immediately. So, I have seen the difference on this one.” 25-year-old mother of five children, Chongwe district

“I did not have any abdominal pains as I usually have after delivery, when I fail to walk and I bleed a lot. But with this child, I did not have excessive bleeding. Even when a child would tell me that ‘mum, there is someone at the door’ I can walk out of the house to meet the visitor.” 37-year-old mother of seven children, Chongwe district

“The placenta always gives me problems coming off. It would always take so much time to come off and when it does, a lot of blood would come along with it. But on this delivery, I did not experience any of these prob-lems. What happened this time was that just after I delivered, and imme-diately after I swallowed the drugs, the placenta came off.” 38-year-old mother of five children, Mwense

:: Did not experience serious side effects“When I took it, I developed a bad headache which only lasted for about 20 minutes, much of the bleeding also stopped and was just normal.” 25-year-old mother of three children, Lufwanyama district

:: CLIENT INTERVIEW: CHRISTINE

Christine Shapi gave birth to her fourth child in her home in Old Palace village, Mwense district three weeks prior to the inter-view. She was given Misosafe during an antenatal visit. “I was told the tablets would help me not to have excessive bleeding after delivery,” she said.

She took the three tablets home and told her husband about them, also telling him that they were located in her baby bag. When her labor started, her hus-band called the local traditional birth attendant who gave her the tablets after the placenta came out. “She knew about the tablets because she was there when the health provider was explaining about the tablets. I had normal bleeding unlike before. The next day was just like normal period,” Christine reported.

Christine planned for a home-birth because the distance and transportation costs to the near-est facility are prohibitive. The same traditional birth attendant has delivered all of her children, but this was the first time she had used Misosafe. When asked if she would recommend it to other women, she responded, “Yes, it’s a good drug.”

1 Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia and Macro International Inc. (2009). Zambia Demographic and Health Survey 2007. Calverton, Maryland, USA: CSO and Macro International Inc.

2 Zambia Ministry of Health, A Study of Factors Associated with Maternal Mortality in Zambia. 1998. 3 ZDHS, 2007. 4 Oxytocin is the preferred uterotonic. It is administered via injection by a skilled provider and requires

cold storage. 5 Where access to oxytocin and/or skilled birth attendants is limited, the use of misoprostol for the preven-

tion of PPH is supported by the International Confederation of Midwives (ICM), the International Federa-tion of Gynaecology and Obstetrics (FIGO), the United States Pharmacopoeia and the WHO.

6 The Zambian MOH is conducting a PPH prevention pilot in five other districts with support from Venture Strategies Innovations.

:: Would recommend the drug to relatives or friends, based on th-eir experiences

“I would tell [my sister/friend] to be taking the three pills from the clinic and to stop listening to the old women from the village who encourage us to take concoctions. I can tell her that she will have some strength after delivery and that there is less bleeding and abdominal pains. As women, we have a lot of things that trouble us after delivery, but after I took the three tablets, the troubles were lessened.” 37-year-old mother of seven children, Chongwe district

The interviews also revealed misperceptions that misoprostol reduces breast milk production and interferes with fertility. The interviews also indi-cate that women report taking misoprostol between one and 10 minutes fol-lowing home delivery, suggesting a need to clarify the importance of taking the drug within one minute of delivery.

RECOMMENDATIONSThe results of the SFH/PSI program thus far indicate that future PPH pre-vention programs in similar rural settings should consider the following:

. Prenatal distribution as an appropriate mechanism for distribution of mi-soprostol in areas where home deliveries are high.

. Training of facility-based providers as well as influential community mem-bers regarding correct use of misoprostol for PPH prevention, with an increased emphasis on the ideal timing and sequence for correct use.

. Incorporating testimonials from women who have experience using mis-oprostol following a home delivery to motivate other women to adopt safe delivery practices, including correct use of misoprostol.

. Developing messages and materials to address myths and misconcep-tions regarding misoprostol.

. Integrating Misoprostol into broader safe motherhood programming and ensuring that misoprostol does not interfere with women’s intentions to deliver at a facility or provider adherence to active management of the third stage of labor.

:: CLIENT INTERVIEW: MUTI

Muti Kapungo, age 20, gave birth to her second child at home in Luko six days prior to the inter-view. During an antenatal visit, she was given three Misosafe tablets and instructed on how to use them. Upon returning to her village, she told her husband and her sister-in-law about the tab-lets. She had planned on deliv-ering in a facility; however, upon arriving at Litoya Rural Health Centre in labor she was informed all the providers had gone else-where.

Muti returned home and had her husband call the traditional birth attendant (TBA). “After the baby was born, I told the TBA to give me the three tablets from the plastic bag before the placenta came out, and I was helped with water by my sister in-law who was also in the delivery room,” she said. “When I settled and was feeding the baby, the TBA asked me about the tablets and I explained that I was given at the clinic in Mongu to prevent exces-sive bleeding after delivery.”

When asked if she would recom-mend MisoSafe to other women, Muti responded, “Yes, because I did not bleed much as in my last delivery and I did not have a problem with the placenta taking long to come out like last time.”