+ All Categories
Home > Documents > Zimbabwe MOH VSI PPH Brief 2013 09...

Zimbabwe MOH VSI PPH Brief 2013 09...

Date post: 12-Oct-2020
Category:
Upload: others
View: 2 times
Download: 0 times
Share this document with a friend
8
Introducing Misoprostol for the Management of Postpartum Hemorrhage in Zimbabwe Final Report in Brief Introduction Postpartum hemorrhage (PPH) is the most common cause of maternal mortality globally, leading to a woman’s death every seven minutes. 1 In Zimbabwe, there has been a 300% increase in the maternal mortality ratio (MMR) between 1994 and 2010 2 and the MMR was estimated at 960 maternal deaths per 100,000 live births in 2012. 3 Overall, 14% of all maternal deaths in Zimbabwe are due to PPH. 4 Ensuring prompt access to highquality prevention and treatment of PPH for all women who deliver is an essential strategy to combat PPHrelated morbidity and mortality and to make progress toward reaching Millennium Development Goal 5, the reduction of maternal mortality by threequarters by 2015. Background The Zimbabwe Ministry of Health and Child Welfare (ZMoHCW) is committed to improving maternal health as outlined in the National Maternal and Neonatal Health Roadmap 20072015. The roadmap presents evidencebased strategies for reversing the decline in maternal health, including the procurement and distribution of essential maternal health commodities. 5 Misoprostol, an effective, safe, low cost and heat stable uterotonic in tablet form, is recommended by the World Health Organization (WHO) for both PPH prevention and treatment. 6 The ZMoHCW aims to increase the availability of misoprostol throughout the country, with the ultimate goal of ensuring that every Zimbabwean woman has access to a uterotonic drug at the time of delivery. Misoprostol as an Evidencebased Strategy for PPH Management Based on recent evidence, the WHO identified the use of uterotonics as the key intervention within the active management of third stage of labor (AMTSL) package, and recommends that all women giving birth should be offered uterotonics for the prevention of PPH. 6 Oxytocin is recommended as the uterotonic drug of choice, for the prevention and treatment of PPH, and misoprostol is recommended in settings where oxytocin is unavailable or cannot be safely used. 6 The WHO also supports the use of misoprostol for the prevention of PPH by community health care workers and lay health workers that are trained in misoprostol use in settings where skilled birth attendants are not present. 6 Misoprostol is included in the WHO Model List of Essential Medicines 7 for PPH prevention; as well as in the Priority Lifesaving Medicines for Women and Children. 8 Furthermore, it is included in the lifesaving commodities list for PPH prevention by the United Nations’ Commission on Lifesaving Commodities for Women and Children, 9 whose goal is to increase the supply and use of essential commodities. Through the work of the Misoprostol Technical Working Group hosted within the ZMoHCW, misoprostol is included in the 2011 Essential Drugs List of Zimbabwe (EDLIZ) for obstetric indications. The ZMoHCW BEmONC Facilitator’s Manual 10 also integrates misoprostol use for PPH prevention and treatment when oxytocin is not available. An important next step in Zimbabwe to ensure ongoing product availability is the
Transcript
Page 1: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

 

   

Introducing  Misoprostol  for  the  Management  of  Postpartum  Hemorrhage  in  Zimbabwe  Final  Report  in  Brief    Introduction  Postpartum  hemorrhage  (PPH)  is  the  most  common  cause  of  maternal  mortality  globally,  leading  to  a  woman’s  death  every  seven  minutes.1  In  Zimbabwe,  there  has  been  a  300%  increase  in  the  maternal  mortality  ratio  (MMR)  between  1994  and  20102  and  the  MMR  was  estimated  at  960  maternal  deaths  per  100,000  live  births  in  2012.3  Overall,  14%  of  all  maternal  deaths  in  Zimbabwe  are  due  to  PPH.4  Ensuring  prompt  access  to  high-­‐quality  prevention  and  treatment  of  PPH  for  all  women  who  deliver  is  an  essential  strategy  to  combat  PPH-­‐related  morbidity  and  mortality  and  to  make  progress  toward  reaching  Millennium  Development  Goal  5,  the  reduction  of  maternal  mortality  by  three-­‐quarters  by  2015.    Background  The  Zimbabwe  Ministry  of  Health  and  Child  Welfare  (ZMoHCW)  is  committed  to  improving  maternal  health  as  outlined  in  the  National  Maternal  and  Neonatal  Health  Roadmap  2007-­‐2015.  The  roadmap  presents  evidence-­‐based  strategies  for  reversing  the  decline  in  maternal  health,  including  the  procurement  and  distribution  of  essential  maternal  health  commodities.5  Misoprostol,  an  effective,  safe,  low-­‐cost  and  heat  stable  uterotonic  in  tablet  form,  is  recommended  by  the  World  Health  Organization  (WHO)  for  both  PPH  prevention  and  treatment.6  The  ZMoHCW  aims  to  increase  the  availability  of  misoprostol  throughout  the  country,  with  the  ultimate  goal  of  ensuring  that  every  Zimbabwean  woman  has  access  to  a  uterotonic  drug  at  the  time  of  delivery.    

Misoprostol  as  an    Evidence-­‐based  Strategy  for    PPH  Management  Based  on  recent  evidence,  the  WHO  identified  the  use  of  uterotonics  as  the  key  intervention  within  the  active  management  of  third  stage  of  labor  (AMTSL)  package,  and  recommends  that  all  women  giving  birth  should  be  offered  uterotonics  for  the  prevention  of  PPH.6  Oxytocin  is  recommended  as  the  uterotonic  drug  of  choice,  for  the  prevention  and  treatment  of  PPH,  and  misoprostol  is  recommended  in  settings  where  oxytocin  is  unavailable  or  cannot  be  safely  used.6  The  WHO  also  supports  the  use  of  misoprostol  for  the  prevention  of  PPH  by  community  health  care  workers  and  lay  health  workers  that  are  trained  in  misoprostol  use  in  settings  where  skilled  birth  attendants  are  not  present.6  Misoprostol  is  included  in  

the  WHO  Model  List  of  Essential  Medicines7  for  PPH  prevention;  as  well  as  in  the  Priority  Life-­‐saving  Medicines  for  Women  and  Children.8    Furthermore,  it  is  included  in  the  life-­‐saving  commodities  list  for  PPH  prevention  by  the  United  Nations’  Commission  on  Life-­‐saving  Commodities  for  Women  and  Children,9  whose  goal  is  to  increase  the  supply  and  use  of  essential  commodities.        Through  the  work  of  the  Misoprostol  Technical  Working  Group  hosted  within  the  ZMoHCW,  misoprostol  is  included  in  the  2011  Essential  Drugs  List  of  Zimbabwe  (EDLIZ)  for  obstetric  indications.  The  ZMoHCW  BEmONC  Facilitator’s  Manual10  also  integrates  misoprostol  use  for  PPH  prevention  and  treatment  when  oxytocin  is  not  available.  An  important  next  step  in  Zimbabwe  to  ensure  ongoing  product  availability  is  the  

Page 2: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

registration  of  a  quality  misoprostol  product  for  these  obstetric  indications.  The  ZMoHCW  and  Venture  Strategies  Innovations  (VSI),  a  US-­‐based  non-­‐profit  organization  with  operations  in  Harare,  collaborated  to  conduct  operations  research  (OR)  to  provide  evidence  on  the  feasibility  and  effectiveness  of  integrating  misoprostol  for  PPH  prevention  and  treatment  for  use  at  all  levels  of  health  facilities,  when  oxytocin  is  not  available  or  cannot  be  safely  used.  The  evidence  presented  in  this  brief  is  intended  to  guide  the  ZMoHCW’s  plans  for  scaling  up  the  integration  of  misoprostol  into  Zimbabwe’s  health  care  system  to  expand  coverage  of  uterotonics  to  all  women  giving  birth,  and  to  support  the  registration  of  misoprostol  for  obstetric  indications.        Operations  Research:  Background  The  ZMoHCW’s  and  VSI’s  collaborative  OR  was  conducted  in  68  health  facilities  in  four  districts  of  Zimbabwe:  Chimanimani,  Matobo,  Mutare,  and  Umguza.  The  districts  were  selected  with  the  aim  of  representing  the  country’s  diversity  in  geography,  resources,  and  political  affiliation.  The  OR  sites  included  one  provincial  hospital,  three  district  hospitals,  13  rural  and  mission  hospitals  and  51  rural  health  centers  (RHCs)  (Figure  1).  A  training  of  trainers  was  conducted  for  40  senior  doctors  and  nurses,  followed  by  cascade  trainings  for  135  primary  care  nurses,  nurses  and  midwives  from  all  sites.      

A  baseline  facility  assessment  was  conducted  at  the  68  facilities  prior  to  the  introduction  of  misoprostol.  Staff  interviews  and  record  reviews  were  conducted  for  services  provided  from  September  2011  to  February  2012  to  collect  information  on  the  number  of  deliveries,  PPH  management  practices,  drug  supplies,  staffing,  and  facility  infrastructure.  During  the  OR,  which  refers  to  the  period  from  January  to  June  2013  where  misoprostol  was  made  available  at  all  facilities,  PPH  management  practices  were  monitored  for  six  months.  Monitoring  data  were  collected  from  Delivery  Registries  that  were  revised  to  include  details  about  uterotonic  provision  for  both  PPH  prevention  and  treatment.    Focus  group  discussions  were  held  with  Village  Health  Workers  to  identify  a  tool  for  measuring  blood  loss  during  home  deliveries,  and  a  community  education  campaign  was  conducted  on  topics  that  included  

birth  preparedness,  the  importance  of  a  facility  delivery,  how  to  recognize  signs  of  excessive  bleeding,  and  the  availability  of  drugs  to  prevent  bleeding  at  facilities.  These  messages  were  incorporated  into  routine  antenatal  care  (ANC)  education  sessions  and  community  meetings,  and  presented  on  a  poster  that  was  displayed  in  key  community  sites.      The  current  ZMoHCW  BEmONC  guidelines  outlining  the  steps  for  active  management  of  the  third  stage  of  labor  (AMTSL)  require  the  administration  of  a  uterotonic  to  all  women  who  give  birth  immediately  after  delivery.    In  line  with  the  WHO  recommendations,  the  ZMoHCW  guidelines  also  recommend  oxytocin  as  the  first-­‐line  drug  for  PPH  prevention  while  misoprostol  is  recommended  for  use  when  no  other  uterotonic  is  available,  or  as  a      second-­‐line  drug  when  oxytocin  or  ergometrine  has  failed.10  Similarly,  the  service  delivery  protocol  for  the  

Figure  1:  Districts  and  health  facilities  that  participated  in  the  operations  research  

MUTARE DISTRICT!Pop. = 434,379!

Rural Health Center = 20!Rural/Mission Hospital = 3!

District Hospital = 1!Provincial Hospital = 1!

CHIMANIMANI DISTRICT!Pop. = 136,055!

Rural Health Center = 15!Rural/Mission Hospital = 5!

District Hospital = 0!Provincial Hospital = 0!

MATOBO DISTRICT!Pop. = 110,266!

Rural Health Center = 8!Rural/Mission Hospital = 4!

District Hospital = 1!Provincial Hospital = 0!

UMGUZA DISTRICT !Pop. = 81,781!

Rural Health Center = 8!Rural/Mission Hospital = 1!

District Hospital = 1 Provincial Hospital = 0!

HARARE!

Page 3: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

OR  included  misoprostol  for  PPH  prevention  when  oxytocin  was  not  available,  and  misoprostol  as  an  additional  option  for  the  treatment  of  PPH.  The  OR  service  delivery  and  referral  protocols  are  summarized  in  Figure  2.      Operations  Research:  Key  Findings  Maternity  Services  A  total  of  8,258  deliveries  were  recorded  at  the  OR  facilities  from  January  to  June  2013.  Of  those,  259  were  caesarean  sections,  and  528  women  delivered  at  home  or  on  the  way  to  the  hospital,  which  left  a  total  of  7,400  vaginal  deliveries  at  

the  facilities  in  the  OR  districts.  Place  of  delivery  was  not  recorded  for  71  women.      Over  one-­‐fourth  (n=2,147)  of  vaginal  facility  deliveries  for  which  facility  level  data  was  available  took  place  at  the  RHCs,  with  another  ten  percent  (n=730)  at  the  rural  hospitals.  Almost  one-­‐third  took  place  at  a  district  hospital  (n=2,308),  while  around  15%  took  place  at  both  mission  hospitals  (n=1,064)  and  the  provincial  hospital  (n=1,134).    Almost two-fifths (n=2,877) of facility deliveries took place at rural health centers and rural hospitals.

Increasing the capacity of these facilities to manage PPH, through trained staff and necessary equipment and supplies, is essential.  Uterotonic  Availability  and  Utilization  While  oxytocin  was  available  at  over  90%  of  the  facilities  at  the  time  of  the  baseline  assessment,  over  half  of  the  facilities  (56%)  reported  having  had  a  stock-­‐out  in  the  past  six  months.i  The  mean  duration  of  

                                                                                                                         i  Oxytocin  availability  and  stock-­‐out  information  was  collected  through  staff  interviews  at  the  sites.  

!Oxytocin infusion, 40 units at

30-40 drops/minute!!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV*!

!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!!SURGICAL INTERVENTION, IF NECESSARY AND AVAILABLE!!

!!!

!!!!

Oxytocin, 10 units IM!!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV*!

!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!

!!!!

!!!!

!!!

Oxytocin infusion, 40 units at 30-40 drops/minute!

!

OR, IF OXYTOCIN NOT AVAILABLE!

!Ergometrine 0.5 mgs, IM or IV!!

OR, IF ERGOMETRINE NOT AVAILABLE!

!Misoprostol 800 mcg sublingual!

!SURGICAL INTERVENTION IF

NECESSARY!!!!

!!

Bleeds > 500 ml (PPH)!

!Perceived PPH!

!!

Bleeds > 500 ml (PPH)!

!!

Bleeds > 500 ml (PPH)!

Provincial/Central Hospitals!District Hospital!Home! Rural Health Center!

!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!

10 IU oxytocin, IM !If oxytocin NOT available!600 mcg misoprostol oral!

10 IU oxytocin, IM !If oxytocin NOT available!600 mcg misoprostol oral!

Self refer to health facility, treatment according to

facility guidelines!

No uterotonic!

!!!!!!!!!!!!!!!!!!!!

10 IU oxytocin, IM!If oxytocin NOT available, !600 mcg misoprostol oral!

Refer if woman continues to bleed or has a

deterioration in vital signs ! *Facility treatment regimens are the same for all women with PPH, regardless of what, if any, uterotonic was used for PPH prevention!

PREVENTION !!!!TREATMENT!

Refer if woman requires a surgical intervention not available at the district

hospital!

Figure  2:  Service  delivery  and  referral  protocols  for  PPH  prevention  and  treatment,  based  on  the  level  of  facility  and  availability  of  uterotonics*  

 

 

Page 4: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

stock-­‐outs  was  highest  at  rural  health  centers  (52  days)  and  mission  hospitals  (14  days).  Only  the  provincial  hospital  did  not  report  a  stock-­‐out  in  that  period.      Although  misoprostol  had  been  included  in  the  ZMoHCW  guidelines  for  PPH  prevention  when  oxytocin  is  not  available,  it  was  found  to  be  available  in  only  6%  of  facilities  at  the  time  of  the  baseline  assessment.  It  was  primarily  the  district  and  provincial  hospitals  that  had  misoprostol;  only  one  RHC  and  one  rural  hospital  reported  misoprostol  in  stock  at  the  time  of  the  baseline  assessment.  In  the  baseline  assessment,  nearly  40%  of  the  RHCs  reported  not  having  electricity  or  a  power  source,  which  is  essential  for  refrigerating  oxytocin  and  ensuring  its  stability,  especially  when  stored  for  over  a  few  months.  In  addition,  monthly  power  outages  were  reported  at  all  facility  levels,  with  the  exception  of  the  provincial  hospital.      Even  when  oxytocin  is  available,  the  additional  availability  of  misoprostol  will  help  to  overcome  possible  challenges  with  oxytocin,  such  as  a  lack  of  ideal  storage  conditions,  stock-­‐outs,  or  shortages  of  providers  who  are  authorized  to  administer  injections.  During  the  OR,  misoprostol  was  regularly  provided  to  all  68  facilities.     Ensuring a supply of misoprostol, especially at rural health centers and rural hospitals, is an effective strategy for increasing overall uterotonic coverage.  

According  to  the  baseline  assessment  of  records  from  September  2011  to  February  2012,  all  women  who  delivered  in  a  provincial  or  district  hospital  received  a  uterotonic  for  PPH  prevention.  In  contrast,  during  that  same  period,  19%  of  women  who  delivered  at  a  RHC  and  22%  of  those  delivering  at  the  rural  hospitals  did  not  receive  any  uterotonic  for  PPH  prevention.  Qualitative  data  from  interviews  with  providers  at  rural  facilities  suggested  that  stock-­‐outs  and  limited  availability  of  uterotonics  were  the  two  primary  reasons  for  women  not  receiving  a  uterotonic  for  PPH  prevention.  Providers  reported  that  with  limited  availability  of  oxytocin,  the  drug  was  sometimes  reserved  for  treatment  rather  than  given  for  prevention.      PPH  Prevention  Near  universal  uterotonic  coverage  for  PPH  prevention  at  facility  deliveries  (99%)  was  achieved  during  the  OR.  Misoprostol  contributed  significantly  to  this  high  coverage  

(Table  1).  Of  the  women  who  delivered  at  a  facility  for  whom  district  and  uterotonic  for  PPH  prevention  were  recorded,  88%  received  oxytocin,  9%  received  misoprostol,  3%  received  ergometrine  and  1%  received  no  uterotonic.  Misoprostol  use  was  highest  in  Matobo  and  Chimanimani  districts,  where  12%  and  11%  of  vaginal  deliveries  received  misoprostol  for  PPH  prevention,  respectively.    In  terms  of  uterotonic  coverage  for  all  births,  the  impact  was  greatest  at  the  RHCs  and  rural  hospitals  where  baseline  coverage  rates  were  lowest.  At  RHCs,  coverage  increased  from  81%  to  97%,  while  at  rural  hospitals,  it  rose  from  78%  to  99%  (Figure  3).  Where  uterotonic  coverage  was  high  at  baseline  (for  mission,  district  and  provincial  hospitals  at  99%  to  100%),  the  coverage  was  unchanged.      The  use  of  misoprostol  during  the  OR  was  higher  at  the  RHCs  and  rural  hospitals  than  at  the  other  types  of  

Table  1:  Uterotonic  used  for  PPH  prevention  among  women  who  had  a  vaginal  delivery  at  a  facility,  by  district  (January  –  June  2013)*    

*There  were  8  women  with  missing  information  on  uterotonic  used,  district,  or  both.      

District

Total (n=7,392)

Chimanimani (n=1,512)

Matobo (n=678)

Mutare (n=4,833)

Umguza (n=369)

Uterotonic used for PPH prevention

Oxytocin 1,166 (77.1%)

596 (87.9%)

4,382 (90.7%)

348 (94.3%)

6,492 (87.8%)

Misoprostol 160 (10.6%)

80 (11.8%)

366 (7.6%)

19 (5.2%)

625 (8.5%)

Ergometrine 150 (9.9%)

1 (0.2%)

42 (0.9%)

1 (0.3%)

194 (2.6%)

No uterotonic

36 (2.4%)

1 (0.2%)

43 (0.9%)

1 (0.3%)

81 (1.1%)

Total women protected with a uterotonic

1,476 (97.6%)

677 (99.9%)

4,790 (99.1%)

368 (99.7%)

7,311 (98.9%)

 

Page 5: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

facilities.  Over  the  six  months,  at  RHCs,  21%  of  maternity  cases  that  were  vaginal  deliveries  and  for  whom  uterotonic  data  was  available  were  given  misoprostol  for  PPH  prevention.  At  rural  hospitals,  the  corresponding  figure  was  16%.    As  expected,  misoprostol  use  for  PPH  prevention  was  less  significant  at  the  district  and  provincial  hospitals,  where  it  was  administered  for  PPH  prevention  to  less  than  one  percent  of  women  with  vaginal  deliveries  (n=15).      Misoprostol played a significant role in ensuring women’s access to a uterotonic for PPH prevention at rural health centers where it was administered to one in five women with vaginal deliveries. Including misoprostol as an available uterotonic for PPH prevention resulted in almost universal (99%) uterotonic coverage at facility deliveries.  

Correct  Administration  of  Misoprostol  for  PPH  Prevention  Training  and  instruction  on  dose  and  route  of  administration  was  given  to  health  providers  during  the  OR  trainings,  supervisory  visits,  and  on  misoprostol  regimen  cards  (Figure  4).  Provider  adherence  to  instructions  was  high.  A  correct  regimen  of  600mcg  orally  was  administered  to  all  women  with  a  vaginal  delivery  for  whom  data  was  recorded.    PPH  Treatment  As  per  service  delivery  and  referral  protocols  in  the  OR,  800  mcg  sublingual  misoprostol  was  to  be  used  as  a  treatment  method  for  PPH  at  all  levels  of  the  health  system  if  oxytocin  was  not  available  or  had  failed  as  prevention  (Figure  2).        A  total  of  259  PPH  cases  among  women  with  vaginal  deliveries,  for  whom  data  was  available  on  treatment  and  facility  level,  were  recorded  at  the  OR  sites  from  

January  to  June  2013.  Overall,  10%  were  treated  with  misoprostol.  Misoprostol  played  the  greatest  role  in  PPH  treatment  at  the  RHCs  and  rural  hospitals.  Over  40%  of  the  total  number  of  PPH  cases  were  treated  at  these  two  levels  of  facilities.  At  RHCs,  19%  (n=15)  of  the  PPH  cases  were  treated  with  misoprostol;  over  one-­‐fourth  (27%;  n=6)  of  the  PPH  cases  at  the  rural  hospitals  were  treated  with  misoprostol.  The  availability  of  misoprostol  played  a  significant  role  in  the  treatment  of  women  suffering  from  PPH,  particularly  women  living  in  rural  areas  who  would  have  had  more  difficulty  reaching  a  referral  hospital  in  an  urban  area  in  a  timely  fashion.      Rural women, who are more likely to confront barriers related to cost, availability of transport and cultural barriers that limit their access to timely maternity services, benefited most from the availability of misoprostol for PPH treatment.  Community  Education  Sessions  Two  focus  group  discussions  (FGDs)  were  held  with  21  Village  Health  Workers  in  order  to  identify  a  culturally  acceptable  means  of  measuring  blood  loss  at  home  deliveries.  Community  education  sessions  held  during  the  operations  research  incorporated  messages  from  the  key  findings  from  the  FGDs.  These  key  findings  included:    1)  Village  Health  Workers  believed  that  measuring  blood  loss  at  home  deliveries  with  two  zambias  was  a  culturally  acceptable  means  of  blood  loss  measurement;  2)  local  stakeholders  (village  headmen,  krawl  heads,  mothers-­‐in-­‐law)  should  

Figure  3:  Proportion  of  facility  deliveries  at  rural  health  centers  and  rural  hospitals  receiving  a  uterotonic  for  PPH  prevention,  at  baseline  and  during  the  operations  research  

81%!78%!

97%! 99%!

50%!

60%!

70%!

80%!

90%!

100%!

Uterotonic coverage at Rural Health Centers !

Uterotonic coverage at Rural Hospitals!

Baseline (Sept 2011-Feb 2012)!

Operations Research (Jan-June 2013)!

n=2,824! n=2,148! n=730!n=764!

 

Page 6: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

be  actively  involved  in  relaying  messages  about  safe  delivery;  and  3)  a  variety  of  information  channels  should  be  used  to  disseminate  community  education  information,  including  community  demonstrations  and  dramas,  home  visits  to  pregnant  women,  and  group  education  sessions  at  health  facilities.  Over  the  course  of  the  OR,  17,134  community  members  were  reached  with  community  education  messages.    Future  Opportunities  The  ZMoHCW  encourages  all  women  to  deliver  at  a  health  facility  in  order  to  be  assisted  by  a  skilled  birth  attendant.  Recent  government  investments  in  maternity  waiting  

homes  and  ambulances,  and  a  policy  change  that  removes  charges  for  maternity  care  at  government  facilities,  are  likely  to  increase  the  percentage  of  deliveries  that  take  place  in  health  facilities.  Yet  an  estimated  34%  of  women  currently  deliver  at  home  in  Zimbabwe.3    Many  of  these  women  will  not  receive  any  uterotonic  for  PPH  prevention,  and  a  portion  of  those  suffering  from  PPH  will  not  reach  a  health  facility  in  time  to  prevent  death  or  disability.  Numerous  studies  have  demonstrated  that  misoprostol  can  be  used  safely  and  effectively  at  the  community  level11  and  the  WHO  recommends  misoprostol  use  by  community  health  care  workers  and  lay  health  

workers  for  PPH  prevention  in  settings  where  skilled  birth  attendants  are  not  present  and  oxytocin  is  unavailable.6  The  available  evidence  suggests  that  advance  distribution  of  misoprostol  for  home  births  will  not  interfere  with  efforts  to  increase  facility-­‐based  deliveries.12,13    

Conclusions  The  OR  provides  strong  evidence  of  the  role  that  misoprostol  can  play  in  the  management  of  PPH,  particularly  at  RHCs  and  at  rural  hospitals,  where  maintaining  a  regular  supply  of  oxytocin  under  optimal  conditions  can  present  greater  challenges.  Providers  at  these  lower-­‐level  facilities  were  able  to  correctly  

CERVICAL RIPENINGDose Route Instructions

400 mcg Vaginal or sublingual Give 3 hours before the procedure.

INTRAUTERINE FETAL DEATHReduce doses in women with not use with previous cesarean section.

Dose Route Instructions13-17 weeks200 mcg Vaginal Every 6 hours, maximum 4 doses.18-26 weeks100 mcg Vaginal Every 6 hours, maximum 4 doses.>26 weeks25 mcg Vaginal Every 6 hours.OR25 mcg Oral Every 2 hours.

MEDICATION ABORTIONUse as permitted within the country’s legal framework.

RegimenMEDICATION ABORTION WITH MIFEPRISTONE AND MISOPROSTOLUp to 9 weeks gestationMifepristone 200 mg oral followed 24 to 48 hours later by misoprostol 800 mcg vaginal, sublingual or buccal. For oral route, 400 mcg misoprostol can be used up to 7 weeks of gestation.9-12 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vagi-nal. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.12-24 weeks gestationMifepristone 200 mg oral followed 36 to 48 hours later by misoprostol 800 mcg vaginal or 400 mcg oral. Subsequent misoprostol 400 mcg vaginal or sublingual can be used every 3 hours until expulsion of the products of conception, up to 4 further doses.Dose Route InstructionsMEDICATION ABORTION WITH MISOPROSTOL ONLYUp to 12 weeks gestation

800 mcg Vaginal or sublingual Every 3 hours, maximum 3 doses.

12-24 weeks gestation

400 mcg Vaginal or sublingual Every 3 hours, maximum 5 doses.

Figure  4:  Misoprostol  regimens  pocket  reference  for  clinicians  

Page 7: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

administer  misoprostol  for  PPH  prevention  and  treatment.  The  addition  of  misoprostol  expands  uterotonic  coverage,  especially  to  more  rural  women,  reducing  the  risk  of  PPH.  Ultimately,  the  burden  on  referral  hospitals  of  providing  PPH  treatment  to  large  numbers  of  women  will  be  reduced.  Most  importantly,  misoprostol  can  contribute  to  preventing  the  unnecessary  loss  of  women’s  lives  from  postpartum  hemorrhage.    Programmatic  Recommendations  1. Integrate  misoprostol  as  an  

additional  uterotonic  for  PPH  management  at  all  health  facilities  that  conduct  deliveries  in  Zimbabwe.  

2. Ensure  that  rural  health  centers  and  rural  hospitals  can  manage  PPH  in  order  to  decrease  costs,  both  to  women  and  to  the  

health  system,  of  managing  complicated  PPH  cases  at  higher  level  facilities.  

3. Disseminate  and  implement  the  BEmOC  guidelines,  to  ensure  that  providers  can  correctly  implement  PPH  management  and  referrals  according  to  protocols.    

4. Provide  training  and  job  aids  on  the  use  of  misoprostol  for  PPH  management,  following  the  service  delivery  protocols,  to  all  maternity  service  providers,  including  physicians,  midwives,  nurses,  primary  care  nurses,  and  nurse  aides.    

5. Incorporate  training  on  misoprostol  for  PPH  management  into  the  pre-­‐service  curricula  of  the  medical,  nursing,  and  midwifery  schools.  

6. Increase  community  awareness  about  the  dangers  of  excessive  blood  loss  at  delivery,  

recognizing  excessive  blood  loss,  and  the  importance  of  delivering  in  a  health  facility.  

7. Register  misoprostol  for  obstetric  uses  in  Zimbabwe,  as  an  important  first  step  to  ensure  the  ongoing  supply  of  a  high  quality  product.    

8. Adopt  and  implement  procedures  for  the  ordering  and  distribution  of  misoprostol  to  ensure  its  availability  for  PPH  management  in  all  levels  of  health  facilities,  with  special  attention  to  ensuring  stocks  in  rural  facilities  where  the  need  is  most  often  unmet.    

9. Consider  the  integration  of  PPH  prevention  with  misoprostol  at  the  community  level  through  appropriate  interventions  to  ensure  uterotonic  coverage  for  all  women  giving  birth.

 

   

Perspectives  from  providers:  One Primary Care Nurse at Masasi Rural Health Center in Mutare District stated: “Misoprostol is useful in a rural setting. It cuts costs and it’s not refrigerated.” Another Primary Care Nurse from Chikwakwa Rural Health Center in Chimanimani District said: “Misoprostol was useful in our setting as we sometimes are short of oxytocin. Although we didn’t have [women who developed PPH] we feel that could have handled it well.”

A Midwife at Nyamazura Rural Health Center in Mutare District reported: “Misoprostol was easy to administer and no problems were encountered in using the drug. We recommend the use of it at areas like outreach points so as to assist the hard-to-reach clients.”

Page 8: Zimbabwe MOH VSI PPH Brief 2013 09 16Fbixby.berkeley.edu/wp-content/uploads/2015/03/Zimbabwe-MOH_VSI… · 16/09/2013  · 600 mcg misoprostol oral! 10 IU oxytocin, IM ! If oxytocin

References                                                                                                                            1  Potts  M,  Prata  N,  Sahin-­‐Hodoglugil  N.  Maternal  mortality:  one  death  every  7  minutes.  Lancet  2010;  375  (9728):  1762-­‐3.  2  Central  Statistical  Office  (CSO)  [Zimbabwe]  and  Macro  International  Inc.  Zimbabwe  Demographic  and  Health  Survey  1994.  Calverton,  Maryland:  CSO  and  Macro  International  Inc,  1995.  3  Zimbabwe  National  Statistics  Agency  (ZIMSTAT)  and  ICF  International.  Zimbabwe  demographic  and  health  survey  2010-­‐11.  Calverton,  Maryland:  ZIMSTAT  and  ICF  International  Inc,  2012.  4  Zimbabwe  Ministry  of  Health  and  Child  Welfare.    Maternal  and  perinatal  mortality  study.  Zimbabwe,  2007a.  5  Zimbabwe  Ministry  of  Health  and  Child  Welfare.    The  Zimbabwe  national  maternal  and  neonatal  health  road  map  2007-­‐2015.  Harare:  Ministry  of  Health  and  Child  Welfare,  2007b.  6  World  Health  Organization  (WHO).  WHO  recommendations  for  the  prevention  and  treatment  of  postpartum  haemorrhage.  Italy:  WHO,  2012.  7  WHO.  WHO  Model  List  of  Essential  Medicines.  17th  list  (updated)  March  2011.  WHO,  2011.    8  WHO.  Priority  Medicines  for  Mothers  and  Children.  Geneva:  WHO,  2012.  9  United  Nations.  UN  commission  on  life-­‐saving  commodities  for  women  and  children.  New  York:  United  Nations,  2012.  10  Basic  Emergency  Obstetric  and  Newborn  Care,  Facilitator’s  Manual,  ZMoHCW,  Reproductive  Health  Unit,  2012.      11  Smith  JF,  Gubin  R,  Holston  MM  et  al.  Misoprostol  for  postpartum  hemorrhage  prevention  at  home  birth:  an  integrative  review  of  global  implementation  experience  to  date.  BMC  Pregnancy  and  Childbirth,  2013;  13:44.  12  Rajbhandari  S,  Hodgins  S,  Sanghvi  H  et  al.  Expanding  uterotonic  protection  following  childbirth  through  community-­‐based  distribution  of  misoprostol:  operations  research  study  in  Nepal.  International  Journal  of  Gynecology  &  Obstetrics,  2010;  108  (3):  282-­‐288.  13  Sanghvi  H,  Ansari  N,  Prata  N  et  al.  Prevention  of  postpartum  hemorrhage  at  home  birth  in  Afghanistan.  International  Journal  of  Gynecology  &  Obstetrics,  2010;  108  (3):  276-­‐281.  

 


Recommended