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Werner K, Kak M, Herbst CH, Lin TK. The role of community health worker-based care in post-conflict settings: a systematic review. Health Policy Plan 2022; 38:261-274. [PMID: 36124928 PMCID: PMC9923383 DOI: 10.1093/heapol/czac072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/28/2022] [Accepted: 09/18/2022] [Indexed: 11/15/2022] Open
Abstract
Countries affected by conflict often experience the deterioration of health system infrastructure and weaken service delivery. Evidence suggests that healthcare services that leverage local community dynamics may ameliorate health system-related challenges; however, little is known about implementing these interventions in contexts where formal delivery of care is hampered subsequent to conflict. We reviewed the evidence on community health worker (CHW)-delivered healthcare in conflict-affected settings and synthesized reported information on the effectiveness of interventions and characteristics of care delivery. We conducted a systematic review of studies in OVID MedLine, Web of Science, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Google Scholar databases. Included studies (1) described a context that is post-conflict, conflict-affected or impacted by war or crisis; (2) examined the delivery of healthcare by CHWs in the community; (3) reported a specific outcome connected to CHWs or community-based healthcare; (4) were available in English, Spanish or French and (5) were published between 1 January 2000 and 6 May 2021. We identified 1976 articles, of which 55 met the inclusion criteria. Nineteen countries were represented, and five categories of disease were assessed. Evidence suggests that CHW interventions not only may be effective but also efficient in circumventing the barriers associated with access to care in conflict-affected areas. CHWs may leverage their physical proximity and social connection to the community they serve to improve care by facilitating access to care, strengthening disease detection and improving adherence to care. Specifically, case management (e.g. integrated community case management) was documented to be effective in improving a wide range of health outcomes and should be considered as a strategy to reduce barrier to access in hard-to-reach areas. Furthermore, task-sharing strategies have been emphasized as a common mechanism for incorporating CHWs into health systems.
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Affiliation(s)
- Kalin Werner
- *Corresponding author. Institute for Health and Aging, Department of Social and Behavioral Sciences, University of California, 490 Illinois Street, 12th Floor, Box 0646, San Francisco, CA 94158, USA. E-mail:
| | - Mohini Kak
- Health, Nutrition and Population Global Practice, The World Bank, 1818 H Street, N.W., Washington, DC 20433, USA
| | - Christopher H Herbst
- Health, Nutrition and Population Global Practice, The World Bank, 1818 H Street, N.W., Washington, DC 20433, USA
| | - Tracy Kuo Lin
- Institute for Health and Aging, Department of Social and Behavioral Sciences, University of California, 490 Illinois Street, 12th Floor, Box 0646, San Francisco, CA 94158, USA
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Dawson A, Tappis H, Tran NT. Self-care interventions for sexual and reproductive health in humanitarian and fragile settings: a scoping review. BMC Health Serv Res 2022; 22:757. [PMID: 35672763 PMCID: PMC9172979 DOI: 10.1186/s12913-022-07916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and manage illness and disability with or without a health care provider. In resource-constrained settings with disrupted sexual and reproductive health (SRH) service coverage and access, SRH self-care could play a critical role. Despite SRH conditions being among the leading causes of mortality and morbidity among women of reproductive age in humanitarian and fragile settings, there are currently no reviews of self-care interventions in these contexts to guide policy and practice. METHODS We undertook a scoping review to identify the design, implementation, and outcomes of self-care interventions for SRH in humanitarian and fragile settings. We defined settings of interest as locations with appeals for international humanitarian assistance or identified as fragile and conflict-affected situations by the World Bank. SRH self-care interventions were described according to those aligned with the Minimum Initial Services Package for Reproductive Health in Crises. We searched six databases for records using keywords guided by the PRISMA statement. The findings of each included paper were analysed using an a priori framework to identify information concerning effectiveness, acceptability and feasibility of the self-care intervention, places where self-care interventions were accessed and factors relating to the environment that enabled the delivery and uptake of the interventions. RESULTS We identified 25 publications on SRH self-care implemented in humanitarian and fragile settings including ten publications on maternal and newborn health, nine on HIV/STI interventions, two on contraception, two on safe abortion care, one on gender-based violence, and one on health service provider perspectives on multiple interventions. Overall, the findings show that well-supported self-care interventions have the potential to increase access to quality SRH for crisis-affected communities. However, descriptions of interventions, study settings, and factors impacting implementation offer limited insight into how practical considerations for SRH self-care interventions differ in stable, fragile, and crisis-affected settings. CONCLUSION It is time to invest in self-care implementation research in humanitarian settings to inform policies and practices that are adapted to the needs of crisis-affected communities and tailored to the specific health system challenges encountered in such contexts.
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Affiliation(s)
- Angela Dawson
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Hannah Tappis
- Jhpiego, 1615 Thames St, Baltimore, MD, USA. .,Johns Hopkins Center for Humanitarian Health, 615 N. Wolfe St, Baltimore, MD, USA.
| | - Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.,Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1211, Geneva 4, Switzerland
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3
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Drew T, Carvalho JCA. Pharmacologic Prevention and Treatment of Postpartum Hemorrhage. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00444-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Oladapo OT, Blum J, Abalos E, Okusanya BO. Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd009336.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research; World Health Organization; Geneva Switzerland
| | | | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP); Rosario Argentina
| | - Babasola O Okusanya
- Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology; Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba; Lagos Nigeria
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Mary M, Diop A, Sheldon WR, Yenikoye A, Winikoff B. Scaling up interventions: findings and lessons learned from an external evaluation of Niger's National Initiative to reduce postpartum hemorrhage. BMC Pregnancy Childbirth 2019; 19:379. [PMID: 31651264 PMCID: PMC6814039 DOI: 10.1186/s12884-019-2502-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Niger has one of the highest maternal mortality ratios in Sub Saharan Africa, of which postpartum hemorrhage is the leading cause. In 2014, Health and Development International and the Ministry of Health of Niger launched an initiative to introduce and scale-up three PPH interventions in health facilities nationwide: misoprostol, uterine balloon tamponade, and the non-pneumatic anti-shock garment. Methods A two-phase mixed-methods evaluation was conducted to assess implementation of the initiative. Health facility assessments, provider interviews, and household surveys were conducted in May 2016 and November 2017. Results All evaluation facilities received misoprostol prevention doses. However, shortages in misoprostol treatment doses, UBT kits, and NASG stock were documented. Health provider training increased while knowledge of each PPH intervention varied. Near-universal uterotonic coverage for PPH prevention and treatment was achieved and sustained throughout the evaluation period. Use of UBT and NASG to manage PPH was rare and differed by health facility type. Among community deliveries, fewer than 22% of women received misoprostol at antenatal care for self-administered prophylaxis. Among those who did, almost all reported taking the drugs for PPH prevention in each phase. Conclusions This study is the first external evaluation of a comprehensive PPH program taking misoprostol, UBT, and NASG to national scale in a low resource setting. Although gaps in service delivery were identified, results demonstrate the complexities of training, managing stock, and implementing system-wide interventions to reach women in varying contexts. The experience provides important lessons for other countries as they develop and expand evidence-based programs for PPH care.
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Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Ayisha Diop
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Wendy R Sheldon
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Aichatou Yenikoye
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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Parashar R, Gupt A, Bajpayee D, Gupta A, Thakur R, Sangwan A, Sharma A, Sharma D, Gupta S, Baswal D, Taneja G, Gera R. Implementation of community based advance distribution of misoprostol in Himachal Pradesh (India): lessons and way forward. BMC Pregnancy Childbirth 2018; 18:428. [PMID: 30373537 PMCID: PMC6206722 DOI: 10.1186/s12884-018-2036-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Postpartum Hemorrhage remains the leading cause of maternal mortality. To prevent PPH, Misoprostol tablet in a dose of 600 micrograms is recommended for use immediately after childbirth in home deliveries wherein the use of oxytocin is difficult. The current article describes an implementation of "community based advance distribution of Misoprostol program" in India which aimed to design an operational framework for implementing this program. METHODS The intervention was carried out in Janjheli block in Mandi district of the state of Himachal Pradesh which is a mountainous terrain with limited geographical access and reported 90% home deliveries in the year 2014-15. An operational framework to implement program activities was designed which was based on WHO HSS building blocks. Key implementing steps included- Ensuring local ownership through program leadership, forecasting and procurement of 600 mcg misoprostol tablets, training, branding and communication, community engagement and counselling, recording and reporting, monitoring, supportive supervision and feedback mechanisms. RESULTS Over the one year of implementation, 512 home deliveries were reported, out of which 89% received the tablets and 84% consumed the tablet within one minute of delivery. No incidence of PPH in tablet consuming mothers was reported. On account of periodic counselling and effective community engagement the intervention also contributed to better tracking of pregnancies till delivery and institutional delivery rates which increased to 93% from 45% and 57% from 11% respectively as compared to the preceding year. CONCLUSIONS The model has successfully shown the use of single misoprostol tablets of 600 mcg, first time in this program. We also demonstrated a HSS based operational framework, based on which the program is being scaled to additional blocks in Himachal Pradesh as well as to other states of India.
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Affiliation(s)
| | - Anadi Gupt
- Maternal Health, Department of Health and Family Welfare, Government of Himachal Pradesh, Shimla, India
| | - Devina Bajpayee
- Maternal and Newborn Health, USAID-VRIDDHI/IPE Global, New Delhi, India
| | - Anil Gupta
- USAID-VRIDDHI/IPE Global, Shimla, Himachal Pradesh India
| | - Rohan Thakur
- USAID-VRIDDHI/IPE Global, Mandi, Himachal Pradesh India
| | - Ankur Sangwan
- USAID-VRIDDHI/IPE Global, Kinnaur, Himachal Pradesh India
| | - Anuradha Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Deshraj Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Sachin Gupta
- Maternal and Child Health, USAID-India, New Delhi, India
| | - Dinesh Baswal
- Maternal Health, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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Durham J, Phengsavanh A, Sychareun V, Hose I, Vongxay V, Xaysomphou D, Rickart K. Misoprostol for the prevention of postpartum hemorrhage during home births in rural Lao PDR: establishing a pilot program for community distribution. Int J Womens Health 2018; 10:215-227. [PMID: 29785142 PMCID: PMC5953317 DOI: 10.2147/ijwh.s150695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The purpose of this study was to gather the necessary data to support the design and implementation of a pilot program for women who are unable to deliver in a healthcare facility in the Lao People's Democratic Republic (PDR), by using community distribution of misoprostol to prevent postpartum hemorrhage (PPH). The study builds on an earlier research that demonstrated both support and need for community-based distribution of misoprostol in Lao PDR. METHODS This qualitative study identified acceptability of misoprostol and healthcare system needs at varying levels to effectively distribute misoprostol to women with limited access to facility-based birthing. Interviews (n=25) were undertaken with stakeholders at the central, provincial, and district levels and with community members in five rural communities in Oudomxay, a province with high rates of maternal mortality. Focus group discussions (n=5) were undertaken in each community. RESULTS Respondents agreed that PPH was the major cause of preventable maternal mortality with community distribution of misoprostol an acceptable and feasible interim preventative solution. Strong leadership, training, and community mobilization were identified as critical success factors. While several participants preferred midwives to distribute misoprostol, given the limited availability of midwives, there was a general agreement that village health workers or other lower level workers could safely administer misoprostol. Many key stakeholders, including women themselves, considered that these community-level staff may be able to provide misoprostol to women for self-administration, as long as appropriate education on its use was included. The collected data also helped identify appropriate educational messages and key indicators for monitoring and evaluation for a pilot program. CONCLUSION The findings strengthen the case for a pilot program of community distribution of misoprostol to prevent PPH in remote communities where women have limited access to a health facility and highlight the key areas of consideration in developing such a program.
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Affiliation(s)
- Jo Durham
- Faculty of Medicine, School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | | | - Vanphanom Sychareun
- Faculty of Post-Graduate Studies, University of Health Sciences, Vientiane, Lao PDR
| | - Isaac Hose
- Faculty of Medicine, School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Viengnakhone Vongxay
- Faculty of Post-Graduate Studies, University of Health Sciences, Vientiane, Lao PDR
| | | | - Keith Rickart
- Communicable Diseases Branch, Department of Health, Brisbane, Queensland, Australia
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Raams TM, Browne JL, Festen-Schrier VJMM, Klipstein-Grobusch K, Rijken MJ. Task shifting in active management of the third stage of labor: a systematic review. BMC Pregnancy Childbirth 2018; 18:47. [PMID: 29409456 PMCID: PMC5801808 DOI: 10.1186/s12884-018-1677-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/29/2018] [Indexed: 11/30/2022] Open
Abstract
Background Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants. Methods A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool. Results Of 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n = 15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n = 6083) and 63 to 100% (9 studies, n = 8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n = 6445); 80 to 99.4% (5 studies, n = 2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n = 6090). Conclusion Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users. In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended. Electronic supplementary material The online version of this article (10.1186/s12884-018-1677-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tessa M Raams
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands
| | - Verena J M M Festen-Schrier
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.,Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.,Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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Ditai J, Frye LJ, Durocher J, Byrne ME, Ononge S, Winikoff B, Weeks AD. Achieving community-based postpartum follow up in eastern Uganda: the field experience from the MamaMiso Study on antenatal distribution of misoprostol. BMC Res Notes 2017; 10:516. [PMID: 29073923 PMCID: PMC5658951 DOI: 10.1186/s13104-017-2849-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 10/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advance provision of misoprostol to women during antenatal care aims to achieve broader access to uterotonics for the prevention of postpartum hemorrhage. Studies of this community-based approach usually involve antenatal education as well as timely postpartum follow-up visits to confirm maternal and neonatal outcomes. The MamaMiso study in Mbale, Uganda sought to assess the feasibility of conducting follow-up visits in the postpartum period following advance provision of misoprostol for postpartum hemorrhage prevention. MamaMiso recruited women during antenatal care visits. Participants were asked to contact the research team within 48 h of giving birth so that postpartum follow-up visits could be carried out at their homes. Women's baseline and delivery characteristics were collected and analyzed with respect to follow-up time ('on time' ≤ 7 days, 'late' > 7 days, and 'lost to follow up'). Every woman who was followed up late due to a failure to report the delivery was asked for the underlying reasons for the delay. When attempts at following up participants were unsuccessful, a file note was generated explaining the details of the failure. We abstracted data and identified themes from these notes. RESULTS Of 748 recruited women, 700 (94%) were successfully followed up during the study period, 465 (62%) within the first week postpartum. The median time to follow up was 4 days and was similar for women who delivered at home or in facilities and for women who had attended or unattended births. Women recruited at the urban hospital site (as opposed to rural health clinics) were more likely to be lost to follow up or followed up late. Of the women followed up late, 202 provided a reason. File notes explaining failed attempts at follow up were generated for 164 participants. Several themes emerged from qualitative analysis of these notes including phone difficulties, inaccurate baseline information, misperceptions, postpartum travel, and the condition of the mother and neonate. CONCLUSIONS Keeping women connected to the health system in the postpartum period is feasible, though reaching them within the first week of their delivery is challenging. Understanding characteristics of women who are harder to reach can help tailor follow-up efforts and elucidate possible biases in postpartum study data. Trial Registration Number ISRCTN70408620 December 28, 2011.
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Affiliation(s)
- James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, P.O Box 2190, Mbale, Uganda.,Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's' Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - Laura J Frye
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Meagan E Byrne
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's' Hospital, Crown Street, Liverpool, L8 7SS, UK
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Rajbhandari SP, Aryal K, Sheldon WR, Ban B, Upreti SR, Regmi K, Aryal S, Winikoff B. Postpartum hemorrhage prevention in Nepal: a program assessment. BMC Pregnancy Childbirth 2017; 17:169. [PMID: 28583092 PMCID: PMC5460329 DOI: 10.1186/s12884-017-1347-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 05/25/2017] [Indexed: 12/04/2022] Open
Abstract
Background In 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program. Methods Data collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities. Results Among recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment. Conclusions In Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed.
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Affiliation(s)
| | | | - Wendy R Sheldon
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | | | - Senendra Raj Upreti
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Kiran Regmi
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Shilu Aryal
- Family Health Division, Department of Health Services, Ministry of Health and Population Kathmandu, Kathmandu, Nepal
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
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Hobday K, Hulme J, Belton S, Homer CS, Prata N. Community-based misoprostol for the prevention of post-partum haemorrhage: A narrative review of the evidence base, challenges and scale-up. Glob Public Health 2017; 13:1081-1097. [PMID: 28357885 DOI: 10.1080/17441692.2017.1303743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Achieving Sustainable Development Goal targets for 2030 will require persistent investment and creativity in improving access to quality health services, including skilled attendance at birth and access to emergency obstetric care. Community-based misoprostol has been extensively studied and recently endorsed by the WHO for the prevention of post-partum haemorrhage. There remains little consolidated information about experience with implementation and scale-up to date. This narrative review of the literature aimed to identify the political processes leading to WHO endorsement of misoprostol for the prevention of post-partum haemorrhage and describe ongoing challenges to the uptake and scale-up at both policy and community levels. We review the peer-reviewed and grey literature on expansion and scale-up and present the issues central to moving forward.
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Affiliation(s)
- Karen Hobday
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Jennifer Hulme
- b Department of Emergency Medicine , University Health Network, University of Toronto , Toronto , Canada.,c Department of Family and Community Medicine , University of Toronto , Toronto , Canada
| | - Suzanne Belton
- a Menzies School of Health Research , Charles Darwin University , Darwin , Australia
| | - Caroline Se Homer
- d Centre for Midwifery, Child and Family Health, Faculty of Health , University of Technology Sydney , Ultimo , NSW , Australia
| | - Ndola Prata
- e Bixby Center for Population Health and Sustainability, School of Public Health , University of California , Berkeley , CA , USA
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Ononge S, Okello ES, Mirembe F. Excessive bleeding is a normal cleansing process: a qualitative study of postpartum haemorrhage among rural Uganda women. BMC Pregnancy Childbirth 2016; 16:211. [PMID: 27503214 PMCID: PMC4976474 DOI: 10.1186/s12884-016-1014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) remains the leading cause of maternal morbidity and mortality worldwide. The main strategy for preventing PPH is the use of uterotonic drugs given prophylactically by skilled health workers. However, in settings where many women still deliver at home without skilled attendants, uterotonics are often inaccessible. In such cases, women and their caregivers need to recognize PPH promptly so, as to seek expert care. For this reason, it is important to understand how women and their caregivers recognize PPH, as well as the actions they undertake to prevent and treat PPH in home births. Such knowledge can also inform programs aiming to make uterotonics accessible at the community level. Methods Between April and June 2012, a phenomenological study was carried out in a rural Ugandan district involving 15 in-depth interviews. Respondents were purposively sampled and included six women who had delivered at home in the past year and nine traditional birth attendants (TBAs). The interviews explored how PPH was recognized, its perceived causes, and the practices that respondents used in order to prevent or treat it. Phenomenological descriptive methodology was used to analyse the data. Results Bleeding after childbirth was considered to be a normal cleansing process, which if stopped or inhibited would lead to negative health consequences to the mother. Respondents used a range of criteria to recognize PPH: rate of blood flow, amount of blood (equivalent to two clenched fists), fainting, feeling thirsty, collapsing or losing consciousness immediately after birth. As a group, respondents seemed to correctly identify women at risk of PPH (those with twin pregnancies, high parity or prolonged labour), but many individuals did not know all the reasons. Respondents used cold drink, uterine massage and traditional medicine to treat PPH. Conclusion The community viewed bleeding after childbirth as a normal process and their methods of determining excessive bleeding are imprecise and varied. This opens the door for intervention for reducing delays in the home diagnosis of PPH. This includes increasing awareness among TBAs, women and their families about the risk of death due to excessive bleeding in the immediate postpartum period.
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Affiliation(s)
- Sam Ononge
- Department of Obstetrics and Gynaecology, College of Health Sciences, Makerere University, Kampala, Uganda.
| | | | - Florence Mirembe
- Department of Obstetrics and Gynaecology, College of Health Sciences, Makerere University, Kampala, Uganda
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Wells E, Coeytaux F, Azasi E, Danmusa S, Geressu T, McNally T, Potts J, Otive-Igbuzor E, Tibebu S. Evaluation of different models of access to misoprostol at the community level to improve maternal health outcomes in Ethiopia, Ghana, and Nigeria. Int J Gynaecol Obstet 2016; 133:261-5. [PMID: 27158098 DOI: 10.1016/j.ijgo.2016.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | | | - Esther Azasi
- Millennium Promise's One Million Community Health Workers (1mCHW) Campaign, Ghana
| | | | | | | | - Jennifer Potts
- Innovations in HealthCare, Duke University, Durham, NC, USA
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Smith JM, de Graft-Johnson J, Zyaee P, Ricca J, Fullerton J. Scaling up high-impact interventions: how is it done? Int J Gynaecol Obstet 2016; 130 Suppl 2:S4-10. [PMID: 26115856 DOI: 10.1016/j.ijgo.2015.03.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale-up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high-impact interventions: the Helping Babies Breathe initiative; pre-service midwifery education in Afghanistan; and advanced distribution of misoprostol for self-administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well-established; the intervention is as simple and cost-effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives.
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Affiliation(s)
| | | | - Pashtoon Zyaee
- International Confederation of Midwives, The Hague, Netherlands
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15
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Vallely LM, Homiehombo P, Walep E, Moses M, Tom M, Kelly-Hanku A, Vallely A, Nataraye E, Ninnes C, Mola GD, Morgan C, Kaldor JM, Wand H, Whittaker A, Homer CSE. Feasibility and acceptability of clean birth kits containing misoprostol for self-administration to prevent postpartum hemorrhage in rural Papua New Guinea. Int J Gynaecol Obstet 2016; 133:301-6. [PMID: 26971258 DOI: 10.1016/j.ijgo.2015.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/09/2015] [Accepted: 02/12/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the feasibility and acceptability of providing clean birth kits (CBKs) containing misoprostol for self-administration in a rural setting in Papua New Guinea. METHODS A prospective intervention study was conducted between April 8, 2013, and October 24, 2014. Eligible participants were women in the third trimester of pregnancy who attended a prenatal clinic in Unggai Bena. Participants received individual instruction and were then given a CBK containing 600μg misoprostol tablets for self-administration following an unsupervised birth if they could demonstrate their understanding of correct use of items in the CBK. Data regarding the use and acceptability of the CBK and misoprostol were collected during postpartum follow-up. RESULTS Among 200 participants, 106 (53.0%) had an unsupervised birth, and 99 (93.4%) of these women used the CBK. All would use the CBK again and would recommend it to others. Among these 99 women, misoprostol was self-administered by 98 (99.0%), all of whom would take the drug again and would recommend it to others. CONCLUSION The findings strengthen the case for community-based use of misoprostol to prevent postpartum hemorrhage in remote communities. Large-scale interventions should be planned to further evaluate impact and acceptability.
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Affiliation(s)
- Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Primrose Homiehombo
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Elizabeth Walep
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Michael Moses
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Marynne Tom
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Angela Kelly-Hanku
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Vallely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Eluo Nataraye
- Eastern Highlands Provincial Health Authority, Goroka, Papua New Guinea
| | | | - Glen D Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Chris Morgan
- Centre of International Health, Burnet Institute, Melbourne, VIC, Australia; School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - John M Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Andrea Whittaker
- School of Social Sciences, Faculty of Arts, Monash University, Melbourne, VIC, Australia
| | - Caroline S E Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology, Sydney, NSW, Australia
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16
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Haver J, Ansari N, Zainullah P, Kim Y, Tappis H. Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience. J Midwifery Womens Health 2016; 61:196-202. [PMID: 26849472 PMCID: PMC5067583 DOI: 10.1111/jmwh.12413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two‐thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self‐administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before‐and‐after study was to determine the effectiveness of advance distribution of misoprostol for self‐administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. Methods Cross‐sectional household surveys were conducted pre‐ (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. Results Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large‐scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self‐reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. Discussion The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self‐administration.
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Tappis H, Koblinsky M, Winch PJ, Turkmani S, Bartlett L. Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan. Glob Public Health 2015; 11:387-406. [PMID: 26645366 DOI: 10.1080/17441692.2015.1114657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.
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Affiliation(s)
- Hannah Tappis
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Marge Koblinsky
- b Office of Health, Infectious Diseases and Nutrition , United States Agency for International Development , Washington , DC , USA
| | - Peter J Winch
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | | | - Linda Bartlett
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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18
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Ononge S, Campbell OMR, Kaharuza F, Lewis JJ, Fielding K, Mirembe F. Effectiveness and safety of misoprostol distributed to antenatal women to prevent postpartum haemorrhage after child-births: a stepped-wedge cluster-randomized trial. BMC Pregnancy Childbirth 2015; 15:315. [PMID: 26610333 PMCID: PMC4662032 DOI: 10.1186/s12884-015-0750-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 11/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral misoprostol, administered by trained health-workers is effective and safe for preventing postpartum haemorrhage (PPH). There is interest in expanding administration of misoprostol by non-health workers, including task-shifting to pregnant women themselves. However, the use of misoprostol for preventing PPH in home-births remains controversial, due to the limited evidence to support self-administration or leaving it in the hands of non-health workers. This study aimed to determine if antenatally distributing misoprostol to pregnant women to self-administer at home birth reduces PPH. METHODS Between February 2013 and March 2014, we conducted a stepped-wedge cluster-randomized trial in six health facilities in Central Uganda. Women at 28+ weeks of gestation attending antenatal care were eligible. Women in the control-arm received the standard-of-care; while the intervention-arm were offered 600 mcg of misoprostol to swallow immediately after birth of baby, when oxytocin was not available. The primary outcome (PPH) was a drop in postpartum maternal haemoglobin (Hb) by ≥ 2 g/dl, lower than the prenatal Hb. Analysis was by intention-to-treat at the cluster level and we used a paired t-tests to assess whether the mean difference between the control and intervention groups was statistically significant. RESULTS 97% (2466/2545) of eligible women consented to participate; 1430 and 1036 in the control and intervention arms respectively. Two thousand fifty-seven of the participants were successfully followed up and 271 (13.2%) delivered outside a health facility. There was no significant difference between the study group in number of women who received a uterotonic at birth (control 80.4% vs intervention 91.4%, mean difference = -11.0%, 95% confidence interval [CI] -25.7% to 3.6%, p = 0.11). No woman took misoprostol before their baby's birth. Shivering and fever were 14.9% in the control arm compared to 22.2% in the intervention arm (mean difference = -7.2%, 95% CI -11.1% to -3.7%), p = 0.005). There was a slight, but non-significant, reduction in the percentage of women with Hb drop ≥ 2g/dl from 18.5% in the control arm to 11.4% in the intervention arm (mean difference = 7.1%, 95% CI -3.1% to 17.3%, p = 0.14). Similarly, there was no significant difference between the groups in the primary outcome in the women who delivered at home (control 9.6% vs intervention 14.5%, mean difference -4.9; 95% CI -12.7 to 2.9), p = 0.17). CONCLUSION This study was unable to detect a significant reduction in PPH following the antenatal distribution of misoprostol. The study was registered with Pan-African Clinical Trials Network ( PACTR201303000459148, on 19/11/2012).
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Affiliation(s)
- Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda.
| | - Oona M R Campbell
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Frank Kaharuza
- School of Public Health, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda
| | - James J Lewis
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Katherine Fielding
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street WC1E 7HT, London, UK
| | - Florence Mirembe
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, PO Box 7072, Kampala, Uganda
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Weeks AD, Ditai J, Ononge S, Faragher B, Frye LJ, Durocher J, Mirembe FM, Byamugisha J, Winikoff B, Alfirevic Z. The MamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community-based, placebo-controlled randomised trial. BMC Pregnancy Childbirth 2015; 15:219. [PMID: 26370443 PMCID: PMC4570250 DOI: 10.1186/s12884-015-0650-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 11/16/2022] Open
Abstract
Background 600 mcg of oral misoprostol reduces the incidence of postpartum haemorrhage (PPH), but in previous research this medication has been administered by health workers. It is unclear whether it is also safe and effective when self-administered by women. Methods This placebo-controlled, double-blind randomised trial enrolled consenting women of at least 34 weeks gestation, recruited over a 2-month period in Mbale District, Eastern Uganda. Participants had their haemoglobin measured antenatally and were given either 600mcg misoprostol or placebo to take home and use immediately after birth in the event of delivery at home. The primary clinical outcome was the incidence of fall in haemoglobin of over 20 % in home births followed-up within 5 days. Results 748 women were randomised to either misoprostol (374) or placebo (374). Of those enrolled, 57 % delivered at a health facility and 43 % delivered at home. 82 % of all medicine packs were retrieved at postnatal follow-up and 97 % of women delivering at home reported self-administration of the medicine. Two women in the misoprostol group took the study medication antenatally without adverse effects. There was no significant difference between the study groups in the drop of maternal haemoglobin by >20 % (misoprostol 9.4 % vs placebo 7.5 %, risk ratio 1.11, 95 % confidence interval 0.717 to 1.719). There was significantly more fever and shivering in the misoprostol group, but women found the medication highly acceptable. Conclusions This study has shown that antenatally distributed, self-administered misoprostol can be appropriately taken by study participants. The rarity of the primary outcome means that a very large sample size would be required to demonstrate clinical effectiveness. Trial registration This study was registered with the ISRCTN Register (ISRCTN70408620).
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Affiliation(s)
- Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital; and Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Brian Faragher
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Laura J Frye
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Florence M Mirembe
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
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