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Hobday K, Zwi AB, Homer C, Kirkham R, Hulme J, Wate PZ, Prata N. Misoprostol for the prevention of post-partum haemorrhage in Mozambique: an analysis of the interface between human rights, maternal health and development. BMC Int Health Hum Rights 2020; 20:9. [PMID: 32268892 PMCID: PMC7140325 DOI: 10.1186/s12914-020-00229-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 03/19/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly. METHODS A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique's misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained. RESULTS Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control. CONCLUSIONS Applying a rights-based approach to the Mozambican misoprostol program is helpful in contextualising and informing the practical changes needed to improve access to misoprostol as an essential medicine, and in turn, preventing PPH. This study adds to the evidence of the interconnection between human rights, health and development and the importance of integrating the concepts to ensure women's rights are prioritized within health service delivery.
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Affiliation(s)
- Karen Hobday
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT 0811 Australia
| | - Anthony B. Zwi
- Health, Rights and Development (HEARD@UNSW), Faculty of Arts and Social Sciences, University of New South Wales, Sydney, NSW 2052 Australia
| | - Caroline Homer
- Burnet Institute, 85 Commercial Road, Melbourne, VIC 3004 Australia
| | - Renae Kirkham
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT 0811 Australia
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Emergency Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Páscoa Zualo Wate
- Department of Women’s and Child Health, Ministry of Health, Avenida Eduardo Mondlane, Maputo, Mozambique
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, University of California–Berkeley, University Hall, Berkeley, CA 94720-6390 USA
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Hobday K, Hulme J, Prata N, Wate PZ, Belton S, Homer C. Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework. Glob Health Sci Pract 2019; 7:66-86. [PMID: 30926738 PMCID: PMC6538124 DOI: 10.9745/ghsp-d-18-00475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
Abstract
Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system. Background: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. Methods: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. Results: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. Conclusion: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.
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Affiliation(s)
- Karen Hobday
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia.
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, University of California-Berkeley, Berkeley, CA, USA
| | - Páscoa Zualo Wate
- Department of Women's and Child Health, Ministry of Health, Maputo, Mozambique
| | - Suzanne Belton
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
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Hobday K, Hulme J, Homer C, Zualo Wate P, Belton S, Prata N. "My job is to get pregnant women to the hospital": a qualitative study of the role of traditional birth attendants in the distribution of misoprostol to prevent post-partum haemorrhage in two provinces in Mozambique. Reprod Health 2018; 15:174. [PMID: 30326927 PMCID: PMC6192310 DOI: 10.1186/s12978-018-0622-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background Post-partum haemorrhage is the leading cause of maternal deaths in Mozambique. In 2015, the Mozambican Ministry of Health launched the National Strategy for the Prevention of Post-Partum Haemorrhage at the Community Level. The strategy included the distribution of misoprostol to women in advance at antenatal care and via Traditional Birth Attendants who directly administer the medication. The study explores the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent post-partum haemorrhage. Methods This descriptive study collected data through in-depth interviews and focus group discussions. Traditional Birth Attendants between the ages of 30–70 and women of reproductive age participated in the study. Data was collected between June–October 2017 in Inhambane and Nampula Provinces. Line by line thematic analysis was used to interpret the data using Nvivo (v.11). Results The majority of TBAs in the study were satisfied with their role in the misoprostol program and were motivated to work with the formal health system to encourage women to access facility based births. Women who used misoprostol were also satisfied with the medication and encouraged family and friends to access it when needed. Women in the community and Traditional Birth Attendants requested assistance with transportation to reach the health facility to avoid home births. Conclusions This study contributes to the evidence base that Traditional Birth Attendants are an appropriate channel for the distribution of misoprostol for the prevention of post-partum haemorrhage at the community level. More support and resources are needed to ensure Traditional Birth Attendants can assist women to have safe births when they are unable to reach the health facility. A consistent supply of misoprostol is needed to ensure women at the community level receive this life saving medication.
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Affiliation(s)
- Karen Hobday
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Jennifer Hulme
- Department of Emergency Medicine, University Health Network, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Caroline Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.,Honorary Fellow, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Páscoa Zualo Wate
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Suzanne Belton
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California, Berkeley, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Martins JS, Zwi AB, Hobday K, Bonaparte F, Kelly PM. Changing the malaria treatment protocol policy in Timor-Leste: an examination of context, process, and actors' involvement. Health Res Policy Syst 2013; 11:16. [PMID: 23672371 PMCID: PMC3665480 DOI: 10.1186/1478-4505-11-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 04/30/2013] [Indexed: 11/10/2022] Open
Abstract
In 2007 Timor-Leste, a malaria endemic country, changed its Malaria Treatment Protocol for uncomplicated falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. The change in treatment policy was based on the rise in morbidity due to malaria and perception of increasing drug resistance. Despite a lack of nationally available evidence on drug resistance, the Ministry of Health decided to change the protocol. The policy process leading to this change was examined through a qualitative study on how the country developed its revised treatment protocol for malaria. This process involved many actors and was led by the Timor-Leste Ministry of Health and the WHO country office. This paper examines the challenges and opportunities identified during this period of treatment protocol change.
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Affiliation(s)
- João S Martins
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- Faculdade de Medicina e Ciências da Saúde, Universidade Nacional Timor Lorosae, Avenida Cidade de Lisboa, Dili, Timor-Leste
| | - Anthony B Zwi
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, University of New South Wales, Sydney, Australia
- Faculdade de Medicina e Ciências da Saúde, Universidade Nacional Timor Lorosae, Avenida Cidade de Lisboa, Dili, Timor-Leste
| | - Karen Hobday
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, University of New South Wales, Sydney, Australia
| | | | - Paul M Kelly
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- National Centre for Epidemiology & Population Health, College of Medicine, Biology & Environment, Australian National University, Canberra, Australia
- Population Health Division, ACT Government Health Directorate, Canberra, Australia
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Martins JS, Zwi AB, Hobday K, Bonaparte F, Kelly PM. The implementation of a new Malaria Treatment Protocol in Timor-Leste: challenges and constraints. Health Policy Plan 2012; 27:677-86. [PMID: 22460007 PMCID: PMC3513764 DOI: 10.1093/heapol/czs019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Timor-Leste changed its malaria treatment protocol in 2007, replacing the first-line for falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. This study explored the factors affecting the implementation of the revised treatment protocol, with an emphasis on identifying key constraints. Methods A mixed method approach drew on both qualitative and quantitative data. The study included data from District Health Services in seven districts, community health centres in 14 sub-districts, four hospitals, five private clinics, one private pharmacy and the country's autonomous medical store. In-depth interviews with 36 key informants, five group interviews and 15 focus group discussions were conducted. A survey was also undertaken at community health centres and hospitals to assess the availability of a physical copy of the Malaria Treatment Protocol, as well as the availability and utilization of artemether-lumefantrine and sulphadoxine-pyrimethamine. Results Many factors impeded the implementation of the new malaria protocol. These included: inadequate introduction and training around the revised treatment protocol; unclear phasing out of sulphadoxine-pyrimethamine and phasing in of the revised treatment, artemether-lumefantrine, and the rapid diagnostic test (RDT); lack of supervision; lack of adherence to the revised guidelines by foreign health workers; lack of access to the new drug by the private sector; obstacles in the procurement process; and the use of trade names rather than generic drug description. Insufficient understanding of the rapid diagnostic test and the untimely supply of drugs further hampered implementation. Conclusion To effectively implement a revised malaria treatment protocol, barriers should be identified during the policy formulation process and those emerging during implementation should be recognized promptly and addressed.
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Affiliation(s)
- João Soares Martins
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052, Australia.
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Ramke J, Maher L, Lee L, Hobday K, Brian G. Diabetes and its ocular complications: awareness among adults aged 40 years and older in Timor-Leste. Clin Exp Optom 2012; 95:377-81. [PMID: 22248299 DOI: 10.1111/j.1444-0938.2011.00681.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim was to assess awareness of diabetes mellitus and its ocular complications among Timorese aged 40 years and older. METHODS An interview-based questionnaire was administered to a subset of five urban and five rural clusters of 45 people aged 40 years and older as part of a population-based cross-sectional survey. RESULTS The participation rate was 96.2 per cent and data were analysed for 413 respondents. Correct nomination of at least one symptom, risk factor, prevention or treatment of diabetes was made by 6.1 per cent of participants. When explicitly asked, 6.8 per cent thought that diabetes caused problems with the body and 3.6 per cent thought diabetes caused eye problems. CONCLUSION There is little awareness of diabetes and its ocular complications in Timor-Leste. Given the predicted urbanisation and economic development in the coming decades, as other health challenges are addressed and resources become available, consideration of diabetes might be prudent. Improving knowledge among the population will be an important component of any strategy developed.
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Klaus H, Goebel JM, Muraski B, Egizio MT, Weitzel D, Taylor RS, Fagan MU, Ek K, Hobday K. Use-effectiveness and client satisfaction in six centers teaching the Billings Ovulation Method. Contraception 1979; 19:613-29. [PMID: 487811 DOI: 10.1016/0010-7824(79)90008-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Use-effectiveness of the Billings Ovulation Method (OM) is reported for 1139 clients from six centers who were followed for at least 24 months. Method failure rates were 1% when calculated by either Pearl formula or life table analysis. Combined method and user failure rates were 20% when calculated with the Pearl formula, and 16% at 12 months and 23% at 24 months by life table analysis. Pregnancy rates were higher for couples using OM alone, than for couples using OM in combination with additional fertility awareness methods or together with barrier methods. The difference was significant when estimated by the Pearl formula but not when analyzed by the life table. The emotional implications underlying the apparent contradiction between a desire to avoid pregnancy and the deliberate coital use of fertile days are reflected in the differences between method and user failure rates, the high client satisfaction levels reported with "user failure," and 56% continuation rate at 24 months. The will require in-depth exploration.
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