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Prevention of Postpartum Hemorrhage at Home Births in Five

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Prevention of Postpartum Hemorrhage at Home Births in Five The Population & Reproductive Health Partnership (PRHP) Pr evention of Postpartum Hemorrhage at Home Births in Five Communities around Zaria, Kaduna State, Nigeria Nigeria has the world’s second highest number of maternal deaths, with 59,000 mothers’ lives lost annually or 10% of the global figure. Postpartum hemorrhage (PPH) makes a significant contribution to these deaths. PPH is mostly unpredictable; up to 90% of women who develop PPH have no LGA). TBAs and community identifiable risk factors and it can be rapidly fatal if treatment oriented resource persons is not applied immediately. Unfortunately, most of the (CORPs) recruited and maternal deaths due to PPH in Nigeria, as elsewhere, occur in counseled pregnant women on places where there are no skilled birth attendants or because the importance of antenatal of a lack of required skills or resources to manage the bleeding care and PPH prevention using and shock. Misoprostol is a proven uterotonic increasingly misoprostol while drug keepers used in the control of PPH. FIGO/ICM jointly recommend that were responsible for storing in home births without a skilled attendant, misoprostol may misoprostol tablets, and be the only available technology to control life-threatening dispensing them to TBAs, PPH. pregnant women, or members of their households seeking misoprostol by non-skilled them for any woman in her last n 2008, the Population and providers in Nigeria so that the month of pregnancy. Midwives Reproductive Health level of access to the drug could and nurses provided Partnership (PRHP) of be expanded to reach women I supportive supervision and Ahmadu Bello University, Zaria, who deliver at home without the technical backstop. Nigeria, partnered with Venture supervision of skilled health care † Strategies and the Bixby Center providers. Majority of women delivered for Population, Health and at home, with TBA Sustainability at the University of Study design California, Berkeley to initiate a The study was cross-sectional The study enrolled 1,875 study to provide empirical and descriptive in design and women from January through evidence to inform policy sought to describe community- December 2009 and results are decision-makers on the safety of level distribution, knowledge, based on the 1,800 women misoprostol administered by acceptance and uptake of who completed postpartum traditional birth attendants misoprostol at home births in interviews. Almost all women (TBAs) to prevent PPH. The five communities (Unguwan participating delivered at home study was undertaken in Godo and Hayin Ojo in Sabon (95%) and with a TBA (70%). response to the Federal Ministry Gari Local Government Area Unguwan Godo had the fewest of Health’s request for local (LGA), Dakace in Zaria LGA, and home births (80%) and evidence on the use of Tsibiri and Yakawada in Giwa Yakawada and Hayin Ojo had Figure 1: Most important source of misoprostol information each campaign component. 100% 2.4 13.4 health facility 90% 19.4 TBAs were the most important 30.4 80% source of misoprostol 16.2 friend/relative 70% 41.5 information in all communities 14.3 drug 60% 30.7 vendor/pharmacist but Dakace, where CORPS 4.2 50% cassettes/radio played more of a role (31%) 38.4 40% (Figure 1). 14.9 38.4 43.8 CORPS 30% 44.6 20% poster/handbill High misoprostol coverage 26.3 10% 20.5 at home births 8.2 TBA 0% 1.4 3.8 Across all communities TBAs Tsibiri Hayin OjoYakawada Dakace Unguwan CHW and CORPS were very effective Godo in recruiting pregnant women community dialogue as were TBAs in distributing misoprostol for PPH prevention. In total 84% of Figure 2: Reported deliveries in the project sites and misoprostol intake enrolled women received 2000 1875 misoprostol to use in the event 1800 1600 1567 they delivered at home. 1400 Enrollment progress is 1200 presented in Figure 2. The gap 1000 between the two lines in the Total reported 800 graph represents those women deliveries 600 who did not take misoprostol, 400 Received including those who had an misoprostol 200 injection after delivery. 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Near universal comprehension of IEC Most women knew that PPH the highest percentage of drama, print materials and can cause death (84%), and home births (98%). Skilled interpersonal communication understood how much is too attendance at delivery by a by TBAs and CORPs. Key much blood loss after delivery doctor, midwife, nurse or messages included information (83%). However, fewer than medical officer was low (7%). on bleeding after delivery, the half mentioned the importance importance of health facility of going to a health facility or Awareness campaign delivery, and the use of getting help from a midwife if successfully reached misoprostol. The most PPH occurs (49%). This could be community important source of a reflection of the lack of The information, education and misoprostol information varied available services in the area communication (IEC) campaign significantly across sites, and that most women deliver included community dialogues, underscoring the importance of at home with TBAs. Table 1: Coverage of misoprostol and protected births Tsibiri Hayin Ojo Yakawada Dakace Unguwan Total Godo n=106 n=1029 n=315 n=253 n=97 n=1800 Took misoprostol (PPH 89 (84.0) 892 (86.7) 215 (68.5) 147 (58.1) 78 (80.4) 1421 (79.0) prevention) Received Injection 9 (8.5) 25 (2.4) 10 (3.2) 26 (10.3) 5 (2.0) 78 (4.3) Did not receive / take any 8 (7.5) 112 (10.7) 89 (28.3) 80 (31.6) 14 (11.3) 303 (16.8) drug Births protected from PPH* 98 (92.5) 917 (89.1) 225 (71.7) 173 (56.5) 83 (85.6) 1499 (83.3) * percentage estimated from all births More births protected; few with misoprostol at home, all Figure 3: Bleeding-related referrals and the need for additional interventions additional interventions but one were successfully treated (Figure 3). Completed postpartum interview The percentage of women who (n=1800) received injectable uterotonics Majority of women Home births was very low (4%). With the safely used (n=1710) addition of misoprostol at misoprostol Used misoprostol for Did not use misoprostol prevention of PPH home births, 83% of deliveries (n=1425) for prevention of PPH Among women who (n=371) were protected from PPH used misoprostol for Developed bleeding & (Table 1). The average PPH received misoprostol for PPH prevention, 98% treatment of PPH Took injection incidence rate 1 across all of the (n=16) (n=33) reported correctly study communities was lower Additional taking three tablets, Developed bleeding than expected (3%). Bleeding- interventions (n=21) and 88% reported (n=1) related problems developed correct route (oral) and Death PPH Death PPH related during home births were related (n=1) timing. Significantly successfully treated at home. (n=1) more misoprostol Of the 1,425 women who Additional users experienced interventions: used received misoprostol, only 16 misoprostol for shivering (42% v. 9%). treatment of PPH who developed bleeding had (n=20) This value is not blood loss of 500ml or more, Death PPH related surprising, given that (n=1) and of those only one received shivering is an additional interventions (IV and Other symptoms such as nausea, expected symptom of blood). From a much smaller vomiting and fever do not differ misoprostol use. It is also number of 371 women who did significantly among users and important to note that overall not take misoprostol, 21 non-users of misoprostol (Table 96% of the women knew to developed bleeding-related 2). expect shivering as a symptom. problems and were given misoprostol at home for Table 2: Reported experience of postpartum symptoms treatment of PPH. Of those Took Did not take Total receiving treatment for PPH misoprostol misoprostol n=1425 n=371 n=1796 p-value Shivering 603 (42.0) 34 (9.2) 637 (35.5) <0.001 1 Because measurement of blood Nausea 83 (5.9) 15 (4.5) 98 (5.5) 0.109 loss at home births can be Vomiting 29 (2.0) 10 (3.0) 39 (2.2) 0.425 inaccurate, PPH incidence is Raise of body temperature 158 (11.1) 19 (5.2) 177 (9.9) 0.001 measured as intention to treat Watery stool 24 (1.7) 12 (3.3) 36 (2.0) 0.061 using those who needed Did not experience any 1040 (74.6) 277 (68.3) 1316 (73.2) 0.035 additional interventions. symptoms Table 3: Acceptability of misoprostol and willingness to pay for the drug Tsibiri Hayin Ojo Yakawada Dakace Unguwan Total Godo n (%) n (%) n (%) n (%) n (%) n (%) Would use misoprostol in 97 (94.2) 967 (97.9) 270 (92.8) 186 (87.3) 108 (97.3) 1628 (95.4) a subsequent pregnancy Would recommend 96 (93.2) 965 (97.6) 277 (95.2) 188 (87.4) 110 (98.2) 1636 (95.7) misoprostol to a friend or relative Would purchase 96 (93.2) 986 (97.8) 285 (91.6) 215 (89.2) 109 (97.3) 1691 (95.3) misoprostol Average amount willing to 745 497 510 320 867 522 pay for misoprostol (Naira) of those willing to pay has the potential to save many cooperation and support of the Women willing to pay for mothers’ lives throughout initiative; the village heads of misoprostol Nigeria. While efforts to Dakace, Hayin Ojo, Tsibiri, Acceptability was extremely increase skilled delivery should Yakawada, and Unguwan high in all communities with continue and are encouraged, Godo; members of the PRHP; 95% of women willing to pay these are medium- to long- the CORPs, TBAs, drug keepers, for the drug. The average price term solutions. The results of midwives and doctors for their (N 522 or $3.50 USD) reported this study provide evidence to commitment and team work; in Table 3 reflects the amount support the expansion of and the community women they are willing to pay if the community-based distribution who received us with open drug becomes available in their of misoprostol to protect arms.
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