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Expanding Access to Postabortion Care in Zimbabwe Through the Integration Of September 2013 Expanding Access to Postabortion Care in Zimbabwe through the Integration of Misoprostol FINAL REPORT Zimbabwe Ministry of Health and Child Care Through the combined efforts of the government, organizations, communities and individuals, the Government of Zimbabwe aims to provide the highest possible level of health and quality of life for all its citizens, and to support their full participation in the socio-economic development of the country. This vision requires that every Zimbabwean have access to comprehensive and effective health services. The mission of the Zimbabwe Ministry of Health and Child Care (ZMoHCC) is to provide, administer, coordinate, promote and advocate for the provision of quality health services and care to Zimbabweans while maximizing the use of available resources. Venture Strategies Innovations (VSI) VSI is a US-based nonprofit organization committed to improving women and girls' health in developing countries by creating access to effective and affordable technologies on a large scale. VSI connects women with life-saving medicines and services by engaging governments and partners to achieve regulatory approval of quality products and integrating them into national policies and practices. Zimbabwe Ministry of Health and Child Care The Permanent Secretary Kaguvi Building, 4th Floor Central Avenue (Between 4th and 5th Street) Harare, Zimbabwe Telephone: +263-4-798537-60 Website: http://www.mohcw.gov.zw Venture Strategies Innovations 19200 Von Karman Avenue, Suite 400 Irvine, California 92612 USA Telephone: +1 949-622-5515 Website: www.vsinnovations.org ii Acknowledgements Zimbabwe Ministry of Health and Child Care: Dr. Bernard Madzima, Director, Maternal and Child Health Ms. Margaret Nyandoro, Deputy Director, Director of Reproductive Health Principal Investigators : Dr. Tsungai Chipato, University of Zimbabwe Dr. Partson Zvandasara, University of Zimbabwe Dr. Velda Mushangwe, University of Zimbabwe VSI program team: Ndola Prata, Medical Director Nuriye Nalan Sahin Hodoglugil, Associate Medical Director Katharine Rivett, Program Manager Engeline Mawere, Program Officer Molly Moran, Monitoring and Evaluation Specialist Alice Mpete, Nurse Administrator Allison Boiles, Communications Specialist This project could not have been completed without the contributions of the expert staff and colleagues at the Zimbabwe Ministry of Health and Child Care (ZMoHCC) and Venture Strategies Innovations (VSI), whose dedication to this operations research and invaluable contributions to its development led to its successful implementation. The operations research program benefited from the participation of the district officials, who contributed to supportive supervision and monitoring of operations research activities. The operations research also benefitted from the participation of community leaders and other community members who led and participated in community awareness activities. Tarra McNally, former VSI Country Representative, initiated the preliminary work on this operations research, and oversaw the activities until August 2013 and Melody Liu provided data management support until August 2013. Debbie Koh provided programmatic support until January 2013. Most importantly, VSI would like to thank all of the women who consented to participate in this operations research. iii Executive Summary The Zimbabwe Ministry of Health and Child Care (ZMoHCC) is committed to preventing maternal mortality and morbidity due to unsafe abortion and miscarriage by ensuring access to high quality postabortion care (PAC). The estimated maternal mortality ratio (MMR) of 960 maternal deaths per 100,000 live births ranks Zimbabwe among the 40 countries globally with the highest MMR. Abortion-related complications are among the primary obstetric causes of maternal death in Zimbabwe. Misoprostol and manual vacuum aspiration (MVA) are two treatment methods recommended by the World Health Organization (WHO) for the treatment of incomplete abortion and miscarriage (TIAM). Misoprostol is a safe, effective, heat-stable and inexpensive treatment method for incomplete abortion and miscarriage. Misoprostol has been shown to be as effective as MVA for TIAM and can be administered by primary care providers in facilities that lack capacity to provide MVA or other surgical methods. In 2011, after successful advocacy by the ZMoHCC, misoprostol was added to the Essential Drugs List of Zimbabwe (EDLIZ). To advance the government objective of ensuring timely access to quality PAC services, the ZMoHCC and Venture Strategies Innovations (VSI), a US-based non-profit organization, conducted operations research (OR) to provide evidence on the feasibility and acceptability of introducing misoprostol in the PAC service package to be delivered at all levels of the health system, from hospitals to rural health centers. The ZMoHCC’s and VSI’s joint OR was conducted in 68 health facilities in four districts of Zimbabwe. The OR sites included a) provincial hospitals b) district hospitals c) rural and mission hospitals and d) rural health centers. A training of trainers was conducted for 40 senior doctors and nurses, followed by cascade trainings for 135 primary care nurses (PCNs), nurses and midwives from all sites. Facility services from September 2011 to February 2012 were reviewed to provide a baseline facility assessment. Operations research (OR) was conducted from January 2013 to June 2013, during which misoprostol was available for women at these facilities. Also during this time, health providers and Village Health Workers (VHWs) disseminated key messages on the dangers of unsafe abortion, the availability of misoprostol for TIAM and family planning services at OR sites, and the importance of preventing unwanted pregnancies. According to the facility assessment, prior to the OR, there was limited availability of PAC services at the OR sites. In addition to the provincial hospital, only one of three district hospitals and six of thirteen rural and mission hospitals reported offering TIAM. Dilatation and curettage (D&C) was the TIAM treatment method available at the largest number of facilities (n=5) with only two facilities offering MVA. Rural health centers (RHCs) and rural and mission hospitals readily introduced PAC services that included TIAM with misoprostol. At RHC’s, 89% of women who enrolled in the OR were treated with misoprostol. At rural and mission hospitals, 95% of those enrolled were treated with misoprostol. Primary care nurses, the highest level of trained staff at most RHCs, treated over 40% of the women who were administered misoprostol for TIAM. The number receiving misoprostol for PAC at RHCs increased fourfold in just four months. iv The introduction of misoprostol for PAC dramatically reduced the proportion of women at RHCs and rural and mission hospitals that had to be referred for treatment. Only 10% of enrolled women who sought PAC services at RHCs were referred to a higher level facility, compared with 98% at baseline. At rural and mission hospitals, the percentage of women referred for PAC treatment declined by nearly 95%, from 48% to 3%. Health providers at the OR facilities and VHWs in the catchment areas increased community awareness of the availability of misoprostol for PAC, the dangers of unsafe abortion, and the importance of family planning during facility-based health education sessions and community meetings. Overall, 13,845 community members were reached with messages about misoprostol for PAC during the course of the OR. Among the women who returned for follow-up for whom data were recorded (n=120), 96% were successfully treated. Only one woman at an RHC had to be referred for further treatment; at rural and mission hospitals only two women received additional treatment. These outcomes are consistent with the 91-98% efficacy rate of misoprostol for PAC observed in randomized controlled studies. The provision of family planning counseling and services at the time and location that women access services for spontaneous or induced abortion is regarded as a proven high-impact practice to maximize investments in a comprehensive family planning strategy, especially when scaled up and institutionalized,. Over 80% of women in the OR accepted a modern contraceptive method as part of PAC services. Rates of contraceptive uptake were highest at the provincial hospital (92%) and RHCs (87%). Women treated with misoprostol were advised to return after 7-14 days for follow-up. Women treated at RHCs were most likely to return for follow-up (75%), compared with those treated at rural and mission hospitals (39%) and the provincial hospitals (12%). Ten percent of the women who returned for follow-up received a contraceptive at follow-up and not at the initial visit. Women treated with misoprostol experienced minimal side effects. Among the 124 women treated with misoprostol who returned for follow-up, 29 women reported having some side effect after taking the tablets. The most commonly reported side effect was abdominal pain reported by 16 women, followed by chills and/or fever (n=8), nausea and vomiting (n=5) and diarrhea (n=5). The following recommendations on opportunities to strengthen PAC services in Zimbabwe are based on the results of the OR and lessons learned by the ZMoHCC and providers during project implementation. Consequently, a number of the recommendations encompass issues related to scaling up PAC services in Zimbabwe that are not specifically tied to data from the OR. 1. Introduce TIAM with misoprostol
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