180233 Misoprostol at the community-level: A feasible postpartum hemorrhage treatment option over the long-term?

Tuesday, October 28, 2008: 10:54 AM

Ndola Prata, MD, MSc , The Bixby Center for Population, Health and Sustainability, School of Public Health, University of California, Berkeley, Berkeley, CA
Godfrey Mbaruku, MD, PhD , Ifakara Health Institute, Dar es Salaam, Tanzania
Martine Holston, MPH , Venture Strategies Innovations, Berkeley, CA
Amy A. Grossman, MPH , Venture Strategies for Health & Development, Berkeley, CA
Kristina Hsieh , School of Public Health, University of California, Berkeley, Berkeley, CA
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Misoprostol tablets are a stable, low-cost, and effective PPH treatment ideal for resource-poor settings. In a 2003 intervention trial in Kigoma, Tanzania we demonstrated that traditional birth attendants (TBAs) could safely and effectively diagnose PPH using a culturally appropriate blood loss measurement tool, the kanga, and treat PPH with 1000g of misoprostol rectally. These communities are unique in that they have continued to follow the study protocol and use misoprostol (in intervention areas) outside a study controlled environment. In 2007, Tanzania registered misoprostol for PPH, portending expansion of its use countrywide. We present results from a study evaluating the long-term community-based use of misoprostol to treat PPH. 950 women who delivered between August 2004 and May 2007 (in intervention and control areas) completed surveys assessing birth outcomes; knowledge of PPH; misoprostol use (among users); and the safety, feasibility and acceptability of misoprostol for home-births. We also conducted five focus group discussions and 31 in-depth interviews with women, TBAs and nurses. Results show that significantly more women were referred for excessive bleeding in the control area (4.2%) than in the intervention area (1.4%). Among referred women, TBAs made the majority of referrals in both areas. Among all misoprostol-users in the intervention area (n=161), two required additional interventions due to PPH; 29.8% experienced no side effects whereas, 70.2% experienced one or more side effects, commonly fever and shivering. No women we referred due to side effects of misoprostol. The vast majority of women found misoprostol to treat PPH highly acceptable; 74% and 85% of women from the intervention and control groups, respectively reported they would recommend misoprostol to a friend. Most women were willing to purchase misoprostol (86%), with many (39%) willing to pay more than 900 TSH for misoprostol, equivalent to a dinner for a family of six. Among women who received misoprostol information in the intervention area (n=202), most women (73.2%) could recall three or more correct statements about misoprostol and TBAs were their most important source of information (79%). Qualitative interviews revealed insights into the perceived barriers to facility-births, and the need for community-based education and access to misoprostol. We recommend the continued training of TBAs and other frontline health workers on misoprostol for PPH and the expansion of its use for prevention or treatment of PPH at the community level.

Learning Objectives:
1. List three measures of misoprostol use at the community-level. 2. Articulate how misoprostol availability at the community level has impacted the women and communities where it has been available for over 3 years. 3. Apply two lessons learned from this evaluation to other settings requiring postpartum hemorrhage prevention and treatment options at the community level.

Keywords: Community-Based Health Care, Maternal Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I assisted in collecting, analyzing, and report writing of these data.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.