Postpartum hemorrhage prevention in Nepal: a program assessment

Abstract

BackgroundIn 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.MethodsData 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.ResultsAmong 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.ConclusionsIn 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.

Factors affecting the prevention of postpartum hemorrhage in Low- and Middle-Income Countries: A scoping review of the literature

“…[30,38] Results from this scoping review also demonstrate the possibility and benefits of distribution of misoprostol to clients either for auto-administration, or administration by community health care professionals, auxiliary midwives or community health workers. [33,34,36,38,39,44,47,53,54] A study conducted in Rwanda [34] to investigate the coverage, acceptability, and feasibility of a program for PPH prevention at community and health facility level found that administration of misoprostol by CHWs at the time of delivery for home births achieved reasonable uterotonic coverage. On the other hand, the program achieved satisfactory uterotonic coverage of 82.5% for all deliveries at the level of health facility due primarily to routine and proper management of the third stage of labor for a high proportion of facility-based deliveries.…”

“…Some challenges have been noted in using prophylactic uterotonics for the prevention of postpartum hemorrhage. Lubinga et al, Rajbhandari et al and Smith et al [27,36,44] report insufficient supplies of misoprostol in some settings. Our findings indicate the underuse of available protocols for PPH prevention and the need to review them to enhance their effectiveness and proper use.…”

Effect of community-based distribution of misoprostol on facility delivery: a scoping review

“…Seven of the studies were from Africa and the remaining seven were from Asia. Three qualitative studies [35,26,12], seven observational studies [36][37][38][39][40][41][42], and four experimental or quasi-experimental studies [43][44][45][46] were included in this review. All studies were published from 2006 to 2018.…”

“…A program evaluation report in Nepal showed that there was no evidence to suggest that misoprostol distributed for the purpose of the prevention of PPH is being misused for labor induction or pregnancy termination [42]. Moreover, as presented in Table 3, in the community-based distribution of misoprostol programs, administration of misoprostol before delivery was reported in less than 2% (n=17) among seven studies involving 11,108 mothers [36,37,40,38,43].…”

“…In Liberia, only 3 of 265 women took misoprostol prior to giving birth [38,46]; while in Ethiopia, less than 2% of women took the tablets before birth [40] (Table 3). Evidence also shows that most women used the misoprostol pills as instructed [39,36,44]; unused doses were returned after birth to the point of distribution; and most others either threw it away or kept it [36,42]. However, qualitative studies in Ethiopia identified, lack of trust in women's capabilities to use misoprostol correctly [12] and fear of misuse [12,26], as a problem limiting the expansion of the program.…”