Engaging Communities in Programs for Postpartum Hemorrhage Prevention
Ann Starrs is president and co-founder of Family Care International.
In the developing world, uncontrolled postpartum bleeding or hemorrhage (PPH) is the leading cause of death in childbirth, killing a woman every five minutes. Misoprostol has been shown to be a safe and effective medicine both for the prevention and for the treatment of PPH. While another drug, oxytocin, is generally recognized as the “gold standard” among uterotonic drugs for preventing or treating PPH, misoprostol has significant advantages for use in settings where maternal mortality is high and most births take place outside of hospitals: misoprostol is delivered in tablet form, and — unlike oxytocin — requires neither refrigeration nor intravenous administration.
In “New global guidance supports community and lay health workers in postpartum hemorrhage prevention,” a commentary I co-authored, along with Dr. Clara Ladi Ejembi of Ahmadu Bello University in Zaria, Nigeria, Pamela Norick of Venture Strategies Innovations, and Dr. Kusum Thapa of Jhpiego, Nepal, for the June 2013 issue of the International Journal of Gynecology & Obstetrics (IJGO), we welcome the release of new global recommendations for misoprostol from the World Health Organization (WHO), the International Federation of Gynecology and Obstetrics (FIGO), and International Confederation of Midwives (ICM). While FIGO and ICM recognize the life-saving benefits of misoprostol to prevent PPH in low-resource settings, the WHO recommends that community and lay health workers administer misoprostol when skilled birth attendants and oxytocin are not available. However, these high-level recommendations aren’t enough: community involvement is crucial to the success of misoprostol interventions. Community members should be active participants in conversations that directly affect their healthcare, and misoprostol programs should empower them to lead implementation and distribution efforts. Our commentary presents two case studies that illustrate the important role of communities in misoprostol programs.
In Nigeria, women’s chances of surviving childbirth are dire: a woman’s lifetime risk of maternal death is 1 in 23, and in the Northwest region where fertility rates are high and cultural and religious beliefs restrict women’s freedom of movement, women are twice as likely to die in childbirth than Nigerians in other regions of the country. More than 90% of births happen at home with only family members or a traditional birth attendant to assist with delivery. With stark statistics such as these, women would have more of a fighting chance if they had access to misoprostol – and that’s where the community comes in.
A team of researchers from Ahmadu Bello University and the University of California, Berkeley, led a series of dialogues with community members concerning maternal health issues as well as PPH warning signs and misoprostol, resulting in community leaders’ support for misoprostol. Through these discussions, the community designated drug keepers, who would give the pills free of charge to traditional birth attendants, pregnant women and family members in the last month of pregnancy, and developed criteria for appointing community members as health educators and birth attendants. Surveys following the program’s implementation revealed that 79% of women who gave birth at home took misoprostol to prevent PPH after delivery. Three years have passed since these dialogues, and community members are still requesting misoprostol from the research team at rates exceeding supply, indicating that a community’s active participation can produce promising results.
A case study from Nepal reveals a similar outcome: community involvement and ownership can lead to an intervention’s success. Because of geographic and cultural barriers, only 1 in 5 Nepalese women attain timely, skilled care for the delivery of their babies. The Nepal Family Health Program II, funded by USAID, and the Government of Nepal sought to remedy Nepal’s high maternal and neonatal death rates by engaging communities in the distribution of misoprostol, renamed Matri Surakchya Chakki or “mothers’ safety pills.” The program recruited the established Female Community Health Volunteers (FCHVs), a group of trusted advocates and community members, to visit homes and provide pre-natal care, educate women and their families on misoprostol, address misconceptions and fears, and give the medication to women during their last month of pregnancy. As a result, there were noticeable increases in use of misoprostol for PPH, as well as an increase in deliveries in health care facilities. FCHVs were proud to provide these services to their neighbors.
When community members have a direct influence on improving the health of their fellow neighbors, a program is more likely to be successful and sustainable. During a community meeting in Nigeria, one woman was relieved she would no longer have nightmares during pregnancy and a proud village chief said, “‘On this day…the joy is immeasurable as we share what we have done.’” As these case studies demonstrate, community members in Nigeria and Nepal decided the progress their own healthcare and became staunch advocates for misoprostol, playing a key role in saving the lives of their neighbors.
You may read the abstract to the commentary here, but subscription is required to read the full text.