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By Imtiaz Kamal
Imtiaz Kamal is the president of the Midwifery Association of Pakistan. She has led a “one-woman crusade” to promote the midwifery profession for more than 50 years.
In June 2013, all four provinces of Pakistan—Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan—included misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) on their respective Essential Medicines Lists (EMLs). EMLs indicate medicines that “satisfy the priority health care needs of the population” and should be affordable and available at all times within the context of a functioning health system. As advocates working towards improving reproductive and maternal health in Pakistan, we’ve come a long way in our mission to expand access to misoprostol. In this post, I share our advocacy strategy and the challenges we faced.
The sixth most populous country in the world, Pakistan has an alarmingly high maternal mortality ratio: 260 maternal deaths per 100,000 live births. Every year, almost 12,000 women in Pakistan die from pregnancy and childbirth related complications, accounting for almost 5% of the world’s maternal deaths, and PPH—excessive bleeding after childbirth—causes 27% of these deaths. About 57% of deliveries still take place without a skilled birth attendant present, and in these situations, women often do not have the means to address life-threatening complications when they arise. Fortunately, there is a safe and effective solution to treat and prevent PPH—misoprostol, a low-cost medicine that is practical for use in both facility and home births.
For many years, the National Committee for Maternal and Neonatal Health, the Midwifery Association of Pakistan (MAP), and the Association for Mothers and Newborns, with support from the Research & Advocacy Fund (RAF), championed the widespread availability of misoprostol in Pakistan.
One step for improving access to this essential medicine was to get provincial governments to include misoprostol on their respective EMLs. Then, the provincial governments can supply it to the public sector health facilities, which would provide this essential medicine at minimal or no cost to women wherever they live.
Usually, the Pakistani government follows the World Health Organization’s (WHO) EML, but due to misoprostol’s association as an “abortion drug,” we had to sell it to policymakers, highlighting misoprostol’s huge lifesaving potential and the urgency to expand access to women who need it. Misoprostol is an essential part of a package of strategies to improve maternal health, and we must ensure that its use for other indications does not lead to limitations on its availability for PPH.
We devised an advocacy strategy to share the evidence and stimulate supportive policy change through:
- Public education and awareness: fact sheets and case studies in English and Urdu, press conferences, trainings with journalists, and air time on television;
- Advocacy with decision-makers, including high-level Ministry of Health authorities, district health officers, OB/GYNs, and other health providers: face-to-face meetings and dissemination seminars in Punjab, Sindh, and the federal capital, Islamabad, to share guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO).
Our advocacy strategy led to very specific, positive outcomes:
- Endorsements from key champions: The Director General of Health in Sindh province became a close ally and guided us on how to move forward in garnering support from OB/GYNs and district health officers;
- A widely distributed position paper on misoprostol for PPH and post-abortion care (PAC) was signed by six professional organisations working for maternal and neonatal health;
- The National Assembly decided that the federal government should provide training to midwives and other health care providers on the administration of misoprostol to manage incomplete abortion and miscarriage and prevent PPH. In Sindh, the Directorate of Nursing came to us for guidance, and the first misoprostol workshop for midwifery teachers is scheduled for late February 2014.
Our advocacy efforts weren’t without challenges, however. For example, many physicians were cautious or opposed to making misoprostol more widely available. The most senior OB/GYN (from a province with very high maternal mortality) raised a number of concerns after a presentation we held on misoprostol, commenting: “It is not candy. We cannot let it be available freely.” We explained that, given the high prevalence of home births, we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births. Distributing misoprostol doesn’t replace efforts to promote skilled care, but we need to recognize the reality that many women are not able to give birth in well-equipped health facilities with skilled staff. All women, wherever they decide to give birth, need access to effective medicines.
We faced similar comments and questions at every advocacy meeting. But this didn’t stop us; we continued to make our case. Eventually, that very same OB/GYN signed our position paper on misoprostol.
The movement to achieve national recognition of misoprostol for PPH has been challenging, but we are making progress, turning heads, and changing minds. Step by step, we push forward. Now that we have achieved Federal approval of misoprostol, we are working to advance community level distribution of misoprostol to women in their eighth month of pregnancy. As a global community, with partners such as FCI rallying behind the cause, we will succeed in making sure women no longer have to fear for their lives when giving birth.
For more information:
The new frontier of community health care: Health huts in Senegal use misoprostol and oxytocin in Uniject to prevent postpartum hemorrhage
[Version française ci-dessous]
Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
While Senegal, a coastal West African country, has made considerable progress in decreasing maternal mortality since 1990, it still grapples with high rates of preventable maternal death. Postpartum hemorrhage (PPH)—excessive, uncontrolled bleeding—remains the leading cause of maternal death in Senegal and around the world. In areas of Senegal where there is still a high prevalence of unattended deliveries, women may not have the means to manage PPH or other life-threatening complications.
Regardless of where they give birth, all women need access to uterus-contracting drugs, or uterotonics, for the prevention and treatment of PPH. The recommended uterotonic, injectable oxytocin, requires cold storage and technical skill to administer; oxytocin is also available as a Uniject® device—a pre-filled, single dose, non-reusable injection—which is easier to administer. Misoprostol is a safe and effective alternative in low-resources settings where oxytocin isn’t available or feasible; it doesn’t need refrigeration and is easy to use—particularly important in the absence of a skilled birth attendant.
Between June 2012 and August 2013, Gynuity Health Projects, ChildFund Senegal, the USAID Community Health Program, and the Senegalese government’s Directorate of Reproductive and Child Health implemented a study to compare community-level administration of oral misoprostol and oxytocin in Uniject® to prevent PPH. One of the two interventions was assigned to each of 28 participating community health huts, one- or two-room concrete structures that bring basic healthcare closer to the communities. Project implementers trained matrones, volunteer birth attendants, to assist with deliveries and administer the designated intervention.
Communities played an integral part in encouraging the use of misoprostol and oxytocin. Community members assisted in identifying pregnant women for initial prenatal check-ups, and project staff recruited women by visiting them in their communities.
Since the launch of the project, over 1300 women received either 600 mg (3 tablets) of misoprostol or 10 IU oxytocin via Uniject® intramuscularly for PPH prevention. Both medicines were effective, and the matrones could manage all side effects, which included chills, tremors and fever. Among all the women who received prophylaxis, only one case of postpartum hemorrhage occurred.
“Before this study, we saw a lot of women with heavy bleeding, and it was always difficult to arrange transportation for referrals [to health facilities],” said Fatou Diouf, a matrone from the Koulouk Mbada hut. “Now, we do not see any hemorrhage after delivery.”
Chief nurse Amadou Gueye from the Ndiaganiao health post noted a similar outcome: “Since the start of the study, we have not seen a single case of PPH.”
As a result of the project, home births decreased from 10% to 1%, project leaders effectively maintained drug stocks, health providers demonstrated commitment and motivation, and the matrones administered medications and filled out data management tools successfully. Birth attendance at the community health huts improved because women sought delivery services in order to benefit from a PPH medication.
“When I came to deliver this morning, the matrone asked me if I wanted to take the three tablets. I said yes,” said Mariama Niang who had recently given birth at the Koulouk Mbada health hut. “I bled less than I did in previous deliveries when I bled a lot and had lots of dizziness. […] now, I am doing well.”
In Senegal where access to health facilities may be limited in remote areas, the community health hut system can play an important role in preventing and treating PPH. According to the study, both misoprostol and oxytocin in Uniject® proved to be equally effective and safe in preventing PPH, and matrones posted at the health huts were capable of administering their assigned medicine. Whereas standard oxytocin injections require specialized skills, misoprostol and oxytocin in Uniject® are viable options at the community level. These health interventions can empower communities to protect women’s health and prevent unnecessary maternal death.
Through research and advocacy, Family Care International (FCI) is working with Gynuity Health Projects to support increased access to and availability of misoprostol for prevention and treatment of PPH. Learn more about FCI and Gynuity’s work to make misoprostol available to women around the globe.
Les nouveaux confins des soins de santé communautaire : Au Sénégal, les cases de santé utilisent le misoprostol et l’ocytocine par Uniject en vue de prévenir l’hémorragie du post-partum
S’il est vrai que le Sénégal, pays côtier de l’Afrique de l’Ouest, a réalisé d’énormes progrès dans la baisse de la mortalité maternelle depuis 1990, il est toujours aux prises avec de forts taux de décès maternels évitables. L’Hémorragie du post-partum (HPP) – des saignements excessifs, difficiles à arrêter – demeure la principale cause de mortalité maternelle au Sénégal et à travers le monde. Dans des régions du Sénégal où il existe une forte prévalence d’accouchements en l’absence d’un personnel qualifié, il est possible que les femmes ne disposent pas de moyens pour le traitement de l’HPP ou d’autres complications potentiellement mortelles.
Quel que soit l’endroit où elles accouchent, toutes les femmes ont besoin d’avoir accès aux utérotoniques, les médicaments provoquant la contraction de l’utérus pour la prévention et le traitement de l’HPP. L’ocytocine injectable, l’utérotonique recommandé, nécessite la conservation à froid et des compétences techniques pour son administration ; l’ocytocine est également disponible en tant que dispositif Uniject® — une injection pré-remplie à dose unique et non réutilisable — qui est plus facile à administrer. Le misoprostol est une méthode alternative à l’ocytocine qui est sûre et efficace, particulièrement dans les milieux à faibles ressources où l’ocytocine n’est pas disponible ou faisable. Le misoprostol ne nécessite pas la réfrigération et est facile à utiliser — ce qui est notamment important en l’absence d’une accoucheuse qualifiée.
Entre juin 2012 et août 2013, Gynuity Health Projects, ChildFund Senegal, Programme de santé communautaire de l’USAID et la Direction de la Santé de la Reproduction et de la Survie de l’Enfant du gouvernement sénégalais ont mené une étude visant à comparer l’administration à l’échelle communautaire du misoprostol oral à celle de l’ocytocine par Uniject® en vue de prévenir l’HPP. Une des deux interventions était assignée à chacune des 28 cases de santé communautaires participantes, des structures en béton d’une à deux pièces, qui fournissent des soins de santé de base aux collectivités. Les exécutants du projet ont fourni une formation aux matrones, accoucheuses bénévoles, à apporter leur aide durant les accouchements et à administrer l’intervention désignée.
Les collectivités ont assumé un rôle essentiel en encourageant l’utilisation du misoprostol et de l’ocytocine. Les membres de la collectivité ont aidé à identifier les femmes enceintes pour les consultations prénatales initiales et le personnel du projet a recruté les femmes en leur rendant visite au sein de leur communauté.
Depuis le lancement du projet plus de 1 300 femmes ont reçu soit 600 mcg (3 comprimés) de misoprostol ou 10 UI d’ocytocine par Uniject® par voie intramusculaire pour la prévention de l’HPP. Les deux médicaments étaient efficaces et les matrones ont pu traiter tous les effets secondaires qui comprenaient notamment les frissons, les tremblements et la fièvre. Seul un cas d’hémorragie du post-partum est survenu parmi les femmes ayant reçu le traitement préventif.
« Avant cette étude, un grand nombre de femmes présentaient des saignements profus et il était toujours difficile d’assurer le transport pour leur acheminement [aux établissements de santé], » dit Fatou Diouf, une matrone de la case Koulouk Mbada. « Désormais, nous n’observons plus d’hémorragie après l’accouchement. »
Amadou Gueye, Infirmier en chef du poste de santé de Ndiaganiao, a noté un résultat analogue : « Nous n’avons observé aucun cas d’HPP depuis le début de l’étude. »
En raison du projet, le nombre d’accouchements à domicile a baissé de 10 % à 1 %, les responsables du projet ont effectivement maintenu les stocks de médicaments, les prestataires de santé ont démontré leur engagement et leur motivation et les matrones ont administré les médicaments et rempli les formulaires de gestion des données de manière adéquate. La présence des accoucheuses dans les cases de santé communautaire s’est renforcée parce que les femmes ont sollicité des services d’accouchement afin de bénéficier des médicaments de l’HPP.
« Ce matin, lorsque je suis venue pour accoucher, la matrone m’a demandé si je voulais prendre les trois comprimés. J’ai répondu oui, » dit Mariama Niang qui a récemment accouché à la case de santé de Koulouk Mbada. « Mes saignements étaient plus légers que ceux de mes accouchements précédents où ils étaient abondants et accompagnés de vertiges. […] maintenant, je me sens bien. »
Au Sénégal où l’accès aux établissements de santé peut être limité dans les zones reculées, le système des cases de santé communautaire peut jouer un rôle important dans la prévention et le traitement de l’HPP. Selon l’étude, le misoprostol ainsi que l’ocytocine par Uniject® se sont tous les deux avérés tout aussi efficaces et sûrs dans la prévention de l’HPP et les matrones affectées aux cases de santé étaient en mesure d’administrer les médicaments qui leur étaient assignés. Alors que les injections standards d’ocytocine nécessitent des compétences particulières, le misoprostol et l’ocytocine par Uniject® constituent des options viables à l’échelle communautaire. Ces interventions médicales peuvent habiliter les collectivités à protéger la santé des femmes et à prévenir des décès maternels évitables.
Family care International (FCI) collabore avec Gynuity Health Projects au moyen de la recherche et du plaidoyer en vue de favoriser un accès accru au misoprostol et sa disponibilité pour la prévention et le traitement de l’HPP. Trouvez de plus amples informations relatives aux travaux de FCI et de Gynuity visant à mettre le misoprostol à la disposition des femmes à travers le monde.
Adama Sanogo is Program Officer at FCI-Mali, working at our national office in Bamako and supervising FCI’s programs in Mopti, a city on the Niger River an 8-hour drive to the north.
Over the past two years, northern Mali has suffered a series of repeated and increasingly devastating crises. Long-term drought that has plagued the Sahel region of Mali and its neighboring countries – the area that borders on the Sahara desert – led to a dramatic rise in food insecurity in 2011; this was followed in 2012 by a worsening security situation, culminating in an invasion of armed rebel groups that declared the independence of the country’s three northernmost regions of Timbuktu, Gao, and Kidal. In March 2012, the national government in Bamako was overthrown in a military coup, and fighting between the military and the northern rebels continued into 2013.
The result has been a humanitarian disaster, as nearly half a million Malians fled their homes to escape fighting and hunger. The city of Mopti, where FCI has been implementing adolescent sexual and reproductive health programs for several years, is the gateway to the northern part of the country, and it has seen a massive influx of people displaced from the north, seeking refuge or transit to other parts of the countries.
To help address this crisis, in a post-coup environment in which it was difficult or impossible for international agencies to work with an unstable new government, UNICEF asked FCI’s team in Mopti to take on emergency projects to provide support to the many women who had experienced gender-based violence when war convulsed their home region, and to help protect the rights of children among the large displaced population.
Working in partnership with local grassroots organizations, FCI supported the formation of 10 “protection teams,” in Mopti and more than 30 villages in the surrounding rural areas, to identify women and children who had been victims of gender-based violence and to refer them for medical care and psychological support. About three dozen health care workers in the area were trained in how to provide appropriate care to survivors of sexual violence. At a women’s center in Mopti, the project provides a safe space where social services are provided, children have a place to play, and theater programs (featuring young people from FCI’s adolescent health programs) help to raise awareness about issues of gender-based violence.
The team psychologist and social workers also visit women and children in their homes when needed. “In Mali,” says FCI outreach worker Aïssata Cissé, “when there’s been a rape it is dealt with inside the family. There is no going to a tribunal or to the police. Often girls do not even tell their mothers what has happened. If it becomes known that a girl has been raped, she will have a problem. Even at school, her friends or other pupils will tease her.”
During 2013, this FCI program has provided emergency financial aid to more than 1,600 displaced families that have taken refuge in the Mopti region, and has provided medical, social, and psychological services to 200 women and children who had fallen victim to sexual violence. Here are three of their stories:
Nana, 35 years old, from Timbuktu:
“I sell cosmetics. One day, seven Islamist rebels came into my shop and they burned all the wigs and cosmetics. I was wearing a wig, so three of the men beat me with a whip, and kicked and punched me. Then they drove me to their base, and held me for three days. Every night, three men raped me.
“I was released because the village chief intervened. But I had nothing more to do in Timbuktu. I had no livelihood since my business had gone up in smoke, and I was humiliated. So with the help of my older brother, I managed to get to Mopti.
“When I arrived in Mopti, I became very sick with sexually-transmitted infections. I had back pains, and terrible pain from being punched in the stomach, and especially from the gang rape violence I was subjected to during those three days. For me, I felt like it was all over.
“One day in April 2013, I met two women who worked for UNICEF and Family Care International to identify displaced people who were victims of violence. They interviewed me, and arranged for me to receive medical care from the Sominé Dolo Hospital in Mopti, and psychosocial care from the Family Care International psychologist within their project financed by UNICEF.
“Since I have benefited from these treatments, I feel like I did before the attacks. I see that there is hope in front of me, that I can continue to live. I am free in my movements, I present myself as I want to, and I wear wigs. I can only thank FCI-Mali and its partner UNICEF, who allowed me to start over and live a happy life.”
Ada, 50 years old, from the village of Douentza (northeast of Mopti):
“When the rebels came to Douentza in October 2012, they shot in the air at the entrance to the town where I lived with my children: my daughter Tata, 13 years old, and my sons Moussa, 20 years old, and Amadou, 10 years old. I am a widow, and I have heart problems that cause me to faint at even the slightest of loud noise.
“Two rebels came to our house. I offered them my belongings but they didn’t want them. They tied up my two sons, Moussa and Amadou, and raped my daughter in front of me. I fainted two times. When they finished their dirty work, they took my two sons with them and kept them hostage for three days. They let them go after the chief of Douentza intervened.
“I fled with my children for Mopti. I stayed with my uncle, who provided some medical care for my daughter. After the incident she was very quiet, didn’t speak to anyone, barely ate, and refused any help. She didn’t want to think about what happened.
“At the slightest noise, I faint. I have no ways to take care of my children’s health, and my uncle no longer has the means. Every night I relive the nightmare. I don’t know how much longer I can stand this. I need help.”
An FCI protection team found Ada and her family and referred them for medical, social, and psychological treatment.
Dada, from Bambaramoudé (Timbuktu):
“After the war, my husband, my children and I left Timbuktu. We had a very difficult time on the journey. We were attacked by an armed group who stole all our belongings. The attack on Konna (a town an hour north of Mopti) arrived just as we did, so we retraced our steps. We spent three days in the bush without water or food. After the French liberation of Konna, we continued on our way towards Sévaré (a village near Mopti). It was very difficult for us. In Sévaré, I am staying with the family of my deceased grandmother. We live day-to-day – I didn’t know how I would survive all of these hardships.”
On a Friday afternoon in June, 2013, Dada left her 9-month-old son, Hamadi, with her oldest daughter, 11-year-old Aicha, so she could go to fetch water from the well. Aicha was also watching over her mother’s stall where she sold dried fish and fried sweet potatoes. When Aicha made a sale, she placed the money on the mat where Hamadi was playing. Suddenly, a piercing scream rang out. The baby was crying as hard as he could, writhing in pain and vomiting. When Dada returned from the well, Aicha said that nothing had happened — Hamadi had suddenly started to cry as he was playing. Dada asked Aicha how much fish and potatoes she had sold; she said she had made about 350 CFA francs (72 US cents). Counting up the money, Dada found only 300 CFA — a 50 CFA coin was missing. She examined Hamadi,and realized that he had swallowed the missing coin. “Oh my God!” she screamed. “What am I going to do? I don’t even provide enough for my children, and now this disaster. What am I going to do?”
“I started asking around for help, and was able to raise 16,000 CFA (US$33). I brought Hamadi to the Sominé Dolo Hospital in Mopti. After a consultation with a pediatrician and reviewing the results of the x-rays, it turned out that the coin was lodged in his stomach. They referred Hamadi to the Gabriel Touré Hospital in Bamako, 400 miles away, so he could be operated on to remove the coin that might kill him.
“Desperate and stunned, I returned to the house and waited for my son to die. I then learned that there was a local NGO who was helping displaced persons. I went to see this NGO, and they directed me to Family Care International, which helped me get him the care he needed, with the help of another NGO in Bamako, Sini Sanuman (Healthy Tomorrow). Hamadi was operated on by the NGO’s pediatrician. He was saved from death, and we returned to Mopti the next day. My husband, myself, and everyone who helped us cannot at this moment afford the amount of support, which cost more than 300,000 CFA (over US$600). When my parents and I set out to thank the 2 NGOs, they both said they received funding from another organization that works for children around the world: UNICEF. We will never be able to give enough thanks to these generous organizations and hope to God that they will always exist to continue saving the lives of thousands of children.”
While the fighting in northern Mali has lessened, the refugee situation in Mopti remains serious, and FCI’s work there continues. To learn more about this partnership between FCI and UNICEF to provide services to victims of gender-based violence, click here.
In the Sahel region in northern Burkina Faso, a remote, arid area on the edge of the Sahara Desert, maternal and newborn mortality levels are substantially higher than in the rest of country. The majority of women, particularly in the Sahel’s hundreds of small, semi-nomadic villages, still give birth at home, without the help of a skilled birth attendant. Family Care International has been working in the Sahel for several years, in partnership with the UN Population Fund—UNFPA, the national Ministry of Health, and local grassroots organizations, to educate women about their maternal and reproductive health, increase use of the maternal health services that are available at the health center in the provincial capital, ensure that women with childbirth complications are able to access the emergency care that can save their lives, and arrange for surgical treatment for women living with obstetric fistula, a devastating injury that results from prolonged or obstructed labor.
Over the course of this work, it has become increasingly clear that local leaders — clergymen, traditional chiefs, elected officials — have the potential to influence women and their families to utilize available health services and avoid harmful beliefs and practices that are rooted in the religious and cultural traditions. Because these leaders play crucial roles in the promotion and preservation of traditional practices and beliefs, it will be difficult to spark meaningful change — like the abandonment of child marriages — until traditional leaders are educated and mobilized to promote the cause.
FCI has therefore focused on working with approximately 30 religious and traditional leaders in each of the four districts that make up the Sahel region. At a series of training workshops, they have learned about all aspects of maternal health care, and have come to better understand the community determinants of maternal health and the ways that encouraging uses of health services, and particularly skilled attendance at birth, could play a large role in saving women’s and babies’ lives. At the end of the workshops, leaders were asked to implement what they learned in their communities. Some time later, a feedback meeting was organized. Here are some stories that the leaders shared at that meeting:
- Bani is a rural town in the Seno province, located about 25 miles outside of Dori, the regional capital. After attending an FCI training session, the Imam of one of Bani’s mosques was committed to promoting maternal and infant health. With educational materials in hand, the Imam held awareness meetings at his mosque and in each of the town’s five neighborhoods, where he discussed the importance of prenatal care, of giving birth at the health center, of preventing obstetric fistula, and of treating fistula when it does occur. The Imam also approached Bani’s mayor to arrange for discussions with the members of the town council, brought health workers to meet with representatives of the five neighborhoods and of 16 surrounding villages, and invited the Dori “Khoolesmen” Association (a grassroots group that works in the community to improve maternal and newborn health) to lead discussions at four mosques and 21 adult literacy centers.
- Diguel is a town located about 37 miles outside of Djibo, capital of the Soum province, and almost 100 miles from Dori. After attending a training workshop in Djibo, Diguel’s Imam also led a series of community discussions, focusing on the critical importance of prenatal care and skilled birth attendance. He spoke about the importance of protecting women health at the end of Friday prayers, at the special Walima marriage ceremony, and at baptisms. During a special prayer for rain, in June 2013, the Imam shared with the worshippers in his mosque what he had learned about pregnancy danger signs, emphasizing the need for husbands and other men to be involved in health issues affecting women and children. As he spoke with the men, the Imam arranged for female community outreach workers to speak with the women in another corner of the mosque’s courtyard. He also spoke with traditional chiefs in order to engage them in these efforts, and is planning to begin visiting families un their homes and to travel into more remote surrounding villages, in order to ensure that lifesaving information gets to those harder-to-reach populations.
One day, when I returned home after a short errand, I met a suffering pregnant woman wandering the street, probably returning from the fields. She was writhing in pain and I quickly recalled the signs of danger that we were shown during the training in Djibo. I went up to the woman and asked her which family she was from. I quickly drove her back to her home and when we arrived I asked for her husband, but he was not there. I then asked if the woman had received any prenatal care; but she had not, so I urged her to go to the health center to get checked out. Our religion teaches us to always care for the well-being of others to the best of our ability. I think, with the knowledge I’ve received from the training, it would be unjust not to use it to help others.
- Imam of Diguel town, Soum province, Burkina Faso
- During May and June, 2013, the radio station of the Ahmadiyya Muslim community in Dori broadcast a program called “Health Mission,” covering topics on maternal and newborn health; the Ahmadiyya community also conducted outreach to several villages through its network of mosques.
- The Sunni Muslim community in Dori held three awareness sessions, after the afternoon prayers in the mosques, concerning women’s health, the responsibility of men in issues of maternal and infant health, and the importance of prenatal care.
- Leaders of the evangelical Christian community were also engaged in these efforts: 65 pastors from the towns of Dori, Sebba, and Gorom-Gorom attended a training meeting, after which they to shared what they had learned about maternal health with the congregants in their network of churches.
- Dori’s Catholic Mission participated as well: after the chaplain and priest received training, they conducted 25 awareness programs after Saturday and Sunday masses. They then held programs with three grassroots Christian Committees, including both women and men; two awareness meetings in the rural villages of Karo and Koumbri; and a meeting with members of the Association of Catholic Women.
These few examples show these leaders’ commitment to raising awareness in their communities about women’s and newborns’ health, and their potential influence on traditional practices that are deeply rooted in social and religious norms and customs. This commitment is durable and sustainable, and they will continue working – with FCI’s partnership – to make these efforts to encourage healthy practices bring real change in the lives and health of women in their communities.
Catherine Lalonde is FCI’s senior program officer for Francophone Africa.
Each year in Burkina Faso, more than 2,000 women die from pregnancy-related complications. Many of these deaths are due to severe and uncontrolled bleeding (postpartum hemorrhage, or PPH) that occurs following childbirth. The vast majority of these deaths can be effectively prevented or treated if women have access to high-quality maternal health care. Essential medicines, such as oxytocin and misoprostol, are safe and effective for preventing and treating PPH; however for many women in Burkina Faso, and in countries around the world, these essential medicines are not available or easily accessible. Access to misoprostol, a safe and effective medicine for preventing and treating PPH, is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used even in poorly-equipped health facilities and home births.
In early September, FCI convened a meeting in Burkina Faso with 40 high-level officials from the Ministry of Health, local and international NGOs, and national professional societies to share the latest evidence and research and identify strategies for making misoprostol more affordable and accessible for preventing and treating PPH. A room full of champions for improved maternal health in Burkina Faso, the participants called for widespread availability of misoprostol, particularly in regions where women may not be able to reach health facilities for delivery. At the same time, participants identified a number of challenges for making misoprostol more widely available; these included:
- High cost of the drug: As it is now, women in Burkina Faso cannot purchase a single dose of misoprostol; only larger packages — 4 or 5 doses, depending on whether it will be used for prevention or treatment — are available, and they cost more than US$5, a considerable sum in Burkina Faso.
- Use for other indications: Some meeting participants were also concerned about the possibility that, if it were made available for PPH, untrained or unskilled health workers could use misoprostol for abortion or to induce labor.
- Conflicts with health facility deliveries: Participants raised the fear that making misoprostol available in community settings could discourage women from going to a health facility for delivery.
- Need for more research/data: Meeting participants discussed whether more research in regions like the Sahel — remote, rural areas, where skilled care is unavailable or very far away and home birth is consequently very common — is needed.
Women in my district die from postpartum hemorrhage, so we can’t be against the use of misoprostol [for PPH] in rural areas. In the Sahel only 38% of births are attended by a skilled professional, and it’s not because women don’t want to deliver in a clinic. Here, travelling 2 kilometers takes as long as it would to travel 30 kilometers somewhere else.- Chief Medical Officer, Gorom-Gorom District, Sahel Region, Burkina Faso
Participants identified a number of agreements and strategies for moving forward. They agreed that:
- The potential use of misoprostol for other indications, including abortion, is not a reason to restrict access to it for PPH. A safe and effective medicine should not be withheld from women who need it simply because it can also be used for other, more controversial indications. Further, evidence suggests that making misoprostol more widely available for PPH does not increase the rate of abortion. Women who want to have an abortion will have one, whether or not they have access to misoprostol.
- Misoprostol should be added to the national Essential Medicines List (EML) for use in peripheral health centers. A small group was established to work on a proposal for including misoprostol for PPH in the national EML.
- There is a need to lower the cost of the drug, either through government funding or social marketing.
FCI works at the global level and in select countries such as Burkina Faso and Kenya, in collaboration with our partners, to support wider understanding, acceptance, and use of misoprostol for PPH. FCI maps advocacy efforts, publishes case studies, articles, and information briefs, disseminates new information, and brings together experts through online events and conferences to discuss evidence and challenges related to misoprostol’s access and availability.
This year’s Women Deliver conference made a strong call for investing in the health and development of adolescents and young people: they were at center-stage, and their health and development needs were discussed in dozens of sessions on different topics. And they were a notable physical presence. In addition to a youth pre-conference that brought together one hundred young leaders from around the world, adolescents and young people spoke on panels, moderated discussions, and chaired a youth networking zone. The conference highlighted the unique problems faced by adolescent girls and young women–some of the most vulnerable and neglected individuals in the world–and stressed the importance of addressing their needs and rights, not only for their individual benefit, but also to achieve global goals such as reducing maternal mortality and HIV infection.
In response to an invitation from the editors of the peer-reviewed journal Reproductive Health, 16 experts from WHO and other UN agencies, academic institutions, and a range of NGOs — including FCI’s global advocacy director Amy Boldosser-Boesch — coauthored a commentary that lays out the key themes that reverberated throughout the conference, on the health and development needs of adolescents and young people, and promising solutions to meet them.
“The time to act,” the authors write, “is now.” With increasing recognition that meeting the needs of young people is essential to achievement of the Millennium Development Goals, and a growing understanding of the challenges faced by adolescents and the interventions that are effective in addressing them, “the real imperative is to apply the knowledge and understanding that we already have.” They conclude:
There is widespread acceptance of the need to address the sexual and reproductive health of adolescents and young people. There is a groundswell of support from national and international bodies to translate words into action. We need to leverage this collective commitment and expertise. For the world’s 1.2 billion adolescents to survive, grow and develop to their full potential, the small scale, time limited, piecemeal projects of yesterday must be transformed into the strong, large scale and sustained programmes of today.
To read the full article, click here.
Every two minutes, a woman in a developing country dies from pregnancy and childbirth complications. Postpartum hemorrhage (PPH) and pre-eclampsia/eclampsia (PE/E) are the leading causes of maternal death. Although these conditions are preventable, too often life-saving medicines do not reach women in developing countries.
On September 26th, Family Care International, USAID’s Maternal and Child Health Integrated Program (MCHIP), PATH, and Jhpiego hosted a Twitter expert hour to discuss how increasing access to simple, affordable maternal health commodities — misoprostol, oxytocin, and magnesium sulfate — has the potential to save millions of women’s lives.
MCHIP Maternal Health Team staff Sheena Currie and Jeff Smith led the Twitter conversation on misoprostol; PATH’s Maternal, Newborn, and Child Health Program Leader Catharine Taylor discussed oxytocin; and Jhpiego and Jeff Smith tweeted about magnesium sulfate. The Twitter chat stimulated an exchange of compelling information and evidence and generated provocative questions from the community. You can check out the discussion in the Storify below and continue the conversation by visiting Twitter and including #supplylife in your tweets.
In the midst of a long and busy week of discussions and events around the annual meeting of the United Nations General Assembly, FCI president Ann Starrs sat down for an interview on the critical role of communities in demanding accessible, high-quality health services.
“Women and their families,” she says, “have to be active, they have to understand what their rights are in terms of access to health care, in terms of access to information, and they have to demand that their political leaders, locally and nationally, make these services available and make these services high quality. If you don’t have that kind of demand and that kind of momentum in place, then any changes that get implemented are not going to be sustainable.”
Watch the video:
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.
Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou, whose previous blogs on this obstetric fistula project can be read here and here. This article is cross-posted from the blog of the Frontline Health Workers Coalition.
“Today,” Mariama Boubacar Diallo says, “Thank God, I no longer suffer. I’m healthy; I am healed.” Mariama, a resident of the village of Kriollo Ourarsaba, located in the northern Sahel region of Burkina Faso, reflects on her recent surgery to repair the obstetric fistula she developed while giving birth to her third child four years ago.
Obstetric fistula, an injury to the birth canal resulting from an obstructed or prolonged birth, causes long-term, physical pain. Mariama, like many women suffering fistula, also experienced emotional distress from losing the respect of her family and community.
Burkina Faso, a land-locked West African country, struggles against chronic poverty like many of its neighbors in the Sahel, the southern band of the Sahara Desert that stretches across the width of the African continent. Most recently, Burkina Faso has been working to overcome the severe food shortage that has plagued the region since 2011.
Recognizing the urgency of the food security crisis, USAID has reserved more than $56.5 million to fund projects working in areas of agriculture, livelihoods, health and water, sanitation and hygiene in the region. To counteract the food security crisis and mobilize productive members of society, policymakers should address the unnecessary loss of life that occurs when mothers suffer or die from preventable pregnancy and childbirth complications. Frontline health workers are a key part of the solution, both for preventing fistula from occurring and for ensuring that survivors receive the treatment they need.
Through our programs in Burkina Faso and around the developing world, Family Care International (FCI) has worked to raise awareness of the causes of and treatment for obstetric fistula. FCI-Burkina Faso, with support from the United Nations Population Fund (UNFPA), has worked with communities and partner organizations in the Sahel region to prevent fistula by improving access to and utilization of emergency obstetric care, which is provided by midwives and doctors in health centers and hospitals that are too often inaccessible to women in rural villages.
In order to get these women to the urgent care they need, FCI and our partners have helped more than 700 villages establish emergency procedures for transporting pregnant women to the nearest health clinic when faced with life-threatening complications. We have also trained hundreds of community health and outreach workers to visit people in their communities, hold meetings to raise awareness of pregnancy complications and their treatment, and bring fistula survivors out from isolation so they can reclaim their lives. Mariama is one of those brave women who, thanks to the tenacity and commitment of frontline health workers, has triumphed over her injury and succeeded in becoming a leader in her community.
Although Mariama wasn’t rejected by her husband when she suffered from obstetric fistula, her in-laws blamed and abused her. A community outreach worker affiliated with an FCI partner found Mariama and helped her arrange surgery in a hospital in the regional capital, Dori. In the months after her surgery, she received training in modern methods of raising cattle and sheep, the primary economic activity in many parts of the Sahel.
At the end of 2010, Mariama received a grant of 100,000 CFA francs (about $200) to purchase a ram and a ewe, along with some feed, in order to establish her own breeding business. Mariama now owns four head of cattle, making her one of the village’s most prosperous and successful citizens, and she generously shares her new agricultural knowledge with her neighbors. She is fully included in baptisms, weddings, and other social events of the village — something that was inconceivable only a year ago — and has fully reunited with her in-laws. “Today,” she says, “thanks to this program, my in-law family has truly accepted me.”
Policymakers must come to better understand the impact of frontline health workers, with the resources and the know-how to empower women and get them to the care they need , on the lives of women like Mariama.
Ann Starrs is president and co-founder of Family Care International. This article has been cross-posted on RH Reality Check, the Kaiser Daily Global Health Policy Report, and the Maternal Health Task Force blog.
Two years ago, in July 2011, UNAIDS launched a joint initiative with PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, to help achieve the goal of an AIDS-free generation. The ambitious, if clumsily named, “Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive” included two global targets:
- Reduce the number of new HIV infections among children by 90%
- Reduce the number of AIDS-related maternal deaths by 50%
Today, UNAIDS and PEPFAR released a new report on progress in this important initiative. The report and accompanying press release highlight the very welcome news that seven countries (Botswana, Ethiopia, Ghana, Malawi, Namibia, South Africa and Zambia)have reduced mother-to-child-transmission of HIV by 50% or more, with two additional countries (Tanzania and Zimbabwe) close to achieving that rate of reduction.
UNAIDS, PEPFAR, and all of their global and country partners deserve sincere congratulations for this tremendous accomplishment, achieved in a relatively short span of time. Progress toward the Global Plan’s first target has been truly impressive.
But their report almost completely ignores the plan’s second target, and in fact the second part of its long title — “…and keeping their mothers alive.” Perhaps a more accurate title for the initiative, at least as reflected in this report, would have been “Global plan towards the elimination of new HIV infections among children, and keeping their mothers alive just as long as they are pregnant or breastfeeding (but after that, not our concern…)”
Ok, maybe I’m being a bit too harsh. But in the report’s 15 pages of text, there is at best one glancing reference (being generous) to the fact that women with HIV who are eligible for treatment should receive antiretrovirals because they have a right to treatment for the sake of their own lives and health. And the target for reducing maternal deaths is not even mentioned in the report’s text (though, to be fair, it is included as an indicator in the country profiles that make up the second part of the report).
Well, the report makes it clear. “Many more women,” it states, have access to antiretroviral medicines to reduce the risk of HIV transmission to their children than four years ago [my emphasis, here and below].” And again, “Special attention is needed in all countries to ensure access to and retention on antiretroviral medicines for pregnant and breastfeeding women living with HIV to cut these numbers of children acquiring HIV infection.” The report betrays, alarmingly, a view of women exclusively as bearers and feeders of children.
It does, at a couple of points, vaguely acknowledge that women’s lives have value even when they are not carrying or breastfeeding babies. “The number of women acquiring HIV infection has to be reduced,” the report states, “and all women living with HIV eligible for antiretroviral therapy must have access to it for their own health.” But this commitment, for which many advocates have fought long and hard, must be translated into concrete action to prioritize ARV treatment for HIV-positive women who are not pregnant, or who have finished breastfeeding. Too often, still, these women do not have access to the life-saving medicines they need, or are dropped from programs when they no longer qualify through their children.
The report does, thankfully, acknowledge the significance of access to family planning as a means of preventing unintended pregnancy, and thereby of preventing infants from being born with HIV:
Reducing unmet need for family planning will reduce new HIV infections among children and improve maternal health. Increasing access to voluntary and noncoercive family planning services for all women, including women living with HIV, can avoid unintended pregnancies. Family planning enables women to choose the number and spacing of their children, thereby improving their health and wellbeing.
Kudos to UNAIDS and PEPFAR for being forthright about this crucial element of PMTCT programs, even though family planning is still far too rarely included in HIV/AIDS prevention efforts.
But in other respects, the agencies need to do better, both in their programs and in the messages they send through reports like this one. Michel Sidibé and Eric Goosby, the heads of UNAIDS and PEPFAR, have both, in many speeches and statements, acknowledged the importance of women, and the right of women living with HIV to get ARV treatment for their own health. This report should have reflected that awareness, and that principle (as, for instance, this one in 2012 did). I hope and expect that the next progress report for the Global Plan will include a clear discussion of the link between HIV infection, maternal mortality, and women’s health more generally, and what the agencies are doing to address it.
Action on the global stage: Life-saving reproductive health commodities getting much-needed attention
Ann Starrs is FCI’s president and co-founder.
During the third week of May, I was in Geneva — together with an impressive collection of global health leaders from governments, UN agencies, and civil society — for the 66th session of the World Health Assembly (WHA). I am in Geneva fairly often, for meetings with WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH) and other partners, but the annual World Health Assembly meeting is unique. The WHA is the governing body of the World Health Organization, and so it is attended by high-level delegations – usually led by the Minister of Health – from WHO’s member states. That makes WHA a great opportunity for networking and strategizing: finding an available seat, much less a table, in the famous (but oddly named) Serpent Bar at the Palais de Nations is always a challenge, as many conference participants spend virtually all of their time huddled there in intense discussion.
Issues around reproductive, maternal, newborn, and child health featured strongly in this year’s agenda, which is why I was there. The MDGs, and development goals beyond 2015; universal health coverage; life-saving commodities; and frameworks for holding countries and donors accountable for fulfilling their health commitments were all on the agenda, for formal discussion, side events, and hours of conversation at the Serpent Bar.
Perhaps most importantly, this year’s WHA considered, and ultimately passed, a resolution to implement the recommendations of the UN Commission on Life-Saving Commodities for Women and Children. The resolution commits countries to improving the quality, supply, and delivery of underutilized and essential commodities for RMNCH, and tasks WHO with reporting back to WHA each year through 2015 on progress in implementing the Commodity Commission recommendations as well as those of Commission on Information and Accountability for Women’s and Children’s Health. The WHA resolution is a clear, global endorsement of the Commodity Commission recommendations, and represents a commitment by the world’s nations to ensure that life-saving medicines and technologies get to the women and children who need them. It is a significant achievement for our community, and it provides an important mechanism for ongoing advocacy, and for holding governments and development partners accountable for keeping their promises.
Notably, the Commodity Commission’s list of 13 priority commodities includes two that are advocacy priorities for FCI: misoprostol, a drug that is highly effective for preventing and treating postpartum hemorrhage (PPH), the leading cause of maternal death; and emergency contraceptives, which help women prevent unintended pregnancy after unprotected sex. (FCI is host organization for the International Consortium for Emergency Contraception—ICEC.) At a very well-attended side event during the WHA, hosted by the delegations from Nigeria, Norway, and the U.S., along with World Vision International and PATH, speakers focused on the importance of innovation in overcoming barriers to access to essential health commodities. Presentations highlighted the substantial achievements that have already been made, and the important step forward represented by the Commodity Commission’s recommendations. Representatives from various countries also noted the significant challenges that remain, including those related to health commodity distribution systems, manufacturing, and supply. Several countries expressed a preference for purchasing and distributing locally-manufactured commodities, although this approach can sometimes raise concerns about quality assurance; further study, and advocacy, will be needed to address this challenge.
Only a few days later, and half a world away, I was one of a dozen FCI staff members who attended Women Deliver 2013, in Kuala Lumpur, Malaysia. This week was even busier – in fact, much crazier – than the previous week in Geneva; there were meetings and events starting at 7 in the morning, and organized social events went until 8 or 9 pm every night. The conference was amazing, bringing together 4,500 leaders, clinicians, program managers, and advocates representing over 2,200 organizations and 149 countries. I could not take full advantage (or anywhere near it) of everything the conference had to offer; there was an endless variety of stimulating plenary and concurrent sessions (including six sessions presenting the latest findings from Countdown to 2015, in which FCI is a leading advocacy partner), as well as Speaker’s Corner (where FCI and WHO presented new tools for strengthening countries’ policies on adolescent sexual and reproductive health). There was a youth corner and a cinema corner, a busy and bustling exhibition hall, and many, many other activities going on at all times. The cumulative value of all the connections made, facts and ideas conveyed, materials disseminated, and plans and strategies developed was immeasurable but immense.
Here, too, essential health commodities were on the agenda. On the Monday morning just before the conference officially started, FCI co-sponsored a side event called “In Our Hands: Successful Strategies to Prioritize Essential Maternal Health Supplies,” at which the Maternal Health Supplies Working Group and the Maternal Health Supplies Caucus of the Reproductive Health Supplies Coalition brought together global and national advocates and program implementers in an interactive forum – including advocacy case studies from Africa, Asia and Latin America – to network, strategize, and exchange ideas for elevating maternal health supplies onto global and national health agendas. At the same time, ICEC co-sponsored a session on “Emergency Contraception: New Research Findings, Programmatic Updates, and Advocacy Strategies,” at which advocates, researchers, pharmaceutical representatives, and other leaders in the field discussed efforts to ensure access to EC globally, with a focus on developing countries.
That afternoon, FIGO and Gynuity Health Projects (our partners in misoprostol advocacy) co-hosted a discussion of misoprostol for PPH: “New Evidence and the Way Forward.” Presenters offered the latest information on ways that the current evidence can help inform and develop effective policies and service delivery programs across varying levels of the health system, and on lessons learned from innovative programs in Afghanistan and Nepal. I concluded the session with a presentation on advocacy opportunities and challenges for “Making Misoprostol an Operational Reality.”
At these and related sessions the level of discussion, the enthusiastic participation by advocates and health workers, and the clear attention that these issues are getting from policy makers, made for an inspiring and energizing two weeks. “Making sure that women and children have the medicines and other supplies they need is critical for our push to achieve the MDGs,” said Secretary-General Ban Ki-moon when he launched the Commodities Commission 15 months ago. Progress is being made, and we, together with our advocacy partners, are working hard to make sure that essential commodities are available to all who need them.
by Gary L. Darmstadt, France Donnay, and Ann Starrs
Gary Darmstadt and France Donnay are, respectively, Director of Family Health and Senior Program Officer, Maternal, Neonatal and Child Health, at the Bill & Melinda Gates Foundation. Ann Starrs is president of FCI. This post first appeared on Impatient Optimists, the blog of the Bill & Melinda Gates Foundation, on June 3, 2013.
This month, the Journal of Maternal-Fetal and Neonatal Medicine published a special issue that sheds new light on the indissoluble links between the health of a mother and that of her newborn baby. Its release comes just weeks after the Global Newborn Health Conference, and simultaneously with a State of the World’s Mothers 2013 report revealing that a baby’s first day is the most dangerous of its life.
That interconnections exist between maternal and newborn health is well known. Most maternal deaths are caused by the woman’s poor health before or during pregnancy, or by inadequate care in the critical hours and days during and just after childbirth; the same is true for most newborn deaths. And when a woman dies after giving birth, her death is far too often followed by the death of her newborn baby. And we know, based on substantial evidence, which interventions are best for improving maternal health and saving women’s lives, and which are effective for improving newborn survival.
What we didn’t sufficiently understand, until now, was the range of interventions that bring health and survival benefits to both mother and newborn. In this new study, a research team from Aga Khan University in Pakistan, working in collaboration with Family Care International and with support from the Bill & Melinda Gates Foundation, looked at more than 150 interventions, assessing them for impact on both maternal and neonatal outcomes. They then grouped the interventions into “packages of care” that can be effectively delivered at each of the key levels of care: community, health center, and hospital.
This study advances our knowledge in important ways. It reinforces the widely-recognized benefits, for women and their babies, of high-quality antenatal care, skilled birth attendance, and postpartum care, which are still too often insufficiently, ineffectively, or inequitably delivered. It highlights the crucial role of family planning, which can be used to delay and space pregnancies. It identifies a number of areas — including management of preconception diabetes, treatment of maternal depression, and community-based approaches for improving birth preparedness and care-seeking — which are currently neglected but could significantly improve maternal and newborn outcomes.
Most importantly, the findings send a clear message: that greater integration of maternal and newborn care — and, more broadly, of services across the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — is one of our most promising strategies for strengthening efforts to save women’s and children’s lives.
This kind of integration may sound like an obvious step, but it is not always easy. Integration of services is critical if countries are to make substantial progress towards national health goals. It forces policy makers, donors, program managers, and health workers to find common ground among their varying constituencies, goals, and agendas; to understand the needs of women and their babies in new and different ways; and to design services that respond to these needs. It requires that the physical, financial, and human architecture of the health system be designed and constructed to efficiently and equitably deliver high-quality services across the continuum of care.
And yet, Progress on reducing maternal and newborn deaths has been too slow, and far too many women and babies die every day. Recognizing and acting on the crucial interconnections between maternal and newborn health revealed by this study, and the broader linkages that tie together the RMNCH continuum, can help save the lives of millions of women and children. The time to take action is now.
by Beverly Winikoff and Ann M. Starrs
Beverly Winikoff and Ann Starrs are the presidents of, respectively, Gynuity Health Projects and Family Care International. This commentary is cross-posted from the MHTF Blog, the blog of the Maternal Health Task Force.
While support for the use of misoprostol to prevent postpartum hemorrhage (PPH) has been growing steadily, governments, donors, and implementing agencies have not given equal emphasis to treating PPH when it does occur. Indeed, the response to PPH — the single leading cause of maternal mortality — has been vigorous, but incomplete. In a series of regional surveys conducted in 2011 and 2012, organizations were asked to describe their programs and activities involving misoprostol for PPH: a broad range of prevention projects was reported. Yet, despite substantial published evidence of the potential for misoprostol use in PPH treatment, not one agency indicated current or planned work focused on use of misoprostol for treating PPH.
Health ministries, implementing agencies, and donors have recognized that addressing PPH could reduce the number of maternal deaths in the highest-burden countries. Indeed, they have developed and promoted strategies for preventing PPH by actively managing the third stage of labor where skilled staff and appropriate medications (uterotonics such as oxytocin and misoprostol) are available. Yet in low-income countries, well-equipped, professionally-staffed health facilities are not accessible to many – sometimes most – women, who still give birth without a skilled attendant, mainly at home. A number of countries in Africa and Asia, including Bangladesh, Nepal, and Zambia, have developed pilot projects to distribute misoprostol for use at home deliveries, as an interim approach for reaching women who lack access to skilled care. Nepal and other countries are scaling up these programs, seeking to ensure that every woman, regardless of where she gives birth, receives a uterotonic to prevent PPH.
While active management and administration of uterotonics can reduce blood loss and prevent many cases of PPH, at least 10% of women who receive preventive care will still experience significant post-partum blood loss that may require additional medical interventions. The lack of concerted attention and support for treatment of PPH at the community level will mean that even women who receive prophylaxis with a uterotonic may be at risk of dying from excessive blood loss. And, at least in the short term, many women are still unlikely to receive uterotonics for preventive care; for these women, the availability of effective treatment options for PPH can be critically important. For a woman who hemorrhages at home or in another setting where lack of refrigeration or skilled staff makes use of IV oxytocin (the gold standard for PPH treatment) not feasible, access to treatment with misoprostol, which has few contraindications or side effects, could mean the difference between life and death.
Community-based PPH prevention programs using misoprostol could provide the platform on which to build an approach for treatment of hemorrhage. In remote and rural areas, where transfer to a higher level of care may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
In many countries, making this happen will require that governments reconsider policies that require administration of medications be carried out only by physicians. These policies are generally promulgated with the argument that lower-level health personnel do not have the expertise to know when to initiate treatment. However, these same personnel are often entrusted with the decision to refer women for treatment, a judgment that requires the same level of discrimination. Because providing treatment would be easy with a pre-packaged dose of misoprostol, it seems both feasible and sensible to provide lower-level health personnel with medicines that can be a critical first aid tool for women who face immediate risk of death.
The emphasis on prevention over treatment is common in public health. “An ounce of prevention,” goes the old adage, “is worth a pound of cure.” But when prevention is not 100% effective, treatment also needs to be available. A well-functioning health system addresses public health challenges by pursuing both prevention and treatment, working to provide universal access to information and services that will keep people healthy while also providing care for those who do become ill. The question for policy makers is how to balance attention to and investment in prevention and in treatment in order to ensure the fewest mortalities and morbidities at the lowest possible cost. A more balanced approach to postpartum hemorrhage could prove to be a critical tool in countries’ efforts to accelerate progress toward achievement of MDG 5.
To learn more about misoprostol and its role in PPH prevention and treatment, join an online community on the Knowledge Gateway. Or visit Family Care International and Gynuity Health Projects to learn more about their work.