Safe at Home: The Expansion of Prevention of Postpartum Hemorrhage at Homebirth in Afghanistan

A Joint Program between MoPH, HSSPJhpiego Supported by USAID

Objectives of the presentation

By the end of this presentation the audience will be able to:
Describe the causes of maternal death in Afghanistan Describe the main findings of the expansion of

Postpartum Hemorrhage (PPH) prevention at homebirth in Afghanistan

Identify the challenges in the expansion of PPH

prevention
Identify the next steps for national expansion

Background
5% 4%

Previous Maternal Mortality Ratio (MMR) est. 1600/100,000 LB (2002)1 Latest MMR est. 374/ 100,000 LB (2010)2 The main cause of maternal mortality is Bartlett et al, 2005 2 hemorrhage APHI et al, Afghanistan Mortality Survey 2010
1 2

5%

20%

56%

11%
Hemorrhage Obstructed labor PE/E Sepsis Other direct causes Indirect

Objectives of the Expansion

To demonstrate that the quality of communitybased distribution of misoprostol for prevention of Postpartum Hemorrhage (PPH) can be maintained during expansion; and To monitor adverse events as the service delivery is expanded

Expansion of Prevention of PPH

Intervention
Household level
Educating women and families on birth preparedness /complication readiness and distribution of misoprostol by CHWs & CHS Community: Sensitize and mobilize health shura (councils) and community leaders Health Facility: Strengthen capacity of skilled providers in prevention and management of PPH

Research

Cross-section pre-/post-intervention (HHSurvey) Postpartum interviews by Community Health Supervisors (monitoring 10%)

Results
Service Delivery Coverage

Household Survey Results

ANC and Delivery Information
Baseline (%)
(N =408 )

Endline (%)
(N =370 )

P value

ANC Did not attend Attend one or two times

19.6 28.2 51.5 Baseline (%) N=408

0.5 31.9 67.6 Endline (%) N=404

38.1 0.9 60.9 59.8 40.2

0.000

Attend three or more times

Place of Delivery Home Midwife Home Health Facility Assistance during delivery SBA Non SBA 50 50 48.5 1.5 50

Household Survey
Women received information about PPH from CHWs

Baseline (N =235) CHW as the source of information 21.28

Respondents (%)
Endlline (N =292) 48.97 0.000 P value

Support persons who received information about PPH

Support person Baseline (N =403) 13.4 13.4 8.44

Respondents (%)
Endlline (N =404) 30.69 35.4 35.64 0.000 P value

Husband

Mother in law

Mother

Household Survey
Received any information about misoprostol
Information received about misoprostol Prevents bleeding Swallow tablets after delivery of baby Take three tablets Side effects 131 132 135 83.4 84.8 85.9 157 135 89.9 Number Respondents (%)

Sources of information about misoprostol

Respondents Source of Information (%) (N = 137) Skilled provider/ midwife CHW 48

88

Others

Household Survey
Uterotonic Coverage

Household Survey
Acceptability

Respondents (%) Would recommend to a friend Would use if pregnant again Would purchase misoprostol Willingness to pay
l

(N = 91) 82.4 80.2 88.4 49.5 30.7

Would pay 50-100AFN ($1-2) Would pay 200AFN ($4)

Verbal Autopsy / Maternal Death Audit

22 deaths reported:
5 outside target population 16 VA conducted
Cause of Death PPH Preeclampsia Eclampsia Infection Unknown Total N (%) 12 (75) 1 (6.25) 1 (6.25) 1 (6.25) 1 (6.25) 16 (100) Breakdown Retention of placenta Uterine rupture* Uterus atony Anemia Abruption of placenta (coagulation defect leading to PPH) No information 1 (8.3) 1 (8.3) 7 (58.3) 1 (8.3) 1 (8.3) 1 (8.3) N (%)

No deaths reported due to misoprostol adverse Total 12 (100) 12 event

Conclusion
High coverage of misoprostol was achieved among the population that was reached by the intervention Household survey results showed increases in the rates of ANC Women were able to recall key information regarding PPH and misoprostol. CHWs were the main source of information There were no adverse events related to misoprostol use

Challenges
Extremely remote area could not be covered due to lack of CHWs Geographical and security barriers encountered Difficulty to find and recruit verbal autopsy reviewers The results of this survey may not be entirely representative of all households in the district, as households that were far from the facility were likely not included, possibly due to security reasons

Next Steps
MoPH PPH working group will lead the following activities: Conduct a national workshop to:

Integrate community based PPH prevention into BPHS Integrate misoprostol into essential drug list Develop a national monitoring system for distribution of misoprostol

Present the result of the expansion of PPH prevention with cost analysis to MoPH Technical Advisory Board and obtain approval for the integration Work with MoPH Grants and Contract unit to issue an amendment on the inclusion of PPH prevention into current BPHS projects