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Hemorrhage is the leading cause of maternal mortality globally; approximately two-thirds of these deaths occur postpartum and are primarily because of atonic uterus. Active management of third-stage labor, most importantly, giving an uterotonic drug (preferably oxytocin [Pitocin]) that is administered after birth of the neonate, has been shown to effectively reduce postpartum blood loss. The relative efficacy and safety of misoprostol (Cytotec) to reduce blood loss because of atonic uterus (compared with oxytocin, ergometrine, or a placebo) has been demonstrated in hospital and community settings.[3-9] When active management cannot be safely performed, the World Health Organization (WHO) and international professional associations recommend that misoprostol be offered to women for oral administration by community or lay health workers trained in its use to prevent postpartum hemorrhage (PPH).[2, 10, 11] A recent systematic qualitative review including 8 published studies and 10 evaluation reports from programs distributing misoprostol for PPH prevention at home birth showed that community-based programs were able to achieve high coverage.
In Ethiopia, the large majority of the population resides in rural areas (85%); virtually all births occur at home (90%); skilled providers (physicians, health officers, nurses, or midwives) attend few births (10%); and maternal mortality is high. PPH is a leading cause of maternal death. In June 2010, the Ethiopian Federal Drug Administration and Control Authority approved registration of misoprostol tablets for oral administration to prevent postpartum hemorrhage, paving the way for the distribution of tablets to community-level health workers who are closest to women in rural communities. The Federal Ministry of Health's Road Map for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality 2011–2015 aims to ensure provision of a core package of maternal and newborn health services through the Health Extension Program, including oral misoprostol to prevent PPH.
The Health Extension Program is implemented through health extension workers and community health development agents. Health extension workers are government employees, mostly young women, with at least a 10th grade education, and one year of mostly didactic training in a package of primary health care focusing on preventive and curative heath, including maternal and newborn health. Compared with health extension workers, community health development agents are volunteers—both women and men—with more years of education. Health extension workers operate at a ratio of 1:2500 households; community health development agents operated at a ratio of 1:30-50 households.[16, 17]
Distribution of misoprostol to prevent PPH through multiple channels has potential to greatly increase women's access to this life-saving drug.
Most women who have access to misoprostol will use it.
Distribution of misoprostol during pregnancy to women who are educated to use it correctly appears to be safe and unrelated to choice of birthplace.
Early distribution of misoprostol during pregnancy for women's self-administration after birth would further expand access and use.
A program of rigorous research comparing the safety and effectiveness of community distribution strategies, including early distribution for women's self-administration, is needed to generate evidence to inform policy recommendations.
The Ethiopian Federal Ministry of Health's Extension Program authorizes health extension workers to give misoprostol to women to prevent PPH immediately after birth of the neonate. However, health extension workers attend less than 1% of births. Low attendance derives from a variety of factors: limited numbers of health extension workers per health post catchment area, lack of confidence in attending births because of limited clinical training and experience, the distance from the health posts to women's homes, conflicting job responsibilities, and women's preference for relatives—or traditional birth attendants (TBAs). In Ethiopia TBAs are older women who typically learned basic midwifery through apprenticeship with another TBA.
Under leadership of the Federal Ministry of Health, MaNHEP worked in 6 woredas (districts) of the Amhara and Oromiya regions to strengthen implementation of the Health Extension Program's community maternal and newborn health (CMNH) component, specifically focusing on improving care during birth and during the early postnatal period when women and newborns are at greatest risk of death. MaNHEP was funded by the Bill and Melinda Gates Foundation and led by Emory University in collaboration with the JSI Research & Training Institute, Inc., University Research Co., LLC, and Addis Ababa University. MaNHEP's objectives were to: 1) improve the capacity and performance of health extension worker, community health development agent, and TBA teams to provide the focused CMNH care; 2) increase women's demand for focused CMNH care and improve their self-care behaviors; and 3) develop and demonstrate the effectiveness of lead woredas to improve CMNH care and services—that is, model districts committed and able to continuously improve care and service delivery to meet the needs of childbearing families. To achieve these objectives, MaNHEP deployed a 3-pronged intervention: 1) facility-based CMNH training of health extension workers, coupled with community-based training and support of health extension workers, community health development agents, and TBAs—who in turn trained pregnant women and family caregivers through a series of CMNH family meetings; 2) continuous quality improvement training and support for community stakeholder groups to ensure that the CMNH care reached women and newborns in a reliable and timely manner; and 3) behavior change communications (TV spots, mobile van video show, poetry contests) to reinforce the above objectives and to shift community norms around the value of CMNH care. Relevant to this article, the CMNH training and CMNH family meetings included knowledge and skills related to the safe use of misoprostol (take 3 tablets by mouth immediately after birth of the placenta), its side effects and what to do if these occur.
MaNHEP conducted a baseline survey from July through August 2010. The survey targeted 3 groups: community-level health care providers (health extension workers, community health development agents, and TBAs), adult women and men aged 18 years and older, and women who gave birth in the year prior to the survey. The survey included a systematic random sample of 1027 women. The findings of this survey indicated that the women had a low awareness of misoprostol to prevent postpartum hemorrhage, particularly in Amhara (< 1% vs 27% Oromiya). The women's use of misoprostol was also low (0% Amhara vs 20% Oromiya).
In late August 2010, MaNHEP initiated the CMNH training of health extension workers, community health development agents, and TBAs. By March 2011, the MaNHEP-trained community health development agents and TBAs began conducting CMNH family meetings with pregnant women and their family caregivers. MaNHEP also purchased and distributed misoprostol tablets to the project area woreda health offices, stipulating that they distribute misoprostol to health extension workers to give to women for PPH prevention. MaNHEP requested approval from the regional health bureaus to allow community health development agents and TBAs to distribute misoprostol to pregnant women during CMNH family meetings for use after birth. Only the Oromiya Regional Health Bureau approved the strategy. Thus, in the Amhara region, only skilled providers and health extension workers were allowed to provide misoprostol to women, whereas in the Oromiya region skilled providers and health extension workers as well as trained community health development agents and TBAs were allowed to provide it, effectively creating a natural experiment of 2 regionally distinct misoprostol distribution strategies.
By February 2012, MaNHEP's monthly quality improvement monitoring data showed rapid increases in women's use of misoprostol in both regions. However, the baseline difference in use between regions persisted: 31% in Amhara versus 93% in Oromiya.
The purpose of this article is to describe—in the context of these 2 strategies—the regional trends in women's use of misoprostol; differences in their awareness, receipt, and use of misoprostol at the project's endline; and the factors that were associated with the correct use of the drug. We then discuss implications for practice and research. A related article in this issue of the Journal of Midwifery & Women's Health focuses on the policy context of misoprostol to prevent PPH in Ethiopia at national, regional, and local levels.