faisel_program implementation bangladesh experience

8/2/2019 Faisel_Program Implementation Bangladesh Experience

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Bangladesh Program for thePrevention of PostpartumHemorrhage: ImplementationExperiences

Dr. S. A. J. M. MusaDirector PHC, & LD, MNCAH, DGHS

Dr. Mohammad SharifDirector MCH, & LD, MCRAH, DGFP

Dr. Abu Jamil FaiselProject Director, Mayer Hashi project &

Country Representative EngenderHealth Bangladesh


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Presentation Outline

Government policies and plans to address PPH prevention:

a two pronged approach: AMTSL: Assessment, interventions, implementation challenges

Misoprostol: Major milestones, pilots, lessons learned, nationalscale-up, implementation challenges


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(Ref: GOB OPs on MNCH)

PPH Prevention Approaches

The government emphasizes the use of community skilled birthattendants (CSBAs) for home births and the development of amidwifery cadre to increase skilled attendance at facilities

In addition, the government initiated other policies for addressingmaternal mortality such as demand side financing (DSF), healthinsurance schemes, community level use of MgSO4 in a loadingdose for prevention of PE/E etc.

The Ministry of Health and Family Welfare proposes a two-prongedapproach for PPH prevention:

1. Active management of the third stage of labor (AMTSL) at the

facility level2. Community-based distribution and use of Misoprostol


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1. Active Management of the Third Stage of Labor

Active management of thirdstage of labor (AMTSL) - aproven simple effectiveintervention (WHO,ICM/FIGO, 2006)

Three components:10 I.U Injection Oxytocin ( intra-muscular) within one minuteafter delivery of babyControl Cord Traction (CCT)

Uterine Massage after delivery ofplacenta


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2008 AMTSL Assessment Key Findings

96.9

83

61.5

44.5

25.7

19

16

0

10

20

30

40

50

60

70

80

90

100 Uterotonic drug at any stage

Uterotonic drug at third stage oflabor (correct stage)

Uterotonic drug at third stage and

immediately after delivery of baby(correct stage & timing)

Uterotonic drug at 3rd stage, afterdelivery of baby, 10 IU (with correctdose)

Uterotonic drug, 3rd stage, afterdelivery of baby, 10 IU, IM (correctdose & route)

Correct use of uterotonicdrug+controlled cord traction

Correct use of uterotonic drug,CCT, uterine massage

Proportion of Deliveries where AMTSL is Correctly Practiced


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Post Assessment Interventions

AMTSL training conducted for doctors and nurses in 25 out of 64

districts (by Mayer Hashi in 21 districts)

Trained maternity care service providers started practicing their newlylearned AMTSL skills

Supervision and coaching with DGFP and DGHS

Information on AMTSL practices collected through monthly reports

Post-training AMTSL practice increased from 16% to 85%

Incidence of PPH in monitored facilities declined drastically by morethan 75%

Mayer Hashi is working with DGHS and DGFP on improving Oxytocinstorage in facilities and warehouses


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Ensuring country-wide training andsupervision of providers

Ensuring correct and consistent useof AMTSL in the facilities

Maintaining the cold chain for

oxytocin

Inclusion of AMTSL in the GOBreporting system and consistentreporting.

Low institutional delivery rateShortage of skilled providers

Limited availability of facilities thatoffer 24/7 delivery services

AMTSL Implementation Challenges


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2. Misoprostol

Misoprostol is a uterotonic increasingly used

in clinical and home settings to prevent andmanage PPH.

Misoprostol tablets are inexpensive, easy tostore, stable under field conditions and havean excellent safety profile.

FIGO and ICM jointly recommend that inhome births without a skilled attendant,misoprostol may be an appropriatetechnology for controlling PPH (ICM/FIGO,2006)

WHO recommends misoprostol for theprevention of PPH where oxytocin is notavailable or cannot be safely used (WHO,2011)


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Establishment of the National PPH Prevention Task Force, Secretariat at

EngenderHealth (October 2006)

Some NGOs started using misoprostol in their working areas (urban and rural).

Approval of misoprostol for prevention of PPH by the Directorate General ofDrug Administration and its inclusion in the updated essential drug list (May2008)

Approval of the piloting of community-based distribution of misoprostol usingfieldworkers (August 2008)

Agreement and approval of the effective misoprostol dose for preventing PPHfor national use400 mcg (March 2010)

Approval of the scale-up plan for misoprostol by the National TechnicalCommittee (NTC) of Directorate General of Family Planning (DGFP) (May2010)

Approval of the national scale-up plan developed with Mayer Hashi technicalassistance (September 2010)

Misoprostol introduction: Major Milestones


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Misoprostol use in two pilot districts with Mayer Hashi TA

District Number ofpregnantwomenregistered

Number of

womendelivered

Number of

womendelivered athome

Number of women

who took Misoprostol

Tangail 22,050* 19,066 16,513 15,605 (95%)CoxsBazar 25,320 19,188 17,477 16,689 (95%)

*in both districts 70% of pregnant women wereregistered by the fieldworkers


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Incorporated misoprostol into the Health, Population and Nutrition Sector

Development Program (HPNSDP) 2011 2016 and respective OperationalPlans of DGHS and DGFP

Allocated budget in the Operational Plans for implementation of scale-up

Phase-wise scale-up has started since July 2011 in 4 Districts

Developed implementation modalities for both DGFP and DGHS. DGFP is usingtheir field workers (FWAs) for distribution of the tablets to the pregnant womenaround 32 weeks of gestation. DGHS is using the Community Clinics and otherfacilities (e.g. UHCs) to distribute the tablets to the pregnant women when theycome for their last ANC visit

A misoprostol card was introduced to avoid duplication of distribution

Implementation guidelines/circulars were sent out to DGFP and DGHS field staff

National Scale-Up


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Tested training and BCC materialsapproved by DGFP and DGHS werehanded over to them

DGFP and DGHS will continue to receiveTA from Mayer Hashi and other partners

to strengthen misoprostol program at thecommunity level

Efforts are underway to institutionalizeMaternal Death Audits (verbal autopsy) aspart of maternal mortality reduction efforts

DGFP has incorporated misoprostol intheir record keeping and reporting system.DGHS is in the process of doing the same

National Scale-Up (2)


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Misoprostol can be effectively distributed through trained and supervised

fieldworkers

One-day training was found to be sufficient for the fieldworkers

Service provider attendance is not required during misoprostol use, and well-counseled women themselves can correctly use Misoprostol to prevent PPH

Misoprostol can reduce PPH compared to previous delivery, as reported by theclients

Delivery attendants need to be educated on misoprostol benefits, so they willnot prevent women from using the tablets

A few women in the pilots reported minor misoprostol-induced side effects

The distribution of misoprostol after 32 weeks pregnancy is advisableClose collaboration with the government, through implementation of pilots andprovision of scientific evidence and continuous technical assistance, increasesthe chances of developing scalable programs

Lessons Learned from NGO & Pilot programs


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Reaching and registering all pregnant women for misoprostol distribution

Distribution of Misoprostol tablets to all registered pregnant women

Raising community awareness about Misoprostol use and removingmyths and misperceptions about delivery and PPH

Preventing inappropriate use of Misoprostol

Raising community awareness regarding facility delivery and use ofSBAs

Ensuring the accuracy and consistency of information provided throughthe governments cascade training

Ensuring a continuous supply of Misoprostol

Ensuring consistent monitoring, supervision, and follow-up of the PPHprevention interventions

Ensuring reporting of the PPH prevention interventions through thegovernments management information system

Misoprostol implementation challenges


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Thank You

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