kc_program implementation nepal experience

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NEPAL: A Pioneer in Community-Based Distribution of Misoprostol

for Prevention of PPH at Homebirth

Dr. Naresh P KC

Ministry of Health and

Population, NepalMay 2012



2

Haemorrhage

24%

Eclampsia

21%

Abortion

7%

Heart disease

7%

Obstructed Labour

6%

Anaemia

4%

Gastroenteritis

4%

Puerperal sepsis

5%

Other direct

6%

Other indirect

16%

Sources: Nepal Demographic and Health Surveys, 2006, 2011; MaternalMortality and Morbidity Survey 2008/09

PPH 17%

MNH Situation in Nepal• Maternal Mortality Ratio one

of the highest in South EastAsia: 281/100,000

• Hemorrhage (APH, PPH)leading cause of maternaldeath

• Deliveries by Skilled BirthAttendants increasing but stilllow

• 19% in 2006

• 36% in 2011

• Low uterotonic coverage

(Oxytocin or Misoprostol)

• Low SBA retention in remote

areas



Basic research Introduction

and pilot

Influential evidence

Policy considerations

RegionalRCTshowingefficacy

Professionalexperience andhospital datasuggesting high riskfor PPH

Jan 2004: NepalGoN committedto pilot followingBangkokworkshop

Apr 2004: Discussionwith professionalorganizations, SafeMotherhood Sub-Committee

Sept 2004:Formation of TechnicalAdvisoryCommittee

Feb 2005:NHRCapproval forpilot

1 year: evidence topilot

Preliminary Work for Pilot



Pilot in Context

• First priority was to increase skilledattendance at birth and

institutional deliveries through:

– Health facility upgrades

– Emphasis on AMTSL at healthfacilities

– SBA in-service training

– Maternity incentive scheme

• Misoprostol distribution by FCHVsfor prevention of PPH at home

birth within a broader community

approaches



Health workers/

Health facilitiesFCHV

Woman & newborn

• FCHVs and HWs work closely for promotion of ANC, Institutional

delivery and PNC. They have key role in:•

Promotion of ANC, institutional delivery and PNC, self-care, hygiene, Essential Newborn Care

• Use of iron/folate, deworming tablets, TT, post-natal Vitamin A•

Birth preparedness (money, transport, SBA and blood)

•Identification of danger signs (pregnancy, delivery and post-natal) and referral

• At 8th month, FCHVs distributes Misoprostol. During PNC home visits

confirms use and retrieves if unused

Community Service Delivery System



Areas Antenatal Delivery Post-natalAssess Danger signs and referral Danger signs and

referral

•Danger signs and referral

(including neonates)

•Birth weight

Counsel

•Birth preparedness and

complication readiness•Danger signs/refer

•Seeking care, TT & anti-

helminthic Rx

• Misoprostol

•Danger signs and

referral

•Promotion of institutional

deliveries

•Essential newborn

care

•ENC

•Exclusive breast feeding•PNC (rest, food, hygiene,

etc.)

•Family Planning

Distribute•Iron/folate•Misoprostol

•BPP action card

•Iron/folate

•Post-natal Vit A

Document Pregnancy registration Pregnancy outcomes

Key Roles of FCHVs



Results of Misoprostol Pilot in

Banke District, 2005-2007



Timing of Misoprostol Use

0

86

14

0

20

40

60

80

100

before the delivery

of the baby

afer the delivery of

the babybut before

the delivery of the

placenta

afer the delivery of

both baby and

placenta

P e r c e n

t

Source: Follow-up survey 2007

Used appropriately



Symptoms Reported

2218.5

3.4

9

26.3

27

6.29.4

1.3

7

15.1

0

10

20

30

40

50

60

70

80

90

100

D i z z y

S h i v e r i n g

N a u s e a

F e v e

r

L o o s e

m o t i o n

H e a d a c h e

P e r c e n t

Used MSC Not used MSC

Source: Follow up survey 2007



Uterotonic Coverage

Baseline Endline

0

20

40

60

80

100

Misoprostol

Inj. Oxytocin

Source: Follow up survey 2007



Use of Skilled Birth Attendant

Associated with increased SBA use

Source: NFHP survey



Conclusion: Pilot Success in Banke

• Significant increase of uterotonic coverage

• High coverage in governmentsystem with mobilization of FCHVs

• Adverse effects were not asignificant problem

• Misoprostol can and shouldbe implemented with effortsto increase Skilled BirthAttendants use

• High degree of correct use,efficacy and safety

• Suggestive to scale-up inother districts



Expansion from Pilot



Progression to scale

Pilot National level scale-up

Influential evidence

Policy considerations

Regional

RCT usedforadvocacy

Pilot results

used todemonstratefeasibility

Mar 2010:Nepal countryteam committedfor nationallevel expansionof MSC

(ReconveningBKK conference)

April/May 2010: Sharing andadvocacy at thenational level

June 2010:MOHP approvedfor nationallevel expansion

July 2010:Developedimplementationguidelines

6 months: pilotresults to scale-

up



Current GON Approach to PPH Prevention

Prevention of PPH

Active Management of Third

Stage of Labor (AMTSL)

Use of Misoprostol at home

birth

Use of uterotonicdrugs: Inj.

Oxytocin within aminute after

delivery of baby

Controlledcord

traction

Uterinemassage

Use of uterotonic drug: TabMisoprostol (600 mcg) after

delivery of a baby

Only trained health workers can do

AMTSL

Feasible in community

settings



Central Region

Eastern Region

Mid-Western Region

Far-Western Region

Western Region

Humla

Darchula

Baitadi

Dadeldhura

Kanchanpur

Kailali

Doti

Bajhang

Bajura

Achham

Bardiya

Mugu

Dolpa

Mustang

Manang

Rasuwa

Kalikot

Dailekh

Surkhet

Jumla

Jajarkot

Banke

Rukum

Salyan

Dang

Rolpa

Pyuthan

Myagdi

Baglung

Gulmi

Kapilvastu

Kaski

Syangha

Rupandehi

Palpa

Lamjung

Tanahu

Gorkha

Chitwan

Dhading

Nuwakot

Makwanpur

Nawalparasi

P a r s a

B a r a

R a u t a h a t *

Taplejung

SolukhumbuSankhuwasava

Sindhupalchowk

S a r l a h i

M a h

o t t a r i

D h a

n u s h a

Siraha

SaptariSunsari

Sindhuli

Kavre

Dolakha

Ramechhap

Okhaldhunga

Udayapur

Morang Jhapa

Ilam

KhotangBhojpur

Dhankuta

K

L

B

N

Districts with Misoprostol

• GoN is committed to increase uterotonic coverage (GON

expanding the intervention and purchasing Misoprostol)

• Priority is AMTSL during deliveries at health facilities

• Misoprostol national level scale-up focusing in remote areas.

Pilot – 2005

Expansion – 2009/10

Expansion – 2010/11

Plan for Expansion – 2011/12

Legend



Major Inputs for Program Scale-up

• Training

• Review/refresher meetings

• Logistic support

• Monitoring



Uterotonic Coverage(in selected program districts)

26

50

1427 33

4327

36

59

44

22

5250

56

5628

34

0

20

40

60

80

100

120

Misoprostol coverage HW/HF delivery

Source: District HMIS, 2011/12



•

National context: Urgent need toreduce MMR due to PPH

• Realistic piloting under MoHPsystem

• Rapid move from pilot to scale-

up (<2 years)

• Consensus and support from allstakeholders (including NepalSociety of Ob/Gyns) for scale-up

•Nepal is pioneer in successfulimplementation of Misoprostoland has been a subject of globalinterest

Conclusions



• Distribution of misoprostol,ensuring availability andtransportation

• Collection of reports from

grassroots level• Program expansion/coverage only

in partners supported districtslimiting the expansion in priority

districts• Ensuring the quality of training to

FCHVs

Challenges



Thank You

Implementing Partners• Government of Nepal (FHD lead)

• Partners• USAID/NFHP II and its partners

• UNICEF• CARE Nepal

• Rural Health Development Program(RHDP)/SDC

• Health Right International

• Nepal Society of Obstetricians andGynaecologists (NESOG)

• One Heart Worldwide (planning to supportin expansion)

kc_program implementation nepal experience

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