As a young doctor in Kenya, Harshad Sanghvi saw woman after woman arrive at the district hospital bleeding profusely after giving birth at home. Many lived in far-off villages where the local health clinic was little more than a one-room hut. Families would do what they could to get their wives, sisters, daughters to a district or regional hospital in the hopes that a doctor like Sanghvi would save them from bleeding to death. “Several hours of transport and they were dying on our doorsteps,’’ says Sanghvi.
That was 20 years ago. Preventing the needless deaths of new mothers and other women became a primary focus of Sanghvi’s research and shaped his response: “The issue was how to take lifesaving, preventive care to all women rather than wait for women to come to hospitals that were so hard to reach.”
Postpartum hemorrhage (PPH) was and is the leading cause of maternal death worldwide. It occurs when the uterus fails to contract following birth. Pregnant women in Kenya and other developing countries are more vulnerable because they have limited access to skilled professional providers and modern health care systems. Sanghvi’s experience as a young doctor in Kenya led him on a path to devising low-cost solutions to health problems of women in the developing world and delivering them far and wide.
For Sanghvi, innovations that save lives of women in developed countries often do not work in low-resource settings because they are far too expensive and require facility-based health care systems. What he has looked for instead are extremely inexpensive interventions that have the chance to reach every woman regardless of where she is giving birth. His work with PPH and misoprostol are one example.
“When information first became available about this drug (misoprostol), we immediately saw the potential for tackling the problem of PPH at home birth,” recalls Sanghvi, Vice President and Medical Director of Jhpiego and senior associate at the Bloomberg School of Public Health at John Hopkins University.
“The challenge was how to deliver this drug to all women who were pregnant, even those not within the health care system.”
The solution for women with little or no access to a trained health care provider took Sanghvi and his research colleagues first to Indonesia and then to rural villages in Faryab, Jawzjan and Kabul provinces in Afghanistan and Banke district in Nepal. The solution lay in training community volunteers to identify all pregnant women, educate these women on the use of misoprostol and then dispense it to them so they could use it immediately following childbirth.
Two studies were designed and carried out between June 2005 and August 2007 in the two South Asian countries. Papers co-authored by Sanghvi were released last month in the “International Journal of Gynecology and Obstetrics.” The studies show that a program to educate rural women on the use of misoprostol after delivering a baby at home can significantly reduce postpartum bleeding and ultimately save lives in the developing world.
As Sanghvi puts it, “We have found a good way to get the drug to the woman in the antenatal period; she now has the means to protect herself from PPH even if she cannot reach a skilled professional provider.”
As a result, both Afghanistan and Nepal are scaling up the intervention nationally, and an introduction is taking place in at least 12 other countries.
More than 50 percent of women in developing countries give birth without a skilled birth attendant at their side. Sixty percent to 80 percent of cases of PPH could be prevented if women had access to appropriate care during labor and birth. Active management of third stage of labor – including the use of a uterontic drug – is the most effective way to prevent postpartum hemorrhage.
Misoprostol is one of the most effective of these drugs and easier to use because it can be taken as a pill and administered without a skilled birth attendant. A research trial in India published in 2006 had shown convincingly that misoprostol given by a health care provider at home or in a birthing center reduced postpartum hemorrhage. In addition:
Sanghvi and his research partners decided to test a strategy for self-administration of the drug, following education of pregnant women and their families.
Community health workers living in some of the most remote areas in Afghanistan identified pregnant women and taught them how to take the medication. They met each pregnant woman and her supporting family members in the months prior to birth, providing one-on-one education on labor and delivery and potential complications of birth, including PPH.
Women who agreed to accept misoprostol were visited again at eight months and given the misoprostol – but only after they showed that they understood how and when to use the drug, what minor effects to expect and what to do if PPH occurred even after taking the pills.
All took misoprostol correctly – immediately after giving birth and before the placenta was delivered.
“In the intervention area where community-based distribution of misoprostol was introduced, near-universal uterotonic coverage (92 percent) was achieved compared with 25 percent coverage in control areas,” the study found.
The Afghan study concluded that “community-based education and distribution of misoprostol is safe, acceptable, feasible and effective” – a model for use in other countries where women have limited access to skilled birth attendants.
The Nepal study found that distribution of misoprostol by community health volunteers associated with the government health system can reach a high proportion of women in a given area. Among the findings:
- 18,761 pregnant women were dispensed misoprostol by female community health volunteers with no significant adverse events or misuse or incorrect use;
- The proportion of deliveries protected by a uterotonic rose from 10.4 percent to 72.5 percent; largest gains were among the poor, illiterate and those living in remote areas;
- Institutional deliveries increased from 9.9 percent to 16.0 percent; and
- The maternal mortality ratio among 13,969 misoprostol users was 72/100,000, significantly lower than among non-users (304/100,000), as well as the national level of 281/100,000.
“To achieve substantial reductions in maternal risk, there is no substitute for wide use of skilled care at delivery, including a full range of clinical support services and ready access to full emergency obstetric care,” the Nepal study’s authors wrote. “But the excellent need not be the enemy of the good. Substantially increasing skilled care at delivery will be difficult in Nepal and elsewhere.
“As we continue efforts to improve coverage and quality of delivery services, interim measures can contribute to driving down the burden of maternal deaths,’’ the authors continued. “This study has demonstrated that high coverage with a preventive dose of uterotonic can be achieved with modest means. Much wider use of misoprostol, focusing on those not yet reachable with more definitive care, targets the principal cause of maternal death in low-resource countries and has the potential to significantly reduce post partum hemorrhage deaths due to atony.”