Abstract
BackgroundA postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia. Advance distribution of misoprostol was offered during antenatal care (ANC) and home visits. Feasibility, acceptability, effectiveness of distribution mechanisms and uterotonic coverage were evaluated.MethodsEight facilities were strengthened to provide PPH prevention with oxytocin, PPH management and advance distribution of misoprostol during ANC. Trained traditional midwives (TTMs) as volunteer community health workers (CHWs) provided education to pregnant women, and district reproductive health supervisors (DRHSs) distributed misoprostol during home visits. Data were collected through facility and DRHS registers. Postpartum interviews were conducted with a sample of 550 women who received advance distribution of misoprostol on place of delivery, knowledge, misoprostol use, and satisfaction.ResultsThere were 1826 estimated deliveries during the seven-month implementation period. A total of 980 women (53.7%) were enrolled and provided misoprostol, primarily through ANC (78.2%). Uterotonic coverage rate of all deliveries was 53.5%, based on 97.7% oxytocin use at recorded facility vaginal births and 24.9% misoprostol use at home births. Among 550 women interviewed postpartum, 87.7% of those who received misoprostol and had a home birth took the drug. Sixty-three percent (63.0%) took it at the correct time, and 54.0% experienced at least one minor side effect. No serious adverse events reported among enrolled women. Facility-based deliveries appeared to increase during the program.ConclusionsThe program was moderately effective at achieving high uterotonic coverage of all births. Coverage of home births was low despite the use of two channels of advance distribution of misoprostol. Although ANC reached a greater proportion of women in late pregnancy than home visits, 46.3% of expected deliveries did not receive education or advance distribution of misoprostol. A revised community-based strategy is needed to increase advance distribution rates and misoprostol coverage rates for home births. Misoprostol for PPH prevention appears acceptable to women in Liberia. Correct timing of misoprostol self-administration needs improved emphasis during counseling and education.
Highlights
A postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia
Misoprostol distribution and coverage During the seven months of implementation, 1,826 deliveries were expected in the intervention area
The national clinical protocols do not explicitly state whether a uterotonic should be used for cesarean section deliveries, and uterotonic use was not recorded for these deliveries (n = 68)
Summary
A postpartum hemorrhage prevention program to increase uterotonic coverage for home and facility births was introduced in two districts of Liberia. Advance distribution of misoprostol was offered during antenatal care (ANC) and home visits. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, accounting for approximately 42% of deaths in Liberia and 34% in Africa overall [2]. In 2009 a Basic Package of Health Services was introduced, which includes key maternal and child health interventions. Despite these efforts, one-third (34.0%) of pregnant women do not receive the recommended four or more antenatal care (ANC) visits [5]. Deliveries in a health facility have increased from 36.9% in 2007 to 55.8% in 2013 [6]. 38.9% of women in Liberia give birth without the assistance of a skilled birth attendant [6]
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