1. PPH Prevention through platform of antenatal care Albert Kitumbo, MD Ifakara Health Institute

2. Rationale for ANC Distribution of Misoprostol for Prevention of PPH PPH is the leading cause of maternal death Misoprostol has been shown to be safe for preventing PPH at home deliveries In Tanzania: – 94% of women attend at least one antenatal care visit (ANC) during their pregnancy – 53% of women deliver outside of facilities By educating women and distributing misoprostol during ANC visits, women who deliver at home will have access to this life-saving technology

3. Operations Research: Testing the ANC Distribution Model Goal: Assess the feasibility, safety, program effectiveness, and acceptability of distribution of misoprostol through ANC visits Conducted in 4 districts of Tanzania between January and December 2009 Collaborating Institutions: Ifakara Health Institute; Venture Strategies Innovations; Bixby Center at the University of California, Berkeley Provide evidence that: Women can safely self- administer misoprostol for prevention of PPH at home births ANC visits are a feasible and effective means of distributing misoprostol for PPH prevention to women Women and communities find misoprostol to be acceptable

4. Components of the ANC Distribution Program Community Awareness Campaign on Birth Preparedness and PPH Prevention Radio Community meetings with CORPs and TBAs Posters and Pamphlets Focused ANC with Misoprostol Distribution ANC Visit Education Session on PPH and Misoprostol Misoprostol Distribution at > 32 weeks gestation Reduce PPH at Home Births

5. Community Awareness Campaign Key messages: – Promote attendance at ANC throughout pregnancy – Importance of delivering in a health facility – Plan early for a safe delivery – PPH consequences & blood loss measurement with the kanga – Misoprostol is available at ANC once a woman is 32 weeks pregnant

6. Focused ANC with Misoprostol Distribution Educate all women coming to ANC about safe delivery and PPH prevention Screen women for eligibility to receive misoprostol Distribute misoprostol to eligible women > 32 weeks gestation

7. Enrollment and ANC/Delivery Characteristics Enrollment ANC Attendance = 12,892 Enrollment = 12,511 (97%) Postpartum Interview = 6,735 ( 54% of enrolled ) ANC/Delivery Characteristics Average number of ANC visits = 3.0 ANC attendance > 32 weeks = 44% Health facility delivery = 67%

8. Feasibility Coverage of Community Awareness Campaign 8

9. Program Effectiveness Comprehension of Campaign Messages PPH InformationMisoprostol Information 9

10. 10 Green color = Birth protected from PPH by use of uterotonic after delivery n= 6,735 Program Effectiveness Births Protected from PPH

11. Program Effectiveness Use of Misoprostol by Location of Delivery Green color = Birth protected from PPH by use of uterotonic after delivery 11

12. Need for Additional Interventions after Home Birth

13. Safety Correct Use of Misoprostol Almost all 1,826 women who took misoprostol at home reported using the drug correctly: – Correct dose (3 tablets)= 99.5% – Correct route (oral) = 98% 13

14. Women’s Acceptability 14

15. Conclusions Integration of misoprostol into existing ANC Services is: Feasible – Reach of community awareness campaign to almost all women – High enrollment and misoprostol distribution to eligible clients Safe – All women used misoprostol correctly at home births – Low report of postpartum symptoms Effective – High comprehension of key community awareness messages – 88% coverage of misoprostol at home births Acceptable – Women feel more secure and protected from PPH 15

16. Limitations and Challenges Women returning for an ANC visit after 32 weeks gestation is lower than anticipated – Greater effort to encourage women to return to the health facility – In the future, consider lowering the gestational age requirement to receive misoprostol 16

17. Policy Implications Other countries with similarly high rates of ANC and lower rates of facility delivery should consider ANC distribution to protect women who deliver at home All ANC providers should be trained to distribute misoprostol at ANC – bring the program to scale Gestational age limitations decrease coverage – consider lower or removing Scale up the community awareness campaign to increase knowledge of key messages Consider other mechanisms of misoprostol distribution for self-administration Misoprostol should be available in all delivery rooms