1. Towards National Impact of PPH Prevention: Bangladesh Experience Prof. Dr. Shah Monir Hossain Director General Directorate General of Health Services Ministry of Health & Family Welfare & Dr. Abu Jamil Faisel Project Director, Mayer Hashi Project & Country Representative, EngenderHealth

2. Background BMHSMMS-2001  MMR 320/100,000 live births (BMHSMMS-2001) BMHSMMS-2001  Estimated number of live births: 3.8 million/year (BMHSMMS-2001)  Annual number of maternal deaths:12,000  85% of deliveries occur at home (BDHS 2007)  AMTSL is practiced in only 16% of the vaginal deliveries (EH, 2008)

3. Background Bangladesh National Strategy for Maternal Health (2001): Emergency Obstetric Care Antenatal Care Skilled Birth Attendance Postnatal Care Family Planning Evidence-based practices have been introduced in projects and programs, and will be included in an updated Maternal Health Strategy, such as: Birth preparedness counseling Active management of third stage of labor (AMTSL) Mg Sulphate for prevention and treatment of eclampsia/pre-eclampsia

4. Major Milestones for PPH Prevention  National Stakeholders’ Meeting on Scaling up of PPH Prevention Activities (October 2006)  National PPH Prevention Task Force under the leadership of the Director General of Health Services (December 2006)  National Assessment on the availability and routine use of AMTSL (2008)  Approval of Misoprostol tablets for prevention & treatment of PPH by Director of Drug Administration (May 2008)  Government approval of Guideline and Implementation Plan for piloting Misoprostol distribution and use (August 2008)

5. At the facility level: AMTSL by maternity service providers: 10 TOT courses for 160 trainers Skill Based Trainings of 530 doctors & 2,250 nurses/paramedics from 25 districts Orientation of 1,225 CSBAs of 15 districts At the community level: Misoprostol Use during home delivery: District planning and orientation meeting for 56 participants 28 training sessions for 1,428 participants Development of BCC materials and conducting BCC activities in the communities Identification of pregnant women, distribution of Misoprostol, monitoring and follow-up Strategy-wise Activities undertaken

6. AMTSL Training: EngenderHealth completed 25 districts, OGSB 5 districts and UNFPA 4 districts. AMSTL Training & Misoprostol Use Misoprostol interventions: EngenderHealth is piloting in 3 districts, ICDDRB in one district and BRAC is using in urban areas of one district and in rural areas of 4 districts. EngenderHealth & UNFPA UNFPA OGSB EngenderHealth ICDDRB BRAC

7. EH Experience of Misoprostol use in one District Summary Overview of Project Monitoring Data Common reasons for not taking Misoprostol: Women with severe anemia believed that they did not have sufficient blood to loose. Women who left the working area after registration forgot to take drug with them. Women who delivered alone at home forgot to take the drug.

8. Lessons Learned  AMTSL is practiced by trained maternity service providers but not consistently reported: practice and documentation need to go hand in hand.  Evidence from 2 hospitals visited shows that AMTSL is reducing the incidence of PPH.  Misoprostol can be safely distributed by the GOB and NGO field workers, but additional distribution channels need to be found to enlarge coverage.  The Misoprostol pilot has encouraged the Government and the PPH Task Force to implement other evidence-based interventions.  Interventions have shown importance of strong GOB commitment and active participation together with detailed monitoring to achieve success and maintain potential for scale-up.

9. Challenges  Lack of availability of the Injection Oxytocin at the facility level and problems with proper storage.  Misoprostol is not yet included in the Essential Drug List.  AMTSL and Misoprostol are not yet included in the Government MIS system.  Lack of supervision, on-site coaching and support by supervisors on AMTSL and broader maternal and newborn health.  Inherent systemic issues in the public sector e.g. vacancies.  The National Strategy for Maternal Health (2001) needs to be updated, but already many evidence-based practices are applied with GOB concurrence in pilots and programs.