1. Misoprostol Delivers!
The use of misoprostol in the prevention
of postpartum hemorrhage (PPH) in Doti
District, Nepal
Implementation and data collection CARE Nepal CRADLE Team
Statistics by Noor Tirmizi and Kristen Yee

2. Outline
• Background
Results from Feasibility Study
• Results from Case Control Study on Effectiveness
• Methods
• Results
• Descriptive statistics
• Bivariate analysis
• Logistic regression
• Limitations
• Conclusions

3. Background: Misoprostol in Doti District, Nepal
• Blanket pilot program initiated in
Dec 2010 in Doti
• Hilly, mountainous region, 768
sq miles
• Aimed to Provide misoprostol
(600μg) to every pregnant
women in 8th month of
pregnancy
• Training of HWs/FCHV and drug
supply facilitated by CARE
• Monitoring and supervision of
rollout done by MoH in
partnership with CARE

4. Operations Research Study
To determine
• feasibility
• acceptability
• safety
of community-based distribution of misoprostol by
community volunteers under government service towards
the prevention of postpartum hemorrhage (PPH) in
pregnant women
3

5. OR – Feasibility Study
Objectives of the study:
• To explore the utilization pattern of Misoprostol in Doti
district during delivery.
• To find out results of Misoprostl and list side
effects/complicatins seen.
Study Design
• A cross section study on feasibility of Misoprostol by
Recently Delivered Women (RDW)
Sample Size for the study
• 15/ 50 VDCs randomly selected. (1) all the FCHVs of those
VDC interviewed (2) Recently delivered women (3) Similarly HW and
HWIC wherever available in these 15 VDCs interviewed.

6. Study Setting & Design
Data Collection
• Quantitative collected from the interview of RDW
• Qualitative collected using IDI and FGDs of FCHVs, HWs,
HFICs
Data processing and analysis
• Data collection tools were coded and analyzed in SPSS
• FGDs/IDIs were transcribed and analyzed using content
analysis approach
Duration of Data Collection
• August 2011 for both qualitative and quantitative data

7. Antenatal & Health Education Characteristics
Cases (N=55) Controls (N=290)
Percent Percent
Variable Freq Freq
Freq Freq
ANC <4 16 28.6 99 34.1
visits
4 visits 39 71.4 191 65.9
Any counseling on No 19 34.5 67 23.1
BPP by FCHV
Yes 36 65.5 223 76.9
BPP counseling by No 43 78.2 185 63.8
FCHV in 8th month
of pregnancy
Yes 12 21.8 105 36.2

8. Delivery Characteristics
Cases (N=55) Controls (N=290)
Percent Percent
Variable Freq Freq
Freq Freq
Place of delivery Home 55 100.0 286 98.6
Cowshed 0 0.0 2 0.7
Road 0 0.0 2 0.7
HW attended No 36 64.7 143 49.2
delivery
Yes 19 35.3 147 50.8

9. Source of Information
Knowledge on MSC Percent (n=169)
Heard about MSC from:
FCHV 72.2
VHW/MCHW/ANM 17.8
Doctors/HA/AHW 8.9

10. OR - The Numbers Game
Feasibility
• 49% Illiterate
• 40% Dalits 345 Women Interviewed
• 95% women had
FCHV < 30 minute
walk
173 Received Misoprostol
Safety
• 88% knew correct timing.
• Common Side Effects 169 took the correct
vomit, diarrhea, shivering dose
• 95% knew advice to go to HF
if bleeding persists
Acceptability: 99.4% of users would recommend MSC
to their friends and relatives

11. FGD/IDI Findings
1) MCHW/ANM
• Interview with nursing staffs revealed that FCHVs were capable for
distribution of MSC and counseling on its usage to mothers.
2) HF- Incharge
• HF in-charges were confident about knowledge of FCHVs on MSC;
dose, time to take, side effects and its return and their ability to distribute
the tablets.
3) FCHV
• FCHV reported that they gave the tablets only after enough counseling
on the dose, time and its general side effects to the mothers.
Some of the more aware mothers came to ask for the tablets at last
months of the pregnancy.

12. Study on Effectiveness of Misoprostol
Objectives:
• Determine the odds of misoprostol ingestion based on receipt
of pills
• Determine the odds of postpartum hemorrhage based on
correct ingestion of misoprostol (600μg taken orally
immediately following childbirth)
Definition:
• PPH – MOH definition – 2 half meter cloths completely soaked
with blood during delivery.
Cases = RDW women who experienced PPH (n=55)
Controls = RDW women who did not experience PPH (n=290)

13. Binary Logistic Regression Results
Effectiveness of MSC reducing PPH
Variable Reduction in PPH CI
Exp (β)
Age
(15-24) yrs of age 1.57 0.85 2.79
25 yrs or older
Ingestion of misoprostol (600 μg) 0.46* 0.25 0.86
Yes
Receipt of Counseling on BPP by FCHV
in 8th month of last pregnancy 0.53** 0.27 1.07

14. Binary Logistic Regression Results—Factors
Affecting Ingestion of MSC
Variable MSC Ingestion CI
Exp (β)
Age
(15-24) yrs of age 0.95 0.60 1.48
25 yrs or older
Literacy
Literate 1.43 0.91 2.26
ANC Visits
Did complete 4 visits 1.78* 1.13 2.81
Continued Counseling
Did not receive any 1.43 0.85 2.40
counseling

15. Cross Tables to Explain Reasons for Non-use
Variable
Did not take MSC following Did take immediately
Access childbirth following childbirth
N (%) N (%)
Got MSC tablets during 67 (40.9) 97 (59.1)
pregnancy
Knowledge: Reasons for
taking MSC
Stop PPH, Prevent Death,
help uterus contraction & 114 (54) 95 (45.0)
placenta expulsion

16. Knowledge on Correct Dose of MSC
Knowledge on dose Incorrect dose Correct dose
N (%) N (%)
Reasons for taking MSC
Stop PPH & Prevent Death 15 (8.8) 155 (91.2)
Counseling
Did receive counseling by FCHV 129 (49.8) 130 (50.2)

17. Limitations
Data collection
• Cross-sectional analysis
• Self-report of misoprostol ingestion and PPH
Data analysis
• Sample size (N=345)
• Proxy measures limit interpretation

18. Key Findings
• Women who completed four antenatal visits had 1.78 the
odds of taking misoprostol correctly relative to those
women who did not complete four antenatal visits
• Women who took misoprostol were associated with a
53% decrease in the risk of postpartum hemorrhage

19. Examples from Literature
• BRAC’s maternal, neonatal and child health program in rural
northern Bangladesh 2008-2010
• Successfully provided misoprostol (400μg) to mothers under direct
supervision of CHW
• Maternal and Newborn Health in Ethiopia Partnership
(MaNHEP)
• Provides basic package of interventions to mother and child within first
48 hours of newborn’s life. Misoprostol part of maternal intervention
• The Center for Health Innovations’ Venture Strategies
Innovation (VSI)
• Improve misoprostol availability
• Work with ministries of health to incorporate misoprostol into national
guidelines and promote task-shifting and training
• Multi-country initiative, more policy level focus

20. Conclusions
National Policy Level
• Pilot program initiated by the Government of Nepal and CARE was
successful. CARE worked with other partners/stakeholders and FHD to
prepare guidelines for a national program on Misoprostol use. It is a part
of SMH program in Nepal and is included in the EDL.
• Program has now been scaled up to function on a national level
• Study findings are consistent with existing literature
• Misoprostol as a tool in the reduction of postpartum hemorrhage
• Feasibility and acceptability of misoprotol use and dissemination of the
community level
• this study adds to existing evidence in demonstrating that in one of the
most remote regions of Nepal (hills and mountains), community-level
distribution of misoprostol is possible

21. References
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L., HOFMEYR, G., LUMBIGANON, P., UNGER, C., PRENDIVILLE, W., PINOL, A., ELBOURNE, D., EL-REFAEY, H. &
SCHULZ, K. 2001. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet,
358, 689-95.
• HASHIMA, E. N., NAHAR, S., AL MAMUN, M., AFSANA, K. & BYASS, P. 2011. Oral misoprostol for preventing postpartum
haemorrhage in home births in rural Bangladesh: how effective is it? Glob Health Action, 4.
• HOFMEYR, G. J., GULMEZOGLU, A. M., NOVIKOVA, N., LINDER, V., FERREIRA, S. & PIAGGIO, G. 2009. Misoprostol to
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effects. Bull World Health Organ, 87, 666-77.
• PRATA, N., GESSESSEW, A., ABRAHA, A. K., HOLSTON, M. & POTTS, M. 2009. Prevention of postpartum hemorrhage:
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uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in
Nepal. Int J GynaecolObstet, 108, 282-8.
• HASHIMA, E. N., NAHAR, S., AL MAMUN, M., AFSANA, K. & BYASS, P. 2011. Oral misoprostol for preventing postpartum
haemorrhage in home births in rural Bangladesh: how effective is it? Glob Health Action, 4.
• HOFMEYR, G. J., GULMEZOGLU, A. M., NOVIKOVA, N., LINDER, V., FERREIRA, S. & PIAGGIO, G. 2009. Misoprostol to
prevent and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related
effects. Bull World Health Organ, 87, 666-77.
• Maternal and Neonatal Health. Preventing Postpartum Hemorrhage: A community-based approach proves effective in rural
Indonesia. Baltimore, USA: MNH Program, 2004.
• PRATA, N., GESSESSEW, A., ABRAHA, A. K., HOLSTON, M. & POTTS, M. 2009. Prevention of postpartum hemorrhage:
options for home births in rural Ethiopia. Afr J Reprod Health, 13, 87-95.
• RAJBHANDARI, S., HODGINS, S., SANGHVI, H., MCPHERSON, R., PRADHAN, Y. V. & BAQUI, A. H. 2010. Expanding
uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in
Nepal. Int J GynaecolObstet, 108, 282-8.
• WORLD HEALTH ORGANIZATION. 2007. WHO recommendations for the prevention of postpartum haemorrhage. Geneva,
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