Scaling Up Misoprostol for
Community-Based Prevention of
Postpartum Hemorrhage in
Bangladesh
Dr. Tapash Ranjan Das
PM (MCH) & Deputy Director (MCH), DGFP
&
Dr. Abu Jamil Faisel
Project Director, Mayer Hashi project
(an Associate Award of the RESPOND project) &
Country Representative EngenderHealth Bangladesh
A mother’s story
Background
The maternal mortality rate in Bangladesh decreased from 322 deaths per
100,000 live births in 2001 to 194 per 100,000 in 2010.
Postpartum hemorrhage (PPH) is still the leading cause of maternal death
(31% in 2010).
Facility deliveries increased from 15% in 2001 to 23% in 2010.
The government emphasizes the use of community skilled birth attendants
(CSBAs) for home births and the development of a midwifery cadre to
increase skilled attendance at facilities.
EngenderHealth, through the USAID-funded Mayer Hashi project, supports
the Ministry of Health and Social Welfare in preventing PPH through a twopronged approach:
– Active management of the third stage of labor (AMTSL) at the facility
level in 21 low-performing districts
– Community-based distribution and use of misoprostol
(Ref: BMMS 2001 and 2010)
Major Milestones
Establishment of the National PPH Prevention Task Force, Secretariat at
EngenderHealth (October 2006)
Approval of misoprostol for prevention of PPH by the Directorate General of
Drug Administration and its inclusion in the updated essential drug list (May
2008)
Approval of the piloting of community-based distribution of misoprostol using
fieldworkers (August 2008)
Agreement and approval of the effective misoprostol dose for preventing PPH
for national use—400 mcg (March 2010)
Approval of the scale-up plan for misoprostol by the National Technical
Committee (NTC) of Directorate General of Family Planning (DGFP) (May
2010)
Approval of the national scale-up plan developed with technical assistance from
EngenderHealth (September 2010)
Pilot Phase
1st pilot: Tangail District (Nov. 2008–June, 2009)
– Implemented by DGFP, DGHS, and NGOs
– Technical assistance, training, monitoring, and
misoprostol distribution by EngenderHealth
Formal evaluation of Tangail pilot (Oct. 2009)
2nd pilot: Cox’s Bazar (Nov. 2009–Mar. 2011)
Mayer Hashi project:
– Transferred skills and developed skills of DGFP
and DGHS to implement pilot
– Conducted training of trainers and provided onsite technical assistance to conduct training and
orientation
– Misoprostol distributed through govt. system
 All misoprostol tablets donated by Venture
Strategies Innovations; produced locally
Implementation Strategy
Training of all fieldworkers (one day)
Identification and registration of pregnant women by trained government
and NGO fieldworkers
Counseling and education by the fieldworkers of pregnant women, their
intended birth attendants, and family members, using behavior change
communication (BCC) materials
Raising of community awareness through BCC activities and courtyard
meetings, with emphasis on facility delivery
Distribution of misoprostol tablets by government/NGO fieldworkers
Follow-up of postpartum women by government/NGO fieldworkers
Back-up of fieldworkers by trained facility-based health care providers,
for management of complications
Results of Pilot Programs
Tangail:
 71% of the expected pregnant
women were registered.
 Among them, of those who
delivered at home, 94% used
misoprostol.
 There were no reported cases of
misuse.
 0.4% (39) of users reported minor
side effects (fever, shivering).
 0.3% (25) of users reported
complications (retained placenta,
PPH due to other cause) and were
referred to hospital.
 An estimated nine maternal
deaths were averted by the use of
misoprostol.
Cox’s Bazar:
 69% of expected pregnant women
were registered.
 Among them, of those who delivered
at home, 95% used misoprostol.
 There were no reported cases of
misuse.
 0.8% (134) of users reported minor
side effects (fever, shivering).
 0.1% (26) of users reported
complications (retained placenta,
PPH due to other cause) and were
referred to hospital.
 An estimated 10 maternal deaths
were averted by misoprostol use.
 Four women died at home due to
obstructed labor and mishandling by
TBA.
Lessons Learned
Misoprostol can be effectively distributed through trained and supervised
fieldworkers.
One-day training was found to be sufficient for the fieldworkers.
Service provider attendance is not required during misoprostol use, and wellcounseled women themselves can correctly use misoprostol to prevent PPH.
Misoprostol can reduce PPH compared to previous delivery, as reported by the
clients.
Delivery attendants need to be educated on misoprostol’s benefits, so they will
not prevent women from using the tablets.
A few women reported misoprostol-induced side effects.
The distribution of misoprostol after 32 weeks pregnancy is advisable.
Close collaboration with the government, through implementation of pilots and
provision of scientific evidence and continuous technical assistance, increases
the chances of developing scalable programs.
Challenges
Raising community awareness about misoprostol use and removing
myths and misperceptions about delivery and PPH
Registering and reaching all pregnant women for misoprostol
distribution
Ensuring the accuracy and consistency of information provided through
the government’s cascade training
Ensuring that women use misoprostol, through consistent monitoring,
supervision, and follow-up
Ensuring the reporting of misoprostol use through the government’s
management information system
Ensuring a continuous supply of misoprostol for prevention of PPH
Preventing inappropriate use once misoprostol is available countrywide
National Scale-Up
Incorporated misoprostol into the Health, Population and Nutrition Sector
Development Program and Operational Plans (2011–2016)
Allocated budget in the Operational Plans for implementation of scale-up
Developed implementation modalities for both DGFP and DGHS
Sent out implementation guidelines/circulars to both DGFP and DGHS
field staff
Tested training and BCC materials approved by DGFP and DGHS and
handed over by Mayer Hashi
Planned for a phased scale-up, and in July 2011 began scale-up in four
districts, with technical assistance from Mayer Hashi
Currently processing bulk procurement of misoprostol tablets
Thank You