Dr. Vikas Yadav, the National Program Manager for Jhpiego’s India program, described his frustration during visits to birthing rooms in health facilities early in his career: “Lifesaving drugs were not correctly used or, in some cases, not used at all.” During childbirth, women may suffer from potentially life-threatening conditions, such as excessive bleeding. Known as postpartum hemorrhage (PPH), excessive bleeding can be prevented with a uterotonic—a drug to make the uterus contract.
According to Dr. Yadav, “You would see health care staff that didn’t know which uterotonic to use and when, because they lacked clear guidance. It is such a simple intervention, yet these staff didn’t have needed information to properly use drugs that could save lives.” Oxytocin is the uterotonic of choice for preventing PPH, but in certain situations, such as home birth, another uterotonic drug known as misoprostol has been recommended.
Dr. Yadav was happy to report that the situation has improved quite a bit in Jharkhand State since those early days. In fact, maternal deaths have decreased dramatically in recent years thanks to the increasing focus of the government and its development partners on training health facility staff and improving the quality of maternal care.
Despite recent improvements, PPH still causes 35% of maternal deaths in the State. And while providing uterotonic drugs is a well-known intervention to prevent PPH, the number of births that receive this intervention is unknown. As in most developing countries, there is no regular or reliable data available on whether uterotonic drugs are provided to women.
It was in part due to this lack of information that staff from USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) partnered with the Directorate of Health Services in Jharkhand state to pilot an innovative approach for estimating the number of women who use a uterotonic drug after birth to protect them from PPH.
Dr. Jeffrey Smith, MCHIP Maternal Health Team Leader, helped the team estimate uterotonic coverage in the State. “In many developing countries, there is more reliable data to measure whether children are receiving lifesaving drugs,” he said. With this knowledge, health experts can design better programs. “Why can’t we also track which women are receiving uterotonic drugs when so many are dying of PPH?” Dr. Smith asked.
Dr. Yadav welcomed the chance to participate in this valuable activity. During a stakeholder meeting, maternal health experts, officials from the state Ministry of Health, private and public hospitals, nongovernmental organizations, development partners, and key policy makers came to a consensus about their estimate after careful discussion and analysis. Using the guidance and worksheets developed by MCHIP, many were surprised to learn that relatively few women—only 43.5%—were protected from excessive bleeding. “This exercise was eye opening for program managers, since they realized that many women were not getting the care they are supposed to get,” Dr. Yadav said.
Oxytocin can be kept at room temperature for only a couple of months before it loses potency. Unlike oxytocin, misoprostol does not require refrigeration and it has also been proven effective at preventing excessive bleeding. Additionally, misoprostol comes in pill form and does not need to be injected using a needle and syringe by a skilled provider. As such, misoprostol is ideally suited for preventing PPH at home births and in resource-poor settings like Jharkhand due to its stability, ease of use, effectiveness and safety.
Distributing misoprostol to women in advance of the birth, enabling them to take it just after delivery, is known to be an effective method of PPH prevention. However, there is currently no program in Jharkhand State that ensures women who give birth at home receive misoprostol. And despite recent increases in facility births, there is still a sizeable portion of women (more than 45%) who choose to give birth at home. Sadly, when women give birth at home, they often do not have assistance from skilled health care workers or access to lifesaving drugs like oxytocin, and are therefore more likely to die of complications.
This estimation exercise came at the ideal time, as the government of India is currently developing guidelines for advanced distribution of misoprostol for women who give birth at home. Given the large population in Jharkhand State, efforts to make misoprostol widely available for use at the community level—especially if adopted nationally—could protect thousands of women from PPH.
USAID/MCHIP’s innovative estimation tool makes it possible to build an accurate picture of whether a country is doing everything it should to stop women from dying of this preventable condition. If there is strong political leadership, as in Jharkhand State and places like Mozambique, this estimation tool has the potential to help governments’ strengthen programs to prevent PPH. Such programs would ensure that oxytocin is available to women who give birth with trained health care workers, and that misoprostol is available to women who give birth at home. These combined efforts could save the lives of countless women, no matter where they give birth.