Population Council Research that makes a difference

Misoprostol is an orally administered drug for the prevention and management of postpartum hemorrhage (PPH), the leading cause of maternal deaths in developing countries, including Pakistan. As part of the PAIMAN project, the Population Council conducted a successful one-year pilot project in two districts of Pakistan to test the feasibility of home administration of misoprostol by community-based health-care providers, including traditional birth attendants (dais) and family members.

Results

The mean age of study participants (872 women in the intervention areas and 826 women in the comparison areas) was 28 years. Mean education was 1.7 years in the intervention areas and 1.3 years in the comparison areas. About 80 percent of the birth attendants in both the intervention and comparison areas were traditional birth attendants/dais. MBBS doctors made up the second largest group of attendants. More than half of the birth attendants in both areas were 45–64 years of age. Just over 70 percent of the birth attendants in both areas were uneducated, as most were traditional birth attendants.

Women in the intervention areas were briefed on the advantages and use of misoprostol during the initial community awareness and registration session. When interviewed one month before their expected date of delivery, 95 percent of the women in the intervention areas had knowledge that tablets taken orally could prevent PPH. Among those who knew about misoprostol, 92 percent also knew how to use it correctly. Almost all of the birth attendants (95 percent) in both the intervention and comparison areas knew how to recognize PPH. Over half of the birth attendants (60 percent) could recall the name of the tablets (misoprostol). Almost all (98 percent) of the birth attendants knew that misoprostol should be administered immediately after delivery of the baby and before delivery of the placenta.

Of the 872 women in the intervention areas, 770 delivered at home and were eligible for misoprostol. Among the remaining, 55 were ineligible because a cesarean section delivery was indicated, and 47 were excluded owing to referral to a facility before delivery for obstetric complications. Among the eligible women in the intervention areas, 678 women (88 percent) took the misoprostol tablets provided to them in the clean delivery kits, and 92 women (12 percent) did not. Of the women who delivered at home in the intervention areas, 647 (84 percent) took the tablets correctly (the correct dose at the correct time). Forty percent of these women reported that they had experienced side effects. The majority reported suffering shivering/chills (69 percent). However, in all of these cases the symptoms were transient and did not require referral for specialized care.

Among the women who delivered at home and used misoprostol, 91 percent said that they would use the tablets in the future. When these women were asked whether they would also be willing to purchase the tablets in the future, 93 percent expressed their willingness to do so. All but two of these women said they would recommend misoprostol to others. Almost all of the birth attendants (98 percent) in the intervention areas who could recall the name of the tablets and had administered misoprostol said that they would recommend the tablets to other clients.

In the intervention areas, three women (0.38 percent) suffered from postpartum hemorrhage that required referral to a higher-level facility. Among these, two took misoprostol; the one who did not later died upon reaching a facility. In the comparison areas, five women (0.64 percent) required referral for the management of PPH; among these cases, two women died.