Pregnancy clubs: Group antenatal care in Uganda and Kenya

Shafia Rashid is principal technical advisor for the FCI Program of Management Sciences for Health. 

Women participate in the opening ceremony of a Lea Mimba pregnancy club session at a health facility in Kenya. (Photo by M4ID)

We were pleased to see the blog post from the Maternal Health Task Force which highlighted a review of published literature and informant interviews to develop a common model for group antenatal care (ANC), an innovative service delivery approach for re-organizing ANC in low-resource settings. In comparison to the current one-on-one model, group ANC is increasingly recognized as being more responsive to women’s and health providers’ needs,  encouraging self-care, and providing women with the emotional and social support to navigate an often isolating and stressful time in their lives. Continue reading “Pregnancy clubs: Group antenatal care in Uganda and Kenya”

Misoprostol for postpartum hemorrhage: Empowering health workers to save lives

Shafia Rashid is a Senior Technical Advisor for the FCI Program of Management Sciences for Health.

In Senegal, approximately 1,800 women lose their lives every year while giving birth. The major cause of these deaths is uncontrolled bleeding after childbirth, or postpartum hemorrhage (PPH). More than half of Senegalese women live in rural areas and have limited access to well-equipped health facilities that can prevent or treat many of these deaths. Many women give birth, attended by matrones or volunteer birth attendants, in maternity huts. Recognized as essential health care providers by their communities, matrones have some formal training and are now registered with the Ministry of Health (MoH).

To effectively prevent or treat PPH, women need access to uterus-contracting drugs, or uterotonics, such as oxytocin or misoprostol. The recommended uterotonic, injectable oxytocin, requires cold storage and technical skill to administer. Misoprostol is a safe and effective alternative where oxytocin isn’t available or feasible; it doesn’t need refrigeration and is easy to use—particularly important features for use in remote, rural areas.

From 2013 to 2014, the Government of Senegal’s Direction of Reproductive Health and Child Survival, in partnership with USAID and Gynuity Health Projects, examined the use of misoprostol (600 mcg oral) or oxytocin (10 UI) via Uniject® for prevention of PPH at the community level. Matrones were trained to assist with deliveries and administer the designated intervention. According to the study, both misoprostol and oxytocin in Uniject® were equally effective and safe in preventing PPH, and matrones  posted at the health huts were capable of administering the medicine they were assigned. Continue reading “Misoprostol for postpartum hemorrhage: Empowering health workers to save lives”

EML Search: New resource for reproductive and maternal health advocates

Shafia Rashid is Senior Technical Advisor at the FCI Program of Management Sciences for Health.

In June 2013, Imtiaz Kamal–a crusader for midwifery and women’s health–celebrated Pakistan’s official recognition of the essential maternal health medicine, misoprostol, which has proven easy to administer, safe and effective for preventing and treating excessive postpartum bleeding. “Given the high prevalence of home births,” Imtiaz explained, “we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births.” Continue reading “EML Search: New resource for reproductive and maternal health advocates”

Misoprostol For Postpartum Hemorrhage – A Life-Saving Technology for Maternal Health

Shafia Rashid is Senior Technical Advisor for the FCI Program of Management Sciences for Health.

Available since the 1980s, the medicine misoprostol was initially marketed to prevent stomach ulcers. Health professionals eventually discovered that misoprostol also stimulates contractions of the uterus, making it useful for a number of maternal and reproductive health conditions, including postpartum hemorrhage (PPH), induction of labor, treatment of miscarriage, and induced abortion (alone or in combination with mifepristone). Misoprostol is stable at room temperature, available in pill form, and inexpensive. Because of these advantages and misoprostol’s wide availability in many countries, health providers began using misoprostol off-label—in a way not specified on its registration—with differing regimens and routes of administration, and in the absence of evidence-based clinical guidelines. Continue reading “Misoprostol For Postpartum Hemorrhage – A Life-Saving Technology for Maternal Health”

New research calls for a different approach for misoprostol for postpartum hemorrhage

Shafia Rashid is senior program officer for the Global Advocacy program at Family Care International.

Postpartum hemorrhage (PPH)—excessive, uncontrolled bleeding during or after childbirth—is the leading cause of maternal death around the world.  Despite this, the condition is almost entirely preventable and treatable. In some parts of the world, women give birth at home or in health facilities lacking the essential supplies and equipment to manage PPH and other life-threatening complications.

Wherever a woman decides to give birth, she needs access to life-saving, uterus-contracting drugs, called uterotonics, for the prevention and treatment of PPH. The recommended uterotonic, injectable oxytocin, requires cold storage and technical skill to administer, making it difficult or impossible to use in many rural and low-resource areas. Misoprostol is a safe and effective uterotonic and a good alternative in community settings since it doesn’t require refrigeration or administration by a professional.

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Continue reading “New research calls for a different approach for misoprostol for postpartum hemorrhage”

Misoprostol for treatment of postpartum hemorrhage added to WHO Essential Medicines List

Shafia Rashid is senior program officer for Global Advocacy at Family Care International.

For more than five years, FCI has been working with Gynuity Health Projects and other partners to build the evidence base for expanded availability and use of misoprostol for the prevention and treatment of postpartum hemorrhage (PPH). PPH is the leading cause of maternal death, and misoprostol is a safe, effective medicine that is especially practical in low-resource settings, because it is available as a tablet and does not require refrigeration or injection.

This week marked an important milestone in global efforts to make misoprostol available to the women who need it, as the World Health Organization (WHO) approved its inclusion on the Model List of Essential Medicines (EML) for the treatment of PPH. Misoprostol was included on the EML for prevention of PPH in 2011, and the recent decision signifies WHO’s full endorsement of misoprostol as an essential maternal health medicine in settings where oxytocin — which requires cold storage and intravenous injection — is not available or cannot be used safely. The WHO Expert Committee for the Selection and Use of Essential Medicines, a panel that meets every two years to update the EML, recommended that misoprostol be listed for the additional indication of treating PPH[1] and retained on the list for prevention of PPH. Continue reading “Misoprostol for treatment of postpartum hemorrhage added to WHO Essential Medicines List”

Making connections: Ensuring access to reproductive and maternal health supplies

Shafia Rashid is Senior Program Officer for Global Advocacy at Family Care International. This post originally appeared on the Maternal Health Task Force blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

The past ten years have witnessed impressive gains in the availability and use of reproductive health supplies like condoms and oral contraceptives that allow men and women to safely and effectively prevent or space pregnancies. As a result of concerted efforts by many partners, contraceptive prevalence rates have risen over 60% in countries around the world.

These dramatic successes in improving access to reproductive health supplies can shed important lessons and guidance for those working to ensure that life-saving maternal health medicines — including, oxytocin, misoprostol and magnesium sulfate — are available to all women, when they need them and wherever they give birth. These medicines — which can save lives by preventing or treating the leading causes of maternal death — remain out of reach for many women, particularly for poor, rural, indigenous and other vulnerable women. Many countries lack clear, supportive policies and adequate budgets to make essential maternal health medicines widely available, or have weak supply chains and logistical systems. Inadequate regulatory capacity, poor quality of medicines and lack of information and guidance on correct use are other barriers to access.

In order to summarize lessons learned and provide concrete tools to improve access to maternal health supplies, the Reproductive Health Supplies Coalition tasked Family Care International to create seven policy briefs that show policy makers and program managers real-world examples of successful interventions. Importantly, there is a brief dedicated to each of the three most critical maternal health supplies: oxytocin, misoprostol and magnesium sulfate. Other briefs cover the cross-cutting issues of policy and financing, supply and demand generation.

Lessons learned from successful efforts to improve access to family planning commodities can help to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua and Paraguay — have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can be effectively adapted and expanded to improve financing and security for maternal health supplies as well.

A wide range of tools and resources can support countries in strengthening their forecasting, procurement and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well and can be used by country managers working to improve the supply of maternal health medicines.

Finally, many countries are moving toward integrating their supply chains to include family planning commodities and other essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was separated vertically by health issue and type of commodity until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain and has now fully automated the system and expanded it to include all essential medicines.

There are many parallels and potential synergies between reproductive and maternal health supply chains and processes. The reproductive and maternal health communities must take the following actions to address the interrelated barriers that prevent access to and use of life-saving commodities:

  • Advocate for development and implementation of supportive policies at the national and sub-national levels,
  • Advocate for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improve government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Invest in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthen the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

More information can be found in Essential Medicines for Maternal Health: Ensuring Equitable Access for All, a set of briefs that highlight challenges and strategies for increasing the availability of these maternal health medicines and identify linkages with reproductive health supplies. You can download the Essential Medicines for Maternal Health policy briefs in English, French and Spanish.

Maternal health supplies ARE reproductive health supplies

Shafia Rashid is senior program officer for global advocacy at Family Care International.

In late October, the Reproductive Health Supplies Coalition (RHSC) held its annual membership meeting in Mexico City. Representatives from governments, international organizations, pharmaceutical companies, and civil society came together to press for greater and more equitable access to reproductive health supplies. The RHSC’s focus includes family planning commodities, such as condoms, oral contraceptives, and other methods that allow men and women to safely and effectively prevent or space pregnancies.

MH supplies briefs coverThis was my first time attending the annual RHSC meeting. I was there because the Coalition has expanded its mandate to explicitly address maternal health supplies. Earlier this year, it commissioned FCI to develop a series of seven policy briefs, Essential Medicines for Maternal Health: Ensuring Equitable Access for All, which were launched at the Mexico City meeting. These briefs highlight challenges and strategies for increasing the availability of three maternal health medicines – oxytocin, misoprostol, and magnesium sulfate – and:

  • Make the case for increasing priority and investment in these medicines
  • Provide examples of successful strategies from around the world
  • Highlight linkages with reproductive health supplies

A special plenary session addressed this crucial question: How are maternal health supplies reproductive health supplies? This sparked a wide-ranging, engaging, and very interesting discussion. Here are some of the key points that emerged:

  • Many countries can already see clear value in linking reproductive and maternal health supplies, and are moving toward integrating their supply chains to include family planning commodities and essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was vertical until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain, which has now been automated and expanded to include all essential medicines.
  • The RHSC and other partners have developed a wide range of tools and resources to support countries in strengthening their forecasting, procurement, and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well, so they can now be used by country managers working to improve the supply of maternal health medicines.
  • Lessons learned from successes in improving access to family planning commodities can help us to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua, and Paraguay – have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues, and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports, and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can effectively adapted and expanded to improve financing and security for maternal health supplies as well.

Many parallels and potential synergies exist between maternal and reproductive health supplies, and the reproductive and maternal health communities must take action to address the interrelated barriers that prevent access to and use of life-saving commodities. These actions include:

  • Advocating for development and implementation of supportive policies at the national and sub-national levels, and for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improving government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Investing in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthening the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

→ For more information, you can download the Essential Medicines for Maternal Health policy briefs here.

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Panelists at the plenary session, RHSC annual meeting, October 2014 Photo: RHSC

Midwives and misoprostol: Saving lives from PPH

Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.

For women around the world, compassionate and competent care from a midwife can mean the difference between life and death. We know that midwives provide life-saving care during pregnancy, childbirth, and in the postnatal period. Midwives, and other mid-level and community health providers, can administer essential medicines, such as oxytocin and misoprostol, which are safe and effective for preventing and treating life-threatening postpartum bleeding or hemorrhage (PPH), the leading cause of maternal death in most developing countries. Access to misoprostol is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used in poorly equipped health facilities and even home births.

A midwife meets with a client during an antenatal care visit.
A midwife meets with a client during an antenatal care visit.

In order for midwives to provide life-saving maternal health care, they need the support of policies that enable them to provide a full range of medical interventions.  In some countries, however, midwives are not legally authorized to administer oxytocin and/or misoprostol —despite evidence that administration by low and mid-level health providers is feasible and effective. But physicians sometimes resist or oppose expansion of midwives’ scope of practice, based on notions of “professional territoriality” and concerns about their capacity to correctly and safely administer these medications.

Most women in low-resource settings give birth in lower-level health facilities or at home, attended by a midwife or other mid-level health provider. So restrictive policies requiring that administration of medications be carried out only by physicians limits women’s access to essential medicines they need for safe pregnancy and childbirth. Placing misoprostol in the hands of non‐physician providers, for example, can expand access to timely PPH treatment. In remote and rural areas, where transfer for emergency obstetric treatment at a higher-level facility may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.[1]

The global health community can play an important role in addressing and removing policy and regulatory barriers, and ultimately in improving women’s access to essential medicines. Making this happen will require that governments, in many countries, revise policies that allow administration of medications only by physicians.  In 2012, WHO issued guidelines  on task-shifting for maternal and newborn health. They called for a “more rational distribution of tasks and responsibilities among cadres of health workers …[to]  significantly improve both access and cost-effectiveness – for example by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions otherwise provided only by cadres with longer (and sometimes more specialized) training.”  This makes excellent sense.

The leading global health professional associations focused on pregnancy and childbirth, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO), can work together to ensure that these international recommendations translate into changes in national norms and in clinical practice. Earlier this year, ICM and FIGO issued a joint statement, Misoprostol for the treatment of postpartum hemorrhage in low resource settings, which called on partners to:

  • Promote task-sharing approach
  • Ensure that skilled health providers (and not just doctors) can administer uterotonic drugs like misoprostol and oxytocin
  • Challenge regulatory and policy barriers that limit access to high quality maternal health care
  • Advocate for increasing the midwifery workforce
  • Implement innovative strategies to strengthen the role of midwives and non-physician providers in providing high-quality maternal health services

Health professionals, policy makers, and other partners must work together to ensure that every woman has access to the uterotonic medicines that can protect her from the suffering and potential death that can be caused by postpartum hemorrhage.

 

[1] Beverly Winikoff, Why misoprostol in the hands of non-physician providers matters, Presentation at the ICM Trienniel Congress, Prague, June 3, 2014.

Mapping maternal health advocacy in Uganda and Zambia

Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.

Civil society organizations (CSOs) around the world are working to improve maternal health and make a difference in the lives of women, families, and communities. In many countries, CSOs play a critical role in the health sector by providing quality maternal health services, and by supporting advocacy to ensure government policies are implemented, funds invested and tracked, and health outcomes measured and published.

A Zambian mother with her child © 2009 Arturo Sanabria, Courtesy of Photoshare
A Zambian mother with her child © 2009 Arturo Sanabria, Courtesy of Photoshare

In 2013, with support from Merck Inc. through the Merck for Mothers Program, Family Care International (FCI) completed a comprehensive mapping of the maternal health advocacy environment in two countries, Uganda and Zambia. Data for the mappings were collected at the national level (and at the district level in Uganda) using a multi-dimensional methodology which triangulated data from key informant interviews, focus group discussions, and desk research.

The mapping examined each country’s maternal health policy framework, identified stakeholders working in maternal health advocacy, and analyzed opportunities and challenges for maternal health advocacy organizations.  It also highlighted the potential for engaging the private sector on maternal health, and put forward a set of recommendations for strengthening maternal health advocacy efforts, and the role of CSOs in particular.

In Uganda, the mapping found that while there is a relatively active health advocacy sector and strong policy framework in place for maternal health, advocacy organizations are not coordinating efforts well, leading to a fragmented advocacy environment. In addition, maternal health advocacy organizations face critical resource constraints, and are not effectively measuring the impact of their advocacy work. For additional information, the full mapping report can be accessed here.

In Zambia, there exists a favorable policy environment for maternal health, and a strong evidence-based decision-making ethos in government. While Zambia is a signatory to a number of commitments to improve maternal health services, the maternal health advocacy environment is not particularly strong or robust. More information is available in the full mapping report here.

The findings from these mappings revealed a number of common themes and recommendations for supporting the critical role of CSOs in both countries:

  • Establish or enhance a coordinating mechanism through which the growing and diverse body of advocacy organizations can work together and advance common messages, agendas, and strategies.
  • Support local advocacy organizations, which often operate with limited resources, staffing, and capacity, to build their administrative, management, and planning capabilities in conducting effective advocacy.
  • Strengthen monitoring and evaluation of maternal advocacy efforts by supporting maternal health advocacy organizations in the development of tools, indicators, and mechanisms for measuring advocacy outcomes and impact.

Sustained and long-term investments in supporting CSOs to conduct effective advocacy for maternal health are needed now, more than ever. Without these investments, we will continue to be far behind in reaching national and global commitments for maternal health.

A health worker in Uganda counsels a client. © 1996 Center for Communication Programs, Courtesy of Photoshare
A health worker in Uganda counsels a client.
© 1996 Center for Communication Programs, Courtesy of Photoshare

 

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