Catharine Taylor, a former practicing midwife, is the Vice President of the Health Programs Group at Management Sciences for Health (MSH). This post originally appeared on MSH’s Global Health Impact Blog.
Shafia Rashid is a Principal Technical Advisor for the FCI Program of Management Sciences for Health (MSH). Kate Ramsey is Senior Principal Technical Advisor for maternal and newborn health at MSH.
Improving the quality of care that women experience during pregnancy, childbirth, and the postpartum period has become a major global priority. Achieving good quality care requires not only clinical improvements, but also a person-centered approach that takes into account women’s and health workers’ needs and perspectives.
In 2016, the World Health Organization (WHO) updated its antenatal care guidelines, calling for a positive pregnancy experience through holistic, person-centered antenatal services that provide pregnant women with emotional support and advice in addition to the standard clinical assessments.
Group antenatal care, initially developed in the U.S. several decades ago, is a promising model that responds to women’s health and information concerns during pregnancy. Facilitated by a health provider, usually a nurse or midwife, group antenatal care offers a forum for pregnant women to learn more about their pregnancies, share their experiences, receive essential health and self-care information, and provide social and emotional support to each other within the group. Health care providers meet individually with group participants after the group sessions for routine physical and clinical care and to discuss any confidential issues. Group antenatal care can also benefit health care providers through increased job satisfaction without substantially increasing the amount of time required. Continue reading “Person-centered group antenatal care in Eastern Uganda: Reaching women through pregnancy clubs”
Andrew Weeks is Professor of Women’s and Children’s Health at the University of Liverpool and the Principal Investigator of the MamaMiso study. Shafia Rashid is a senior program officer at Family Care International (FCI).Through research and advocacy,FCI works with Gynuity Health Projects and other partners to support increased access to and availability of misoprostol for prevention and treatment of postpartum hemorrhage.
Sarah Nerima was working on her banana plantation when she went into labor. Unable to reach a health center – the nearest was 6 miles away – Sarah gave birth in the fields, attended only by her mother-in-law. Already a mother of two, she had bled heavily in each of her previous deliveries, and she was afraid that a hemorrhage could take her life, leaving three motherless children.
For the 50% of women in rural Uganda who, like Sarah, give birth outside a health facility, a simple, safe and effective medicine, called misoprostol, can prevent or stop life-threatening bleeding. Misoprostol is a medicine that comes in tablet form, can be stored without refrigeration, and be administered without any specialized skills. The World Health Organization (WHO) recommends misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) in settings where the standard of care, oxytocin – which requires cold storage and is administered by injection – is not available or cannot safely be used. WHO also recommends that misoprostol can be administered by community health workers for PPH prevention when skilled health providers are not present.
Some countries with high rates of non-facility births distribute misoprostol at antenatal care visits to women directly (a strategy called ‘advance distribution’), but WHO – citing unanswered questions about the safety and effectiveness of self-administered misoprostol in home births – has held off on recommending advance distribution, calling for additional research.
In Uganda, a research team from the University of Liverpool, Gynuity Health Projects, and Makerere University has tested the safety and feasibility of this community-based distribution model. MamaMiso, as this 2012 study was aptly called, provided misoprostol tablets to pregnant women for self-administration immediately after childbirth to prevent bleeding. Working in 200 villages in Mbale district, Eastern Uganda, the research team recruited women who came for antenatal care at Mbale Regional Referral Hospital or 3 large health centres (Busiu, Lwangoli and Siira) nearby.
Every pregnant woman at more than 34 weeks of gestation living in the recruitment villages was eligible to participate. Each participant was given a small purse, with a string that could be hung around the neck, containing 3 foil-packed tablets (600 micrograms misoprostol or placebo). Women were told to bring the purse home, to keep it with them, and to swallow the pills immediately after birth if they delivered at home. They were given an instruction sheet with written and pictorial instructions on how to take the tablets. Women were advised not to take the tablets if they went to a health facility for their delivery. Each participant was visited at 3 to 5 days after birth to check whether she had taken the medicine and to collect clinical outcomes.
MamaMiso’s results showed that self-administration of misoprostol is safe, and that advance distribution during antenatal care has the potential to increase the number of women who receive a medicine to prevent PPH. Of the women who enrolled in the research study, 57% gave birth at a facility and 43% delivered at home. Of those women who delivered at home, almost all (97%) took the study medicine after childbirth. Only 2 women (0.3%) took the medicine prior to delivery, and neither suffered adverse effects. Women who took misoprostol did experience fever and shivering, but they found these side effects to be acceptable.
These findings, together with results from other studies examining community-level use of misoprostol, have spurred national stakeholders to take action. The national Ugandan ob-gyn society has called for updating the national guidelines on PPH prevention to recommend community use of misoprostol, specifically enabling women to receive misoprostol as part of antenatal care. ‘We cannot continue to let women die when we have the solutions,’ said Dr. Charles Kiggundu, vice president of the Association of Obstetricians and Gynaecologists of Uganda. ‘The hindrance to using scientifically proven drugs is with health workers, not the women.”
Sarah Nerima was one of the women included in the MamaMiso study. After delivering her baby daughter among the banana trees, she opened her MamaMiso purse, and took the pills. “The bleeding was very, very little this time”, she said, “As you see, I am already very strong.”
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.
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.