Transcript Document

Spot-light
on
Preventing Postpartum Hemorrhage
USAID Support
PPH Working Group
April 6, 2009
Lily Kak
Background
USAID interest in addressing the biggest killer on a global scale
• <2002 - R&D:Uniject – Indonesia, Vietnam (PATH), Angola (WHO),
Misoprostol -Indonesia (MNH), review of off-label use (USP)
• >2002 – Special initiative in four countries (Prime II, MNH,
RPMplus), and FIGO/ICM Jt. Statement, Bangkok regional
conference
• 2004 – Special initiative to expand the use of AMTSL
(POPPHI, ACCESS). Identified three key bottle-necks to
expansion:
– Lack of knowledge of evidence and lack of practice of AMTSL (policy
change, advocacy, correct info on uterotonics and skills needed)
– Uterotonics not available in quantities needed to scale up AMTSL
(systems strengthening for drug logistics needed)
– 50% of births take place at home (new policy, technology needed)
Program Coverage
Total countries: 32. Total MCH priority countries: 22
65% to 99% coverage in target areas
Comprehensive Program Approach
Global & Country
policies &
guidelines,
research
WHO, Govts,
Drug Logistics
RPMPlus/SPS
Program Support
POPPHI, ACCESS,
Bilateral projects
PVOs: HealthRight, MIHV
Technology
HealthTech
Strategies to Achieve Scale
Catalytic Influence
Global: PPH working grp, global/national policy
(WHO, FIGO&ICM, USP, govt), global survey
Regional: SOTA workshops by USAID, POPPHI,
ACCESS
National: Taskforce, operations research, national
consensus
Collaboratives
Using systematic peer learning sessions by HCI for
quality improvement & national expansion
Partnerships
WHO, USP, FIGO, ICM, Ventures Str., Govts,
national prof. assns, & global, bilateral, PVO
projects
Balanced approach for
100% uterotonic
protection
Everywhere, Every time: facility & home births
Remove bottle-necks (e.g., task-shifting policy for
Malian matrones, Uniject technology, storage)
Catalytic Influence on Policy
• Influenced change in oxytocin storage requirements in USP
monograph
• Pushed to replace ergometrine with oxytocin. FIGO
advocated for countries to delegate use of oxytocin to
midwives (many countries in Africa allowed midwives at the
periphery to use only ergometrine & not oxtyocin).
• Supported 2006 WHO Technical Consultation leading to
policy changes re misoprostol and delayed cord clamping
• POPPHI shift to integrate immediate postpartum/essential
newborn care with AMTSL
• WHO research to evaluate simplified AMTSL (minus CCT)
• Review of induction/ augmentation influenced WHO to
develop induction guidelines for low resource settings.
National surveys in 10 countries
Percent of observed deliveries w/ uterotonic given
during 3rd/4th stages of labor and correct use of
AMTSL (uterotonic administration within 1 mn)
100.0
99.7
100.0
100.0
97.6
95.6
95.6
92.6
89.2
90.0
86.7
80.0
70.0
% of deliveries
60.0
60.0
50.0
40.0
31.8
29.0
30.0
20.0
17.0
10.0
6.7
7.1
5.4
3.0
4.5
2.6
0.3
Source: POPPHI
Received uterotonic 3rd/4th stage
AMTSL (1 min)
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Low AMTSL
practice in
national
surveys
served to
inform and
influence
policy and
strategies for
scaling up
PPH
prevention
activities
Niger:
Working at Scale through Collaboratives
Source: HCI
7 of 8 regions; 64 districts; 27% of annual facility births
Bangladesh: Comprehensive approach
for national expansion
National taskforce
National SOTA conference
National AMTSL survey
Broad consensus to reach all births
regardless of place
District approach to reach all district
and Upazila facilities with AMTSL
(25 districts so far)
Misoprostol approved by Drug Authority
Pilot in 1 district
MOHFW plans for expansion
National
District hospital
Upazila Health
Complex
(7%)*
Home Births
(85%)
*8% in pvt sector but not included in program
Afghanistan:
Successful Pilot Catalyzes National Expansion
120
100
80
60
40
20
0
96
67
26
26
Perceived PPH is lower among women who
use misoprostol
27
0
Control
Intervention
Used Miso Received injection Any uterotonic
Percent
Percent
Near universal uterotonic protection is
possible with a balanced approach to
reaching women even in remote areas
60
50
40
30
20
10
0
49.3
18.6
11
3.1
Perceived PPH
Source: ACCESS
Perceived Severe PPH
control intervention
Uniject: Yes, it’s real!
Source: HealthTech
Uniject: Status
LAC
Development Status
BIOL: Received
Argentine FDA approval
Oct 08
LAC countries:
submit request
for approval
Apply for WHO
prequalification
(July 09)
Marketing
launch in
Argentina
(July 09)
Asia
BIOL production capacity relatively low but can grow with paying demand
Gland-Pharma:
Skeptical about
market demand
Program Status
Previous
•Indonesia
•Vietnam
Current
•Mali
•Guatemala
•Honduras
•South Africa
•Argentica
Best-case scenario:
FDA approval in 2010
Worst-case scenario:
Drop project
Way Forward
Ensure commercial
supply: WHO
prequalification20092010
Plan for roll-out in
2010/11
Generate demand
through additional
country pilots
2009-2010
Challenges to Scaling Up
•
•
•
•
Tracking information not mainstreamed in HMIS
Getting knowledge/skills to providers; motivation
Misoprostol: Mixed messages
Quality of drugs questionable – non-optimal
storage conditions, fake drugs on market, (possible
misuse)
• Control cord traction limits program to skilled birth
attendants
• Uniject still very new; promising but has not
developed a niche yet
Way Forward for USAID Support
• Continued support to global expansion of
PPH reduction
• Expand to include PPH treatment
• Expand to include pre/eclampsia prevention
and management
A goldmine of information on PPH and Uniject materials:
http://www.pphprevention.org
http://www.path.org/projects/uniject-oxytocin-resources.php
Acknowledgements