|Year : 2017 | Volume
| Issue : 2 | Page : 67-77
Assessing strategies for distribution of misoprostol at community level and its uptake for prevention of postpartum hemorrhage in two semi-urban communities in Kaduna State, Northwestern Nigeria
Farouk Adiri1, Clara Ladi Ejembi2
1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||30-Apr-2018|
Dr. Farouk Adiri
Department of Community Medicine, Kaduna State University, Kaduna State
Source of Support: None, Conflict of Interest: None
Introduction: This study assessed two strategies for distribution of misoprostol using identified and trained community persons (village heads) and distribution in a Primary Health Care (PHC) facility during antenatal visits and its uptake for the prevention of postpartum hemorrhage (PPH) in two semi-urban communities in Sabon-Gari Local Government Area of Kaduna State, Northwest Nigeria. Materials and Methods: Using a quasi-experimental study design, two semi-urban communities, Hayin Dogo and Basawa, in Sabon-Gari LGA of Kaduna State were selected, and each was assigned either of the two misoprostol distribution methods using balloting. At baseline, 300 women who had delivered within 6 months of onset of the study were sampled in the two communities using multistage sampling technique. Using structured, interviewer-administered questionnaires, information was collected on their knowledge of PPH, misoprostol and its uptake after delivery. This was followed by communication interventions, mainly through community dialogues to raise awareness and create demand for misoprostol, identification, and training of traditional birth attendants (TBAs) and drug keepers in the two communities and positioning of the drug in the PHC center in Hayin Dogo and at community level in Basawa community. Subsequently, all the 320 deliveries in the two communities that occurred during the 6 months following intervention were identified at endline and the same questionnaire administered to the women. A monitoring phase was carried out for 6 months in between the pre- and postintervention where 284 deliveries in Hayin Dogo and Basawa communities were monitored whether they used or did not use misoprostol during home births. Results: Respondents knowledge significantly improved from 2.0% at baseline to 7.1% postintervention in Hayin Dogo (χ2 = 4.7; df = 1; P < 0.05) and from 2.7% to 7.3% in Basawa, (χ2 = 3.4; df = 1; P < 0.05). The uptake of misoprostol rose from 0% to 48.5% in Hayin Dogo and 37.7% in Basawa. There was no statistically significant difference in uptake of misoprostol in the two communities (z = −1.9; df = 318; P > 0.05). The educational level of the women had a greater influence on their use of misoprostol. Conclusion: There was an increase in knowledge of prevention and treatment of PPH. The intervention led to significant increase in the use of misoprostol, but the method of distribution did not significantly affect the uptake of the drug. Both strategies are feasible for distributing misoprostol for increasing its use at home deliveries.
Keywords: Distribution strategies, homebirths, misoprostol, postpartum hemorrhage, traditional birth attendants
|How to cite this article:|
Adiri F, Ejembi CL. Assessing strategies for distribution of misoprostol at community level and its uptake for prevention of postpartum hemorrhage in two semi-urban communities in Kaduna State, Northwestern Nigeria. Arch Med Surg 2017;2:67-77
|How to cite this URL:|
Adiri F, Ejembi CL. Assessing strategies for distribution of misoprostol at community level and its uptake for prevention of postpartum hemorrhage in two semi-urban communities in Kaduna State, Northwestern Nigeria. Arch Med Surg [serial online] 2017 [cited 2019 Dec 15];2:67-77. Available from: http://www.archms.org/text.asp?2017/2/2/67/231636
| Introduction|| |
Maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy due to pregnancy, delivery, its management or complications, irrespective of the site or duration, excluding incidental causes. Globally, about 287,000 maternal deaths occurred in 2010. Ninety-nine percent (284,000) of the maternal deaths occur in developing countries, with 245,000 (85%) of these deaths occurring in Africa and Asia. Sub-Saharan Africa has a higher maternal mortality burden in the world; with maternal mortality ratio of 500/100,000 live births which is over twice the global estimate of 210/100,000 live births.
Nigeria has one of the highest maternal mortality ratios in the world. The World Health Organization (WHO) estimates that the maternal mortality ratio is at 630/100,000 live births in 2010, though, the 2013 National Demographic and Health Survey showed that the rate has declined to 576/100,000 live births. There is a wide regional variation in maternal mortality in the country with rates ranging from 1549/100,000 live births in the North East, 1025/100,000 live births in the North West and 165/100,000 live births in the South West zones of the country. Furthermore, the maternal mortality ratio in the rural areas (828/100,000 live births) is more than twice the rate in the urban areas (351/100,000 live births).,
Globally, postpartum hemorrhage (PPH) is the leading cause of maternal death. It accounts for one-third of maternal deaths in Africa (33.9%) and Asia (30.8%). Similarly, in Nigeria, it is the leading cause of maternal mortality, responsible for 23% maternal deaths though figures as high as 44% have been reported. A community study in three communities around Zaria documented a figure of 40%.
Uterine atony, which is failure of the uterus to contract after the baby is delivered, is the leading cause of PPH, accounting for 80% of the causes. Other causes of PPH include retention of placenta or retained products of conception, laceration, cervical tear, vaginal tear, cesarean section, instrumental delivery, episiotomy, and uterine rupture among others such as disseminated intravascular coagulation. PPH can kill within 2 hours.
Characteristically, PPH is unpredictable as 90% of women do not present with identifiable risk factors. Furthermore, given the high prevalence of anemia in pregnancy and childbirth, blood loss in the absence of prompt management and life-saving measures could be fatal. This makes PPH prevention a very important strategy, especially in resource poor settings. The impact of preventing and managing PPH on reducing maternal mortality is estimated to be from 55% to 82%.
Active management of the third stage of labor (AMTSL) is the strategy for the prevention of PPH. AMTSL involves administration of prophylactic uterotonics, delivery of placenta using controlled cord traction, and uterine massage after delivery of the placenta. Thus, AMTSL requires oxytocin, which is given as an injection by a skilled attendant administered in a health facility, a viable supply of uterotonic and items needed for injection administration.
A skilled birth attendant is defined by the WHO as a person with midwifery skills who has been trained for a minimum period of 6 months up to proficiency in the management of normal deliveries and diagnosis, management or referral of obstetric emergencies. Sub-Saharan Africa has one of the lowest proportions of deliveries supervised by skilled birth attendants (47%) compared to the developed world (95%). In Nigeria, the majority (64%) of the deliveries take place at home, and only 38% are supervised by skilled birth attendant. Like maternal mortality, wide regional variations exist in the proportion of deliveries supervised by skilled attendants, with figures ranging from as low as 12.3% in the North West to 82.5% in the South West. Studies have demonstrated a relationship between skilled attendance at delivery and reducing maternal mortality. Skilled attendants are important because all the complications that result in maternal mortality can only be adequately treated by them.
Oxytocin is the uterotonic of choice for AMTSL available. It requires refrigeration and administration by injection and therefore can only be administered by skilled birth attendants in settings where refrigeration is available. For the vast majority of women in Nigeria, AMTSL is not accessible or feasible strategy for the prevention of PPH as 64% women deliver at home without the supervision of skilled attendants (38%). There is thus a need to explore alternative strategies for this group of women.
Misoprostol, a prostaglandin E1 analog, a drug initially used for the treatment of peptic ulcer, was discovered to have an important obstetric use, as a side effect. It has been found to be a very effective uterotonic for preventing and treating PPH. The drug comes in tablet form, is cheap, easy to administer as it does not require parenteral injection, it can be given by multiple routes (rectal, oral, sublingual, or vaginally) and is stable in tropical climates. It does not have effect on the blood vessels or bronchi and has minimal side effects such as fever, abdominal cramps, nausea, vomiting among others which are dose-dependent and self-limiting; this makes it an ideal life-saving solution for prevention and treatment of bleeding at home births., Controlling PPH by increasing the availability of misoprostol for home births has been recognized as important, safe, and efficacious strategy and is approved for use in Nigeria. It is major potential is the feasibility of increasing access to uterotonics, where AMTSL is not feasible, especially in home births or where appropriate storage conditions for oxytocin or ergometrine are not available.,,
Implementing interventions with misoprostol, aimed at preventing PPH would reach women who deliver at home and without skilled birth attendants hence averting maternal deaths. At present, despite key messages on facility delivery and use of skilled birth attendants, assistance by a traditional birth attendant (TBA), a family member or delivering alone at home without the benefit of AMTSL is practiced by millions of pregnant women in Africa and trained lay providers of misoprostol during home births affords a woman a shift from the status quo. This clearly presents an advantage over some of their shortcomings. Studies have clearly demonstrated that TBAs can effectively administer misoprostol in home births. TBA's in the community are responsible for supervising 64% deliveries in developing countries. They enjoy trust, respect, and patronage from the community. Therefore, TBA's are a vital public health resource and their involvement in community-based interventions with misoprostol will ensure a smooth coexistence and integration with the modern health system by increasing access to life-saving interventions for the prevention and treatment of PPH thereby help in reducing maternal mortality due to PPH.,
A study in Zaria used a variety of community distribution channels, patent medicine vendors, community drug keepers, TBAs, etc., for keeping and dispensing of misoprostol. Doctors from the Departments of Community Medicine and Obstetrics and Gynecology, Ahmadu Bello University, were assigned to each of the five communities where the study took place to among other things, monitor drug storage and use and to replenish stocks. This research mode is resource intensive and not feasible in scaling-up. Noting that antenatal care (ANC) attendance is much higher than institutional delivery, from the Zaria study, the Federal Ministry of Health recommended using the primary health care (PHC) facilities in exploring alternative and more sustainable approaches to the distribution of the drug at the community level. The aim of the study is to compare two distribution strategies to community-based distribution of misoprostol on knowledge and use of misoprostol for the prevention of PPH during home births in Hayin dogo and Basawa communities in Sabon-Gari LGA Kaduna State, Nigeria.
| Materials and Methods|| |
The selected communities; Hayin Dogo and Basawa communities are semi-urban slums which have a combined population of 67,299 in Sabon Gari LGA of Kaduna state, in the North West geopolitical zone. The Hausa and Fulani Muslims are the dominant ethnic groups with a sub-section comprising of Christians and other heterogeneous and diverse ethnic groups from other parts of the country. They are characterized by their high population, moderate–to-high ANC attendance but low facility deliveries, home deliveries are usually the norm, assisted by TBA's as such were considered for the study. The study was conducted from July 2011 to June 2012. In between, a monitoring period of 6 months was done from December 2011 to June 2012.
The study population comprised pregnant women who were 36-week pregnant and above, women who had delivered within 6 months of the onset of the study and women who had delivered within 6 months of the intervention in the two study communities. This includes the ability to give written informed consent and complete the interviewer-administered questionnaire and assessment by the trained community midwife that the woman does not have a history of a high-risk pregnancy or delivery for which she should be counseled and referred. Pregnant women with severe pregnancy complications breech or with known comorbidities in pregnancy as assessed by the midwife were excluded from the study.
The study was a quasi-experimental study that sought to assess the effect of two different approaches of distribution of misoprostol and its uptake of misoprostol for prevention of PPH by parturient women in the two study communities.
A sample size of 300 was computed for each community, i.e., 150 per community in the pre evaluation and 150 in the postevaluation using the formula:
P1= Proportion of women that took misoprostol for prevention of PPH from a similar study done in similar setting = 79% = 0.79.
q1= The complimentary probability of p1= (1 − p) = 21% = 0.21
P2= Proportion of increase in uptake of misoprostol estimated from a similar study = 89% = 0.89.
q2= The complimentary probability of p2= (1 − p2) = 11% = 0.11.
P1− p2= Degree of difference or accuracy between the two proportions at 10% =0.1
Z1−α= Standard normal deviate corresponding to 95% level of significance at 1.64 on normal distribution table
Z1−β = Standard normal deviate corresponding to the power of the test at 80% which is 0.84 on the normal distribution table
n = Minimum sample size
n = 112 pregnant women and women who had a live birth in the past 6 months
To calculate for 10% = 0.1 nonresponse rate (f), the formula:
The sample size was increased to 150 per community to increase the accuracy and precision of the study for the pre- and postintervention each.
A multi-stage sampling technique was used to select the respondents.
- Stage 1 (selection of wards): From a list of wards in Sabon Gari LGA, Bomo and Basawa wards were selected purposively due to their high population, high ANC attendance with home deliveries usually by TBA's
- Stage 2 (selection of communities): A list of communities was compiled for each ward, and Hayin Dogo and Basawa communities were selected using simple random sampling by balloting
- Stage 3 (selection of clusters/“anguwas”): A list of clusters/anguwas was obtained, which formed the sampling frame. Using the calculated sample size, the sampling fraction and interval was calculated, and a systematic sampling used to select the “anguwas”
- Stage 4 (selection of houses): All the houses in the clusters selected were entered, eligible respondents were identified and questionnaire administered after obtaining verbal and signed written consent
- Stage 5 (selection of respondents): In the houses, the household list was gotten and alternate households were sampled by balloting the first household. Eligible respondents were identified and administered the questionnaire. If there was more than one eligible respondent in a household, one was selected by balloting.
A structured, close-ended, precoded, interviewer-administered postpartum questionnaire, adapted from a previous study was used to elicit responses at pre- and postintervention by five trained community midwives. The questionnaire sought information on the sociodemographic characteristics of respondents, ANC and place of delivery, knowledge of PPH, misoprostol, and knowledge of sources of supply of misoprostol, collection and use of misoprostol for the prevention of PPH after delivery.
The intervention was carried out 4 weeks after the baseline survey. The intervention consisted of creating demand for misoprostol through information, education, and communication (IEC) activities, training of TBAs, and providing them delivery kits and positioning of misoprostol in the village heads house in Basawa community and the PHC facility in Hayin Dogo community. Monitoring of misoprostol use, replenishment of misoprostol and other interventions were included by the researcher. The intervention lasted for 6 months in both study communities. The study drug was a single dose of 600 μg (3 tablets) of generic oral misoprostol which was sourced through the Population and Reproductive Health Initiative and administered after spontaneous vaginal delivery of the baby and within minutes of clamping and cutting the umbilical cord before delivery of placenta by the parturient woman or the attending TBA. Women were monitored for signs of blood loss in excess of 500 ml using the “moda bowl” as in the approved course manual up to 2 h and determine the need for additional 5 tablets (1000 μg) rectally for treatment of PPH. The trained TBAs and drug keepers recruited women, provide information on the drug, monitor for side effects which were mostly transient and for complications. The community midwife was called using stipends provided for calls, so that the pregnant woman can be assessed, counseled or subsequently referred based on the assessment. Monthly community review meetings were held with the health workers, drug keepers and TBA's to monitor and replenish stock, review outcomes of deliveries captured with or without misoprostol and use of misoprostol for the whole duration of the study.
Seventeen TBAs who were trained for a week using approved course manual and pregnant women who were 36 weeks pregnant (9 months) pregnant were trained for one day and received key messages and collected the drug from the trained health worker in the community PHC facility in Hayin Dogo community. Seven trained, literate and trusted persons who were identified by community members in Basawa community during the community dialogues kept and issued the drug on request to pregnant and TBAs for administration after delivery. The drug was collected from the identified community drug keeper, TBA, or health worker during ANC at Hayin Dogo after providing information on the importance of ANC, facility delivery and use of misoprostol for women who may eventually deliver at home. Those who may deliver in the health facility were encouraged to carry the drug along to be administered by the attending midwife. The drug should not be taken any time before delivery or be given to women with previous high-risk pregnancy or delivery. This requires assessment by the community midwife, after which the woman is referred to the facility.
The same questionnaire and sampling method used in the baseline was applied during postintervention to assess knowledge of prevention of PPH and use of misoprostol by 5 trained and experienced midwives from Community Medicine Department, A.B.U.T.H. Zaria for all women that delivered at home. This was done at the end of 6 months following onset of intervention. Postintervention data collection lasted 5 days in each community.
Data were analyzed using Statistical Package for Social Sciences (SPSS Inc. version 17.0) after cleaning. The data were presented using tables and charts drawn from excel software. Summary indicators used included means, percentage, and proportions. A scoring system for knowledge was developed. Each correct response entitles 1 mark and the percentage correct responses derived. This was used to compute the respondents' knowledge of prevention of PPH and use of misoprostol. The level of knowledge was graded as poor, fair, and good using the following cutoff points: <49%, poor; 50%–69%, Fair; and >70%, good. A comparison of the baseline and endline knowledge of prevention of PPH and use of misoprostol was done for each community. Postintervention comparison of knowledge of PPH prevention and use of misoprostol was done. A Chi-square test was used to test for difference in knowledge of prevention of PPH among the study subjects in the two communities. P < 0.05 was considered statistically significant. The proportion of uptake of misoprostol by supply strategy in the two study groups was calculated, and a z-test was applied to test for difference in the uptake of misoprostol. A <0.05 was considered statistically significant.
Ethical approval was obtained from the Ethical and Scientific Committee of Ahmadu Bello University Teaching Hospital in Zaria (ABUTH/HREC/TRG/36). At the Local Government Area, permission was obtained from the chairperson. At the community level, community leaders granted permission to conduct the study. The respondents gave written consent before being interviewed, which included brief information on the research, misoprostol and its expected side effects, opportunity to freely enroll or withdraw from the study without any prejudice, etc., while confidentiality was ensured.
| Results|| |
At baseline, 150 women in Hayin Dogo community and 150 women in Basawa were interviewed, giving a response rate of 100% each. Also at end line, 169 women in Hayin Dogo and 151 women in Basawa were interviewed, giving a response rate of 112% and 100%, respectively. During the intervention, the health facility was used as the source of misoprostol for the women who deliver in Hayin Dogo community while the community head, drug keepers, and TBAs were used as a source of misoprostol in Basawa community.
About four out of ten respondents in both communities [Table 1] were within 20–24 years. The mean age of the women in Hayin Dogo and Basawa communities was 25.44 (±4.76) and 24.90 (±6.17) years, respectively. About 67% and 59% had at least primary education in Hayin Dogo and Basawa, respectively. Only 24% and 20% have more than primary education in Hayin Dogo and Basawa, respectively. About 80% in each community had no occupation or were housewives, and over 95% in each community were Hausas and Muslims, respectively. Women with parity ≥5 were 33% and 38% in Hayin Dogo and Basawa, respectively. The mean number of living children was 3.68 ± 2.27 for Hayin Dogo and 3.89 ± 2.60 for Basawa. All women interviewed in both study communities were married. The difference in age, ethnicity, religion, and parity was not statistically significant at P > 0.05, but the difference in educational level and occupation was statistically significant at P < 0.05.
A majority (93% and 86%) of the women attended ANC in Hayin Dogo and Basawa communities [Table 2] with an average of 3 ANC visits during pregnancy. The difference in ANC attendance was not statistically significant at P > 0.05. High proportions of home deliveries were recorded in both communities; however, the proportion was higher in Basawa (85%) than Hayin Ojo (75%). The difference between the home and health facility delivery was statistically significant (χ2 = 5.26; df = 1; P < 0.05).
In general, at baseline [Table 3], there was average knowledge of PPH and its signs and symptoms. The knowledge of misoprostol, its dosage and side effect was generally poor in both study communities. The differences in knowledge scores between the communities were statistically significant at P < 0.05.
|Table 3: Baseline knowledge of prevention and treatment of postpartum hemorrhage with misoprostol in Hayin Dogo and Basawa communities|
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The baseline knowledge of causes, prevention, and treatment was generally poor in the two study communities, 98% in Hayin Dogo and 97.3% in Basawa. The differences in knowledge grade between the two communities was not statistically significant (χ2 = 0.15; df = 1; P > 0.05).
At postintervention [Table 4], there was a general improvement in knowledge of causes, prevention and treatment of PPH in the two communities, especially in their knowledge of misoprostol. A comparable proportion of women knew PPH can cause death (more than three-quarters in both communities). About 6 out of 10 women in both communities said a woman with PPH should go to the health facility promptly. The knowledge of use and dosage of misoprostol was at least 70% in each of the two communities. The TBA was the most important source of information on misoprostol with 45% and 87.4% in H/Dogo and Basawa communities, respectively. The health facility accounted for only 21.3% in H/Dogo and 2.6% in Basawa communities. The knowledge of side effects was generally low except for knowledge of shivering which accounted for 73% and 93% in Hayin dogo and Basawa, respectively. In general, the differences in scores between the two communities were statistically significant at P < 0.05.
|Table 4: Postintervention knowledge of prevention and treatment of postpartum hemorrhage with misoprostol in Hayin Dogo and Basawa communities|
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In spite of the intervention, the overall postintervention knowledge remained poor in both communities. Only about 7% of the population in both Hayin dogo and Basawa had fair/good knowledge of causes, prevention, and treatment of PPH using misoprostol. The difference in knowledge was not statistically significant (χ2 = 0.005; df = 1; P > 0.05).
In addition, in spite of the intervention, fair knowledge rose from 2% to 7% in Hayin Dogo. The difference in the pre- and postintervention knowledge of causes, prevention, and treatment of PPH using misoprostol was statistically significant (χ2 = 4.7; df = 1; P < 0.05). However, fair knowledge increased from about 3% to 7% in Basawa. The difference in the pre- and postintervention knowledge of causes, prevention, and treatment of PPH using misoprostol was significant (χ2 = 3.4; df = 1; P < 0.05).
About 74% and 93% in H/Dogo and Basawa respectively knew they can obtain misoprostol from the right source (Health facility in Hayin Dogo and TBA in Basawa) after the intervention. The difference in their knowledge of where to obtain misoprostol was statistically significant (χ2 = 21.3; df = 1; P < 0.05).
From monthly review meetings with the TBAs and midwives in each of the communities, data collected from the TBAs records on number of deliveries taken by each TBA and number of women that took misoprostol postdelivery for PPH prevention. There were a total of 284 deliveries recorded by TBAs in Hayin Dogo and Basawa. In Hayin Dogo where the women collected the drug from the clinic, 86 (30.3%) were reported to have taken misoprostol compared to 114 (40.1%) in Basawa where the women collected the drug from drug keepers in the community.
From the survey data at baseline, the uptake of misoprostol was nil in both Hayin Dogo and Basawa. At postintervention [Table 5], the uptake of misoprostol was about half (48.5%) in Hayin Dogo and over a third (37.7%) in Basawa. The difference was not statistically significant at P > 0.05.
|Table 5: Endline comparison of uptake of misoprostol for the prevention of postpartum hemorrhage|
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There was an increase in uptake of misoprostol of 48% after the intervention in Hayin Dogo and the difference was statistically significant at P < 0.05. In addition, in Basawa, there was an increase in uptake of misoprostol of 38% after the intervention. The difference in Basawa was not statistically significant at P > 0.05.
A high proportion, about 67% women who used misoprostol after delivery, reported knowledge of shivering as the commonest side effect compared to 27% among those who did not take misoprostol. Abdominal cramps accounted for 39% and 14% among those who took and did not take misoprostol respectively, nausea recorded 32% and 13%, respectively. Diarrhea and fever accounted for the least experienced symptom of 4.3% each among those that took and 2.3% and 7.1% in those that did not take, respectively. The difference in the experience of shivering, nausea, abdominal cramps, vomiting, and fever among women who actually took misoprostol and those that did not take was statistically significant at P < 0.05.
There was universal acceptance (100%) of misoprostol after the intervention in Hayin Dogo community compared to over 97% before the intervention. Furthermore, there was near universal acceptance of misoprostol of over 98% in Basawa community both before and after the intervention.
| Discussion|| |
The age distribution showed both study communities had twice the proportion of women compared to the national aggregate (18.4%) in the age bracket of 20–24 years which decreases to (9.1%) as the age increased for women in the age bracket 40–44 years. The mean age of the women was similar to the 25.8 ± 6.4 years reported in a study in a similar setting. This shows that the communities are youthful, as is typically expected for most developing countries. The age difference was not statistically significant between Hayin Dogo and Basawa at P > 0.05.
Women with at least primary education were by far higher than the national average of about 20%, showing that women in both communities were literate, even though, the proportion of women having more than primary education is a far cry from the national average of 45% as previous studies showed girls in these settings drop out of school due to some sociocultural reasons., The difference in educational level between the communities was statistically significant at P < 0.05.
About twice the 37% for not employed women reported by NDHS 2013 was found in the two study communities as they were mainly homemakers. The difference in occupation between the two communities was statistically significant at P < 0.05. It is worthy of note that educational level and occupation of women has a relationship with their access and utilization of Health services as established in literature. Studies in similar settings, just like this study, showed that majority of women were married, and were Hausa's of the Islamic faith. This is typical of most rural and semi-urban communities in Northern Nigeria where the study was conducted.,, The difference in the ethnicity and religion between Hayin Dogo and Basawa communities was not statistically significant at P > 0.05, respectively.
The mean number of living children slightly surpasses the national aggregate of 3.27 for currently married women but less than the 4.50 reported by Oguntunde et al. in a similar setting. This may be due to the more peri-urban nature of the two study communities compared to that of Oguntunde et al. Furthermore, communities which are strictly rural have been found to have higher parity and low use of modern contraception., The difference in number of living children in the two communities was not statistically significant at P > 0.05.
There was a higher proportion of ANC attendance in both communities compared to the national aggregate of 58% which is an expected finding in these communities. A study on protecting women who deliver at home from PPH in Tanzania recorded ANC attendance at 94% while over half (53%) deliver at home. This paradoxical phenomenon is widely reported across the African subregion. A study in three communities in Kaduna state reported ANC utilization of 76.2% which is higher than the national average but lower than the figure recorded in the study communities. Although women are recommended to visit ANC at least 4 times during pregnancy, ANC attendance was higher in Hayin Dogo slightly less in Basawa compared to the 89% recorded for women who attended ANC at least once in a previous study by Ejembi and Prata. These were all higher than NDHS 2013 national average value of 58% and 31% for North West geopolitical zone. The average ANC visits were lower than the figure of 5.2 ± 1.72 recorded in an earlier study in similar setting but similar to the 3.0 ± 0.02 reported by Ndola et al. This may be as a result of the less heterogeneous population of women (mostly Hausa's and Muslims) in the two study communities and low educational and socioeconomic attainment which has been found to directly affect the health-seeking behavior of women. The difference in the proportion of ANC attendance was not statistically significant between the two study communities at P > 0.05.
The proportion of home delivery recorded for Hayin Dogo and Basawa was both less than the 95% home delivery reported in an earlier study, possibly due to the paradoxically high ANC but low facility-based delivery reported in most of the Northern Nigerian communities. Home delivery was the preferred norm in these communities, mostly supervised by TBAs due to sociocultural and poor health service delivery. The difference in home deliveries between the two communities was statistically significant at P < 0.05.
The study found there was average knowledge of PPH, its signs and symptom but the knowledge of misoprostol, its dosage and side effect were generally poor at baseline in both study communities. The overall baseline knowledge was poor and the difference between the two communities not statistically significant when compared to the figures reported in an earlier study where women scored over 90% good knowledge. This finding highlights the importance of strategies aimed at creating awareness and increase women's knowledge about maternal health programs and interventions to close the gap as demonstrated in a previous study. Another study in similar setting recorded the fact that 36% of girls in these communities drop out of school to marry before or after they complete their primary education further exacerbates the problem of low knowledge. The difference in knowledge scores between the two communities was statistically significant at P < 0.05.
At postintervention, there was a general improvement of above average knowledge of PPH, misoprostol and its dosage though, still less than figures reported in an earlier study. The knowledge of PPH as a cause of maternal death rose to over two-thirds, just short of the 84% found in the community-based distribution of misoprostol study in Kaduna state compared to the 90% figure reported by Ndola et al. in the Tanzanian study. Women who knew that a woman with PPH should go to the health facility promptly had a proportion far higher than the 49% and 43% from the previous studies, respectively. The knowledge on function, route and dosage of misoprostol was higher in Basawa, rivaling the over 99% reported in the previous study while Hayin Dogo got less, over three-quarter knowledge on misoprostol when compared. This may demonstrate the quality of the IEC materials and awareness campaign mounted in the communities during the intervention.
The TBA was the most important source of information on misoprostol in both study communities. The TBA as a source was higher in Basawa, but Hayin Dogo got only about half the 85% reported in the previous study. The health facility as a source of information was low in both communities which do not differ from studies done previously in a similar setting which recorded 21.5%. This is expected because the health facility may not be the usual source of information for women who attended ANC only once, i.e., at booking and may likely deliver at home all things being equal. Second, TBAs in this study were found to direct women to the ANC in the health facility after giving information on misoprostol. Figures reported in a Zambian study on community distribution of misoprostol: New approaches and challenges, showed the health facility accounting for 78% and TBA 9%. Therefore, this is not to ignore the role played by other information sources which may be key in reaching some women with the information on misoprostol for PPH. The duration of exposure to the various IEC campaign strategies and underscoring the importance of each distribution strategy may be worthy of note in this instance. TBAs however, offered misoprostol to women more than health facilities or other sources of misoprostol that were mentioned.
The knowledge of the information on shivering as side effect of misoprostol was very high, especially in Basawa community which is close to and compares to findings from the previous study of 96%. This is expected as shivering is one of the main symptoms of misoprostol use. The difference in the knowledge of shivering was statistically significant between the two communities at P < 0.05, but on comparing the overall knowledge after the intervention, the marginal improvement in overall fair knowledge was not statistically significant between the two communities at P > 0.05.
In spite of the intervention in Hayin Dogo and Basawa, only a modest increase in fair knowledge about prevention and treatment of PPH was observed between the pre- and postintervention knowledge scores. Hayin Dogo recorded a slightly higher increase compared to Basawa community. The duration of exposure to the various IEC campaign strategies may be the case as explained earlier. The difference in knowledge of where to obtain misoprostol was statistically significant at P < 0.05. However, the knowledge of where to obtain misoprostol was high in both communities, i.e., health facility in Hayin Dogo and TBA/Community drug keeper in Basawa which recorded 74% and 93%, respectively. This shows the level of awareness and comprehension of the IEC messages about misoprostol generated in both communities due to the campaign. The difference between the two communities was statistically significant at P > 0.05.
Overall, going by the review of TBAs records during the study, 70.4% of the women enrolled in the study were protected from PPH using misoprostol after delivery during home births. This figure compares with the 79% reported in an earlier study and lays credence to the importance attached to home-based interventions in those communities. However, only about half this value is recorded per community.
At baseline, the uptake of misoprostol was poor in both communities. When compared to the postintervention, the uptake increased to about half the 79% reported in a previous study. Hayin Dogo recorded a slightly higher uptake compared to Basawa community. Other studies reported uptake as high as 49% in Zambia, 88% in Tanzania, and 95% in Kenya during home births. The finding in this study may be limited by the short duration of the study and large geographical size of the communities which may reduce and not allow for a full magnitude of effect in view of the limited resources and delay in the supply of misoprostol for this study. Hence, the importance of adopting different distribution strategies in reaching a vast majority of women in need of the life-saving intervention as demonstrated in previous studies which showed near universal uptake after over a year of instituting intervention with misoprostol is key. The difference in uptake between the two study communities was not statistically significant at P > 0.05.
For the individual communities, Hayin Dogo recorded an increase and a slightly higher uptake of almost average between the pre- and postintervention using its health facility distribution strategy in which the difference between the pre and post intervention uptake was statistically significant at P < 0.05. When compared to Basawa in which the distribution strategy was community-based, the increase in uptake was just over a third though, still about half of the 79% from previous study. This may be because of the difference in reach, that may be attainable between the different distribution strategy, delay in supply of misoprostol as some women may not return to health facility to collect misoprostol after the ANC visit and that the finding may be limited by the fact that the study did not necessarily follow-up the same women at baseline to the end-line for questionnaire administration which may affect the uptake. Surprisingly and unexpectedly, the difference between the pre- and postintervention uptake of misoprostol in Basawa was not statistically significant at P > 0.05. The finding may also lay credence to the fact that women who took misoprostol for prevention of PPH took it at the right dose, route and timing showing the efficacy and effectiveness of the awareness campaign. This may imply that the IEC materials were standard, of good quality, easy to comprehend, and adopt in practice by the women during home deliveries by lay individuals.
Shivering accounted for the highest experienced symptom among those that took misoprostol which is expected side effect of the drug, followed by abdominal cramp which signifies the effect of the drug on the uterus. The figures recorded far exceeded the values from previous study in similar setting (shivering 42%, nausea 6%, fever 11%, vomiting 2%, diarrhea 2%, and no symptom 74%) probably because, all women interviewed experienced one symptom or another and no woman said she did not experience any symptom thereby accentuating the proportion of symptoms actually experienced when compared. A study in Tanzania also showed higher proportions of symptoms among those that took misoprostol compared to those that did not but, lower values (18% shivering, 8% nausea, 7% vomiting, 5% fever, and 76% no symptom). The difference in the experience of side effect between those who took misoprostol and those that did not take were all statistically significant at P < 0.05.
There was high acceptance of the drug both at pre and post intervention and in each community similar to the 95% reported in Kaduna state and 99% in the Tanzanian study. When comparing the acceptance of the drug among those who actually took misoprostol, the acceptance was universal across the board. This finding may not be unusual as interventions aimed at improving maternal health, especially when provided free and women do not have to pay out of pocket and proper awareness and sensitization conducted, may be received and patronized overwhelmingly by communities in Nigeria despite initial resistance.
The limitations of this study include the fact that the study is based on the previous history of PPH and use of misoprostol with the likelihood of recall of events bias. Error in sampling respondents could occur as the study did not do a total population study of parturient women. Furthermore, the study did not manage pregnancies and deliveries or its complications. The study focused on distribution strategy options by self/TBA and health-care worker/ANC, other studies elsewhere incorporated the community health workers, patent medicine vendors among many others such as the Zaria and Sokoto studies. However, despite these limitations, the study has filled a gap in information while providing an opportunity for further research.
| Conclusion|| |
There was an increase in the knowledge of prevention of PPH and treatment, including the use of misoprostol during home births in Hayin Dogo and Basawa communities using the health facility and community-based distribution strategies after the intervention. Both distribution strategies are viable and should be integrated into all ANC and delivery services alongside the sustained supply of misoprostol to pregnant women at ANC. Increased awareness should be continuously embarked on for all PHC workers involved in antenatal and delivery services to sustain the demand and use of misoprostol after delivery by pregnant women who attend ANC. Pregnant women and TBAs at community level should be encouraged by health-care workers with the right key messages to deliver in the facility as much as possible and collect misoprostol early as many complications of pregnancy and delivery must be managed in the health facility and not easy to tackle at home, even with a skilled attendant. This may help increase coverage substantially and also encourage women who may otherwise not return to health facilities to deliver to utilize the facility for delivery. This will help tackle complications and reduce maternal mortality and its comorbidities.
The authors wish to acknowledge Hayin Dogo and Basawa communities for participating in the project. The Population and Reproductive Health Initiative, Ahmadu Bello University Teaching Hospital for its support, Dr. C.L. Ejembi for providing encouragement, support, guidance and mentorship through-out the project, all research assistants, community midwives and the entire research team for its dedication and cooperation and last but not the least, Network on Behavioural Research for Child Survival in Nigeria (NETBRECSIN) for its technical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Oraganziation. Trends in Maternal Mortality: 1990-2008. WHO, UNICEF, UNFPA and The World Bank; 2010. p. 25-30.
National Population Commission (NPC) Nigeria and ICF Macro. Nigeria Demographic Health Survey. Abuja: National Population Commission; 2013.
Harrison KA. The struggle to reduce high maternal mortality in Nigeria. Afr J Reprod Health 2009;13:9-20.
Prata N, Sreenivas A, Vahidnia F, Potts M. Saving maternal lives in resource-poor settings: Facing reality. Health Policy 2009;89:131-48.
Ejembi C, Prata N. Prevention of Postpartum Hemorrhage at Home births in Five Communities around Zaria, Kaduna State, Nigeria. Technical Report. Population and Reproductive Health Partnership (PRHP), Ahmadu Bello University Teaching Hospital (ABUTH). Zaria: Ventures Strategies Innovations (VSI), Bixby Center For Population Health and Sustainability; February, 2010. p. 8-30.
Ijadunola KT, Ijadunola MY, Esimai OA, Abiona TC. New paradigm old thinking: The case for emergency obstetric care in the prevention of maternal mortality in Nigeria. BMC Womens Health 2010;10:6.
Gulmezoglu A. Misoprostol for prevention and treatment of postpartum heamorrage: Current knowledge and future directions. WHO Guidelines, EDL and Pre-Qualification Status of Misoprostol, UNDP, UNFPA and World Bank Special Programme of Research Training in Human Reproduction. The Bill and Melinda Gates Foundation; 2009. p. 1-12.
Bergstrom S, Aronsson A. Misoprostol in resource poor countries: Its cheap and effective, yet its availability remains restricted. BMJ 2008;336:1032.
Prata N, Mbaruku G, Grossman AA, Holston M, Hsieh K. Community-based availability of misoprostol: Is it safe? Afr J Reprod Health 2009;13:117-28.
Starrs A, Winikoff B. Misoprostol for postpartum hemorrhage: Moving from evidence to practice. Int J Gynaecol Obstet 2012;116:1-3.
Sutherland T, Meyer C, Bishai DM, Geller S, Miller S. Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis. Int J Gynaecol Obstet 2010;108:289-94.
Orobaton N, Austin A, Fapohunda B, Abegunde D, Omo K. Mapping the prevalence and sociodemographic characteristics of women who deliver alone: Evidence from demographic and health surveys from 80 countries. Glob Health Sci Pract 2016;4:99-113.
Smith HJ, Colvin CJ, Richards E, Roberson J, Sharma G, Thapa K, et al.
Programmes for advance distribution of misoprostol to prevent post-partum haemorrhage: A rapid literature review of factors affecting implementation. Health Policy Plan 2016;31:102-13.
Oguntunde O, Aina O, Ibrahim M, Umar H, Passano P. Antenatal care and skilled birth attendance in three communities in Kaduna state, Nigeria. Afr J Reprod Health 2010;14:89-95.
Nmadu G, Avidime S, Oguntunde O, Dashe V, Abdulkarim B, Mandara M. Girl child education; Rising to the challenge. Afr J Reprod Health 2010;14:107-12.
Orobaton N, Abdulazeez J, Abegunde D, Shoretire K, Maishanu A, Ikoro N, et al.
Implementing at-scale, community-based distribution of misoprostol tablets to mothers in the third stage of labor for the prevention of postpartum haemorrhage in Sokoto state, Nigeria: Early results and lessons learned. PLoS One 2017;12:e0170739.
Weeks AD, Ditai J, Ononge S, Faragher B, Frye LJ, Durocher J, et al.
The mamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: A community-based, placebo-controlled randomised trial. BMC Pregnancy Childbirth 2015;15:219.
Ononge S, Campbell OM, Kaharuza F, Lewis JJ, Fielding K, Mirembe F, et al.
Effectiveness and safety of misoprostol distributed to antenatal women to prevent postpartum haemorrhage after child-births: A stepped-wedge cluster-randomized trial. BMC Pregnancy Childbirth 2015;15:315.
Smith JM, Gubin R, Holston MM, Fullerton J, Prata N. Misoprostol for postpartum haemorrhage prevention at homebirths: An intergrative review of global implementation experience to date. BMC Pregnancy Childbirth 2013;13:44.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]