Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework

Karen Hobday; Jennifer Hulme; Ndola Prata; Páscoa Zualo Wate; Suzanne Belton; Caroline Homer

doi:10.9745/GHSP-D-18-00475

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FIGURE 1
The Evolution of the Distribution of Misoprostol for Prevention of Postpartum Hemorrhage in Mozambique
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FIGURE 2
ExpandNet/World Health Organization Scale-Up Framework
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FIGURE 3
The Innovation: Misoprostol Distribution Chain

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TABLE 1.

Estimated Access to and Utilization of Misoprostol to Prevent Postpartum Hemorrhage in Inhambane and Nampula Provinces, Mozambique, January–September 2017

Location	A	B	C	D	E	F	G	H	I	J	K
Location	Misoprostol Distributed Through ANC and TBAs	Misoprostol Distributed Minus Returned	District Population (2017)	Annual Births in District (2017)^a	Proportion of Health Facilities Enrolled in Misoprostol Program	Annual Births in Misoprostol Areas^b	Births in Misoprostol Areas (First 9 Months of 2017)^c	Home Births in Misoprostol Areas (First 9 Months of 2017)^d	Access to Misoprostol at Home Births^e	Utilization of Misoprostol at Home Births^f	Interpretation
Inhambane Province
Zavala	616	243	163,620	7,363	38%	2,798	2,098	630	98%	39%	Excellent access, poor utilization
Homoine	417	45	131,680	5,926	46%	2,726	2,044	613	68%	7%	Fair access, very poor utilization
Total both districts	1,033	288	295,300	13,289	42%	5,581	4,143	1243	83%	23%	Good access, poor utilization
Nampula Province
Mecuburi	1,464	840	189,880	8,545	43%	3,674	2,756	827	100%^g	100%^g	Excellent access and utilization
Erati	2,568	2,034	322,737	14,523	54%	7,842	5,882	1,765	100%^g	100%^g	Excellent access and utilization
Monapo	1,357	1,039	389,902	17,546	43%	7,545	5,659	1,698	80%	61%	Good access, fair utilization
Total 3 districts	5,389	3,913	902,519	40,613	47%	19,088	14,296	4,289	100%^g	91%	Excellent access and utilization

↵a Column C * 4.5%.
↵b Column E * Column D. The calculation uses a fixed number of residents and assumes population figures are similar across the country, leading to imprecision in the calculation of access and utilization indicators.
↵c Column D * 0.75.
↵d Column G * 0.30.
↵e Column A/Column H.
↵f Column B/Column H.
↵g In Mecuburi, access was 100% with 637 remaining doses and 13 additional doses utilized; Erati had 100% access with 803 remaining doses and 269 additional doses utilized. In total, there were 1,440 remaining doses in all 3 districts of Nampula.

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TABLE 2.

Program Inputs Provided in Inhamabane vs. Nampula Provinces, Mozambique

Inputs	Inhambane	Nampula
Supervision	Ad hoc supervision from health staff when time/resources permitted	Routine supervision from Jhpiego MCSP staff Some initial supervision visits from AMOG (funded by MCSP)
Personnel	Health staff strongly believed the misoprostol program was a pilot project as it was only in selected districts in the province Strictly implemented eligibility criteria Significantly less misoprostol distributed at ANC (989 doses) than Nampula Fear of misuse limited distribution	Greater sense of support from health staff as many were aware of the 2009–2010 pilot and appreciated the potential misoprostol has to reduce PPH and MMR Less sense of a need to limit women due to criteria Significantly more distributed at ANC (13,602 doses) than Inhambane
Champions	Lack of clear champion; MNCH leaders supportive yet constrained by lack of resources	Provincial and district MNCH leaders showed very strong support for the program and encouraged implementation
Training	Funded by UNFPA; led by trained MOH master trainers, with UNFPA technical support Training imbalanced; targeted more CHWs (337) than TBAs (47)	Funded by Jhpiego's MCSP program; led by AMOG and MOH with MCSP technical support Provided significantly more TBAs with training (980), providing greater community coverage
Logistics	Challenges distributing stock from province to districts; as of October 2017, 87% of misoprostol stock remained in provincial warehouse	Fewer challenges distributing stock from province to districts; only 1% of stock remained in provincial warehouse as of October 2017
Monitoring and evaluation	Parallel system; not integrated in the national health information system	Parallel system; not integrated in the national health information system MCSP provided technical support to develop M&E tools but they were not adopted at the national level No data available provincially on misoprostol returns from CHWs/TBAs

Abbreviations: AMOG, Association of Mozambican Obstetricians and Gynaecologists; ANC, antenatal care; CHW, community health worker; MCSP, Maternal and Child Survival Project; M&E, monitoring and evaluation; MMR, maternal mortality ratio; MNCH, maternal, newborn, and child health; MOH, Ministry of Health; PPH, postpartum haemorrhage; TBA, traditional birth attendant; UNFPA, United Nations Population Fund.

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TABLE 3.

Distributed and Returned Misoprostol by Cadre, January–October 2017

Province	Total Distributed at ANC	Total Distributed by CHWs	Total Distributed by TBAs	% of Total Distributed to CHWs Reaching TBAs^a	% of Total Distributed at ANC via TBAs^b	Returned to ANC	Returned to ANC by CHW or TBA
Inhambane (Homoine, Zavala districts)	989	325	44	14%	4.4%	201	87
Nampula (Mecurburi, Erati, Monapo districts)	13,602	5,578	900	16%	6.6%	1662	Unknown

Abbreviations: ANC, antenatal care; CHW, community health worker; TBA, traditional birth attendant.
↵a Total distributed by TBAs divided by total distributed by CHWs * 100.
↵b Total distributed by TBAs divided by total distributed at ANC * 100.

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TABLE 4.

Facilitators and Barriers to Scaling Up Misoprostol for the Prevention of Postpartum Hemorrhage in Mozambique, by ExpandNet/WHO Framework

Factors	Facilitator	Barrier
*Planning Phase*
Environment
1. Financial situation		✓
2. Government support including champions	✓
3. Changes in abortion law	✓
4. Limited capacity of health system		✓
5. Wavering support for TBAs		✓
Innovation
1. Clear, concise, well-defined	✓
2. Adaptation of criteria		✓
3. Flow of distribution		✓
User Organization
1. MOH Central	✓
2. MOH MNCH health staff	✓	✓
3. MOH pharmacists		✓
4. APE (dependent on TBA relationship and distance)	✓	✓
5. TBA recruitment (close to health facility)		✓
Resource Team
1. Members	✓	✓
2. Existence of SWAp MNCH Technical Working Group	✓
3. SWAp MNCH Technical Working Group irregularity of meetings		✓
Management Phase
Type of Scale-Up
1. Horizontal (phased expansion)	✓
2. Limited sites in each district (5 health facilities in selected districts)		✓
3. Untrained health staff due to mobility		✓
4. Vertical (institutionalization)	✓
Dissemination and Advocacy		✓
1. Development of National PPH Strategy	✓
2. Communication of PPH Strategy		✓
3. Training of health staff, APEs, and TBAs	✓	✓
Organizational Process
1. MOH Central	✓
2. MOH Provincial	✓	✓
3. MOH District		✓
Costs/Resource Mobilization
1. Available Budget		✓
Outcomes
1. Utilization and access in Nampula province	✓
2. Utilization and access in Inhambane province		✓
3. Logistics system		✓

Abbreviations: APE, Agentes Polivalentes Elementares (community health worker); MNCH, maternal, newborn, and child health; MOH, Ministry of Health; PPH, postpartum hemorrhage; SWAp, Sector Wide Approach; TBA, traditional birth attendant; WHO, World Health Organization.