In Chitral district of Khyber-Pakhtunkhwa (KP) Province, Pakistan, a high rate of home births translates to inadequate or nonexistent treatment for life-threatening obstetric complications, like postpartum hemorrhage (PPH). According to the 2012-13 Pakistan DHS report, nearly two-thirds of women deliver at home in rural areas of KP province.
Customarily, home births are managed by a traditional birth attendant (TBA) and if a complication like PPH arises, the only care available is to transfer the woman to a higher level facility or have a skilled provider called to the woman’s home to administer oxytocin as treatment. In Chitral, many villages are located far from health centers and access to care is especially difficult due to poor infrastructure and limited transport. Faced with these barriers, women who develop PPH are rarely transferred to a facility, so having treatment options available at home is critical.
Misoprostol, a prostaglandin analog that reduces blood loss after delivery, is a useful drug in this setting because it requires neither cold storage nor a skilled attendant to administer it. A recent study—implemented in Chitral by Gynuity Health Projects and Aga Khan Health Service, Pakistan—explored the feasibility of providing misoprostol to traditional birth attendants and having them administer it to prevent and treat PPH in home deliveries.
In this study, women received misoprostol prophylaxis (a 3-tablet dose) and in the event of PPH, the TBA administered a treatment dose of misoprostol with referral to a higher level of care. Study trainings reiterated the importance of transfer if a woman experiences a delivery complication. Despite prophylaxis, there were women who were diagnosed with PPH and received study treatment. The study confirmed that TBAs are able to administer misoprostol correctly and safely for both prophylaxis and treatment.
There has been an increase in the number of facility-based deliveries worldwide; yet for many women, a facility delivery is not an option. Among women in our study who had planned to have a facility delivery, many delivered at home due to road blocks, unavailable transportation, or unavailability of a family member to accompany them to the facility.
There will always be women who will not be able to deliver at a facility, despite plan to do so. Among women who deliver at home and experience PPH, many will experience delays or will never be transferred to a health facility. For these women, it is imperative to have a treatment option available at the community level since the average time from onset of PPH to death is only two hours.
The following video showcases infrastructure barriers to safe delivery and expresses the thoughts of TBAs and other healthcare providers on access to obstetric services in Chitral and the use of misoprostol to manage PPH.
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 Caucus, Family 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.