MSH, a global health nonprofit organization, uses proven approaches developed over 40 years to help leaders, health managers, and communities in developing nations build stronger health systems for greater health impact. We work to save lives by closing the gap between knowledge and action in public health. Since its founding in 1971, MSH has worked in over 150 countries with policymakers, health professionals, and health care consumers to improve the quality, availability and affordability of health services. Working with governments, donors, nongovernmental organizations, the private sector, and health agencies, MSH responds to priority health problems such as HIV & AIDS; tuberculosis; malaria; maternal, newborn and child health; family planning and reproductive health; and chronic non-communicable diseases such as cancer, diabetes, and lung and heart disease. Through strengthening capacity, investing in health systems innovation, building the evidence base, and advocating for sound public health policy, MSH is committed to making a lasting difference in global health.
The purpose of this consultant is to Review the National Level Policies for Community-Based Distribution of Misoprostol for Prevention of Postpartum Hemorrhage and Subsequent Status of Implementation and Scale-Up.
Principal Work Location:
The consultant is responsible for the following tasks:
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The African Strategies for Health (ASH) project is a five-year (2011-2016) contract funded by the United States Agency for International Development (USAID). ASH works to improve the health status of populations across Africa through identification of and advocacy for best practices, enhancing technical capacity, and engaging African regional institutions to address health issues in a sustainable manner. ASH provides information on trends and developments in the continent to USAID and other development partners to enhance decision making regarding investments in health.
Despite a 45 percent global decline in the number of annual maternal deaths from 1990 to 2013, maternal mortality remains unacceptably high, particularly in the developing world where 99 percent of these deaths occur. The sub-Saharan Africa region alone accounted for 62 percent of global maternal deaths in 2013 and has the highest regional maternal mortality ratio (MMR) at 510.[i] Postpartum hemorrhage (PPH) defined as blood loss of 500mL or more, is the leading cause of maternal mortality in low-income countries and is the primary cause of nearly one quarter of all maternal deaths globally.[ii] Postpartum hemorrhage currently accounts for 34 percent of maternal deaths in Sub-Saharan Africa where the lifetime risk of dying from pregnancy or childbirth is 1 in 38.[i] [iv]
The vast majority of postpartum hemorrhage cases can be effectively prevented or treated with evidence-based interventions such as uterotonics which are used to induce contraction or greater tonicity of the uterus. Oxytocin is currently the most widely used uterotonic and is the World Health Organization’s uterotonic of choice for administration in the third stage of labor for prevention of PPH. Although oxytocin is the recommended drug, it requires both administration via injection by a skilled provider and refrigeration, making it unfeasible in resource-poor settings or in areas where the majority of women deliver in the home. In a region where 50 percent of births occur without attendance by skilled health personnel, access to an alternative uterotonic or intervention for the prevention of postpartum hemorrhage is critical to achieving maternal mortality reduction in Africa[i].
Misoprostol is an alternative uterotonic increasingly used in obstetrical and gynecological practice including for the prevention and treatment of PPH. The utilization of misoprostol for PPH prevention in the developing world has gained increasing interest over the past decade as it is inexpensive, does not require cold chain storage, and recent studies have shown it can be safely and effectively administered by a lay/unskilled health worker. Since the first misoprostol placebo controlled trial for prevention of PPH in home births was conducted in India in 2005, dozens of studies of community-based misoprostol distribution have been conducted globally as well as various reviews and evaluations of implementation.[ii] [iii] The findings overwhelmingly support community-based distribution of misoprostol for prevention of PPH as a safe and effective strategy in settings where skilled birth attendance is low. Despite this body of evidence, the addition of misoprostol to the WHO Model List of Essential Medicines for the prevention of PPH, the inclusion of misoprostol in various global clinical guidelines (FIGO/ICM, ACOG, RCOG) and the World Health Organization’s 2012 recommendation for the administration of misoprostol by a lay health worker in the absence of a skilled birth attendant, very few countries in Africa have adopted national policies or service delivery guidelines for the scale-up of this intervention.[iv] In 2011 and 2012, “A Global Survey on National Programs for the Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia” found that of 20 African countries surveyed, misoprostol is on the essential medicines list (EML) for prevention of PPH in 16, 11 countries have conducted pilots on community-based distribution, but only four are beginning to scale-up misoprostol at home births through the ratification of national policies (Ethiopia, Equatorial Guinea, Mozambique, and Nigeria).
The Review of National Misoprostol Policies for Community-Based Distribution of Misoprostol for Prevention of Postpartum Hemorrhage and Subsequent Status of Implementation and Scale-Up study will explore the policy-making process and subsequent roll-out of the intervention in four of the seven African countries which have national policies in place for the use of misoprostol at home-births for prevention of postpartum hemorrhage. These countries include Madagascar, Mozambique, Nigeria, and South Sudan.
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