Increasing Access to Prevention of Postpartum Hemorrhage Interventions for Births in Health Facilities and at Home in Four Districts of Rwanda

The proportion of facility-based births increased from 28% in 2005 to 69% in 2010. The maternal mortality ratio declined from 750 to 476 maternal deaths per 100,000 live births over the same period. The main direct causes of maternal death in Rwanda are hemorrhage, sepsis, and hypertensive disorders. The Rwandan Ministry of Health estimates that 46.1% of maternal deaths are due to severe bleeding, with 31% from postpartum hemorrhage (PPH), 11% from intrapartum hemorrhage, and 4% from antepartum hemorrhage. To prevent PPH, the World Health Organization recommends the use of a uterotonic drug during the third stage of labor for all women. The recommended uterotonic is oxytocin, which is typically administered during childbirth in health facilities. However, oxytocin has limited use in low-resource settings due to its requirement for cold chain storage and administration via injection by a skilled birth attendant. Misoprostol is a less effective uterotonic but can be used in settings where oxytocin is not feasible. The current recommended dose of misoprostol for PPH prevention is 600 micrograms (mcg), which is three tablets of 200 mcg each. A comprehensive program was implemented in Rwanda to introduce community-based administration of misoprostol for home births by community health workers, called Animatrices de Santé Maternelle (ASMs), and improve the use of active management of the third stage of labor (AMTSL) for births at health facilities. The program was implemented in four districts of Rwanda: Nyanza, Musanze, Gakenke, and Rubavu. The districts were selected from the 13 districts where the Maternal and Child Health Integrated Program (MCHIP) was implementing activities and represented the four different geographical provinces of Rwanda. The program aimed to assess the coverage, acceptability, and feasibility of efforts to prevent PPH at community and facility levels. A longitudinal observational study was conducted to answer the following research questions: 1) Is it feasible and effective to have ASMs provide education and administer misoprostol for PPH prevention to women who deliver at home; 2) does the availability of misoprostol for preventing PPH at home births affect skilled birth attendance at facilities; 3) is misoprostol acceptable to Rwandan women for PPH prevention; and 4) what do ASMs think of the program. The study population consisted of pregnant women age 15 and older who were recruited by ASMs at the community level in the course of their routine work. Written informed consent was obtained from the pregnant women, and they were provided information about PPH prevention, the importance of skilled attendance at birth, and the availability of misoprostol from their ASM at the time of birth. The ASMs strongly encouraged the pregnant women to deliver in a facility. Those who met the eligibility criteria and provided informed consent were enrolled in the program. A total of 4,074 pregnant women were enrolled in the program, representing 20.5% of estimated deliveries. The overall uterotonic coverage was 82.5%, with 85% of women who delivered at a facility receiving a uterotonic to prevent PPH. The administration of misoprostol at the time of birth for home births achieved moderate uterotonic coverage, with 76% of women ingesting misoprostol. The distribution of misoprostol through antenatal care services could further increase coverage.