Preventing postpartum hemorrhage in home births: the indonesia

FOSTERING CHANGE:
INITIATING A COMMUNITY-BASED APPROACH TO PREVENTING POSTPARTUM
HEMORRHAGE
What was the context for the change? Postpartum hemorrhage (PPH) is the largest cause of maternal death in
developing countries. PPH is defined as excessive bleeding after childbirth. A critical period when PPH often
occurs is during the third stage of labor: the time period between the birth of the infant and the delivery of the
placenta. The amount of blood lost depends, in part, on how quickly the separation and delivery of the placenta
occur. If the uterus does not contract normally, the blood vessels at the placenta site do not adequately contract, and
severe bleeding results. Even if the new mother does not die, PPH can leave her weak and anemic, causing serious
physical, emotional, and financial stresses for mother, baby, and family.
Studies have shown that 60 percent of PPH can be prevented by active management of the third stage of labor
(AMTSL), which includes administering a uterus-contracting drug within one minute of the birth. The most
common drug in AMTSL is oxytocin, which must be injected by a skilled health worker. But several studies have
demonstrated that misoprostol, which a pregnant woman can take orally or place under the tongue, is equally safe
and effective, is less expensive, doesn’t require cold storage, and can be delivered at the community level.
In Konda – a rural district of the country of Bonaria – a large NGO wanted to assess the safety, effectiveness, and
acceptability of training community health workers (CHWs) to do three things: 1) provide women with information
about preventing PPH, 2) distribute misoprostol to pregnant women, and 3) provide follow-up support. This
required a major change in the skills and practices of the CHWs and their supervisors. It also required support from
community leaders and the Ministry of Health, which was ultimately responsible for the health and safety of the
new mothers and their babies.
How did the change come about? Before the demonstration began, a steering committee was formed, made up of
key stakeholders: leaders from communities within Konda District, NGO staff, health professionals with strong
reputations, a member of the District Health Team, and MOH representatives. They arranged the required ethical
reviews and obtained approvals from community leaders; the MOH, and directors at provincial and district levels.
This steering committee constituted the Change Coordination Team. The team members were well aware that in
Konda District, one-third of the deaths related to pregnancy and childbirth were due to PPH. The steering
committee also knew that nearly half the women in the area had unattended births in their homes. The challenge
was to reduce PPH without access to sophisticated health services – in other words, to enable trained CHWs to
provide misoprostol for women to use when they delivered.
Although they recognized the problem, not all committee members were immediately in favor of introducing the
new practice. Some wondered whether CHWs could ever be adequately trained to carry out these responsibilities.
Others were concerned about the potential for misuse of misoprostol, including the dangers of taking it during labor
to speed up delivery. The health professionals on the committee paid careful attention to these concerns. They
provided examples of training materials for CHWs from other countries along with data that showed how
effectively those trained CHWs had performed. They also provided data showing the extremely low incidence of
misuse where the protocols were well constructed, information was clearly presented, and CHWs were well
supervised. After about two months of the exchange of concerns and information, all the committee members
agreed to promote the new practice.
The committee identified a change agent: an obstetrician/gynecologist with strong academic credentials, practical
experience at the community level, and an enthusiasm for community-based health. She oversaw the demonstration
with the assistance of a team that included a field epidemiologist, a study manager, and a senior obstetrical nurse
trainer. All those involved were fully informed that the International Confederation of Midwives and International
Federation of Gynecologists & Obstetricians had endorsed community administration of misoprostol, and that the
practice had proven safe and effective in several countries in settings similar to Konda.
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What were the elements of the demonstration? The steering committee was able to arrange demonstration and
comparison sites. At both demonstration and comparison sites, a trained community volunteer offered counseling
on the dangers and prevention of PPH as soon as she identified a pregnant woman. At the demonstration sites,
CHWs offered additional information about appropriate timing, correct use, the dangers of taking misoprostol
during labor, and potential side effects. At these sites, the CHW distributed misoprostol during the eighth month of
the pregnancy, along with a second round of counseling. At the comparison sites, whenever a trained nurse or
midwife attended a birth, she administered either oxytocin or misoprostol immediately after the birth.
The demonstration was designed to show whether this new practice could overcome potential obstacles: Could
CHWs be trained in the misoprostol regimen and, in turn, establish correct use for pregnant women delivering at
home? Would new mothers accept misoprostol and be willing to take it on their own? Could they use misoprostol
safely and effectively where no trained birth attendant was available? Would they be satisfied with the treatment
and recommend it to others?
The steering committee anticipated that, on the basis of experience elsewhere, the answer to these questions would
be “yes.” Even before the demonstration began, the committee worked with the Ministry of Health to consider next
steps if the intervention succeeded. They began to plan for expansion to new geographic areas where home births
were prevalent and where skilled birth attendants were a rarity.
How did the steering committee evaluate the demonstration? During and after the intervention, the field study
team received reports on the number of women who took the medications correctly and the pregnancy outcomes.
They also interviewed women in the study, their husbands, community leaders, and supervisors, to help assess
community acceptance and feasibility of expanding the intervention. An obstetrician investigated all complications
that occurred during childbirth.
What were the results? The field study team documented that fewer women were brought to the hospital with PPH
from the demonstration area than from the comparison sites, and that when PPH did occur, it was less severe for
women who used misoprostol. These measures showed that home-based community distribution of misoprostol
could be provided safely and effectively. The study also found that the intervention was acceptable. Most women
were pleased with the effects of the misoprostol and the counseling they received. The great majority of users stated
that they would take misoprostol again, recommend it to a friend, and be willing to pay for it.
At the end of the study, the steering committee presented key findings to the Minister of Health and recommended
expanding the PPH preventive practice. They disseminated the study results widely and advocated for commitment
from regional health authorities and donors. As a result of the steering committee’s efforts, the Minister agreed to
expand the practice to three more districts and included this expansion in the Ministry’s budget for the next fiscal
year.
QUESTIONS ABOUT THE CASE

How did the steering committee play its role as the change coordination team, contributing to the
new practice in and beyond Konda District?
1. What initial actions did the steering committee take to pave the way for a successful demonstration 2. A clear definition, and agreement on, the problem or challenge to be addressed is fundamental to an effective change process. Did the Change Team identify a clear challenge and reach agreement in this case? If so, what was the clear challenge? 3. What were some of the issues on which members of the steering committee differed?
4. Did the Steering Committee address these issues of difference or resistance? If so, what did they do?
5. What might have happened if the steering committee had recommended immediate countrywide
adoption of the new practice without a chance to test this intervention locally and obtain data showing 6. What obstacles might the steering committee face as they scale up the new practice to the new 7. How might these obstacles be overcome?

Source: http://www.ewc-popcomm.org/pdf/10_Fostering_Change/Fostering_change_casestudy.pdf