Postpartum hemorrhage (PPH) is a major public health issue in South Sudan as recent estimates show a maternal mortality rate of 2,054 deaths per 100,000 live births. Compounded with an equally high infant mortality of 102 per 1,000 live births and under-five mortality of 135 per 1,000 live births, South Sudan’s maternal and child health indicators are among the worst in the world. During his visit to South Sudan last year in May, USAID Administrator Rajiv Shah addressed this issue and reaffirmed the agency’s commitment to improving maternal and child health in the country.
In June 2011, USAID asked partners in South Sudan, including the South Sudan Health Transformation Project, the Maternal and Child Health Integrated Program (MCHIP), the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, and Ventures Strategies Innovations (VSI) to design a start-up program for introducing misoprostol for prevention of PPH at the community level to help reduce maternal mortality. Misoprostol is a safe and an effective option for prevention of PPH, which unlike the injectable uterotonics, can be handled and administered outside the health facilities. It is relatively inexpensive, stable, and can be administered orally or vaginally.
The preliminary phase of the program is being carried out in two counties within South Sudan —Mundri East and Mvolo where 21 and 11 health facilities are located respectively. This includes 35 villages and a total population of 105,400.
Prenatal care providers and community volunteers called home health providers (HHPs) who are assigned to specific health facilities will be trained to counsel pregnant women on danger signs of complications during pregnancy, birth preparedness, complication readiness, and the importance of delivering at a health facility. They will also counsel women on safe delivery messages and use of misoprostol to prevent PPH during home births in the event they do not reach a facility.
The program itself will then assess and determine—
- If prenatal care visits and community-based distribution of misoprostol through community health workers are effective in educating women on how to prepare for birth and in preventing PPH.
- The use of misoprostol for home births.
- If misoprostol is acceptable to South Sudanese women and their families.
- If the availability of misoprostol for preventing PPH at home births affects skilled birth attendance coverage at facilities.
- The proportion of women with vaginal births who receive correct active management of the third stage of labor by skilled providers.
Role of SIAPS
SIAPS is working to ensure that misoprostol reaches the lowest levels of the health system and is available to prenatal care providers, HHPs, and ultimately, pregnant women. To better understand the current situation, SIAPS visited the two counties and met with health officers, supply managers, and supervisors to discuss misoprostol supply chain options. During the visit, SIAPS staff found that while there was overall high prenatal care attendance, there were a low number of deliveries at the health facilities demonstrating the need for a community-based strategy for PPH prevention.
SIAPS has worked closely with VSI to ensure timely misoprostol imports into South Sudan, while complying with local regulatory requirements. The program also helped with customs clearance and receipt and storage of the misoprostol at the Central Medical Stores (CMS) prior to distribution to the two counties. In preparing the misoprostol for dispensing, SIAPS assisted by placing three 200-microgram tablets in sealed plastic bags along with the appropriate label on the pack.
By liaising with the Reproductive Health Department and CMS, SIAPS helped develop a distribution plan to the two counties and their respective providers. Necessary job aids have been created for these providers, such as how to store the misoprostol correctly and pictorial instructions for women that outline how to store and take misoprostol, precautionary instructions on when to take, and what to do in case of side effects.
To strengthen pharmaceutical management information system in the two counties and avoid creating a parallel supply system, SIAPS adapted existing inventory management tools, such as stock cards, medicine dispensing register, and monthly report/requisition vouchers for use in capturing and reporting consumption data from the facility level. To simplify record keeping for HHPs, SIAPS advocated with MCHIP to ensure that the log that captures clinical data, also captures data on drug consumption and adverse drug reactions. For clarity of roles and better coordination, SIAPS further developed and shared with partners a roles and responsibility matrix for pharmaceutical functions in the start-up program.
Progress to Date
About 20,000 tablets of misoprostol were received in August 2012 of which 1,720 tablets have been distributed to four health facilities within South Sudan and 35 HHPs in Mundri East, while a slightly higher quantity was sent to Mvolo county. SIAPS has conducted supportive supervision and on-the-job training on pharmaceutical management aspects of the start-up program in both counties.
The delivery of the first doses of misoprostol was timed to coincide with commencement of the HHP training program by MCHIP to ensure the HHPs go home equipped with the knowledge, skills, and supplies necessary to begin saving maternal lives. Alice Nyalia from Mvolo became the first woman to receive misoprostol on August 25, 2012.
Staff from Save the Children and SIAPS received a phone call from the HHP about Alice’s delivery and rushed to her home to check on her. They found her warming herself and the baby with hot coal as done traditionally. She was pleased to report that she took the three tablets with a glass of water; the only side effects were a short period of feeling cold and minor bleeding.
SIAPS will continue to connect with MCHIP and county health departments and partners on the ground to monitor misoprostol stock status and ensure timely replenishment. More providers will be trained during subsequent supportive supervisions, during which pharmaceutical management practices will be monitored and corrective action instituted with support from implementing partners on the ground.