A Model for the Distribution of Misoprostol

  • How are we going to get the misoprostol (drug) to those who need it most?
  • How do we keep track of a drug in a low-resource and rural area?
  • How do we involve the community to ensure the model is sustainable long-term?

Overview

Framework

Project Objective

*Thus far, our interactions with the Ministry of Health in Jigawa have indicated a preference for selling only through the primary health care centers. Until we receive a definitive response, we plan to test the success rate of both and compare

About Postpartum Hemorrhage and Misoprostol

*Nigeria’s high fertility rate [source] indicates that women are more at risk of PPH given that previous pregnancies and unspaced pregnancies are both contributing factors to PPH. **Anemia affects nearly 50% of all Nigerian women [source]

Locational Analysis

Table of Metrics

Figures and Statistics

  • Deliveries by skilled birth attendants
  • Deaths of women relating to pregnancy
  • Causes of maternal death PPH
  • Causes of maternal death APH (antepartum hemorrhage: bleeding after 20–24 weeks of pregnancy) [Excluded from analysis as there is minimal relation with the intervention]
  • Number of total deliveries by TBAs (or % of total deliveries in state done by TBAs)
  • Existing PHC referral and transportation systems
  • The total number of primary healthcare centres (PHCs) and proprietary patent medical vendors (PPMVs) in each state
  • How often misoprostol is taken after birth
LGAs in Jigawa State by Highest MMR per 100,000 live births
  • Jahun has 300 communities which are among the highest facing maternal and neonatal health challenges in Jigawa State
  • Has more rural communities compared to Hadejia LGA
  • Jahun also has 300 focal persons who are also health workers known as Jakadar Lafiya
  • The number of TBAs is typically one per village (meaning 300 TBAs within Jahun)
  • There are between 40–50 primary health care workers in Jahun
  • 25% of women in the state given birth at facilities while 75% give birth at home
  • Voluntary Community Mobilizers (VCMs) are available in Jahun

Structure of Healthcare System

  1. Comprehensive Health Centres (CHCs) — to serve communities of <20,000 people
  2. Primary Health Centres (PHCs) — to serve 5,000 to 20,000 persons
  3. Health Clinics (HCs) — to serve 2,000 to 5,000 persons

Current State of the Healthcare System

The National Health Information System

Background on Health Information Systems

  1. HIS Resources: regulatory, legislative, and planning methodologies used to create a functioning HIS, some resources include personnel and information and communications technology (ICT)
  2. HIS Indicators: predetermined set of targets for health information, includes health system inputs, outputs, and outcomes (national status of health)
  3. Data Sources: three main sources (1) population-based data such as census or survey results and (2) institution-based data such as service records and (3) community-based organizations (CBOs) may provide research or health surveys
  4. Data Management: encompasses collection storage, transmission and analysis of data, guidelines for timeliness and frequency of actions are predetermined
  5. Information Products: converting the data into a more useable form
  6. Information Use: the dissemination of health information, making it accessible to decision-makers in healthcare

The Nigerian HIS Review

Stakeholders in the Nigerian Health Information System

Operational Considerations

User Experience Challenges

Technical Obstacles

Stakeholders

Roles and Responsibilities

Pilot Study

  1. The pilot is not feasible
  2. The pilot is feasible if changes are made*
  3. The pilot is feasible without any necessary changes
  4. The pilot is feasible with enhanced and close monitoring

Government Survey

  1. Medium: What software is being used?
  2. Accuracy: How often is it updated? Are there guidelines to ensure data completeness?
  3. Accessibility: Who currently has access to the HMIS? Are there certifications required/certain position to gain entry to the database?
  1. PHC Workers: What is the list of personnel at all PCHs within potential pilot LGAs? Are they familiar with/have received training on the use of technology for data collection?
  2. Rotary Schedule: How often are workers transferred between facilities on a rotary schedule? What does staff turnover look like? Are there existing procedures in place to mitigate internal brain drain?
  3. Gender Distribution: Of all CHWs (nurses, doctors, CHEWs) how many (%) are female?
  4. Salary: How often are different levels of health workers paid? How much are they paid? Are payments consistent? Over what period are they paid (bi-weekly, monthly, annually)?
  5. NPHCDA CHEW Curriculum: What is included in the curriculum? Who has access to it?
  1. Facility Protocols: Are there sanitation methods in place? What resources do facilities have access to (i.e., sanitizer, wipes) if any? Who supplies these resources?
  2. Informal Healthcare Protocols: Are there regulations in place for TBAs or midwives such as avoiding physical examinations pre-birth?

On-Ground Resource Review

  1. TBA Culture: How are TBAs viewed in the community? What is their social circle like? Do they have councils/TBA organizations?
  2. PPMV Knowledge and Experience: How often does NAPMED update its policies? Do PPMVs receive training? If so, how often? What does the training curriculum include? Have they worked on distribution interventions in the past?
  3. Internet Network Availability: What are the largest networks in each of the potential pilot LGAs? How much do they charge? Are they reliable?
  4. Electricity Access: Who has the most consistent access to electricity? What does electricity use look like in each of the potential pilot LGAs? Do/what percentage of health facilities have access to electricity? What do they currently use it for?

Focus Groups

TBA and CHEW Digital Literacy Focus Group

Familial Sentiments Towards PHCs and CHEWs Focus Group

Religious and Traditional Leaders Focus Group

Pilot Model

Overview of Pilot Structure

  1. To give mothers choice. For many women, this will be their first time participating in a health program run by an NGO, let alone a program dedicated to safe births. To ensure that they feel comfortable, we would like to give mothers options in how they can receive misoprostol, from whom, and to what extent they will receive formal care in addition to informal care (which is mandatory).
  2. To give the Ministry of Health leeway. In order for this model to remain sustainable long-term, the Ministry of Health must adopt the model and use it long-term in addition to integrating the updated training provided by EMM into the education system for healthcare. Providing multiple options that all lead to the same outcome, more mothers being saved, increases the chances of long-term integration.
  3. To identify the most optimal paths for long-term use. EMM aims to eventually save mothers in countries beyond Nigeria. Testing several options during the pilot will allow us to identify what works and what does not in rural and low-resource areas. It will provide invaluable data points about cultural acceptance, on-ground friction, and ease of understanding.

Pilot Model Option 1

Note: All pink boxes indicate the stakeholder involved, all orange boxes indicate the task being carried out by the stakeholder, and the dark green boxes indicate the data collection involved. The order in which these tasks happen can be read from left to right visually.
  1. DKT International: The distribution model begins with our misoprostol supplier, DKT International. Based on conversations that EMM has had with DKT and quotes we have received, DKT is willing to provide the initial transport of misoprostol to Nigeria. In this model, DKT will supply misoprostol to a few distribution centres. These distribution centres, which are on-ground, are all formal healthcare centres including Primary Healthcare Centres, Health Clinics, and Health Posts. The latter resembles a dispensary. See Phase 1 under the data collection outline for the monitoring that occurs at this step.
  2. CHEWs: Community Health Extension Workers are the next to become involved. Once EMM has ensured supply on-ground (which is step one) registration of women can begin. CHEWs will go door-to-door and register all married women. This includes those who are not currently pregnant. The high fertility rate in Nigeria would suggest that most married women give birth eventually, so by pre-registering those who may not yet be pregnant, EMM is more likely to involve more women and save more lives. This concept is known as projection bias and it explains how people are more likely to engage with a program when pre-enrolled because they are more likely to not opt-out than to opt-in. See Phase 2 under the data collection outline for the monitoring that occurs at this step.
  3. TBAs: Traditional Birth Attendants can now begin to gather a supply of misoprostol for administration now that women have registered for the intervention. Women who are registered by a CHEW will be referred to a TBA. Once a TBA meets the mother and collects her prescription (further explained in the data collection outline), she will travel to the nearest EMM registered health facility to retrieve misoprostol. The prescription will be used to grant the TBA access to misoprostol. To ensure that TBAs do not, however, run out of misoprostol in an emergency (e.g., a mother gives birth prematurely) she will maintain a minimum stock supply as well. Once collected, the TBA will store the misoprostol until the mother’s birth, after which she will administer it. See Phase 3 under the data collection outline for the monitoring that occurs at this step.
  1. Phase 1: Inbound Misoprostol this phase happens during the first part of the distribution model outline in the previous section.

Pilot Model Option 2

Note: All pink boxes indicate the stakeholder involved, all orange boxes indicate the task being carried out by the stakeholder, and the dark green boxes indicate the data collection involved. The order in which these tasks happen can be read from left to right visually. Additionally, the green box indicates the difference between this model version and model option one.
  1. DKT International: The distribution model begins with our misoprostol supplier, DKT International. This step is the same as was described for model one. See Phase 1 under the data collection outline for the monitoring that occurs at this step.
  2. CHEWs: Community Health Extension Workers are the next to become involved. This step is the same as was described for model one. See Phase 2 under the data collection outline for the monitoring that occurs at this step.
  3. TBAs: Traditional Birth Attendants can now begin to gather a supply of misoprostol for administration now that women have registered for the intervention. Women who are registered by a CHEW will be referred to a TBA. Once a TBA meets the mother and collects her prescription (further explained in data collection outline), she will travel to the nearest EMM registered health facility to retrieve misoprostol. The prescription will be used to grant the TBA access to misoprostol. To ensure that TBAs do not, however, run out of misoprostol in an emergency (e.g., a mother gives birth prematurely) she will maintain a minimum stock supply as well. Once collected, the TBA will store the misoprostol until the mother is seven months pregnant, at which time she will give the misoprostol to the mother for storage until her birth. The purpose of providing the mother with the misoprostol while she is pregnant is so that she does not have to rely on a TBA to show up to the birth on time to receive it and prevent post-partum hemorrhage from happening. However, the issue with this is that the chances of misuse are higher as misoprostol can be used for abortion if taken during pregnancy. To avoid this but still provide mothers with the option of safekeeping the misoprostol, a pricing incentive may be used. Should the mother opt to follow model one, she may receive the misoprostol at a discounted price because she will not have access to the drug until it is safe to use. If she chooses to follow this model and keep the drug ahead of time, she will pay a higher fee. See Phase 3 under the data collection outline for the monitoring that occurs at this step.
  1. Phase 1: Inbound Misoprostol this phase happens during the first part of the distribution model outline in the previous section. It is the same as described in model one.
  2. Phase 2: Registration and Prescription this phase happens during the second part of the distribution model outline in the previous section. It is the same as described in model one.
  3. Phase 3: Outbound Misoprostol this phase happens during the third part of the distribution model outline in the previous section.

Pilot Model Option 3

Note: All pink boxes indicate the stakeholder involved, all orange boxes indicate the task being carried out by the stakeholder, and the dark green boxes indicate the data collection involved. The order in which these tasks happen can be read from left to right visually. Additionally, the green box indicates the difference between this and model one.
  1. DKT International: The distribution model begins with our misoprostol supplier, DKT International. Based on conversations that EMM has had with DKT and quotes we have received, DKT is willing to provide the initial transport of misoprostol to Nigeria. In this model, DKT will supply misoprostol to a few distribution centres. These distribution centres, which are on-ground, are all formal healthcare centres including Primary Healthcare Centres, Health Clinics, and Health Posts. The latter resembles a dispensary. See Phase 1 under the data collection outline for the monitoring that occurs at this step.
  2. Mothers: Once EMM has ensured supply on-ground (which is step one) registration of women can begin. In this model, women have the option to visit an EMM health facility and register themselves (as opposed to waiting for CHEWs to visit and register them as in previous models). While Primary Healthcare Centres are quite sparse and rural areas, Health Clinics and Health Posts are abundant [source]. See Phase 2 under the data collection outline for the monitoring that occurs at this step.
  3. TBAs: Traditional Birth Attendants can now begin to gather a supply of misoprostol for administration now that women have registered for the intervention. Women who are registered at a health facility will be referred to a TBA. Once a TBA meets the mother and collects her prescription (further explained in data collection outline), she will travel to the nearest EMM registered health facility to retrieve misoprostol. The prescription will be used to grant the TBA access to misoprostol. To ensure that TBAs do not, however, run out of misoprostol in an emergency (e.g., a mother gives birth prematurely) she will maintain a minimum stock supply as well. Once collected, the TBA will store the misoprostol until the mother’s birth, after which she will administer it. See Phase 3 under the data collection outline for the monitoring that occurs at this step.
  1. Phase 1: Inbound Misoprostol this phase happens during the first part of the distribution model outline in the previous section. It is the same as described in model one.
  2. Phase 2: Registration and Prescription this phase happens during the second part of the distribution model outline in the previous section.

Post Birth Procedure

  1. Post-Birth Toll Number: In all versions of the model, a TBA assists a mother in delivering her child and administering the misoprostol. Once a TBA has finished caring for the mother and the newborn(s), she must dial a toll-number to notify a Data Collector. The Data Collector will likely be a trained collector from FAYOHI, EMM’s on-ground partner.
  2. Post-Birth Data Collection: This collector will have up to two weeks after the birth to collect the following data:

Summarized Advantages and Disadvantages

Pilot Forms

Post-Pilot

Monitoring and Analysis

Next Steps and Scalability

  • A Widely Applicable Training Curriculum and Best Practices
  • Guides for Finding Human Resources On-Ground
  • Collections of Detailed Procedures for Operating On-Ground
  • Suggested Connections to Key Stakeholders (i.e., a supplier)
  • Fundraising Resources (i.e., grants, scholarships to apply to)
  1. Delay in deciding to seek care
  2. Delay in reaching a treatment facility
  3. Delay in receiving adequate treatment at the facility
  1. Community Mobilization: Creating action groups with village men who transport pregnant women by hammock to the nearest road in hopes of getting her on a vehicle to a facility
  2. Local Transport Unions: Conduct sensitization workshops to help workers understand the significance of the issue and have them create an emergency fuel fund for drivers helping women reach facilities
  3. Local Drivers: Pay local drivers a predetermined fee to transport women in the case of an emergency

Data Protection Policy Compliance

  • Comply with Data Protection Policies
  • Protect data subject rights
  • Are open and transparent about how personal data is processed
  • Protect EMM from the risks of a data breach.

Registration and Consent Forms

  • Giving a data subject adequate information concerning the study
  • Providing adequate opportunities for the subject to consider all options
  • Responding to the subject’s questions
  • Ensuring that the subject has comprehended the information
  • Obtaining the subject’s voluntary agreement to participate
  • Continuing to provide information as the subject or situation requires.
  • Present the information to potential subjects on more than one occasion
  • Allow a period to elapse between imparting the information and requesting a signature on the consent form
  • Ensure that a subject understands the treatment and the risks and benefits involved
  • Ask open-ended and non-directive questions to assess subject comprehension
  • Retrieve the subject’s signature and date on the consent form once an agreement to participate in the study has been reached
  • Include the signature of an EMM member who has oriented the subject
  • Provide the subject with a copy of the consent form as a continual reference for items such as scheduling of procedures and emergency contact information
  • Provide a certified translation of the English consent form to consent non-English speaking subjects

Contact

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18 y/o innovator working towards impacting billions. A curious writer, learner and emerging tech enthusiast.

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Ruhani Walia

Ruhani Walia

18 y/o innovator working towards impacting billions. A curious writer, learner and emerging tech enthusiast.

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