Implementing at-scale, community-based distribution of misoprostol tablets to mothers in the third stage of labor for the prevention of postpartum haemorrhage in Sokoto State, Nigeria: Early results and lessons learned.

BACKGROUND: Postpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale. METHODS: A community-based system for the distribution of misoprostol tablets (in 600ug) and chlorhexidine digluconate gel 7.1% to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013, with the potential to reach an estimated 190,467 annual births. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers' conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths. RESULTS: Misoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014. Between April and December 2013, 33 women (< 1%) reported that heavy bleeding persisted after misoprostol use and were promptly referred. There were a total of 11 deaths in the 2013 cohort which were confirmed as maternal deaths by verbal autopsies. Between January and December of 2014, a total 434 women (1.25%) that ingested misoprostol reported associated side effects. CONCLUSION: It is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State's at-scale program implementation, to assure every mother's right to uterotonics, can inform scale-up elsewhere in Nigeria.

Monitoring maternal, newborn, and child health interventions using lot quality assurance sampling in Sokoto State of northern Nigeria.

BACKGROUND: Maternal mortality ratio and infant mortality rate are as high as 1,576 per 100,000 live births and 78 per 1,000 live births, respectively, in Nigeria's northwestern region, where Sokoto State is located. Using applicable monitoring indicators for tracking progress in the UN/WHO framework on continuum of maternal, newborn, and child health care, this study evaluated the progress of Sokoto toward achieving the Millennium Development Goals (MDGs) 4 and 5 by December 2015. The changes in outcomes in 2012-2013 associated with maternal and child health interventions were assessed. DESIGN: We used baseline and follow-up lot quality assurance sampling (LQAS) data obtained in 2012 and 2013, respectively. In each of the surveys, data were obtained from 437 households sampled from 19 LQAS locations in each of the 23 local government areas (LGAs). The composite state-level coverage estimates of the respective indicators were aggregated from estimated LGA coverage estimates. RESULTS: None of the nine indicators associated with the continuum of maternal, neonatal, and child care satisfied the recommended 90% coverage target for achieving MDGs 4 and 5. Similarly, the average state coverage estimates were lower than national coverage estimates. Marginal improvements in coverage were obtained in the demand for family planning satisfied, antenatal care visits, postnatal care for mothers, and exclusive breast-feeding. Antibiotic treatment for acute pneumonia increased significantly by 12.8 percentage points. The majority of the LGAs were classifiable as low-performing, high-priority areas for intensified program intervention. CONCLUSIONS: Despite the limited time left in the countdown to December 2015, Sokoto State, Nigeria, is not on track to achieving the MDG 90% coverage of indicators tied to the continuum of maternal and child care, to reduce maternal and childhood mortality by a third by 2015. Targeted health system investments at the primary care level remain a priority, for intensive program scale-up to accelerate impact.

A Report of At-Scale Distribution of Chlorhexidine Digluconate 7.1% Gel for Newborn Cord Care to 36,404 Newborns in Sokoto State, Nigeria: Initial Lessons Learned.

BACKGROUND: With an annual estimated 276,000 neonatal deaths, Nigeria has the second highest of any country in the world. Global progress in accelerating neonatal deaths is hinged to scaled-up interventions in Nigeria. We used routine data of chlorhexidine digluconate 7.1% gel utilized by 36,404 newborns delivered by 36,370 mothers, to study lessons associated with at-scale distribution in Sokoto State, North West Nigeria. METHODS AND FINDINGS: Under state government leadership, a community-based distribution system overseen by 244 ward development committees and over 3,440 community-based health volunteers and community drug keepers, was activated to deliver two locally stored medicines to women when labor commenced. Newborns and their mothers were tracked through 28 days and 42 days respectively, including verbal autopsy results. 36,404 or 26.3% of expected newborns received the gel from April 2013 to December 2013 throughout all 244 wards in the State. 99.97% of newborns survived past 28 days. There were 124 pre-verified neonatal deaths reported. Upon verification using verbal autopsy procedures, 76 deaths were stillborn and 48 were previously live births. Among the previous 48 live births, the main causes of death were sepsis (40%), asphyxia (29%) and prematurity (8%). Underuse of logistics management information by government in procurement decisions and not accounting for differences in LGA population sizes during commodity distribution, severely limited program scalability. CONCLUSIONS: Enhancements in the predictable availability and supply of chlorhexidine digluconate 7.1% gel to communities through better, evidence-based logistics management by the state public sector will most likely dramatically increase program scalability. Infections as a cause of mortality in babies delivered in home settings may be much higher than previously conceived. In tandem with high prevalence of stillborn deaths, delivery, interventions designed to increase mothers' timely and regular use of quality antenatal care, and increased facility-based based delivery, need urgent attention. We call for accelerated investments in community health volunteer programs and the requisite community measurement systems to better track coverage. We also advocate for the development, refinement and use of routine community-based verbal autopsies to track newborn and maternal survival.