title: 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.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Nosakhare
authors.initials: N
authors.lastname: Orobaton
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Jumare
authors.initials: J
authors.lastname: Abdulazeez
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Dele
authors.initials: D
authors.lastname: Abegunde
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Kamil
authors.initials: K
authors.lastname: Shoretire
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Abubakar
authors.initials: A
authors.lastname: Maishanu
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.
authors.forename: Nnenna
authors.initials: N
authors.lastname: Ikoro
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Bolaji
authors.initials: B
authors.lastname: Fapohunda
authors.affiliation: Department of Family Health, Federal Ministry of Health, Abuja, Nigeria.
authors.forename: Wapada
authors.initials: W
authors.lastname: Balami
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.
authors.forename: Katherine
authors.initials: K
authors.lastname: Beal
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Akeem
authors.initials: A
authors.lastname: Ganiyu
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Ringpon
authors.initials: R
authors.lastname: Gwamzhi
authors.affiliation: JSI Research &Training Institute, Inc., Boston, Massachusetts, United States of America.|USAID/Targeted States High Impact Project (TSHIP), Sokoto, Nigeria.
authors.forename: Anne
authors.initials: A
authors.lastname: Austin
mesh_terms: D000328:Adult; D003695:Delivery of Health Care; D005260:Female; D006700:Home Childbirth; D006801:Humans; D007743:Labor, Obstetric / Q000187:drug effects; D008428:Maternal Mortality; D008880:Midwifery; D016595:Misoprostol / Q000627:therapeutic use*; D009035:Mothers; D009549:Nigeria; D006473:Postpartum Hemorrhage / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology
chemical_list: D016595:Misoprostol