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Misoprostol for Postpartum Hemmorhage (PPH)

Post-partum hemorrhage (PPH), or excessive bleeding after childbirth, is a leading cause of maternal mortality. Misoprostol is a uterotonic that is used to manage the third stage of labor and prevent postpartum hemorrhage. While other uterotonic drugs require refrigeration and injection by a trained provider, misoprostol is inexpensive, stable at room temperature and is in tablet form, making it well suited to use in low income settings and at lower levels of healthcare systems.

Unit of interventionper tablet

Number of tablets per dosethree tablets

Formulation200 mcg of prostaglandin per tablet

Target populationWomen, immediately after a vaginal delivery

For more information about how PSI is increasing access to misoprostol to improve health and save lives, visit our website at:
http://www.psi.org/program/post-partum-hemorrhage-prevention/

Model Overview

PSI’s misoprostol for PPH impact model is based on the Lives Saved Tool (LiST). LiST is used to estimate the number of deaths averted with complete coverage of misoprostol in select countries, representing the projected impact of misoprostol. This number of deaths averted at the population level is translated to deaths averted per misoprostol tablet, using country specific parameters such as population size and number of tablets needed per dose. Once we have deaths averted per misoprostol tablet, we apply data from the 2010 Global Burden of Disease study to estimate the corresponding number of DALYs averted.

Model Outputs (impact metrics)

Estimates of DALYs averted, deaths averted, CYPs provided, and unintended pregnancies averted represent the projected health impact of the intervention. It is projected because it has not been directly measured.

Examples based on distribution of misoprostol tablets in Myanmar in 2015 Statement of modeled results, examples:

In 2015, an estimated 3 deaths and 187 DALYs would be averted from postpartum hemorrhage if 100,000 misoprostol pills were distributed in Myanmar.

For more details about how PSI models misoprostol impact for postpartum hemorrhage, see below.

Model Details

Step 1: Running a projection in the Lives Saved Tool (LiST)LiST is a multi-cause mortality model developed by Johns Hopkins Bloomberg School of Public Health that estimates the number of deaths averted (or lives saved) through the scale up of maternal and child health interventions.

PSI begins by running a projection in LiST for select countries. We use “Active management of the third stage of labor (AMTSL)” in LiST as a proxy for misoprostol for PPH, changing the effectiveness from 0.27 to 0.24 for unassisted and assisted home deliveries, as well as births facilities with essential care available. In this projection, AMTSL is increased from the current, country-specific baseline to 100%. LiST then projects the number of deaths averted among pregnant women by this increased level of coverage.

Step 1 Output:
Number of additional deaths averted (or lives saved) among pregnant women if coverage of misoprostol increased from baseline to 100% in select countries

Step 2: Estimating deaths averted per misoprostol tablet among pregnant women PSI uses the step 1 output (deaths averted at 100% coverage of misoprostol) to estimate the number of deaths averted by a single misoprostol tablet. To do this, we divide the number of deaths averted at 100% coverage by the number of misoprostol tablets needed to reach 100% coverage among pregnant women.

PSI estimates the number of misoprostol tablets needed to reach 100% coverage using a number of parameters, including baseline coverage of misoprostol and number of tablets needed per dose. We also account for wastage of misoprostol in the supply chain, assumed to be 10% across all interventions.

Step 2 Output:
Deaths averted coefficient for misoprostol

Step 3: Estimating DALYs averted per misoprostol tablet among pregnant women A DALY (or disability adjusted life year) includes two components: years of life lost due to premature death (YLL) and years lived with disability (YLD). DALYs averted are in turn comprised of YLLs averted and YLDs averted or, put simply: death and disability that is prevented by PSI interventions.

To estimate YLLs averted per misoprostol tablet among pregnant women, PSI first estimates the number of years of life lost per death among pregnant women due to postpartum hemorrhage. This is equal to the life expectancy at the average age of death from postpartum hemorrhage. Age specific life expectancies are taken from the 2010 Global Burden of Disease study (GBD 2010). The number of years of life lost per postpartum hemorrhage death is then multiplied by the number of deaths averted per misoprostol tablet among pregnant women (deaths averted coefficient), calculated in step 2 above for a selected country. This gives us the YLLs averted per misoprostol tablet.

To estimate YLDs averted per misoprostol tablet among pregnant women, we use a YLD/YLL ratio, based on the 2010 GBD. This ratio represents the relative number of years lived with disability for every year lost due to death from postpartum hemorrhage. We apply this ratio to the number of YLLs averted per misoprostol tablet to estimate the number of YLDs averted per misoprostol tablet among pregnant women.

Finally, YLLs averted and YLDs averted are added together to estimate the number of DALYs averted per misoprostol tablet among pregnant women.

Step 3 Output:
DALYs averted coefficient for misoprostol