Saving the Pair: Integrated Scale-up of Chlorhexidine and Misoprostol for Newborns and Mothers in Rural Madagascar

Session: Critical Elements for Successful Introduction and Scale of Chlorhexidine for Umbilical Cord Care

Presenter: Echah Mady, John Snow, Inc.
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Background: The most recent Demographic Health Survey (2008/9) showed a neonatal mortality rate (NMR) of 24/1000 live births and a maternal mortality ratio (MMR) of 498 per 100,000 live births. Only 44% of births had a skilled birth attendant; 35% occurred in a health facility.

Methods: Using lessons learned from a study tour to Nepal to observe the JSI/Chlorhexidine Navi Care Program in 2012, the MOH-led Technical Working Group (TWG) initiated a pilot program for CHX use for umbilical cord care for home and facility births in 1 district, Mahabo, in 2013. Partners (PSI, USAID/MCHIP, JSI/MAHEFA) provided technical support for all aspects of program design and implementation.

Results: Based on early results showing good acceptance, the TWG decided to expand the intervention to a second district, Vohemar, in 2014. Considering the high MMR, a new component was added- the use of misoprostol for home births to prevent postpartum hemorrhage – utilizing the same program platform. Monthly follow-up visits and postpartum questionnaires assessed usage and acceptability. CHX was administered appropriately to 83% of newborns and 98% of women who received misoprostol took it appropriately after birth, before the placenta was expelled. Both misoprostol and CHX were used appropriately by 77% of mother-newborn pairs. The MOH and partners are committed to progressively scale-up the combined package for home births, increasing program coverage annually for 18% of women and 16% of newborns to reach 90% by 2019.

Conclusion: In settings with high neonatal and maternal mortality, with a high percentage of home births and a functional community-based health worker network, CHX and misoprostol can be introduced together, utilizing the same service platform and existing MOH systems, to accelerate reduction of neonatal and maternal deaths.