Programmatic learnings on advance community-based distribution of misoprostol for prevention of postpartum hemorrhage: experience of Aweil East County, South Sudan

Abstract For mothers in contexts where institutional delivery rates remain significantly low, community-based advance distribution of misoprostol may be a critical intervention for preventing postpartum hemorrhage and subsequent mortality. The International Rescue Committee (IRC) piloted community-based advance distribution of misoprostol as part of a Community-Based Maternal and Newborn Care model in rural South Sudan. This paper synthesizes programmatic learnings on said distribution, taken from data from a parent implementation research study. Intervention coherence around misoprostol was strong, with most women understanding its purpose. The population level coverage of misoprostol was about 69%, with almost all women self-reporting use. However, 29% of women who received misoprostol self-reported taking it at the incorrect timing by consuming the medication after the placenta was delivered. While demand-side respondents rarely raised concerns about misuse for abortion, community health workers voiced significant anxiety about being blamed for any misuse and higher-level government and county stakeholders expressed distrust of community-level distribution, citing literacy concerns and abortion-misuse risks despite the lack of documented cases. Finally, the lack of availability of properly packaged doses of the medication via supply chain posed operational challenges. Community-based advance distribution of misoprostol shows promise for scale in South Sudan, but with more investment needed in increasing effective coverage, destigmatizing the medication, and global-level revisitation of supply packaging. As more global-level attention is spent on facility-based investments for prevention and treatment of postpartum hemorrhage, mothers in contexts where universal health coverage are far off in the future must not be left behind in implementing lifesaving interventions.