Misoprostol – Saving Mothers’ Lives with a Simple Intervention
I am writing this from Nepal, where I have spent 4-8 weeks every spring for the past four years working with One Heart World-wide (OHWW), a small non-governmental organization (NGO) whose mission is to save lives of mothers and babies in places where the death rates are way too high. In the country of Nepal as a whole, the past ten years or so have seen encouraging improvement in these statistics (and the lives of the women and babies that statistics represent), but in the most remote rural and mountainous areas, inaccessible except by walking for days, births occur at home, unattended by a trained nurse or doctor. In these areas, the mortality rates are still way too high. The training of village nurses as skilled birth attendants (SBAs), the building of simple one-room birth centers with necessary supplies and equipment, and the recruitment and training of female community health volunteers (FCHV) are strategies that are hoped to improve outcomes for these women, but the improvements are slow in coming.
In the meantime, a simple but exciting intervention that can easily be implemented in these remote areas may make a significant difference in the short term. Misoprostol is a drug initially developed to prevent gastric ulcers caused by non-steroidal anti-inflammatory drugs; however it was soon recognized that the drug also has powerful uterotonic properties (causing the uterine muscle to contract, closing the blood vessels in the uterine wall and preventing bleeding). It has been used extensively in obstetrics in developed countries to control postpartum hemorrhage and to induce labor. In developing countries as well, in a birth center or a hospital, a trained provider can give oxytocin, the most effective and preferred uterotonic drug. However, oxytocin requires refrigeration prior to use and must be injected – it cannot be used by an unskilled person. Misoprostol comes in a tablet form to be taken orally, does not require refrigeration, and can be used by a person with no special skills. It is cost-effective, stable, and has few and self-limited side effects or contraindications. In 2011, the World Health Organization added misoprostol for PPH prevention to its List of Essential Medicines, providing legitimacy and validating programs using it for PPH.
In Nepal, before the introduction of this program on a large scale, a pilot project was conducted in Banke District in 2005. The FCHVs there already used a “birth preparedness package” with pregnant women, counseling them on the importance of healthy practices such as eating nutritious foods, avoiding smoking and alcohol, attending four antenatal visits, taking iron and folate supplements and getting a tetanus shot, and avoiding heavy work. During the pilot, misoprostol was added as just another step in achieving a good outcome. The counselors told women how and when to use the drug, and also stressed that coming to the birth center for an attended delivery, if possible, was even better – if there were complications during the birth, the SBA would be able to help with them. The pills were packaged In the correct dose and labeled as “mother’s safety pills – it saves the mother,” to assure that they would be used for the intended purpose and at the right time. Rigorous monitoring and documentation showed that pregnant women who were given misoprostol in the eighth month of pregnancy used the drug appropriately, taking it just after delivery of the baby; that they were not using it for abortion, a chief concern among early critics; and that the program actually increased the number of women who came to the birth centers for delivery, rather than decreasing it, addressing another chief concern of critics.
In 2010, the Banke model was replicated in four mountain districts, and the following year to 20 additional districts, with support from many international organizations including USAID, UNICEF, and Care.
Misoprostol has been a success story in Nepal and elsewhere. PPH has declined in rural areas; it is no longer the main cause of maternal mortality, but has been replaced by preeclampsia/eclampsia. Misoprostol is now registered in more than 30 countries for the indication of PPH, and accepted for off-label indications in others. In 2011 the World Health Organization added misoprostol for the prevention of PPH to its List of Essential Medicines.
References
Grenier L, Smith J, Currie S, Suhowatsky S. Advance Distribution of Misoprostol for Self- Administration: Expanding Coverage for the Prevention of Postpartum Hemorrhage: Program Implementation Guide Revised, November 2013; USAID, MCHIP.
Misoprostol for Postpartum Hemorrhage: Reaching Women Wherever They Give Birth. Stories of Success in Bangladesh, Nepal, Zambia. Family Care International, 2012.