The number one cause of maternal deaths in childbirth is postpartum hemorrhage, or excessive bleeding. Women in Africa and Asia suffer the most. Many mothers in these regions give birth at home or in facilities that lack refrigeration, so they can’t access oxytocin, the drug traditionally used to stop this kind of heavy bleeding.
Another drug can save these mothers, though: It is easier to store and administer, costs less than a dollar a dose and has been proven to be 90 percent effective. People in the health community have called misoprostol a “magic drug” for stopping postpartum hemorrhage – but it is also a controversial one.
Misoprostol can be combined with mifepristone or used alone to perform a nonsurgical abortion that terminates an early pregnancy. The drug’s connection to this procedure means government officials in some countries in Africa, Asia and other parts of the world are reluctant to consider it as an alternative to the more established treatment for postpartum hemorrhage. That means this life-saving drug isn’t available in parts of Asia and South America and most of Africa – places where it’s needed most.
Every year, 8 million women develop postpartum hemorrhage, which can lead to severe anemia or shock, require a blood transfusion or hysterectomy or result in death. Oxytocin is the gold standard for treatment, but it needs to be refrigerated and requires a skilled attendant to inject it with sterile equipment.
In places where oxytocin is unavailable or there are no skilled birth attendants to administer it, the World Health Organization (WHO) recommends giving a misoprostol tablet to all women immediately after they give birth to prevent postpartum hemorrhage. It can be administered orally or as a suppository, meaning health workers don’t need special training or sterile instruments to give it to patients, and it doesn’t need to be refrigerated. For those reasons – plus the drug’s low cost and high effectiveness – the WHO put misoprostol on its Model List of Essential Medicines, a list of minimum medicine needs for a basic healthcare system. It is also second on the U.N. Commission on Life-Saving Commodities for Women and Children‘s list of overlooked products that could help save more than 6 million women and children.
Misoprostol is saving lives in places where it has been embraced. In Nigeria, Africa’s most populous country with more than 180 million people, 65 percent of women deliver at home and maternal mortality rates are high at 814 per 100,000 live births.
Two of the country’s northern states, Sokoto and Bauchi, took part in pilot initiatives by the U.S. Agency for International Development/Targeted States High Impact Project (USAID/TSHIP) between 2009 and 2015 to increase the use of life-saving family planning and reproductive health interventions. While it was already known how effective misoprostol is at stopping postpartum hemorrhage, the pilot project wanted to determine how best to introduce the drug so it would be accepted by healthcare officials and community alike.
The key, according to Nosa Orobaton, former USAID/TSHIP chief of party, was early stakeholder engagement, building support for misoprostol among local leadership and distributing the drug through a community-based system, an approach he describes as “transformative” in getting people comfortable using the drug.
“This is a critical obligation we have – as donors, government officials or international development practitioners – to use community-based delivery systems that are durable and sustainable,” Orobaton says.
A qualitative study among misoprostol users, their spouses and members of the drug-distribution system found widespread acceptance of the drug. As a result, in 2013, the Sokoto state’s ministry of health added misoprostol to its procurement list for all health facilities providing maternity services.
Nepal, too, couldn’t ignore the drug’s benefits. Injectable oxytocin is the preferred treatment for postpartum hemorrhage, but in 2010, after a five-year pilot phase, the government endorsed misoprostol for a national program. Between 1990 and 2015, the country reduced maternal mortality by 71 percent, a drop that experts attribute in part to the use of misoprostol during home deliveries or en route to a health facility, according to the WHO.
“The proportion of maternal deaths attributable to postpartum hemorrhage went down by more than half between 1998 and 2008, from 46 to 19 percent,” says Leela Khanal, project director for JSI Research and Training Institute, Inc., which implemented the program in Nepal. “This was during a period when we were scaling up the use of misoprostol from a pilot project in one district to 39.”
Governments preventing women around the world from accessing a drug that could easily and inexpensively save their lives is unacceptable to Orobaton. “Good governance – that determines to what extent the right decisions and interventions are being supported,” he says. “There should be zero tolerance for women dying in childbirth.”