For laboring mothers in Bangladesh, the generic medicine, misoprostol, can mean the difference between a happy, healthy delivery and one marred by fear, or worse, life-threatening blood loss. When we think of pregnant women having access to essential maternal health supplies such as misoprostol tablets, rarely do we think of a journey that involves planes, boats, rickshaws and feet. But that’s exactly how a single box of misoprostol tablets journeyed from the capital of Bangladesh, Dhaka, to women in rural Moheshkhali upazilla (district) in Cox’s Bazar.
After a one-hour flight out of Dhaka, six colleagues from VSI and EngenderHealth and one box of 15,000 misoprostol tablets arrived in Cox’s Bazar. Like us, the tablets were bound for Moheshkhali, a small and remote island sub-district off the coast.
1. Ferry Area: How do the tablets get to the boats?
2. Boardwalk: Thousands of people have walked this boardwalk on their way to boats that will take them to Moheshkhali.
The island is cut off from the rest of the country several months of the year during the rainy season. Wooden boats are the only means of crossing the waters between the island and the mainland. If the island does not have an adequate supply of these tablets before the waters become too treacherous, pregnant women will not have access to these life-saving tablets for months on end.
3. Boats: Typical wooden boats that make the round-trip journey between the mainland and Moheshkhali.
One man is responsible for delivering misoprostol to a monthly meeting of Family Welfare Assistants (FWAs) who will then distribute the tablets to pregnant women in their geographical jurisdiction.
4. On the way to Moheshkhali: With precious cargo in hand, the porter opts for a speedboat. By using a speedboat, he cuts the transit time by about 30 minutes. But the cost is beyond the reach of most residents of this area.
5. The journey continues: Upon arrival on the island, scores of rickshaw drivers vie for business. For a nominal fee, they will take you to your destination, or until roads give out
6. Family Welfare Assistants’ monthly meeting: FWAs gather on a monthly basis where, among other things, they receive supplies of misoprostol.
7. Beyond the reach of rickshaws: When the roads can no longer accommodate a rickshaw, FWAs often travel on foot to visit pregnant women.
8. Soon-to-be-miso-moms: The misoprostol tablets will eventually reach these women for prevention of postpartum hemorrhage for those women who cannot reach a facility to deliver, and instead give birth at home.
9. Moharam and baby Samjeeda: Another satisfied customer!
As the Government of Bangladesh embarks upon the laudable goal of expanding community distribution of misoprostol beyond a few pilot districts, they will need to confront the real challenge of getting tablets from point A to point B. Bangladesh’s geography serves only to complicate matters. Prolonged periods of intense rainfall usher in flooded and washed out roads, communities are cut off from each other, and islands such as Moheshkhali are left isolated.
Consider the journey misoprostol tablets must travel if they are to be available to the women who need them most. Delivery of essential maternal health supplies is one of the formidable challenges still confronting public health programming and will need to remain a focus if we are to achieve our shared goal of saving mothers’ and newborns’ lives.