The United Nations Sustainable Development Goals (SDGs) set an ambitious target of reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Perhaps this is achievable, but only if we take a practical approach that puts the power in women’s hands. Discussion about this practical approach will take soon take place at the first-ever Global Maternal Newborn Health Conference in Mexico City, October 18-21.
Though one such approach already exists: expand access to advance distribution of misoprostol for prevention of postpartum hemorrhage for women who give birth at home or in facilities without a cold chain for oxytocin, a uterotonic like misoprostol. Misoprostol is an inexpensive, heat-stable pill that, when taken immediately after delivery, can reduce the risk of postpartum hemorrhage by between 24 to 47%.[i],[ii],[iii] While many efforts to address maternal mortality are focused on the long term goals of increasing access to skilled birth attendants and encouraging facility delivery, more immediate solutions are needed. Misoprostol provides a safety net for women who, for whatever reason, end up giving birth without access to oxytocin, either at home or in a facility.
The difficulty that women often face accessing care became abundantly clear when, as a member of an evaluation team looking at interventions to reduce deaths from postpartum hemorrhage in Ethiopia, Ghana and Nigeria, I had the opportunity to speak with women in rural areas about their birth experiences. Many stated they could access basic antenatal care during their pregnancy, but most told us they were unable to access a facility, or even skilled delivery care, at the time of delivery – the uncertainty about the timing of labor, lack of access to a vehicle or petrol, poor road infrastructure and great distances to services made it virtually impossible. Even if they could have made it to a facility, some of the women said they did not want to go because they knew they would be treated poorly (a finding that, unfortunately, is not uncommon in many parts of the world).[iv]
But, these women were quick to recount the positive impact that misoprostol had had on reducing deaths from postpartum hemorrhage in their rural communities, providing them with a practical way to overcome the logistical challenges to obtaining good delivery care. In each community, the MacArthur Foundation funded a pilot project to test models for increasing access to misoprostol at the time of delivery. The most successful model gave misoprostol pills to women in advance of delivery, trusting them to be able to store the drugs appropriately and take them according to the instructions provided if they were unable to reach a facility to deliver their baby. Not only did this approach improve the safety of giving birth at home, but it also resulted in more women seeking delivery services at facilities. The success of this approach is echoed by studies conducted in South Asia and Africa that have shown that community-based distribution of misoprostol is feasible, acceptable to users, safe and effective.[v],[vi]
Unfortunately, our evaluation also found that politics and fear are preventing more widespread access to misoprostol, with some groups afraid that distributing misoprostol will discourage women from seeking services at facilities or afraid that the pills will be used for abortion or labor induction. Experience suggests this fear is not warranted; misoprostol is an important addition to providers’ clinical toolkit and it is also a drug women can safely and effectively take by themselves, in their homes, with little or no assistance from a health care provider. It is time to put misoprostol in women’s hands, so that they can use it when they need it, which is often at home.
Photo: “Ghana Visit March 2006” © 2006 IICD, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/
[i] Mobeen N, Durocher J, Zuberi N, et al. Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. BJOG. 2011;1 18(3): 353–61.
[ii] Derman RJ, Kodkany BS, Goudar SS, et al. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006; 368(9543): 1248–53.
[iii] Prata N, Ejembi C, Fraser A, et al. Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria. Soc Sci Med. 2012; 74(8): 1288–96.
[iv] Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. (2015) The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med 12(6): e1001847.
[v] Prata N, Passano P, Bell S, et al. New hope: community-based misoprostol use to prevent postpartum hemorrhage. Health Policy Plan 2013; 28(4): 339–46.
[vi] Prata N, Bell S, Weidert K. Prevention of postpartum hemorrhage in low-resource settings: current perspectives. Int J Womens Health. 2013; 5: 737–52.