The Sustainable Development Goals (SDGs) call for a reduction in global maternal mortality to fewer than 70 deaths per 100,000 live births by 2030. Achieving this target will require specific attention to postpartum hemorrhage (PPH), which is estimated to cause more than a quarter of maternal deaths worldwide. The burden of PPH is even higher in certain regions: In Eastern Asia and Northern Africa, more than 35% of maternal deaths are attributable to hemorrhage.
A relatively basic set of interventions can dramatically reduce the rates of PPH, including skilled care before, during and after childbirth, active management of the third stage of labor (AMTSL) and, in many cases, administration of uterotonics. The preferred uterotonic of choice is oxytocin, which is delivered to the mother by intravenous injection immediately following delivery. Where oxytocin is not available, storage conditions are inadequate or health workers are not trained to administer it safely, misoprostol is currently the best alternative. Unlike oxytocin, misoprostol tablets do not need to be refrigerated or administered with a syringe, which can make it a more viable option in low-resource settings.
In 2012, the International Federation of Obstetrics and Gynecology (FIGO) produced guidelines for the prevention and treatment of PPH with misoprostol along with a chart detailing recommended dosages of misoprostol when used alone for a variety of gynecologic and obstetric indications. In June 2017, FIGO released an updated chart informed by recent scientific evidence and developed through consultation with maternal health experts.
The chart, divided into stages of pregnancy, outlines recommendations for dosages and routes of administration for misoprostol use for several indications including medically induced abortion, clinical management of miscarriage, cervical preparation for surgical abortion, fetal death, induction of labor and management of PPH. The chart has been endorsed by the FIGO Prevention of Unsafe Abortion Working Group and the FIGO Safe Motherhood and Newborn Health Committee.
Some of the changes to this updated version include the addition of alternative routes for misoprostol administration and the introduction of secondary prevention of PPH. A group of experts agreed that secondary prevention of PPH is a strong, alternative approach to universal prophylaxis because it involves medicating far fewer women (only 5-10%), thus risking fewer adverse effects and substantially reducing costs.
While the development of the dosage chart and its dissemination are critical steps in reducing the global burden of PPH, further work is needed to ensure that misoprostol is included in national essential medicine lists, high quality misoprostol is available—particularly in low-resource settings—and that health workers are trained to administer it safely.
For more information, please contact Samia Khatun.
Access different versions of the new FIGO misoprostol charts in English, Spanish, French and Portuguese.
Learn more about the updated FIGO guidelines.
Access resources related to the maternal mortality targets under the SDGs.