Barriers to Misoprostol Use in Developing Countries

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By: Sarah Hodin, MPH, CD(DONA), LCCE, National Senior Manager of Maternal Newborn Health Programs, Steward Health Care

Where oxytocin is not readily available for post-abortion care (PAC) and postpartum hemorrhage (PPH) prevention, misoprostol is the recommended alternative. Nevertheless, many countries have not been able to ensure access to safe misoprostol use to prevent maternal deaths.

A recent systematic review by Amir Ali Barket Ali Samnani, Narjis Rizvi, Tazeen Saeed Ali and Farina Abrejo published in Reproductive Health identified barriers to misoprostol use for PAC and PPH prevention in developing countries. The authors analyzed nineteen studies conducted in Eastern and Southern Asia and sub-Saharan Africa that outlined challenges for programs and policies that support the administration of misoprostol for these indications.

Barriers to successful implementation

Leadership, governance and policies

  • Lack of national policies or registration of misoprostol for the management of PAC or PPH
  • Fear and confusion among implementers, policymakers and government officials
    • No awareness about existing policy
    • Technical inconsistencies in guidelines and protocols
  • Inadequate integration of misoprostol in basic health service packages
  • Suboptimal road infrastructure and communication systems

Health service delivery

  • Fragmented supply and distribution chain for essential medicines
  • PAC services not available
  • Poor supervision or monitoring capacity
  • Lack of access to misoprostol
  • Provider’s preference is not misoprostol

Health workforce

  • Shortages of skilled birth attendants, traditional birth attendants and community health workers
  • Fear and confusion among providers related to potential misuse
  • Belief that misoprostol will increase home birth rates and discourage facility-based delivery
  • Lack of knowledge and skills among providers due to inadequate training
  • Limited scope of midwifery practice
  • Poor inter-professional collaboration and communication

Community perception, knowledge and preference

  • Stigma surrounding misoprostol due to its abortion-inducing properties
  • Socioeconomic, ethnic and cultural barriers to access
  • Lack of community awareness of and knowledge about misoprostol
  • Inequitable distribution or geographic disparities in utilization

Health information system

  • Absence of national reporting system on uterotonics
  • Gaps in inclusion of important national-level maternal health indicators

Cost of medicine

  • Paying for medicine hindering efforts to increase coverage
  • Financial constraints to training traditional birth attendants

Recommendations for improvement

The authors concluded the paper with policy and practice recommendations for countries, facilities, providers and communities such as establishing supportive policies that reflect international standards; strengthening health monitoring and reporting systems; training health care workers to administer misoprostol safely and effectively; designing supply plans to ensure reliable availability of misoprostol; and developing educational materials for community members about appropriate misoprostol use. These efforts represent a critical step towards ending preventable maternal mortality.

Read the full open access paper.

Learn about the new guidelines for misoprostol use from the International Federation for Gynecology and Obstetrics.

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