What about an ounce of cure…? Treating PPH with misoprostol in low-resource settings
by Beverly Winikoff and Ann M. Starrs
Beverly Winikoff and Ann Starrs are the presidents of, respectively, Gynuity Health Projects and Family Care International. This commentary is cross-posted from the MHTF Blog, the blog of the Maternal Health Task Force.
While support for the use of misoprostol to prevent postpartum hemorrhage (PPH) has been growing steadily, governments, donors, and implementing agencies have not given equal emphasis to treating PPH when it does occur. Indeed, the response to PPH — the single leading cause of maternal mortality — has been vigorous, but incomplete. In a series of regional surveys conducted in 2011 and 2012, organizations were asked to describe their programs and activities involving misoprostol for PPH: a broad range of prevention projects was reported. Yet, despite substantial published evidence of the potential for misoprostol use in PPH treatment, not one agency indicated current or planned work focused on use of misoprostol for treating PPH.
Health ministries, implementing agencies, and donors have recognized that addressing PPH could reduce the number of maternal deaths in the highest-burden countries. Indeed, they have developed and promoted strategies for preventing PPH by actively managing the third stage of labor where skilled staff and appropriate medications (uterotonics such as oxytocin and misoprostol) are available. Yet in low-income countries, well-equipped, professionally-staffed health facilities are not accessible to many – sometimes most – women, who still give birth without a skilled attendant, mainly at home. A number of countries in Africa and Asia, including Bangladesh, Nepal, and Zambia, have developed pilot projects to distribute misoprostol for use at home deliveries, as an interim approach for reaching women who lack access to skilled care. Nepal and other countries are scaling up these programs, seeking to ensure that every woman, regardless of where she gives birth, receives a uterotonic to prevent PPH.
While active management and administration of uterotonics can reduce blood loss and prevent many cases of PPH, at least 10% of women who receive preventive care will still experience significant post-partum blood loss that may require additional medical interventions. The lack of concerted attention and support for treatment of PPH at the community level will mean that even women who receive prophylaxis with a uterotonic may be at risk of dying from excessive blood loss. And, at least in the short term, many women are still unlikely to receive uterotonics for preventive care; for these women, the availability of effective treatment options for PPH can be critically important. For a woman who hemorrhages at home or in another setting where lack of refrigeration or skilled staff makes use of IV oxytocin (the gold standard for PPH treatment) not feasible, access to treatment with misoprostol, which has few contraindications or side effects, could mean the difference between life and death.
Community-based PPH prevention programs using misoprostol could provide the platform on which to build an approach for treatment of hemorrhage. In remote and rural areas, where transfer to a higher level of care may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
In many countries, making this happen will require that governments reconsider policies that require administration of medications be carried out only by physicians. These policies are generally promulgated with the argument that lower-level health personnel do not have the expertise to know when to initiate treatment. However, these same personnel are often entrusted with the decision to refer women for treatment, a judgment that requires the same level of discrimination. Because providing treatment would be easy with a pre-packaged dose of misoprostol, it seems both feasible and sensible to provide lower-level health personnel with medicines that can be a critical first aid tool for women who face immediate risk of death.
The emphasis on prevention over treatment is common in public health. “An ounce of prevention,” goes the old adage, “is worth a pound of cure.” But when prevention is not 100% effective, treatment also needs to be available. A well-functioning health system addresses public health challenges by pursuing both prevention and treatment, working to provide universal access to information and services that will keep people healthy while also providing care for those who do become ill. The question for policy makers is how to balance attention to and investment in prevention and in treatment in order to ensure the fewest mortalities and morbidities at the lowest possible cost. A more balanced approach to postpartum hemorrhage could prove to be a critical tool in countries’ efforts to accelerate progress toward achievement of MDG 5.
To learn more about misoprostol and its role in PPH prevention and treatment, join an online community on the Knowledge Gateway. Or visit Family Care International and Gynuity Health Projects to learn more about their work.