WHO sends mixed message to Africa on Maternal Health

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In Uganda and most of Sub-Saharan Africa one in 35 women will die in childbirth, this statistic is over 1000 times higher a women risk in the industrialized world.  Post-partum hemorrhage (PPH) accounts for the greatest percentage of excess maternal mortality.  Oxytocin is an IV medication which is effective at decreasing PPH, but it is expensive medication and requires a cold chain for distribution.  Misoprostol has a similar action and is available in a generic, stable pill form.

Maternity Ward at District Hospital, Soroti Uganda

Misoprostol can also be used for gastric ulcers and abortions, thus religious, anti-abortion groups and the US government under the Bush administration have lobbied against its adoption. This May, after a prolonged battle, the WHO added Misoprostol to the list of essential medicines for women and children. Essential Medicines are ones that address priority health needs of a population and are to be available at all times. This list is an important guideline that countries and donor agencies use to assist their programing. However the WHO failed place it model medicine plans or priority list of citing that Oxytocin is cheaper and more effective when available. Yet in Uganda as is the case in most of sub-saharan african less than 40% of women give birth with a skilled attendant, far fewer in a hospital setting. Oxytocin is 10x more expensive in Uganda, not accounting for administration costs. Multiple studies have demonstrated the effectiveness and safety of Misoprostol with unskilled birth attendants, reducing post-partum hemorrhage by over 50%.

Oxytocin has an incremental benefit over Misoprostol, but is impractical in much of the developing world. The WHO’s recommendations demonstrate a failure to understand the realities of childbirth in sub-saharan africa or the undue influence of anti-abortion groups. Neither explanation appears adequate when considering the scope of the problem. Misoprostol is a medication that can promote primary health care now, and truly change the health and lives of women in Sub-Saharan Africa.

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4 Responses to “WHO sends mixed message to Africa on Maternal Health”

  1. riwunze Says:

    I am happy to see this as your blog topic. It seems to me that this issue has not gotten the attention it needs. Luester, you have it exactly right, this is a “failure to understand the realities of childbirth” in many low resources settings in the world. If I remember correctly, there was a study done in Afghanistan, which showed misoprostol was used correctly, decreased incidence of PPH, and not misused. Not only is PPH is a major cause of maternal mortality, a child’s survival decreases when the child’s mother dies. Misoprostol is pro-life for mothers and children in that it saves the lives of mothers and their children.

  2. 121316go Says:

    Considering the rate of maternal mortality in the sub-Sahara countries, it is way over due that WHO makes the Misoprostol available to the communities in these countries. Postpartum hemorrhage will continue to be a major issue until enough skilled birth attendants are working through out the communities. True, the fact that medications are available goes a long way but training also should focus in educating the public as to why mothers need to get follow up Antenatal care earlier or at least one time before delivering. If people are educated the misuse of misoprostol could decline. If family planning is strengthen and access is there for every one, there will not be abortions to a greater degree. I truly believe the availability of effective drugs such as misopostol is vital but it would need to be supplemented with an effective family planning program and educating of health care providers and the community as well.

  3. hbbos Says:

    Although is use for abortions is often citing by those opposing misoprostol availablity, it is actually not very good at inducing abortions. It works better when combined with methotrexate (a chemotherapy agent) or RU-486 (an anti-progesterone medication). However, not only is misoprostol good at reducing the incidence of PPH, it is very effective for treating hemorrhage associated with incomplete miscarriage – an under through out complication of pregnancy. Ironically, I have taken more people to the OR for hemorrhage in the first trimester under emergent situations than I have in the third trimester. Women are very unlikely to seek medical treatment in Africa for miscarriage, to the risk is quite high with an invomplete miscarriage (and that of course is not considering incomple/septic/illegal abortions)

    Another example of misoprostol being limited is in Bolivia. In most countries, misoprostol is pennies a pill. In Bolivia it is $35 dollars, because of the governmental concern it will be used for illegal abortions.

    A final point – misoprostol is primary prevention for PPH. If a postpartum hemorrhage occurs, it is not as effective for stopping it, but it is useful again for tertiary prevention once the bleeding is slowed down. Unfortunately, PPH is higher is developing countries due to the high rate of prolonged and obstructed and infective labours. For these risk factors, oxytocin can be used to reduce the occurs of the predisposing factors, and that is why is considered essential for safe pregnancies.

  4. priscillanowusu Says:

    I just read an article online that compares oxytocin administration with that of misoprostol. One important difference is the existence of fewer side effects with oxytocin than with misoprostol. Putting aside the cost factor, could this be the primary reason why the WHO endorses oxytocin on the essential medications list?
    If we think about it, in a resource-poor environment, it becomes more costly in the immediate and long term to have to treat patients for associated side effects. Does that then make the two drugs break even, in terms of cost? Also, being a multilateral agency, is the WHO subject to significant influence by US propaganda? My inclination is to say probably not.
    We must also explore the reasons for which oxytocin is much more expensive in Uganda. Furthermore, in advocating for patient safety, especially that of vulnerable third world populations, I would say that we push for the “safer” option, which in this case is oxytocin, even though it might be more expensive. With developing country government prioritization of health care spending, as well as a commitment to meeting the MDG5, both before and after 2015, the cost aspect can be taken care of by truly committed nations.
    Lastly, if misoprostol administration is to be widely used (which I strongly advocate for, over doing nothing!), then health ministries must properly train birth attendants on not only correct use of the drug, but on other active management of third stage of labor procedures such as ensuring the complete delivery of the placenta; uterine massage, etc.

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