POWER TO THE PEOPLE! Getting misoprostol to CHW – Saving Lives


Yesterday the world celebrated the 103rd International Women’s Day, and yesterday 800 women died from complications of pregnancy and childbirth, a loss that occurs every single day of the year. Almost 350,000 women die every year due to complications of pregnancy and childbirth. According to the World Health Organization, 99% of those deaths occur in the developing world, with sub-Saharan Africa bearing a disproportionate part of the burden. And while maternal mortality has declined almost 47% since 1990, the number is still much, much too high.

Video: Dying to Give Birth: One Woman’s Tale of Maternal Mortality
In Sierra Leone, photographer Lynsey Addario met 18-year-old Mamma Sessay, whose harrowing final hours of life show the perils of pregnancy in the developing world

The preceding video is disturbing and graphic as it illustrates the human face behind the numbers. Each maternal death cuts a story short; it changes a family forever, and leaves remaining family members vulnerable to poverty, illness and death.


Over 80% of maternal deaths occur just before, during, or immediately after childbirth, with the leading cause of death being postpartum hemorrhage (PPH). A catastrophic obstetric emergency, PPH can lead to death in less than an hour if not properly managed. There are several effective means to manage this complication, including the medications oxytocin and ergonovine. These medications, while effective, are administered via injection and require refrigeration, both of which are barriers to use.

Recently, studies have proven the effectiveness of misoprostol in preventing and treating PPH. Misoprostol is a shelf stable, inexpensive oral medication that effectively prevents and/or treats PPH, with few serious side effects. It is my strong belief that misoprostol should be available to lay health workers, women and their families in low resource settings to prevent this devastating complication of childbirth. This strategy has been recommended by several major health organizations, including WHO and the International Federation of Gynecology and Obstetrics (FIGO), yet despite these endorsements, adoption of this policy has been slow.

VSIIn July 2012, a regional summit was held in Dar es Salaam, Tanzania, bringing together leading women’s health experts from 12 African countries. After a week of intense activities, the participants returned home, enthusiastic to reduce maternal mortality in their respective countries by supporting the use of misoprostol. It is now time to follow through on that promise.

A second conference is needed to renew enthusiasm for this life saving drug. In addition to leading physicians, this time national midwife organizations need to be included, as well as representatives of community health workers, and drug manufacturers. A strong collaboration needs to be forged between these entities; often seen as competitors, these disparate factions need to set differences aside and remember that each and every group is working towards the same goal. A united front of these key stakeholders cannot be ignored by policymakers. Please join me in calling for a renewed effort to place misoprostol where it can do the most good- at the bedside.


15 Responses to “POWER TO THE PEOPLE! Getting misoprostol to CHW – Saving Lives”

  1. roshinigeorge Says:

    Thank for you for post highlighting the importance of Misoprostol in areas like Sub-Saharan Africa. It’s great to see that the CHWs are enthusiastic and supportive. While we get the “demand side” enthusiastic, I am wondering if the pharma companies (Pfizer and generic makers of the drug) have been engaged to provide a cheap or no cost supply (if we can get the drugs donated or produced in cheaper markets)? Also, are there distribution mechanisms to get the drug to health facilities and CHWs? You raise a good point that this must be a united front of these key stakeholders.

  2. miyoha Says:

    According to the WHO, bleeding and hypertension are the most common cause of maternal death in developing countries. Many promises at various conferences and summits have been made and I agree that it is time to stop making these promises and follow through on those made in the past by empowering CHWs to take much needed care to the households. Misoprostol is cheap, heat stable and so easy to administer that it should be made more readily available to even Traditional birth attendants.
    I suggest that Women groups and NGOs focused on women’s health be mobilized to advocate for the implementation of this policies. A consistent action will take this issue from the back burners of National policies.
    However adequate training of these health workers should be ensured before empowering them with this life saving drug. Because like every drug, misoprostol has side effects which include hypertension, another major cause of maternal death.

  3. jackiewallace Says:

    Thank you so much for your comments. Roshini, I know the situation varies greatly from country to country, and some are farther along in getting misoprostol out into the field. Because it is generic, it is very inexpensive (here in the State, pennies a pill). But then the problem becomes that companies don’t want to make it- less profit! I know there are some companies that are donating the med.

    There is a second hurdle in that some trained providers feel uncomfortable having lay health workers using this drug. I think that’s why there is so much emphasis on use by CHW “in low resource settings” Even WHO makes a point of saying it supports its use by CHW only when nothing else is available. In that situation, I think the balance between risk and benefit is clearly in the favor of the drugs use. As you point out, Miyoha, adequate training is a must.

  4. ehatef Says:

    Thank you for starting this discussion on women health and PPH. Misoprostol is a good alternative treatment for PPH. To make sure that the medication becomes more available and will be more accepted among healthcare professionals a series of factors should be taken into consideration.

    As you mentioned it is important to educate physicians as well as other healthcare providers such as midwives and community health workers about the medication, its way of administration and storage of the medication. It is also important to make sure that medication is available in health care facilities and the source is sustainable over a long period of time. The collaboration with pharmaceutical companies to produce the medication at a reasonable price has an important impact on sustainability of this way of treatment for PPH. Raising awareness through international conferences and campaigns targeting different healthcare professionals and stakeholders is also important. It would be of great help to educate patients about this alternative method of treatment for PPH. It is important to make ministries of health in countries with higher PPH incidence involved in the process of planning and implementation of this new treatment.

  5. samanthaholcombe Says:

    Hi Jackie,

    Thank you for posting about this. I am most interested in this post as I currently work for an international health non-profit as a Program Coordinator for Zambia. In Zambia, we have a maternal and newborn health program that focuses on increasing the quality of labor/delivery and postpartum/post natal care services in target districts, expanding availability of quality post-partum family planning services in facilities, and building capacity of the Ministry of Health facilities in our targeted district to increase uterotonic coverage through use of active management in the third stage of labor (AMSTL) with a focus on doing this through distribution of misoprostol. In Zambia support for the use of misoprostol is high. We have collaborated partners to develop standard training curriculums in PPH to accompany misoprostol national guidelines – resulting in a training package for healthcare providers responsible for distributing misoprostol and another for Safe Motherhood Action Groups (SMAGs) to educate communities about misoprostol and both have been approved for national use.

    At this point providers have been trained but we face a huge challenge in national-level stock-outs of misoprostol and haven’t been able to procure the drug, leaving a huge gap to be filled. I’m sure that many countries made commitments at the regional summit in Dar that were left unfulfilled, but I also think a huge challenge facing countries is one similar to Zambia’s, where the desire for implementation is there but the needs remain unmet.

  6. okonkwos78 Says:

    Thank you Jackie for the great post on Misoprostol and PPH. There has be success stories with the use of misoprostol distribution for the prevention of PPH by CHW’s in Nepal and Indonesia to mention a few cases.



    Aside being cost-effective, easy to use, stable medication it is also and abortifacient and countries that have strong laws on abortion may use this angle to thwarts the intension or progress to adopt the policy. In Nepal it took Health official, the society of Obstetrics and Gynecologist armed with success stories from Indonesia for the country to add Misoprostol to their essential drug list. This means the pharmaceutical companies are now able to supply misoprostol readily.

    http://familycareintl.org/UserFiles/File/Thapa_Nepal.pdf .

    Even with professionals there is this issue of convincing some of them that women can use misoprostol effectively and at the right timing. Some think there is no sufficient evidence ie to back the safe use, reduction in maternal mortality from PPH with community distribution of Misoprostol by CHW’s.

    Rethinking WHO guidance: review of evidence for misoprostol use in the prevention of postpartum hemorrhage. Journal of the Royal Society of Medicine. Retrieved from http://www.who.int/selection_medicines/committees/expert/19

    Clearly the use of Misoprostol is still undergoing the stages of change, some countries are at the precontemplation, some are contemplation, others action stage, while others is in the maintenance stage. I agree with you there should be a renewed effort to make a call on stakeholders and policy makers to make misoprostol available for use.

  7. gahanfurlane Says:

    Jackie- Thanks so much for posting about this extremely important topic. I think that a lot of important points have been made in previous comments about task shifting. Currently, many governments in low income countries are very hesitant to allow non-physicians to distribute the drugs despite the ease with which it can be done with proper training. Currently, my organization is doing a prevention of postpartum hemorrhage program in Liberia. This project was a facility and community based program. In the facility, skilled birth attendants (SBAs) distributed misoprostol to pregnant women. In the community, two district reproductive health supervisors were trained to give counseling and misoprostol at home. During the learning phase of this program, a little over half of the pregnant women in the community were enrolled in the program. Fewer than 25% of these women enrolled were reached by the DRHS. This statistic shows the importance of task shifting. Because there were only two DRHSs for the entire community, they were unable to reach most of the women least likely to attend ANC visits or to have a facility birth. Community-based prevention of post-partum hemorrhage programs have also been shown to increase facility births due to the counseling that women receive.
    In order to reach the maximum numbers of pregnant women at the community level, community-level workers need to be involved. While trained traditional midwives (TTM) can be used to mobilize women to come for ANC visits, relying on the existing health system in a country where it is not strong did not yield high coverage rates. In some countries, TTMs are trained to provide misoprostol themselves which has provided higher coverage. This policy change would be ideal in all countries where human resources in health care are scarce (such as in Liberia). TTMs are well known and connected in the communities that can not necessarily be reached by trained health workers. In many countries, doctors are concentrated in the cities. In these cases, countries need to work with the resources that they have in order to prevent needless maternal death caused by postpartum hemorrhage.
    There are also a number of issues with stock outs that have been addressed in previous comments. Moving forward, countries need to focus on supply chain management and commodity availability (often having to do with production and price).
    There is still a great deal of with that needs to be done to convince governments and pharmaceutical companies to help prevent the leading cause of death in women of reproductive age.

  8. shtsa Says:

    I agree with the blogger and the commentators. Misoprostol is a good drug of choice for prevention and treatment of PPH in low income countries. It is very cheap, easy to store and simple to administer. However, I’m still a bit skeptical about how safely the drug can be handled by lay health workers and village health workers. It is an adjunct medication, used in medical abortion. A single 600 mcg dose (same as the dose to prevent PPH), when administered at the wrong time, can cause quite the opposite effect. I’m certain that the guidelines and the WHO have already looked into this possibility. They probably considered that benefits outweighted risks. Nevertheless, misoprostol is the “perfect” drug in those settings. But, access to the drug needs to remain restricted, and allowing many lay health workers- in the absence of a monitoring system to- to have access to it, is just quite dangerous to me.

  9. jackiewallace Says:

    Thank you for all the great comments. I was very interested to hear about your program in Liberia, Gahane. As noted, different countries are at very different stages of implementation. And as the previous comment states, the use of misoprostol has a lot of political baggage- some countries are very hesitant to move forward with it’s usage because of it’s use in medical abortions.

  10. monsurahsalami Says:

    hi Jackie,
    This is an interesting blog and one that is so important and close to my heart as Nigeria has among the highest maternal mortality ratios in the world of about 545 deaths per 100,000 live-births. (http://www.unicef.org/nigeria/ng_publications_Nigeria_DHS_2008_Final_Report.pdf)

    As a intern doctor, i can remember the number of maternal deaths certificates i wrote on a daily basis(not less than 3 per day) and how horrific it was.
    Misoprostol is such a cheap and effective drug and it has been shown to reduce maternal mortality in different studies. Some studies have even shown that traditional birth attendants (TBAs) can effectively administer the drug. One of such randomized study was carried out in Pakistan, in which TBAs were trained on the use and administration of misoprostol and a reduction of 24% in maternal deaths caused by post-partum haemorrhage was seen.
    (Mammen C, Sharma M. Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in home births in Pakistan: randomised placebo-controlled trial. BJOG 2011 Jul;118(8):1018; author reply 1018-9)

    This will definitely go a long way in reducing the many unnnecessary deaths of women around the world.

  11. margaretkuder Says:

    Jackie- what a moving video to portray a very important topic. I found your post very interesting. I do not know much about this topic, so I was interested to learn more about the possibility of misoprostol as a means to reduce maternal mortality. I agree with many of the other commenters that appropriate training would be necessary to make this drug widely available to community health workers in a safe way. This drug could be an effective and inexpensive means to combat the issue of PPH and its effect on maternal mortality. However, I hope that organizations continue to tackle the larger issues at hand- the inaccessibility of health care in general for many women and the subjugation of women in many places that has such a negative effect on their health. These societal changes that would allow women to have safer pregnancies will take much more time, and misoprostol provides an immediate means to reduce harm to women.

  12. samarnahas Says:

    Thank you all for the great topic and comments. Women’s health and maternal mortality during child birth touches me the most, because of my background being an OB/GYN physician. During my residency and work I’ve handled many cases of PPH. Treatment most times are simple by uterine massaging and some medications, but some time very serious and requires a series of fast action from everyone dealing with the case. Most times the most important person to start the action is the nurse or the midwife that was taking care of the patient.
    As we saw in the video, the women was left alone to bleed to death, by the time they called for action Mama was dead, very sad, and heart breaking.
    From that we learn that the solution is a lot more complex than Misoprostol. Calling for a second conference and involving drug companies to supply cheap or free drug is a great start, but to help reduce Women’s mortality from child birth, we have to do extensive campaigns to most rural areas to teach them about the necessary acts to do with any PPH, starting from regular vital signs, uterine massaging, and misoprostol use, and calling for help earlier in the case to prevent similar disaster like in Mama’s case. We see in the video how much attention was given to the second baby but very little to dieing Mama, as if that it was normal to bleed and even to die!!
    I know many Canadian organization that goes to several places in Africa to help in teaching cesarean section skills. I think them and other organizations with the help of the local governments should focus as well in teaching what we call PPH drill, which is a serials of actions to do for any women with PPH, and it’s most times very successful with simple act alone. Misoprostol should be part of that drill, as by it self is not enough.

  13. udoanosike Says:

    Thanks for posting this. Post- partum hemorrhage (PPH) is a very important topic in obstetrics as it can happen so suddenly even when not anticipated by the obstetrician, hence the need for effective proactive measures in tackling the problem. It is so sad that we haven’t been able to reduce significantly the rate of maternal mortality in many parts of the world especially in Sub- Saharan African region.

    Though, misoprostol is quite effective in the control of PPH and due to its wide- ranging applications in reproductive health, it is in WHO’s model list of essential medicines, however I support it’s use by trained health workers only and not lay workers because of some risks associated with its use and the tendency of abuse of the medication by some workers in the community and village settings who are ignorant of its potential side effects. For example, I have managed an unbooked patient in Lagos, Nigeria who had misoprostol inserted by an auxilary nurse in her home before coming to the hospital. She was almost entering into second stage of labor when she came to the hospital I was managing then and the baby was breech presentation. This became an emergency which ordinary could have been well planned for if she had good antenatal care.

    The lay workers who have seen doctors use misoprostol to induce labor, go to practice same in their homes which is quite dangerous ’cause caution should be applied to its use. Therefore, if we make available misoprostol to lay workers the risks will outweigh its benefits.

    I support the initiative to make available misoprostol to community health centers, but its use should be by well trained health workers if we will enjoy the benefits. Also, health education should be carried out in various hospitals, maternity/delivery homes,community health centers etc as regards to its use.

    Furthermore, ability to recognize patients who are at risk of developing PPH is number one priority in the management of PPH. Factors such as multi- parity, previous history of PPH, prolonged labor etc should be considered before onset of labor and the obstetrician, midwife, trained community health worker should take appropriate precautions!

    The major problem of increased maternal mortality in Sub- Saharan African region is due to unqualified workers and poorly trained TBAs who take deliveries of pregnant women and efforts should be channeled in getting them trained through community health programs.

  14. Justin Price Says:

    Jackie, thank you so much for bringing this issue to our attention via your excellent post. Treatment with prophylactic uterotonics (either misoprostol or oxytocin) has been repeatedly shown to be the most significant single intervention to prevent PPH. I am in strong agreement with you that such an intervention should be rolled out post-haste. I also agree with others who have noted that prophylactic uterotonics are merely an initial step towards fostering a stronger healthcare infrastructure necessary to truly tackle the problem of PPH. João Paulo Souza makes this exact point in a recent PLoS article (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001525), and I think it’s important to remember. The original study to which he is responding analyzed whether Oxytocin injections as prophylactic for PPH could be expanded to peripheral healthcare providers, to increase coverage. In this article, the authors conclude with their support of adapting this expansive model (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001524). I would tend to echo this later approach, as I think the severity of PPH calls for some level of intervention immediacy. Whilst prophylactic uterotonics certainly carry some complications/risks of their own, they provide an important first step than can quickly address the underlying problem and perhaps serve as a catalyst for improving other aspects of healthcare in areas where they are implemented.

  15. jackiewallace Says:

    I couldn’t agree more, Margret, that it’s tremendously important not to loose sight of the underlying cause of much maternal mortality- inadequate access to adequate healthcare. Using misoprostol for PPH could be looked at as “low hanging fruit” in that its cheap, fairly easy to store and to use, and quite effective. But it really lends itself to vertical programming, and the true, root cause of the problem remains unchanged.

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