Cheap, Easy Drug to Save Mothers From Bleeding to Death

from All Africa

New Vision (Kampala)

By Alice Emasu And Irene Nabusoba
Kampala

If misoprostol, a drug that treats and prevents excessive bleeding during childbirth, receives political blessings, it would enable countries to achieve their Millennium Development Goals (MDGs) particularly on the reduction of pregnancy - related death (maternal mortality).

Misoprostol is a single dose white generic tablet, which a woman can put under her tongue or insert it into the vagina after giving birth. It dissolves fast, making the uterus that had failed to contract to do so, thereby averting excessive bleeding.

Dr. Henry Kakande, a gynaecologist from Engender Health Uganda project- a USAID funded initiative on maternal health, HIV and AIDS, says if misoprostol is used properly, it would reduce Post Partum Heamorrhage (PPH) excess bleeding after childbirth up to 90%.

Kakande, who was recently responding to studies on community-based approaches to improve child and maternal health at the fifth international African Population Conference in Arusha, Tanzania, adds that 60% of deaths that occur as a result of bleeding happen immediately after childbirth.

"This is why the use of misoprostol is very critical," Kakande says, explaining that it is a hormone-like drug that rapidly stimulates powerful uterine contractions.

Kakande says in a normal labour, contractions after birth deliver the placenta in a timely fashion and start the process of reducing the uterus back to its normal size. "If this process is delayed or fails, the bleeding that accompanies childbirth becomes excessive. By stimulating contractions, misoprostol can prevent the bleeding before it starts or stop it after it has started," he explains.

Kakande was one of the over 1000 participants at the global conference that takes place every four years. It was organised by the Union of African Population Studies, a non-profit organisation, which promotes scientific study of population in Africa through research, training, information, technological assistance and cooperation.

Misoprostol has been marketed since 1987 for treatment of gastric ulcers. Its value for PPH had been recognised since the early 1990s, but the drug has not been distributed in most developing countries where maternal mortality rates are high.

According to a World Health Organisation (WHO) update, globally, a total of 529,000 women die annually due to pregnancy and childbirth complications, majority of them from the sub-Saharan Africa, with haemorrhage, contributing most (39%). The picture is more worrying in Sub-Saharan Africa, because over 60% of mothers deliver at home without the care of skilled medical personnel. In Uganda, of the 6,000 mothers that die annually due to pregnancy complications, haemorrhage alone accounts for 25-40% deaths. This is worsened by the fact that only 42% of mothers in Uganda are delivered by midwives according to the 2006 National Demographic report.

Researchers at the conference said that bleeding (heamorrhage), which is caused by malnutrition, anaemia, poor health and giving birth to many children or at close intervals, often occurs during delivery or shortly after childbirth, but may also present in cases of induced and unsafe abortions, which is the second major cause of maternal deaths in Uganda.

The population and health experts say governments need to urgently adopt short term cost effective interventions like the use of misoprostol to save mothers who die or suffer long consequences of heamorrhage like anaemia.

Two drugs, oxytocin and ergometrine, are already licensed to treat over bleeding after pregnancy but neither can be used outside of a clinic or hospital setting, as they require cold storage and administration by drip or injection by a medically-trained person.

In developing countries - where most births take place at home and are unsupervised or attended either by family members or traditional birth attendants, who may be illiterate - these drugs are simply unavailable.

Misoprostol, on the other hand, is stable enough to stay on a shelf in hot climate for months. It can be safely administered through the vagina by a midwife, or the patient can swallow it as a pill.

It is cheap. In Uganda, in private clinics it would go for sh3,000, but in government hospitals if approved will be given out free of charge. In addition none of its few side effects - shivering, nausea and high body temperature - are not life-threatening. However, experts at the conference urged governments to put in place proper monitoring systems to ensure that the drug is not abused.

Misoprostol can be used to induce abortions if it is given to a pregnant mother. Abortion is illegal in Uganda unless it is medically recommended if the life of the mother is at risk.

Kakande re-echoes the experts' concerns saying: "We should introduce misoprostol consciously because even the trained medical providers we have are not yet comfortable administering it. We need to update our health providers on the use and administration of this drug."

He says the National Drug Authority has not registered misoprostol yet, but local studies in Tanzania, Nigeria, Uganda Egypt and Bangladesh have shown that it would reduce excessive bleeding after child birth by up to 90%.

"Most strategies call for recruitment and training of medical staff which requires enormous requirements that our governments are incapacitated to achieve in the near future. Oral misoprostol reduces 6.5% of death due to bleeding and does not need training of the service providers or close supervision. All that is required is sensitising the mother on the dosage and the danger signs," says Harshadkumar Sanghvi, while presenting a paper on preventing PPH at home births.

Harshadkumar says he conducted a pilot project in Bangladesh where mothers were given misoprostol at the eighth month to take home, and the results were successful.

"You just need to counsel the mother on the danger signs that often present with childbirth and what they can do. But risky pregnancies should be closely monitored otherwise with us, there is no mother that took a wrong dosage, or at a wrong time," he says.

Dr. Betty Kyadondo, from the Population Secretariat Uganda, says the WHO has proposed that misoprostol be promoted as part of the 'Mama Kit'-a package of basics required by a mother to prepare for childbirth.

The Kit is being promoted by the government. However, some participants at the conference expressed fears that providing the drug to pregnant mothers could encourage more unskilled deliveries.

But Kyadondo dismissed the fears saying: "If mothers living with HIV are able to effectively utilise nevarapine to prevent mother to child transmissions, why can't they do the same with misoprostol?"

Nevertheless, Kyadondo warned that mothers should be counselled to ensure that the afterbirth is out before they can take the tablet because the uterus can contract closing in the placenta.