Pakistan needs affordable solutions to reducing maternal deaths. Credit: Zofeen Ebrahim/IPS

By Zofeen Ebrahim
KARACHI, Sep 12 2012 (IPS)

“I can’t imagine life without misoprostol,” says Dr. Azra Ahsan, a gynaecologist and obstetrician who has, for more than a decade, been using the controversial drug to stop women from bleeding to death after delivery.

Originally intended for treating gastric ulcers misoprostol has since 2000 been gaining in popularity for its ability to induce labour and stop post partum haemorrhage (PPH).

“I knew that it can save women from dying long before 2009 when it was registered for use in Pakistan,” said Ahsan, a member of the government’s National Commission on Maternal and Neonatal Health.

WHO guidelines advocate the use of misoprostol against PPH, while the International Federation of Gynaecology and Obstetrics (FIGO) suggests using the drug in situations where regular ‘uterotonic’ drugs like oxytocin and ergometrine are not available.

Doctors like Ahsan are dismayed at moves to get WHO to reverse its listing in April 2011 of misoprostol among essential medicines that “satisfy the healthcare needs of the majority of the population” and are  “available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford.”

Findings of scientific studies published in the August issue of the Journal of the Royal Society of Medicine are being cited in suggesting that WHO should “rethink its recent decision to include misoprostol on the essential medicines list.”

Allyson Pollock, who led the study, stated that there is insufficient evidence to suggest that misoprostol works in preventing PPH. Instead, she urges poor countries to improve primary care and prevent anaemia to lower the risk of haemorrhage following delivery.

Ahsan, however, says that in Pakistan some 80 percent of pregnancy cases end up with the mother’s uterus failing to contract naturally after delivery, calling for the use of uterotonic medicines to reduce bleeding.

“Nearly 27 percent of maternal deaths in Pakistan are caused by excessive blood loss after childbirth,” Ahsan explained to IPS.

According to the latest Pakistan Demographic and Health Survey (2006), Pakistan’s maternal mortality ratio stands at 276 for every 100,000 live births, and is among the highest in South Asia.

Bleeding, the leading cause of maternal deaths worldwide, is defined by the WHO as blood loss greater than 500 ml following a delivery.

The fact that misoprostol is also misused in Pakistan – and other developing countries like Brazil – to induce abortion cheaply, has added to controversies over the drug.

“I don’t care if people think it is used, misused or even abused…I know it saves mothers from dying,” says Ahsan.

Unlike other uterotonics, misoprostol has the advantage that it does not need refrigeration for storage and can be easily administered orally by trained birth attendants, Ahsan said.

A joint statement by FIGO and the International Confederation of Midwives states: “… in home births without a skilled attendant, misoprostol may be the only technology available to control PPH.”

Zulfiqar Bhutta, head of women and child health at the Aga Khan University, Karachi, and member of the independent expert review group for maternal and child health to the United Nations secretary-general, agrees with Pollock that misoprostol needs to be evaluated more robustly.

“But I wouldn’t throw out the baby with the bath water yet,” Bhutta told IPS. “There is a need to increase its use in the right circumstances and also carefully monitor misuse. It is no magic bullet and should not lead to complacency in provision of essential maternal services,” he said.

“I think the point of the paper published recently is to try and separate  science from messianic zeal,” says Bhutta who is also co-chair of ‘Countdown to 2015’, a global scientific and advocacy group tracking progress towards the U.N. Millennium Development Goal Five pertaining to maternal health.

“Misoprostol is promising and we should do our best to evaluate its safe use,” said Bhutta. “But, there are people in Pakistan who are recommending large scale distribution to families for use in all births. Will this be cost-effective or indeed safe?”

Pollock’s study has stirred international concern. International Planned Parenthood Federation’s Upeka de Silva told IPS in an e-mail that if WHO withdraws misoprostol, it would mean “countless women will be denied life-saving care and forced to suffer pregnancy-related complications which are entirely preventable.”

“We are fully aware that all studies have limitations and that continued research on best practices for maternal care is needed,” de Silva said.

“However, for the purposes of meeting the urgent needs of women, particularly in rural, underserved communities, we are confident about being guided by the abundant literature and expert evidence supporting the safety and effectiveness of misoprostol for multiple reproductive health indications,” de Silva said.

Further, she said: “The increasing number of clients provided with safe abortion services, treatment for incomplete abortion and PPH through clinics run by our member associations is further evidence that misoprostol should remain available and accessible.”

“It’s alright to stir confusion sitting in cushy offices, but the ground reality in Pakistan is quite different,” said Ahsan. “The conditions we work under are very, very constrained…let’s not forget the hot temperatures and long power outages (causing refrigeration failure).”

A year after the Laotian government launched a safe pregnancy programme news of this initiative,  involving the dispatch of teams of midwives across the country, is yet to reach women in the remote  communities.

A 30-year-old mother of three from the Akha ethnic minority in the Baan Monlem village of the northern province of Bokeo told Mona Girgis, director of Plan International’s local office, that she has never heard of the National Skilled Birth Attendance programme.

But, Girgis told IPS, the woman who identified herself as Noi welcomed the prospect of trained midwives coming to her village to support women in their pregnancies and deliveries.

Noi’s community of 60 families, that makes a living by growing rice on the hilly slopes of Bokeo, currently depends on the experience of older village women rather than a skilled birth attendant or midwife.

The situation of pregnant women in Baan Monlem is true for most other rural communities in Laos. A majority of the country’s 6.5 million people live in rural communities scattered across this mountainous Southeast Asian nation, and over 80 percent of the women give birth at home, according to studies by the United Nations Population Fund (UNFPA).

Laos’s mountain communities include some 100 ethnic minorities, forming one-fourth of the population and contributing heavily to the country’s high maternal mortality ratio (MMR) of 470 deaths per 100,000 live births.

Laos currently has the worst national record in Asia, topping even war-torn Afghanistan which has a MMR of 460 for every 100,000 live births, according to ‘Trends in Maternal Mortality: 1990-2010’, a study by the World Bank, World Health Organisation and UNFPA released this year.

“Families living in remote ethnic communities are usually very poor, and do not have the financial resources to pay for transport or fees to receive (health care) services,” explains Girgis.

“I have frequently heard this from women in different parts of Laos,” Girgis said. “We are aware that there are other obstacles, such as the condition of roads, language barriers and awareness of the need to seek medical care,” she added.

Lack of professional help has resulted in an average of two women dying every day in Laos from pregnancy-related complications and childbirth, notes the UNFPA in a report. “For every woman who dies many more suffer from illnesses or disability from complications during pregnancy and childbirth.”

It was to overcome Laos’s notoriety as the most dangerous place in Asia for a woman to give birth that drove Vientiane to aggressively advance the cause of safe pregnancies.

June saw 80 midwives graduate from a special programme shaped by the ministry of health, international donors and the UNFPA. This second graduating class added to the initial group of 140 midwives who qualified last year, pioneering a professional cadre of community midwives in the communist-ruled country.

The programme received a shot in the arm when the government declared June as the “Month of Midwives,” going beyond just the one day, on May 5, when the world annually marks the International Day of Midwives.

“Every community needs to have its own professional midwife to work with community leaders, families,individual women and adolescent girls to improve knowledge of safe pregnancy, childbirth and care of mothers and babies after birth,” Som Ock Kingsada, vice-minister of health, was reported saying at an event to mark the special month.

The current midwives training programme comes after a lapse of two decades during which no midwives were produced in the country. It has a curriculum that addresses a national weakness – low use of health facilities.

“We had to build in a lot of skills with laboratory work as trainees have limited access to cases, given the low utilisation of health facilities,” says Della Sherratt, international programme coordinator for skilled birth attendance at the Laos office of UNFPA.

“They are required to do a lot of hands on practice and case loads, as would be expected in other countries, (and) we have to send them to clinical areas with some exposure first,” Sherrat said.

And as the community midwives programme forges ahead, focus is shifting to more professional care in isolated communities in the mountainous areas and rural lowlands. “We are focusing this year on those areas where there are no health workers,” Sherrat told IPS.

These efforts are expected to help Laos meet one of the targets in the United Nations Millennium Development Goal of reducing MMR by 75 percent between 1990 and 2015.

According to the World Bank,  women dying while giving birth represents  a “determinant of poverty as well as a constraint to overcoming poverty.”

“Broader interventions that improve the macroeconomic and socioeconomic environment in the country are needed,” Ajay Tandon, the Bank’s senior economist focusing on health-related issues in Laos, said in an interview.

“Many of the determinants of poor maternal health are due to factors outside the health system, (such as) poor road connectivity, poor education, inadequate water and sanitation facilities, as well as low income levels.”