Marge Berer and Lisa Hallgarten: Sacrificing the good for the perfect

Post partum haemorrhage (PPH) is one of the leading causes of maternal deaths. According to WHO estimates, in 2010 there were 287,000 maternal deaths, 25% of which were associated with PPH. The risk of PPH is greatest in anaemic women and the risk of PPH resulting in death is greatest in settings where there is a lack of timely referral processes, long distances to or a lack of transport to adequately staffed and equipped clinics, and inadequate emergency obstetric care at referral centres.

An effective maternity service would include provision of universal high quality antenatal care, during which anaemia and other pregnancy complications could be diagnosed and treated, and health systems in which all women give birth attended by skilled midwives, in or close to comprehensive emergency care by experts within a safe timeframe. This is something Reproductive Health Matters has published articles on since its foundation 20 years ago. In our most recent issue in May 2012, we published hopeful stories of progress as well as heart breaking cases of negligence, and health system failures to improve maternity care. The case studies from sub Saharan Africa in particular show how far some countries are from reaching this ideal.

To prevent PPH in active management of the third stage of labour, the gold standard treatment is to administer oxytocin which is safe, effective, and free of side effects. However, as the drug is heat sensitive it makes transportation and storage in places without refrigeration problematic. It also needs to be administered by injection, which requires training. In 2011 misoprostol was included on the WHO list of essential medicines for use in preventing PPH, as a pragmatic alternative to oxytocin in low resource settings. Misoprostol can be taken orally, by a woman on her own, or provided by a midwife or community health worker, which means that it is not reliant on a clinician for administration, is heat stable, and can be stored without refrigeration.

An article in Reproductive Health Matters in November 2007 reported on a pilot using misoprostol in Myanmar. The pilot was carried out in five townships and in each centre 50 women at high risk of PPH, and 50 women picked randomly were selected. In total, 500 women participated in the study, which included training midwives to screen the women and administer the misoprostol. At the end of the project there were no cases of post partum haemorrhage amongst either the high risk or the randomly selected women. Midwives took the opportunity to instruct other people attending births, including friends and relatives, of how and when to administer the drug, and concluded it is feasible for misoprostol to be given by non clinicians.

Several other papers published on misoprostol for PPH also make the case for using it. While women may experience short term side effects, such as shivering and pyrexia, they support use of misoprostol as a pragmatic alternative, though not equivalent to oxytocin. A recent paper by Sheldon W.R. et al, reviewed all the available evidence on misoprostol and concludes that misoprostol is a suitable uterotonic for the management of PPH.

For both PPH prevention and treatment, its use in healthcare systems, particularly at the lowest levels, can fill a gap in service delivery. The authors report that their findings support their extensive experience using the drug on the ground.

Last month Chu C.S et al published a paper in the Royal Society of Medicine Journal suggesting that misoprostol be taken off the WHO list of essential medicines. Based on their analysis of existing research, they argue that there is insufficient evidence for misoprostol’s efficacy as well as concerns about side effects. The authors’ analysis and conclusions have been criticised in this paper amongst others.

The authors’ primary point seems to be that we should not promote the “second best option” ̶  the priority should be to push for the kinds of health system reforms that would lead to a gold standard service for all women: “The money being spent on purchasing the drug would be better spent elsewhere, for instance, in ensuring there are skilled attendants during delivery and adequate antenatal services that can detect and help to prevent complications.”

But isn’t this a case of sacrificing the good (saving many women’s lives) for the perfect? While we would all want gold standard maternity services in place for all women, the obstacles to this are great and the pace of change is slow. Supporting the provision of a safe, easily stored, and easily administered life saving drug does not preclude anyone campaigning for and working towards the pot of gold at the end of the rainbow, universal good quality maternity care. Until that goal is achieved, who, in good conscience, would possibly deny misoprostol to the women who need it now.

Marge Berer is the editor, Reproductive Health Matters.
Lisa Hallgarten is the social media manager at Reproductive Health Matters.