Misoprostol for postpartum hemorrhage: Closing the gap between knowledge and action

By Shafia Rashid and JoAnn Paradis

Shafia Rashid is Senior Technical Advisor for the FCI Program of Management Sciences for Health and JoAnn Paradis is Strategic Communications Advisor for African Strategies for Health.

In many countries around the world, women give birth at home, often with only a family member or traditional birth attendant by their side. For these women, and for those giving birth in a health facility without reliable electricity, refrigeration, and/or IV therapy, misoprostol may be the best option for preventing and treating postpartum hemorrhage (PPH), one of the leading causes of maternal death globally.

A pregnant girl at Kigali District Hospital, Kigali, Rwanda. (Photo Credit: Todd Shapera)
Photo: Todd Shapera

Despite a global consensus on misoprostol’s safety and effectiveness for PPH prevention, few countries have closed the gap between knowledge and action–taking the steps to ensure that misoprostol is available to women where they are and when they most need it. Only a handful of countries have adopted evidence-based national policies and clinical guidelines that support the use of misoprostol for PPH, and even fewer have scaled these policies into national programs.

At a side event during the global 2016 Women Deliver conference, the FCI program of Management Sciences for Health and the African Strategies for Health (ASH) project, supported by USAID’s Bureau for Africa, highlighted the experience of three countries (Nigeria, Madagascar and Mozambique) in developing national misoprostol policies, and examined progress towards national implementation and scale-up. The findings from a review led by ASH highlight the following recommendations:

Ensure broad-based support. While government leadership, often in the form of a high-level champion from the Ministry of Health, is needed to bring about the necessary policy, regulatory, and budgetary decisions, effective adoption and implementation of policies cannot be achieved by the government alone. A national multi-stakeholder group can help to ensure broad-based ownership, counter any potential opposition or resistance, and support the implementation of policies through adequate financing, consistent supply and distribution, and provider knowledge and training. In Madagascar, a technical working group launched the initial misoprostol pilot studies and coordinated a study group tour to Nepal, which led to the high-level ministerial note supporting misoprostol for PPH in 2014.

Address concerns about misoprostol’s use. Resistance to widely introducing misoprostol is often based on concerns about its potential use for other indications, including abortion, and the possibility that it could deter facility-based deliveries. A number of strategies can help address these concerns, including:

  • Collection of data during pilot and implementation stages can show effects on facility births and demonstrate whether misoprostol was used correctly.
  • Careful packaging can support the use of misoprostol for PPH. For instance, in Nigeria and Madagascar, national stakeholders packaged misoprostol with chlorhexidine, an antiseptic applied to newborns from infections, to signal its use for a maternal health indication.
  • Engaging traditional and religious leaders, civil society, and the media can persuade decision makers to introduce and support misoprostol for PPH and help facilitate implementation efforts once policies are in place.

Engage communities and ensure accountability. Effective and participatory accountability mechanisms need to be in place so that civil society, women, and other community members can ensure that policies are implemented and programs scaled. Together, communities and civil society can help call for sufficient funding in national or subnational health budgets, and monitor program implementation and the quality of health services, including the availability of misoprostol, at the facility level.

Armed with these lessons, and taking into account their unique challenges, needs, and populations, countries can develop strategies to expand access to misoprostol for PPH and close the gap between knowledge and action.

For more information:
Misoprostol Policy and Scale-up for the Prevention of Postpartum Hemorrhage in Madagascar, Mozambique, and Nigeria: A Synthesis Brief

Misoprostol for Postpartum Hemorrhage: Questions and Answers for Policy Makers

Scaling up Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Action

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