Misoprostol for postpartum hemorrhage: from evidence to action

Shafia Rashid is a senior program officer in FCI’s Global Advocacy program.

Around the corner from the New York Stock Exchange, where financial decisions of global importance are made every day, more than 50 obstetricians, midwives, women’s rights advocates, public health programmers,  researchers, and policy makers from around the world gathered last week for discussions on a different, but equally momentous, subject. FCI, working in collaboration with Gynuity Health Projects, brought together this diverse group for a two-day meeting to help shape policy and advocacy on the use of the drug misoprostol for the prevention and treatment of postpartum hemorrhage (PPH). In the developing world, uncontrolled post-partum bleeding is the leading cause of death in childbirth, killing a woman every five minutes.

In studies conducted by Gynuity and others, misoprostol has been shown to be a safe and effective medicine both for the prevention and for the treatment of PPH. While another drug, oxytocin, is generally recognized as the “gold standard” among uterotonic drugs for preventing or treating PPH, misoprostol has significant advantages for use in settings where maternal mortality is high and most births take place outside of hospitals:  misoprostol is delivered in tablet form, and — unlike oxytocin — requires neither refrigeration nor intravenous administration. Earlier this year, misoprostol was added to the World Health Organization’s Model List of Essential Medicines for the prevention of PPH, providing another opportunity to expand women’s access to this safe and inexpensive medicine. Misoprostol, originally developed for treatment of stomach ulcers, is also used for a range of reproductive  health indications, including induction and augmentation of labor and medical abortion.

The New York meeting aimed to translate the scientific evidence on misoprostol’s safety and efficacy into effective strategies for expanding women’s access to misoprostol at the country level. After reviewing the scientific research, the global clinical and policy guidelines that shape the use and availability of misoprostol, and the strategies being used by misoprostol advocates and programmers, participants discussed opportunities, barriers, and challenges related to promoting greater access to misoprostol for PPH. Human rights experts framed how access to misoprostol is a human right enshrined in several international frameworks, including the Universal Declaration of Human Rights. Presentations and discussions highlighted the need not only to drive policy change at the country level (e.g., getting misoprostol registered for this indication, including it on national essential drug lists, and incorporating it within national clinical norms and guidelines), but also to ensure that these policies are adequately implemented and funded so that they translate into real progress for women.

Presenters from Nepal, Kenya, and Ecuador shared lessons from successful efforts to achieve policy approval and expand distribution of misoprostol, and participants from countries including India, Tanzania, Uganda, Burkina Faso, and Laos also contributed their experiences. These discussions included promising results from several countries where distribution of misoprostol tablets to women in their communities has proven effective in addressing the risk of hemorrhage among women who give birth at home — where more than half of births in the developing world still take place — with extremely low levels of diversion of the drug for other uses, incorrect dosage or timing of administration, or other signs of poor compliance. Attendees also learned about advocacy campaigns in related sectors, including emergency contraception, medical abortion, and the HPV vaccine for cervical cancer, and considered how those lessons may be applied to improving access to misoprostol for PPH.

Looking ahead, FCI will work with our partners to develop and implement an advocacy and communications strategy that will drive real progress in helping countries, health care providers, and women themselves address the leading cause of maternal death. Please stay tuned to The FCI Blog for more information as this exciting and important project moves forward.

To read FCI’s mapping report on advocacy for access to misoprostol, click here:  Mapping_Miso_For_PPH.

To read about FCI’s work on misoprostol for PPH, click here.

Kenyan parliamentarians commit to maternal health advocacy

by Angela Mutunga and Sam Mulyanga

Angela Mutunga and Sam Mulyanga are country director and senior program officer, respectively, at FCI-Kenya.

In Kenya today, a woman dies every hour from complications of pregnancy or childbirth, and many more suffer illness or injury. Kenya’s maternal mortality ratio currently stands at 488 deaths per 100,000 live births. In order to achieve MDG 5 — the fifth Millennium Development Goal calls for developing countries to reduce maternal mortality by ¾ and to provide universal access to reproductive health — Kenya needs to reduce that ratio to 147 per 100,000 by 2015. Unfortunately, momentum has been moving in the wrong direction: maternal mortality actually worsened by 18% between 2003 and 2009.

Last Friday in Nairobi, members of Kenya’s Parliament came together with maternal health advocates to commit themselves to reversing these deplorable statistics. The meeting, organized by the advocacy coalition Women Alive, aimed to enlist parliamentarians, including members of the Kenya Women Parliamentary Association (KEWOPA),  as advocates for increased national investment in programs that save women’s lives.

At the meeting, Dr. Issak Bashir, head of the Division of Reproductive Health in the Ministry of Health, began with a presentation on the current state of maternal health in Kenya, noting that only 43% of births take place in health facilities that offer skilled delivery care. Responding to Dr. Bashir’s presentation, members of Parliament called on the Ministry of Health to work more closely with key parliamentary committees (particularly the House Health Committee) and to strengthen accountability mechanisms. “There’s a tendency in Africa to ask for more all the time, but what have we done with what we are given?” asked Hon. Abdul Bahari, a member of the Budget Committee.

I will be ready to make noise in Parliament and villages. If I can be of use in any other forum I am ready.

-Hon. Amina Abdallah
Member of Parliament

Dr. Bashir noted that in certain rural areas maternal mortality figures are more than double the national average. MPs lamented the lack of access and availability of quality maternal health services in their districts. “Where I come from, husbands are delivering their wives,” said Hon. Sophia Abdinoor. Members committed to network with fellow members and with parliamentarians from other countries in the region, to enact supporting legislation that addresses health service inequities, and to work for more funding. “We are leaving from here to the budget discussions, and we need to go there and discuss this,” remarked Hon. Ekwe Ethuro. Members also promised to become active advocates for maternal health. “I will be ready to make noise in Parliament and villages. If I can be of use in any other forum I am ready,” affirmed Hon. Amina Abdallah.

Women Alive is a coalition that works to strengthen political commitment for maternal health in Kenya; FCI-Kenya serves as its secretariat. In the coming weeks, coalition members will meet to map out the next steps in translating these parliamentary commitments into concrete action to save women’s lives.

A price too high to bear: the costs of maternal mortality to families and communities

Robinson Karuga is research coordinator at FCI-Kenya.

A meeting today in Nairobi, hosted by FCI-Kenya, brought Kenyan government officials together with representatives from research organizations, health and development NGOs, civil society groups, and the private sector, for the launch of a groundbreaking research project that will shed new light on the financial and non-financial costs of maternal mortality.

This research, to be conducted by FCI in partnership with the Kenyan health ministry’s Division of Reproductive Health, the International Center for Research on Women (ICRW), and the Kenya Medical Research Institute/Centers for Disease Control (KEMRI/CDC-Kisumu), and with support from the John D. and Catherine T. MacArthur Foundation and the Kenya office of the UK Department for International Development (DFID-Kenya), aims to fill a critical gap in knowledge about the impact of a woman’s death in pregnancy or childbirth on her family, her community, and her nation. This will provide a critical resource for advocates working — in Kenya, in other developing countries, and at the global level — for increased political commitment and financial investment in improving the availability, quality, and utilization of maternal health services.

Previous studies in a number of countries have suggested that children who lose their mother are more likely to die themselves or experience stunted growth and less likely to be educated. This three-year research project seeks to provide the first full accounting of the direct monetary cost of a maternal death for the household, the indirect costs in terms of lost productivity and income, and the “social costs” of maternal deaths to families and communities in terms of the changes in household structure and household responsibilities. Research will take place in Nyanza Province in western Kenya, in an area of high poverty, low utilization of skilled childbirth care, and among the highest levels of maternal mortality in Kenya.

We are all eagerly awaiting the findings of this research to propel advocacy around safe pregnancy and childbirth, and will report occasionally on The FCI Blog about the project’s progress.

Partnering to promote reproductive health for Latin America’s indigenous women

Martha Murdock is FCI’s vice president for regional programs.

I have just arrived in Lima, Peru, where — together with Alexia Escobar and Maritza Segura, FCI’s national coordinators in Bolivia and Ecuador — I will be attendingthe High Level Meeting on Reproductive Health and Intercultural Care in Latin America.

This meeting, hosted by the Peruvian Ministry of Health and the Organismo Andino de Salud as part of  a regional framework sponsored by the Spanish Agency for International Development (AECID) and the UN Population Fund—UNFPA, will bring together high-level health officials from the health ministries of Bolivia, Chile, Colombia, Ecuador, Guatemala, Honduras, Peru, and Venezuela. FCI, a partner in this regional program, is one of the few NGOs invited to the meeting.

In Latin American and the Caribbean, maternal mortality was reduced by 41% between 1990 and 2008. Looking at overall regional and national data, the many countries in the region seem to be on track to achieve the Millennium Development Goal(MDG) 5 target of reducing maternal mortality by ¾ over 20 years. However, when the data is disaggregated by ethnicity,there remain substantial gaps in access to reproductive health services, information, and commodities among indigenous women. Surveys in countries like Guatemala have shown that maternal mortality is up to 3 times higher among indigenous women (211 maternal deaths per 100,000 live births) than among non-indigenous women (70 per 100,000).

In seeking to address these gaps and achieve MDG 5 among all population groups, governments in the region recognize the need to adopt an intercultural approach to maternal and reproductive health services. Since 2009, FCI has been working to strengthen the advocacy capacity of indigenous women’s organizations to demand culturally-appropriate health care, and to promote their direct participation in the design and monitoring of maternal health care services that are sensitive to their cultural traditions. We also work with ministries of health across the region to advance maternal health policies and programs that better respond to indigenous women’s cultural expectations and needs.

This week’s meeting will review the progress that has been made so far, share lessons learned, and set a path to define and agree upon a basic set of indicators of culturally-friendly maternal health services. One expected, and important, outcome of the meeting will be the adoption by all of the Ministers of Health of a joint statement that commits to strengthening and further intensifying measures to make maternal health services more culturally acceptable to indigenous women, in order to improve their health status. Follow The FCI Blog to read their final statement, and to stay up to date as FCI closely monitors its implementation.

Mapping Misoprostol for Postpartum Hemorrhage

Shafia Rashid is a senior program officer in FCI’s Global Advocacy program.

Postpartum hemorrhage (PPH) is the largest cause of maternal mortality, accounting for nearly one-quarter of maternal deaths. Preventing and treating PPH is especially difficult in places where most births occur in homes or in local clinics and where access to emergency obstetric care is limited. Evidence shows that misoprostol —a medicine that can be delivered in pill form and stored without refrigeration — can play an important role in preventing and treating PPH.

Just last month, misoprostol was added to the World Health Organization’s Model List of Essential Medicines for the prevention of PPH, providing another opportunity to expand women’s access to this safe and inexpensive medicine. It is critically important that clear, evidence-based information about misoprostol and its appropriate uses be disseminated to ministries of health, regulatory authorities, health system managers, health workers, and other key audiences.

FCI, working with Gynuity Health Projects, commissioned a mapping to identify activities and approaches being taken by organizations working on misoprostol for PPH. Over thirty organizations were asked to describe their activities, share their motivations for including misoprostol in their work, discuss barriers they have encountered, and suggest strategies for addressing these barriers.  One of our most surprising findings: the integration of misoprostol for PPH into reproductive health programming is rapidly gaining traction.  Several organizations noted that misoprostol offers a real opportunity to make a difference in maternal mortality—one that is not dependent on waiting for health systems to be strengthened—and they want to act on this opportunity as quickly as possible to save women’s lives.

The mapping highlights the need for several key actions:

  • Build consensus around evidence-based guidelines: There remain concerns about insufficient data supporting misoprostol’s distribution and use at the community/home level, and whether promotion of misoprostol at this level could deter women from seeking care at facilities with trained providers. While these concerns may be valid from an intellectual perspective, they ignore the realities faced by women giving birth in low-resource settings: that basic childbirth care in facilities (including access to oxytocin, which requires refrigeration and injection) is still not available to a large number of women.
  • Address misoprostol’s association with abortion: Misoprostol is a drug that has multiple promises for saving lives, including its use for abortion. While this has political implications in many areas, health providers require accurate, evidence-based information about how misoprostol is best used for each indication— labor induction, PPH prevention, PPH treatment, postabortion care, and abortion.

The mapping revealed key areas of convergence, as well as disagreement, within the global policy and scientific community. Building on the findings, and in response to the challenges outlined in this report, FCI will work with partners to identify policy approaches on which consensus can be achieved; to harmonize messages regarding the use of misoprostol for PPH; and to influence policy change in support of misoprostol at the national and global levels.

While more research is needed to build the evidence on community-level distribution, misoprostol clearly shows promise for meeting several reproductive health needs of women, including the prevention and treatment of postpartum hemorrhage. It is time to capitalize on its ready availability, low cost, convenience, and safety, and get it to women in ways that will best protect their health and preserve their lives. 

To read the full mapping report, click here: Mapping_Miso_For_PPH

To read about FCI’s work on misoprostol for PPH, click here.

What happened to the G8’s commitment to maternal, newborn & child health?

Amy Boldosser is Senior Program Officer, Global Advocacy, at Family Care International.

When the G8 Summit wrapped up in Deauville, France last week, many maternal, newborn and child health advocates were left saying, “What a difference a year makes.” 2010 was a year full of new commitments for improving maternal, newborn and child health. The G8 launched the Muskoka Initiative and committed US$5 billion for maternal, newborn and child health with promises to raise an additional $10 billion by 2015; the African Union hosted a Summit on Maternal, Infant and Child Health and Development which resulted in new commitments including the Africa wide launch of the Campaign for the Accelerated Reduction of Maternal Mortality in Africa (CARMMA);  and the MDG Summit included the launch of the Global Strategy for Women’s and Children’s Health by the UN Secretary-General and 90+ stakeholders who together made US$40 billion in commitments to improve the health of hundreds of millions of women and children around the world.

At the 2011 G8 Summit hosted by France, however, maternal, newborn and child heath was nowhere on the official agenda and warranted only one paragraph in the final 25 page declaration. In that paragraph, the G8 leaders reaffirm their commitment to “improving maternal health and reducing child mortality, most notably through the Muskoka Initiative for Maternal, Newborn and Child Health launched in 2010,” and assert that, “We are delivering our Muskoka commitments.” While advocates welcomed the reaffirmation of the G8 commitments on maternal, newborn and child health, questions remained about whether the G8 governments are indeed delivering on those commitments. Advocacy groups and mainstream media criticized the G8’s 2011 Deauville Accountability Report which was meant to review the progress member countries made in meeting their commitments on food security and global health. Advocates from ONE and Oxfam called the report a “whitewash,” since a review of the numbers indicated that, after accounting for inflation, the G8 was actually $19 billion away from meeting $50 billion target it claimed to have met.  The New York Times wrote in an editorial , “It is disheartening to know how low a priority the wealthy countries still put on development in the poor world. What’s more, the sleight of hand by the G-8 is unlikely to inspire much confidence in future promises.”

As noted by our colleagues at the Global Health Council in their official statement, there were a few bright spots for global health in general. The G8 did reaffirm its commitments to the Global Fund to Fight AIDS, TB and Malaria, and the GAVI Alliance, which works to expand access to vaccines in the poorest countries. The G8 also indicated that it will implement the recommendation of the Commission on Information and Accountability for Women’s and Children’s Health which is tracking pledges to the Global Strategy and the Muskoka Initiative. Dr. Carole Presern, Director of the Partnership for Maternal, Newborn and Child Health welcomed this announcement saying, ”The G8 members are playing a key role in seizing the opportunity afforded by the Commission recommendations to ensure that commitments to women and children are honored, and the resources are used in the most effective ways to prevent deaths and save lives.”

Commenting on the outcomes of the Summit, FCI’s President Ann Starrs summed it up best. “The G8’s reaffirmation of the commitments they made last year at Muskoka is welcome, as is their support for the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health. But these statements really amount to nothing more than a promise to keep a promise. Meanwhile, women, newborns, and children in developing countries are dying every few seconds from causes that are routinely prevented or treated in the G8 countries. To make a real, lifesaving difference, the leaders of the world’s most powerful economies must move from simply making statements supporting accountability to delivering the investments they have promised in the high-impact, low-cost interventions that prevent needless maternal and child deaths.”

For more updates from global health advocates at the G8 Deauville Summit, click here

WHO approves misoprostol to prevent hemorrhage

Shafia Rashid is a senior program officer in FCI’s Global Advocacy program.

Last week, the WHO Expert Committee on the Selection and Use of Essential Medicines approved the inclusion of misoprostol for the prevention of postpartum hemorrhage (PPH) on the WHO List of Essential Medicines.  PPH,or severe bleeding following childbirth, is one of the major causes of maternal death and disability in developing countries. The Expert Committee noted that “600 micrograms [misoprostol] given orally is effective and safe for the prevention of PPH” in settings where oxytocin, currently the standard of care to prevent PPH, is not available or feasible. Moreover, the committee moved misoprostol from the complementary to the core list of essential medicines, validating the drug’s important role in women’s health.

Structure of the misoprostol molecule/www.3dchem.com
Structure of the misoprostol molecule

Misoprostol, a prostaglandin, offers several potential advantages over oxytocin for managing PPH in resource-constrained settings. It is widely available in developing countries, is relatively inexpensive, can be transported and stored without refrigeration, and can be administered without an injection.

The addition of misoprostol to the WHO List of Essential Medicines is an important step forward in making the drug more widely available for PPH, and provides a critical opportunity for disseminating clear, evidence-based information to ministries of health, regulatory authorities, health system managers, health workers, and other audiences.

Strong, effective, and consistent advocacy at the global, regional, and country levels is critical for improving women’s access to misoprostol for both prevention and treatment of PPH. FCI is working with Gynuity Health Projects and other partners to develop an evidence-based advocacy agenda and communications plan to harmonize and disseminate messages on the use of misoprostol for preventing and managing PPH.

  • For more information on FCI’s work on misoprostol for PPH, click here.

FCI co-sponsoring NYC event on indigenous women

FCI, together with partners UNFPA, the Continental Network of Indigenous Women of the Americas, the International Indigenous Women’s Forum—FIMI, and Spanish International Development Cooperation Agency—AECID, are organizing a side event as part of the 10th Session of the UN Permanent Forum on Indigenous Issues. The side event — Indigenous Women, Health & Rights: Strengthening indigenous women to realize their right to reproductive health — will feature presentations by indigenous women leaders from Ecuador, Bolivia, and Peru. Speakers will discuss ways in which the “Indigenous Women, Health & Rights ” initiative, launched by UNFPA and AECID in 2008, has strengthened the capacity of indigenous women’s organizations to advocate for safe motherhood, and will discuss advances, challenges, and plans for the future. The event will be held on Tuesday, May 17, 2011, at the Beekman Tower Hotel, NYC, from 1 to 3PM. English/Spanish translation will be available.

FCI está co-organizando con UNFPA, el Enlace Continental de Mujeres Indígenas de las Américas, el Foro Internacional de Mujeres Indígenas—FIMI y la Agencia Española de Cooperación Internacional para el Desarrollo—AECID, un evento paralelo en el marco de la 10 ª Sesión del Foro Permanente para las Cuestiones Indígenas de las Naciones Unidas. El evento, titulado “Mujer Indígena, Salud y   Derechos: Fortaleciendo a las mujeres indígenas para la realización de su derecho a la salud reproductiva” contará con presentaciones a cargo de mujeres líderes indígenas de Ecuador, Bolivia y Perú. Las lideresas hablarán sobre lo que ha significado para ellas y sus organizaciones la iniciativa “Mujer Indígena, Salud y Derechos“, lanzada por el UNFPA y la AECID en 2008. La iniciativa se ha centrado en el fortalecimiento de las organizaciones indígenas para abogar por sus derechos reproductivos, en especial la salud materna. El evento tendrá lugar el martes, 17 de mayo 2011, en el Beekman Tower Hotel, Beekman Ballroon, Nueva York, de 13 a 15 horas. Se facilitará interpretación simultánea: español/inglés.

Meeting with Maternal Health Champions

Martha Murdock is Vice President, Regional Programs at Family Care International.

About a year ago, the global change organization Ashoka partnered with the Maternal Health Task Force to launch a program called the Ashoka Young Champions for Maternal Health. Fourteen young social entrepreneurs, from 12 countries around the world, were selected through a rigorous online competition to be the first of “a new generation of global leaders dedicated to improving maternal health.” The Young Champions have spent the past nine months as interns gaining hands-on knowledge about maternal health and change-making, mentored by Ashoka Fellows in Asia, Latin America and Africa.

Last week, I had the good fortune to spend some time with the Young Champions, at their end-of-program conference (the “Young Champions Future Forum”) in Accra, Ghana. I heard about the incredible range of innovative social ventures that they had the opportunity to develop  — from a program that reintegrates obstetric fistula survivors using community-based credit schemes, to a project that develops links between traditional birth attendants and skilled obstetric care providers in rural areas where use of institutional delivery care is low. Over three days of fellowship and robust debate, these young innovators discussed how to ensure community ownership of social change initiatives in isolated rural areas, the most effective strategies for conducting advocacy and outreach using social media, and the challenges faced by new professionals as they enter the maternal health field. As someone who’s been doing this work for more than two decades, I found the experience — the energy and commitment of my young colleagues, and the originality and quality of their thinking — to be frankly inspiring. I’m looking forward to seeing a lot more of these Young Champions, whose work I expect will make real impact in our field.

After the Ghana conference, I moved onto Ouagadougou, where I spent four days meeting with the team at FCI-Burkina Faso. They are doing exciting work, and I’ll report on developments there in a follow-up post.

  • Read blogs by the Ashoka Young Champions for Maternal Health

NYC screening of No Woman No Cry film

Next Monday evening, May 2nd, the Paley Center for Media will host a screening of Christy Turlington Burns’ documentary No Woman, No Cry, which illuminates the global tragedy of women dying needlessly in pregnancy and childbirth. The screening will be followed by a panel discussion, moderated by NBC News anchor Brian Williams and featuring FCI president Ann Starrs along with Christy Turlington Burns and Dr. Suellen Miller of the University of California-San Francisco.

In her deeply moving film, Christy relates how, after a childbirth complication during her own first pregnancy, she wanted to learn more about maternal health around the world. She shares the powerful stories of at-risk pregnant women in four parts of the world: a remote Maasai tribe in Tanzania, a slum in Bangladesh, a post-abortion care ward in Guatemala, and a prenatal clinic in the United States.

If you’re in or around New York, please join us for this important event. Here are the details:

The Paley Center for Media
25 West 52nd Street, NYC
Monday, May 2nd @ 6:30 pm
Tickets: $20 (Paley Center members: $15)
More info here.

No Woman, No Cry will have its TV debut on OWN, the Oprah Winfrey Network next Saturday, May 7th, at 9:30 pm Eastern time.