Misoprostol for Postpartum Hemorrhage: Translating Promise Into Reality
In Kenya, where I work as an advocate for women’s health and rights, women continue to die during pregnancy and childbirth at alarming rates. Approximately 25% of these deaths are due to heavy bleeding following childbirth, also known as postpartum hemorrhage or PPH. More than half of women deliver at home; that proportion can be even higher in some counties with limited infrastructure and predominantly rural populations. Even in cases where a woman arrives to a health facility in time, she can still face significant barriers to receive the care she needs:
- supplies needed for childbirth—such as a blood pressure cuff or clean gloves—may not be available;
- essential medicines—such as oxytocin or misoprostol, which can prevent or treat postpartum bleeding—may be in short supply; and
- a skilled health provider may not be present to provide the care a woman needs to have a safe delivery.
A key strategy for improving maternal health is to ensure that every woman has access to effective medicines to prevent and treat PPH during childbirth. Oxytocin and misoprostol are proven, lifesaving medicines for the prevention and treatment of PPH. Misoprostol offers a number of advantages for women living in remote, rural areas: misoprostol does not need refrigeration, is available in tablet form and can therefore be administered with no specialized equipment or skills. Misoprostol provides an effective option for preventing and treating PPH in settings such as homes and health facilities lacking electricity, refrigeration and IV equipment.
For these reasons, Kenya’s Ministry of Health established a national-level task force to provide a common forum for addressing policy-level issues related to the use of misoprostol for the prevention and treatment of PPH. While misoprostol is registered in Kenya for the management of PPH, and national guidelines govern its use, studies have shown that misoprostol’s procurement and availability in public health facilities is irregular and inconsistent.
This national, multi-stakeholder task force—composed of government, NGO, research, faith-based and health profession representatives[1]—was tasked with spearheading access to and use of misoprostol for PPH. Beginning in 2014, the Misoprostol Task Force, convened by the ministry of health, met regularly to identify the key policy gaps at the national level and to take concrete action. Key policy priorities identified by the Task Force:
- Harmonize the national clinical guidelines: Kenya has numerous clinical management guidelines advising health professionals on how to administer misoprostol for all its indications (PPH, induction of labor and post-abortion care): the 2009 Clinical Guidelines for Management and Referral of Common Conditions at Levels 4-6 and the 2012 National Guidelines for Quality Obstetric and Perinatal Care. While these guidelines recommend the use of misoprostol to prevent and treat PPH when oxytocin is unavailable, they do not reflect the latest evidence and were inconsistent with each other. The Task Force developed a handout that harmonizes these different guidelines and produced a job aid for health workers. Both documents are waiting approval by the ministry of health; once approved, they will be disseminated at the national and sub-national/county levels.
- Revise the national essential medicine list: While the Kenya Essential Medicine List (KEML, 2010) classifies misoprostol as a complementary and core[2] oxytocic drug, no specification is made for its use in PPH prevention or treatment. The Task Force drafted a letter to the National Medicines and Therapeutics Committee, to call for the addition of misoprostol to the KEML for PPH prevention and treatment at all levels of the health system. This letter will likely be deliberated by the committee when it meets this year to update the KEML.
Continued advocacy is still needed to ensure these positive developments in the Kenyan national policy framework translate into actual improvements in the availability and use of misoprostol. The Task Force has served as a critical forum for bringing together key stakeholders, promoting national level discussion and supporting effective action.
For more information and tools for conducting effective advocacy:
This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies Caucus, Family Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.
[1] Membership includes representatives from the Ministry of Health-Reproductive Maternal Health Services Unit, Family Care International-Kenya, PATH, Management Sciences for Health, the Population Council, UNFPA, AMREF, Institute of Family Medicine (INFAMED), Christian Health Association of Kenya (CHAK), Jhpiego, the World Health Organization and professional organizations of gynecologists and nurses.
[2] The Core List represents the priority needs for the health care system. Medicines on the Core List are considered to be the most efficacious, safe and cost‐effective; are expected to be routinely available in health facilities; and should be affordable to the majority of the population. Complimentary medicines are essential medicines needed for specialized diagnostic or monitoring facilities, and/or specialist medical care, and/or specialist training.