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Building the momentum: Misoprostol for postpartum hemorrhage in Pakistan

2014 February 26

By Imtiaz Kamal

Imtiaz Kamal is the president of the Midwifery Association of Pakistan. She has led a “one-woman crusade” to promote the midwifery profession for more than 50 years.

In June 2013, all four provinces of Pakistan—Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan—included misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) on their respective Essential Medicines Lists (EMLs). EMLs indicate medicines that “satisfy the priority health care needs of the population” and should be affordable and available at all times within the context of a functioning health system. As advocates working towards improving reproductive and maternal health in Pakistan, we’ve come a long way in our mission to expand access to misoprostol. In this post, I share our advocacy strategy and the challenges we faced.

The sixth most populous country in the world, Pakistan has an alarmingly high maternal mortality ratio: 260 maternal deaths per 100,000 live births. Every year, almost 12,000 women in Pakistan die from pregnancy and childbirth related complications, accounting for almost 5% of the world’s maternal deaths, and PPH—excessive bleeding after childbirth—causes 27% of these deaths. About 57% of deliveries still take place without a skilled birth attendant present, and in these situations, women often do not have the means to address life-threatening complications when they arise. Fortunately, there is a safe and effective solution to treat and prevent PPH—misoprostol, a low-cost medicine that is practical for use in both facility and home births.

For many years, the National Committee for Maternal and Neonatal Health, the Midwifery Association of Pakistan (MAP), and the Association for Mothers and Newborns, with support from the Research & Advocacy Fund (RAF), championed the widespread availability of misoprostol in Pakistan.

One step for improving access to this essential medicine was to get provincial governments to include misoprostol on their respective EMLs. Then, the provincial governments can supply it to the public sector health facilities, which would provide this essential medicine at minimal or no cost to women wherever they live.

Usually, the Pakistani government follows the World Health Organization’s (WHO) EML, but due to misoprostol’s association as an “abortion drug,” we had to sell it to policymakers, highlighting misoprostol’s huge lifesaving potential and the urgency to expand access to women who need it. Misoprostol is an essential part of a package of strategies to improve maternal health, and we must ensure that its use for other indications does not lead to limitations on its availability for PPH.

We devised an advocacy strategy to share the evidence and stimulate supportive policy change through:

  • Public education and awareness: fact sheets and case studies in English and Urdu, press conferences, trainings with journalists, and air time on television;
  • Advocacy with decision-makers, including high-level Ministry of Health authorities, district health officers, OB/GYNs, and other health providers: face-to-face meetings  and dissemination seminars in Punjab, Sindh, and the federal capital, Islamabad, to share guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO).

Advocates conducted seminars with health care providers to present evidence on the life-saving potential of misoprostol for PPH and post-abortion care (PAC). (Image: Midwifery Association of Pakistan)

Our advocacy strategy led to very specific, positive outcomes:

  • Endorsements from key champions: The Director General of Health in Sindh province became a close ally  and guided us on how to move forward in garnering support from  OB/GYNs and  district health officers;
  •  A widely distributed position paper on misoprostol for PPH and post-abortion care (PAC) was signed by six professional organisations working for maternal and neonatal health;
  • The National Assembly decided that the federal government should provide training to midwives and other health care providers on the administration of misoprostol to manage incomplete abortion and miscarriage and prevent PPH.  In Sindh, the Directorate of Nursing came to us for guidance, and the first misoprostol workshop for midwifery teachers is scheduled for late February 2014.

Midwives will receive training 0n the administration of misoprostol for PPH and PAC. (Image: Midwifery Association of Pakistan)

Our advocacy efforts weren’t without challenges, however. For example, many physicians were cautious or opposed to making misoprostol more widely available. The most senior OB/GYN (from a province with very high maternal mortality) raised a number of concerns after a presentation we held on misoprostol, commenting: “It is not candy. We cannot let it be available freely.”  We explained that, given the high prevalence of home births, we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births. Distributing misoprostol doesn’t replace efforts to promote skilled care, but we need to recognize the reality that many women are not able to give birth in well-equipped health facilities with skilled staff. All women, wherever they decide to give birth, need access to effective medicines.

We faced similar comments and questions at every advocacy meeting. But this didn’t stop us; we continued to make our case. Eventually, that very same OB/GYN signed our position paper on misoprostol.

The movement to achieve national recognition of misoprostol for PPH has been challenging, but we are making progress, turning heads, and changing minds. Step by step, we push forward. Now that we have achieved Federal approval of misoprostol, we are working to advance community level distribution of misoprostol to women in their eighth month of pregnancy. As a global community, with partners such as FCI rallying behind the cause, we will succeed in making sure women no longer have to fear for their lives when giving birth.

For more information:

Mapping Misoprostol for Postpartum Hemorrhage Regional Perspectives on Challenges and Opportunities South Asia

Advocacy for PPH Prevention and PAC: PowerPoint Presentation at the Research and Advocacy Fund 2nd Annual Conference

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