Midwives and misoprostol: Saving lives from PPH
Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
For women around the world, compassionate and competent care from a midwife can mean the difference between life and death. We know that midwives provide life-saving care during pregnancy, childbirth, and in the postnatal period. Midwives, and other mid-level and community health providers, can administer essential medicines, such as oxytocin and misoprostol, which are safe and effective for preventing and treating life-threatening postpartum bleeding or hemorrhage (PPH), the leading cause of maternal death in most developing countries. Access to misoprostol is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used in poorly equipped health facilities and even home births.
In order for midwives to provide life-saving maternal health care, they need the support of policies that enable them to provide a full range of medical interventions. In some countries, however, midwives are not legally authorized to administer oxytocin and/or misoprostol —despite evidence that administration by low and mid-level health providers is feasible and effective. But physicians sometimes resist or oppose expansion of midwives’ scope of practice, based on notions of “professional territoriality” and concerns about their capacity to correctly and safely administer these medications.
Most women in low-resource settings give birth in lower-level health facilities or at home, attended by a midwife or other mid-level health provider. So restrictive policies requiring that administration of medications be carried out only by physicians limits women’s access to essential medicines they need for safe pregnancy and childbirth. Placing misoprostol in the hands of non‐physician providers, for example, can expand access to timely PPH treatment. In remote and rural areas, where transfer for emergency obstetric treatment at a higher-level facility may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
The global health community can play an important role in addressing and removing policy and regulatory barriers, and ultimately in improving women’s access to essential medicines. Making this happen will require that governments, in many countries, revise policies that allow administration of medications only by physicians. In 2012, WHO issued guidelines on task-shifting for maternal and newborn health. They called for a “more rational distribution of tasks and responsibilities among cadres of health workers …[to] significantly improve both access and cost-effectiveness – for example by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions otherwise provided only by cadres with longer (and sometimes more specialized) training.” This makes excellent sense.
The leading global health professional associations focused on pregnancy and childbirth, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO), can work together to ensure that these international recommendations translate into changes in national norms and in clinical practice. Earlier this year, ICM and FIGO issued a joint statement, Misoprostol for the treatment of postpartum hemorrhage in low resource settings, which called on partners to:
- Promote task-sharing approach
- Ensure that skilled health providers (and not just doctors) can administer uterotonic drugs like misoprostol and oxytocin
- Challenge regulatory and policy barriers that limit access to high quality maternal health care
- Advocate for increasing the midwifery workforce
- Implement innovative strategies to strengthen the role of midwives and non-physician providers in providing high-quality maternal health services
Health professionals, policy makers, and other partners must work together to ensure that every woman has access to the uterotonic medicines that can protect her from the suffering and potential death that can be caused by postpartum hemorrhage.
 Beverly Winikoff, Why misoprostol in the hands of non-physician providers matters, Presentation at the ICM Trienniel Congress, Prague, June 3, 2014.