‘Misoprostol should be available over the counter’

Some gynaecologists believe this ‘abortion-related drug’ should be banned


Our Correspondent November 20, 2012

KARACHI: A group of gynaecologists have decided to bring misoprostol, a drug used for the prevention of postpartum haemorrhage and the treatment of incomplete and missed abortions, into local pharmacies.

The doctors gathered at the launch of the National Committee for Maternal and Neonatal Health (NCMNH) project, called ‘Saving Women’s Lives with Misoprostol’, on Tuesday. This project, in collaboration with three partner organisations - Midwifery Association of Pakistan, Association for Mothers and Newborns, and Research and Advocacy Fund, at advocating misoprostol.

NCMNH president Prof. Sadiqua N Jafarey, explained that, “The objective of the project is the inclusion of misoprostol in the national essential medicines list of Pakistan”. He added that “this will ensure the medicine’s availability to women through public sector facilities, even in remote areas.”

The World Health Organisation (WHO) included misoprostol in its essential medicines’ list in May, 2011. The medication was also endorsed by the International Federation of Gynaecology and Obstetrics and the International Confederation of Midwives.

In Pakistan, the medicine carries, however, a taboo with its name due to its use and misuse in abortion cases. “There is a lobby among gynaecologists and obstetrics which stands against the idea of making misoprostol common due to their religious belief that abortion is haram,” said Dr Shershah Syed, the founder of Pakistan National Forum on Women Health. “Misoprostol is often labelled by such people as an abortion-related drug.”

The specialists, such as Dr Samrina Hashmi, Dr Nighat Shah, Dr Sahab Jan Badar, Dr Azra Aasan, Dr Sadiah Ahsan Pal and Imtiaz Kamal, however, said that the medicine is a life-saving drug and even its misuse, which is a purview of law enforcement agencies, should not deter its availability as an over-the-counter drug.

Every year, 16,000 women die at the prime of their lives due to maternal, health-related complications, which otherwise could have been prevented without even introducing high-tech equipment or expensive medication and treatment, said Prof. Jafarey.

Postpartum haemorrhage causes 27% of birth-related deaths

In South Asia, Pakistan has the highest maternal mortality ratio of 276 per 100,000 live births. The ratio in rural areas is twice (319) that of urban areas (175). The leading cause of maternal death is excessive blood loss after childbirth or postpartum haemorrhage, which accounts for around 27 per cent of such deaths in Pakistan.

Prof. Sadiqua N Jafarey

“Every 30 to 40 minutes, a mother loses her life while giving birth to a new life,” said Prof. Jafarey. In a majority of cases this is due to the failure of the uterus to contract, she explained. “The uterotonic medicines, such as oxytocin, ergometrine and misoprostol, help the uterus to contract and reduce blood loss at childbirth, thereby preventing postpartum haemorrhage.”

A mother suffers a haemorrhage usually after a loss of 500ml of blood following vaginal delivery. Chances of dying from postpartum haemorrhage increase when women are anaemic while around half the women in Pakistan suffer from anaemia. “What rings alarm bells is the fact that around 65 per cent of all births in Pakistan take place at home and only five per cent of these are attended to by skilled birth attendants,” Prof. Jafarey added. Thousands of women die simply because the danger is not recognised at the time or the transport is not available to take the women to the health centre or the hospital is just too far away, said Prof. Jafarey, adding that, “many daais [traditional birth attendants], for instance, consider the symptom as riddance of bad blood following the delivery and say ‘let it happen’.”

In some cases, even when a woman reaches the health centre, necessary equipment or medication is not available. A woman can bleed to death in two hours if not treated. The WHO recommends oxytocin injection for prevention and treatment of postpartum hemorrhage, which has to be refrigerated to maintain its effectiveness and also requires a trained person to give injections.

“Misoprostol, however, is inexpensive (Rs10 per tablet) and does not require refrigeration like oxytocin, making it a cost effective and valuable drug to use in the developing world,” said Prof. Jafarey, adding that the medicine in contrast to oxytocin can be given orally or rectally for this use, making it much more useful in areas where nurses and physicians are less available.

Post-abortion  complications

Meanwhile, around six per cent of maternal deaths in Pakistan occur due to post-abortion complications. One of every six pregnancies in Pakistan ends in abortion. “Traditional birth attendants and midlevel healthcare providers, including nurses, midwives and other non-physician clinicians are mostly responsible for complications associated with abortions, leading to high levels of morbidity and mortality,” said Prof. Jafarey.  Around 65 per cent of women who had abortions in Pakistan are aged 30 or above and around 82 per cent of them have three or more children. These women opt for abortion in connection with family planning and usually supported by their husbands. Misoprostol has proved to be effective even as a self-administered abortion pill until the 12th week of pregnancy.

Published in The Express Tribune, November 21st, 2012.

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