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Misoprostol - a pill which saves women's lives or an excuse not to give them care? Misoprostol – a pill that saves women's lives or an excuse not to give them care?
(about 17 hours later)
Seldom has there been a drug which has excited as much controversy as misoprostol. It is used in rich countries to prevent gastric ulcers, but in poor countries, it is increasingly given to women to prevent them bleeding to death in childbirth. Some people believe it is saving countless lives. Others violently disagree. Seldom has there been a drug that has excited as much controversy as misoprostol. It is used in rich countries to prevent gastric ulcers, but in poor countries, it is increasingly given to women to prevent them bleeding to death in childbirth. Some people believe it is saving countless lives. Others violently disagree.
Misoprostol causes the uterus to contract, which is why it can stop post partum haemorrhage, the cause of around a quarter of maternal deaths. But there has been a huge fight over whether and how well it works, which in some quarters has been ideologically motivated, because misoprostol can also bring about an abortion. Finally last year, the World Health Organisation put misoprostol on its essential drugs list, which gave it the seal of approval. That is a recommendation to all nations to stock it. Misoprostol causes the uterus to contract, which is why it can stop postpartum haemorrhage, the cause of around a quarter of maternal deaths. But there has been a huge fight over whether and how well it works, which in some quarters has been ideologically motivated, because misoprostol can also bring about an abortion. Finally last year, the World Health Organisation put misoprostol on its essential drugs list, which gave it the seal of approval. That is a recommendation to all nations to stock it.
But a paper just published by the journal of the Royal Society of Medicine shows that the furore is not going away any time soon. The paper, written by Professor Allyson Pollock from the Centre for Primary Care and Public Health at Queen Mary, University of London and colleagues, calls on the WHO to take misoprostol off the essential drugs list.But a paper just published by the journal of the Royal Society of Medicine shows that the furore is not going away any time soon. The paper, written by Professor Allyson Pollock from the Centre for Primary Care and Public Health at Queen Mary, University of London and colleagues, calls on the WHO to take misoprostol off the essential drugs list.
Pollock and her team say that there is not enough evidence from studies that misoprostol works in preventing post partum haemorrhage. They looked at 172 studies and dismissed as inadequate all but six. Those six were randomised controlled trials (RCTs), which means that women who took part were either randomly allotted misoprostol or nothing or an alternative if they began to haemorrhage. This is the gold-standard way to test whether a drug works and is safe. But the team found even these six were not without problems and overall, concluded the evidence base was not good enough for the drug to be listed by the WHO. Pollock and her team say there is not enough evidence from studies that misoprostol works in preventing postpartum haemorrhage. They looked at 172 studies and dismissed as inadequate all but six. Those six were randomised controlled trials (RCTs), which means that women who took part were either randomly allotted misoprostol or nothing or an alternative if they began to haemorrhage. This is the gold-standard way to test whether a drug works and is safe. But the team found even these six were not without problems and, overall, concluded the evidence base was not good enough for the drug to be listed by the WHO.
Pollock put it more strongly than that on the phone.Pollock put it more strongly than that on the phone.
It is like giving snake oil to women and saying it is better than nothing.It is like giving snake oil to women and saying it is better than nothing.
She argues that the drive for misoprostol use is coming from "a few very determined paediatricians and midwives... this is ideology and belief and faith". She says we would not use misoprostol in this way in rich countries - so why do the poor have to accept a sub-standard treatment? Her paper calls on countries to spend their money on improving primary care, preventing anaemia which puts women at high risk of haemorrhage, and training up birth attendants, instead of relying on a pill. She argues that the drive for misoprostol use is coming from "a few very determined paediatricians and midwives … this is ideology and belief and faith". She says we would not use misoprostol in this way in rich countries – so why do the poor have to accept a sub-standard treatment? Her paper calls on countries to spend their money on improving primary care, preventing anaemia, which puts women at high risk of haemorrhage, and training up birth attendants, instead of relying on a pill.
But Pollock does not have a monopoly on strong language in this debate. This was the response of Malcolm Potts, Bixby Professor of Population and Family Planning at the University of California, Berkeley, who is the author of an editorial calling for community distribution of misoprostol published in the Lancet medical journal in 2010, before the WHO decision.But Pollock does not have a monopoly on strong language in this debate. This was the response of Malcolm Potts, Bixby Professor of Population and Family Planning at the University of California, Berkeley, who is the author of an editorial calling for community distribution of misoprostol published in the Lancet medical journal in 2010, before the WHO decision.
Tens of millions of women deliver their babies without a trained midwife. I think the authors of this naive and misleading paper should crawl on their knees and beg forgiveness from these women for suggesting we deny them access to a proven life-saving medication called misoprostol. Tens of millions of women deliver their babies without a trained midwife. I think the authors of this naive and misleading paper should crawl on their knees and beg forgiveness from these women for suggesting we deny them access to a proven life-saving medication called misoprostol.
There are 45 million women who deliver without a trained birth attendant. Oxytocin, the gold standard drug to prevent bleeding, is not heat-stable and has to be injected. Misoprostin is heat-stable and comes in tablet form. Women can have it at home to take by themselves at the end of their labour. Under these circumstances, Potts and others believe, denying women misoprostol is going to cost lives. There are 45 million women who deliver without a trained birth attendant. Oxytocin, the gold-standard drug to prevent bleeding, is not heat-stable and has to be injected. Misoprostin is heat-stable and comes in tablet form. Women can have it at home to take by themselves at the end of their labour. Under these circumstances, Potts and others believe, denying women misoprostol is going to cost lives.
The trial data is not as good as anybody would like, but Potts insists there is reliable, acceptable scientific evidence, even if it is not always in the form of randomised controlled trials - those are hard to do in settings where women often give birth alone at home. The trial data is not as good as anybody would like, but Potts insists there is reliable, acceptable, scientific evidence, even if it is not always in the form of randomised controlled trials – those are hard to do in settings where women often give birth alone at home.
The International Federation of Gynaecology and Obstetrics recommends the use of misoprostol for prevention and treatment of post partum haemorrhage and is part of a Gates-funded initiative to bring about wider distribution of the tablets. It will be surprising if the WHO changes its stance at the next meeting to discuss the essential medicines list, early next year. The International Federation of Gynaecology and Obstetrics recommends the use of misoprostol for prevention and treatment of postpartum haemorrhage and is part of a Gates-funded initiative to bring about wider distribution of the tablets. It will be surprising if the WHO changes its stance at the next meeting to discuss the essential medicines list, early next year.