By: Dr. Aoife Kenny, a maternal health advocate and clinician in New Zealand
Pregnancy and childbirth can be dangerous, no matter where you are in the world. But it is the ability to deal with, or better yet prevent, things from going wrong that makes the difference.
A study published in BJOG, the International Journal of Obstetrics and Gynaecology, in July 2012 highlights an exciting development for women worldwide. The study showed that crushed misoprostol tablets put under the tongue was more effective than the injected oxytocin in preventing post-partum hemorrhage (PPH), a high loss of blood after delivery. The skin under the tongue rapidly absorbs medications, especially if the drug is crushed. This means that the amount of misoprostol required to be effective is lower than in previous studies – and therefore the side effects are decreased. The study was large and statistically sound, showing that this new way of administering misoprostol significantly reduced the amount of blood loss after delivery, as well as the drop in hemoglobin (anemia) in the days following.
PPH is defined as blood loss of more than 500 mililiters after a vaginal delivery or more than 1 liter after a caesarean section. It is the leading cause of maternal deaths, killing more than 100,000 women per year globally. Well-established preventative steps are recommended immediately after the birth of the infant: uterotonic medication, controlled cord traction, and early cord clamping and cutting – known collectively as ‘active management of the third stage of labor.’ The third stage refers to the delivery of the placenta.
In New Zealand, where I work as a doctor in a tertiary-level women's hospital, the maternal mortality rate is 15 deaths per 100,000 pregnancies, among the lowest in the world. We have the tools – well-trained midwives, an efficient referral system, and effective medications, for example – to make childbirth safe. Women in many other parts of the world are not so fortunate – in some countries women have up to a 1 in 16 chance of dying just because they are pregnant or give birth.
In New Zealand, and many other countries, the uterotonic medication of choice is the synthetic version of the hormone oxytocin. Oxytocin is integral in the separation of the placenta from the uterus. If the placenta does not separate from the uterine wall, PPH may occur. The synthetic hormone is injected into the thigh muscle and assists this natural process. It is considered the ‘gold-standard’ in uterotonic medication and the most effective. However, it requires a number of things that may not be available to women globally – safe needles and syringes, skilled attendants, and an ability to keep the medication refrigerated. Using misoprostol avoids these complications, and it can be taken as a tablet and is heat-stable. It is easily transported, and it requires simple training to administer. Unfortunately, until now, it was seen as inferior to oxytocin for preventing PPH. Clinical trials have shown the tablets to be less effective, with unwanted side effects like uncontrollable shivering. Appropriately, efforts have mainly been focused on making oxytocin more available to women globally.
As with any scientific breakthrough, more work needs to be done before we can consider delivery of crushed misopristol under the tongue a practice-changing development. However, in a world where hope for women is a precious commodity, we should be ecstatic. Is this a turning point? Will this simple but highly effective change in medication administration make global equality in maternal care a closer reality? Will it change clinical guidelines in rich as well as developing countries? As a clinician, I can see potential pitfalls and look forward to further studies. As a maternal health advocate, I want to trumpet this to the world as a major step forward. And, as a woman, I wish in my heart that for all of you, my sisters, this is as extraordinary as it could be.
To access the article published in BJOG, please click here.
Flickr photograph via farlukar.