Maternal health drug misses in health facilities

By Esther Nakkazi

A life saving drug for women with obstetric and gynecologic complications, Misoprostol, is about to expire in Uganda government stores, which will undo the gains in maternal health achieved so far.

Although, Uganda’s maternal mortality statistics had over a decade gone down from 435 to 310 deaths per 100,000 live births, health officials are afraid that minus Misoprostol, more deaths due to unsafe abortion may occur. In Uganda, unsafe abortions account for 26 percent of maternal mortality, although these are completely preventable.

Misoprostol, a safe technology, has been approved by the World Health Organisation for use in Post Abortion Care (PAC) and is being promoted by the Uganda Ministry of Health.

But at Mulago, the biggest referral hospital in the country and in a number of health facilities except health centre IIIs, there is a shortage of Misoprostol. “We have not been getting Misoprostol for sometime now at Mulago and we are wondering why, said Dr. Charles Kiggundu a consultant gynecologist and obstetrician with Mulago Hospital.

Kiggundu also the vice president of the Association of Obstetricians and Gynecologists of Uganda (AOGU) said, “our interest in this drug is because it stops women from excessive bleeding, which is the most common cause of maternal deaths. When administered it causes the uterus to contract and stops blood loss.”

An official from the National Medical Stores (NMS) who did not want to be named said they have enough stocks of Misoprostol to supply all health facilities but under the pull system, which is user-driven, district health officials have to requisition for it.

Misoprostol, therefore, can now only be found in Health Centre IIIs because they use the push system, which is Ministry of Health driven, where the drugs are supplied irrespective of the need.

Independent analysts said NMS now being profit- driven does not pay a lot of attention to Misoprostol because it is a government drug and has no benefits. It costs only Ushs.300 ($0.1) in public and 15,000 ($6) in private health facilities. 

Health care providers in Uganda administer Misoprostol in high risk pregnancies like for women who birth twins, triplets, more than five pregnancies, those who go through long and obstructed labor as well as women under going surgery.

But recently, they have realized that all women who deliver potentially need Misoprostol including those in the low risk group said Kiggundu. Low risk in this case refers to women having the first baby and those having normal labor.

This, thus, means all the 2 million women who get pregnant in Uganda annually are potential users of Misoprostol, which is now about to expire in government stores. Misoprostrol is also cheap, safe, private, efficient, painless, easy to transport, store and administer even by non-health workers with training, which helps ease up professional health workers time, a much needed resource in poor settings. 

Health officials attending a national conference on unsafe abortion in Kampala last week expressed anger about the absence of Misoprostol in the various health facilities even as women continue to be rushed to them for post abortion care after carrying out unsafe abortions. Abortions are restricted in Uganda and only permitted to save a woman’s life.

Uganda’s abortion rate is among the highest in the world at 54 abortions per 1000 women and its estimated that 26 percent of maternal mortality result from unsafe abortions.

In a 2005 World Health Organization survey, it was estimated that 300,000 abortions occur per year in Uganda. But nearly 85,000 women are treated for complications- most of these are incomplete abortions where the uterus continues to bleed until medical care is sought.

In such circumstances, Misoprostol comes in handy, and it has been demonstrated that if taken orally, only 3 tablets, it can reduce on the bleeding or remove the products of the uterus. It could also be used in early pregnancy termination of abnormal fetus or to save the mother. 

Dr. Collins Tusungwire a senior medical officer with the Ministry of Health said they have taken a number of steps to address the issue of unsafe abortion using Misoprostol. In collaboration with PACE Uganda, in 2011 the ministry got the drug registered for all gynecological indications in Uganda.

It was also put in Mama kits – an all-in-one package that contains everything needed to help provide a clean and safe delivery-but it was withdrawn because women used to use it and not go to health facilities.

Dr. Dorothy Balaba, an official from PACE Uganda said they have increasing accessibility and availability of Misoprostol in the private sector, trained over 2,000 health workers on its use and worked to integrate it in post abortion care services.

As Hillary Clinton, US Secretary of State 2009 observed in 2009, “You cannot have maternal health without reproductive health. And reproductive health includes contraception and family planning and access to legal, safe abortion.”

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