Graphic: MamaYe Guana. Data: World Health Organization
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Dr. Stacie Geller told Ghana’s Ministry of Health she wanted to put misoprostol – a lifesaving drug for mothers after childbirth – directly into the hands of pregnant women. They thought she was crazy because the drug is also commonly used in abortions.
“After I wiped them up off the floor, they said, ‘You can’t do that,’” Geller recalled as she spoke during the Global Urban Challenges three-day conference in Chicago this week. “I said, ‘Why can’t I do that?’”
She didn’t want to give the drug to expectant moms for abortions – quite the opposite, actually.
Geller wanted to use misoprostol to decrease postpartum hemorrhage, or excessive bleeding after delivery. Postpartum hemorrhage is the leading cause of maternal death in developing countries and that's where 99 percent of the loss of life due to childbirth occur worldwide.
Women can bleed to death after delivery within just a few hours, according to Geller. And for women in developing countries who deliver at home or in very basic health facilities, those few hours can be the difference between life and death.
“The government was convinced the women were going to sell it, were going to save it for an abortion, lose it, their children were going to swallow it. Their fantasies were unbelievable,” Geller said. “My reality was women don’t want to die in pregnancy; they’re going to keep the drug safe, and if they stay home [to deliver], they’re going to take it.”
Misoprostol was approved by the FDA in 1988 to treat gastric ulcers, but U.S. doctors regularly use it off-label to prevent postpartum hemorrhage.
Geller has been studying the use of misoprostol in postpartum hemorrhage for decades, finding it a critical drug for reducing the death toll of childbirth in developing nations. In India, her clinical trials reduced postpartum hemorrhage by 50 percent and severe postpartum hemorrhage by 80 percent. The World Health Organization added it to the essential drug list.
But in Ghana, how do you get a medication to women who don’t always use doctors, nurses or midwives to help them deliver?
“We thought who’s always going to be at the delivery? Who? The woman herself, right? Maybe nobody else,” Geller said.
So when the Ministry of Health said Geller couldn’t hand out a drug out to somebody who’s not a medical provider, Geller went to the health providers expectant moms visit during their pregnancy.
And they put it in the expectant moms’ hands.
“If we could get them to the midwife at some point in their pregnancy, preferably sometime during the third trimester, the midwife could educate the woman and hand her the medication and let her take it home,” Geller said.
Geller and her team gave midwives the medication and, as part of the study, a plastic drape for the mothers to measure blood loss, collected in a plastic pouch with two alert lines – a yellow and a red. After home delivery, women could see whether they were bleeding more than average if their blood loss reached the yellow alert line. The red warning line meant hemorrhaging. But all the women took the medicine after delivery to prevent hemorrhaging.
Women only used 10 percent of the approximately 1,000 doses given out, however. All the rest were returned because of one of the unanticipated benefits. Geller said that was - in talking to women about visiting a midwife if they could - they started going to health centers for their labor. The home birth rate dropped from 70 percent of women in the study to 30 percent.
Decreasing home birth rate was only part of the success. Women were able to use the medication correctly, the Ghana Health Service agreed to integrate it into a national model, and the World Health Organization said that in the absence of a skilled provider, a low or minimally skilled person can give misoprostol, Geller said.
“They are yet to say we can put it in the hands of the pregnant woman, but our paper’s about to come out in BJOG and so hopefully that paper’s about to change their mind,” Geller said.
BJOG is an international journal of obstetrcis and gynecology.
Geller returning to Ghana Nov. 29 to meet with Ghana health officials about rolling out the program nationally.