Preventing post-partum haemorrhage at home during COVID-19: what are we waiting for?

Disruptions in health service delivery due to the COVID-19 pandemic have had a devastating effect on maternal, neonatal, and child health (MNCH) with rises in maternal and neonatal deaths expected.¹ Post-partum haemorrhage is the leading cause of maternal mortality in low-income countries and is likely to increase because of estimates of, at best, a 10% reduction in MNCH services.¹

Misoprostol is a safe and cost-effective alternative uterotonic that is used when oxytocin is not available. It is heat stable, available in tablet form, and can be distributed by a community health worker, traditional birth attendant, or taken by the woman herself after birth.² In November, 2020, WHO recommended the advance distribution of misoprostol at antenatal visits for the prevention of post-partum haemorrhage for women who give birth at home and cannot access a skilled birth attendant.³

Advance distribution of misoprostol for the prevention of post-partum haemorrhage in contexts where women cannot access a health facility because of disruptions in essential health services, such as the COVID-19 pandemic, is now a crucial consideration. Misoprostol has previously been distributed in humanitarian emergencies where access to health services was difficult. During the 2014–16 Ebola outbreak in Liberia, misoprostol was included in clean birth kits and distributed by trained community health workers.4, 5, 6 Nepal, one of the first countries to scale up the use of misoprostol for the prevention of post-partum haemorrhage in the community, continued to make use of this strategy during the 2015 earthquake.5, 7

Scaling-up misoprostol for the prevention of post-partum haemorrhage in the community in Nepal has again reaped benefits during the COVID-19 pandemic. Facility-based births were reduced by half (49·9%) during Nepal's COVID-19 lockdown (between March 21 and May 30, 2020).⁸ In May, 2020, the Nepalese Ministry of Health and Population approved the distribution of misoprostol to all women who cannot reach a health facility to give birth and were 8 months pregnant.⁹ This was expedited because women were facing difficulties in accessing maternal health services because of the lockdown and their reluctance to give birth at the health facility.

The examples during the Ebola outbreak in Liberia and recently in Nepal highlight that misoprostol can be distributed in complex emergencies where health systems have been disrupted. In both contexts, a cadre of trained community health workers assisted with distribution. Ministries of Health and partners, including Jhpiego in Liberia and One Heart Worldwide in Nepal, were able to quickly adapt and distribute misoprostol to women within the community. This ability to mobilise misoprostol was partly due to political support, previous experience, and evidence for the distribution at community level for post-partum haemorrhage prevention.² In both countries, misoprostol for post-partum haemorrhage was on the National Essential Medicines List and part of the essential MNCH drugs, alongside oxytocin. In the case of the Ebola outbreak in Liberia, available guidelines and recommendations by WHO and UNICEF probably accelerated its use.

The 2020 WHO guidelines affirm that misoprostol can be distributed in advance to women in humanitarian contexts with considerations to integration with other response strategies and the values and preferences of women in emergency situations.³ The Minimum Initial Services Package for Sexual and Reproductive Health is a response strategy that can be used to increase access to misoprostol for post-partum haemorrhage in humanitarian crises. The Inter-Agency Working Group on Reproductive Health in Crises also recommends pre-positioning supplies of misoprostol for the prevention of post-partum haemorrhage and training and equipping community providers during COVID-19 in settings where health facilities are inaccessible.¹⁰

COVID-19 has shown that innovative mitigation strategies are needed to resume gains made in MNCH. Governments and policy makers need to update their national guidelines to ensure that misoprostol for post-partum haemorrhage prevention can be distributed at the community level, at least until the pandemic improves. Community health workers and traditional birth attendants play a crucial role in bridging the service delivery gap and can provide clean delivery kits that include misoprostol to prevent post-partum haemorrhage.

Now is the opportunity to ensure that all women in need can protect themselves against post-partum haemorrhage and reduce the risk of dying in childbirth. Misoprostol can prevent post-partum haemorrhage and save women's lives. What are we waiting for?