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FIGO Misoprostol for PPH in Low Resource Settings Initiative
Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
Achieve, by 2015, universal access to reproductive health
The number of women dying as a result of complications related to pregnancy and childbirth remains unacceptably high. This is especially true in low resource countries across sub-Saharan Africa and South Asia where almost all these deaths occur and where a high percentage of women deliver at home or outside a health facility without immediate recourse to emergency obstetric care or a skilled birth attendant.
Post-partum haemorrhage (PPH) is the most significant direct cause of maternal mortality in low resource countries, accounting for approximately 30 per cent of maternal deaths worldwide, and is one of the most preventable. The most common cause of PPH is uterine atony, a failure of the uterus to contract adequately after delivery of the newborn(s). A key aspect in PPH prevention and treatment is uterotonic therapy and the most widely recommended agent is oxytocin. Certain factors can hinder its use in low resource settings. Oxytocin requires parenteral administration, and, therefore, skills to give injections as well as sterile equipment, and refrigeration.
In settings where injectable uterotonics are neither available nor feasible, misoprostol, a synthetic E1 prostaglandin analogue, has increasingly been adopted as an alternative intervention strategy for PPH care – one endorsed by FIGO and other international bodies. Misoprostol is available in tablet form, relatively inexpensive, stable at room temperature, well absorbed orally and sublingually, and requires few skills to administer.
ABOUT THE FIGO INITIATIVE (2010-2014)
The FIGO Initiative, funded by a grant to Gynuity Health Projects from The Bill & Melinda Gates Foundation, advocates for and disseminates evidence-based information on misoprostol for PPH, aimed at healthcare providers and clinical policymakers. It is part of a global project that is looking at ways to translate scientific and operational research on misoprostol for PPH into effective policies, programmes and practice.
In collaboration with FIGO’s Committee for Safe Motherhood and Newborn Health, professional associations and others, FIGO’s activities include:
- Conducting expert panel sessions at global obstetric and gynaecologic meetings to present current evidence & to discuss programmatic implications
- Publishing scientific articles, editorials & communications in FIGO’s official journal, the International Journal of Gynecology and Obstetrics (IJGO)
- Producing an IJGO supplement on Misoprostol for PPH
- Conducting expert panel sessions at the FIGO World Congress in Rome
- Developing guidelines, protocols and other training materials
- Conducting national workshops
Project Director - (FIGO Chief Executive) Hamid Rushwan
FIGO GUIDELINES ON THE PREVENTION AND TREATMENT OF PPH WITH MISOPROSTOL These Guidelines, published by FIGO in 2012, reflect the latest best available research on the use of misoprostol for PPH prevention and treatment. The guidelines include evidence-based recommendations for dosages and routes of administration, as well as the side effects and precautions associated with its use.
The Guidelines were developed after a review of the published literature by an expert panel that met in New York in 2011, and were subsequently endorsed by FIGO’s Executive Board members at their annual meeting in May 2012. They are available in French and Spanish translation.
FIGO recommends a single dose of 600mcg misoprostol administered orally immediately after delivery of the newborn and after it is established that there are no additional babies in utero.
FIGO recommends a single dose of 800 mcg misoprostol, administered sublingually immediately after PPH is diagnosed and if 40 IU IV oxytocin is not immediately available (irrespective of the prophylactic measures).
Related link FIGO’s Guidelines on the Prevention and treatment of postpartum hemorrhage in low-resource settings offer a comprehensive overview of a combination of best practice approaches and life-saving interventions along a continuum of care from community to hospital. Published in the International Journal of Gynecology and Obstetrics [Volume 117, Issue 2, May 2012, Pages 108–118]. The Guidelines are available in French and Spanish translation.
A policy brief – Scaling up misoprostol for postpartum haemorrhage: Moving from evidence to action – published by Family Care International (endorsed by FIGO, Gynuity Health Projects & PATH) (French version)
A special editorial by Professor Hamid Rushwan - Misoprostol: An essential medicine for managing postpartum hemorrhage in low-resource settings? - was published in the September 2011 issue of the IJGO.
WHO MODEL LIST OF ESSENTIAL MEDICINES
18th Expert Committee on the Selection and Use of Essential Medicines
The 18th Expert Committee on the Selection and Use of Essential Medicines took an important step when it approved the addition of misoprostol for the prevention of PPH to the WHO Model List of Essential Medicines.
For further information: The Selection and Use of Essential Medicines - Report of the WHO Expert Committee, 2011
19th Expert Committee on the Selection and Use of Essential Medicines
In April 2013, the 19th Expert Committee on the Selection and Use of Essential Medicines will meet in Geneva to review and to update the WHO Model List of Essential Medicines.
An application for the inclusion of misoprostol (800 mcg sublingual) on the List for the treatment of post-partum haemorrhage (PPH) was submitted by Gynuity Health Projects and will be considered by the Expert Committee during the meeting.
FIGO supports this effort to include misoprostol on the EML for its PPH treatment indication.
EXPERT PANEL SESSIONS – REGIONAL MEETINGS of OBSTETRICIANS and GYNAECOLOGISTS
FIGO is sponsoring a series of expert panel sessions on the use of misoprostol for PPH as part of a joint initiative with Gynuity Health Projects to increase access to evidence-based clinical and operational research to a global audience of obstetricians and gynaecologists. In 2012, sessions will be convened at several congresses, including:
FIGO World Congress of Gynecology and Obstetrics
Panel Sessions on Misoprostol for the Prevention and Treatment of PPH
In October 2012 Rome provided the setting for FIGO’s XX World Congress of Gynecology and Obstetrics, an important triennial event attracting leading experts in women’s health and rights from around the world. The Scientific Programme included two FIGO-sponsored expert panel sessions that focused on the prevention and treatment of PPH with misoprostol.
PANEL 1 - Misoprostol for the Prevention and Treatment of Post-Partum Haemorrhage: The Clinical Evidence & International Recommendations
Session Moderator: Zarko Alfirevic (University of Liverpool)
Name of Presenter and Title of Presentation
1. Sir Sabaratnam Arulkumaran (FIGO) - The Global Challenge of PPH and New FIGO Guidelines on the Prevention and Treatment of PPH with Misoprostol;
2. Metin A. Gülmezoglu (WHO) - The World Health Organization Recommendations on PPH;
3. Wilfrido León (Hospital Gineco-Obstétrico Isidro Ayora) - Sublingual Misoprostol for Treatment of PPH: Dose and Side Effects;
4. Rasha Dabash (Gynuity Health Projects) - Programmatic Implications of Current Strategies and New Approaches to Integrating Misoprostol for PPH Management;
5. Beverly Winikoff (Gynuity Health Projects) - Why Misoprostol Matters.
PANEL 2 - Misoprostol for the Prevention and Treatment of Post-Partum Haemorrhage: Innovative Country Approaches in Low Resource Settings
Session Moderator: Jeffrey Smith (Jhpiego)
Name of Presenter and Title of Presentation
1. Jennifer Blum (Gynuity Health Projects) - Misoprostol: A Proven Technology for Prevention and Treatment of PPH - Overview of the Clinical Evidence;
2. Swaraj Rajbhandari (Senior Public Health Specialist) - Scale-up of Misoprostol for PPH Prevention at the Country Level: Nepal;
3. Andrew Weeks (University of Liverpool) - Community-Based Use of Misoprostol for PPH Prevention: Snapshot from a Pilot Study in Uganda Documenting Self-Administration of Misoprostol in a Home Delivery Setting;
4. Susan Mukasa (Population Services International / PACE-Uganda) - Community-Based Distribution Models for Rolling Out Misoprostol for PPH Prevention: Experience and Lessons Learned from Uganda and Tanzania;
5. Shafiq Mirzazada (Aga Khan Health Services, Afghanistan) - Misoprostol for the Treatment of PPH Following its Use for Prevention (Afghanistan & Pakistan).