Misoprostol – a pill that saves women's lives or an excuse not to give them care?

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http://www.guardian.co.uk/society/sarah-boseley-global-health/2012/aug/23/maternal-mortality-maternal-health

With a quarter of women's deaths in childbirth caused by bleeding, a pill to prevent or stop haemorrhage is a godsend, say many. But the evidence for the safety and efficacy of misoprostol, which can also be used to bring about abortion, continues to be furiously contested


Pregnant women wait to enter the maternity ward of the Katine health centre in north-east Uganda. Photograph: Dan Chung for the Guardian

Seldom has there been a drug that has excited as much controversy as misoprostol. It is used in rich countries to prevent gastric ulcers, but in poor countries, it is increasingly given to women to prevent them bleeding to death in childbirth. Some people believe it is saving countless lives. Others violently disagree.

Misoprostol causes the uterus to contract, which is why it can stop postpartum haemorrhage, the cause of around a quarter of maternal deaths. But there has been a huge fight over whether and how well it works, which in some quarters has been ideologically motivated, because misoprostol can also bring about an abortion. Finally last year, the World Health Organisation put misoprostol on its essential drugs list, which gave it the seal of approval. That is a recommendation to all nations to stock it.

But a paper just published by the journal of the Royal Society of Medicine shows that the furore is not going away any time soon. The paper, written by Professor Allyson Pollock from the Centre for Primary Care and Public Health at Queen Mary, University of London and colleagues, calls on the WHO to take misoprostol off the essential drugs list.

Pollock and her team say there is not enough evidence from studies that misoprostol works in preventing postpartum haemorrhage. They looked at 172 studies and dismissed as inadequate all but six. Those six were randomised controlled trials (RCTs), which means that women who took part were either randomly allotted misoprostol or nothing or an alternative if they began to haemorrhage. This is the gold-standard way to test whether a drug works and is safe. But the team found even these six were not without problems and, overall, concluded the evidence base was not good enough for the drug to be listed by the WHO.