Analysis Abortion

Misoprostol Is a Game-Changer for Safe Abortion and Maternal Health Care. Why Isn’t it More Widely Available?

Francine Coeytaux & Elisa Wells

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide—postpartum hemorrhage and unsafe abortion—why have we not taken more advantage of it?

Misoprostol: Have you heard about this small, inexpensive, and most importantly available pill that can save women’s lives? Pragmatic Brazilian women first discovered the potential of misoprostol (or Cytoteca, in their parlance) in the 1980s. According to the label on this widely used peptic ulcer drug, it was not to be taken during pregnancy as it could induce bleeding. Living in a country with very restrictive policies and little access to safe abortion services, they recognized the opportunity to circumvent the system and, by word of mouth, spread the word to other women about this easily obtainable pill that could help them safely end an unwanted pregnancy.

Thirty years later, women in countries around the world are beginning to do the same—continuing to spread the word, talking to each other about misoprostol, and trying to get their hands on these pills. The women who are accessing the drug in their communities and taking it by themselves have shown us that there are relatively few health risks involved with misoprostol. What began in Brazil as a natural public health experiment has been validated by rigorous clinical studies conducted by international groups such as the World Health Organization and Gynuity. These studies have shown that the use of misoprostol for abortion is very safe, especially when taken early on in the pregnancy; while not as effective as when taken in combination with mifepristone (another abortion pill), misoprostol taken alone will safely terminate 75 to 90 percent of early pregnancies when taken as directed.

Misoprostol has also been proven to have numerous other lifesaving properties, including the ability to prevent and treat postpartum hemorrhage and to induce labor. It is registered in more than 85 countries, usually as an anti-ulcer medication, and is used off-label by clinicians around the world for numerous reproductive health indications. In addition to these clinical uses, we are beginning to see positive public health outcomes from community-based use of misoprostol. In countries where abortion is restricted and women are using misoprostol, we have seen a reduction in infections. And in under-served communities, where women delivering at home are taught to take misoprostol immediately after delivery, postpartum hemorrhage is significantly reduced.

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide—postpartum hemorrhage and unsafe abortion—why have we not taken more advantage of this exciting technology? Given the global attention being paid to meeting the fifth Millennium Development Goal (MDG 5)—that of reducing maternal mortality—it is difficult to fathom why we continue to squander the opportunity misoprostol offers us.

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The public introduction of any new technology takes time and is not easy; the introduction of emergency contraception is just one of the latest examples. Reproductive health advocates have been working for decades to increase women’s access to this safe, effective, and non-abortifacient technology. While much progress has been made around the world, the recent action of the Obama administration to prevent full over-the-counter access in the United States is a sad illustration of the hurdles women face in accessing reproductive health technologies. The hurdles we face in introducing misoprostol will be even higher given three inherent characteristics:

  • It has multiple indications, including abortion.

  • It is only “second best” to existing drugs, competing with a “gold standard.”

  • It can be used by women without the assistance of a provider.

The Challenge of Multiple Indications

Misoprostol’s greatest clinical asset—the fact that it can be used for numerous reproductive health indications—also poses enormous challenges for implementation. As mentioned, misoprostol has many uses: to both prevent and treat postpartum hemorrhage, to induce labor, to induce abortion, and for post-abortion care. But these multiple indications pose two major challenges for implementation, one political and the other educational.

The political challenge lies in overcoming the stigma of abortion. A survey we conducted in 2010 of organizations that were working with misoprostol for postpartum hemorrhage revealed that the second biggest barrier to the introduction of misoprostol was its association with abortion. To quote one respondent who was asked about the challenges and opportunities for its introduction: “Hypersensitivity of misoprostol as an abortifacient [is a barrier]. We see this in clinical providers, government officials, even donors—a disproportionate concern that if misoprostol were to be made available for PPH prevention and treatment, it would be used for abortion. This is a major obstacle in accepting misoprostol for other OB/GYN indications—the abortion stigma.”

This political fear is strong, despite the evidence that all indications of misoprostol use are potentially life-saving. And because of this fear, there is a great deal of sidestepping going on as organizations begin to introduce misoprostol at the community level for postpartum hemorrhage while trying to stay clear of its potential use for abortion. “We feel there is tremendous promise for use of misoprostol for [postpartum hemorrhage], so we do not want to jeopardize that application by highlighting the other indications,” said another respondent.

The political controversy only exacerbates the programmatic challenge of informing women, their partners, and their health-care providers of the different doses and the proper timing of administration needed for different indications. This is usually facilitated by the registration and labeling of products in appropriate doses for each of misoprostol’s various indications. But because the vast majority of misoprostol use is currently done “off-label”(it’s being used for an indication other than the one the product is registered for) there is an urgent need to find ways to get women accurate information about how to use it for the different reproductive health purposes. Mobile technologies are beginning to open the information door to some women, but challenges remain. We need to find ways of achieving a broader level of knowledge about correct use, and to help women differentiate between the proper uses for each indication, including abortion.

The Challenge of Competing Against a “Gold Standard”

For both indications—abortion and postpartum hemorrhage—misoprostol is the second best option, up against another drug long considered the “gold standard.” For abortion, the most effective medical abortion regimen is mifepristone combined with misoprostol; when used together, the success rate is 93 percent, and when misoprostol is used alone it is 78 percent successful. Thus, where mifepristone is available, such as in the United States, it is the drug of choice.

In the case of postpartum hemorrhage, injecting oxytocin is the first line of treatment because, when oxytocin is at full potency, it is more effective than misoprostol. But oxytocin, unlike misoprostol, needs to be refrigerated. As a result, the quality of the drug is easily compromised by exposure to heat—a problem in many Global South countries. Finally, the administration of oxytocin requires that the women deliver in a health-care facility, another “gold standard” established by the medical community.

In reality, in many places in the world, we are not meeting these “gold standards,” in spite of decades of trying to do so. Mifepristone is far from universally available, oxytocin stock-outs are common in many places and/or the quality has been compromised, and many women continue to deliver at home, without skilled attendants. In these situations, misoprostol is a very good alternative and even has the advantage of being in pill form, making home use possible and safe.

Which brings us to the third challenging characteristic…

Women Can Use it Without the Assistance of a Provider

Another survey respondent summed it up nicely: “This is a gender issue. Misoprostol faces this unbelievable barrier because it is a drug for women.”

Therein lies both the greatest opportunity and the greatest challenge. Misoprostol has the potential to be a game-changer when it comes to maternal health precisely because it can be used safely and effectively by women themselves. The foremost obstacle to achieving MDG 5 is the weak health-care infrastructures of many countries. Misoprostol offers the opportunity to circumvent this obstacle for two of the three principal causes of maternal mortality—postpartum hemorrhage and unsafe abortion. Yet despite growing evidence that women can safely and effectively take misoprostol by themselves, in their homes, for both uses, health-care practitioners are insisting on controlling access to the drug, viewing it as an important addition to their clinical tool kit and a service only they can “provide” instead of as a pill that can be used by women, to help themselves, with little or no assistance from a health-care provider. The failure to relinquish control over the use of misoprostol not only gets in the way of women who are intent on helping themselves, it risks negating the most attractive aspect of this new technology: it’s self-use properties. To quote another respondent to our survey: “Many people are more concerned about what might happen with an intervention (i.e., side effects) than what might happen without an intervention (i.e., maternal death). In this case, women are more likely to be harmed by omission of the intervention than from any danger posed by the intervention itself.”

Obviously, as we work to make misoprostol available at the community level we need to acknowledge that it is a powerful drug and that incorrect use can lead to serious consequences—such as uterine rupture during labor induction. While some would use this as an argument for placing restrictions on access, we see this as a call to put accurate and comprehensive information about its safe use into the hands of women.

The Way Forward

This week policy makers from around the world are gathering in Malaysia at the third Women Deliver Conference to continue to share ways of reducing maternal mortality. Misoprostol is the single-best opportunity to do just that. But the true potential of this simple and cost-effective technology lies in our willingness to abandon our “provider” frame and put the pills directly in women’s hands. Our challenge is to let women be the shapers and the users of this new technology, not the beneficiaries of what we can provide or what we think they need. Can we stop worrying about women’s “misuse” or “abuse” of misoprostol and show that we truly trust women with their own reproductive health care? Let us remember that it was women who discovered this drug in the first place, specifically to circumvent the weakness of the health-care system. Let us give them back this powerful tool and get out of their way.  Our responsibility is to ensure that women have easy access to the pills and all the knowledge necessary to use them effectively and safely.

News Maternity and Birthing

New Jersey Lacks Law Addressing Shackling of Pregnant Inmates Because Gov. Christie Wouldn’t Sign It

Nicole Knight Shine

New Jersey Gov. Chris Christie signed nearly 100 bills as the legislative session came to a close this January, but a measure to severely curtail the shackling of pregnant inmates wasn’t one of them.

New Jersey Gov. Chris Christie signed nearly 100 bills as the legislative session came to a close this January, but a measure to address the shackling of pregnant inmates wasn’t one of them.

Despite winning unanimous bipartisan support in the state assembly and senate, the bill died without the Republican presidential hopeful’s signature. The measure, S 221, would have severely curtailed the use of restraints on inmates during all stages of pregnancy, including after delivery.

The medical community has denounced shackling during pregnancy, which can include placing handcuffs, waist chains, and leg irons on a person. The American Medical Association has called it “barbaric,” while the American Congress of Obstetricians and Gynecologists described it as “demeaning and unnecessary.”

Data from the Sentencing Project, a criminal justice research and advocacy group, indicate that one in 25 women in state prisons and one in 33 in federal prisons are pregnant when admitted to prison.

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When asked about Christie’s failure to sign the new safeguards into law, the governor’s Deputy Press Secretary, Joelle Farrell, told Rachel Roth for MomsRising that, “Many of these bills seek to address important issues that deserve attention, but not with an 11th hour, ill-considered rush.”

The United States adopted a federal anti-shackling policy in 2008, but that does not apply to the more than 86 percent of U.S. prisoners housed in state prisons, as a recent shadow report to the U.N. Committee Against Torture pointed out. At present, 18 states restrict the use of restraints on pregnant inmates by law, while another 24 states limit their use through institutional policies. Eight states do not have any form of regulation at all. There exists a number of gaps in the policies that do exist, the report indicates, and many are not implemented.

Shackling during pregnancy, labor, delivery, and postpartum recovery can pose substantial medical risks to the health of the woman and her fetus, the report notes.

Assemblywoman Valerie Vainieri Huttle (D-Bergen), one of the New Jersey bill’s sponsors, called the bill “commonsense [and] humane,” according to MomsRising.

Last month, New York Gov. Andrew Cuomo (D) signed a bill that generally bars the use of restraints prior to or after childbirth for inmates. That legislation, like the New Jersey bill, enjoyed bipartisan support.

Commentary Media

The Economy Isn’t Rebounding for Everyone

Eleanor J. Bader

As explained in Tim Wise’s new book, Under the Affluence: Shaming the Poor, Praising the Rich and Sacrificing the Future of America, class inequality is a nationwide problem—and it is getting worse every year.

When Democrat Bill de Blasio campaigned to become New York City’s 109th mayor in 2013, he addressed the class inequality rampant in the metropolis and pledged that, if elected, he’d do what he could to level the economic and social playing fields. “We have the worst income disparity since the Great Depression,” de Blasio told audience after audience, adding that it was unacceptable to allow 46 percent of the city’s population to live at or below the poverty level while the “1 percent,” a total of just 34,500 households in a city of 8.2 million, held one-third of the income reported by residents.

Candidate de Blasio’s focus on ending “the tale of two cities” roused voters and he sailed into office with 73 percent of the vote. But his message, that a huge chasm divides the rich from everyone else, isn’t only applicable to New York City. In fact, as explained in Nashville, Tennessee-based activist and essayist Tim Wise’s new book, Under the Affluence: Shaming the Poor, Praising the Rich and Sacrificing the Future of America from City Lights Publishers, class inequality is a nationwide problem—and it is getting worse every year.

Although Under the Affluence zeroes in on the many ways that the rich are lauded and the poor debased in popular discourse and media, it’s a statistic-heavy book. This is unfortunate, given that people seem to remember stories and anecdotes far more than they recall facts and figures, no matter how upsetting or horrifying they are. Nonetheless, Under the Affluence is an important source of data—bubbling over with hard, footnoted facts—to strengthen readers’ resolve against the escalating inequalities in the United States.

In Section One, “Pulling Apart,” Wise sets the stage with some startling numbers—among them, that a tremendous number of United States residents are presently living in extreme poverty, subsisting on less than $5,500 a year for a single person and $11,800 for a household of four. “As of 2013, nearly twenty million people lived in this state of destitution,” he writes, using a statistic gleaned from the 2014 Current Population Report of the U.S. Census. This, he adds, is an increase of about eight million people since 2000.

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Not surprisingly, kids are disproportionately affected. Wise uses statistics from the Southern Education Foundation to report that since 2013, slightly more than half of public school students have qualified for free or reduced-price meals, the demarcation used by the federal government to designate a child as low-income. All told, he puts the number of impoverished youth at about 15 million, a number taken from the 2014 U.S. Census Bureau.

What’s more, Wise adds that The Global Wealth Databook and research compiled by writer Les Leopold suggest that roughly three in four Americans live from paycheck to paycheck, “meaning that they either have no savings or so little in savings that they could not withstand a layoff or medical emergency.”

Additionally, thanks to entrenched systemic racism, people of color often face higher rates of unemployment and greater financial insecurity than their white counterparts.

Overall, in 2010, the “bottom half,” meaning the 50 percent with the least earned income and fewest assets, owned approximately 1 percent of all national wealth, while the richest 1 percent mirrored what Mayor de Blasio was seeing in New York City: They possessed more than a third of the nation’s assets.

And little has changed, despite claims that the economy is rebounding. Wise points out that the three million people who comprise the U.S. 1 percent saw their incomes rise by more than 30 percent from 2009 to 2013, “largely making up for whatever stock market-related losses they suffered during the recent Great Recession.” On top of this, Wise adds that corporate profits are now at an 85-year high, while “worker compensation as a share of the economy remains at the lowest point in the past sixty-five years.”

More mind-blowing is this tidbit: In 2013, 165,000 Wall Street bankers took home bonuses averaging $162,000 each—almost double the combined take-home pay of the 1.1 million U.S. workers who were then earning the minimum wage, a finding initially reported by the Tax Policy Center.

Are you angry yet?

If not, you’re far from alone; the second section of Under the Affluence, “Resurrecting Scrooge: Rhetoric and Policy in a Culture of Cruelty,” explains that the body politic has been conditioned to accept huge wage differentials and idolize the ultra-privileged, as if they are somehow superior—smarter and better-prepared—rather than luckier or better-connected. The result is that many working-and-middle-class people hunker down as individuals, focusing on improving themselves and their kin, as if that will inevitably lead to material success.

It wasn’t always like this: Wise explains that during the 1930s, people helped one another because they understood that poverty had little to do with gumption or personal frailties and was instead the function of cultural barriers, a theory influenced by preachers and writers of the social gospel. Starting in the 1960s, however, a backlash against two decades of progressive economic policy that culminated with Lyndon Johnson’s Great Society erupted, and resentment toward the “welfare state” conjured images of the “undeserving” demanding a handout.

“Resurrecting Scrooge” further documents the raft of speeches and policy initiatives that fueled this misconception and that presented the poor as morally weak, lazy, and undeserving. Both Democrats and Republicans have been responsible for promulgating these ideas, but in recent years, Tea Party and other conservative activists have led the attacks and Wise chronicles some real doozies that, thanks to Fox News, conservative talk-radio, and the Internet, have spread like wildfire. There’s Rush Limbaugh, who has likened the poor to wild animals who have forgotten how to hunt because they are fed by keepers. There’s Ann Coulter, who has insisted that “welfare” creates “generations of utterly irresponsible animals.” Lastly, let’s not forget Bill O’Reilly, who apparently thinks that anyone who receives welfare, food stamps, or federal aid should be publicly shamed for their needs.

Still other conservatives, including lawmakers and policymakers, are what Wise calls poverty deniers. They argue that “America’s poor are fabulously wealthy by global standards and thus should essentially stop complaining; second, that the poor buy expensive food with their SNAP benefits and have all manner of consumer goods in their homes, which means they aren’t poor in any sense that should cause concern; and third, that large numbers of welfare recipients commit fraud in order to get benefits, and then misuse the benefits they receive.”

Obviously, this is hogwash. Shocker alert: The average food stamp recipient receives $133 per person, per month (less than $1.50 per meal), so is unlikely to buy anything gourmet. In addition, Wise concludes that no one receiving assistance is living like a Kardashian: When it comes to Temporary Assistance for Needy Families, average monthly grants amount to $387 per family.

Still, when lawmakers pass legislation to bar TANF recipients from using their benefits on “psychics, tattoos, or lingerie”—as recently happened in Kansas—it promotes the idea that recipients squander their grants on frivolities and stupidity.

Wise makes clear that this portrayal is intentional, meant to fuel resentment and rivalries between those who get “something for nothing” while others toil. Whether the buzz is around the so-called culture of poverty or social dependence on benefits programs, the impact is the same—it stokes anger, dividing would-be-allies along race, class, and gender lines, and limiting solidarity between people who could and should support each other. It also deflects attention from the rich, who are, more often than not, making out like bandits thanks to tax breaks, income shelters, and subsidies.

Wise lays out these factors in stark terms, but also contends that it does not have to be this way. In fact, he’s amazingly optimistic, arguing that we can build a society that is more just and loving.

First up, he writes, is contesting the idea that the United States is a meritocracy: that if you work hard, success will automatically follow. The fact that this has worked for many notable people—think Barack Obama, Bernie Sanders, and Bill Clinton—has allowed the idea to flourish, but Wise urges his readers to challenge this and demonstrate the racial, gender, ethnic, and religious biases that have limited many other meritorious people from rising. “Only by directly confronting the myth of meritocracy—indeed the very idea what the United States is, at present, a land of unfettered opportunity—might progressives build the kinds of coalitions needed to truly replace a culture of cruelty with a culture of compassion,” he offers.

Similarly, he points out the fallacy of the idea that some women and men are self-made—people who, by dint of character, have triumphed. This myth, too, needs to be trampled. Wise urges each and every one of his readers to acknowledge the help we’ve received—whether from a mentor, a scholarship, a subsidized school loan, welfare, food stamps, Medicaid, or other forms of aid. In addition, he prods us to call out racism and sexism, and be wary of the ways they are typically used to split us and keep us unorganized.

Under the Affluence does not provide concrete policy proposals—a road map to construct a new “war on poverty.” Some may see this as a weakness, since it will require us to do the hard work of planning and strategizing for solutions to economic injustice. Still, the book is an essential compendium of numbers, one that will prove useful in strategizing to end inequality and arming readers with the facts they need to tackle these seemingly intractable problems. Overall, the book is an impassioned and heartfelt defense of the poor that is rooted in the idea that America can, as Wise says, “crawl from under the affluence to a place more equitable.”