Roundtable: Making Pregnancy Safer in Myanmar: Introducing Misoprostol to Prevent Post-Partum Haemorrhage as Part of Active Management of the Third Stage of Labour

In Myanmar, we carried out a successful pilot intervention with the prostaglandin misoprostol in the active management of the third stage of labour, for prevention of post-partum haemorrhage. The pilot aimed to appraise the operational feasibility, efficiency, impact and cost-effectiveness of the intervention at family and community level, and focused on a number of managerial and logistics issues in relation to scaling-up the intervention nationally and within the public sector, where it proved to be successful.

Myanmar is the largest country in mainland Southeast Asia geographically, with over 70% of its population in rural areas. Over 60% of the population (55.4 million in December 2006) consists of mothers and children, who are the most vulnerable group.¹ Administratively, there are 14 states and divisions, which are sub-divided into 66 districts, 325 townships and so on, down to 65,148 villages. Maternity care is equally spread across the whole country, in both urban and rural areas, but there is still an under-served group in very remote, hard-to-reach areas, though their numbers are not very large. The number of facilities with functioning basic essential obstetric care in 2005 was eight per 500,000 population and that of comprehensive essential obstetric care was four per 500,000 population.²

In 2006, the Ministry of Health estimated a crude birth rate of 19.1 live births per 1,000 population in urban areas, and 22 per 1,000 in rural areas. Thus, approximately 1.3 million women give birth each year. The most recent National Mortality Survey, conducted by the Central Statistical Organization in 1999, showed a maternal mortality ratio of 255 per 100,000 live births,³ of which 31% was due to post-partum haemorrhage, the leading cause of maternal deaths, particularly in rural areas.⁴ The home delivery rate is high but decreasing; it was estimated to be 87% in 1999 and 70% in 2004.⁵

In response to the felt need for a strategic approach to reducing maternal mortality that embodies national aspirations for maternal health, a consensus meeting on the use of oxytocics and magnesium sulfate⁶ in reducing maternal mortality was held in 2004 with obstetrician–gynaecologists and public health administrators, organised by the Maternal and Child Health section of the Department of Health. As regards prevention of post-partum haemorrhage, use of injectable oxytocin by midwives is recommended for use in the active management of the third stage of labour. The meeting reviewed evidence on the use of misoprostol as an alternative to oxytocin,⁷⁸ as a way to address constraints on midwives in Myanmar giving oxytocin injections to women, as they often assist labour and delivery alone, especially in rural settings. There have also been logistic problems with the supply of oxytocics, which are heat labile. Misoprostol is heat stable and can be given orally, and was considered to be more appropriate for home deliveries by a midwife alone.

Oral administration of misoprostol in the active management of third stage of labour was therefore piloted in five townships from January to June 2005. Since there was a limited supply of misoprostol for this pilot phase, only 50 high-risk cases for post-partum haemorrhage and 50 random cases per township (=500 women in total) were selected, with misoprostol to be administered after screening. After giving a half-day training on this use of misoprostol to midwives in each of the five townships, misoprostol tablets were distributed. Feedback, including information on obstetric history, mode of delivery, administration of misoprostol, immediate post-partum condition and side effects, was collected from the pilot townships, compiled at the Maternal and Child Health section of the Department of Health and analysed both quantitatively and qualitatively.

The findings were very encouraging.⁹ At the end of the pilot, there were no post-partum haemorrhage cases among either the high-risk women or the randomly chosen women, and there were only very minimal side effects, such as nausea and vomiting. All the women in this study were attended by midwives during delivery. However, all the midwives were instructed to teach any other attendants, such as relatives and friends, when to give them as well. Operational feasibility was very high, since any other attendants who might be present, apart from the midwife, could in future also give the tablets to the woman during the third stage of labour.

Now that use of misoprostol has been agreed as best practice for prevention of post-partum haemorrhage during the third stage of labour in Myanmar, it is included in the Training Manual for Midwives and Auxiliary Midwives for Management of Normal Pregnancy, Childbirth, Postnatal and Newborn Care, which was adapted from the 2004 WHO IMPAC guidelines on management of normal labour. In the last quarter of 2006 and early 2007, the intervention has begun to be taught in all on-the-job training for midwives and auxiliary midwives in the 120 townships in Myanmar with UNFPA-funded reproductive health projects and the 125 townships with Women and Child Health Development projects, and replicated in those townships. The existing Continuing Medical Education system at township level will also include the intervention in training in the non-project townships of the country as well. The intervention has also already been included in the current National Health Plan for Maternal, Newborn and Child Care (2007–2010) for scaling up throughout the country.

Thus, we have now found one way to help to bring down maternal mortality, especially in the remote rural areas, by introducing this simple, cost-effective, appropriate and feasible intervention. However, the challenge is how to achieve universal coverage. It will cost US$1.5 million annually to provide misoprostol tablets for every delivery. We believe intersectoral coordination, community participation and social marketing are part of the answer.