Health experts say the drug misoprostol is saving women's lives around the world. It's also controversial.
Originally developed to prevent gastric ulcers, it's also been shown to prevent excessive bleeding after childbirth. That's the leading cause of maternal death in the developing world. It's estimated that one woman dies from postpartum hemorrhage every seven minutes.
The controversy comes because misoprostol, or miso, can also be used to induce abortion.
So in places like Mozambique in southeastern Africa, it carries both promise, and risk.
'A Miraculous Drug'
A group of four traditional birth attendants welcomes Mozambican doctor Cassimo Bique back to their community in rural Nampula province in northern Mozambique.
These women were part of a yearlong trial of misoprostol in rural communities.
The trial, led by Bique, was designed and carried out by an American women's health nonprofit called Venture Strategies Innovations.
Bique is an OB-GYN and has practiced medicine for decades in Mozambique. And he knows well how deadly childbirth can be in his country. In Mozambique, a woman has a 1 in 37 lifetime risk of maternal death. By comparison, in the U.S., that number is 1 in 2,100, according to the World Health Organization. And in Mozambique, Bique says, most of those deaths will be from postpartum hemorrhage:
"They can die in two hours," he says.
The traditional birth attendants have their own way of measuring the effectiveness of misoprostol. Their gauge is the brightly colored cloth called the capulana, which is worn as a skirt, or a shawl, or as a sling to carry a baby. And it's useful in childbirth, too.
Atia Joao explains that before misoprostol, they would need three or four capulanas to soak up typical blood loss from the mother. After miso, they needed just one.
When the traditional birth attendants are asked if they have watched women die because they were bleeding after giving birth, before miso was available, they nod and say yes.
They talk of cases they remember well.
Julieta Gracinda Kharise describes a woman "bleeding like water running from a faucet." She says she sent the family to look for a car to take the woman to the hospital, but it was too late; she died.
"I can say in one word, simple word, misoprostol is something — a miraculous drug," says Bique.
For one, it's cheap. And unlike oxytocin, which is given as a shot and requires refrigeration, misoprostol is taken in pill form — a real benefit in rural areas without electricity.
There are risks though: If it's taken to induce labor, in too high a dose, misoprostol can cause uterine rupture, which can be fatal to mother and child.
But for Bique, and other advocates of misoprostol, the widespread benefits far outweigh those risks. They want the Mozambican government to train traditional birth attendants in how to use misoprostol, and to scale up supply for the whole country.
The World Health Organization's Take
Their case is bolstered by a recent decision from the World Health Organization. WHO added misoprostol to its core list of essential medicines for preventing postpartum hemorrhage. That decision came after a lot of impassioned debate.
"A tablet seems like a really good idea as a quick fix," says WHO pharmacologist Suzanne Hill.
But she says she still has reservations about misoprostol.
"It's on the list, and if I was giving birth in the middle of nowhere with nothing else, and this was available, would I use it personally? Yes. No question. But do I think it's an essential medicine, as WHO defines essential? Well, I actually think oxytocin is the real essential medicine here," she says.
Oxytocin is more effective, Hill says. And she worries that seeing misoprostol as a panacea might obscure the real long-term need.
"We know the real fix to the problem involves fixing the system, so that women can get to facilities, can get care, can give birth in a controlled environment, and that's much harder to fix than handing out a tablet and hoping," she says.
For others, the real problem with misoprostol is that it can be used to induce abortion, and that it makes abortion too easy. Anti-abortion groups also cite studies showing that if the drug doesn't work and the pregnancy goes to term, there is an increased risk of birth defects.
Misoprostol And Medical Abortions
At the Maputo Central Hospital in the Mozambican capital, a dozen young women who recently had abortions gather to learn about contraception.
Many of them are high-schoolers and they told a similar story: When they got pregnant, their friends or mothers told them about the pills that would cause an abortion. They bought misoprostol from a pharmacy and took the pills at home. Then they went to the hospital, where a nurse performed vacuum aspiration to complete the abortion.
Technically, abortion is still illegal in Mozambique. That's on the books. But in practice, it's extremely common, with abortions performed all the time at government-run hospitals.
Misprostol is readily available over the counter at drugstores.
"It's not prescribed.," says Aida Libombo, an adviser to Mozambique's minister of health and an OB-GYN. "Anyone can go to the pharmacy to buy it."
In her view, misoprostol has made abortions much safer. She remembers the horrific botched abortions she dealt with as a young doctor in the 1980s, when unsafe abortion was one of the leading causes of maternal death.
"What I've seen at the beginning of my training, my internship, it was terrible," Libombo says. "I saw intestines coming out from the vagina. They used these kinds of instruments that were perforating the uterus and giving a lot of complications. And women die. But now with misoprostol, the maternal death due to abortion is reduced."
Libombo will be among those in Mozambique's Ministry of Health promoting a rollout of misoprostol around the country to prevent postpartum hemorrhage.
And the traditional birth attendants up in the north of the country sang a song for Dr. Cassimo Bique, thanking him for the training — and asked him to bring them more misoprostol.