When the Covid-19 pandemic made misoprostol scarce, Nepali women were placed at risk.
In the midst of 2020's Covid-19 response, a member of Direct Relief's emergency response team received an unusual request.
Like the rest of his team, Dan Hovey, an emergency response manager at the nonprofit organization, was fielding requests for ventilators, PPE, and other Covid-19-related medical aid from all over the world. But One Heart Worldwide, a maternal health aid group and long-term Direct Relief partner, was asking for something else entirely: misoprostol, a lifesaving drug that's used to stop postpartum hemorrhage, and that plays an essential role in preventing maternal deaths.
The medicine was intended for Nepal, where it's an important part of the government's strategy to prevent maternal deaths across a mountainous, geographically diverse region where help isn't always close by or easy to reach. The pandemic was making misoprostol hard to come by -- and in the process, endangering Nepali women.
A LARGE-SCALE EFFORT
When it comes to preventing maternal deaths, Nepal has made significant strides in recent decades. According to the Nepal Demographic and Health Survey, the country's maternal mortality ratio, measured at 529 deaths per 100,000 live births in 1996, decreased to 239 in 2016.
The government has placed birthing facilities in remote communities all over the country, and staffed them with skilled birth attendants. Trained female community health workers, so women are educated about safe and healthy births. Made maternal health services free of cost. Created waiting homes for women preparing to deliver -- making it more likely that a woman will make it to a skilled birth attendant in time.
One Heart Worldwide has been working with the Nepali government since 2010 to improve maternal and child health outcomes. Direct Relief has been involved with those efforts since the 2015 Nepal earthquake.
Partnering with One Heart Worldwide, Direct Relief spent $775,000 over four years to build, repair, and equip public birthing centers in rural Nepal, as well as train skilled birthing attendants to staff them. The organization has also donated more than $1.7 million in medical aid to One Heart Worldwide since the earthquake.
"One of the big problems in Nepal is the lack of infrastructure," said Arlene Samen, a maternal-fetal medicine nurse practitioner and the founder of One Heart Worldwide.
Samen explained that the country's altitude, mountainous terrain, and lack of paved roads in some areas make local, easily accessible birthing facilities a necessity.
As part of its strategy to combat maternal mortality, the Nepali government piloted a program to give misoprostol to women unable to access a birthing center -- so that, if the need arose, women could take the medication themselves.
"Nepal is the country that proved that misoprostol can be safely distributed," said Surya Bhatta, executive director of One Heart Worldwide in Nepal.
But Covid-19 has threatened those gains. A study in the Lancet found that, over the course of four months in lockdown in Nepal, the number of births in government institutions dropped to less than half of their previous levels, although Bhatta explained that local community birthing facilities have actually seen an increase in attendance.
"There are a lot of women in rural Nepal who remain unable to come to the health facilities to deliver their babies," he said. "We hear of a lot of maternal deaths. We don't feel it's right to just stay quiet" and not help.
To save lives, the government has begun instructing female community health volunteers -- an important resource in Nepali health care -- in the majority of Nepal's 77 districts to distribute misoprostol directly to women who have completed their seventh month of pregnancy. (The districts are ones in which numbers of home deliveries are high.)
Fifty-five districts are currently receiving misoprostol through these highly trusted educators and counselors. In every town or village, Bhatta said, a female community health volunteer "is a well-known person. She knows more than anybody in her community."
A VITAL SHORTAGE
But the pandemic has also made it harder to get misoprostol in Nepal -- and Samen said there have been reports of deaths specifically due to postpartum hemorrhage during home births.
Although Direct Relief maintains a large medical warehouse, the organization didn't have misoprostol on hand.
But Hovey didn't want to give up. He asked a colleague to reach out to a long-term partner -- the pharmaceutical company Pfizer -- to see if they were able to donate the medication.
Pfizer generously donated more than 34,000 doses of misoprostol, which Direct Relief sent to Nepal in late January.
"Direct Relief always comes through when we have challenges that are beyond our control," Samen said.
Bhatta stressed that, even with essential medications and high-quality facilities, there's a long road ahead.
"The needs are so great, the geography is so challenging, the literacy, the poverty...it is really difficult to deal with maternal death," he said. "It takes a village to save a mom."