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ROBERT SIEGEL, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel

MELISSA BLOCK, host:

And I'm Melissa Block.

Now, the latest in our series Beginnings: Stories of Women and Childbirth. Today, we'll hear about a drug that health experts say is saving women's lives around the world, a drug that's also controversial.

It's called Misoprostol or Myzoprostol(ph). Originally developed to prevent gastric ulcers, it's also been shown to prevent excessive bleeding after childbirth. That is 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.

I went to Mozambique, in southeastern Africa, to learn more about this drug, its promise and its risks.

(Soundbite of women singing)

BLOCK: A group of four traditional birth attendants welcomes Mozambican doctor Cassimo Bique back to their community in rural Nampula Province, in northern Mozambique.

(Soundbite of women singing)

Dr. CASSIMO BIQUE (Obstetrician/Gynecologist): (Foreign language spoken)

BLOCK: These women were part of a year-long trial of Misoprostol in rural communities. The trial was designed and carried out by an American women's health nonprofit called Venture Strategies Innovations. It was led by Dr. Bique.

Dr. BIQUE: (Foreign language spoken)

BLOCK: Dr. Bique is an Ob-Gyn, 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 one in 37 lifetime risk of maternal death. By comparison, in the U.S., that number is about one in 2,000. And in Mozambique, Dr. Bique says, most of those deaths will be from postpartum hemorrhage.

Dr. BIQUE: They can die in two hours.

BLOCK: 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.

Ms. ATIA JOAO (Birth Attendant): (Foreign language spoken)

BLOCK: Atia Joao explains that before Misoprostol they would need three or four capulanas to soak up typical blood loss from the mother; after miso, just one.

Ms. JOAO: (Foreign language spoken)

BLOCK: Have all of you watched women die because they were bleeding after giving birth, before miso was available?

Ms. JOAO: (Foreign language spoken)

BLOCK: The traditional birth attendants nod and talk of cases they remember well.

Ms. JULIETA GRACINDA KHARISE (Birth Attendant): (Foreign language spoken)

BLOCK: 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.

Ms. KHARISE: (Foreign language spoken)

Dr. BIQUE: I can say in one word, simple word that Misoprostol is something a miraculous drug.

BLOCK: A miraculous drug, says Dr. 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 Dr. Bique, and other advocates of Misoprostol, the widespread benefits far outweigh those risks. They want the Mozambican government to train traditional birth attendants on how to use Misoprostol and to scale up supply for the whole country.

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.

Dr. SUZANNE HILL (Pharmacologist, World Health Organization): A tablet seems like a really good idea as a quick fix.

BLOCK: But WHO pharmacologist Suzanne Hill still has reservations about Misoprostol.

Dr. HILL: 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 an essential medicine? Well, I actually think oxytocin is the real essential medicine here.

BLOCK: Oxytocin is more effective, Hill says. And she worries that seeing Misoprostol as a panacea might obscure the real long-term need.

Dr. HILL: We know that the real fix to the problem involves fixing the system, so that women can get to the facility, can get care, can give birth in a controlled environment. And that's much harder to fix than handing out a tablet and hoping.

BLOCK: 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's an increased risk of birth defects.

At the Maputo Central Hospital in the Mozambican capital, I sat in on a session for a dozen young women who recently had abortions; a group meeting to teach them about contraception, maybe for the first time.

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 induce 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.

Unidentified Woman: (Foreign language spoken)

BLOCK: Now, 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. Misoprostol is readily available at drug stores over the counter.

Dr. AIDA LIBOMBO (Ministry of Health, Mozambique): It's not prescribed. Anyone can go to the pharmacy to buy it. It's not prescribed.

BLOCK: Aida Libombo is an advisor to Mozambique's minister of health and an ob-gyn. 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.

Dr. LIBOMBO: What I've seen at the beginning of my training, my internship, it was terrible.

BLOCK: What did you see?

Dr. LIBOMBO: I saw, like, intestines coming out from the vagina.

BLOCK: The intestines.

Dr. LIBOMBO: Yes. They used these kind of instruments that were perforating the uterus and giving a lot of complications. And women die. But now, with the Misoprostol, the maternal death due to abortion is reduced.

BLOCK: Dr. Libombo is 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 we met up in the north of the country?

(Soundbite of women singing)

BLOCK: At the end of our visit, they sent us out this way, with a song thanking Dr. Cassimo Bique for training them, and asking him to bring them more Misoprostol.

(Soundbite of women singing)

BLOCK: Our series continues on Friday with a story about the booming business of in-vitro fertilization in China. And next week, the last of my reports from Mozambique; we'll hear about efforts to prevent the transmission of HIV from mother to child. That's next Wednesday, on ALL THINGS CONSIDERED.

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