We read with interest the Comment by Saumya RamaRao and colleagues entitled "Postabortion Care: Going to Scale" [2011, 37(1):40–44]. Misoprostol, a uterotonic drug that contracts the uterus and ripens the cervix, has been approved by the World Health Organization (WHO)1 for the treatment of incomplete abortion and included in WHO's priority medicines list for mothers and children.2 According to studies that compared misoprostol with manual vacuum aspiration (MVA), the two treatments were equally effective,a href="#3" name="3a">3–8 and misoprostol was safe and had minimal side effects.9 The drug has been added to essential medicines lists in many countries, including Ethiopia, Tanzania, Nigeria, Kenya and Zambia, for the treatment of incomplete abortion.
The different treatment options for incomplete abortion should complement each other, depending on the drug's availability and a woman's screening and eligibility for medical treatment. Inclusion of this simple medical method (a single 600 mcg oral or 400 mcg sublingual dose10) obviously has great potential for scaling up postabortion care (PAC) services globally.11 RamaRao and colleagues highlight the benefits of MVA in bringing PAC services "closer to the communities." They also note the benefits of misoprostol use, which—through referral links—can make these services more accessible in remote areas and peripheral health facilities where surgical methods are not available.
Misoprostol has other advantages for expanding the availability of postabortion care: It is easy to train health care providers to use the misoprostol treatment regimen. Overall, it may be more cost-effective when integrated into PAC services because it decreases treatment time and lowers the cost of supplies and equipment. In several studies, women who could choose between treatment with misoprostol and MVA have selected misoprostol.3,4,10 We agree with RamaRao and colleagues that research findings on PAC should guide the scale-up of services; strong evidence supports the immediate integration of misoprostol into PAC services.
We believe that any PAC delivery program should include misoprostol as a key tool for expanding services, and that misoprostol should be included directly and extensively in the treatment of incomplete abortion. Moreover, any international guidance for scaling up PAC should provide full integration of all proven and approved methods, so that all stakeholders, including funders, can follow it.
Nuriye Nalan Sahin-Hodoglugil
Venture Strategies Innovations
University of California, Berkeley
1. World Health Organization (WHO), Model List of Essential Medicines (16th list updated), 2010, <http://www.who.int/medicines/publications/essentialmedicines/en/index.html>, accessed June 11, 2011.
2. WHO, Priority Medicines for Mothers and Children, WHO/EMP/MAR/2011.1, 2011, <http://www.who.int/ medicines/publications/A4prioritymedicines.pdf>, ?accessed June 11, 2011.
3. Bique C et al., Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion, International Journal of Gynaecology & Obstetrics, 2007, 98(3):222–226.
4. Dabash R et al., A randomized controlled trial of 400-mcg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals, International Journal of Gynaecology & Obstetrics, 2010, 111(2):131–135.
5. Dao B et al., Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa, BJOG, 2007, 114(11): 1368– 1375.
6. Shwekerela B et al., Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania, BJOG, 2007, 114(11):1363–1367.
7. Taylor J et al., Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana, International Journal of Gynaecology & Obstetrics, 2011, 112(1):40–44.
8. Weeks A et al., A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion, Obstetrics and Gynaecology, 2005, 106(3):540–547.
9. Blum J et al., Treatment of incomplete abortion and miscarriage with misoprostol, International Journal of Gynaecology & Obstetrics, 2007, 99(Suppl. 2)186–189.
10. Diop A et al., Two routes of administration for misoprostol in the treatment of incomplete abortion: a randomized clinical trial, Contraception, 2009, 79(6):456– 462.
11. Ipas and VSI ed., Misoprostol Use in Postabortion Care: A Service Delivery Toolkit, 2011, Chapel Hill, NC: Ipas.