Better Odds for Surviving Childbirth

The safety of home childbirth in rural India is a gamble, with thousands of women dying annually from postpartum hemorrhage and many more suffering severe complications from anemia. So it seems fitting that two Bloomberg School researchers used a computer simulation named after a famous casino to investigate an approach to making childbirth a safer process for women in that developing country.

Graduate student Tori Sutherland and David Bishai, associate professor of Population, Family and Reproductive Health, used what is called a “Monte Carlo simulation” to find out whether administering a commonly used and widely available ulcer medication, misoprostol, is an effective way to save mothers’ lives in India. (Monte Carlo simulations use numbers and probability statistics to investigate problems ranging from nuclear physics to traffic patterns.)

Not only was the answer “yes,” but the study also concluded that misoprostol is cost-effective.

“We knew that misoprostol can prevent blood loss by women in labor. That’s been proven in previous studies,” says Bishai, MD, PhD, MPH. “What we wanted to learn was how many lives could potentially be saved by administering misoprostol immediately postpartum. Our study is the first to link the concepts of prevented blood loss with prevented death.”

Each year in India, 535,000 women die in childbirth. Experts estimate that one quarter to one half of these women succumb to postpartum hemorrhage. In developed countries such as the U.S., the condition is rare because most women deliver their infants in settings where emergency care is readily available. In developing nations such as India, however, the majority of women give birth at home, raising their risk of complications.

Bishai and Sutherland’s computer program was designed to reflect the delivery outcomes of 10,000 women in India. It included data about blood loss, hemoglobin levels and the corresponding probability of mortality culled from peer-reviewed literature, population-level datasets and expert consultations. The program then predicted women’s risk of death from both hemorrhage and anemia, and the predicted impact of misoprostol on those outcomes.

According to the simulation, there was a 38 percent reduction in maternal mortality among mothers who were given 600 micrograms of misoprostol by trained village workers immediately after delivery.

“These results are so impressive and may get the attention of decision makers in countries where misoprostol is not yet on the formulary for the prevention of postpartum hemorrhage,” says Suellen Miller, director of Safe Motherhood Programs at the University of California San Francisco.

A single dose (600 micrograms) of misoprostol costs about $1 in India and 36 cents in Bangladesh. The research team’s simulation concluded that, taking into account the cost of the medication, provider training and delivery fees, it costs about $1,400 to save a life using misoprostol.

“To understand that figure, you have to compare what it would cost to improve the quality of comprehensive emergency obstetric care there—about $10,000 per life saved,” says Sutherland.