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For those struggling to improve the health of women in the developing world, 2005 could mark a turning point. The World Health Organisation's (WHO) focus on the mother and child, the G8 summit on Africa, and increasing access to anti-retrovirals may all result in real benefits.

But providing health care to women in the developing world is tough. Not only are there more seriously ill patients, but also fewer resources to treat them. The question facing a doctor treating overwhelming sepsis is rarely just ‘what is the ideal antibiotic combination?’ but also ‘is it worthwhile for the family to spend two months' wages on laboratory tests and the latest cephalosporin?’ and what are the consequences if they do? Who will go hungry, and who will not be able to afford help for their next attack of malaria?

How much more then do those running the health services need to make the most effective use of limited resources? This theme issue addresses the art of practicing in such settings, with a focus on low-cost interventions with potentially large impacts: screening for cervical cancer, appropriate technology, misoprostol, guidelines and audit. In addition you will find challenges, new insights, and ideas to improve individual practice.

Should the WHO fund IVF for the developing world?

  1. Top of page
  2. Should the WHO fund IVF for the developing world?
  3. Preventing mother-to-child transmission of human immunodeficiency virus (HIV)
  4. Misoprostol–good for treatment of PPH but not prophylaxis
  5. Reference

In some societies infertile women are ‘despised, perceived as evil beings and excluded from societal events’. No wonder that for them ‘treatment of infertility comes first, before the treatment of their own illnesses (even if life threatening)’. Yet many governments and aid agencies ignore the problem, and even view it as a partial solution to the problem of over-population. Professor Aboulghar argues on pages 1174–1176 that infertility is a huge public health problem that should not be ignored. He appeals to health providers to ‘provide not what they think women should have, but what the women really want’.

Preventing mother-to-child transmission of human immunodeficiency virus (HIV)

  1. Top of page
  2. Should the WHO fund IVF for the developing world?
  3. Preventing mother-to-child transmission of human immunodeficiency virus (HIV)
  4. Misoprostol–good for treatment of PPH but not prophylaxis
  5. Reference

McIntyre's authoritative review of the various regimens for preventing mother-to-child transmission of HIV is timely (pp. 1196–1203). Intrapartum nevirapine halved transmission rates to 10–15% and is cost-effective, but with more expensive anti-retrovirals widely available in poor settings, more complex regimens are possible. Highly active combination anti-retroviral therapy (HAART) has reduced mother to child transmission to around 1% in Europe and recently a Mozambique cohort has shown that a reduction to similar levels is also possible in poorer African countries. Huge challenges remain in translating this research into effective national programmes.

Misoprostol–good for treatment of PPH but not prophylaxis

  1. Top of page
  2. Should the WHO fund IVF for the developing world?
  3. Preventing mother-to-child transmission of human immunodeficiency virus (HIV)
  4. Misoprostol–good for treatment of PPH but not prophylaxis
  5. Reference

When misoprostol was introduced in 1985, obstetricians throughout the world recognised its potential for reducing maternal mortality. With the manufacturer unwilling to support its obstetric use, it has taken 20 years of publicly-funded research for its role to become clearer. In May this year the BJOG published a systematic review demonstrating the efficacy of misoprostol for treatment of post partum haemorrhage.

For prophylaxis however, the benefits are less clear. In 2001 a World Health Organisation (WHO) trial showed that it is was less effective than 10iu oxytocin,1 but the authors suggested it might still prevent mortality in rural settings where oxytocin is often unavailable and where most maternal deaths occur. This month Walraven et al. (pp. 1277–1283) report a randomised controlled trial of oral misoprostol versus oral ergometrine (used as a placebo) in Gambian village home births attended by illiterate traditional birth attendants. They managed to accurately measure blood loss in all but one of the 1229 individually randomised women and obtained 94% of all post-partum haemoglobin measurements.

Their results will disappoint many misoprostol enthusiasts. There were no significant differences in the primary outcomes of blood loss over 500 mls or postpartum Hb less than 8 g/dl. Nevertheless both this study and the WHO trial suggest that misoprostol could benefit those with prolonged heavy bleeding from atonic uteri. Larger studies are needed to test any effect on maternal mortality.

Reference

  1. Top of page
  2. Should the WHO fund IVF for the developing world?
  3. Preventing mother-to-child transmission of human immunodeficiency virus (HIV)
  4. Misoprostol–good for treatment of PPH but not prophylaxis
  5. Reference
  • 1
    Gülmezoglu AM, Villar J, Ngoc NN, et al. The WHO multicentre double-blind randomized controlled trial to evaluate the use of misoprostol in the management of the third stage of labour. Lancet 2001;358: 689695.