A simple pill that could save thousands of lives remains locked behind counters, shrouded in confusion and stigma.
"Stock outs." "Lack of demand." "Unwillingness to stock an abortifacient." These were the reasons pharmacy workers in Senegal gave researchers when asked why they didn't carry a drug that could prevent women from bleeding to death after childbirth. In a country where maternal mortality remains a critical public health challenge, the story of misoprostol—a safe, effective, and affordable medication—reveals the complex gap between medical innovation and real-world access.
This article explores the groundbreaking STEP UP research that uncovered why this potential lifesaver remains out of reach for so many Senegalese women, and what it tells us about the future of reproductive healthcare in developing nations.
Senegal, like many of its neighbors in Sub-Saharan Africa, faces stubbornly high rates of maternal mortality. While significant advances have been made in recent years, the country continues to work toward reducing its maternal mortality rate from 392 deaths per 100,000 live births to the target of 127 deaths per 100,000 live births established under the Millennium Development Goals5 .
The leading causes of these tragic deaths are well-known: postpartum hemorrhage (excessive bleeding after childbirth) and complications from unsafe abortions. Together, they represent a silent emergency playing out in homes and clinics across the nation. What makes these deaths particularly tragic is that both conditions are largely preventable with access to appropriate medications and care.
deaths per 100,000 live births
Senegal aims to reduce maternal mortality to 127 deaths per 100,000 live births, in line with global development targets.
The leading cause of maternal death globally, accounting for approximately 27% of maternal deaths in developing countries.
Complications from unsafe abortions contribute significantly to maternal mortality in countries with restrictive abortion laws.
Misoprostol, a simple tablet initially developed for stomach ulcers, has revolutionized reproductive healthcare worldwide. When it was discovered that the drug could also cause uterine contractions, it opened new possibilities for managing obstetric complications.
This versatile medication now plays a crucial role in several reproductive health applications:
The World Health Organization has placed misoprostol on its List of Essential Medications for these obstetric indications, recognizing its potential to save thousands of lives. Unlike many obstetric drugs, misoprostol has several distinct advantages in low-resource settings: it doesn't require refrigeration, can be administered by non-physicians, and is relatively inexpensive to produce.
Despite misoprostol's proven potential, questions remained about whether it was actually reaching the women who needed it most in Senegal. To solve this puzzle, researchers from Marie Stopes International and the Population Council conducted a landmark study as part of the STEP UP research program in 20142 4 5 .
The study focused on a critical link in the healthcare chain: private pharmacies. In Senegal's healthcare system, pharmacies are integral points of access for medications, supplying both the general public and even public health providers. If misoprostol wasn't available here, it likely wasn't available anywhere.
The research team aimed to understand:
The answers they uncovered would reveal a system struggling to deliver a lifesaving medication to those who needed it most.
To obtain accurate data about misoprostol knowledge and practices, the research team employed a rigorous cross-sectional survey methodology1 . Here's how they conducted this crucial research:
The study involved face-to-face interviews with 110 pharmacy workers across Dakar, Senegal's capital and largest city. These interviews used structured questionnaires to collect standardized information about knowledge and practices relating to misoprostol provision.
The research team obtained approval from multiple ethical review boards, including the Senegal National Ethics Committee for Health Research, the Population Council Institutional Review Board, and the Marie Stopes International Independent Ethics Review Committee1 . The Order of Pharmacists of Senegal endorsed the study and encouraged participation among its members.
Trained researchers conducted the interviews using questionnaires that covered demographic information, awareness and knowledge of misoprostol, understanding of its approved uses, current stocking practices, reasons for not selling, and willingness to receive training.
| Research Component | Description | Function in the Study |
|---|---|---|
| Cross-Sectional Survey Design | One-time assessment of pharmacy workers | Provides a snapshot of knowledge and practices at a specific point in time |
| Structured Questionnaire | Standardized interview instrument | Ensures consistent data collection across all participants |
| Pharmacy Worker Sampling | 110 participants from private pharmacies in Dakar | Represents key medication dispensers in the Senegalese healthcare system |
| Ethical Review Protocols | Approval from multiple ethics committees | Protects participant rights and ensures research integrity |
| Informed Consent Process | Detailed explanation of study purposes and procedures | Respects participant autonomy and meets ethical standards |
The study findings, published in BMC Pregnancy and Childbirth in 2017, painted a concerning picture of misoprostol's availability in urban Senegal1 . The data revealed significant gaps between the drug's potential and its real-world presence.
| Knowledge Area | Percentage | Findings |
|---|---|---|
| Overall Awareness | 72% | 79 of 110 pharmacy workers had heard of misoprostol |
| Sales Activity | 35% | Of those aware, only 27 actually sold the product |
| Reproductive Health Indications | Low | Rarely sold specifically for postpartum hemorrhage or post-abortion care |
| Willingness to Sell | 49% | Nearly half of non-sellers expressed willingness to stock misoprostol with proper training |
| Barrier Category | Specific Challenges | Impact on Availability |
|---|---|---|
| Supply Chain Issues | Frequent stockouts; product unavailability from suppliers | Physical absence of medication even when demanded |
| Knowledge Limitations | Low awareness of approved uses and regimens | Inability to recommend or properly dispense |
| Perceived Demand | Belief that there is little customer need for the product | Reduced incentive to stock and promote |
| Stigma and Reluctance | Unwillingness to stock an abortifacient | Active avoidance despite medical need |
Perhaps most alarming were the significant knowledge gaps regarding misoprostol's approved uses, registration status, appropriate treatment regimens, and potential side effects. These deficiencies occurred in a context where pharmacy workers reported low levels of training on misoprostol's reproductive health applications.
The statistics tell only part of the story. Behind the numbers lie real-world consequences for Senegalese women facing obstetric emergencies.
Even when pharmacists wanted to stock misoprostol, they often couldn't obtain it consistently from suppliers. This suggests problems at the manufacturing, importation, or distribution levels that create bottlenecks in the pipeline delivering the drug to end users.
With limited training on misoprostol's legitimate obstetric uses, pharmacy workers were poorly equipped to educate customers or even recognize appropriate indications for the medication. This created a cycle of ignorance that suppressed both supply and demand.
Perhaps the most complex barrier was the "unwillingness to stock an abortifacient" expressed by some pharmacy workers. In a country with restrictive abortion laws, this reflects the broader social and religious tensions surrounding reproductive healthcare.
The situation creates a cruel paradox: misoprostol is at its most revolutionary when it reaches the women most vulnerable to obstetric complications, yet it's precisely these women—often poor, rural, and with limited healthcare access—who face the greatest barriers to obtaining it.
The STEP UP study did more than just document problems—it pointed toward concrete solutions. Based on the findings, researchers recommended several key actions:
Targeted programs for pharmacy workers on misoprostol's registered indications, proper dosing regimens, and potential side effects. This could leverage the nearly half of non-selling pharmacy workers who expressed willingness to stock the drug with appropriate training.
Working with the Senegalese government and pharmaceutical distributors to ensure consistent misoprostol availability. The Ministry of Health had already committed to ensuring the availability of essential medicines, including misoprostol4 .
Increasing awareness among both healthcare providers and the public about misoprostol's legitimate uses in postpartum hemorrhage and post-abortion care to create appropriate demand.
Working with professional associations and regulatory bodies to integrate misoprostol into standard pharmacy practice and overcome stigmatizing perceptions.
The challenges are significant, but the potential payoff is enormous. As one researcher noted, misoprostol represents a potential "revolution" in reproductive health care because of its potential to reduce mortality and morbidity in countries with under-resourced health systems.
Yet this revolution remains incomplete without addressing the distribution, knowledge, and stigma barriers uncovered by the STEP UP study.
The story of misoprostol in Senegal is more than just about one drug—it's a case study in the complexities of implementing global health innovations. It demonstrates that developing effective medications is only the first step in improving health outcomes. Ensuring they reach the people who need them requires addressing a web of distribution, knowledge, cultural, and economic factors.
As the Senegalese government and its partners work to strengthen the country's healthcare system, the journey of misoprostol from research lab to pharmacy shelf offers crucial lessons. It reminds us that true healthcare innovation requires not just scientific discovery, but also the less glamorous work of training healthcare workers, strengthening supply chains, and engaging with local communities.
With continued effort and evidence-based approaches like the STEP UP research, the promise of misoprostol and other essential medicines may yet be fulfilled for all Senegalese women, regardless of where they live or their economic circumstances. The distance between a lifesaving drug and the woman who needs it may be only a few miles, but bridging that gap requires crossing a chasm of logistical, educational, and social barriers—a challenge that Senegal, with the help of rigorous research, continues to confront.