Misoprostol: The Social Life of a Life-saving Drug in Global Maternal Health

Abstract

This paper is about a drug called misoprostol and its controversial clinical and social lives. Although originally developed as a prevention for gastric ulcers, in the 1980s, it developed an off-label reputation as an abortifacient. The drug’s association with clandestine abortion has profoundly shaped its social life as a marginal and suspect character in the realm of global maternal and reproductive health where it has the potential to prevent two major causes of maternal death––postpartum hemorrhage and unsafe abortion. The social life of misoprostol has also been shaped by the question of authoritative practice, that is, the question of who can deliver medicine. Both issues are about the specters of misuse of misoprostol: off-label, illegal, immoral, or by unlicensed providers. In this paper, I focus ethnographically on two women’s health nongovernmental organizations that have been conducting clinical testing and advocacy for the use of misoprostol for reproductive indications in global maternal health settings. Drawing on the notions of pharmaceutical activism and protocol feminism, I describe and analyze how the tools of evidence and authoritative practice have been reassembled in new networks of expertise toward the social justice goals of life, access, and dignity for women.

A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa

“…Yet, study participants pointed to gaps in health worker training and medication supplies in national health systems in countries where they worked. To a certain extent, these gaps reflect continuing debates about the role of TBAs in obstetric care (MacDonald, 2020). At the same time, the informal dispensing of misoprostol by doctors, nurses, midwives, and pharmacists suggests that formal health workers are actively facilitating safer, albeit illegal, abortions.…”

“…At the same time, despite its proven safety record and integration into national and global LEM, misoprostol's capacity to terminate pregnancy continues to threaten its legitimacy as a reproductive health drug (Starrs and Winikoff, 2012;MacDonald, 2020) and renders it incompatible with US funding mechanisms for family planning aid. Despite USAID support for research and programming on misoprostol for PPH and PAC (Grenier et al, 2013;Barot, 2014), misoprostol cannot be procured with US development assistance under the 1973 Helms Amendment, which prohibits the "performance of abortion as a form of family planning (Barot, 2013: p.…”

“…Even for a legitimate obstetric indication like PPH, misoprostol's capacity to disrupt medical power over pregnancy, abortion, and delivery continues to generate professional debates over where it should be used, and by whom (MacDonald, 2020). Indeed, misoprostol disrupts conventional knowledge about where maternal health care itself should be administered.…”

The Duogynon controversy and ignorance production in post-thalidomide West Germany

“…Misoprostol, for instance, is indicated for ulcers, but is widely used informally both as an abortifacient ( Löwy et al, 2020 , MacDonald, 2020 ) and to induce labour ( Towghi, 2014; Voigt et al, 2015 ). Soon after the FDA approved DES as a menopause drug, in 1941, physicians started prescribing it, off label, as an informal treatment for miscarriage ( Bell, 2009: 17 ).…”

Legal geographies of medication abortion in the USA

“…Medication abortion is widely used in clinical settings for early abortion 1 and outside of clinical settings for clandestine self‐managed abortion in countries with restrictive laws (MacDonald, 2020). Medication abortion is a regime of two drugs: mifepristone followed by misoprostol.…”