Objective To explore the clinical practices, risks, and maternal outcomes associated with postpartum haemorrhage (PPH).Design Secondary analysis of cross-sectional data.Setting A total of 352 health facilities in 28 countries. Methods We used multivariate logistic regression to examine factors associated with PPH among all births, and the Pearson chi-square test to examine correlates of severe maternal outcomes (SMOs) among women with PPH. All analyses adjust for facilityand country-level clustering.Main outcome measures PPH, SMOs, and clinical practices for the management of PPH.Results Of all the women included in the analysis, 95.3% received uterotonic prophylaxis and the reported rate of PPH was 1.2%. Factors significantly associated with PPH diagnosis included age, parity, gestational age, induction of labour, caesarean section, and geographic region. Among those with PPH, 92.7% received uterotonics for treatment, and 17.2% had an SMO. There were significant differences in the incidence of SMOs by age, parity, gestational age, anaemia, education, receipt of uterotonics for prophylaxis or treatment, referral from another facility, and Human Development Index (HDI) group. The rates of death were highest in countries with low or medium HDIs.Conclusions Among women with PPH, disparities in the incidence of severe maternal outcomes persist, even among facilities that report capacity to provide all essential emergency obstetric interventions. This highlights the need for better information about the role of institutional capacity, including quality of care, in PPH-related morbidity and mortality.

Analysis 1.2. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 2 Serious maternal morbidity.. .. .. . Analysis 1.3. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 3 Admission to intensive care unit.. .. . Analysis 1.4. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 4 Hysterectomy.. .. .. .. .. . Analysis 1.5. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 5 Average blood loss after enrolment in millilitres. Analysis 1.6. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 6 Blood loss 500 mL or more after enrolment. Analysis 1.7. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 7 Blood transfusion.. .. .. .. .. Analysis 1.8. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 8 Blood loss 1000 mL or more after enrolment. Analysis 1.9. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 9 Additional uterotonics.. .. .. .. Analysis 1.10. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 10 Manual removal of the placenta after enrolment. Analysis 1.11. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 11 Uterine tamponade after enrolment.. . Analysis 1.12. Comparison 1 Misoprostol (any route) versus placebo or no additional treatment given to women simultaneously treated with conventional uterotonics, Outcome 12 Artery ligation (uterine and/or hypogastric arteries

ObjectiveTo determine if misoprostol is safe and efficacious in preventing postpartum haemorrhage (PPH) when administered by trained traditional birth attendants (TBA) at home deliveries.DesignA randomised, double-blind, placebo-controlled trial.SettingChitral, Khyber Pakhtunkhwa Province, Pakistan.PopulationA total of 1119 women giving birth at home.MethodsFrom June 2006 to June 2008, consenting women were randomised to receive 600 μg oral misoprostol (n = 534) or placebo (n = 585) after delivery to determine whether misoprostol reduced the incidence of PPH (≥500 ml).Main outcome measuresThe primary outcomes were measured blood loss ≥500 ml after delivery and drop in haemoglobin >2 g/dl from before to after delivery.ResultsOral misoprostol was associated with a significant reduction in the rate of PPH (≥500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59–0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62–1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34–0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants.ConclusionsPostpartum administration of 600 μg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible. Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug.Trial registrationhttp://clinicaltrials.gov/NCT00120237 Misoprostol for the Prevention of Postpartum Hemorrhage in Rural Pakistan.

Objective To assess the effectiveness of 600 Ag oral misoprostol on postpartum haemorrhage (PPH) and postpartum anaemia in a low income country home birth situation. Design Double blind randomised controlled trial.Setting Twenty-six villages in rural Gambia with 52 traditional birth attendants (TBAs).Sample One thousand, two hundred and twenty-nine women delivering at home under the guidance of a trained TBA. Methods Active management of the third stage of labour using three 200-Ag misoprostol tablets and placebo or four 0.5-mg ergometrine tablets (standard treatment) and placebo. Tablets were taken orally immediately after delivery. Main outcome measures Measured blood loss, postpartum haemoglobin (Hb), difference between Hb at the last antenatal care visit and three to five days postpartum. Results The misoprostol group experienced lower incidence of measured blood loss !500 mL and postpartum Hb <8 g/dL, but the differences were not statistically significant. The reduction in postpartum (compared with pre-delivery) Hb ! 2 g/dL was 16.4% with misoprostol and 21.2% with ergometrine [relative risk 0.77; 95% confidence interval (CI) 0.60 -0.98; P ¼ 0.02]. Shivering was significantly more common with misoprostol, while vomiting was more common with ergometrine. Only transient side effects were observed. Conclusions Six hundred micrograms of oral misoprostol is a promising drug to prevent life-threatening PPH in this setting.

No abstract