Should oral misoprostol be used to prevent postpartum haemorrhage in home‐birth settings in low‐resource countries? A systematic review of the evidence

Abstract

Background Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial.Objectives To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings.Search strategy The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012.Selection criteria Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded.Data collection and analysis Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate.Main results Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38-0.87), additional uterotonics (RR 0.34, 95% CI 0.16-0.73), and referral for PPH (RR 0.49, 95% CI 0.37-0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects.Author's conclusions The finding that the distribution of oral misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries. However, given the limited number of high-quality studies in this review, further randomised controlled trials are required to confirm the association, particularly in different implementation settings. Adverse effects have not been systematically captured, and there has been limited consideration of the potential for inappropriate or inadvertent use of misoprostol. Further evidence is needed to inform the development of implementation and safety guidelines on the routine availability of misoprostol.

From research to action: Oral Misoprostol for preventing postpartum haemorrhage during home delivery in rural Bangladesh

“…The search strategy was guided by a recent systematic review recommended by an expert at the London School of Hygiene and Tropical Medicine. 12 Medical subject headings (MESH) for the search included 'Parturition' and 'Delivery, Obstetric' and keywords were: 'labour' or 'labor', 'clean delivery', 'safe delivery', 'birth*', 'childbirth*', 'intrapartum', 'peripartum', 'perinatal', 'postpartum', 'postnatal', 'obstetric*', 'misoprostol', and 'haemorrhage' or 'hemorrhage'.…”

“…12 However, over the past 10 years, an increasing amount of research has been conducted, exploring its beneficial effects, one of which is its use as a cheap uterotonic to prevent and treat PPH. 12 Initially, some hospital-based studies didn't find enough evidence in favour of the effectiveness of misoprostol use to prevent PPH.…”

“…12 However, over the past 10 years, an increasing amount of research has been conducted, exploring its beneficial effects, one of which is its use as a cheap uterotonic to prevent and treat PPH. 12 Initially, some hospital-based studies didn't find enough evidence in favour of the effectiveness of misoprostol use to prevent PPH. 12 A lot of the existing studies compared the effectiveness of misoprostol against that of oxytocin, 13 which was found to be more effective and widely acceptable as the best preventive and treatment measure, especially in an institutional setting.…”

“…12 Initially, some hospital-based studies didn't find enough evidence in favour of the effectiveness of misoprostol use to prevent PPH. 12 A lot of the existing studies compared the effectiveness of misoprostol against that of oxytocin, 13 which was found to be more effective and widely acceptable as the best preventive and treatment measure, especially in an institutional setting. 12 However, it was not clear whether the use of misoprostol would be effective in resource-poor rural settings, where oxytocin is absent, and most of the birth take place outside the hospital with the help of traditional birth attendants.…”

Journal Club via social media: authors take note of the impact of #BlueJC

“…For example, our Journal Club paper discussed online in March 2013 was the only paper published in 2013 to achieve the highest number of downloads in the same year. 10 This example suggests that #BlueJC may have increased the visibility of Journal Club papers and encouraged access to the full text of these papers soon after they were published.…”