Community-based distribution of misoprostol for the prevention of postpartum hemorrhage: misconceptions related to misuse and diversion of facility birth

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Abstract Introduction : In low-resource settings, most maternal deaths caused by hemorrhage, occur in poorly resourced facilities or outside of health facilities where there is no access to skilled obstetric care. Community distribution of misoprostol is one of the compelling strategies for preventing or treating postpartum hemorrhage to avert maternal deaths. This scoping review was conducted to synthesize existing evidence that shows the negative impact of community distribution of misoprostol on facility delivery and misuse for labor induction or pregnancy termination. Methods: We identified and included all peer-reviewed articles on misoprostol implementation from PubMed, Cochrane Review Library, Popline, and Google Scholars. Narrative synthesis was used to analyze and interpret the findings in which quantitative and qualitative syntheses are integrated. Results: Three qualitative studies, six observational studies, and four experimental or quasi-experimental studies from Africa and Asia are included in this study. All before-after household surveys reported, increased delivery coverage after the intervention: ranging from 4 to 46 percentage points at the end of the intervention when compared to the baseline (5 studies). The pooled analysis of experimental and quasi-experimental involving 7,564 women from four of the studies revealed that there is no significant difference in facility delivery among the misoprostol and control groups [OR 1.011; 95% CI: 0.906-1.129]. A qualitative study among professionals also indicated that community distribution of misoprostol for the prevention of postpartum hemorrhage is acceptable to community members and stakeholders and it is a feasible interim solution until access to facility birth is improved. In the community-based distribution of misoprostol programs, administration of misoprostol before delivery was reported in less than 2% among seven studies involving 11,108 mothers. Evidence also shows that most women used misoprostol pills as instructed. No adverse outcomes from misuse in either of the studies reviewed. Conclusions: The claim that community-based distribution of misoprostol would divert institutional delivery strategies to home deliveries and promote misuse are not supported with evidence. Therefore, community-based distribution of misoprostol can be an appropriate strategy for reducing maternal deaths which occur due to postpartum hemorrhages especially in resource-limited settings where many deliveries take place outside of health facilities.

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