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

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.

Quality of care for maternal and newborn health: the neglected agenda

The quality of care received by mothers and babies in developing countries is often reported as poor. Yet efforts to address this contributory factor to maternal and newborn mortality have received less attention compared with barriers of access to care. The current heightened concern to achieve Millennium Development Goals 4 & 5 has illuminated the neglected quality agenda. Whilst there is no universally-accepted definition of "quality care", it is widely acknowledged to embrace multiple levels--from patient to health system, and multiple dimensions, including safety as well as efficiency. Quality care should thus lie at the core of all strategies for accelerating progress towards MDG4 &5. Interventions to measure and improve quality need themselves to be evidence-based. Two promising approaches are maternal and perinatal death reviews and criterion-based audit. These and other quality improvement tools have a crucial role to play in the implementation of effective maternal and newborn care.

Professional assistance during birth and maternal mortality in two Indonesian districts

OBJECTIVE

To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia.

METHODS

We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios.

FINDINGS

The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen.

CONCLUSION

Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesia's maternal mortality ratio.

Criterion-based clinical audit in obstetrics: bridging the quality gap?

The Millennium Development Goal 5 - reducing maternal mortality by 75% - is unlikely to be met globally and for the majority of low-income countries. At this time of heightened concern to scale-up services for mothers and babies, it is crucial that not only shortfalls in the quantity of care - in terms of location and financial access - are addressed, but also the quality. Reductions in maternal and perinatal mortality in the immediate term depend in large part on the timely delivery of effective practices in the management of life-threatening complications. Such practices require a functioning health system - including skilled and motivated providers engaged with the women and communities whom they serve. Assuring the quality of this system, the services and the care that women receive requires many inputs, including effective and efficient monitoring mechanisms. The purpose of this article is to summarise the practical steps involved in applying one such mechanism, criterion-based clinical audit (CBCA), and to highlight recent lessons from its application in developing countries. Like all audit tools, the ultimate worth of CBCA relates to the action it stimulates in the health system and among providers.

Measuring maternal mortality: an overview of opportunities and options for developing countries

BACKGROUND

There is currently an unprecedented expressed need and demand for estimates of maternal mortality in developing countries. This has been stimulated in part by the creation of a Millennium Development Goal that will be judged partly on the basis of reductions in maternal mortality by 2015.

METHODS

Since the launch of the Safe Motherhood Initiative in 1987, new opportunities for data capture have arisen and new methods have been developed, tested and used. This paper provides a pragmatic overview of these methods and the optimal measurement strategies for different developing country contexts.

RESULTS

There are significant recent advances in the measurement of maternal mortality, yet also room for further improvement, particularly in assessing the magnitude and direction of biases and their implications for different data uses. Some of the innovations in measurement provide efficient mechanisms for gathering the requisite primary data at a reasonably low cost. No method, however, has zero costs. Investment is needed in measurement strategies for maternal mortality suited to the needs and resources of a country, and which also strengthen the technical capacity to generate and use credible estimates.

CONCLUSION

Ownership of information is necessary for it to be acted upon: what you count is what you do. Difficulties with measurement must not be allowed to discourage efforts to reduce maternal mortality. Countries must be encouraged and enabled to count maternal deaths and act.

Universal reporting of maternal mortality: An achievable goal?

This paper aims to highlight the importance of aspiring to achieve universal reporting of maternal deaths as a part of taking responsibility for these avoidable tragedies. The paper first discusses the reasons for reporting maternal deaths, distinguishing between individual case notification and aggregate statistics. This is followed by a summary of the status of reporting at national and international levels, as well as major barriers and facilitators to this process. A new framework is then proposed - the REPORT framework, designed to highlight six factors essential to universal reporting. Malaysia is used to illustrate the relevance of these factors. Finally, the paper makes a Call to Action by FIGO to promote REPORT and to encourage health professionals to play their part in improving the quality of reporting on all maternal deaths - not just those directly in their care.

Describing safe motherhood programs for priority setting: The case of Burkina Faso

OBJECTIVE

This study was implemented to describe safe motherhood programs in Burkina Faso for planning and programming purposes.

METHODS

Twenty safe motherhood programs were described from November 2003 through May 2004 using a structured questionnaire, interviews with safe motherhood program managers and document reviews.

RESULTS

Only 2 of the 20 programs were designed to improve the availability of comprehensive emergency obstetric care, and only 2 comprehensively addressed all components of skilled attendance at delivery. Other gaps identified included poor availability of baseline data, few monitoring measures, and lack of planning for evaluation needs. National geographical coverage was also uneven.

CONCLUSION

A systematic overview of safe motherhood programs in a country can help to set priorities and aid in decision making for the allocation of resources towards contextually relevant strategies to curtail maternal mortality and severe morbidity. Planning for program design and evaluation may also be aided by such a process.

A randomised trial comparing local versus general anaesthesia for microwave endometrial ablation

OBJECTIVE

To compare the acceptability of microwave endometrial ablation using a local anaesthesia/sedation regime or general anaesthesia. To compare recovery following treatment with each type of anaesthetic.

DESIGN

Prospective randomised controlled trial with follow up of women who declined randomisation.

SETTING

The gynaecology department of a large teaching hospital in the UK.

POPULATION

All women referred for microwave endometrial ablation at the Aberdeen Royal Infirmary between July 1999 and September 2000 without a medical reason to favour one or other type of anaesthetic.

METHODS

191 women were equally randomised to undergo microwave endometrial ablation under general or local anaesthesia. Details were also collected for women not randomised because of an anaesthetic preference. All procedures were undertaken in an operating theatre.

MAIN OUTCOME MEASURES

Data collected by questionnaire including the woman's view of treatment acceptability, operative details and post-operative recovery.

RESULTS

Sixty-nine percent of eligible women would consider treatment under local anaesthesia. Ninety-one percent of microwave endometrial ablation procedures that started under local anaesthesia were completed without conversion to general anaesthesia. Anaesthetic type and allocation by randomisation or preference made no significant difference to the proportion of women describing treatment as totally or generally acceptable at two weeks. Neither parity nor cavity size predicted acceptability. Women allocated general anaesthesia were more likely to describe the procedure as totally acceptable and to choose the same anaesthetic again. There was no significant difference between anaesthetic groups regarding post-operative pain, nausea or recovery time.

CONCLUSIONS

Microwave endometrial ablation under local anaesthesia was acceptable to the majority of women referred for treatment. There was no recovery advantage from local anaesthesia and almost 1 in 10 women who starting treatment under local anaesthesia needed a general anaesthetic because of discomfort. The incidence of post-operative pain and nausea means that treatment with this local anaesthetic/sedation regime remains a day case rather than an outpatient procedure.

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data

OBJECTIVE

To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.

DESIGN

A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.

PARTICIPANTS

All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988-1997 (28,484 deliveries).

MAIN OUTCOME MEASURES

Odds ratios for each intervention in older maternal age groups compared with women aged 20-29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).

METHODS

Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio-demographic characteristics.

RESULTS

Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.

CONCLUSIONS

Higher levels of intervention among older women are not explained by the obstetric complications we considered.

Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries

The objective of the study described is to assess the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life-threatening obstetric complications--hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a "before and after" design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re-evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life-threatening complications occurring over 66 hospital-months; Review II included 342 complications over 42 hospital-months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion-based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life-threatening obstetric complications.

An investigation of women's involvement in the decision to deliver by caesarean section

OBJECTIVE

To assess the degree and nature of women's involvement in the decision to deliver by caesarean section, and women's satisfaction with this involvement.

DESIGN

Observational study.

SETTING

The maternity unit in a large teaching hospital.

SAMPLE

One hundred and sixty-six women undergoing caesarean section.

METHODS

Interviews with the women on the third or fourth day postpartum, questionnaires sent to the women at 6 weeks and at 12 weeks postpartum, and extraction of information from the women's medical records.

MAIN OUTCOME MEASURES

Women's knowledge, satisfaction, and involvement in making the decision concerning their caesarean section.

RESULTS

The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections. For 7% of the women, maternal preference for caesarean section was a direct factor in making the decision. Just over half of the 166 women reported that they were not debriefed on the reasons for their caesarean section before their discharge from hospital. Almost a third of the women undergoing emergency caesarean section expressed negative feelings towards their delivery, compared with 13% of those undergoing elective caesarean sections.

CONCLUSION

Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section.

Outcomes and effectiveness in reproductive health

Measuring reproductive health is problematic. Awareness of the problems needs to be raised both among those collecting and those using data on reproductive health. This paper discusses two major measurement questions--one related to ascertainment and the other to attribution. The first question is to what extent the observed levels and patterns of reproductive health outcomes in women are valid as opposed to artefacts of the data sources and the data collection methods? The second question is can lack of evidence of effectiveness for any reproductive health intervention ever confidently be separated into no effects vs an inability to measure effects? Determining the effectiveness of health interventions is notoriously difficult. Reproductive health may not be a case for special pleading in the competition for scarce resources, but equally it should not be a case for special standards of proof of the effectiveness of interventions--standards which have not indeed been met by many other, and yet unquestioned, health care priorities. "What works" in reproductive health should in fact be judged from at least four different perspectives: from that of women and their families, health professionals, the scientific community, and national and international policy-makers.

Malaria is an important cause of anaemia in primigravidae: evidence from a district hospital in coastal Kenya

A study was undertaken in order to determine the prevalence and aetiology of anaemia in pregnancy in coastal Kenya, so as to establish locally important causes and enable the development of appropriate intervention strategies. 275 women attending the antenatal clinic at Kilifi district hospital, Kenya, were recruited in November 1993. The prevalence of anaemia (haemoglobin [Hb] < 11 g/dL) was 75.6%, and the prevalence of severe anaemia (Hb < 7g/dL) was 9.8% among all parities; 15.3% of 73 primigravidae were severely anaemic, compared with 7.9% of 202 multigravidae (P = 0.07). In primigravidae, malaria infection (Plasmodium falciparum) was strongly associated with moderate and severe anaemia (chi 2 test for trend, P = 0.003). Severe anaemia was more than twice as common in women with peripheral parasitaemia as in those who were aparasitaemic, and parasitaemia was associated with a 2.2g/dL decrease in mean haemoglobin level (P < 0.001). In multigravidae, iron deficiency and hookworm infection were the dominant risk factors for anaemia. Folate deficiency and human immunodeficiency virus infection were not strongly associated with anaemia. It is suggested that an intervention that can effectively reduce malaria infection in primigravidae could have a major impact on the health of these women and their infants.

Demonstrating programme impact on maternal mortality

Reducing maternal mortality if one of the primary goals of safe mother hood programmes in developing countries. Maternal mortality is not, however, a feasible outcome indicator with which to judge the success of these programmes. This is due to an unfortunate combination of obstacles to measurement--some general to assessing the mortality impact of health programmes and some peculiar to estimating maternal mortality. There is a need to promote alternative views and measures of programme success, and alternative uses for information on maternal deaths.

Maternal mortality in the Thyolo District of southern Malawi

The Sisterhood Method, a community-based survey technique, was used to estimate the Life Time Risk of a woman dying a maternal death in Southern Malawi. With this figure, the maternal mortality ratio for that area was calculated to be 409 deaths per 100,000 live births. The 4124 adults interviewed reported 150 maternal deaths in sisters. An in-depth questionnaire was then used to determine that 56% of these deaths occurred outside a health facility, largely due to lack of transportation or poor access to fixed health care facilities; 25% died from excessive hemorrhage; 20% from obstructed labour; 18% from abortion; 13% from sepsis; while eclampsia accounted for only 4% of the maternal deaths. This field experience with the Sisterhood Method technique combined with an in-depth questionnaire for determining causes of maternal deaths has provided useful information in a simple and cost-effective manner for use in planning intervention strategies designed to decrease maternal mortality.

Maternal health and the measurement trap

This paper focuses on the contribution of measurement-related factors to the neglect of maternal health in resource allocation for programmes and in public health research. As the recent interest in maternal health has now progressed beyond the need for information primarily for the purpose of advocacy, measurement-related factors have emerged as powerful constraints on programme action. Three outstanding needs for information can be identified: first, to establish the levels and trends of specific maternal health outcomes; secondly, to identify the characteristics and determinants of health outcomes; and thirdly, to monitor and evaluate the effectiveness of programmes designed to influence health outcomes. In order to meet these needs, the emphasis placed on operational research by the current major initiatives in maternal health must be complemented by an equivalent emphasis on methodological studies. The call for improved information by international and national agencies should be made in unison with the call for action. Inadequate information is a reality that has to be faced throughout the world, but particularly in developing countries. The quality, quantity and scope of health-related data are the elements of this inadequacy and may be discussed in terms of four factors: the indicators, the data sources, the measurement techniques, and the conceptual framework. In this paper, the neglect of maternal health and the lack of information are shown to be self-reinforcing and constitute a measurement trap sprung by these four factors. Dismantling this trap has revealed a weak conceptual framework to lie at the very centre. Maternal health has tended to be conceptualized as a discrete, negative state, characterized by physical rather than social or mental manifestations, and by a narrow time-perspective focusing on pregnancy, delivery and the puerperium. The need to broaden this perspective and to develop equally broad operational definitions represent important steps forward that must be taken.

Investigating induced abortion in developing countries: methods and problems

Interest in abortion research is reemerging, partly as a result of political changes and partly due to evidence of the contribution of induced abortion to maternal mortality in developing countries. Information is lacking on all aspects of induced abortion, particularly methodological issues. This article reviews the methodological dilemmas encountered in previous studies, which provide useful lessons for future research on induced abortion and its complications, including related deaths. Adverse health outcomes of induced abortion are emphasized, because these are largely avoidable with access to safe abortion services. The main sources of information are examined, and their relevance for assessing rates of induced abortion, complications, and mortality is addressed. Two of the major topics are the problems of identifying cases of induced abortion, abortion complications, and related deaths, and the difficulties of selecting a valid and representative sample of women having the outcome of interest, with an appropriate comparison group. The article concludes with a discussion of approaches for improving the accuracy, completeness, and representativeness of information on induced abortion. Although the prospects for high-quality information seem daunting, it is essential that methodological advances accompany program efforts to alleviate this important public health problem.

Principles of oncology: how radiation therapy works

Radiation therapy remains the primary mode of treatment for many types and stages of cancer as well as playing an extremely important adjunct role in the treatment of many other malignancies, often in combination with medical and surgical oncology. The combination treatments often yield cure and long-term control rates far in excess of single modality treatment.

Identifying health problems and health research priorities in developing countries

When we were invited to prepare this background paper on the health problems of the developing countries for the Commission on Health Research for Development, our first thought was to compile and organize available data on the causes of morbidity and mortality affecting different age groups in various populations. It soon became clear that this would not be especially useful. There are major gaps in the available data, particularly from the poorer countries and for people above 5 years of age. The data that are available are often of poor or uncertain quality, collected from unrepresentative or undefined subpopulations, and not strictly comparable due to different definitions and data-collection methods. Additionally, in the absence of agreed definitions and analytical frameworks, it is not clear what could or should be done with the data on health problems so amassed. More fundamentally, we have come to doubt whether the current array of epidemiological concepts and tools is sufficient for the task. We therefore decided that, while giving an overview of current knowledge on levels and trends of morbidity and mortality, the emphasis of this paper should be more towards concepts, methods, and data deficiencies. In Section 1, we set out definitions and frameworks for considering health problems and health research; we review recent conceptual models for the analysis of the determinants of child survival; and we outline a framework, focusing on modifiable determinants of health and life-cycle health effects, which is used in subsequent sections. In Section 2, relationships between national and societal level determinants and health are reviewed and then set aside. In Section 3, we review available data on world patterns and trends of morbidity and mortality, highlighting the data deficiencies and lacunae. In Section 4, we follow the life of a woman in a developing country and examine the health problems, and their determinants, which she and her children face. In Section 5, we draw these strands together and, having reviewed current approaches to prioritizing health problems and suggested some ways in which they could be improved, in Section 6 identify several research priorities, emphasizing the need for methodological research. This paper was commissioned in March 1987; prepared in draft and presented to a meeting at Chateau de Bossey, Geneva, Switzerland during 15-17 July; and revised and completed in September 1987. It is in no sense definitive or final.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of pilonidal sinus by phenol injection

This report reviews the treatment of pilonidal sinus by phenol injection in 54 patients. Forty-four patients were treated initially by phenol injection and this was successful in 70%. The median number of injections per patient was one (range 1-5) with a median hospital stay per injection of two days (range 1-17 days). The median time to complete healing for patients treated by injection alone was two months (range 1-32 months). These results compare very favourably with more radical methods of treatment.

Differential radioprotection of normal tissues by hydrophilic chemical protectors

Analogous to certain radiosensitizers which are too hydrophilic to enter tumor cells, certain radioprotectors, because of their hydrophilicity, may also be hindered from entering tumor cells and thus protect only normal tissues. In testing this hypothesis, we utilized thin layer chromatography as convenient means to measure radioprotector hydrophilicity. Dose reduction factors (DRF's) for hematopoietic radioprotection were determined in BALB/c mice given half maximum tolerated doses (MTD/2) of 11 radioprotectors 30 min prior to graded doses of gamma rays. DRF's for tumor protection were determined in MCa-11 tumor-bearing mice using a regrowth delay assay. Differential radioprotection was found to be significantly correlated (r = 0.86) with hydrophilicity. Thus, radioprotector hydrophilicity appears to be a significant factor in the differential radioprotection observed and should be useful in designing or selecting better differential radioprotectors.

Analysis of terrorist injuries treated at Craigavon Area Hospital, Northern Ireland, 1972-1980

As a result of terrorist incidents, 482 patients were seen at a district hospital between September 1972 and December 1980. Details of 339 bomb victims and 115 gunshot victims were available for analysis. Most patients in both categories suffered injuries not affecting vital structures and there was an admission rate of 42 per cent for bomb victims and 81 per cent for gunshot victims. Five patients died in hospital as a result of explosions, and 12 of gunshot wounds. The majority of patients (72 per cent) were seen outside normal working hours (9.00 am-5.00 pm). Initial emergency treatment was carried out at Craigavon Area Hospital and ultimately 41 cases were transferred for either security or medical reasons.

Angiosarcoma treated with radiation therapy alone

A case of angiosarcoma of the thumb, treated with radiation therapy alone, is described., The patient is alive and well at ten-years post-therapy, with no evidence of disease.

Scattered radiation from trimmer bars in the cobalt-60 teletherapy machines

The amount of scattered radiation resulting from four Cobalt-60 teletherapy units in four different hospitals when trimmer bars were fully extended was studied. Scatter was present for all machines checked at between 10% and 20% of the central axis dose. Clinical significance is also discussed.

Bilateral testicular torsion in the newborn

A neonate with bilateral torsion of the testes is described. Torsion occurred in utero and was discovered only on routine examination after birth. The relevance of the comparatively silent torsion is discussed in relation to the age of the child, and the timing of routine examination of the newborn.