A report from #BlueJC: Should oral misoprostol be used in home births in low-resource countries?

Paper discussed: Hundley V, Avan B, Sullivan C, Graham W. Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence. BJOG 2013;120:277–87.

Location: Twitter

Date of Journal club: 20 March 2012

Number of participants: 27 (including author)

Number of tweets: 182

Structured question:

ParticipantsWomen delivering at home in low-resource countries
InterventionOral misoprostol
ComparisonPlacebo or no treatment
OutcomePostpartum haemorrhage, use of other uterotonics, referral and adverse effects
Study designSystematic review and meta-analysis of randomised controlled trials and studies reporting effectiveness

Research literacy

Grades of Recommendation, Assessment, Development and Evaluation (GRADE)

The GRADE Working Group has developed a system to define the quality of evidence as ‘the extent to which one can be confident that the effect shown in a study is close to the quantity of specific interest’ (Guyatt et al. BMJ 2008;336:924–6). Despite its widespread usage, this system could be prone to subjectivity.

Feedback on the study

Adverse effects, route of administration and acceptability of misoprostol

Although our contributors were aware of the adverse effects of misoprostol, systematic capture of the prevalence and severity of these adverse effects is needed. It was acknowledged that oral routes were useful but traditional birth attendants could also administer misoprostol via alternative routes (e.g. rectal administration). Contributors with previous experience of using oral misoprostol at home births in low-income countries described women's positive reactions with improved access to misoprostol.

Current controversies

Should the widespread use of oral misoprostol be encouraged in low-resource countries?

The question of efficacy attracted a polarised debate. Some contributors were concerned about study quality of existing research. Moreover, effective use of intramuscular oxytocin in home birth has been demonstrated in countries such as the Netherlands, and injectable uterotonics (compared with oral misoprostol) have been associated with lower risks of severe postpartum haemorrhage (Tunçalp Ö, Cochrane Database Syst Rev. 2012 Aug 15;8:CD000494). In addition, misuse (e.g. illegal abortion) and incorrect administration of misoprostol could cause harm. These concerns cast doubt over the appropriateness of the inclusion of misoprostol on the Essential Medicines List by the World Health Organization.

On the other hand, oral misoprostol has the potential to save lives and is relatively easy to distribute and administer. Some contributors believed that discouraging the widespread use of oral misoprostol could risk ‘doing nothing’ for women delivering at home without skilled attendance.

Social media has the potential to skew interpretation of evidence

Some contributors feared that lobbying groups were pushing for the use of misoprostol in the absence of evidence. A balanced view from many perspectives should be sought to help clinicians and policy-makers make informed decisions in healthcare.

Take home message

The use of misoprostol in home births remains controversial. The findings from new studies of community-based misoprostol administration are currently being evaluated and should improve the evidence base about safety and effectiveness in the near future.


We are grateful for all contributions to this Journal Club. For the transcript of the Journal Club and the full list of our contributors, please go to http://bit.ly/Z8PFBW.

Declaration of interests

EYLL is a BJOG Associate responsible for Journal Club.

Contribution to authorship

JH planned this Journal Club, collected all relevant Tweets and summarised them. EYLL contributed significantly to the compilation of this manuscript.

J Husseina & EYL Leungb

aImmpact, University of Aberdeen, Aberdeen, UK

bWomen's Health Research Unit, Katherine Twining Network, Queen Mary, University of London, London, UK

About #BlueJC: For a background and introduction to #BlueJC, please refer to BJOG 2013;120:657-60. Further information is available on www.BJOG.org. Follow @BJOGTweets to join the next #BlueJC. Queries should be sent to bjog@rcog.org.uk