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.
Date of Journal club: 20 March 2012
Number of participants: 27 (including author)
Number of tweets: 182
|Participants||Women delivering at home in low-resource countries|
|Comparison||Placebo or no treatment|
|Outcome||Postpartum haemorrhage, use of other uterotonics, referral and adverse effects|
|Study design||Systematic review and meta-analysis of randomised controlled trials and studies reporting effectiveness|
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.
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.