In early 2011 misoprostol was added to the World Health Organization’s Model List of Essential Medicines for the prevention of PPH as a safe and effective medicine. Misoprostol is a tablet alternative and has the advantages of being stable at room temperature, easy to administer, and widely accessible, features especially critical in lower resource settings. A recent study by the Food and Drugs Authority Ghana highlighted problems with the quality of oxytocin in that country, finding that the majority of samples of oxytocin (65.5 %) did not meet the required standards for quality. In addition, problems with the quality of the oxytocin product available have been identified in some settings. While new aerosol formulations of oxytocin are being developed that do not require skilled health workers for administration or cold chain storage, these products remain in development. In the world’s least developed countries it is estimated that only 35 % of births are attended by skilled health workers. However, widespread use of oxytocin is impeded by its need for cold-chain storage and either intravenous or intramuscular administration by a skilled birth attendant. The gold standard treatment for the prevention of PPH is 10 iU oxytocin, recommended by the World Health Organization (WHO), the International Federation of Gynecology and Obstetrics and International Confederation of Midwives. ĭrugs that can be used for PPH prophylaxis include oxytocin (intravenous (IV) or intramuscular (IM)) syntometrine (IM) ergometrine (IV or IM) and oral misoprostol.
Even with these efforts to prevent PPH, some women will require treatment for excessive bleeding and timely interventions including use of additional uterotonics by skilled providers. The latter is not recommended in all guidelines. WHO guidelines for AMTSL include prophylactic administration of a uterotonic soon after the birth of the baby, delivery of the placenta by controlled cord traction (where skilled birth attendants are available) and late cord clamping (performed after 1 to 3 min after birth). It is therefore recommended that active management of the third stage of labour (AMTSL) be offered to all women during childbirth by a skilled attendant to prevent PPH. Almost one-third of maternal deaths worldwide are due to haemorrhage, mostly in the postpartum period. Postpartum haemorrhage (PPH) continues to be a leading cause of maternal deaths, particularly in low-income countries. These benefits need to be weighed against the large number of additional side effects such as shivering and fever, which have been described as tolerable and of short duration. Our findings confirm that, even though misoprostol is not the optimum choice in the prevention of PPH, misoprostol could be an effective and cost-saving choice where oxytocin is not or cannot be used due to a lack of skilled birth attendants, inadequate transport and storage facilities or where a quality assured oxytocin product is not available. Sensitivity analyses indicate that the results are sensitive to the incidence of PPH-related outcomes, drug costs and the proportion of hospital births. An additional 217 women would experience shivering and 70 fever. oxytocin not available in the hospital setting), 37 cases of PPH could be prevented ten fewer women would require additional uterotonics and six fewer women a blood transfusion. If misoprostol is used in both the hospital and community setting compared with no treatment (i.e. Oxytocin/misoprostol was found to be cost saving (US$320) compared to oxytocin/no treatment.
An additional 130 women would experience shivering and an extra 42 women fever. Six fewer women would require additional uterotonics and four fewer women a blood transfusion. Using oxytocin in the hospital setting and misoprostol in the community setting in a cohort of 1000 births, instead of oxytocin (hospital setting) and no treatment (community setting), 22 cases of PPH could be prevented. Costs were estimated based on 2012 US dollars. MethodsĪ cost-consequences analysis was conducted from the international health system perspective, using data from a recent Cochrane systematic review and WHO’s Mother-Baby Package Costing Spreadsheet in a hypothetical cohort of 1000 births in a mixed hospital (40 % births)/community setting (60 % births). This study evaluates the costs and health outcomes of use of oral misoprostol to prevent PPH in settings where injectable uterotonics are not available. While inferior to oxytocin injection in both efficacy and safety, orally administered misoprostol has been included in the World Health Organization Model List of Essential Medicines for use in the prevention of postpartum haemorrhage (PPH) in low-resource settings.
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