Advance distribution of misoprostol for preventing and treating excessive blood loss after birth

Excessive blood loss after birth remains an important cause of severe ill health and death of mothers particularly in settings where births still occur at home. The commonly used drugs (oxytocin and ergometrine) that help to reduce blood loss by making the womb contract immediately after birth need to be given by injection, and therefore cannot be used in the absence of a trained health professional. They also need to be stored in the refrigerator to remain effective. Misoprostol, another drug that helps the womb to contract strongly after birth, has an advantage over oxytocin and ergometrine because it is almost as effective, can be given by mouth and does not have any special storage requirements. Its side effects (particularly fever and shivering) are often minor and self-limiting and so do not require any additional medication. For these reasons, misoprostol could be used by lay health workers and the women themselves or a family member in places where births outside of a health facility are the norm. In some remote parts of the world where home birth is unavoidable, providing misoprostol well ahead of labour and childbirth to lay health workers and pregnant women themselves for self-use has recently become an attractive approach to ensure that the drug is available to the women who need it at the point of birth. However, there are concerns that misoprostol provided in this way may cause harm to the mother and her baby if used for other purposes such as starting labour or terminating a pregnancy. This review set out to determine whether increasing access to misoprostol by providing it ahead of labour and childbirth to lay individuals makes a difference to the health of the mother and her baby. The review found that no randomised trials had been conducted on this topic. There is therefore insufficient evidence to support a system of distributing misoprostol ahead of labour and childbirth within the community for preventing or treating excessive blood loss after birth.

Authors' conclusions: 

There is no evidence from randomised or quasi-randomised trials on the benefits or risks of a strategy of advance misoprostol distribution for PPH prevention or treatment in non-facility births. In view of the increasing interest to scale up this strategy, there is an urgent need for large and well-designed randomised trials to evaluate its comparative benefits and risks.

Read the full abstract...

Advance community distribution of misoprostol for preventing or treating postpartum haemorrhage (PPH) has become an attractive strategy to expand uterotonic coverage to places where conventional uterotonic use is not feasible. However, the value and safety of this strategy remain contentious.


To assess the effectiveness and safety of a strategy of advance misoprostol distribution for PPH prevention and treatment in non-facility births.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (5 October 2011). We did not apply any language restrictions.

Selection criteria: 

Randomised or quasi-randomised controlled trials of advance misoprostol distribution to lay health workers or pregnant women compared with usual care for PPH prevention or treatment in non-facility births. We excluded studies without any form of random design.

Data collection and analysis: 

Two review authors independently assessed trial eligibility for inclusion.

Main results: 

The search strategies identified three studies. None of the studies met the inclusion criteria.