Open Access Highly Accessed Research article

Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date

Jeffrey Michael Smith1*, Rehana Gubin2, Martine M Holston3, Judith Fullerton4 and Ndola Prata5

Author Affiliations

1 Jhpiego, 1776 Massachusetts Ave., NW#300, Washington, DC 20036, USA

2 Jhpiego, 1615 Thames St. #300, Baltimore, MD 21231, USA

3 Venture Strategies Innovations, 2115 Milvia St., Suite 4A, Berkeley, CA 94704, USA

4 University of California, San Diego (Ret), 7717 Canyon Point Lane, San Diego, CA 92126, USA

5 School of Public Health, University of California, Berkeley, 229 University Hall, Berkeley, CA 94720-6390, USA

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BMC Pregnancy and Childbirth 2013, 13:44  doi:10.1186/1471-2393-13-44

Published: 20 February 2013



Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births.


We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events.


Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries.


Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication.

Community-based distribution mechanisms; Misoprostol; Coverage; Safety; Serious adverse events; Home birth; Postpartum hemorrhage