Should oral misoprostol be used to prevent postpartum haemorrhage in home birth settings in low resource countries? A systematic review of the evidence

Background
Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial.

Objectives
To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings.

Search strategy
The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012.

Selection criteria
Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded.

Data collection and analysis
Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate.

Main results
Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38–0.87), additional uterotonics (RR 0.34, 95% CI 0.16–0.73), and referral for PPH (RR 0.49, 95% CI 0.37–0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects.