RHO archives : Topics : Safe Motherhood

Annotated Bibliography

This is page 4 of the Safe Motherhood Annotated Bibliography. This page contains:

• Essential obstetric care
• Postabortion care
• Impact of family planning on maternal mortality
• Use of misoprostol for obstetric and gynecological indications

To access more bibliographic entries, visit page 1, page 2, page 3, or page 5, or return to the complete list of topics covered in the Safe Motherhood Annotated Bibliography. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

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Essential obstetric care

Abreu, E. and Potter, D. Recommendations for renovating an operating theater at an emergency obstetric care facility. International Journal of Gynecology & Obstetrics 75:287–294 (2001).
Offering essential obstetric care requires the capacity to perform cesarean sections. This article offers practical advice to hospital administrators and health care providers on renovating existing operating theaters to meet necessary standards of care. It reviews the functioning of an ideal operating theater, including the need to keep the paths of "dirty" and "clean" items from crossing. It emphasizes low-cost approaches and the use of appropriate, locally available materials. It is important to use appropriate materials, establish good maintenance practices, and provide continuous support services (such as electricity, water, and laundry).

Barnes-Josiah, D. et al. The "three delays" as a framework for examining maternal mortality in Haiti. Social Science and Medicine 46(8):981–93 (April 1998).
The goal of this study was to analyze 12 maternal deaths that occurred in a longitudinal cohort of pregnant Haitian women using the "three delays" model. Researchers interviewed family and friends to obtain details about the medical and social circumstances surrounding each maternal death. Results revealed that eight out of 12 deaths (67%) were due to a delayed decision to seek medical care; inadequate medical care was a factor in seven deaths; and delays in transportation were a factor in two deaths. The researchers stated that improvements which focus on reducing the second delay (improving the quality and scope of care available at existing medical facilities) will have the greatest impact in reducing maternal mortality in Haiti. In addition, education about the need to seek care promptly when complications arise was also stressed.

Benagiano G, Thomas B. Safe motherhood: the FIGO initiative. International Journal of Gynecology and Obstetrics. 2003;82(3):263–274.
This article summarizes the main results from five projects initiated through partnerships between professional societies of obstetricians and gynecologists in more and less developed countries in 1997. In general, the results are positive. The projects demonstrated that maternal lives can be saved by making more efficient use of existing resources, by motivating health professionals, and with modest financial expenditures. In addition to training, there is need for supervision and support of health professionals. Modifications of routine practices and improved communications can have significant impacts. Involving the community and addressing cultural beliefs and practices are important. Involving midwives, doctors, and nurses and getting governments to make modest budget allocations to emergency obstetric care can save many lives.

Benagiano, G. and Thomas, B. Saving mothers lives: the FIGO Save the Mothers Initiative. International Journal of Gynecology and Obstetrics 80:198–203 (2003).
The International Federation of Obstetrics and Gynecology (FIGO), with funding form UNFPA, the World Bank, and Pharmacia Corporation, has established the Save the Mothers Initiative. By partnering professional societies of obstetricians and gynecologists in more-developed countries with those in less-developed countries, the initiative seeks to mobilize the obstetric communities to demonstrate the feasibility and effectiveness of integrated, comprehensive, essential obstetric services. Following a survey of FIGO members worldwide, five partnerships were established (Uganda-Canada, Central America–United States, Ethiopia-Sweden, Mozambique-Italy, and Pakistan–United Kingdom). A country team of local and international experts directs each project. In each country, a needs assessment is conducted using the monitoring guidelines established by UNICEF, WHO, and UNFPA. Based on these findings, a demonstration project is developed to address maternal mortality in the selected area. The activities in the initial five countries are ongoing, but reports of activities, obstacles, and lessons learned are being published in the International Journal of Obstetrics and Gynecology.

Borghi J et al. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy and Planning. 2003;18(4):383–390.
The results of this study of the costs of spontaneous vaginal delivery and five types of obstetric complications (“near-miss”) in Benin and Ghana indicate that the high costs associated with hospital-based delivery care are likely to deter or delay women’s use of these health services. Retrospective cost data were collected from 121 mothers in three hospitals in Ghana (1999–2000), and prospective data were collected from 420 pregnant women in two hospitals in Benin (2000). In Benin the costs ranged from US$15 for a spontaneous vaginal delivery to US$256 for a near-miss complication caused by dystocia. In Ghana the costs ranged from US$18 for a spontaneous vaginal delivery to US$115 for a near-miss complication caused by hemorrhage. The high costs of complications (34% of annual household cash expenditure in Benin) can deter women from seeking care, and have a devastating effect on household budgets when they occur.

Curet, L.B. et al. FIGO Save the Mothers Initiative: the Central America and USA collaboration. International Journal of Gynecology and Obstetrics 80:213–221 (2003).
The American College of Obstetricians and Gynecologists (ACOG) and the Central American Federation of Associations and Societies of Obstetrics and Gynecology (FECASOG) joined together to improve the provision of basic emergency obstetric care in selected departments in four Central American countries (Guatemala, El Salvador, Honduras, and Nicaragua). Based on a needs assessment performed in 1998, pilot-project activities were developed to improve services. These included training, revised protocols, systematic data gathering, and improved communications. The cost of the pilot project was about US$200,000 per year, indicating that improvements in emergency obstetric care can be made relatively inexpensively in these four areas. Most notably, the project collected more reliable data on maternal mortality and highlighted the risks involved with home deliveries. It also pointed out the need to bridge the gap between the medical and sociopolitical realms in order to improve womens health.

Desai, J. The cost of emergency obstetric care: concepts and issues. International Journal of Gynecology & Obstetrics 81:74–82 (2003).
Assessing the costs and cost-effectiveness of emergency obstetric care (EmOC) requires an understanding of the inputs and benefits of the services. This article offers a definition of EmOC provision cost, and explains how to identify all the components, including those that are shared inputs. It provides a spreadsheet for tracking and calculating the cost of these inputs. It is important to select and justify the measures used to evaluate cost-effectiveness of EmOC (for example, cost per obstetric patient, cost compared to other health interventions, etc.).

Djan, J.O. et al. Upgrading obstetric care at the health center level, Juaben, Ghana. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S83–S90 (November 1997).
This article describes an effort to improve the quality of obstetric care at a health center in Ghana. Midwives received training in life saving skills and provider-client interaction, skilled doctors were posted to the health center, a revolving fund for drugs was established, supervisors made regular visits, and a surgical theater and blood supply were established. From 1993 to 1995, the utilization of obstetric services rose as did the number of surgical obstetric procedures. Over the same time period, the percentage of women with complications who had to be referred to a tertiary facility for correct treatment fell from 42 percent to 14 percent.

Dwivedi, H. et al. Planning and implementing a program of renovations of emergency obstetric care facilities: experiences in Rajasthan, India. International Journal of Gynecology and Obstetrics 78:283–291 (2002).
The experiences renovating emergency obstetric care facilities in 71 institutions in Rajasthan, India, yielded many lessons learned about how best to undertake such renovations. Two elements are key: conducting a thorough needs assessment in consultation with all stakeholders prior to the start of renovations, and careful monitoring of the renovation process by those qualified to assess and to take action to improve renovations. Other lessons learned include: expect to make renovations to general facility support (electricity, water, housekeeping, and biomedical-waste disposal), expect changes and delays, and plan for disruptions of emergency obstetric services at the facility. At a cost of about US$7,000 per facility, this project demonstrated that facilities can be renovated and services improved at modest cost.

El Joud, D.O. et al. Epidemiological features of uterine rupture in West Africa. Paediatric and Perinatal Epidemiology 16:108–114 (2002).
Data from a large, prospective, population-based study of pregnant women in West Africa (the MOMA study) were analyzed to determine the incidence of uterine rupture, identify risk factors, and assess its predictiveness. Of the 20,326 pregnant women analyzed, there were 25 cases of symptomatic uterine rupture, giving an incidence rate of 1.2 uterine ruptures per 1,000 deliveries. Five variables were significantly associated with uterine rupture: uterine scars, malpresentation, limping, cephalopelvic disproportion, and high parity. While a uterine scar increases the risk of uterine rupture by 11, rupture cannot be predicted from currently known risk factors. The high case-fatality rate identified here (33.3%) indicates the inadequacy of obstetric care available in West Africa, even in major cities.

El Tahir, A. and Maine, D. Estimating Resources for Emergency Obstetric Care: A Management Tool. Prepared for the Division of Family Health, World Health Organization (WHO), New York: Prevention of Maternal Mortality Program, Center for Population and Family Health, Columbia University (October 1995).
This handbook enables program planners and managers to estimate the resources needed to provide emergency obstetric care (EOC) to a defined target population (for example, within a health area, district, or province). Providing EOC does not necessarily require the building of hospitals or comprehensive health care facilities. Instead, existing facilities can often be equipped with the requisite personnel, equipment, and drugs to provide the necessary care. This handbook provides the specific equations needed to calculate the number of personnel, the instruments, the supplies (including intravenous solutions, and blood transfusions), and the drugs needed to provide specific types of EOC to a given population. Using the accompanying computer disk and worksheet (Lotus spreadsheet), a program manager can enter variables such as the population size and birth rate, and the program will calculate the required resources. While this guide is based on the average global incidence of individual obstetric complications, each facility can adapt the model to accommodate the needs of the population it serves. The handbook appendix includes lists of the resources needed by facilities to provide basic and comprehensive EOC (following WHO guidelines).

Figa-Talamanca, I. Maternal mortality and the problem of accessibility to obstetric care: the strategy of maternity waiting homes. Social Science and Medicine 42(10):1381–1390 (1996).
This paper describes some examples of maternity waiting homes in different countries (e.g., Ethiopia, Cuba, Colombia, Malawi, Nicaragua, and Brazil). It discusses some of the issues related to successful functioning of maternity waiting homes, and provides an analytical framework for the planning, management, and evaluation of these facilities.

Filippi V et al. Obstetric audit in resource-poor settings: lessons from a multi-country project auditing ‘near miss’ obstetrical emergencies. Health Policy and Planning. 2003;19(1):57–66.
This paper outlines the steps involved in setting up and running multi-professional, in-depth case reviews of “near miss” obstetrical complications. The study took place during 1998–2001 at 12 first level and regional or teaching hospitals in Benin, Côte d’Ivoire, Ghana, and Morocco. The principles of the audit approach were well accepted by staff, but were most successful in first referral level centers. Factors that contribute to the successful audit are staff having adequate time for audit activities, financial incentives for groups not individuals, involvement of senior staff and management, incorporation of patients’ views, and the external support provided by the research team. Poor-quality case notes were observed at all hospitals. Implementation was most successful at first level referral hospitals showing ownership and leadership of the project. Sustainability of the project activities will require high-level commitment in the health care system and allocation of some resources to follow-up recommendations.

Gill Z, Ahmed JU. Experience from Bangladesh: implementing emergency obstetric care as part of the reproductive health agenda. International Journal of Gynaecology and Obstetrics. 2004;85(2):213–220.
The Ministry of Health and Family Welfare and UNFPA worked together to introduce emergency obstetric care services into the reproductive health agenda for Bangladesh. Investments in training, infrastructure, management information systems, quality assurance mechanisms, and linkages between health facilities have resulted in increased utilization of services. Starting in one section of the country, the Ministry of Health later scaled up to include all Maternal and Child Welfare Centers in the country. Despite these gains, there are still many obstacles, including lack of resources, maldistribution of trained personnel and lack of decision-making power by women.

Gohou V, Ronsmans C, Kacou L, et al. Responsiveness to life-threatening obstetric emergencies in two hospitals in Abidjan, Côte d’Ivoire. Tropical Medicine and International Health. 2004;9(3):406–415.
This study at two hospitals in Côte d’Ivoire (Cocody and Abobo) during 2000–2001 found the yearly incidence of severe obstetric morbidity was 224.5 and 11.8 per 1000 live births, respectively. In Cocody the decision-to-delivery time was extremely long (median 4.8 hours), in part due to the time necessary to obtain a complete surgical kit (2.8 hours). At Abobo the decision-to-delivery time was shorter (median 1.0 hours). At both hospitals these delays exceed the recommended 30 minutes generally advocated in more developed countries. The huge case load of severe cases and the absence of any policy ensuring prompt treatment for life-threatening emergencies contribute to these delays.

Ifenne, D. et al. Improving the quality of obstetric care at the teaching hospital, Zaria, Nigeria. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S37–S46 (November 1997).
This article describes an effort to improve the utilization and quality of emergency obstetric services at a Nigerian teaching hospital. Interventions included a new surgical supply system, the repair and purchase of surgical equipment, a new blood donation system, and in-house training of midwives and resident doctors in emergency obstetric care. From 1990 to 1995, the quality of care improved: women with complications were seen more promptly and case fatality rates dropped. However, utilization of the hospital's obstetric services declined, probably because of the bad economic climate, an increase in fees, a strike by health care professionals, and competition from another hospital.

Jamisse L, Songane F, Libombo A, et al. Reducing maternal mortality in Mozambique: challenges, failures, successes and lessons learned. International Journal of Gynaecology and Obstetrics. 2004;85(2):203–212.
Following needs assessments, four different interventions were developed to improve access to emergency obstetric care in Mozambique. Two interventions focused on the capital, Maputo, one in a district of Maputo province, and one covering all of Sofala Province. The results indicate several lessons: (1) improving essential obstetric care is feasible, even in resource-poor areas like Mozambique; (2) payment of salaries should not be dependent on donor funding; (3) management and supervision is best done at the site of the intervention; (4) non-medical health personnel need to play a fundamental role in the delivery of essential obstetric care; and (5) many of the tools of the interventions (guidelines, manuals, etc.) are applicable to sites throughout the country.

John Snow, Inc. Family-centered maternity care—MotherCare's approach in Ukraine, Moldova and Russia. MotherCare Matters 7(2):1–22 (August 1998). Available at: www.jsi.com/intl/mothercare/mcmatters/mcm7_2.htm.
This paper discusses MotherCare's efforts to introduce the family-centered maternity care approach in the Ukraine, Moldova, and Russia. The approach focuses primarily on meeting the informational, social, emotional, and physical needs of pregnant women and their families during pregnancy, childbirth, and postpartum. It emphasizes education and preparation for childbirth so that a woman and her family can assume more active roles. The issue presents lessons learned from the different country programs and suggests recommendations to improve maternity care services.

Kerstiens B, Akii A, Mona N, et al. Improving the Management of Obstetric Emergencies in Uganda through Case Management Maps. Bethesda, Maryland: University Research Co., LLC; 2004. Available at: www.qaproject.org.
This report describes the introduction of two Case Management Maps (CMMs) in Uganda’s 500-bed Jinja Hospital. A CMM is a guide for providers in case management. It is kept in the patient’s chart or on the wall near the patient’s hospital bed to inform providers of the treatment protocol, what treatment was provided when and by whom, what to do should a critical event occur, etc. The two CMMs used in this study focused on pregnancy-induced hypertensive disorders (PIHD) and postpartum hemorrhage (PPH), respectively. Acute pelvic inflammatory disease (PID), for which there was no CMM, was measured for a comparison condition. Pooled adherence for three management indicators increased significantly for PIHD (22.6% to 87.3%). Adherence to care standards for PPH also increased, but at about the same level also observed for PID. More information is needed about which conditions benefit from CMMs prior to going to scale.

Lalonde, A.B. et al. The FIGO Save the Mothers Initiative: The Uganda-Canada collaboration. International Journal of Gynecology and Obstetrics 80:204–212 (2003).
As part of the FIGO Save the Mothers Initiative, in 1998 the obstetrics and gynecology associations of Uganda (AOGU) and Canada (SOGC) established a district-wide intervention to increase the availability and utilization of emergency obstetric care services in rural Kiboga, Uganda. Baseline data were gathered for the district according to the UN guidelines, and discussions were held with health professionals, government officials, and women in the district. A demonstration project was implemented March 1, 1999, and consisted of several activities aimed at reducing maternal morbidity and mortality in the district. After 24 months of activity, noted improvements were made. The number of births in project facilities increased from 17 percent in 1998 to 23 percent in 2000. The met need for treatment of women with obstetric complications increased from 4 percent to 47 percent. Met need for cesarean sections increased slightly, from 1.3 percent to 2.1 percent. The case fatality rate among women with obstetric complications fell from 9.4 percent to 1.9 percent. Use of antenatal care increased during the first year, but there was no substantial increase in the proportion of these women returning to deliver at the facility. The first two years of the project has produced improved emergency obstetric care services, and has shown that obstetricians, especially in partnership with midwives, have important roles to play in improving district services.

Leigh, B. et al. Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S55–S65 (November 1997).
This article describes an effort to improve the quality of emergency obstetric care at a district hospital in Sierra Leone. There were a wide array of interventions, including physician transfers, a sensitization workshop to improve staff attitudes, refresher courses for midwives and nurses, rescheduling of staff to provide 24-hour services, the purchase of equipment, drugs, and supplies, a change in payment policies for emergency patients, cash incentives for the staff, and improvements to the referral system. Data show that, from 1990 to 1994, maternity admissions increased as did the number of Caesarian sections and abortion-related procedures. At the same time, the case fatality rate declined from 32 percent to 4 percent, despite increases in the number of women with complications.

Maine, D., ed. Prevention of Maternal Mortality Network. International Journal of Gynecology & Obstetrics 59 (Suppl. 2) (November 1997).
This supplement provides detailed results from the Prevention of Maternal Mortality Network. Supported by Columbia University, the Network teams designed and implemented a range of activities to reduce maternal mortality by improving emergency obstetric care in Africa. This supplement includes the complete papers presented at the PMM Results Conference, June 1996, in Accra, Ghana.

Maine, D. The strategic model for the PMM Network. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S23–S25 (November 1997).
The author argues that providing emergency obstetric care should be the first priority for reducing maternal deaths, because most obstetric complications cannot be predicted or prevented, only treated.

Maine, D. and Rosenfield, A. The AMDD program: history, focus and structure. International Journal of Gynecology & Obstetrics 74:99–103 (2001).
The Averting Maternal Death and Disability Program (AMDD) was established at the Mailman School of Public Health at Columbia University in 1999. The five-year program builds on previous work done at the School through the Prevention of Maternal Mortality (PMM) Program, and emphasizes emergency obstetric care; the use of process indicators to measure progress; working with partners; and applying human rights principles to maternal health. Of the five major causes of maternal deaths, only one—complications of unsafe abortion—can be prevented. The other causes cannot be predicted or prevented, but can be treated. Prompt treatment of obstetric emergencies can avert deaths and many disabilities.

Maine, D. and Rosenfield, A. The Safe Motherhood Initiative: why has it stalled? American Journal of Public Health 89(4):480–482 (April 1999).
More than a decade after the founding of the Safe Motherhood Initiative, there is no evidence that maternal mortality has declined, and there are few large programs. The authors argue that this lack of progress is due to common misconceptions about how maternal mortality can be reduced and lack of a clear, concise, feasible strategy. Making better use of existing resources to improve emergency obstetric care could result in a substantial reduction in maternal mortality.

Martey, J. et al. Referrals for obstetrical complications from Ejisu district, Ghana. West African Journal of Medicine 17(2):58–63 (April–June 1998).
This study in the Ejisu district of Ghana assessed which institutions received referrals for obstetric complications and examined the outcomes of those referrals. A total of 192 referrals were made from 15 health facilities in the district. Three receiving institutions were identified and included Komfo Anokye Teaching Hospital (KATH) (87 women admitted out of 139 referred), Agogo Presbyterian Hospital (17 of 34 admitted) and St. Michael's Hospital (14 of 19 admitted). Maternal hemorrhage was the most common complication referred (29 percent of women admitted). The proportion of pregnant women referred to the three hospitals who were admitted varied from 8 percent to 56 percent. Results from focus group discussions revealed various factors that inhibited the use of health services: high hospital fees, illegal fees and bribes, irregular transport and uncooperative drivers, poor roads, lack of drugs and essential supplies, and negative staff attitudes.

Mavalankar, D. and Abreu, E. Concepts and techniques for planning and implementing a program for renovation of an emergency obstetric care facility. International Journal of Gynecology and Obstetrics 78:263–273 (2002).
This paper reviews the steps required in assessing, planning, and implementing renovations of emergency obstetric care facilities. These three phases are broken down into 12 steps by the authors. During the assessment, the layout, capacity, and condition of buildings are determined, along with the needs of the staff. In planning, input from stakeholders, consultants, building designers, building contractors, and hospital staff are all important. The implementation phase requires frequent quality checks and careful timing of many interlinked processes. Following the steps outlined can help save time and resources in the renovation process.

Mavalankar, D.V. Policy and management constraints on access to and use of life-saving emergency obstetric care in India. Journal of the American Medical Womens Association 57(3):165–167 (2002).
In India, maternal mortality is about 540 deaths per 100,000 births. This is due in part to poverty and a lack of resources. However, the author proposes that policy barriers and management problems hinder the provision of emergency obstetric care in rural areas. By changing government policy to encourage general practitioners to provide cesarean sections and to allow nurses to provide intravenous oxytocics, antibiotics, and anticonvulsants could greatly expand access to emergency obstetric care. Similarly, providing hospital managers with management skills could improve the quality of services. The author proposes that international organizations and women doctors lobby for these policy changes.

Mbaruku, G. and Berstrom, S. Reducing maternal mortality in Kigoma, Tanzania. Health Policy and Planning 10(1):71–78 (1995).
This retrospective study of maternal deaths at a regional hospital in Tanzania found that maternal deaths were grossly underreported and that maternity services suffered from shortages of blood, drugs, equipment and water as well as the indifference and poor skills of staff members. Twenty-two interventions were implemented to improve the quality of care. They included staff training activities, delegating more responsibility to nurses and midwives, repairing and maintaining equipment, storing essential drugs, and recruiting blood donors. Utilization of the hospital's maternity services increased, while the maternal mortality ratio declined from 849 deaths per 100,000 live births in 1984–86 to 275 per 100,000 in 1987–91.

McCord, C. et al. Efficient and effective emergency obstetric care in a rural Indian community where most deliveries are at home. International Journal of Gynecology & Obstetrics 75:297–307 (2001).
Although life-threatening obstetric complications require hospital treatment, this study shows that emergency obstetric care is obtainable in a rural area where the majority of births occur at home and there is little access to government hospitals. Follow-up of 2,905 pregnancies in rural Maharashtra, India, found that 85 percent took place at home, and 14.4 percent had complications. Of the complicated deliveries, almost 80 percent took place in a hospital. There were two maternal deaths from obstetrical causes. The study concludes that a network of private clinics and a low-cost hospital is providing effective and efficient obstetrical services. Because patients make intelligent decisions about seeking hospital care, the overall cost per capita is low. However, cost is still an issue for many poor families, and funds might be best invested in improving the purchasing power of families rather than investing in government facilities to improve emergency obstetric care.

McCord, C. and Chowdhury, Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. International Journal of Gynecology & Obstetrics 81:83–92 (2003).
A small hospital (50 beds) can provide basic hospital services, including emergency obstetric care, at low cost and be cost-effective. This study calculates the cost of a small hospital at Gonoshastathaya Kendra Hospital, Savar, Bangladesh. The cost per patient-day is US$13.15, and the cost per-capita for the population served is US$0.62. per year. Using Disability Life Years (DALYs) to calculate cost-effectiveness, the study estimated the total cost of all hospital activities for three months, divided by the sum of the DALYs for all patients successfully treated for life-threatening or disabling conditions. This gives a cost per DALY of US$10.93. This compares favorably with estimates for measles immunization (US$30), acute lower respiratory infection detection and treatment (US$20), and tetanus immunization of pregnant women (US$2). The majority (62%) of the DALYS saved come from emergency obstetric care activities. Cost-effective basic hospital care can be added to the range of services (for example, immunization, family planning, and other basic health services) now made available in many countries, and the benefits to maternal and neonatal health will be significant.

Mekbib, T. et al. The FIGO Save the Mothers Initiative: the Ethiopia-Sweden collaboration. International Journal of Gynecology & Obstetrics 81:93–102 (2003).
Collaboration between the Ethiopian Society of Obstetricians and Gynecologists (ESOG) and the Swedish Society of Obstetrics and Gynecology (SFOG), begun in 1999, has resulted in improved emergency obstetric care services at three hospitals in West Showa Zone, Ethiopia. Capacity building was a major emphasis of the collaboration, and included training of physicians and other staff as well as purchases of equipment, materials, and supplies. In 2001, the cesarean section rate at Ambo Hospital increased from 3.7 to 17.3 percent; and the case fatality rate dropped from 7.2 to 4.6 percent. Emergency obstetric care services are now available 24 hours a day and seven days a week at Ambo Hospital. Shenen and Ijaji health centers also received upgrades and staff training, and these now offer basic emergency obstetric care services. These interventions cost $US100,000 over three years.

Miller S et al. Quality of care in institutionalized deliveries: the paradox of the Dominican Republic. International Journal of Gynecology and Obstetrics. 2003;82(1):89–103.
This study used a rapid assessment to better understand the paradox of relatively high maternal mortality in the Dominican Republic despite nearly universal institutional deliveries. The research team reviewed national statistics and hospital records, inventoried facilities, and observed patient-provider interactions at 14 facilities. The major referral hospitals (40% of deliveries) were overcrowded and understaffed. Uncomplicated labors and deliveries were often overmedicalized, and complicated cases were poorly managed. Emergencies were not dealt with quickly. At peripheral hospitals, doctors were often not present and clients were either turned away or delivered by unprepared nursing staff. In all of the facilities assessed, the quality of care was poor. Clearly access to and availability of institutional care is not sufficient to reduce maternal mortality. Quality of care saves lives.

Nirupan, S. and Yuster, E.A. Emergency obstetric care: measuring availability and monitoring progress. International Journal of Gynecology & Obstetrics 50 (Suppl. 2):S79–S88 (1995).
This article reports on the availability of emergency obstetric care in India, based on district profiles and a 1992–93 survey of first referral units (FRUs) in ten districts. A common problem was that emergency obstetric services were concentrated at district hospitals. In seven of ten districts, less than 10 percent of all deliveries took place at FRUs. Only an estimated 16 percent of all women who needed emergency obstetric services actually received them. The quality of care was relatively good in half the districts, as indicated by case fatality rates below 2 percent for complicated cases. The authors assess the usefulness and practicability of various indicators for monitoring obstetric services.

Penny, S. and Murray, S. Training initiatives for essential obstetric care in developing countries: a state of the art review. Health Policy and Planning 15(4):386–393 (2000).
Increased awareness of the importance of providing quality essential obstetric care (EOC) to reduce maternal mortality and morbidity has increased the need for training in EOC. This article reviews experience in training, including different educational approaches and methods. Competency-based approaches (CBT) emphasize the "hands-on" development of new skills, and have been used extensively by JHPIEGO and by the American College of Nurse-Midwives in their "Life Saving Skills" curriculum. Problem-solving approaches and participatory learning methods also have been used. Assessing the efficacy of training programs is difficult, but a variety of methods have been tried. These include: learner self-assessments, evaluations by users and the community, trainer assessments of skills and competency, and use of proxies for health outcomes derived from service statistics. Despite advances in training, programs still have inadequate resources and time for necessary training. It is difficult to rigorously evaluate and compare training methods across different methodologies. Good training can be compromised by a lack of good equipment and service protocols. Given the costs involved in training providers in remote locations, the use of self-directed distance learning should be explored.

Post, M. Preventing Maternal Mortality Through Emergency Obstetric Care. Support for Analysis and Research in Africa (SARA) Project, SARA Issues Paper (April 1997).
This paper discusses the importance of emergency obstetric care in preventing maternal mortality. Key issues covered included: rationale for emergency obstetric care; barriers to timely and appropriate emergency care; lessons learned and best practices for improving emergency obstetric care; and other topics.

Prevention of Maternal Mortality Network. Abstracts from the PMM Results Conference, June 19–21, 1996, Accra, Ghana. Center for Population and Family Health, School of Public Health, Columbia University, New York (November 1996).
These abstracts summarize the activities undertaken by the Prevention of Maternal Mortality Network to reduce maternal mortality in Africa from 1988 to 1996. The PMM Network was organized by the Columbia University School of Public Health's Center for Population and Family Health. It included a dozen multidisciplinary research teams in Nigeria, Ghana, and Sierra Leone, with technical support from Columbia University. The PMM Network was established to strengthen the capacity of African institutions to design, implement, and evaluate health programs; to foster a cadre of professionals experienced in the area of maternal mortality; to develop operations research methods for use in maternal mortality; and to inform decision makers about maternal mortality and share strategies on how to reduce it. The PMM approach was to design and implement activities to address delays in receiving emergency obstetric care. The project results show that even in resource poor areas, it is possible to improve emergency obstetric care. Solutions need to be tailored to the particular situation, and often involve the functioning of the entire medical system and its relationship to the community. Results from PMM projects provided the basis for many lessons learned in the reduction of maternal mortality; for example, improving care is not too costly; process indicators are necessary to track progress; and community efforts are key to successful interventions. The complete project results are published in the International Journal of Gynecology & Obstetrics 59 (Suppl. 2) (November 1997).

Stekelenburg, J. and van Roosman, J. The maternal mortality review meeting: experiences from Kalabo District Hospital, Zambia. Tropical Doctor 32:219–223 (October 2002).
Maternal mortality review meetings were instituted at the Kalabo District Hospital in Zambia in 1999. These meetings, chaired by the medical officer in charge and attended by a range of medical personnel, provided a forum for discussion of any maternal deaths occurring at the hospital. Patient files and minutes of maternal mortality review meetings for the 15 deaths occurring between 1999 and 2001 were reviewed for this study. Ten of these deaths were caused by direct obstetric causes and five by indirect causes. In nine deaths, 20 different substandard care factors in the hospital were identified; 12 of these related to organizational weaknesses and 8 related to substandard clinical care. Recommendations were made to improve care in nine cases; these were completely implemented in five cases, partially implemented in two, and not implemented in two. Delay in seeking care factors were determined in nine cases, and in five cases both substandard care and delay factors were found. The meetings offer a valuable forum for practical discussion of fatal cases and allow personnel to evaluate their own performance as well as that of the hospital organization.

Thaddeus, S. and Maine, D. Too far to walk: maternal mortality in context. Social Sciences and Medicine 38(8):1091–1110 (1994).
This literature review examines the factors that contribute to three important delays in receiving emergency obstetric care: the delay in deciding to seek care, the delay in reaching a health care facility, and the delay in receiving adequate care at that facility. The decision to seek care is based on perceived accessibility of services, perceived quality of care, and sociocultural factors. Actual access to facilities is determined by the distribution of services, travel distances, transportation, and cost. Prompt and adequate treatment at a facility depends on the availability of equipment, supplies, and trained staff. The authors discuss a wide range of program strategies to reduce these delays, such as offering obstetrical services at more facilities, improving the quality of care, raising the status of women, and educating the community about when to seek obstetrical care.

Wagaarachchi PT et al. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. International Journal of Gynecology & Obstetrics. 2001; 74(2):119–130.
This study assessed the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in Ghana and Jamaica. The audit cycle included five steps: establishing the criteria for good quality care, measuring current practice (first review), feedback findings and setting targets, taking action to change practice, and reevaluating practice (second review). Thirty-one audit criteria were selected following a literature review, panel discussions, and pilot work. The audits were done in two district hospitals in Ghana (Holy Family Hospital-Berekum, Goaso District Hospital) and two in Jamaica (Spanish Town Hospital, St. Ann’s Bay Hospital) between 1998 and 2000. There were many common areas for improvement across the four hospitals, and the mechanisms for improvement included clinical protocols, staffing reviews, and training. There were significant improvements noted between the first and second audits in management of obstetric hemorrhage, eclampsia, and genital tract sepsis. Criterion-based clinical audit is useful for monitoring practice and as a self-examination educational tool for staff. It can be used at different levels of the health care system, and can be repeated as needed to evaluate progress.

Weeks AD et al. Introducing criteria based audit into Ugandan maternity units. British Medical Journal. 2003;327(7427):1329–1331.
A pilot project, “Audit in Maternity Care”, was conducted between August and December 2001 in Uganda. Participants from a rural district hospital and undergraduate and postgraduate students in obstetrics at Makere University participated in the training. Over six months, 170 maternity health workers were taught audit methods and 23 audit projects were completed. The pilot project was very successful in stimulating health workers to analyze their own situations and develop solutions to their problems. Teaching criteria-based audit can produce low cost improvements in the standard of care.

World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Geneva: WHO (2000). Available at: www.reproline.jhu.edu/english/2mnh/2mcpc/index.htm.
This manual reflects internationally established best practices in maternal and newborn care. Developed by WHO and JHPIEGO, it provides guidance to skilled providers in the care of women presenting with complications during pregnancy, childbirth, or immediately postpartum, and immediate problems of newborns. The manual is organized by symptom to facilitate its use in treating a woman presenting with specific problems. It emphasizes rapid clinical assessment and decision making, with little reliance on laboratory or other tests. It also summarizes the main steps to be taken in procedures necessary to manage a condition, highlighting the most effective and least expensive therapies.

WHO. Maternity Waiting Homes: A Review of Experiences. Geneva: WHO, Maternal and Newborn Health/Safe Motherhood Unit, Division of Reproductive Health. WHO/RHT/MSM/96.21 (1996).
Maternity waiting homes provide a place for high-risk pregnant women to stay during the final weeks of their pregnancies and have access to a hospital offering essential obstetric services. While the idea is not new, this review shares experiences from different countries in establishing and operating maternity waiting homes. The key to the success of these homes is their ability to address the needs of the community, and to be an effective link between women in need of care and facilities that offer the required services. The determination of "high risk" can be locally determined and include nonmedical criteria, such as cultural factors and distance from a woman's home to a hospital. To be effective, maternity waiting homes must be accepted and supported by the community and its cultural institutions. The home must provide a reliable system for transfer of women from the waiting home to a facility offering skilled obstetric services. Prior to establishing a maternity waiting home, a needs assessment should be conducted to determine the causes of maternal morbidity and mortality in the community. Waiting homes only address the need for access to skilled obstetric care. Homes should be planned and implemented with the involvement and support of the community, including a variety of key decision makers (including husbands, religious leaders, politicians, health care providers, and women). Periodic evaluations are important to the long-term sustainability of waiting homes to ensure they have local support and continue to address the needs of the community.

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Postabortion care

Baird, T.L. et al. Community education efforts enhance postabortion care programs in Ghana. American Journal of Public Health 90 (4):631–632 (April 2000).
This article summarizes an operations research project undertaken by the Ghana Ministry of Health, the Ghana Registered Midwives Association, and Ipas (implemented under USAID's MotherCare contract) that sought to improve women's access to postabortion care in Ghana. Unsafe abortion is the greatest single contributor to maternal mortality in Ghana (740 deaths per 100,000 live births). Eighty midwives in the Eastern Region participated in the project. Half of these midwives were trained to stabilize women with abortion complications, treat incomplete abortions with manual vacuum aspiration, refer women with severe complications, and offer postabortion family planning counseling and services. Most of the trained midwives also began community outreach and education about their new services. As a result, the midwives saw many more clients for treatment of abortion complications. This project used existing personnel and mechanisms to educate the community, and is being expanded through ongoing training of midwives and physicians.

Berer, M. Making abortions safe: a matter of good public health policy and practice. Bulletin of the World Health Organization 78(5):580–592 (2000).
Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws, and high mortality and morbidity from abortion all contribute to maternal morbidity and mortality. Their prevention is an important part of safe motherhood initiatives. This article reviews published and unpublished articles to determine the changes in policy and provision of health services necessary to make abortions safe. The transition from unsafe to safe abortion requires changes at the national policy level; abortion training for services providers at the appropriate community level; ensuring women access to the services of these trained providers; and making women aware of the availability of these services.

Billings DL et al. Comparing the Quality of Three Models of Postabortion Care in Public Hospitals in Mexico City. International Family Planning Perspectives. 2003;29(3):112–120.
In this study, 803 women receiving postabortion care services were surveyed in six Mexican Institute of Social Security (IMSS) hospitals in Mexico City (April 1997 through August 1998). Three models of care were compared: sharp curettage standard care, sharp curettage postabortion care, and manual vacuum aspiration postabortion care. Women receiving both models of postabortion care rated the quality of services they received more highly than those receiving standard care. Greater proportions of women receiving postabortion care received information about their health status, about the uterine evacuation procedure, about signs of postabortion complications and care at home. These women were also more likely to accept a contraceptive method before leaving the facility (64–78% versus 40%). The authors recommend that the standard IMSS model of postabortion treatment be modified to include more comprehensive postabortion care, linking counseling and family planning services to clinical postabortion care.

Billings, D.L. Training Midwives to Improve Postabortion Care. Summary Report of A Study Tour in Ghana, October 12–19, 1997 (February 1998).
This report documents the activities and outcomes of a study tour in Ghana aimed at giving health managers and providers within the region (South Africa, Uganda, Tanzania, and Zambia) an opportunity to learn from recent efforts in Ghana to expand and improve postabortion care services. The report provides key lessons learned from the MotherCare operations research project and also overall lessons learned from the study tour on the topic of training, policy advocacy, health care systems, and research.

Brazier, E., Rizzuto, R., Wolf, M. Prevention and Management of Unsafe Abortion: A Guide for Action. New York: Family Care International (1998). Available in English, French, and Spanish. Single copies provided free of charge to individuals in developing countries; orders can be placed online at: www.familycareintl.org/pubs/pubs_order1.htm.
This guide has been designed for workers in settings where abortion is legally restricted, and where the complications of unsafe abortion are a major public health concern. The guide includes eight sections on the social and economic impact of unsafe abortion; preventive measures such as reducing unwanted pregnancy and the need for abortion; postabortion care (including emergency treatment of complications, postabortion family planning, and links to reproductive health services); provision of safe services for the legal termination of pregnancy; tailoring services to women's needs; community education; research; and laws, policies, and procedures that can be developed to establish an appropriate framework. Each section contains an overview, case studies, and an annotated catalogue of resources. The guide also includes several appendices that provide contact information and policy statement from a wide range of organizations and resources.

Ghosh, A. et al. Establishing postabortion care services in low-resource settings. JHPIEGO Strategy Papers, Paper 7 (October 1999).
This paper presents the key issues that must be addressed in establishing postabortion care (PAC) services in resource-poor settings. The goal of the PAC strategy is to improve women's health by expanding access and providing quality services at all levels of the health care system. In the first section, the key elements (advocacy, access to services, institutionalization of training, and sustainability) in a PAC strategic framework are described briefly. In subsequent sections, these elements are integrated into the major steps needed to introduce and expand PAC services in countries with limited resources.

Goyaux, N. et al. Complications of induced abortion and miscarriage in three African countries: a hospital-based study among WHO collaborating centers. Acta Obstetricia et Gynecologica Scandinavica 80:568–573 (2001).
This prospective study is based on admissions to hospitals in Benin, Cameroon, and Senegal for complications of abortion or miscarriage. Of the 1,957 women included, 988 were admitted for complications of miscarriage, and 969 for complications of induced abortions. There were 26 deaths, 22 of these from complications related to induced abortion. Women dying from abortion-related complications died within a short time of hospital admission and showed signs of sepsis. The risk of dying was higher for women not undergoing surgery after admission than among those who did. This is most likely due to a womans state of health upon arrival at the hospital. Delays in seeking care often make surgery impossible. This hospital-based study confirms the need for emergency obstetric care to prevent deaths from induced abortion. However, more studies are needed to understand what happens to women before they get to the hospital and to devise preventive solutions.

Greenslade, F.C. et al. Post-abortion care: a women's health initiative to combat unsafe abortion. Advances in Abortion Care 4(1):1–4 (1994).
Advances is a technical update series which presents up-to-date information about topics that are central to postabortion care training and management/delivery of services. This issue introduces the concept of postabortion care as a means to reduce global levels of maternal mortality and morbidity from unsafe abortion.

Huntington, D. Meeting Womens Health Care Needs After Abortion. Washington, DC: Population Council/FRONTIERS (2000). Individual study summaries are available at: www.popcouncil.org/frontiers/fpbriefs.html.
This summary of operations research on postabortion care highlights the most effective strategies for improving the delivery of care. It includes results from studies in Bolivia, Burkina Faso, Kenya, Mexico, Peru, and Senegal. Clinical care should be improved to use appropriate emergency treatment techniques, appropriate pain management, and correct infection protocols, and to ensure adequate supplies. Provider interactions with patients also should be improved. Family planning counseling should be offered before patients are discharged and should include information about the rapid return of fertility following abortion. Access to PAC and outreach need to be expanded to reach those most in need. PAC should be a routine part of obstetric and gynecologic care, and should be offered on an outpatient basis. With the womans prior consent, male partners should be informed about PAC care, treatment, and follow-up.

Huntington D, Nawar L. Moving from research to program—the Egyptian Postabortion Care Initiative. International Family Planning Perspectives. 2003;29(3):121-125.
Research on postabortion care began in Egypt in the early 1990s with assistance from the Population Council. This developed into the provision of training and equipment at two sites, and then expanded to 10 district, general, university, and teaching hospitals during 1996-7. The Population Council collaborated with several agencies to undertake operations research studies at these sites. The research findings were openly discussed at a series of meetings and helped stimulate public discussion of postabortion care. The Ministry of Health and Population has incorporated many of the research results in its safe motherhood program’s essential obstetric care protocols for managing bleeding in pregnancy. Notably, these protocols do not mention postabortion care, and do not emphasize family planning counseling. Making the linkages between the national safe motherhood and family planning programs will be important to take postabortion care to the national level.

Johnson, B. et al. Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception. Studies in Family Planning 33(2):195–202 (June 2002).
In this prospective study, women being treated for incomplete abortions in two public hospitals in Zimbabwe were offered highly effective contraceptive methods to prevent future unplanned pregnancies. At the intervention site, following treatment for incomplete abortion, women were provided free, ward-based family planning services. At the control site, no special efforts were made to provide family planning services, although contraceptive methods were available in the maternity ward, and at nearby clinics for a fee. Women who desired to postpone a future pregnancy by at least two years were followed for twelve months. The study included 982 women, 527 of whom were followed for twelve months. During the follow-up period, there were more than twice as many unplanned pregnancies among the women at the control site than at the intervention site. The women receiving postabortion family planning services were more likely to use contraception, have fewer unplanned pregnancies, and have fewer repeat abortions than those in the control group. There is a strong demand for contraception among women being treated for incomplete abortion in Zimbabwe, and strong support from hospital staff for providing postabortion family planning.

Salter, C. et al. Care for postabortion complications: Saving women's lives. Population Reports L(10) (September 1997) Available at: www.jhuccp.org/pr/l10edsum.stm.
This Population Reports issue reviews the problem of maternal mortality and morbidity cause by unsafe abortions. It discusses the importance of postabortion care as an effective strategy to reduce the 50,000 to 100,000 maternal deaths caused by unsafe abortions each year. It contains a chart that shows the four levels of a typical postabortion care referral network community, primary, first referral, and secondary or tertiary levels. The chart describes the family planning services offered and the staff and types of health care services available at each level, as well as the facilities, equipment, and supplies needed for effective management of postabortion complications.

Thonneau, P. et al. Abortion and maternal mortality in Africa. New England Journal of Medicine 347(24):1984–1985 (December 12, 2002).
This letter reports on a large multi-center study in Africa of the contribution of complications of abortion to maternal mortality. From May to October 1999, all women admitted within 15 weeks of their last menstrual period for ectopic pregnancy, complications of spontaneous abortion, complications of induced abortion, and molar pregnancy in 12 main obstetrical hospitals in Benin, Ivory Coast, and Senegal were enrolled in the study. Of the 4,116 women in the study, 37 percent were admitted for complications of induced abortion, 45 percent for complications of spontaneous abortion, 16 percent for ectopic pregnancies, and 3 percent for molar pregnancies. Forty-two of the 4,116 women died, 88 percent (37 women) of them from complications of induced abortion. Twenty-five percent of all women admitted for delivery during the study period had major complications, and 79 (3%) died. This is very similar to the fatality rate of 2.4 percent among women admitted for complications of induced abortion. The results suggest that complications of induced abortion may be responsible for almost 33 percent of all maternal deaths in West African countries, not the 15 percent estimated by WHO.

USAID. Family Planning Prevents Abortion. POP Briefs. Washington, DC : USAID Center for Population, Health and Nutrition (November 2001). Available at: www.usaid.gov.
This briefing paper reviews data from several countries on the role of family planning in preventing abortion. It presents research findings on the impact of contraceptive use on abortion in a range of countries worldwide including South Korea, Chile, Hungary, Russia, and others. The paper stated that contraceptive services play a crucial role in reducing abortions by providing the means for avoiding unintended pregnancies.

Yeneneh H, Andualem T, Gebreselassie H, et al. The potential role of the private sector in expanding postabortion care in Addis Ababa, Amhara, and Oromia regions of Ethiopia. Ethiopian Journal of Health and Development. 2003;17(3):157–165.
A cross-sectional study of private sector postabortion care services in Addis Ababa, Amhara, and Oromia in Ethiopia indicates the potential for expanding the contributions from the private sector. Eighty-eight, 31, and 32 facilities were assessed in Addis Ababa, Amhara, and Oromia respectively. Postabortion treatment was provided in 44 percent, 52 percent, and 63 percent of eligible facilities in the respective areas. Manual vacuum aspiration (MVA) was used in 61 percent of patients in Addis Ababa and sharp curettage was used in over 80 percent of those in Amhara and Oromia. About 80 percent of patients did not receive postabortion family planning methods. Patient-provider interactions were satisfactory, and all medium level and above clinics have at least one general practitioner and many have nurse-midwives. High-level disinfection practices need improvement. The majority of facilities not providing services would like to provide comprehensive postabortion care, if provided with equipment and training in the market. There is potential to expand the role of the private sector in providing postabortion care in Ethiopia.

Yumkella, F. and Githiori, F. PRIME'S Technical Report 21: Expanding Opportunities for Postabortion Care at the Community Level through Private Nurse-Midwives in Kenya (Final Report). Chapel Hill, North Carolina: Intrah (September 2000). Available at: www.prime2.org/prime2/pdf/TR21.pdf.
In this pilot project, nurse-midwives from the private sector Nursing Council of Kenya (NCK) received postabortion care (PAC) training. Following a needs assessment, nurse-midwives from 32 facilities received training in manual vacuum aspiration (MVA), postabortion family planning counseling and methods, and linkages with other reproductive health services. An evaluation 19 weeks after their training found that the nurse-midwives were successfully providing safe, high-quality PAC services at the community level. Given their level of experience, training the nurse-midwives was rapid and cost-effective. The project increased the number of facilities providing PAC, and made these services available at the community level. In turn, this reduced the burden placed on referral facilities for PAC and increased the opportunities for public/private linkages. Despite the success of this pilot intervention, it was found that data collection tools and infection prevention practices need continued strengthening. Using nurse-midwives to provide PAC at the community level is an important part of the strategy to reduce maternal mortality in sub-Saharan Africa.

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Use of misoprostol for obstetric and gynecological indications

Barbosa, R.M. and Arilha, M. The Brazilian experience with Cytotec. Studies in Family Planning 24(4):236–240 (1993).
The authors provide a description of the Brazilian abortion environment, analysis of sales data for Cytotec (misoprostol), and results from focus groups with women and providers. Focus groups with women of different social and age strata revealed that women self-administer Cytotec orally or vaginally in dosages of four to sixteen 200-mcg pills. Women had a distinct pre ference for a dosage of four pills (two taken orally and two taken vaginally), although dosages of as many as 60 pills have been reported. Women indicated that most attempts to interrupt pregnancy with Cytotec occurred during the first trimester. They cited Cytotec's low cost, easier decision-making process, privacy, and perceived safety as key factors for choosing Cytotec. After using Cytotec, however, many women perceived their experience as negative due to significant pain and/or required hospital assistance. Although women shared information about how to take the drug, they ignored dosage limits and lacked factual information about when to seek assistance. Focus groups conducted with male and female gynecologists confirmed the widespread use of Cytotec as an abortifacient. Gynecologists considered Cytotec a valuable therapeutic resource. They also reported that Cytotec enables them to perform abortions without becoming involved with the police, as women who have taken misoprostol can present at public health services as though they were undergoing a miscarriage and have their abortions completed in a safe environment. As result of Cytotec availability, prejudice against abortion has diminished in Brazil, and a favorable atmosphere for promoting discussion of legalized abortion has developed.

Blanchard, K., Winikoff, B., Ellertson, C. Misoprostol use alone for termination of early pregnancy: a review of the evidence. Contraception 59:209–217 (1999).
This article reviews eight English-language studies of the use of misoprostol alone for early pregnancy termination. The authors note that the efficacy rates demonstrated by the same total dose differ among studies, perhaps due to varying definitions of success, varying time to measurement of outcome, and varying duration of pregnancy of study participants. Despite the differences in study design, the evidence suggests that a vaginal regimen (as opposed to an oral regimen) could greatly improve access to safe medical abortion services by women in developing countries. The authors note, however, that two significant problems exist. First, vaginal regimens are complex. Second, the side effects (pelvic pain and cramping comparable to the mifepristone-misoprostol regimen) might prove intolerable for some women. The authors state that while little information about oral misoprostol-only regimens is available, the oral regimen would be easier to administer, easier to register with drug regulatory bodies (since the toxicology and safety data already on file for misoprostol's ulcer treatment/prevention indications could be relevant), and more acceptable to women. They recommend investigating the potential of an oral regimen and making efforts to simplify promising vaginal regimens; they note that reducing the number of doses and the need for vaginal ultrasounds would be vital to use in developing countries. The authors conclude that the misoprostol-only regimen holds promise but that more research is needed.

Blanchard, M., Winikoff, B., Coyaji, K., Ngoc, T.N. Misoprostol alone—a new method of medical abortion? Journal of the American Medical Women's Association 55(3 Suppl.):189–190 (2000).
This commentary reviews the documented obstetric/gynecological benefits of misoprostol as well as the difficulties inherent to deciphering the available data. The authors note that regimens used in clinical trials are difficult to compare and often cumbersome for women. They also cite a lack of data on pharmacokinetics as well as observed differences in the success rates of various regimens. These issues prompt the authors to ask, "How good is good enough?" They call for more thorough assessments of misoprostol's benefits (for example, success rates, easy access, and increased privacy) and risks (including treatment failure, side effects, and the possibility of incomplete abortions or ongoing pregnancies). They suggest that acceptability may increase by improving misoprostol's benefits, reducing its risks, or both. The authors conclude that simplified misoprostol regimens, including self-administration, should be evaluated. They also recommend that researchers identify reasons for the differences in reported success rates and develop a coherent research strategy for the future.

Clark, S. et al. Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States. International Journal of Gynecology & Obstetrics 76:65–74 (2002).
This survey of 228 gynecologists and obstetricians in Brazil (123), Jamaica (52), and the United States (53) investigated the current clinical use of misoprostol for the treatment of a range of reproductive health indications. Providers reported using the drug for labor induction (46%), preventing postpartum hemorrhage (8%), intra-uterine fetal death (61%), cervical priming prior to abortion (21%), missed abortion (57%), incomplete abortion (16%), first-trimester abortion (27%) and second-trimester abortion (13%). The regimens used varied considerably, and those commonly used in clinical practice differed from those recommended in medical literature. Since misoprostol is not labeled for any reproductive health indications, it is often not available in obstetrical and gynecological wards, and protocols for its use are often lacking. Providers in Jamaica and Brazil clearly favored the drug, and are eager to obtain more supplies and information about its use. There is need for more research to determine optimal regimens for the use of misoprostol, and education for providers to ensure women receive safe, quality care.

Darney, P. Misoprostol: a boon to safe motherhood . . . or not? Lancet 358(9283):682–683 (September 1, 2001).
While more than 200 studies indicate that misoprostol has various reproductive health uses, not everyone agrees that it should have widespread use. The WHO multicenter trial on its use to prevent postpartum hemorrhage found that 10 IU of oxytocin performed better, with fewer side effects. However, this author argues that context is the key to its use. Proponents of misoprostol argue it should be available to midwives for use at home births and to doctors in rural health posts where parenteral drugs are not available or affordable. Even if oral misoprostol is less effective, it can still save many lives, especially as a potential treatment for postpartum hemorrhage. While trials demonstrating the effectiveness of misoprostol in various rural situations are needed, the drug has the potential to prevent some deaths from unsafe abortions and obstetric hemorrhage.

El-Refaey H, Rodeck C. Post-partum haemorrhage: definitions, medical and surgical management. A time for change. British Medical Bulletin. 2003;67:205–217.
Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality worldwide. Preventing death from PPH depends on a functioning system of trained birth attendants, emergency transport, availability of blood transfusion, and other essential obstetric care at the first referral level. While several medicines have been used to treat PPH, misoprostol has now been shown in several studies to be effective in preventing and treating PPH. Studies continue to define its effect given orally, vaginally, and rectally. PPH can also be managed surgically with hysterectomy, ligation of internal iliac arteries, balloon compression, and the B-Lynch suture. Some of these new pharmacological and technical interventions can reduce the incidence of PPH and its consequences.

Goldberg, A.B., Greenberg, M.B., Darney, P.D. Misoprostol and pregnancy. New England Journal of Medicine 344(1):38–47 (2000).
This article provides a thorough review of studies evaluating the use of misoprostol in pregnancy. Using U.S. Preventive Service Task Force guidelines to grade the strength of their recommendations, the authors review the pharmacokinetics, mechanism of action, dosage, efficacy, and safety of misoprostol in pregnant women. The authors first review misoprostol's use during the first trimester. Given the inconsistency of complete-abortion rates when vaginal misoprostol is used alone, particularly in light of safe alternative regimens, they conclude that misoprostol cannot be recommended for medical abortions in the first trimester. In the case of early failed pregnancy or embryonic death, the authors conclude that 800 mcg of misoprostol administered vaginally once or twice (with the second dose given 24 hours after the first) is effective in evacuating the uterus. The authors conclude that misoprostol is not recommended for the treatment of inevitable or incomplete abortion, due to low success rates and decreases in hemoglobin concentrations. For cervical ripening in the first trimester, the authors state that 400 mcg of vaginal misoprostol given three to four hours before suction curettage is the best regimen.

Comparing data for abortion during the second trimester is more difficult. The authors conclude that the optimal regimen has not been determined, but they state that 200 to 600 mcg of misoprostol given vaginally every 12 hours, or 400 mcg given vaginally every 3 hours, successfully induces labor in the second trimester. During the third trimester, available data suggest that the best dose for inducing of labor with misoprostol is 25 mcg given vaginally every four to six hours. In cases of induction of labor with fetal death at term, a dose as low as 50 mcg given every 2 hours may be adequate. The authors note that misoprostol should not be used to induce labor in women with uterine scars due to s everal reports of uterine rupture. In their discussion of misoprostol use for treatment of postpartum hemorrhage, the authors state that there currently is insufficient evidence to support the routine use of misoprostol when oxytocin or methylergonovine is available, but misoprostol may lower the incidence of postpartum hemorrhage if these drugs are not readily available. In their conclusion, the authors state that misoprostol is one of the most important medications in obstetrical practice, and that more than 200 studies involving a total of more than 16,000 pregnant women support its continued use.

Gulmezoglu, A. M. et al. WHO multicentre randomized trial of misoprostol in the management of the third stage of labour. Lancet 358(9283):689–695 (September 1, 2001).
The results of a multicenter, double-blind, randomized controlled trial reported in this article indicate that 10 IU oxytocin (intravenous or intramuscular) is preferable to 600 mcg oral misoprostol in the active management of the third stage of labor in hospital settings where active management is the norm. Hospitals in Argentina, China, Egypt, Ireland, Nigeria, South Africa, Switzerland, Thailand, and Vietnam took part in this trial. Women delivering vaginally were randomly assigned to receive oxytocin (n = 9,266) or misoprostol (n = 9,264) immediately after delivery as part of the active management of the third stage of labor. Severe blood loss of 1000 ml or more was about the same between the two groups (3% and 4%). More women in the misoprostol group (15%) than in the oxytocin group (11%) required additional uterotonic drugs to control bleeding. Misoprostol use was also associated with significantly more shivering (relative risk = 3.48) and raised body temperature (RR = 7.17) in the first hour after delivery. The article concludes that where active management with oxytocin is the norm, there is no need to change the practice. Hospitals considering active management should choose oxytocin over misoprostol. This trial did not address the use of misoprostol versus oxytocin for treatment of postpartum hemorrhage, and further research is needed on this issue.

Joy SD et al. Misoprostol use during the third stage of labor. International Journal of Gynecology and Obstetrics. 2003;82(2):143–152.
This article summarizes the results of a systematic review of the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor. Published studies from January 1996 to May 2002 were reviewed. Overall, misoprostol was inferior to oxytocin and other uterotonics with regard to the outcomes of third- stage labor assessed. When compared to placebo, misoprostol was associated with a decreased risk of needing additional uterotonics. In less developed countries and where administration of parenteral uterotonic drugs may be difficult, misoprostol represents a reasonable choice for management of third-stage labor. More randomized clinical trials examining objective outcomes (such as need for blood transfusion) are needed to define the risks and benefits of misoprostol during third-stage labor.

Kundodyiwa, T.W. et al. Misoprostol versus oxytocin in the third stage of labor. International Journal of Gynecology & Obstetrics 75:235–241 (2001).
In this double-blind, randomized, controlled trial at the tertiary hospital in Harare, Zimbabwe, misoprostol was found to be as effective as oxytocin in the prevention of postpartum hemorrhage. Postpartum hemorrhage occurred in 15.2 percent of the women given 400 micrograms of oral misoprostol, and in 13.3 percent of women given 10 IU oxytocin intramuscularly. There was no significant difference in the need for additional oxytocic drugs or blood transfusion in women given misoprostol. Misoprostol was associated with shivering and a rise in temperature. The authors conclude misoprostol has potential use in reducing the high incidence of postpartum hemorrhage in developing countries.

Mousa, H.A. and Alfirevic, Z. Treatment for primary postpartum haemorrhage (Cochrane review). In: Cochrane Library, Issue 1. Oxford: Update Software (2003).
This review assessed the effectiveness and safety of pharmacological and surgical interventions used for the treatment of primary postpartum hemorrhage. One study comparing rectally administered misoprostol versus syntometrine and oxytocin showed that women receiving misoprostol were less likely to continue to bleed and were significantly less likely to require medical co-interventions to control the bleeding. Further randomized, controlled trials are needed to identify the best drug combinations, route, and dose for treatment of postpartum hemorrhage, but rectal misoprostol in a dose of 800 micrograms could be a useful first line drug for treating primary postpartum hemorrhage.

Oboro, V.O. and Tabowei, T.O. A randomized controlled trial of misprostol versus oxytocin in the active management of the third stage of labour. Journal of Obstetrics and Gynaecology 23(1):13–16 (2003).
This study of 496 women randomized to receive either 600 micrograms of misoprostol orally (n = 247) or 10 IU oxytocin intramuscularly (n = 249) after delivery found no significant differences between the groups in incidence of postpartum hemorrhage. The two groups were also similar in length of third-stage labor, and percentages requiring manual removal of the placenta, further oxytocics, or blood transfusion. Shivering was significantly higher among those receiving misoprostol (57% versus 14%). The authors conclude that oral misoprostol can be used as an alternative to intramuscular oxytocin to reduce postpartum hemorrhage in low-risk women in developing countries.

PATH and EngenderHealth. Misoprostol for Obstetric and Gynecologic Uses: A Literature Review. Seattle: PATH and EngenderHealth (April 2001). Click here for a PDF of this document.
This document reviews 100 articles that investigate the efficacy and safety of misoprostol used for first-trimester abortion, second-trimester abortion, spontaneous abortion and complicated pregnancy, cervical priming, induction of labor, prevention and management of postpartum hemorrhage, absorption kinetics, safety and teratogenicity, and experiences with misoprostol use in developing countries. These articles were identified through MEDLINE, PubMed, Ovid, Cochrane, and Internet searches for misoprostol-only regimens for obstetric and gynecological indications; articles that addressed the mifepristone-misoprostol regimen were excluded from this review (except in relation to some misoprostol-specific issues). The review is divided into 12 sections, each of which includes an overview of the section's topic, brief descriptions of relevant articles, and supporting tables as appropriate. An alphabetical index of articles is provided at the end of the document.

Templeton A. Misoprostol for all [commentary]. British Journal of Obstetrics and Gynaecology 105:937–939 (1998).
After stating that few drugs have been as enthusiastically received by obstetricians and gynecologists as misoprostol, this commentary briefly chronicles misoprostol's history—from FDA review in 1985 to demonstration of its abortifacient potential in 1987 to present uses of the drug. The author acknowledges that misoprostol has several therapeutic uses, including induction of labor, first- and second-trimester induced abortion, evacuation of the uterus following miscarriage, postpartum hemorrhage, and cervical dilation. The article notes that misoprostol has a shelf life of several years at room temperature, is easily stored and transported, and has an extremely low cost. It also states that the uterus becomes progressively more sensitive to the drug with advancing gestation, noting that single doses of 400 g to 800 mcg are therapeutic in the first trimester following mifepristone, while doses of 50 mcg or even 25 mcg can be used for the induction of labor. The author notes that, in the UK, gemeprost has been the main prostaglandin used for cervical preparation prior to surgical abortion, but that there is increasing interest in the use of misoprostol, which has been shown in several randomized studies to have comparable efficacy to gemeprost. Acknowledging that issues such as the optimum route, dose, and time of administration remain undetermined, the author states that a vaginal dose of 400 mcg is better than 200 mcg at gestations of 7 to 11 weeks, and that the added benefit or risk of higher doses (such as the 600 mcg to 800 mcg doses recommended by 1997 RCOG guidelines) are unclear. When given orally, th e therapeutic effect of misoprostol occurs in <12 hours due to rapid absorption and swift onset of action. Where surgical abortions are being performed, misoprostol has established itself as one of a range of effective dilation options, and its place for other reproductive indications will become clearer in the near future.

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