International Journal of Gynecology & Obstetrics
Volume 108, Issue 3 , Pages 269-275, March 2010

Uterotonic use at home births in low-income countries: A literature review

  • Dawn Flandermeyer

      Affiliations

    • The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
    • Corresponding Author InformationCorresponding author.
    • ,
  • Cynthia Stanton

      Affiliations

    • The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
    • ,
  • Deborah Armbruster

      Affiliations

    • PATH, Washington DC, USA

published online 06 January 2010.

Article Outline

Abstract 

Objectives

This literature review compiles data on rates of use, indications, types of provider, mode of administration, and dose of uterotonics used for home births in low-income countries, and identifies gaps meriting further research.

Methods

Published and unpublished English language articles from 1995 through 2008 pertaining to home use of uterotonics were identified via electronic searches of medical and social science databases. In addition, bibliographies of articles were examined for eligible studies. Data were abstracted and analyzed by the objectives outlined for this review.

Results

Twenty-three articles met the inclusion/exclusion criteria. Use rates of uterotonics at home births ranged widely from 1% to 69%, with the large majority of observations from South Asia. Descriptive studies suggest that home use of uterotonics before delivery of the baby are predominantly administered by nonprofessionals to accelerate labor, and are not perceived as unsafe.

Conclusions

To achieve maximum benefit and minimal harm, programs that increase access to uterotonics for postpartum hemorrhage prevention must take into account existing practices among pregnant women. Further research regarding access to uterotonics and intervention studies for provider behavior change regarding uterotonic use is warranted.

Keywords: Home birth, Labor augmentation, Misoprostol, Oxytocin, Postpartum hemorrhage, Uterotonics

 

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1. Introduction 

Home use of uterotonics at birth administered by a person without medical qualifications has been considered unsafe. Safety concerns include administration of the drug, dosage, its use to initiate or accelerate labor, and the inability to monitor the woman and fetus and respond to complications [1], [2]. Recent developments in the mode of administration and packaging of oxytocin and availability of misoprostol have increased interest in expanding uterotonic drug use for postpartum hemorrhage (PPH) prevention by nonprofessional birth attendants trained in its use.

The World Health Organization (WHO) now recommends use of uterotonics by a health worker trained in their administration as a part or in the absence of active management of the third stage of labor for PPH prevention, but does not recommend distribution of misprostol to community level health workers or family members for prevention or treatment of PPH [3], [4]. Current WHO recommendations state that oxytocin is the drug of choice owing to its relative benefit in preventing blood loss compared with misoprostol, and to its lower rates of adverse effects. Misoprostol, in 200-μg tablets, is now widely available throughout low-income countries. The published literature suggests that it is currently registered for obstetric and gynecologic use in Brazil, Peru, Egypt, France, Russia, Spain, India, Nepal, Bangladesh, Ghana, Kenya, Nigeria, Sudan, Tanzania, Uganda, and Zambia [5], although in some of these countries, misoprostol is registered only as a program drug. Furthermore, a community-based randomized controlled trial (RCT) in India has shown significant decreases in PPH with semi-skilled birth attendants (auxiliary nurse midwives) providing misoprostol tablets as a part of expectant management of the third stage of labor at home births and in low-level facilities [6]. Studies using misoprostol in a home birth setting are underway in Bangladesh, Pakistan, Afghanistan, and Ethiopia [7]. Current, published information on cost is not available, but previous studies have found that misoprostol can be inexpensive (in 2008 the majority of estimates ranged from US $0.27 to $1.73 per 600-µg dose [4], [8], [9]. Additionally, misoprostol is heat stable and in tablet form is a good candidate for use in remote areas.

Traditionally, two issues have complicated use of oxytocin for PPH prevention at home; the drug requires refrigeration and administration via injection, which in many countries requires a medical professional. However, oxytocin administered via the Uniject device (PATH, Seattle, USA) with a time/temperature indicator alleviates many of these barriers. Uniject is a drug delivery device that assures accurate dosage with a nonreusable needle [10]. It has been used extensively by nonmedical personnel in vaccination campaigns [11]. The time/temperature indicator is a sticker adhered to the package of the Uniject device which changes color when the drug has been exposed to temperatures high enough to decrease its effectiveness [12]. Studies have shown that oxytocin contains more than 85% of the chemically-active drug when stored below 30°C for one year [13]. Thus, by managing re-supply with access to some refrigeration or even coolers, it is now feasible to consider using oxytocin in Uniject in a broader array of settings.

Given that (1) just under half of births in low-income countries occur at home [14]; (2) PPH is among the leading causes of maternal death; (3) PPH has an effective preventive intervention; (4) two options exist for this intervention at home births; and (5) this intervention can be harmful to the woman and fetus when used before delivery of the baby; it is critical that healthcare programmers and researchers understand the context of home deliveries into which uterotonics are introduced to maximize benefit and minimize harm.

A recent literature review exploring uterotonic use in low-income countries resulted predominantly in hospital-based findings [15]. To explore use of uterotonic drugs at home births in low-income countries, a broader search of the literature targeting both medical and social sciences was required. The objectives of this paper are to document the prevalence, provider-types, indication, mode of administration, and access to uterotonics used at home births in low-income countries, and to highlight gaps in the literature indicating where further research is needed.

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2. Methods 

A structured review of the published and unpublished literature was undertaken to identify prevalence, access, indication, method, and type of provider associated with uterotonic drug use for home births in low-income countries. Broad search terms including home childbirth, home birth, oxytocin, misoprostol, ergometrine, oxytocics, uterotonics, labor, delivery, birth, and homecare services were used. Ten databases were searched: PubMed, CINAHL, Scopus, EMBase, Medical Anthropology, JSTOR, Popline, Proquest Dissertation Database, Soc Abstracts, and Global Health. Articles were included if they were published from 1995 through 2008 to ensure that the reports reflected recent data, if they were in English or with an English translation, and with data pertaining to the objectives. Articles were excluded if they referred to uterotonic use in hospitals, did not have primary data, addressed birth practices before 1995, or took place in a high-income country.

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3. Results 

The literature searches identified 974 articles, of which 81 remained after review of abstracts. An additional 44 articles were identified from reference lists. After full-text review of all articles, 23 met the inclusion and exclusion criteria (Fig. 1). Of 23 studies, 7 were trials or quasi-experimental studies that distributed uterotonics as an intervention, 4 were cross-sectional or prospective studies of uterotonic use, 10 were qualitative descriptions of uterotonic use at home births, and 2 described herbal uterotonic preparations for home deliveries. There were 15 references from South/Southeast Asia (10 from India), 6 were from Sub-Saharan Africa, and 2 studies were from Latin America.

3.1. Prevalence of uterotonic use at home birth 

Table 1 provides rates of uterotonic use in studied populations. Only oxytocin use for accelerating labor (augmentation) was noted. All studies addressing prevalence of uterotonic use at home deliveries took place in South Asia. Prevalence of oxytocin use ranged from 1.5%–78.4% and varied by maternal and provider factors. The quality of studies varied. Most were published in peer-reviewed journals, but 3 came from a review article listing sources of unpublished data presented at meetings [16]. These unpublished studies give ranges of oxytocin prevalence of between 48.0% and 68.9% [16].

Table 1. References reporting prevalence of home use of oxytocin to accelerate labor.
AuthorReference yearaCountryPrevalence of uterotonic use [%]Denominator
Matthews et al.[17]1996India21.0 Total243
51.0 (ANM)93
7.0 (dai)31
2.0 (lay person)119
Sharan et al.[19]1999India23.0527
Bang et al. [34]1995India23.1680
200021.24874
Jeffery et al. [16]2000India48293
not statedIndia48.22992
not statedIndia68.9not stated
Barnes et al. [26]2005India62.532
Fronczak et al. [18]1994Bangladesh1.5 (completed delivery at home)1238
78.4 (oxytocin given prior to emergency transfer to facility)88

Abbreviation: ANM, auxiliary nurse midwife dai, term for lay traditional birthing attendant in India.

aMedian year of the reference period, or where reference period was not available, publication year.

Prevalence was associated with the birth attendant in some studies. One study reported 2% of births receiving oxytocin during the first stage of labor with a lay birth attendant, but 51.0% with an auxiliary nurse midwife (ANM) attending [17]. Another study found differential uterotonic use depending on the eventual delivery setting [18]. Of the 1506 pregnant women prospectively followed to birth, oxytocin prevalence given during the first stage of labor at home was reported as 1.5% among women in Bangladesh who completed their delivery at home (n=1238), but 78.4 % among women who required emergency transfer to a facility (n=88) [18]. Consequences of this use of oxytocin were noted. Of the women receiving uterotonics and completing their delivery at home, 76% of these self-reported a postpartum morbidity, including perineal tears, weakness or pain in the leg, pelvic infections, urinary tract infection, vaginal tract infection, secondary postpartum bleeding, uterine prolapse, fistula, and/or feeling poorly with no specific morbid condition [18].

One study that followed 600 pregnant women prospectively who had planned a home delivery in a district in northern India found 23% of women self-reporting oxytocin use in the first stage of labor in postpartum interviews [19]. This use was positively and significantly associated with higher education, higher socioeconomic status, primigravidity, and use of an extrafamilial provider. Primigravidity was also associated with increased prevalence of oxytocin injections during the first stage of labor in another Indian setting during deliveries from 1998–2002 [16]. Of the 346 home births, the women delivering 62.3% of first births (n=53) were given oxytocin injections compared with 45% of women with higher parities (n=293) [16].

Descriptive and observational studies also noted high rates of uterotonic use at home deliveries (data not shown). Four of 5 observed home births in a qualitative study in rural India received oxytocin injections, and in the 5th, the ANM arrived too late to order an injection [20].

3.2. Herbal uterotonics used at home birth 

Four studies described herbal preparations used as uterotonic agents, 3 from two areas of Africa and 1 from India. Only one paper described 2 therapies that were tested and verified to have oxytocic properties [21]. The same authors also identified 75 separate plants and one fungal preparation used for induction and acceleration of labor as well as for removal of retained placenta [22]. A qualitative study from India described self-administration of kasayams: mixtures of ginger, jaggery, cumin, anise, and black coriander seeds [23]. These home-made herbal concoctions are taken to determine if labor has started. If contractions increased in frequency and intensity after ingesting the medicine, kasayam is credited as accelerating them. If they subside, a woman knows she is not in true labor. These kasayams are used concurrently with oxytocin injections. Through semi-structured interviews and group discussions with traditional birth attendants (TBAs) in the Gambia [24], a liquid solution of the Baobab tree was stated by midwives as useful for prevention and treatment of postpartum hemorrhage as well as to expel a retained placenta. No prevalence data were available for use of herbal medication for home births, but a survey of women at two rural health centers in Uganda [22] found that nearly all women interviewed reported use of herbs to maintain pregnancy, induce labor, and/or to aid childbirth. It is unknown whether these herbs have uterotonic properties.

3.3. Providers of uterotonic at home birth 

Twenty-two references described the provider of uterotonics at home births (Table 2). Providers included laboring women self-administering misoprostol [25], lay TBAs [17], [18], [24], [26], [27], [28], nurses or birth attendants with training [7], [17], [23], [29], [30], [31], [32], [33], and unqualified male practitioners [16], [19], [20], [26], [34], [35], [36]. None of the studies identified physicians as providers of uterotonics.

Table 2. Studies reporting the provider of uterotonics in home births.
AuthorReference year aCountryDrug usedUseTiming of uterotonic administration bComment on Provider ID
Bij de Vaate et al.[24]2000GambiaErgometrinePrevent PPHAfter expulsion of placentaTraditional birth attendants
Ahmed and Daffala [40]2001SudanSyntocinonNot statedNot statedTraditional midwives
Prata et al. [29]2003TanzaniaMisoprostolTreat PPHAfter deliverySTUDY: trained birth attendants
Walraven et al. [30]2005GambiaMisoprostol vs ErgometrinePrevent PPHImmediately after delivery of babySTUDY: Trained traditional birth attendants
Kamatenesi-Mugisha and Oryem-Origa [21]2007UgandaTraditional (76 species)Induce, accelerate, & remove retained placentaBefore and during labor and after deliveryTraditional medical practitioners and Lay traditional birth attendants
Van Hollen [23]1995IndiaOxytocinAccelerate labor & increase pain for female powerBefore and during laborMPHW: multi-purpose health worker [18-month training]
Matthews et al. [17]1996IndiaOxytocin“increase pain”During laborLay person; dai-home birth attendants with varying training and experience; ANM/nurse
Sharan et al.[19]1999IndiaOxytocin“increase pain”, Accelerate laborDuring labor“village doctors” who “have shops on the roadside”; “unqualified practitioners running their private practice in rural areas”
Bang et al.[34]1995; 2000IndiaOxytocinAccelerate laborDuring labor“unqualified private doctors who quickened the delivery by giving oxytocics”
Pinto [36]2000IndiaOxytocinAccelerate laborDuring laborupper caste men and women acting as self-taught doctors
Pinto [35]2000IndiaOxytocinInduce, accelerate laborNot statedElected pradhan, self-taught in medicine “doctor”
Derman et al.[6]2003IndiaMisoprostolPrevent PPHAfter delivery of the baby within 5min of clamping and cutting the cordSTUDY: auxiliary nurse midwives
Barnes [26]2005IndiaOxytocinAccelerate labor & treat PPHDuring laborRMPs (gaon ka daktar or johla chap daktar) “doctor” who only gives injections and does not assist with other aspects of the birth
Jeffery et al. [16]2007IndiaOxytocinAccelerate laborDuring laborGovernment pharmacist (as part of illegal private practice); untrained private rural medical practitioners (male) “private doctors”
Iyengar et al.[20]2008IndiaOxytocin & valenthamate bromideAccelerate laborDuring laborUnqualified “modern provider” AKA “village doctor”
Fronczak et al.[18]1994BangladeshOxytocinAccelerate laborDuring laborDai
Tsu et al. [31]2004VietnamOxytocinPrevent & treat PPHWithin 2 minutes of birth; if excess bleeding was notedDistrict and commune health center trained midwives
JHPIEGO [25]2003IndonesiaMisoprostolPrevent PPHImmediately after the birthSTUDY: women themselves
Tsu et al.[32]1998IndonesiaOxytocinPrevent PPHAfter birthSTUDY: professional midwives/bidan di desa given Uniject and oxy inj. Equipment
Htay [33]2005MyanmarMisoprostolPrevent and treat PPHAfter birthSTUDY: trained birth attendants
Sargent and Bascope [27]1992MexicoOxytocinAccelerate laborDuring laborLay midwives
Berry [28]2002GuatemalaOxytocinNot statedNot statedIyoma: lay/unskilled midwife

Note: STUDY denotes contexts where uterotonics are not typically used, but given to providers as part of a study.

aMedian year of the reference period, or where reference period was not available, publication year.

bTerms author used or implied.

Commonly identified uterotonic providers in India were male medically untrained local villagers described as “private doctors” or registered medical providers [26]. Several studies from India described these individuals as unqualified practitioners, prevalent in rural areas, and whose only role in the birth process was administering oxytocin injections [19], [26], [34].

These “doctors” were requested during deliveries by a family member [20], TBA [19], or ANM [16]. Qualitative interviews with mothers who had delivered at home revealed that they were encouraged to accept the injection by a TBA acquainted with a village doctor who performed the injection. Often the TBA summoned the doctor at the onset of labor, and sometimes she advised him on when to give the injection [19]. When negative effects of these oxytocin injections are made public in India, blame often falls on the TBA and rural women, rather than the male providers [35].

These male “doctors” often began their careers filling medical gaps in rural communities with little access to health care, a situation which allowed self-taught practitioners to institutionalize themselves. One researcher in Uttar Pradesh, describes these “ersatz doctors” as achieving their status through elections as a village pradhan [36]. A pradhan is a ministerial title in the Hindu tradition, literally translated as “greatest leader of all” [37].

Many studies in this review show a positive association between the experience and training of providers and use of oxytocin to augment labor. For example, in one study, 51% of births attended by an ANM or nurse received oxytocin for augmentation compared with births attended by TBAs (7%) and lay persons (2%). This suggests that increased access to providers with oxytocin is related to training [17]. In Bangladesh, experience with births among TBAs was positively and significantly associated with injectable oxytocin use [18]. When 489 TBAs who reported use of injectable oxytocin to augment labor were stratified by their experience, the prevalence of oxytocin use rose significantly from 7% among those with fewer than 10 lifetime deliveries to 52% among those with more than 500 lifetime deliveries [18].

There was substantially less information from Latin America (probably due to including only English language publications). However, one author described the confusing nature of education for TBAs in Guatemala: “The pharmacist tells them to use pitocin (brand name of oxytocin), the MSPAS (Guatemalan Ministry of Health) tells them not to and yet they see doctors in the hospital using it… consequently, iyoma (TBAs) concur with anthropologists who view biomedical advice as variable across time, as well as from provider to provider” [28].

3.4. Access to uterotonics at home deliveries 

Only 3 studies (2 from India, 1 from Guatemala) noted where providers obtain uterotonics [19], [28], [36]. All 3 studies revealed that uterotonics are widely available without prescription or other restrictions through local pharmacies.

3.5. Uterotonic use at home birth 

Table 3 describes uterotonics used at home births, their administration, dose, and use. All 5 references on misoprostol for home deliveries represent intervention studies to prevent PPH, with administration of the drug during the third stage of labor. There were no studies describing misoprostol use at home births other than in the context of an intervention study.

Table 3. Studies documenting administration methods for home use of a uterotonic.
AuthorReference year aCountryRouteDoseUse
Misoprostol
JHPIEGO [25]*STUDY2003Indonesianot statednot statedPrevent PPH
Prata et al.[29]*STUDY2003TanzaniaRectal1000µgTreat PPH
Walraven et al.[30]*STUDY2005GambiaOral600µgPrevent PPH
Derman et al. [6]*STUDY2003IndiaOral600µgPrevent PPH
Htay [33]*STUDY2005MyanmarOralnot statedPrevent PPH

Oxytocin
Van Hollen [23]1995IndiaInjection and IVnot statedAccelerate labor & increase pain for female power
Bang et al. [34]1995; 2000IndiaInjectionnot statedAccelerate labor
Matthews et al. [17]1996IndiaInjectionnot stated“increase pain”
Sharan et al. [19]1999IndiaInjectionnot statedIncreases pain, Accelerate labor
Pinto [36]2000IndiaInjectionnot statedInduce; accelerate labor
Barnes [26]2005IndiaInjection4–7 injectionAccelerate labor & treat PPH
Jeffery et al.[16]2007IndiaInjection1–2 injectionAccelerate labor
Iyengar et al. [20]2008IndiaInjection with Epidosin [valethamate bromide]1–5 injectionAccelerate labor (when os opened “three fingers”)
Fronczak et al.[18]1994BangladeshInjectionnot statedAccelerate labor
Tsu et al. [32]*STUDY1998IndonesiaUniject10IUPrevent PPH
Tsu et al.[31]*STUDY2004VietnamUniject, and Injection10IU; Injection: 5IUUniject: Prevent PPH; Injection: treat PPH
Ahmed and Daffala [40]2001SudanInjectionnot statedNot stated
Sargent and Bascope [27]1992MexicoInjectionnot statedAccelerate labor
Berry [28]2002Guatemalanot statednot statednot stated

Ergometrine
Bij de Vaate et al.[24]2000GambiaOral2mg [4 tabs of 0.5mg]Prevent PPH
Walraven et al.[30]2005GambiaOral2mg [4 tabs of 0.5mg]Prevent PPH
Methergine
Barnes [26]2005IndiaInjectionnot statedTreat PPH

Note: *STUDY indicates where the method was introduced and given as an intervention.

aMedian year of the reference period, or where reference period was not available, publication year.

Fourteen references described oxytocin use for home deliveries, of which only 2 reported oxytocin use for prevention or treatment of PPH [32], [33] and both of these were quasi-experimental designs where Uniject was distributed as part of the study. The remaining reports of oxytocin all involved injected oxytocin as a means of accelerating labor (with one report of induction). One reference referred to a combination of injections: valethamate bromide was given as an adjunct to oxytocin and is described as a smooth muscle relaxant used to shorten the first stage of labor [20].

Most sources reporting oxytocin use at home births did not specify details of its timing, spacing, and dosage. It is striking, however, that qualitative studies report from 1–2 to 4–7 injections to accelerate labor [16], [20], [26]. Such large numbers of injections raise doubts as to whether all were in fact oxytocin, or were perhaps Vitamin B12, tetanus vaccine, saline, etc. [23], [36], and whether the oxytocin was chemically active. None of the references reported the pharmaceutical quality of the oxytocin. Another injectable uterotonic, methergine, was reported in one reference from India [26]. None of the references reported the pharmaceutical quality of the oxytocin.

A study in Indonesia specified that 96% of professional midwives who were surveyed reported at baseline routine use of 10IU of oxytocin after delivery of the baby to manage the third stage of labor [32]. However, the safety of these injections is suspect as 41% of these midwives reported reusing a needle and syringe for oxytocin injections before Uniject was introduced.

Many references in this review highlight the use of oxytocin at home births to accelerate labor. One study describes teaching among lay TBAs in India in which combination injections of oxytocin and valethamate bromide were suggested “when the ‘mouth’ (cervical os) is opened about three fingers” (approximately 4–5cm) [20]. Other authors noted that TBAs “did not monitor the frequency or strength of contractions or routinely assess cervical dilation before summoning the male practitioners… the male practitioners did not perform internal examinations and rarely examined the laboring woman externally to ascertain the baby's presentation” [16]. Technology used to monitor or to diagnose malpresentation or fetal or maternal distress was not reported in any study.

Two references reported the use of oral ergometrine in home deliveries in the Gambia [24], [30]. Gambian TBAs are trained to give oral ergometrine after the expulsion of the placenta for hemorrhage prevention. Based on the literature, this practice was still ongoing in 2005. However, home use of ergometrine for PPH is not recommended because it is less effective than other uterotonics and is contraindicated in women with hypertension, often not diagnosed before home use [38], [39].

3.6. Perceived effects of uterotonics by women (users) 

Social science literature was best able to document mothers’ opinions toward uterotonics. For example, “The mothers believed that the injections shortened labor duration and facilitated delivery… and were appreciative of its benefits” [19]. Women interviewed in rural India believed that the oxytocin injections had been administered to cause pain [26]. Women frequently mentioned that oxytocin-induced pain increased sakti, or regenerative power and at times produced a spiritual experience [23]. Other women pointed to the need for oxytocin because women's bodies had changed owing to modernity and thus required medication to accelerate labor. In addition, the women interviewed preferred to receive injections through local (although uncertified) hands than in hospitals as there was distrust and rumors “that they put poison in the needle for the poor people” [35].

3.7. Perceived effects of uterotonics by providers 

References that addressed the provider perception of uterotonics were largely positive reports about the drug's capabilities. During qualitative interviews, TBAs in north India reported oxytocin to have many benefits including speeding up delivery, giving strength to the laboring woman, and easing delivery [19]. “Even those who were aware of its dangers did not perceive them to be serious enough to not be used for labor augmentation” [19]. One author documented that “doctors” in India perceived varying amounts of postpartum blood loss to be normal, beneficial, or dangerous depending on the woman's physique [26]. Oxytocin was perceived to be a “modern” health practice, both associated with socioeconomic status for the laboring woman as well as a status of affiliation with modern medical knowledge for TBAs. Several authors suggested the use of uterotonics as a form of “crowd control” by providers in home and facility settings as accelerating labor potentially alleviates the volume and unpredictability of the birth process [19], [23], [35]. Changing these perceptions surrounding uterotonics may be difficult as a culture of positive association with their use seems prevalent in many settings.

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4. Discussion 

A previous review that documented uterotonic use for induction and augmentation largely in hospitals in low-income countries also identified a few citations on uterotonic use at home and in low-level facility births [15]. Based on our searches of the literature, this is the first literature review to specifically examine uterotonic practices for home births. This review ultimately identified 23 citations, of which approximately one-third reported results of intervention studies in which a uterotonic drug was used at home, and two-thirds were descriptive studies. Although intervention studies may not reflect widespread practice, excluding them from this review would have resulted in an important loss of information. Among intervention studies, misoprostol, oxytocin or ergometrine were given most frequently for the prevention of PPH and occasionally for the treatment of PPH. Among the descriptive studies, home use of injectable oxytocin was reported most commonly to accelerate labor. Only two references mentioned home use of uterotonics for induction [15], [21]. To date, no citations were identified describing home use of misoprostol before delivery of the baby.

Few patterns could be discerned among these results. A majority of the results are from South Asia, in particular India, with few citations from Sub-Saharan Africa and Latin America. The sparse data from Latin America may result from the exclusion of Spanish language literature in this review. Prevalence varied from 1% to 78% of deliveries and there are almost no data on trends. Uterotonic providers included TBAs, medically trained midwives, and untrained village “doctors” and pharmacists. Not surprisingly, indication-specific dosages reported in intervention studies followed international standards for PPH prevention. However, studies describing oxytocin use, generally to accelerate labor, varied widely with reported doses from 1–2 injections to 4–7 injections, or was not stated at all. In addition, the use of herbals to induce labor (in Uganda), accelerate labor (in Uganda and India), and prevent and treat PPH (in the Gambia) was described.

The qualitative data identified in this review add depth to an understanding of why uterotonics are used in home births. It appears to largely stem from demand by laboring women, who are then supplied pharmaceuticals by their birth attendant or another community member. Qualitative research also suggests that birth attendants perceive benefits of uterotonic use prior to delivery of the baby, and that the practice is not perceived as dangerous.

Positive associations noted between provider training and administration of uterotonics in the first and second stage of labor may be because birth attendants with less experience have less access to or knowledge about uterotonics. It could also be because more highly trained providers have increased confidence to handle the potential complications that oxytocin is perceived to cause and/or treat.

Although this review identified substantially more information regarding home use of uterotonics than the review by Lovold et al. [15], it raises many questions and further research is warranted. For example, do the data from South Asia reflect real regional differences in practice compared with Sub-Saharan Africa and Latin America, or is this due to publication bias or the lack of Spanish-language literature represented in this review? What drugs are being administered intramuscularly in South Asian settings where women report multiple injections? How often is oxytocin chemically inactive in such settings? In settings where use of oxytocin to accelerate labor appears normative (generally in South Asia), how and when did this practice start? Did women first experience this practice at a facility and then transfer the desire for the same at subsequent home births? Are family members partially responsible for increased demand for uterotonics? Do women know that a 200-μg misoprostol tablet taken before delivery of the baby is dangerous and that is why this practice has not yet been described in the literature? Is it just a matter of time before misoprostol is used to accelerate labor? On the supply side, do some countries better enforce regulations regarding sales of prescription drugs, or is such enforcement differential by drug? Do increased reports of use in South Asia reflect increased affordability or availability of uterotonics? What proportion of a village doctor's or drug seller's income is based on sales of uterotonics? Once woman-based demand of uterotonics for medically inappropriate reasons has been established, what interventions could be effective at diminishing this potentially dangerous demand?

Wider distribution and promotion of oxytocin and misoprostol to prevent PPH is among the more feasible and effective interventions available to health planners responsible for maternal mortality reduction. However, implementation of such programs must be informed by an understanding of existing practices among both pregnant women and those who could or do provide them with uterotonic drugs for acceleration of labor. A number of these practices have been highlighted in this review. Simply admonishing the practice and trying to regulate or enforce the cessation of it is unlikely to improve behavior.

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Acknowledgments 

Funding for this literature review was provided under grant # 51592 from the Bill and Melinda Gates Foundation to PATH.

Conflict of interest

Deborah Armbruster is an employee of PATH, the original developer of Uniject, which has no commercial interest in the device. Dawn Flandermeyer and Cynthia Stanton also have no conflicts of interest.

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PII: S0020-7292(09)00648-1

doi:10.1016/j.ijgo.2009.12.001

International Journal of Gynecology & Obstetrics
Volume 108, Issue 3 , Pages 269-275, March 2010

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