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The use of uterotonics for home births is an idea whose time has come. When I first began to work in this field some 35years ago, wiser minds than mine had already been thinking along these lines. Yet despite the importance of postpartum hemorrhage (PPH) as the leading cause of maternal death, the idea didn't—couldn't—fly because the uteronics in question were oxytocin and ergometrine, neither of which is suitable for a variety of reasons. Very real concerns included the fear of misuse by traditional birth attendants, how the drugs should be administered, and the inability to store these substances under suitable conditions.

The advent of misoprostol changed all this because it is less easily misused, is administered orally, and can be stored at room temperature for a relatively long period. Furthermore, discussion on accessibility quickly shifted from the birth attendant to the pregnant woman herself. The four papers in this issue of the Keystone Section all refer to home use of misoprostol to prevent PPH: a literature review [1], two field trials targeting pregnant women [2], [3], and a cost effectiveness analysis [4].

It is important to keep in mind that uterotonics including misoprostol can only prevent PPH due to uterine atony; other causes of PPH (such as uterine rupture, cervical and vaginal injury, placental abnormalities) are unaffected. It is also important to remember that these papers refer only to home births; oxytocin remains the uterotonic of choice where it can be safely given intravenously or intramuscularly by skilled birth attendants in an institutional setting. As more national programs move toward increased facility-based deliveries, misoprostol will become less important. In the interim, it is a useful and cost-effective tool in national programs.

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References 

1. Flandermeyer D, Stanton C, Armbruster D. Uterotonic use for home births in low-income countries: A literature review. Int J Obstet Gynecol. 2010;108(3):269–275
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2. Sanghvi H, Ansari N, Prata NJ, Gibson H, Ehasan AT, Smith JM. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Obstet Gynecol. 2010;108(3):276–281
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3. Rajbhandari S, Hodgins S, Sanghvi S, McPherson R, Pradhan YV, Baqui AH. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: Operations research study in Nepal. Int J Obstet Gynecol. 2010;108(3):282–288
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4. Sutherland T, Meyer C, Bishai DM, Geller S, Miller S. Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis. Int J Obstet Gynecol. 2010;108(3):289–294
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