Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster‐randomised non‐inferiority community trial

BJOG; 2016 Jan; 123(1):120-7; doi:10.1111/1471-0528.13540

The article describes a community trial implemented by a team from India and the USA that compared two approaches to the management of postpartum hemorrhage – the leading complication of childbirth that causes approximately a quarter of all maternal deaths each year. The study compared the current standard, ‘universal prophylaxis’ --a commonly-advocated community approach for reducing postpartum hemorrhage whereby every woman is administered a preventive uterotonic medicine to contract the uterus-- to a novel approach, ‘secondary prevention/early treatment’ -- where only the small proportion of women who bleed more than average are offered a treatment dose of misoprostol. Results show that the secondary prevention approach medicated substantially fewer women (4.7% versus 99.7%), who experienced significantly fewer side effects. There were no statistical differences in post-delivery hemoglobin levels, rate of postpartum hemorrhage, and rate of transfer to higher level facilities. The authors conclude that this new research shows secondary prevention/early treatment to be a feasible non-inferior alternative strategy to universally medicating all women who deliver with prophylaxis. The approach has the potential for being more acceptable, cost-effective and sustainable, with the additional potential to equip community-level providers with a timely strategy to manage bleeding before it reaches the point of an emergency.