Use of oxytocin and misoprostol for induction or augmentation of labor in low-resource settings

1. Use of oxytocin and misoprostol for induction or augmentation of labor in low-resource settings A Report of a Working Meeting POPPHI project, PATH, Washington DC March 20, 2008 Prepared by: Ann Lovold, BHSc, RM, MPH Cynthia Stanton, PhD Department of Population, Family and Reproductive Health The Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland

2. Background • International agencies, NGO projects and national health programs are promoting the expanded availability of uterotonics (particularly oxytocin) for AMSTL purposes to prevent postpartum hemorrhage • Especially to peripheral services • Such (needed) expansion raises concerns regarding the inappropriate use of uterotonics for other reasons – induction and augmentation

3. Background • The literature and anecdotal information suggest induction and augmentation are taking place in low resource settings • Electively • Improperly administered • Inadequately monitored • In all levels of health facilities • At home births

4. A few examples: • W Africa: Demi Demi - an observed practice of giving 5IU oxytocin IM in each buttock to begin or speed up labor; • Nigerian study: 61% of inductions reviewed in the hospital had incorrect dose, route and/or monitoring (Ezechi 2004); • Nepal: 22% of 527 mothers who had home births with TBAs reported oxytocin injections during labor (Sharan et al. 2005); • Bangledesh: nurse negotiates with family and provides “an injection” to avoid the cesarean recommended by the physician (Parkhurst and Rahaman 2007) • Brazil: Women who cannot afford elective CS, choose elective induction, only those who are very poor have no interventions (Behague 2002);

5. Objectives of the Expert Meeting • Summarize the literature review and working paper. • Discussion of content. • Making a decision about whether this is an important public health problem. • Seeking feedback on recommendations and next steps. • To identify potential partners, agencies and groups for leadership.

6. Summary of working paper: Data sources for the review: • Compilation of international obstetric practice guidelines; • Analysis of induction and augmentation rates from a seven country study on AMTSL; and • A structured literature review

7. Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane database References identified (excluding duplicates): 962 Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane database References identified (excluding duplicates): 962 References remaining after review of abstracts: 278 References remaining after review of abstracts: 278 References meeting inclusion/exclusion criteria after full review of article: 140 References meeting inclusion/exclusion criteria after full review of article: 140 Reference providing rates, trends or indications: 43 Reference providing rates, trends or indications: 43 References providing data on misoprostol for induction/augmentation: 7 References providing data on misoprostol for induction/augmentation: 7 References specifically on elective inductions: 12 References specifically on elective inductions: 12 References providing data on maternal/perinatal outcomes: 24 References providing data on maternal/perinatal outcomes: 24 References specifically on low resource settings: 36 References specifically on low resource settings: 36 Meta-analyses identified and reviewed in the Cochrane library: 18 Meta-analyses identified and reviewed in the Cochrane library: 18 Literature Review Summary

8. Current Recommendations • Misoprostol 25ug vaginally every four hours until delivery or 50ug orally every four hours until delivery or 25ug vaginally, then after four hours start 25ug solution orally every two hours (take 25mls of a solution made up of a 200ug tablet dissolved in 200mls water For IUFD, the dose may be doubled if two doses have no effect

9. National induction rates in HRS

10. Rising trends in induction in HRS

11. Outcome of CS with elective induction vs. spontaneous labor. Odds Ratios and 95% confidence intervals.

12. Induction and augmentation rates from 7 LRS countries (source: AMSTL study)

13. Hospital specific rates of induction in LRS from the literature.

14. Hospital specific rates of elective induction in LRS

15. Uterine Rupture and induction in LRS

16. Neonatal Outcomes in LRS • Most cases of ruptured uterus also result in perinatal death. • Dujardin et al: increased risk of stillbirth and resuscitation shown for those with oxytocin use during normal labor (augmentation) in 3 sub-Saharan African countries. • High priority for research due to lack of data.

17. Non-pharmacological methods Mechanical dilators: Cochrane review shows less risk than oxytocin or misoprostol Stripping of membranes: shortens pregnancy, reduces post-dates. No increased infection risk. ARM: no evidence to do it routinely, avoid with HIV positive.

18. AvailabilityOxytocin Misoprostol

20. Outcome of working group: • The group found the issue to be of public health importance and that we should move forward on it.

21. Next Steps • Define/quantify the public health problem in terms of maternal and perinatal mortaltiy/morbidity. • Prioritize recommendations • Build bridges between those responsible for reproductive and neonatal issues in terms of funding, programs and research.

22. Priorities Research Priority: gathering empirical data to describe the magnitude of the problem in public, private and home based deliveries. Clinical Practice Guidelines: ideally headed by WHO with support of FIGO and ICM to address appropriate indications, parameters and methods of both oxytocin and misoprostol use for induction and augmentation specifically in low resource settings. Address out of hospital use of oxytocin and misoprostol (materials, community based, research).

23. Thank you