Misoprostol distribution

Summary of Qualitative Findings Table

Review question
What are to the barriers/gaps in the implementation of misoprostol use for prevention of postpartum
hemorrhage and management of Post-abortion care services in developing countries.

Authors of the review

Amir Ali Barket Ali Samnani, Narjis Rizvi Tazeen Saeed Ali, and Farina Abrejo

Corresponding author
Amir Ali Barket Ali Samnani - am_samnani@hotmail.com

Has the review been published?

| DOI:

Additional Information

GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

1. LEADERSHIP, GOVERNANCE, AND POLICY

1 Lack of registration High confidence four studies with Osur J et al. 2013; Starrs A
& Winikoff B 2012; Moore
for misoprostol for moderate concerns JE et al. 2016; Sheldon WR
community regarding et al. 2014;
admnistration in the methodological
prevention of PPH limitations and
was absent as most Minor concerns
countries and regarding coherence
government with only one study.
ministries did not No/Very minor
have misoprostol concerns regarding
registered or adequacy, and
lincenced for the relevance
management of PAC
or PPH. Preference
was for use of
oxytocin in hospitals
in the management
of . There was also
limited
understanding of
existing policy.
2 Implementers did not Moderate confidence Minor concerns Starrs A & Winikoff B 2012;
Spangler SA et al. 2014;
have clarity on the regarding Haver J et al. 2016; Smith
key policies and methodological JM et al. 2014; Brief 2012;
guidelines, with limitations with two Sheldon WR et al. 2014;
Vogel JP et al. 2016;
some policy makers studies with limited
and government No reflexivity in one
officials study and sampling
demonstrating fear not clear in other
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

and confusion on study. No/Very

misoprostol use. This minor concerns
lack of leadership regarding coherence,
hindered integration adequacy, and
of distribution of relevance from all
misoprostol into seven studies
routine health
services in the health
facilities. There were
also technical
inconsistences and
ambiguity, with out
clarity in the
guidelines. This was
exarcebated by poor
communication and
transportation.
2. HEALTH SERVICE DELIVERY, AVAILABILITY AND ACCESS TO MEDICINES
3 Access to essential High confidence Minor concerns Osur J et al. 2013; Spangler
SA et al. 2014; Moore JE et
Medicines; Across regarding al. 2016; Smith JM et al.
most studies, methodological 2014; Casey SE et al. 2015;
participants reported limitations with clear Brief 2012; Ansari N et al.
2015; Vogel JP et al. 2016;
inconsistencies in study methods in all
supplies of essential studies. Minor
medicines due to concerns regarding
fragmentation in the coherence, adequacy,
supply chain and and No/Very minor
distribution. This concerns regarding
reduced access to relevance
misoprostol, limiting
optimal coverage
and utilization
3. HEALTH WORK FORCE
4 Inadequate Staffing; High confidence Moderate concerns Osur J et al. 2013; Haver J et
al. 2016; Casey SE et al.
Scarcity and regarding 2015; Prata N et al. 2014;
inadequate staffing methodological Brief 2012; Vogel JP et al.
in health facilities limitations as 2016;

was reported by a sampling strategy in

number of two studies not
participants. justified, No/Very
minor concerns
regarding coherence
and Minor concerns
regarding adequacy,
and relevance
5 Perceptions among Moderate confidence Minor concerns Starrs A & Winikoff B 2012;
Moore JE et al. 2016; Brief
health workers; regarding 2012; Sheldon WR et al.
Health workers were methodological 2014;
not confident in limitations with All
community studies reflexive on
distribution of the reliability and
misoprostol as they validity of measures
held fears on drug used yet None of the
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

misuse due to the studies provides

risk for abortion justification sample
inducing properties representative of
and unsafe use for population, No/Very
abortion. Some fears minor concerns
were associated with regarding coherence,
use before birth adequacy, and
(intrapartum), and relevance
undiagnosed
pregnancy, or
sharing of
medications. This
was a concesus on a
lack of knowledge
and skills among
community service
providers.
4. COMMUNITY PERCEPTION, KNOWLEDGE & PREFERENCE
6 Community Low confidence Moderate concerns Prata N et al. 2014; Ansari N
et al. 2015; Sheldon WR et
perception; Some regarding al. 2014;
participants reported methodological
negative and poor limitations based on
attitutide towards two cross sectional
misoprostol due to study designs, and
its abortion inducing one web basd design,
properties. Serious concerns
regarding coherence
as varying views on
misoprostol use are
not reasonably
presented in review
finding including the
perceptions of
sideeffects which are
varingly mentioned
across the studies,
Minor concerns
regarding adequacy,
and relevance
7 Community Barriers: Moderate confidence No/Very minor Prata N et al. 2014; Mir AM
et al. 2012; Ejembi C et al.
Access to concerns regarding 2014;
misoprostol was coherence. Minor
limited due to poor concerns regarding
socio economic methodological
status, poor limitations adequacy,
knowledge on and relevance as
misoprostol, ethnic three study designs
and cultural barriers. used for all studies,
There was
perceptions that
equitable distribution
of misoprotol could
address this
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

disparity.
5. HEALTH INFORMATION SYSTEMS
8 Abscence of Low confidence Minor concerns Smith JM et al. 2013;
National Reporting regarding
System; Only one methodological
study (of the 19) limitations based on
reported on health one study, Minor
management concerns regarding
information system coherence and
on national relevance, Moderate
uterotonic use. The concerns regarding
gaps indentified adequacy.
included on
inclusion of key
maternal health
indicators at national
level. Proper
reporting on
misoprostol use
helps guide evidence
based supply chains,
supports planning.
6. COST OF MEDICINE
9 Cost of medicine; A Low confidence Serious concerns Brief 2012; Smith JM et al.
2013;
multicountry regarding
national level study methodological
found payment for limitations based on
medicines as a key situational analysis,
barrier to coverage and data from only
of the programs. one country
Limited resources extracted in one
also limited training study despite the
of staff in a other being in about
situational analysis 37 countries.
from Ethiopia. Moderate concerns
regarding coherence
and relevance.
Serious concerns
regarding adequacy
as findings are from
only Ethiopia, while
the data on the other
multicountry study
was not extracted in
the review reports
Evidence Profile Table

GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

1. LEADERSHIP, GOVERNANCE, AND POLICY

1 Lack of Moderate concerns Minor concerns No/Very minor No/Very minor High confidence Moore JE et al. 2016;
Osur J et al. 2013;
registration for concerns concerns Sheldon WR et al. 2014;
misoprostol for Explanation: two Explanation: All Explanation: four Starrs A & Winikoff B
community studies with studies explore Explanation: Data is Explanation: studies with 2012;

admnistration in moderate concerns; policy environment adequately rich; Data Studies reflect moderate concerns
the prevention of No reflexivity, in the countries; One is from over 70 context from multiple regarding
PPH was absent as limited reflection on study highlights countries, and hence countries, including methodological
most countries and interviewer bias; licencing of covers multiple Africa, Asia and limitations and
government Another only misoprostol for other contexts to inform represent both urban Minor concerns
ministries did not evaluated a limited purposes, which is the finding. and rural populations regarding coherence
have misoprostol category of service not explicitly with only one study.
registered or providers mentioned in review No/Very minor
lincenced for the finding. Review's concerns regarding
management of comment on adequacy, and
PAC or PPH. inconsistence in use relevance
Preference was for of other guidelines
use of oxytocin in does not explicity
hospitals in the mention specific
management of . guidelines
There was also
limited
understanding of
existing policy.
2 Implementers did Minor concerns No/Very minor No/Very minor Minor concerns Moderate Brief 2012; Haver J et al.
2016; Sheldon WR et al.
not have clarity on concerns concerns confidence 2014; Smith JM et al.
the key policies Explanation: 7 Explanation: Study 2014; Spangler SA et al.
and guidelines, studies, all with clear Explanation: One Explanation: Data participants not Explanation: Minor 2014; Starrs A & Winikoff
B 2012; Vogel JP et al.
with some policy aims; Three not clear study mentioned rich from contexts in described in two concerns regarding 2016;
makers and sample was healthcare providers Africa, and Asia. 7 studies. Studies methodological
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

government representative in one don’t know about studies included. One across varied limitations with two
officials web based study; guidelines and No study data not contexts and relevant studies with limited
demonstrating fear three did not specify guideline for adequately described. e.g in Afagnistan, No reflexivity in one
and confusion on reponse rates. and misoprostol specific Tanzania, Ethiopia study and sampling
misoprostol use. one does not describe for PPH. Fear of not clear in other
This lack of validity and misuse of study. No/Very
leadership reliability measures. misoprostol outside minor concerns
hindered Various study the intended purpose regarding coherence,
integration of designs such as for labor induction adequacy, and
distribution of indepth interviews, relevance from all
misoprostol into mixed methods. One seven studies
routine health study used special
services in the communication. No
health facilities. reflexivity in one
There were also study. Sampling
technical highlighted in all
inconsistences and studies
ambiguity, with
out clarity in the
guidelines. This
was exarcebated by
poor
communication
and transportation.
2. HEALTH SERVICE DELIVERY, AVAILABILITY AND ACCESS TO MEDICINES
3 Access to essential Minor concerns Minor concerns Minor concerns No/Very minor High confidence Ansari N et al. 2015;
Brief 2012; Casey SE et
Medicines; Across concerns al. 2015; Moore JE et al.
most studies, Explanation: Had Explanation: One Explanation: One Explanation: Minor 2016; Osur J et al. 2013;
participants clear and diverse study over study had no baseline Explanation: Stdues concerns regarding Smith JM et al. 2014;
Spangler SA et al. 2014;
reported methods and designs interpretitive. data collected. One across many methodological Vogel JP et al. 2016;
inconsistencies in including one study Another focus on other did not countries in Low and limitations with clear
supplies of that incorporated supplies in adequately describe middle income study methods in all
essential medicines mixed methods with Postabortion Care the data countries, including studies. Minor
indepth interview, (PAC). in Africa and in Asia. concerns regarding
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

due to document review; coherence, adequacy,

fragmentation in Sample size and No/Very minor
the supply chain described in all but concerns regarding
and distribution. two studies. relevance
This reduced Reliability and
access to valididty of measures
misoprostol, described in all but
limiting optimal two. One study had
coverage and one interviewer
utilization across the country,
and had no baseline
data collected. All
studies had
reflexivity
3. HEALTH WORK FORCE
4 Inadequate Moderate concerns No/Very minor Minor concerns Minor concerns High confidence Brief 2012; Casey SE et
al. 2015; Haver J et al.
Staffing; Scarcity concerns 2016; Osur J et al. 2013;
and inadequate Explanation: Explanation: Five of Explanation: three Explanation: Prata N et al. 2014; Vogel
staffing in healthExplanation: six Explanation: One the six studies of the studies are Moderate concerns JP et al. 2016;

facilities was studies in which study highlights describe data from conducted among regarding
reported by a indepth interviews, shortage of TBAs. adequately. women who are methodological
number of cross sectional study Only one of the six service users, and limitations as
participants. design, etc. sampling studies is two among service sampling strategy in
strategy in two overinterpretive, and providers. Rural and two studies not
studies not provided attempts to explain urban, and facility justified, No/Very
while four studies causality in a cross and community minor concerns
did. five of the six sectional survey contexts are regarding coherence
studies reflexive. method explored. Five of the and Minor concerns
studies describe regarding adequacy,
generalizability of and relevance
the findings
5 Perceptions among Minor concerns No/Very minor No/Very minor No/Very minor Moderate Brief 2012; Moore JE et
al. 2016; Sheldon WR et
health workers; concerns concerns concerns confidence al. 2014; Starrs A &
Health workers Explanation: One Winikoff B 2012;
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

were not confident study uses realist Explanation: One Explanation: Data Explanation: 2 Explanation: Minor
in community evaluation and study reported adequately described studies are in concerns regarding
distribution of another uses special Misuse of in all but one study multiple developing methodological
misoprostol as they communication. All misoprostol outside countries, while two limitations with All
held fears on drug studies reflexive on the intended purpose others are in Ethiopia studies reflexive on
misuse due to the the reliability and for labor induction. and Kosovo the reliability and
risk for abortion validity of measures Another highlights respectively. All validity of measures
inducing properties used. None of the the focus on punitive studies discuss used yet None of the
and unsafe use for studies provides interventions to generalizability of studies provides
abortion. Some justification sample health workers. Fear their findings. justification sample
fears were representative of of the promotion of representative of
associated with use population. abortion. One of the population, No/Very
before birth studies interpretive minor concerns
(intrapartum), and regarding coherence,
undiagnosed adequacy, and
pregnancy, or relevance
sharing of
medications. This
was a concesus on
a lack of
knowledge and
skills among
community service
providers.
4. COMMUNITY PERCEPTION, KNOWLEDGE & PREFERENCE
6 Community Moderate concerns Moderate concerns Minor concerns Minor concerns Low confidence Ansari N et al. 2015;
Prata N et al. 2014;
perception; Some Sheldon WR et al. 2014;
participants Explanation: three Explanation: one Explanation: Explanation: Two Explanation:
reported negative studies in which two study mentioned Findings from three studies include Moderate concerns
and poor attitutide used cross sectional stigma associated studies women who are regarding
towards study design, and one with its abortion service users and methodological
misoprostol due to web basd design. inducing properties . another includes limitations based on
its abortion sampling strategy in another highlighted members of FIGO. two cross sectional
two studies Inadequate Coverage All studies describe study designs, and
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

inducing underrepresented of SBAs and TBA’s. the generalizability one web basd design,
properties. providers. All but Another did not ask of their findings. Serious concerns
one studies about which Two studies regarding coherence
demonstrated healthcare providers conducted in as varying views on
reflexivity. only one were able to give key bangladesh and misoprostol use are
study provides medicines, and was Afaghanistan and one not reasonably
justification of directed at the amombers member presented in review
sample representative guidelines for developing countries finding including the
of population obstetricians and of FIGO perceptions of
gynecologists rather sideeffects which are
than other healthcare varingly mentioned
providers across the studies,
Minor concerns
regarding adequacy,
and relevance
7 Community Minor concerns No/Very minor Minor concerns Minor concerns Moderate Ejembi C et al. 2014; Mir
AM et al. 2012; Prata N
Barriers: Access to concerns confidence et al. 2014;
misoprostol was Explanation: Before Explanation: two of Explanation: studies
limited due to poor and after study Explanation: One three studies in Bangladesh, Explanation:
socio economic design, quasi study highlighted adequately describe Northern Nigeria and No/Very minor
status, poor experimental and cultural and data in detailed way. Pakistan. need for concerns regarding
knowledge on cross sectional structural barrier further studies in coherence. Minor
misoprostol, ethnic designs used. two limits coverage. other contexts. All concerns regarding
and cultural studies do not Review does not studies in methodological
barriers. There was provide ustification highlight findings communities. Two in limitations adequacy,
perceptions that sample representative related stigma rural settings, and and relevance as
equitable of population associated with use one in mixed rural three study designs
distribution of of misoprostol in the and urban settings. used for all studies,
misoprotol could family. All studies discuss
address this genarizability
disparity.
5. HEALTH INFORMATION SYSTEMS
8 Abscence of Minor concerns Minor concerns Moderate concerns Minor concerns Low confidence Smith JM et al. 2013;
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

National Reporting Explanation: one Explanation: some Explanation: Only Explanation: only Explanation: Minor
System; Only one study with moderate data not explored one study, despite based on one concerns regarding
study (of the 19) limitations comprehensively being a multicountry multicountry study, methodological
reported on health study which offers which explores limitations based on
management some richness, the different contexts. one study, Minor
information system review did not extractfurther studies to concerns regarding
on national data from the study. explore other settings coherence and
uterotonic use. The further studies in relevance, Moderate
gaps indentified other contexts concerns regarding
included on required, limited adequacy.
inclusion of key reporting on health
maternal health information systems.
indicators at
national level.
Proper reporting on
misoprostol use
helps guide
evidence based
supply chains,
supports planning.
6. COST OF MEDICINE
9 Cost of medicine; Serious concerns Moderate concerns Serious concerns Moderate concerns Low confidence Brief 2012; Smith JM et
al. 2013;
A multicountry
national level study Explanation: data Explanation: Data Explanation: only Explanation: Explanation:
found payment for extraction based on extraction based on two studies provide assessment based on Serious concerns
medicines as a key one study only. One one study only. insights in cost of only two countries; regarding
barrier to coverage study only a Whereas medicines medicines, and one Ethiopia. The study's methodological
of the programs. situational analysis, were costly at of does not have data data is not extracted limitations based on
Limited resources with reflxivity not community level, extracted during the situational analysis,
also limited reflected upon. other providers found process of review. and data from only
training of staff in these cost effective, The other's design is one country extracted
a situational and a low tech not so strong in one study despite
analysis from intervention the other being in
about 37 countries.
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

Ethiopia. Moderate concerns

regarding coherence
and relevance.
Serious concerns
regarding adequacy
as findings are from
only Ethiopia, while
the data on the other
multicountry study
was not extracted in
the review reports