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 Licencing was High confidence four studies with Osur J et al. 2013; Starrs A
& Winikoff B 2012; Moore
absent as most moderate concerns JE et al. 2016; Sheldon WR
countries or regarding et al. 2014;
ministries did not methodological
have misoprostol limitations and
registered or Minor concerns
lincenced for the regarding coherence
management of PAC with only one study.
or PPH. Our focus No/Very minor
was on prevention of concerns regarding
PPH. There was also adequacy, and
limited relevance
understanding of
existing policy.
2 Implementers did not High confidence Minor concerns Starrs A & Winikoff B 2012;
Spangler SA et al. 2014;
have clarity, with regarding Haver J et al. 2016; Smith
fear and confusion methodological JM et al. 2014; Brief 2012;
among some limitations with two Sheldon WR et al. 2014;
Vogel JP et al. 2016;
implementing studies with limited
partners. This limited No reflexivity in one
integration of study and sampling
distribution of not clear in other
misoprostol into study. No/Very
routine health minor concerns
services in the health regarding coherence,
facilities. There were adequacy, and
also technical relevance from all
ambiguity, with out seven studies
clarity in the
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

guidelines. This was

exarcebated by poor
communication and
transportation. As a
result, only a few
countires had
implemented pilot
studies, which have
not been scaled
nationally.
2. HEALTH SERVICE DELIVERY, AVAILABILITY AND ACCESS TO MEDICINES
3 Inconsistencies in High confidence Minor concerns Osur J et al. 2013; Spangler
SA et al. 2014; Moore JE et
supplies due to regarding al. 2016; Smith JM et al.
fragmentation in the methodological 2014; Casey SE et al. 2015;
supply chain and limitations with clear Brief 2012; Ansari N et al.
2015; Vogel JP et al. 2016;
distribution resulted study methods in all
to lack of studies. Minor
misoprostol, limiting concerns regarding
access to optimal coherence, adequacy,
coverage and and No/Very minor
utilization concerns regarding
relevance
3. HEALTH WORK FORCE
4 Scarcity and High confidence Moderate concerns Osur J et al. 2013; Haver J et
al. 2016; Casey SE et al.
inadequate staffing regarding 2015; Prata N et al. 2014;
were the most methodological Brief 2012; Vogel JP et al.
common gap limitations as 2016;

sampling strategy in
two studies not
justified, No/Very
minor concerns
regarding coherence
and Minor concerns
regarding adequacy,
and relevance
5 Fear and confusion Moderate confidence Minor concerns Starrs A & Winikoff B 2012;
Moore JE et al. 2016; Brief
among the health regarding 2012; Sheldon WR et al.
workers, fearing methodological 2014;
drug misuse due to limitations with All
the risk for abortion studies reflexive on
inducing properties the reliability and
and unsafe use for validity of measures
abortion. SOme fears used yet None of the
were associated with studies provides
use before birth, and justification sample
poor knowledge of representative of
the status of the population, No/Very
pregnancy. This minor concerns
seemed linked to a regarding coherence,
lack of knowledge adequacy, and
and skills among relevance
some providers.
4. COMMUNITY PERCEPTION, KNOWLEDGE & PREFERENCE
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

6 Community Moderate confidence Moderate concerns Prata N et al. 2014; Ansari N

et al. 2015; Sheldon WR et
perception was low, regarding al. 2014;
with a poor attitutide methodological
towards misoprostol limitations based on
due to its abortion two cross sectional
inducing properties. study designs, and
one web basd design,
Moderate concerns
regarding coherence,
Minor concerns
regarding adequacy,
and relevance
7 Access to Moderate confidence No/Very minor Prata N et al. 2014; Mir AM
et al. 2012; Ejembi C et al.
misoprostol was concerns regarding 2014;
lomited by inequities coherence. Minor
due to poor socio concerns regarding
economic status, methodological
ethnic and cultural limitations adequacy,
barries. Equitable and relevance as
distribution of three study designs
misoprotol could used for all studies,
address this, and
reduce the limited
awareness and
knowledge on the
use of misoprostol
5. HEALTH INFORMATION SYSTEMS
8 Most studies did not Low confidence Minor concerns Smith JM et al. 2013;
comprehensively regarding
report on the methodological
monitoring and limitations based on
evaluation structures one study, Minor
in the countries, concerns regarding
hence difficulty in coherence and
ascetaining a relevance, Moderate
complete structure. concerns regarding
However, one study adequacy.
did report the
absence of national
reporting system for
use ot uterotonics,
including
misoprostol.
Reporting on
misoprostol use
helps guide evidence
based supply chains,
supports planning.
6. COST OF MEDICINE
9 Cost of medicine Very low confidence Serious concerns Brief 2012; Smith JM et al.
2013;
was identified in regarding
systems that methodological
involved payment limitations based on
 GRADE-CERQual Explanation of
Summarised review
# Assessment of GRADE-CERQual References
finding
confidence Assessment

for medicines, hence situational analysis,

reducing coverage of and data from only
the programs. one country
Limited resources extracted, Moderate
also limited training concerns regarding
of staff in a coherence and
situational analysis relevance. Serious
from Ethiopia. concerns regarding
adequacy as findings
are from only
Ethiopia, while the
data on the other
multicountry study
was not extracted
Evidence Profile Table

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

1. LEADERSHIP, GOVERNANCE, AND POLICY

1 Licencing was Moderate concerns Minor concerns No/Very minor No/Very minor High confidence Moore JE et al. 2016;
Osur J et al. 2013;
absent as most concerns concerns Sheldon WR et al. 2014;
countries or Explanation: two Explanation: All Explanation: four Starrs A & Winikoff B
ministries did not studies with studies explore Explanation: Data is Explanation: studies with 2012;

have misoprostol moderate concerns; policy environment adequately rich; Data Studies reflect moderate concerns
registered or No reflexivity, in the countries; One is from over 70 context from multiple regarding
lincenced for the limited reflection on study highlights countries, and hence countries, including methodological
management of interviewer bias; licencing of covers multiple Affrica, Asia and limitations and
PAC or PPH. Our Another only misoprostol for other contexts to inform represnt both urban Minor concerns
focus was on evaluated a limited purposes, which is the finding. and rural populations regarding coherence
prevention of PPH. category of service not explicitly with only one study.
There was also providers mentioned in review No/Very minor
limited finding. Review's concerns regarding
understanding of comment on adequacy, and
existing policy. inconsistence in use relevance
of other guidelines
does not explicity
mention specific
guidelines
2 Implementers did Minor concerns No/Very minor No/Very minor Minor concerns High confidence Brief 2012; Haver J et al.
2016; Sheldon WR et al.
not have clarity, concerns concerns 2014; Smith JM et al.
with fear and Explanation: 7 Explanation: Study Explanation: Minor 2014; Spangler SA et al.
confusion among studies, all with clear Explanation: One Explanation: Data participants not concerns regarding 2014; Starrs A & Winikoff
B 2012; Vogel JP et al.
some aims; Three not clear study mentioned rich from contexts in described in two methodological 2016;
implementing sample was healthcare providers Africa, and Asia. 7 studies. Studies limitations with two
partners. This representative in one don’t know about studies included. One across varied studies with limited
limited integration web based study; guidelines and No study data not contexts and relevant No reflexivity in one
of distribution of three did not specify guideline for adequately described. e.g in Afagnistan, study and sampling
misoprostol into reponse rates. and misoprostol specific Tanzania, Ethiopia not clear in other
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

routine health one does not describe for PPH. Fear of study. No/Very
services in the validity and misuse of minor concerns
health facilities. reliability measures. misoprostol outside regarding coherence,
There were also Various study the intended purpose adequacy, and
technical designs such as for labor induction relevance from all
ambiguity, with indepth interviews, seven studies
out clarity in the mixed methods. One
guidelines. This study used special
was exarcebated by communication. No
poor reflexivity in one
communication study. Sampling
and transportation. highlighted in all
As a result, only a studies
few countires had
implemented pilot
studies, which
have not been
scaled nationally.
2. HEALTH SERVICE DELIVERY, AVAILABILITY AND ACCESS TO MEDICINES
3 Inconsistencies in Minor concerns Minor concerns Minor concerns No/Very minor High confidence Ansari N et al. 2015;
Brief 2012; Casey SE et
supplies due to concerns al. 2015; Moore JE et al.
fragmentation in Explanation: Had Explanation: One Explanation: One Explanation: Minor 2016; Osur J et al. 2013;
the supply chain clear and diverse study over study had no baseline Explanation: Stdues concerns regarding Smith JM et al. 2014;
Spangler SA et al. 2014;
and distribution methods and designs interpretitive. data collected. One across many methodological Vogel JP et al. 2016;
resulted to lack of including one study Another focus on other did not countries in Low and limitations with clear
misoprostol, that incorporated supplies in adequately describe middle income study methods in all
limiting access to mixed methods with Postabortion Care the data countries, including studies. Minor
optimal coverage indepth interview, (PAC). in Africa and in Asia. concerns regarding
and utilization document review; coherence, adequacy,
Sample size and No/Very minor
described in all but concerns regarding
two studies. relevance
Reliability and
valididty of measures
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

described in all but

two. One study had
one interviewer
across the country,
and had no baseline
data collected. All
studies had
reflexivity
3. HEALTH WORK FORCE
4 Scarcity and Moderate concerns No/Very minor Minor concerns Minor concerns High confidence Brief 2012; Casey SE et
al. 2015; Haver J et al.
inadequate staffing concerns 2016; Osur J et al. 2013;
were the most Explanation: Explanation: Five of Explanation: three Explanation: Prata N et al. 2014; Vogel
common gap Explanation: six Explanation: One the six studies of the studies are Moderate concerns JP et al. 2016;
studies in which study highlights describe data from conducted among regarding
indepth interviews, shortage of TBAs. adequately. women who are methodological
cross sectional study Only one of the six service users, and limitations as
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 Fear and confusion Minor concerns No/Very minor No/Very minor No/Very minor Moderate Brief 2012; Moore JE et
al. 2016; Sheldon WR et
among the health concerns concerns concerns confidence al. 2014; Starrs A &
workers, fearing Explanation: One Winikoff B 2012;
drug misuse due to study uses realist Explanation: One Explanation: Data Explanation: 2 Explanation: Minor
the risk for evaluation and study reported adequately described studies are in concerns regarding
abortion inducing another uses special Misuse of in all but one study multiple developing methodological
properties and communication. All misoprostol outside countries, while two limitations with All
unsafe use for studies reflexive on the intended purpose others are in Ethiopia studies reflexive on
abortion. SOme the reliability and for labor induction. and Kosovo the reliability and
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

fears were validity of measures Another highlights respectively. All validity of measures
associated with use used. None of the the focus on punitive studies discuss used yet None of the
before birth, and studies provides interventions to generalizability of studies provides
poor knowledge of justification sample health workers. Fear their findings. justification sample
the status of the representative of of the promotion of representative of
pregnancy. This population. abortion. One of the population, No/Very
seemed linked to a studies interpretive minor concerns
lack of knowledge regarding coherence,
and skills among adequacy, and
some providers. relevance
4. COMMUNITY PERCEPTION, KNOWLEDGE & PREFERENCE
6 Community Moderate concerns Moderate concerns Minor concerns Minor concerns Moderate Ansari N et al. 2015;
Prata N et al. 2014;
perception was confidence Sheldon WR et al. 2014;
low, with a poor Explanation: three Explanation: one Explanation: Explanation: Two
attitutide towards studies in which two study mentioned Findings from three studies include Explanation:
misoprostol due to used cross sectional stigma associated studies women who are Moderate concerns
its abortion study design, and one with its abortion service users and regarding
inducing web basd design. inducing properties . another includes methodological
properties. sampling strategy in another highlighted members of FIGO. limitations based on
two studies Inadequate Coverage All studies describe two cross sectional
underrepresented of SBAs and TBA’s. the generalizability study designs, and
providers. All but Another did not ask of their findings. one web basd design,
one studies about which Two studies Moderate concerns
demonstrated healthcare providers conducted in regarding coherence,
reflexivity. only one were able to give key bangladesh and Minor concerns
study provides medicines, and was Afaghanistan and one regarding adequacy,
justification of directed at the amombers member and relevance
sample representative guidelines for developing countries
of population obstetricians and of FIGO
gynecologists rather
than other healthcare
providers
7 Access to Minor concerns No/Very minor Minor concerns Minor concerns Moderate Ejembi C et al. 2014; Mir
AM et al. 2012; Prata N
misoprostol was concerns confidence
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

lomited by Explanation: Before Explanation: two of

Explanation: studies et al. 2014;
inequities due to and after study Explanation: One three studies
in Bangladesh, Explanation:
poor socio design, quasi study highlighted Northern Nigeria and No/Very minor
adequately describe
economic status, experimental and cultural and data in detailed way.
Pakistan. need for concerns regarding
ethnic and cultural cross sectional structural barrier further studies in coherence. Minor
barries. Equitable designs used. two limits coverage. other contexts. All concerns regarding
distribution of studies do not Review does not studies in methodological
misoprotol could provide ustification highlight findings communities. Two in limitations adequacy,
address this, and sample representative related stigma rural settings, and and relevance as
reduce the limited of population associated with use one in mixed rural three study designs
awareness and of misoprostol in the and urban settings. used for all studies,
knowledge on the family. All studies discuss
use of misoprostol genarizability
5. HEALTH INFORMATION SYSTEMS
8 Most studies did Minor concerns Minor concerns Moderate concerns Minor concerns Low confidence Smith JM et al. 2013;
not
comprehensively Explanation: one Explanation: some Explanation: Only Explanation: only Explanation: Minor
report on the study with moderate data not explored one study, despite based on one concerns regarding
monitoring and limitations comprehensively being a multicountry multicountry study, methodological
evaluation study which offers which explores limitations based on
structures in the some richness, the different contexts. one study, Minor
countries, hence review did not extractfurther studies to concerns regarding
difficulty in data from the study. explore other settings coherence and
ascetaining a further studies in relevance, Moderate
complete structure. other contexts concerns regarding
However, one required, limited adequacy.
study did report the reporting on health
absence of national information systems.
reporting system
for use ot
uterotonics,
including
misoprostol.
 GRADE-CERQual
Summarised review Methodological
# Coherence Adequacy Relevance assessment of References
finding limitations
confidence

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 Very low Brief 2012; Smith JM et
al. 2013;
was identified in confidence
systems that Explanation: data Explanation: Data Explanation: only Explanation:
involved payment extraction based on extraction based on two studies provide assessment based on Explanation:
for medicines, one study only. One one study only. insights in cost of only two countries; Serious concerns
hence reducing study only a Whereas medicines medicines, and one Ethiopia. The study's regarding
coverage of the situational analysis, were costly at of does not have data data is not extracted methodological
programs. Limited with reflxivity not community level, extracted during the limitations based on
resources also reflected upon. other providers found process of review. situational analysis,
limited training of these cost effective, The other's design is and data from only
staff in a and a low tech not so strong one country
situational analysis intervention extracted, Moderate
from Ethiopia. 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