Use of oxytocinand misoprostolfor induction or augmentation of

laborin 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 HealthThe Johns Hopkins Bloomberg School of Public HealthBaltimore, Maryland

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

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

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);

Objectives of the Expert Meeting1. Summarize the literature review and working

paper.

2. Discussion of content.

3. Making a decision about whether this is an important public health problem.

4. Seeking feedback on recommendations and next steps.

5. To identify potential partners, agencies and groups for leadership.

Summary of working paper: Data sources for the review:1. Compilation of international obstetric

practice guidelines;

2. Analysis of induction and augmentation rates from a seven country study on AMTSL; and

3. A structured literature review

Literature Review Summary

Reference providing rates, trends or indications: 43

References providing data on misoprostol for induction/augmentation: 7

Meta-analyses identified and reviewed in the Cochrane library: 18

References specifically on low resource settings:36

References specifically on elective inductions: 12

References providing data on maternal/perinatal outcomes: 24

Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane databaseReferences identified (excluding duplicates): 962

References remaining after review of abstracts: 278

References meeting inclusion/exclusion criteria after full

review of article: 140

Reference providing rates, trends or indications: 43

References providing data on misoprostol for induction/augmentation: 7

Meta-analyses identified and reviewed in the Cochrane library: 18

References specifically on low resource settings:36

References specifically on elective inductions: 12

References providing data on maternal/perinatal outcomes: 24

Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane databaseReferences identified (excluding duplicates): 962

References remaining after review of abstracts: 278

References meeting inclusion/exclusion criteria after full

review of article: 140

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

National induction rates in HRSCountry Reference year Induction Rate

(in %)

Sweden 2001-2002 33.2

Australia 2006 36.7

France 1981-1995 25.0

Scotland 2003-2004 24.0

New Zealand 2004 20.4

USA 2005 22.3

Canada 2000-2001 22.0

UK 2005-2006 20.2

Wales 2004 19.1

The Netherlands 1993-2002 15.0

Rising trends in induction in HRS

05

10

15

20

30

40

Ind

uctio

n R

ate

(in

%)

1988 1992 1996 2000 2004 2008Reference Yr

UK USACanada NetherlandFrance New Zealand

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

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Scheiner 02(Isreal)

Seyb '98(USA)

Prysak '98(USA)

Maslow '00(USA)

Johnson '03(USA)

Glantz '05(USA)

Crane '03(Canada)

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

3.2

0.5

8.3

25.5

22.6

10.5

17.1

37.9

11.9

8.7

18.8

32.3

32.1

58.9

87.6

83.0

56.2

58.6

57.2

50.8

18.3

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Benin

Ethiopia

Tanzania

Indonesia

El Salvador

Honduras

Nicaragua

% of deliveries

Induced Augmented only Neither

Hospital specific rates of induction in LRS from the literature.Author/year Country Data collec-

tion yearRate of induced

labor(%)

Denominator

Loto O, Fadahunsi A, et al., 2004

Nigeria 2002-3 18 All deliveries

Behague D, et al., 2002

Brazil 1993 31.2 All deliveries

Chigbu C, Exeome I, et al., 2007

Nigeria 2003-06 16.3 All deliveries

Saunders D and Makutu S, 2001

Fiji 1986-96 14 All deliveries

Hospital specific rates of elective induction in LRS

Author Reference year

Country Rate (in %)

Oboro V, Isawumi A, et al., 2007

2001-2005 Nigeria 13.7

Saunders D and Makutu S, 2001

1986-96 Fiji 30.0

Chigbu C, Ezeome I et al., 2007

2003-2006 Nigeria 7.4

Uterine Rupture and induction in LRSAuthor Reference

yearCountry % of uterine

ruptures associated with

induction

Notes from authors

Aboyeji A, Ijaiya M et al., 2001

1992-1999 Nigeria 39 Unskilled use of oxytocin

Ahmed S, 2001 1992-1997 Sudan 10.5 Injudicious use of oxytocin outside of hospital

Al-Jufairi A, 2001 1990-1999 Bahrain >50 Oxytocin used excessively

Chuni N, 2006 1999-2004 Nepal 44  

Ezechi O, 2004 1991-2000 Nigeria 41 61%of inductions in hospital had wrong dose, route and monitoring

Konje J, Odukoya O, et al., 1990

1975-1986 Nigeria 4.9 Others suffered from no access to augmentation

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.

Non-pharmacological methodsMechanical 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.

AvailabilityOxytocin Misoprostol

Outcome of working group:

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

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.

PrioritiesResearch 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).

Thank you