Use of oxytocin and misoprostol for induction or ... - POPPHI

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Executive Summary The aim of this working paper was to compile in one place; definitions, recommended methods, rates, trends, indications and maternal and perinatal risks associated with induction and augmentation. The focus of this working paper is on induction and augmentation in the developing world, and the inclusion of data from developed countries was intended only for comparative purposes. The impetus for this working paper is the recent call for expanded availability of oxytocin and misoprostol to all maternity settings in developing countries for the purposes of active management of the third stage of labor (AMTSL) to reduce postpartum hemorrhage, coupled with concerns that these drugs would then be widely available for induction and augmentation. The information presented in this working paper comes from three sources: a compilation of international obstetric practice guidelines, analysis of induction and augmentation rates from a seven country study on AMTSL, and a structured literature review which searched five electronic databases using broad search terms related to induction and augmentation. The working paper compiled data from 42 countries, representing all MDG regions, except for North Africa. Not surprisingly, few data are available from the private sector or smaller health centers. The samples from three of the seven countries in the AMTSL study (all sub-Saharan African countries) did include health center data and suggest that induction and augmentation are being performed in those facilities. Authors’ comments and references from some studies also suggest that induction and augmentation are being performed at lower levels of the health system (without surgical capacity) and outside of the health system often putting maternal and perinatal health at risk. In general, definitions, descriptions of the methods and indications for cervical ripening, induction and augmentation are consistent across obstetric practice guidelines from several countries and from guidelines and position papers from international agencies. Overall, data on induction and augmentation from developing countries are sparse and there is a need for more research. National rates of induction and augmentation for all health facility-based births are not known for any developing country due to the lack of 1
data from lower level and private facilities. Where data are available, induction rates were documented in individual hospitals or samples of hospitals and ranged from 0.5 percent in Ethiopia to 31 percent in Brazil. Augmentation rates ranged from two percent in Senegal to 38 percent in Benin. Only a small number of papers specifically documented the rate of elective induction or augmentation in developing countries. However, combined rates of induction and augmentation which reach 40 to 50 percent of deliveries clearly imply some use of elective procedures. In developed countries, recent national rates of induction (from 2000 or later) were available from ten countries and ranged from 15 to 37 percent. Elective induction is reported to be responsible for much of the increasing trends in these countries. Developing and developed country data, however, are not comparable due to substantially lower rates of institutional delivery and a lack of comprehensive perinatal data collection in most developing countries. Data from clinical trials suggest that induction and augmentation in developed countries are generally safe. Elective induction as compared to spontaneous labor was significantly associated with increased risks of Cesarean section, but not of other adverse maternal or perinatal outcomes. In contrast, little is known about the safety of elective or medically indicated induction and augmentation in developing countries. Seven descriptive studies from sub-Saharan Africa, China and Nepal documented between ten to greater than 50 percent of uterine ruptures associated with induction, and the authors commented that these oxytocin-related ruptures were due to injudicious, unskilled, unmonitored or excessive use of oxytocin both in and out of the health system. The results of three small studies (two in sub-Saharan Africa one and one in India) suggest that induction with misoprostol relative to oxytocin may be associated with an increased risk of meconium staining, but this did not translate to neonatal asphyxia or NICU admissions. Non-pharmacological methods, which are used to encourage the initiation of labor but are not expected to result in the immediate onset of labor, are often used internationally in obstetric care as complementary practices which may avoid formal induction of labor. 2
Page 1: Use of oxytocin and misoprostol for
Page 5 and 6: the literature provides us with ver
Page 7 and 8: Acronyms ACOG AMRN AMTSL CS EFM FDA
Page 9 and 10: List of Tables Table 1.1a Published
Page 11 and 12: 1. Introduction Low and middle inco
Page 13 and 14: Comment Setting Country Source and
Page 15 and 16: 4) To summarize current rates, tren
Page 17 and 18: eview given its focus on the use of
Page 19 and 20: Category Inclusion Exclusion Ration
Page 21 and 22: Table 3.1a provides definitions for
Page 23 and 24: Prerequisite clinical conditions fo
Page 25 and 26: practitioner’s discretion as outl
Page 27 and 28: Table 3.3c WHO recommendations for
Page 29 and 30: Table 3.4a National induction rates
Page 31 and 32: variable induction rates in Washing
Page 33 and 34: Table 3.4c: The percent distributio
Page 35 and 36: studies that assessed this outcome.
Page 37 and 38: 3.5 Rates, Trends, Indications and
Page 39 and 40: Tables 3.5b presents rates of induc
Page 41 and 42: Table 3.5d Hospital-specific rates
Page 43 and 44: adverse outcomes of induction becau
Page 45 and 46: this is not associated with increas
Page 47 and 48: use in LRS, particularly given the
Page 49 and 50: Sweeping of the membranes was compa
Page 51 and 52: concern regarding its use for early
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Misoprostol is now available in som
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Figure 3.6 c World map showing glob
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documented rates of elective induct
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In general, definitions, descriptio
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An evidence-based safe and effectiv
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Appendix A: Glossary of common term
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References 1. World Health Organiza
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28. Beebe LA, Rayburn WF, Beaty CM,
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55. Maternity statistics, england:
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81. Roberts CL, Algert CS, Douglas
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105. Nigam A, Singh VK, Dubay P, Pa
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Use of oxytocin and misoprostol for induction or ... - POPPHI

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