Table 2.
Barriers or gaps identified from included articles
| S.No | Health System Building Blocks/Thematic Areas | Sub-Themes for identified gaps or barriers | Number of studies identified similar gap/barriers |
|---|---|---|---|
| 1 | Barriers or gaps related to Leadership, governance, Guidelines and Policy related (12 Studies) | Lack of national policies and guidelines for MPAC or PPH | 2 |
| No Registration of misoprostol Specific for PAC or PPH | 3 | ||
| Fear and apprehensions related to its use | 3 | ||
| Misoprostol not included in National list of essential medicines | 1 | ||
| legal restrictions that only permits pregnancy termination to save life of mother | 1 | ||
| No or Less Preference to misoprostol | 1 | ||
| Lack of integration of misoprostol with Basic package of health services/ health care resources | 2 | ||
| Poorly developed Commodity security strategies. | 1 | ||
| Rudimentary or absent Transportation and communication system. | 2 | ||
| Lack of ability to implement and monitor implementation and current practices. | 1 | ||
| Lack of trust between clinicians and policy makers | 1 | ||
| Gaps in pre-service medical and midwifery education program curriculum. | 1 | ||
| Technical inconsistencies and ambiguity in guidelines and protocols- incomplete and out dated. | 2 | ||
| Lack of communication or awareness of existing policy | 2 | ||
| 2 | Barriers or gaps related to Health Service Delivery, and availability and access to essential medicine (10 Studies) | Lack of Access to misoprostol | 2 |
| PAC services not available | 1 | ||
| Issues related to inconsistencies in supplies/ fragmented supply chain and distribution | 8 | ||
| Lack of Supervision/Monitoring capacity | 1 | ||
| Reduced institutional delivery | 1 | ||
| Lack of provider preference of Medical Abortion using misoprostol | 1 | ||
| 3 | Barriers or gaps related to Health Workforce (14 studies) | Lack of Knowledge & Skills (Technical & non –technical) of providers | 3 |
| Lack of training and training capacity of providers | 2 | ||
| scarcity of staff or inadequate staffing (SBA’s, TBA’s, CHW’s) | 6 | ||
| Fear, apprehensions and doubt related to misoprostol | 5 | ||
| Negative or Judgmental attitude of providers | 1 | ||
| Limited scope of practice of midwifes | 1 | ||
| Lack of awareness/Clarity of the guidelines/evidence. | 4 | ||
| Lack of communication/inter-professional collaboration | 2 | ||
| Lack of Motivation among provider | 1 | ||
| 4. | Issues related to Community perception, Knowledge and preference: (8 Studies) | Lack of acceptability and negative attitude due to stigma associated due to its abortion inducing properties | 3 |
| Hindrance from relatives in taking misoprostol | 1 | ||
| Lack of community awareness and knowledge for misoprostol | 2 | ||
| Lack of health seeking behavior | 2 | ||
| Lack of preference to Medical Abortion using misoprostol | 1 | ||
| Lack of access to misoprostol due socio-economic, Ethnic and cultural barriers | 2 | ||
| Patients’ lack of trust of lower-cadre health workers | 1 | ||
| Disparities in service utilization between rural and urban | 1 | ||
| 5 | Barriers or gaps related to Health information system (1 Study) | Lack of national reporting on HMIS on use of uterotonics. | 1 |
| Gaps in inclusion of maternal health indicators in national data | 1 | ||
| 6 | Barriers or gaps related to cost of medicine (2 Studies) | Paying for medicine is a bottle neck to improve coverage despite to be inexpensive | 2 |
| Financial constraints in term of training TBA’s, cost of drug | 1 |