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. 2020 Jun 23;2020(6):CD009336. doi: 10.1002/14651858.CD009336.pub3

Summary of findings 1. Advance misoprostol distribution/provision to pregnant women for postpartum self‐administration versus usual (or standard) care for prevention of postpartum haemorrhage.

Advance misoprostol distribution/provision to pregnant women for postpartum self‐administration versus usual (or standard) care for prevention of postpartum haemorrhage
Patient or population: women in the third stage of labour
Settings: non‐facility birth settings
Intervention: advance misoprostol distribution/provision to pregnant women for postpartum self‐administration
Comparison: usual (or standard) care
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI) No of participants
(studies) Quality of the evidence
(GRADE) Comments
Assumed risk Corresponding risk
Usual (or standard) care Advance misoprostol distribution/provision to pregnant women for postpartum self‐administration
Severe postpartum haemorrhage See comment See comment Not estimable 299
(1 study) Not reported Not reported.
Serious maternal morbidity See comment See comment Not estimable 299
(1 study) ⊕⊝⊝⊝
very low1,2 No cases of severe maternal morbidity were recorded among women who had non‐facility births.
Maternal death See comment See comment Not estimable 299
(1 study) ⊕⊝⊝⊝
very low1,2 No cases of maternal death were recorded among women who had non‐facility births.
Blood transfusion See comment See comment Not estimable 299
(1 study) ⊕⊝⊝⊝
very low1,2 No cases of blood transfusion were recorded among women who had non‐facility births.
Women not using/receiving misoprostol at birth 40 per 1000 20 per 1000
(5 to 79) RR 0.50
(0.13 to 1.95) 299
(1 study) ⊕⊝⊝⊝
very low1,3  
Inappropriate use (or misuse) of misoprostol 0 per 1000 0 per 1000
(0 to 0) RR 4.97 
(0.24 to 102.59) 299
(1 study) ⊕⊝⊝⊝
very low1,3  
Maternal transfer or referral to a health facility 20 per 1000 13 per 1000
(2 to 79) RR 0.66 
(0.11 to 3.91) 299
(1 study) ⊕⊝⊝⊝
very low1,3  
*The basis for the assumed risk is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 We downgraded (by one level) for serious indirectness because the usual (or standard) care was advance distribution and postpartum self‐administration of inactive study drug.
2 We downgraded (by two levels) for very serious imprecision because there were no events and the sample size was small.
3 We downgraded (by two levels) for very serious imprecision because of few events, small sample size and wide confidence intervals.