Politics of Childbirth in Nepal

Nepal has been hailed as a global success in reducing the maternal mortality ratio from around 540 women dying per 100,000 births in 1996 to about 240 in 2016. The chapter will critically analyse two interventions implemented around 2005. First, we will look at the USAID-funded Nepal Family Health Program, through which oral misoprostol (to control bleeding after delivery) was launched across Nepal. Second, we will look at Aama Surakshya Karyakram (or mother programme), which was implemented to promote institutional delivery. These two programmes, despite aiming to address high maternal mortality ratio in Nepal, adopted very different approaches, reflecting ideological struggles on women’s agency and the politics of childbirth. The chapter concludes that the costs of these changes (such as the lack of resources or the commercialization of healthcare) have been overlooked in the claims of Nepal’s ‘success’.

A randomized control study of titrated and oral misoprostol solution for induction of labor at term

Background: Quest for an induction method with safety, efficacy, feasibility, low cost, and patient preference is a constant pursuit for all obstetricians. Oral misoprostol is one such method which has been shown to be effective in achieving vaginal birth and has been recommended by WHO (2011) and FIGO (2012) for induction of labor. This study aimed to evaluate effectiveness and safety of hourly titrated oral misoprostol solution in comparison with two hourly static-dose oral misoprostol solution for induction of labor at term.Methods: Single centre interventional single-blinded randomized controlled trial conducted in a tertiary care centre in Ludhiana. 264 term pregnant women were randomly given titrated (group A) or static oral misoprostol solution (group B) till the onset of active labor. Induction to delivery time was the primary outcome measure while the secondary outcome measures pertained to efficacy and safety of the regimens.Results: 268 women were randomized, 4 patients were excluded from analysis because of drop out, leaving 264 women for intention to treat analysis. The mean interval between induction and delivery was 16.19±10.48 hours in group A and 15.28±8.34 hours in group B (p>0.10, NS). 71 women (53.8%) in group A and 72 women (54.5%) in group B had vaginal delivery within 24 hours (p>0.10, NS). 40.9% women in group B required more than 8 hours to receive the required number of doses as compared with 8.3% women in dose group A (p<0.01, SS). Oxytocin requirement was significantly higher in group A (76.5%) as compared to group B (59.8%) (p<0.05, SS). Incidence of fetal and maternal complications, rate of cesarean section and instrumental delivery was comparable between the two groups (p>0.10, NS).Conclusions: Titrated oral misoprostol, considering its efficacy, safety and time saving is comparable to WHO recommended static oral misoprostol.

A comparison of the efficacy and safety of repetitive hourly dose of oral misoprostol and two hourly dose oral regimens for cervical ripening and labor induction: A R.C.T

Background Labor induction most frequently conducted through interventional procedures, and their use has been increasing in the past several decades. In a survey by the National Center for Health Statistics the rate of labor induction was noted to have increased from 9.5% in 1991 to 22.5% in 2006. This randomized controlled trial was conducted at Ain Shams University Maternity Hospital (pre-labour ward) in the period between January 2019 and January 2020. Patients and Methods This study was conducted on 150 pregnant women attending Ain Shams University Hospital outpatient clinic, they were classified according to the indication for labor induction into 2 groups, high risk group and low risk group. Results that there was no statistically significant difference between groups according to baseline characteristics, indication of induction and need for oxytocin. Regarding medications side effect and maternal outcomes, our results showed that there was statistically significant difference between groups according to pyrexia. Regarding mode of delivery, our results showed that there was no statistically significant difference between groups. Regarding no. of req. doses and duration of delivery, our results showed that there was statistically significant difference between groups according to no. of req. doses and duration of delivery (hrs) and total dose of misoprostol (µg), more in group I (hourly dose) than II (2 hours dose). Regarding fetal outcomes (Apgar score at 1 and 5 min, birth weight (kg), meconium staining, NICU admission), our results showed that there was no statistically significant difference between 2 groups. Conclusion The repetitive hourly dose of misoprostol solution (10 μg -10 mL- oral misoprostol administered hourly up to12 doses) has similar efficacy as oral misoprostol solution every 2 hours (20 μg -20 mL- administered every 2 hours up to 6 doses) but with more side effects.

Comparison of Oral Misoprostol with Intravenous Oxtocin in the In the Management of the Third Stage of Labour: A Randomized Controlled Trial

Background: Postpartum haemorrhage (PPH) is defined as the loss of 500ml of blood or more from the vagina following vaginal birth or 1000ml following caesarean delivery. The third stage of labour is the period between the delivery of the baby and the delivery of the placenta and membranes and its management is central to the prevention of postpartum haemorrhage (PPH). There are basically two methods of managing the third stage of labour namely active and physiological/expectant. The active management includes the use of uterotonic drugs immediately following delivery of the fetus, early cord clamping and cutting, and controlled umbilical cord traction. The active management of the third stage of labour with oxytocin has been found to reduce the risk of primary PPH significantly; however, the problem of inadequate supply of electricity, high cost and paucity of skilled manpower to administer it has negatively affected its use in developing countries and has made the search for a more suitable alternative expedient. Misoprostol on the other hand has been found to have good uterotonic activities, affordable and stable at room temperature; making its use in the resource-poor countries a veritable alternative. Aims: To determine if there is any difference in the efficacy of intravenous oxytocin over oral misoprostol in the management of the third stage of labour Study Design: This was a prospective, double-blinded, randomized trial of uncomplicated pregnant women who had vaginal delivery in the labour ward of the ESUT Teaching Hospital, Enugu. Sample Size: Two hundred (200) pregnant women who satisfied the inclusion criteria were recruited into the study with each arm accommodating 100 participants. Methodology: The eligible women were recruited on presentation to the labour ward after giving their consent. They were randomly allocated into 2 groups: A and B. Group A received 2 tablets (400µg) of oral misoprostol and 1mililtre(ml) of sterile water intravenously while group B received 2 tablets of white vitamin c and 1ml (10iu) of intravenous oxytocin immediately after cord clamping and cutting following the delivery of the baby. The patient was observed for significant clinical vaginal bleeding or PPH. For the purposes of this study, any bleeding/PPH accompanied with a greater than 30% rise in baseline pulse rate qualified for transfusion. A proforma was used to record the necessary data Statistical Analysis: Data collected from the study was analyzed with the Statistical Package for Social Sciences (SPSS) computer software version 20.0 for Windows. Statistical analysis was both descriptive and inferential at 95% confidence level. The socio-demographic variables were used to categorize the data and this was subjected to comparative statistical evaluation to yield frequencies, means, and percentages. Test of significance between class differences was by Pearson’s Chi-square test for categorical variables and student’s t-test for continuous variables. All P<0.05 at one degree of freedom (df=1) was considered statistically significant. Results and Conclusion: There was no significant difference in the number of women that received blood transfusion, the amount of blood transfused and the need for additional oxytocics on both arms of the study. However, there was a significant difference in the occurrence of side-effects with shivering and vomiting being prominent in the misoprostol and oxytocin arms respectively. Conclusion: There was no difference in the efficacy of oxytocin over misoprostol in the management of the 3rd stage of labour. We therefore, recommend that misoprostol can be adopted as an alternative/substitute to oxytocin in the management of the third stage of labour especially in developing countries.

The Induction with Foley OR Misoprostol (INFORM) Study dataset. A dataset of 602 women with hypertensive disease in pregnancy, in India, randomised to either Foley catheter or oral misoprostol for induction of labour

Objectives Induction of labour (IOL), or starting labour artificially, can be a lifesaving intervention for pregnant women and their babies, and rates are rising significantly globally. As rates increase, it becomes increasingly important to fully evaluate all available data, especially that from low income settings where the potential benefits and harms are greater. The goal of this paper is to describe the datasets collected as part of the Induction with Foley OR Misoprostol (INFORM) Study, a randomised trial comparing two of the recommended methods of cervical ripening for labour induction, oral misoprostol and Foley catheter, in women being induced for hypertension in pregnancy, at two sites in India during 2013–15. Data description This dataset includes comprehensive data on 602 women who underwent IOL for hypertensive disorders in pregnancy. Women were randomly assigned to cervical ripening with oral misoprostol or a transcervical Foley catheter in two government hospitals in India. The main dataset has 367 variables including monitoring during the induction of labour, medications administered, timing and mode of delivery, measures of neonatal morbidity and mortality, maternal mortality and morbidity, maternal satisfaction and health economic data. The dataset is anonymised and available on ReShare.

A COMPARATIVE STUDY OF SAFETY & EFFICACY OF ORAL MISOPROSTOL VERSUS OXYTOCIN IN PREVENTION OF POSTPARTUM HAEMORRHAGE

OBJECTIVE: To compare oral misoprostol with intramuscular oxytocin in prevention of postpartum haemorrhage in low risk vaginal birth in a tertiary care centre. METHOD: In a prospective , open label controlled trial, 60 women were randomly allocated to 2 groups. Gr A – 10 units oxytocin i.m Gr B - 600µg misoprostol orally within 1 minute of delivery. The outcome measured was blood loss within 1 hour and 24hrs of delivery. RESULTS: The mean blood loss in 1 hour post delivery was 151.14 ±12.40ml in Group A and 149.82±10.36 ml in Group B. The mean blood loss within 24hrs after delivery was 218.59 ±33.63 ml in Group A and 230.11±31.82 ml in Group B. There was no signicant difference between the groups in terms of blood loss within1 hr and 24 hrs of delivery. CONCLUSION: oral misoprostol 600μg is as effective as intramuscular oxytocin 10IU in the prevention of PPH in low risk vaginal delivery.

Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial

Background Every year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared. Methods This pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women’s experience are also planned. Discussion Avoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman’s care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin. Trial registration Clinical Trials.gov, NCT03749902, registered on 21st Nov 2018.