Recent efforts to prevent post-partum haemorrhage (PPH) in low-income countries have focusedon providing women with access to oral misoprostol during home birth. The WHO recommendsusing lay health workers (LHWs) to administer misoprostol in settings where skilled birth attend-ants are not available. This review synthesizes current knowledge about the barriers and facilitatorsaffecting implementation of advance community distribution of misoprostol to prevent PPH, wheremisoprostol may be self-administered or administered by an LHW.We searched for and summarized available empirical evidence, and collected primary data fromprogramme stakeholders about their experiences of programme implementation.We present key outcomes and features of advanced distribution programmes that are in operationor have been piloted globally. We categorized factors influencing implementation into those thatoperate at the health system level, factors related to the community and policy context and thosefactors more closely connected to the end user.Debates around advance distribution have centred on the potential risks and benefits of makingmisoprostol available to pregnant women and community members during pregnancy for admin-istration in the home. However, the risks of advance distribution appear manageable and the bene-fits of self-administration, especially for women who have little chance of expert care for PPH, areconsiderable.


Helen J Smith, School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK

Christopher J Colvin and Jeffrey Roberson, Division of Social andBehavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, South Africa

Esther Richards, Department for International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK

Geeta Sharma, United Missionto Nepal, Kathmandu, Nepal

Kusum Thapa, Jhpiego (an affiliate of Johns Hopkins University), Lalitpur, Nepal

A Metin Gulmezoglu, UNDP/UNFPA/UNICEF/WHO/World Bank Special programme of research, development and research training in humanreproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva,Switzerland

Accepted on 11 January 2015