title: Modeling maternal mortality in Bangladesh: the role of misoprostol in postpartum hemorrhage prevention.
abstract: BACKGROUND
  Bangladesh is one of the few countries that may actually achieve the fifth Millennium Development Goal (MDG) in time, despite skilled birth attendance remaining low. The purpose of this paper is to examine the potential role misoprostol can play in the decline of maternal deaths attributed to postpartum hemorrhage (PPH) in Bangladesh.
  
  
  METHODS
  Using data from a misoprostol and blood loss measurement tool feasibility study in Bangladesh, observed cause specific maternal mortality ratios (MMRs) were estimated and contrasted with expected ratios using estimates from the Bangladesh Maternal Mortality Survey (BMMS) data. Using Crystal Ball 7 we employ Monte Carlo simulation techniques to estimate maternal deaths in four scenarios, each with different levels of misoprostol coverage. These scenarios include project level misoprostol coverage (69%), no (0%), low (40%), and high (80%) misoprostol coverage. Data on receipt of clean delivery kit, use of misoprostol, experience of PPH, and cause of death were used in model assumptions.
  
  
  RESULTS
  Using project level misoprostol coverage (69%), the mean number of PPH deaths expected was 40 (standard deviation = 8.01) per 100,000 live births. Assuming no misoprostol coverage (0%), the mean number of PPH deaths expected was 51 (standard deviation = 9.30) per 100,000 live births. For low misoprostol coverage (40%), the mean number of PPH deaths expected was 45 (standard deviation = 8.26) per 100,000 live births, and for high misoprostol coverage (80%), the mean number of PPH deaths expected was 38 (standard deviation = 7.04) per 100,000 live births.
  
  
  CONCLUSIONS
  This theoretical exercise hypothesizes that prophylactic use of misoprostol at home births may contribute to a reduction in the risk of death due to PPH, in addition to reducing the incidence of PPH. If findings from this modeling exercise are accurate and uterotonics can prevent maternal death, misoprostol could be the tool countries need to further reduce maternal mortality at home births.
authors.affiliation: Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, 229 University Hall, UC Berkeley, Berkeley, CA 94720-7360, USA. ndola@berkeley.edu.
authors.forename: Ndola
authors.initials: N
authors.lastname: Prata
authors.forename: Suzanne
authors.initials: S
authors.lastname: Bell
authors.forename: Md Abdul
authors.initials: MA
authors.lastname: Quaiyum
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D002423:Cause of Death; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006301:Health Services Needs and Demand; D006700:Home Childbirth / Q000009:adverse effects*; D006801:Humans; D008428:Maternal Mortality / Q000639:trends; D008880:Midwifery / Q000379:methods*; D016595:Misoprostol / Q000627:therapeutic use*; D008962:Models, Theoretical; D010120:Oxytocics / Q000627:therapeutic use; D006473:Postpartum Hemorrhage / Q000453:epidemiology / Q000517:prevention & control*; D011247:Pregnancy; D012189:Retrospective Studies
chemical_list: D010120:Oxytocics; D016595:Misoprostol