title: Stakeholder Analysis of Community Distribution of Misoprostol in Lao PDR: A Qualitative Study.
abstract: BACKGROUND
  Globally, significant progress has been made in reducing maternal mortality, yet in many low-resource contexts it remains unacceptably high. Many of these deaths are due to postpartum haemorrhage and are preventable with access to essential obstetric care. Where there are barriers to access, maternal deaths could be prevented if community-level misoprostol was available. The purpose of this study was to explore perceptions of stakeholders regarding misoprostol use in the Lao People's Democratic Republic, a setting with high maternal mortality.
  
  
  METHODS
  Semi-structured interviews were conducted with 35 stakeholders in the capital, Vientiane and in one northern province identified as a site for a possible intervention. The sample included international and national stakeholders involved in policy-making and providing maternal and reproductive health services.
  
  
  RESULTS
  Most stakeholders supported a pilot program for community distribution of misoprostol but levels of awareness of the drug's use in preventing postpartum haemorrhage and level of influence over policy direction varied considerably. Some international organizations, all identified as powerful in influencing policy, were ambivalent about the use of community distribution of misoprostol. Concerns related to the capacity of village health workers or lay people to safely administer misoprostol, whether its distribution would undermine efforts to improve access to safe delivery services and active management of the third stage of labour, the ease with which prescription drugs can be bought over the counter, and technical, logistical, and financial constraints.
  
  
  CONCLUSIONS
  Access to appropriate oxytocic drugs is a matter of health equity. In settings without access to essential obstetrical care, misoprostol represents a viable solution for the prevention of postpartum haemorrhage. Understanding stakeholders' perspectives and their legitimate concerns on misoprostol can inform interventions in order to assuage these concerns and enable disadvantaged women to access misoprostol and its potentially life-saving benefits.
authors.affiliation: Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, Queensland, Australia, 4006.
authors.forename: Jo
authors.identifier: http://orcid.org/0000-0003-0544-9424
authors.initials: J
authors.lastname: Durham
authors.affiliation: Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, Queensland, Australia, 4006.
authors.forename: Melissa
authors.initials: M
authors.lastname: Warner
authors.affiliation: University of Health Sciences, Vientiane, Lao PDR.
authors.forename: Alongkone
authors.initials: A
authors.lastname: Phengsavanh
authors.affiliation: University of Health Sciences, Vientiane, Lao PDR.
authors.forename: Vanphanom
authors.initials: V
authors.lastname: Sychareun
authors.affiliation: University of Health Sciences, Vientiane, Lao PDR.
authors.forename: Viengnakhone
authors.initials: V
authors.lastname: Vongxay
authors.affiliation: Communicable Diseases Unit, Chief Health Officer Branch, Health Service & Clinical Innovation Division, Department of Health, Queensland Government, Brisbane, Queensland Australia, 4006.
authors.forename: Keith
authors.initials: K
authors.lastname: Rickart
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007812:Laos; D016595:Misoprostol / Q000627:therapeutic use*; D006473:Postpartum Hemorrhage / Q000517:prevention & control*; D011247:Pregnancy; D055815:Young Adult
chemical_list: D016595:Misoprostol