***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Abstract Objective To evaluate whether routine administration of sublingual misoprostol 600 μg after delivery reduces postpartum haemorrhage . Design R and omised double blind placebo controlled trial . Setting Primary health centre in Bissau , Guinea-Bissau , West Africa . Participants 661 women undergoing vaginal delivery . Intervention Misoprostol 600 μg or placebo administered sublingually immediately after delivery . Main outcome measures Postpartum haemorrhage , defined as a loss of ≥ 500 ml and decrease in haemoglobin concentration after delivery . Results The incidence of postpartum haemorrhage was not significantly different between the two groups , the relative risk being 0.89 ( 95 % confidence interval 0.76 to 1.04 ) in the misoprostol group compared with the placebo  group . Mean blood loss was 10.5 % ( −0.5 % to 20.4 % ) lower in the misoprostol group than in the control group . Severe postpartum haemorrhage of ≥ 1000 ml or ≥1500 ml occurred in 17 % ( 56 ) and 8 % ( 25 ) in the placebo group and 11 % ( 37 ) and 2 % ( 7 ) in the misoprostol group . Significantly fewer women in the misoprostol group experienced a loss of ≥1000 ml ( 0.66 , 0.45 to 0.98 ) or ≥ 1500 ml ( 0.28 , 0.12 to 0.64 ) . The decrease in haemoglobin concentration tended to be less in the misoprostol group , the mean difference between the two groups being 0.16 mmol/l ( −0.01 mmol/l to 0.32 mmol/l ) . Conclusion Sublingual misoprostol  reduces the frequency of severe postpartum haemorrhage International research partnerships bring together some of the best and the brightest in an effort to tackle global health problems . Such collaborations also pose complex challenges , such as maintaining ethical principles in the conduct of research in developing nations . In implementing a r and omized clinical trial to reduce  postpartum hemorrhage ( PPH ) during childbirth in rural India , U.S. and Indian collaborators addressed three such issues : the appropriateness of an ethical r and omized controlled trial in the developing world , the inclusion of a placebo arm , and the relevance of informed consent in a semiliterate rural population Objective . The main objective of this study was to identify factors associated with variation in the rate of acute postpartum hemorrhage ( PPH ) , defined as blood loss ≥ 500 mL within 2 hours of delivery , observed in a r and omized clinical trial of misoprostol for the prevention of PPH , conducted in rural India . Although the women in the misoprostol group had a significantly lower probability of having a PPH , we also noted a reduction in the rate of PPH in the placebo group over the course of the study . We hypothesized that this was due to the changing skills of the auxiliary nurse midwives ( ANMs ) over the course of the study . Methods . We conducted a post-hoc analysis examining variation in PPH rates over the duration of the trial among the women r and omized to the placebo arm ( n = 808 ) . Descriptive , correlation analysis and generalized estimating equations ( GEE ) were used to predict PPH rates . With no direct measure of ANM skills , we used proxy measures , including : ( 1 ) the ANM 's point of entry into the study ( original ANMs at the initiation of the trial were less skilled than replacement ANMs ) ; ( 2 ) the study duration , representing exposure of the ANM to ongoing training and monitoring ; and ( 3 ) duration of the second stage of labor as a measure of improved delivery practice s. Results . As the study duration increased , the duration of the second stage of labor decreased ( −0.12 , p = 0.001 ) and as the duration of the second stage of labor decreased , the rate of PPH decreased ( 0.0282 ; 95 % CI 0.0201–0.0363 ) . For each 10-minute increase in the duration of second stage labor increased PPH odds by 7.1 % and each 30-day duration of the trial decreased PPH odds by 3.4 % . Additionally , a patient delivered by an original ANM was 3.14 times more likely to have a PPH compared to a patient delivered by a replacement ANM . Conclusions . Declining PPH rates were associated with improved skills and delivery practice s that decreased duration of the second stage of labor . These improvements appeared to be consistent with the introduction of the more skilled replacement ANMs as well as ongoing training and monitoring for all ANMs over the duration of the trial BACKGROUND Postpartum haemorrhage is a leading cause of maternal morbidity and mortality . Active management of the third stage of labour , including use of a uterotonic agent , has been shown to reduce blood loss . Misoprostol ( a prostagl and in E1 analogue ) has been suggested for this purpose because it has strong uterotonic effects , can be given orally , is inexpensive , and does not need refrigeration for storage . We did a multicentre , double-blind , r and omised controlled trial to determine whether oral misoprostol is as effective as oxytocin during the third stage of labour . METHODS In hospitals in Argentina , China , Egypt , Irel and , Nigeria , South Africa , Switzerl and , Thail and , and Vietnam , we r and omly assigned women about to deliver vaginally to receive 600 microg misoprostol orally or 10 IU oxytocin intravenously or intramuscularly , according to routine practice , plus corresponding identical placebos . The medications were administered immediately after delivery as part of the active management of the third stage of labour . The primary outcomes were measured postpartum blood loss of 1000 mL or more , and the use of additional uterotonics without an unacceptable level of side-effects . We chose an upper limit of a 35 % increase in the risk of blood loss of 1000 mL or more as the margin of clinical equivalence , which was assessed by the confidence interval of the relative risk . Analysis was by intention to treat . FINDINGS 9264 women were assigned misoprostol and 9266 oxytocin . 37 women in the misoprostol  group and 34 in the  oxytocin  group had emergency caesarean sections and were excluded . 366 ( 4 % ) of women on misoprostol had a measured blood loss of 1000 mL or more , compared with 263 ( 3 % ) of those on oxytocin ( relative risk 1.39 [ 95 % CI 1.19 - 1.63 ] , p<0.0001 ) . 1398 ( 15 % ) women in the misoprostol group and 1002 ( 11 % ) in the oxytocin group required additional uterotonics ( 1.40 [ 1.29 - 1.51 ] , p<0.0001 ) . Misoprostol use was also associated with a significantly higher incidence of shivering ( 3.48 [ 3.15 - 3.84 ] ) and raised body temperature ( 7.17 [ 5.67 - 9.07 ] ) in the first hour after delivery . INTERPRETATION 10 IU oxytocin ( intravenous or intramuscular ) is preferable to 600 microg oral misoprostol in the active management of the third stage of labour in hospital setting s where active management is the norm Please cite this paper as : Mobeen N , Durocher J , Zuberi N , Jahan N , Blum J , Wasim S , Walraven G , Hatcher J. Administration of misoprostol by trained traditional birth attendants to prevent  postpartum haemorrhage in homebirths in Pakistan : a r and omised placebo‐controlled trial . BJOG 2011;118:353–361 OBJECTIVE To study whether paramedical workers from rural primary health centers in India are able to administer oral misoprostol and actively manage the third stage of labor to prevent postpartum hemorrhage ( PPH ) . METHOD Cluster r and omization was used to enroll 1200 women at 30 peripheral health centers from 5 states in India , 600 forming the study 's intervention group ( active management of the third stage of labor with 600 mug of oral misoprostol )  and 600 forming the comparison group ( in which the current government guidelines for the prevention of PPH were followed ) . The primary outcome was blood loss after delivery , which was measured using a calibrated blood collection drape . RESULTS Age , literacy level , occupation , and gravidity were similar in the 2 groups . More than 70 % of women in both groups had moderate anemia ( hemoglobin level < 10 g/dL ) . Paramedical workers followed instructions in almost all deliveries in the intervention group ( 99 % ) . There was a significant reduction in duration of the third stage of labor ( 7.9 + /- 4.2 min vs. 10.9 + /- 4.3 min ; p < .001 ) and median blood loss after delivery ( 100 mL vs. 200 mL ; p < .001 ) in the intervention group . Overall , a low incidence of PPH was observed ( < 1 % ) in both groups . A greater number of women had moderate to severe shivering ( 12.7 % vs. 0.5 % ) and a temperature higher than 38 degrees C ( 9.7 % vs. 4.3 % ) in the intervention group , which was statistically significant . CONCLUSION Simple interventions can be easily implemented in rural health care setting s to reduce the blood loss during labor . This finding has significant implication s for developing countries , in which the prevalence of anemia is high Objectives To evaluate the observer accuracy and intra-observer test – retest reliability of visual estimation of  blood loss  by midwives and obstetricians . Methods This was a prospect i ve , single-blinded observational study conducted at a London teaching hospital . The accuracy of visually estimating five maternity pads  that had been soaked with 25 , 50 , 100 , 150 and 200 ml of blood was assessed . The reproducibility in estimating the same volume ( two sets of pads soaked with 50 , 100 , 150 and 200 ml of blood r and omly placed at separate stations ) was evaluated by asking participants to visually estimate these volumes . Results Although there is a tendency to overestimate , the mean percentage difference ( estimated – actual volumes ) was not significantly different among consultants , trainees and midwives . Visual estimations were especially inaccurate with smaller volumes , which could be overestimated by up to 540 % . Test – retest reliability was poor for the larger volumes but statistically acceptable for the smaller volumes , although the difference between the two estimates of the same volume could be as much as 300 % . Conclusions Visual estimations were inaccurate by health-care professionals who have a tendency to overestimate . Experience did not appear to have a confounding effect on accuracy . Further training in visual assessment skills is necessary in order to improve the clinicians ’ estimation Objective . To investigate the side effects of 600 μg oral misoprostol given for the mother and the newborn to prevent postpartum hemorrhage ( PPH ) . Methods . One thous and six hundred twenty women delivering at home or subcentres in rural India were r and omised to receive misoprostol or placebo in the third stage of labour . Women were evaluated for shivering , fever , nausea , vomiting and diarrhea at 2 and 24 h postpartum . Newborns were evaluated within 24 h for diarrhea , vomiting and fever . Symptoms were grade d as absent , mild-to-moderate or severe . Results . Women who received misoprostol had a significantly greater incidence of shivering ( 52%vs . 17 % , p < 0.001 ) and fever ( 4.2%vs . 1.1 % , p < 0.001 ) at 2 h postpartum compared with women who received placebo . At 24 h , women in the misoprostol  group experienced significantly more shivering ( 4.6%vs . 1.4 % , p < 0.001 ) and fever ( 1.4%vs . 0.4 % , p < 0.03 ) . There were no differences in nausea , vomiting or diarrhea between the two groups . There were no differences in the incidence of vomiting , diarrhea or fever for newborns . Conclusions . Misoprostol is associated with a significant increase in postpartum maternal shivering and fever with no side effects for the newborn . Given its proven efficacy for the prevention of PPH , the benefits of misoprostol are greater than the associated risks OBJECTIVE To examine the effect of supplemental prenatal folic acid , folic acid-iron , folic acid-iron-zinc , and multiple micronutrients on  maternal morbidity in rural Nepal . METHODS A cluster-r and omized double-masked controlled trial of pregnant women who received daily supplements from early pregnancy through 3 months post partum as per the treatment allocation . Women were interviewed at birth about labor and delivery complications and for 9 days post partum to obtain 24-hour histories of morbidity . RESULTS A total of 3986 ( 97.3 % ) women completed an interview regarding labor and delivery ; morbidity history was available for 3564 ( 87.0 % ) women .  Folic acid-iron reduced the risk of postpartum hemorrhage ( relative risk [ RR ] 0.59 ; 95 % confidence interval [ CI ] 0.35 - 0.98 ) . Risk of dysfunctional labor increased with multiple micronutrient supplement 
    Output:
    
There is no evidence from r and omised or quasi-r and omised trials on the benefits or risks of a strategy of advance misoprostol distribution for PPH prevention or treatment in non-facility births .