***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND Active management of the third stage of labour reduces the risk of  post-partum haemorrhage . We aim ed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage . METHODS We did a multicentre , non-inferiority , r and omised controlled trial in 16 hospitals and two primary health-care centres in Argentina , Egypt , India , Kenya , the Philippines , South Africa , Thail and , and Ug and a. Women expecting to deliver singleton babies vaginally ( ie , not planned caesarean section ) were r and omly assigned ( in a 1:1 ratio ) with a central ly generated allocation sequence , stratified by country , to placental delivery with gravity and maternal effort ( simplified package ) or controlled cord traction applied immediately after uterine contraction and cord clamping ( full package ) . After r and omisation , allocation could not be concealed from investigators , participants , or assessors . Oxytocin 10 IU was administered immediately after birth with cord clamping after 1 - 3 min . Uterine massage was done after placental delivery according to local policy . The primary ( non-inferiority ) outcome was blood loss of 1000 mL or more ( severe haemorrhage ) . The non-inferiority margin for the risk ratio was 1·3 . Analysis was by modified intention-to-treat , excluding women who had emergency caesarean sections . This trial is registered with the Australian and New Zeal and Clinical Trials Registry , ACTRN 12608000434392 . FINDINGS Between June 1 , 2009 , and Oct 30 , 2010 , 12,227 women were r and omly assigned to the simplified package group and 12,163 to the full package group . After exclusion of women who had emergency caesarean sections , 11,861 were in the simplified package group and 11,820 were in the full package group . The primary outcome of blood loss of 1000 mL or more had a risk ratio of 1·09 ( 95 % CI 0·91 - 1·31 ) and the upper 95 % CI limit crossed the pre-stated non-inferiority margin . One case of uterine inversion occurred in the full package group . Other adverse events were haemorrhage-related . INTERPRETATION Although the hypothesis of non-inferiority was not met , omission of controlled cord traction has very little effect on the risk of severe haemorrhage . Scaling up of haemorrhage prevention programmes for non-hospital setting s can safely focus on use of oxytocin . FUNDING United States Agency for International Development and UN Development Programme/UN Population Fund/WHO/World Bank Special Programme of Research , Development and Research Training in Human Reproduction , Department of Reproductive Health and Research 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 Cynthia Stanton and colleagues conducted a cluster-r and omized controlled trial in rural Ghana to assess whether oxytocin given by injection by community health officers at home births was a feasible and safe option in preventing postpartum hemorrhage . Please see later in the article for the Editors ' Background Postpartum hemorrhage ( PPH ) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries . PPH can be prevented by active management of the third stage of labor ( AMTSL ) , a series of steps recommended by the World Health Organization to be performed by skilled birth attendants ( SBAs ) . Task shifting in the AMTSL step of uterotonic drugs administration to community health workers , traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages . The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self- assessment . Methods and Design The study is an individual-level two-arm non-inferiority r and omized controlled trial ( RCT ) . A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra , Ghana . Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self- assessment of uterine tonus will be eligible for inclusion . Women with an increased risk for PPH will be excluded . Women will be r and omized to uterine tone assessment by a skilled birth attendant ( midwife ) or uterine tone self- assessment ( with the safety back-up of a midwife present in case of PPH or uterine atony ) . Postpartum blood loss will be measured through weighing of disposable mats . The main study endpoints are PPH ( ≥500 ml blood loss ) , severe PPH ( ≥1000 ml blood loss ) , mean blood loss , and routine maternal and neonatal outcomes . Participants and caregivers will not be blinded given the nature of the intervention . Discussion A reduction of PPH-related maternal mortality requires full implementation of AMTSL . Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in ( clinical ) setting s where SBAs capacity is constrained . Trial registration Clinical trials.gov : NCT02223806 , registration August 2014 . PACTR : PACTR201402000736158 , registration July 2014 . University of Ghana , Medical School Ethical and Protocol Review Committee : MS-Et/M.8–P4.1/2014 - Aims : Evidence exists about prevention of postpartum haemorrhage ( PPH ) by oral administration of misoprostol in low-income countries , but effectiveness of prevention by lay community health workers ( CHW ) is not sufficient . This study aim ed to investigate whether a single dose ( 400 µg ) of oral misoprostol could prevent PPH in a community home-birth setting and to assess its acceptability and feasibility among rural Bangladeshi women . Methods : This quasi-experimental trial was conducted among 2,017 rural women who had home deliveries between November 2009 and February 2010 in two rural districts of northern Bangladesh . In the intervention district 1,009 women received 400 µg of misoprostol immediately after giving birth by the lay CHWs , and in the control district 1,008 women were followed after giving birth with no specific intervention against PPH . Primary PPH ( within 24 hours ) was measured by women 's self-reported subjective measures of the normality of blood loss using the ‘ cultural consensus model . ’ Baseline data provided socio-economic , reproductive , obstetric , and bleeding disorder information . Findings : The incidence of primary PPH was found to be lower in the intervention group ( 1.6 % ) than the control group ( 6.2 % ) ( p<0.001 ) . Misoprostol provided 81 % protection ( RR : 0.19 ; 95 % CI : 0.08–0.48 ) against developing primary PPH . The proportion of retained and manually removed placentae was found to be higher in the control group compared to the intervention group . Women in the control group were more likely to need an emergency referral to a higher level facility and blood transfusion than the intervention group . Unexpectedly few women experienced transient side effects  of misoprostol . Eighty-seven percent of the women were willing to use the drug in future pregnancy and would recommend to other pregnant women . Conclusion : Community-based distribution of oral misoprostol ( 400 µg ) by CHW appeared to be effective , safe , acceptable , and feasible in reducing the incidence of PPH in rural areas of Bangladesh . This strategy should be scaled up across the country where access to skilled attendance is limited BACKGROUND Postpartum haemorrhage is a major cause of maternal mortality in the developing world . Although effective methods for prevention and treatment of such haemorrhage exist -- such as the uterotonic drug oxytocin -- most are not feasible in re source -poor setting s where many births occur at home . We aim ed to investigate whether oral misoprostol , a potential alternative to oxytocin , could prevent postpartum haemorrhage in a community home-birth setting . METHODS In a placebo-controlled trial undertaken between September , 2002 , and December , 2005 , 1620 women in rural India were r and omised to receive oral misoprostol  ( n=812 ) or placebo ( n=808 ) after delivery . 25 auxiliary nurse midwives undertook the deliveries , administered the study drug , and measured blood loss . The primary outcome was the incidence of acute postpartum haemorrhage ( defined as > or = 500 mL bleeding ) within 2 h of delivery . Analysis 
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Conclusion Task shifting of AMTSL has thus far been evaluated for administration of uterotonics ( misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives ) and result ed in reduction of PPH , high rates of appropriate use and satisfaction among users .