For decades, oxytocin and ergometrine have been the treatments of choice for postpartum haemorrhage caused by ineffective uterine contraction (uterine atony). Although both drugs are effective, oxytocin is more widely used because it has fewer side effects and can be used safely in women with hypertension and pre-eclampsia. However, in their usual form both drugs can be given only by injection, and both require refrigeration. They are therefore of limited availability and benefit in low resource settings, especially in rural areas. Misoprostol, an orally active and heat stable prostaglandin E₁ analogue, has therefore emerged as a popular alternative. Until a year ago, there was limited evidence for its ability to treat postpartum haemorrhage.1 2 However proponents have argued that it should be “parachuted in” to high risk areas despite the lack of evidence.3 This, in part, has been responsible for its inclusion in multiple guidelines on postpartum haemorrhage both in rich and poor settings (despite the call in a systematic review for more studies2).

Since the systematic review of the treatment of postpartum haemorrhage was last updated in 2007,2 three large double blind randomised trials have been published.4 5 6 Few research …