Table 2 Barriers or gaps identified from included articles
S.No | Health System Building Blocks/Thematic Areas | Sub-Themes for identified gaps or barriers | Number of studies identified similar gap/barriers |
|---|---|---|---|
1 | Barriers or gaps related to Leadership, governance, Guidelines and Policy related (12 Studies) | Lack of national policies and guidelines for MPAC or PPH | 2 |
No Registration of misoprostol Specific for PAC or PPH | 3 | ||
Fear and apprehensions related to its use | 3 | ||
Misoprostol not included in National list of essential medicines | 1 | ||
legal restrictions that only permits pregnancy termination to save life of mother | 1 | ||
No or Less Preference to misoprostol | 1 | ||
Lack of integration of misoprostol with Basic package of health services/ health care resources | 2 | ||
Poorly developed Commodity security strategies. | 1 | ||
Rudimentary or absent Transportation and communication system. | 2 | ||
Lack of ability to implement and monitor implementation and current practices. | 1 | ||
Lack of trust between clinicians and policy makers | 1 | ||
Gaps in pre-service medical and midwifery education program curriculum. | 1 | ||
Technical inconsistencies and ambiguity in guidelines and protocols- incomplete and out dated. | 2 | ||
Lack of communication or awareness of existing policy | 2 | ||
2 | Barriers or gaps related to Health Service Delivery, and availability and access to essential medicine (10 Studies) | Lack of Access to misoprostol | 2 |
PAC services not available | 1 | ||
Issues related to inconsistencies in supplies/ fragmented supply chain and distribution | 8 | ||
Lack of Supervision/Monitoring capacity | 1 | ||
Reduced institutional delivery | 1 | ||
Lack of provider preference of Medical Abortion using misoprostol | 1 | ||
3 | Barriers or gaps related to Health Workforce (14 studies) | Lack of Knowledge & Skills (Technical & non –technical) of providers | 3 |
Lack of training and training capacity of providers | 2 | ||
scarcity of staff or inadequate staffing (SBA’s, TBA’s, CHW’s) | 6 | ||
Fear, apprehensions and doubt related to misoprostol | 5 | ||
Negative or Judgmental attitude of providers | 1 | ||
Limited scope of practice of midwifes | 1 | ||
Lack of awareness/Clarity of the guidelines/evidence. | 4 | ||
Lack of communication/inter-professional collaboration | 2 | ||
Lack of Motivation among provider | 1 | ||
4. | Issues related to Community perception, Knowledge and preference: (8 Studies) | Lack of acceptability and negative attitude due to stigma associated due to its abortion inducing properties | 3 |
Hindrance from relatives in taking misoprostol | 1 | ||
Lack of community awareness and knowledge for misoprostol | 2 | ||
Lack of health seeking behavior | 2 | ||
Lack of preference to Medical Abortion using misoprostol | 1 | ||
Lack of access to misoprostol due socio-economic, Ethnic and cultural barriers | 2 | ||
Patients’ lack of trust of lower-cadre health workers | 1 | ||
Disparities in service utilization between rural and urban | 1 | ||
5 | Barriers or gaps related to Health information system (1 Study) | Lack of national reporting on HMIS on use of uterotonics. | 1 |
Gaps in inclusion of maternal health indicators in national data | 1 | ||
6 | Barriers or gaps related to cost of medicine (2 Studies) | Paying for medicine is a bottle neck to improve coverage despite to be inexpensive | 2 |
Financial constraints in term of training TBA’s, cost of drug | 1 |