Table 1 Country health system contexts

Bangladesh

Located in South Asia, Bangladesh is the third most populous country in the region and one of the most densely populated countries in the world. A recent national survey reported the maternal mortality ratio in Bangladesh to be 196 deaths per 100,000 live births in 2016, with 31% due to haemorrhage (antepartum and postpartum) [13]. The public service delivery structure includes national, district, upazilla (sub-district), union and ward levels [14]. At the union level, union sub-centres and health and family welfare centres provide the first contact between the population and the health care system and a minority of these facilities offer normal delivery services [15]. At the upazilla level, maternal and child welfare centres and upazilla health complexes typically offer normal delivery services and some are equipped to provide caesarean section. Approximately one third of deliveries occur in a private facility and approximately one half of women give birth outside of a health facility [13]. The Government of Bangladesh has outlined a strategy to scale up misoprostol for the prevention of PPH outside of facilities through an advanced distribution model [16]. A 2015–2016 evaluation showed that community distribution of misoprostol had reached 17% of all births in Bangladesh at this stage of program roll out [13].

Ethiopia

Ethiopia is located in North-East Africa and, with a population of just over 94 million, it is the second most populous country in Africa. Maternal mortality has decreased substantially in the last decade, and most recent reports estimate a maternal mortality ratio of 422 [17]. The government is the main provider of health care services in the country through a three-tier system consisting of specialist hospitals, general hospitals and primary care units (composed of a network of primary hospitals, health centres and health posts). At the primary care level, emergency obstetric care services are available at some primary hospitals, while health centres provide delivery services and some are equipped to provide basic emergency obstetric care. Each health centre is connected to four health posts, which are staffed by two health extension workers (HEWs). This cadre provide a package of basic curative, promotive and preventative care at the health post or in the home. While national policy in Ethiopia permits use of misoprostol by HEWs, progress towards scale up beyond research areas is uncertain [18, 19]. The Ministry of Health has introduced integrated refresher in-service training to improve the skills of HEWs and to upgrade these health workers from HEW3 to HEW4 (which includes competencies to support skilled attendance at birth). Despite the conduct of pilot programs to explore the feasibility and acceptability of advanced distribution of misoprostol to pregnant women [18, 20], the government of Ethiopia has elected not to adopt this strategy into policy.