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International survey of the active management of the 3rd stage of labor: Results from Ethiopia,Tanzania

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Title: International survey of the active management of the 3rd stage of labor: Results from Ethiopia,Tanzania


1
International survey of the active management of
the 3rd stage of labor Results from
Ethiopia,Tanzania Uganda
9 July, 2008 AED, Washington, DC Holley Stewart
2
Acknowledgements
  • USAID Bureaus for Global Health, for Africa and
    for East Africa
  • Africas Health in 2010 and SARA at AED
  • Prevention of Postpartum Hemorrhage Initiative
    (POPPHI) at PATH-DC
  • East Central and Southern African Health
    Community Secretariat (ECSA)
  • Ministries of Health Ethiopia, Tanzania, and
    Uganda

3
The Lifetime Risk of Maternal Death in Africa is
Staggering
12,800
194
116
1160
The chance of a woman dying as a result of
pregnancy is 150 x greater in SSA than it is in
the US
Source WHO, UNICEF and UNFPA. Maternal
Mortality in 2000 Lancet Neonatal Survival
Series, 2005
4
Causes of maternal deaths in Africa
Khan S et al. WHO analysis of causes of maternal
death a systematic review. The Lancet, 2006,
367 1066-1074.
4
5
What is AMTSL The ICM/FIGO 2003 Joint Statement
  • Prophylactic administration of a uterotonic drug
  • Controlled cord traction (CCT)
  • Uterine Massage

6
Benefits of AMTSL
  • Uterine atony accounts for 70-90 of all PPH
    cases
  • AMTSL reduces
  • incidence of PPH by 60
  • quantity of blood lossthereby decreasing
    incidence and severity of anemia
  • emergencies and related cost, transport
  • the use of blood transfusion

Active Management Physiologic Management
OR and 95 CI Bristol Trial 50/846
(5.9) 152/849 (17.9)
3.13 (2.3-4.2) Hinchingbrooke Trial 51/748
(6.8) 126/764 (16.5) 2.42
(1.78-3.3)
7
Rationale and Objectives for Survey
  • Part of a global effort to provide stakeholders
    with information that
  • Describes current practices regarding AMTSL and
    identifies major barriers to its use
  • Can be used for the development of interventions
    to improve adoption and implementation of the
    practice of AMTSL
  • Can inform advocacy for promotion of skilled
    birth attendance

8
Components of the survey re Use of AMTSL
Historical Precedent, Influence
of Leader, WHO, In-service training
National guidelines
Policy
AMTSL protocol In hospital
Expected behavior in hospital
Presence In Pre-service training
Champions for Use of AMTSL
Woman receives AMTSL (per ICM/ FIGO Statement)
Implementation
Motivation to use
Skills in AMTSL
Know- ledge
Provider
Proper storage
Logistics
Sufficient availability of oxytocics, needles, syr
inge on site
Amount procured
Transport issues
Procure- ment at hospital level
Uterotonics included on Essential Drug
List (oxytocin drug of choice)
9
Specific research questions
  • Is AMTSL formally promoted in the Standard
    Treatment Guidelines (STGs) in each country?
  • For what proportion of deliveries is AMTSL used
    at a national level?
  • How is the need for AMTSL drugs quantified at
    national and facility levels?
  • What drug is used?
  • At the facility level, is enough oxytocin
    available to allow for routine use of AMTSL?
  • What are the major barriers to correct use of
    AMTSL?

10
To achieve objectives, 5 types of data
collection are required
  • Observation of deliveries
  • Structured interviews (national level data)
  • Assessment visits (pharmaceutical storage sites)
  • Document review
  • Structured interviews (health professionals
    responsible for delivery in selected facilities,
    community leaders, TBAs women who recently
    delivered)

11
METHODS Selection Criteria
  • Nationally representative sample of (public)
    facility-based, vaginal deliveries
  • Facilities (minimum of 2-3 deliveries a day)
  • Difficult to select health centers or hospitals
    with low volume of deliveries
  • Sample size 23-30 facilities and 200 deliveries
  • Samples were weighted for analysis
  • Thus far, there have been very few visits to
    private facilities in Uganda only
  • Health care providers responsible for managing
    deliveries
  • Consent

12
Survey countries maternal health profiles
Ethiopia Tanzania Uganda
Total pop 70M 39M 29M
Women Ages 15-49 25 23 21
TFR 5.4 5.7 6.7
MMR 850 770 880
Institutional deliveries 12 37 42
13
Methods - Data Collection
Ethiopia Tanzania Uganda
of data collectors (dr/midwives) 8 12 14
of days of training of weeks of data collection 3 days 3 weeks 3 days 5-6 weeks 3 days
of facilities selected 23 29 48
of vaginal deliveries observed 286 251 259
of days in each facility 2.5 2.5 2
of providers interviewed 69 106 60
14
Selected Results
15
Availability of uteronics related issues
Issue Ethiopia (n23 facilities) Tanzania (n29) Uganda (n48)
Availability Acceptable Acceptable Acceptable
Storage 86 75 65
Stocks (months) 6.5 2 1-3
Quantification Historical consumption Historical consumption Historical consumption
Selection No clear guidelines No clear guidelines No clear guidelines
Purchase price (US) Oxytocin Ergometrine 0.2 0.1 0.19 0.16 0.11-0.19 0.8 to 0.19
Point Source Freegt90 Private lt10 Freegt90 Private lt10 Free 79 Private 21
Procurement Tender based on known suppliers Tender based on known suppliers Tender based on known suppliers
Quality assurance Standard procedures exist Standard procedures exist Standard procedures exist
16
Policy National level Essential Drug List (EDL),
Standard Treatment Guidelines (STG) and Curriculum
Issue Ethiopia Tanzania Uganda
Registered uteronics Ergometrine, oxytocin, Syntometrine and misoprostol Ergometrine Oxytocin Ergo, oxy
Formularies in contradiction to current recommendations Ergometrine .5mg 1st line drug Oxytocin 5_IU 2nd line Oxy 10IU Ergo, 0.2mg
STG PPH not included A separate STG exists AMTSL is not specifically emphasized Stated in STGs conflicting re CCT
Restrictions Ergometrine no restrictions Oxytocin no restrictions except for induction augmentation Ergometrine no restrictions Oxytocin no restrictions except for induction augmentation Ergometrine no restrictions Oxytocin no restrictions except for induction augmentation
Pre-service curriculum For high risk group only Included uterine massage missing Not included
In-service curriculum No official material exists No official material exists No official material exists
In-service curriculum Included in MPS trainings LSS trainings LSS trainings (need updating)
17
Two definitions of uterotonic drug use
  • CORRECT USE Strict ICM/FIGO definition based on
    use of oxytocin (drug of choice), plus timing
    within 1 minute of delivery of fetus
  • ADEQUATE USE Less strict ICM/FIGO definition
    based on use of oxytocin (drug of choice), plus
    timing within 3 minutes of delivery of fetus
  • AMTSL includes uterotonic, controlled cord
    traction and uterine massage

18
Maternal Deaths and Correct Use of AMTSL
MMR Use of uterotonics during 3rd or 4th stage of labor Correct use of AMTSL
Ethiopia 850 100 29
Tanzania 770 97 7
Uganda 880 89.2 5.4
19
Use of AMTSL in Uganda
20
Quality of Care Percent distribution of the
timing of the administration of uterotonic drugs,
Tanzania
21
Potentially harmful practices, Tanzania
22
Qualitative findings
23
Percent of providers with knowledge on various
components of AMTSL Tanzania
24
Percent of providers making correct statements on
components of AMTSL, Ethiopia
25
Factors identified as barriers to AMTSL use
  • Knowledge gap
  • Providers poor understanding of steps/components
    of AMTSL.
  • Limited opportunity for in-service training
  • Lack of literature
  • Poor reading culture
  • lack of knowledge sharing
  • Staffing levels are low compared to clients load.
  • Difficult to provide massage every 15 mins for 2
    hrs.
  • Inadequate supplies
  • Fear of retained placenta and snapping of cord

26
TBAs and Mx of the 3rd Stage of Labor
  • TBAs physiologically manage the third stage of
    labor with
  • variations in the type of uterotonic drugs
    (cold drink, herbs)
  • method of Mx 3rd stage (fundal pressure to
    deliver placenta)

27
PPH according to TBAs (Uganda)
  • Definition of PPH more than one tumpeco (mug) or
    500ml.
  • Causes
  • full bladder
  • retained membranes
  • early or premature separation of the placenta
  • multi-parous women were more likely to bleed that
    prima gravida women

28
Constraints TBAs face in case of PPH
  • Lack of transport
  • Poor TBA relationships with health workers.
  • Lack of birth plan by the mothers
  • Pregnant women preference for TBA than a health
    unit
  • Lack of motivation little pay for the service

29
Community involvement in PPH prevention/MX
  • In Uganda more women deliver at home than in the
    health facility (58 vs 42).
  • Distance from the communities to the health
    units,
  • Inadequate facilities in the health units,
  • Health workers reception,
  • Presence of TBAs in the health facility etc
  • In case of obstetric emergency like PPH, the
    communities have to look for transport
  • Nakaseke - Motor Bike
  • Arua Civil servant has personal car
  • Mbale and Kabale Bicycle ambulance or taxi

30
Role of communities from H/W perspective
  • Communities can play a leading role in
  • encouraging mothers to deliver at the hospitals
    and health centres
  • transport a woman to hospital
  • Sensitize stakeholders about consequences of home
    birth

31
Conclusions
  • PPH is most common cause of maternal deaths
  • -Highly preventable
  • AMTSL is a proven intervention to reduce PPH,
    hence maternal mortality
  • -Seldom practiced, and when practiced, usually
    incorrectly
  • Since AMTSL is effective, it is imperative to
    promote it as a way to improve EmOC.

32
Recommendations
  • Revise the national STG formularies
  • Include AMTSL in pre-service training
    curriculum/orientation
  • Low cost training approaches
  • Improve drug management
  • Monitoring supervision
  • Prioritize interventions with AMTSL
  • High level advocacy on prevention of PPH
  • Develop standard in-service training material on
    RH/FP

33
Next steps
  • ECSA with TA from Africa 2010 will work with
    governments of Ethiopia, Tanzania and Uganda to
    update the STGs as necessary and train providers
    to systematically provide AMTSL
  • Results from all 10 countries will be presented
    at the FIGO conference in Kuala Lumpur in
    November 2008 (Benin, Ghana, Ethiopia, Tanzania,
    Uganda, Indonesia, El Salvador, Honduras,
    Guatemala and Nicaragua)
  • Survey tools are available for use by others on
    http//www.pphprevention.org/Surveytools.php

34
Thank you
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