El Salvador - Active Management of the Third Stage of Labor - POPPHI

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1. BackgroundPostpartum hemorrhage is one of the world’s leading causes of maternal mortality. Activemanagement of the third stage of labor (AMTSL) is a feasible and inexpensive intervention thatcan help save thousands of women’s lives.AMTSL involves three main components:• The use of a uterotonic agent within one minute following the birth of the baby.• Delivery of the placenta with controlled cord traction.• Massage of the uterus after delivery of the placenta.This definition is supported by the International Federation of Gynecology and Obstetrics(FIGO), the International Confederation of Midwives (ICM) 1 and the World Health Organization(WHO) 2 . This definition differs from the original research protocol in the Bristol 3 andHinchingbrooke 4 trials because the original protocols include immediate cord clamping and didnot include massage of the uterus. The FIGO/ICM joint statement 1 and Managing Complicationsin Pregnancy and Childbirth, 5 produced by WHO, do not include immediate cord clamping.Clinical trials in developed countries have shown that the use of AMTSL significantly reducespostpartum hemorrhage, in contrast to physiologic management of the third stage of labor whereoxytocic drugs are not used and the placenta separates spontaneously and is delivered by gravityand maternal effort. When compared to AMTSL, the use of physiologic management has ahigher rate of postpartum hemorrhage and severe postpartum hemorrhage, greater need for bloodtransfusion and therapeutic oxytocics, and a longer duration of the third stage of labor. ACochrane review of these trials concludes by recommending AMTSL for all women deliveringin a hospital and anticipating the vaginal birth of a single infant. 6Endorsement and use of AMTSLBased on this body of evidence, ICM and FIGO issued a joint statement in November 2003stating that every woman should be offered AMTSL “as a means of reducing the incidence ofpostpartum hemorrhage due to uterine atony.” 1 The inclusion of AMTSL in the WHO evidencebasedmanual Managing Complications in Pregnancy and Childbirth also attests to theinternational acceptance of this practice as the standard of care. 5Evidence regarding adoption of this practice, however, is limited. Evaluations of donor-fundedprojects incorporating AMTSL tend to be limited to reporting on the numbers of providerstrained and the percent achieving competence following training. Apart from anecdotalinformation, a 2003 article by the Global Network for Perinatal and Reproductive Health (Festinet al.) 7 offers a limited glimpse into the adoption of this practice. Their results, based on anevaluation of 15 university-based referral obstetric centers in developed and developingcountries, show substantial variation between and within hospitals. Overall, only 25 percent ofobserved deliveries included AMTSL. Only one (in Dublin, Ireland) consistently used all threecomponents of the practice. Variation in the prophylactic use of oxytocic drugs ranged from 0 to100 percent; the practice of controlled cord traction ranged from 13 to 100 percent; and thenumber of women who received additional doses of oxytocin during the third stage of labor4
anged from 5 to 100 percent. There is insufficient evidence for drawing conclusions about theeffectiveness of this practice in its altered states. These results do suggest, however, that the useof AMTSL is quite low and, where it is practiced, the definition varies within and betweencountries. 7Since 1997, the Safe Motherhood Initiative has stated that maternal mortality is an issue of healthinfrastructure. AMTSL is a highly measurable, evidence-based, life-saving aspect of this healthinfrastructure. Given that postpartum hemorrhage is a leading cause of maternal death in manycountries with high maternal mortality, there is an important and urgent need for informationfrom these countries on current practices regarding AMTSL.About this studyAs a complement to work undertaken by the Global Network for Perinatal and ReproductiveHealth, these surveys have been carried out to advance the understanding of current AMTSLpractices in East and West Africa (Ethiopia, Tanzania, and Benin), Asia (Indonesia), and CentralAmerica (El Salvador, Guatemala, Honduras, and Nicaragua). Surveys are underway in Ugandaand Ghana. This report focuses on El Salvador, where maternal mortality was estimated at 71 per100,000 live births in 2006, according to the Maternal Mortality Baseline Study, 8 ,withhypertensive disease of pregnancy and hemorrhage as the two leading causes of maternal death(representing 42 percent and 38 percent of all maternal deaths, respectively). As of 2003, thepercent of births delivered in public health facilities was 54 percent, 12 percent were in socialsecurity facilities, and only three percent occurred in private sector institutions, 9 suggesting thatmore than two-thirds of births that take place in facilities could potentially benefit fromAMTSL.The ten country AMTSL surveys focus on policy, provider-related factors, and supplies andlogistics. When viewed together, these components provide important insights on routine use ofAMTSL (Figure 1.1).PolicyAt the national level, a number of influences determine the priority given to AMTSL. Forexample, given that AMTSL has been a standard of care in the United Kingdom (UK) for manyyears, some researchers have hypothesized that AMTSL is more common in former UK coloniesand among providers who have trained in the UK. Likewise, effective leaders from national orinternational agencies may have been able to influence national policies, the inclusion of drugs inthe essential drug list and country formulary, and health provider education regarding AMTSL.In turn, such training may influence facility-based policies and behavioral expectations.Provider-related factorsThe knowledge and skills required to perform AMTSL are essential for routine use of thepractice. Provider motivation, which is influenced by facility-based behavioral expectations, alsois key.5
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Page 6 and 7: AcronymsAMTSLActive management of t
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El Salvador - Active Management of the Third Stage of Labor - POPPHI

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