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

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2. MethodsThis study is part of a multiple country study to assess use of AMTSL among facility-baseddeliveries. The development of the study was a participatory process which involved an initialexpert meeting in Washington, DC in May 2005 to elicit feedback on the draft protocol, aplanning workshop in Nairobi, Kenya in July 2005 for the first two country studies, and planningworkshops in Panama and El Salvador in January and February 2006 with representatives of theCentral American Federation of the Associations and Societies of Gynecologists andObstetricians (COMIN-FECASOG) to further refine the protocol and questionnaires before thebeginning of data collection in El Salvador, Guatemala, Honduras, and Nicaragua.In the case of El Salvador, prior to data collection the study protocol was submitted to andapproved by the Ministry of Public Health and Social Work (MSPAS) of El Salvador. Followingthis approval, the protocol was submitted to the Committee for Human Research at the JohnsHopkins Bloomberg School of Public Health in Baltimore, Maryland. The Johns HopkinsCommittee for Human Research judged the protocol to be exempt from review for humansubjects research because no personal identifiers were collected and because the proceduresobserved were all standards of care. They did specify that informed consent must be obtained atadmission to the health facility and not in the labor and delivery room. In this study, informedconsent consisted of describing the study and requesting participation from women at admissionto the health facility. PATH deferred to Johns Hopkins for their review. The MSPAS did notconsider review by local ethics committees to be necessary.Questionnaire developmentThe processes and outcomes identified in the conceptual framework for the study (Figure 1.1)determined the content and number of questionnaires required for the study. In all, threequestionnaires were developed:• National-level questionnaire. This questionnaire was designed to capture the policyenvironment for AMTSL. It includes questions regarding the content of the essential druglist, STGs, pre-service training curricula, procurement practices for uterotonic drugs, andstorage conditions for uterotonic drugs at the central pharmaceutical storage site. Completingthis questionnaire required document review, interviews with MOH staff and otherpolicymakers, and a visit to the pharmaceutical storage site. The study’s country coordinatorconducted the national-level data collection.• Facility-level questionnaire. This questionnaire was designed to capture the policyenvironment at the individual facility level. It includes questions on the availability ofclinical guidelines in the facility, provision of in-service training on AMTSL, the cost ofuterotonic drugs to the facility and to patients, access to the facility pharmacy, procurementpractices for uterotonic drugs, and supply and storage conditions at the facility. Completingthis questionnaire required interviews with hospital administrators and the pharmacist and avisit to the facility pharmacy. One of the two members of the data-collection team completedthis questionnaire during his/her visit to selected facilities.• Observation-of-deliveries questionnaire. This questionnaire was designed to documentprovider practices during the third stage of labor and the first 30 minutes of the fourth stage8
of labor for all vaginal deliveries. It was based on the questionnaire used in the study byFestin et al. 7 The questionnaire documents the availability of uterotonic drugs and othersupplies in the labor and delivery unit as well as storage conditions for uterotonic drugs.Members of the data collection team completed the questionnaire based on their observationof deliveries during the visit to selected facilities.Training for data collectorsA group of eight data collectors was trained to observe deliveries in selected health facilities. Theteam was made up of eight graduate nurses. The country coordinator and the Regionalrepresentative COMIN-FECASOG were in charge of observer training. A three-day trainingsession (July 22 to 24, 2006) was held in San Salvador, El Salvador. The training involvedlectures, a visual CD-ROM presentation on AMTSL, demonstrations and practice using ananatomical model, and field practice that provided an opportunity to pretest the questionnairesand to supervise the observers.Sample DesignA nationally-representative sample of approximately 200 facility-based deliveries was requiredto meet the aims of the study described in the methodology section. Sample size calculationsassumed a prevalence of 30 percent, a 90 percent response rate, and a design effect of two. Dueto budgetary and logistical concerns, the sample was restricted to public facilities. El Salvadorhas 28 national public health maternity hospitals, which are distributed throughout all fiveregions of the country. All of these public maternity hospitals were included in the sample.One team of two data collectors visited each health facility for two days. Each data collectorobserved all vaginal deliveries during an eight-hour period during the first and second day, thusensuring observations over a 16-hour period per day for two days. A total of 190 deliveries wereobserved across 28 facilities. In two facilities there were no deliveries during the two-day periodof observation.To ensure a nationally-representative sample of deliveries, weights were calculated for useduring analysis. When the number of deliveries observed in a facility over the two-day period isnot proportional to the reported annual number of deliveries in that facility, weights will correctfor this over- or under-representation. The weighted number of observed deliveries is 190. All ofthe tables in this report show weighted values for n.FieldworkThe MSPAS sent a memorandum to the directors of the 28 hospitals authorizing the study. Thestudy coordinator provided a copy of the memorandum to the observers as letters of introductionfor each facility. Four teams of two data collectors carried out fieldwork from July 28 to August12, 2006. The study coordinator made one quality-control visit to hospitals in each regional zone.9
Page 1 and 2: ActiveManagementof the ThirdStage o
Page 3: Federation of Gynecology and Obstet
Page 6 and 7: AcronymsAMTSLActive management of t
Page 8 and 9: palpation to assess the need for co
Page 10 and 11: 1. BackgroundPostpartum hemorrhage
Page 12 and 13: Supplies and logisticsThe sufficien
Page 16 and 17: Data entry and analysisThe study te
Page 18: Table 3.1. Availability and storage
Page 21 and 22: ased on current consumption of oxyt
Page 23 and 24: 4. Findings regarding the managemen
Page 25 and 26: delivery of the placenta, followed
Page 27 and 28: (38 versus 30 percent, and these di
Page 29 and 30: With massage immediately after deli
Page 31 and 32: Duration of the third stage of labo
Page 33 and 34: 5. Conclusions and recommendationsT
Page 35 and 36: definition described in the clinica

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