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International survey of the active management of the 3 rd stage of labor: Results from Ethiopia,Tanzania & Uganda. 9 July, 2008 AED, Washington, DC Holley Stewart. Acknowledgements. USAID Bureaus for Global Health, for Africa and for East Africa Africa’s Health in 2010 and SARA at AED

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

9 July, 2008AED, Washington, DC

Holley Stewart


  • USAID Bureaus for Global Health, for Africa and for East Africa

  • Africa’s 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

The Lifetime Risk of Maternal Death in Africa is Staggering





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

Causes of maternal deaths in africa
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.


What is amtsl the icm figo 2003 joint statement
What is AMTSL: The ICM/FIGO 2003 Joint Statement

  • Prophylactic administration of a uterotonic drug

  • Controlled cord traction (CCT)

  • Uterine Massage

Benefits of amtsl
Benefits of AMTSL

  • Uterine atony accounts for 70-90% of all PPH cases

  • AMTSL reduces:

    • incidence of PPH by 60%

    • quantity of blood loss—thereby 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)

Rationale and objectives for survey
Rationale and Objectivesfor 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

Components of the survey re: Use of AMTSL



Influence of










In hospital



in hospital

Presence In



“Champions” for

Use of AMTSL




(per ICM/





to use



Skills in






Sufficient availability

of oxytocics,


syringe on site







at hospital



included on


Drug List


drug of


Specific research questions
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?

To achieve objectives 5 types of data collection are required
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)

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

Policy: National level Essential Drug List (EDL), Standard Treatment Guidelines (STG) and Curriculum

Two definitions of uterotonic drug use
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

Quality of Care: Percent distribution of the timing of the administration of uterotonic drugs, Tanzania

Potentially harmful practices tanzania
Potentially harmful practices, Tanzania administration of uterotonic drugs, Tanzania

Qualitative findings administration of uterotonic drugs, Tanzania

Factors identified as barriers to amtsl use
Factors identified as barriers to AMTSL use of AMTSL, Ethiopia

  • 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

Tbas and mx of the 3rd stage of labor
TBAs and Mx of the 3rd Stage of Labor of AMTSL, Ethiopia

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)

Pph according to tbas uganda
PPH according to TBAs (Uganda) of AMTSL, Ethiopia

  • 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

Constraints tbas face in case of pph
Constraints TBAs face in case of PPH of AMTSL, Ethiopia

  • 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

Community involvement in pph prevention mx
Community involvement in PPH prevention/MX of AMTSL, Ethiopia

  • 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

Role of communities from h w perspective
Role of communities from H/W perspective of AMTSL, Ethiopia

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

Conclusions of AMTSL, Ethiopia

  • 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.

Recommendations of AMTSL, Ethiopia

  • 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

Next steps
Next steps of AMTSL, Ethiopia

  • 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

Thank you
Thank you of AMTSL, Ethiopia