Use of Active Management of the Third Stage of Labor in Eleven - - PowerPoint PPT Presentation

Use of Active Management of the Third Stage of Labor in Eleven Developing Countries

Deborah Armbruster Senior Maternal and Newborn Health Advisor Bureau for Global Health, USAID Reality Check: Challenges and Innovations in Addressing the PPH Agenda Washington, DC January 25, 2011

Active Management of the Third Stage of Labor (AMTSL)

What is AMTSL?

• High impact, evidence-based

intervention – 2 seminal RCTs and many additional studies support evidence – Reduces postpartum hemorrhage (PPH) by up to 60%

• 3 components

– Administration of a uterotonic agent (oxytocin is the drug of choice) – Controlled cord traction – Uterine massage after delivery of the placenta

History and Focus on AMTSL

• 20 yrs of use in G. Britain

and Commonwealth

• Not used in US
• USAID created PPH

Initiative – Initial focus on AMTSL – Added community-based intervention with miso

• 4 country projects, POPPHI,

integration into MH projects

• Is on the global agenda;

many partners

0.3 3 3 5 5 7 7 16 17 29 32 75 20 40 60 80 100 Nicaragua El Salvador Ghana Uganda Honduras Guatemala Tanzania Bangladesh Benin Ethiopia Indonesia Percent National USAID‐Supported district

POPPHI Project Multi-Country Survey. http://www.pphprevention.org/briefs_newsletters.php

National coverage of AMTSL is low in all countries

With support, AMTSL coverage increased rapidly in Cirebon district

• f Indonesia

AMTSL national surveys in 11 countries – 2005-2010

95.6 92.6 97.6 60.0 86.7 95.6 100.0 99.7 22.8 6.7 29.0 2.6 7.1 4.5 0.3 31.8

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Benin Tanzania Ethiopia El Salvador Guatemala Honduras Nicaragua Indonesia % o f d eliveries Received uterotonic 3rd/4th stage AMTSL (1 min)

Percent of observed deliveries w/ uterotonic given during 3rd/4th stages of labor and correct use of AMTSL (1 mn)

79.2 87.6 72.0 62.0 88.3 38.7 54.0 36.4 23.5 31.6 6.1 10.2 77.8 77.8 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Benin Tanzania Ethiopia El Salvador Guatemala Honduras Nicaragua Indonesia % o f d e liv e rie s Immediate massage after delivery of baby Massage, plus palpation

NA NA

Percent of observed deliveries with uterine massage following delivery of placenta

Critical Elements for AMTSL Expansion

All women are

• ffered and

receive PPH prevention intervention Reduced PPH Reduced mortality

Drug logistics in place Appropriate amount of drugs procured, appropriately stored, & available for all births

LOGISTICS (DRUGS & SUPPLIES)

MIS & supervision system in place

MONITORING/SUPERVISION

Awareness & endorsement

• f national

expansion Policies, guidelines, protocols, standards in place

POLICY PROVIDER

Standardized pre- & in- service training Improved provider knowledge, skills & motivation

Lessons learned: AMTSL

• What is NOT so

effective in increasing use of AMTSL?

• ONLY changing policies
• ONLY training providers
• ONLY having drugs

available

• ONLY recording data and

monitoring

Lessons Learned: AMTSL

• Need creative and

alternative ways to:

• Increase the practice
• f AMTSL
• Ensure competence
• f providers
• Provide support &

supervision

• Ensure drugs are

available for AMTSL

• Record & collect

data

Think outside the box

• Try new innovations;

engage your local partners to create solutions

• Recognize the critical

importance of the combined efforts of the MOH and all groups within a country to scale-up AMTSL for impact

• Are we having an impact?

Are we saving lives? We need indicators, record keeping and data collection efforts to let us know.

Noteworthy News and Issues

• AMTSL trial ( WHO multi-centre (8)) will report

results in early March 2011. Could find that controlled cord traction not needed

• Oxytocin potency may be more of a concern

that previously thought – watch for new study results to come out soon

• Will that make oxytocin in Uniject with its TTI

more popular? Will this push for increased use

• f misoprostol?
• Miso is available, miso is being used… are

providers and the public properly educated on its use?

Thank you

Join us in Addis Ababa, Ethiopia Feb. 21-25

Africa Regional Meeting on Interventions for Impact in Essential Obstetric and Newborn Care