Overview of Study

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Overview of Study Management of the Third Stage
of Labor In Uganda
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Our ultimate goal

• Provide Ministry of Health/international partners
  the descriptive information needed to assess
  current practices regarding active management of
  the third stage of labor (AMTSL).
• Identify major barriers to its use.
• In order to
• Develop interventions to improve adoption and
  implementation of the practice of AMTSL.
• (Secondary aim) Produce public domain tools and a
  methodology that could be employed by others in
  the future to document change.

3
International Confederation of Midwives
(ICM)/International Federation of Gynecology and
Obstetrics (FIGO) definition of AMTSL

• Administering a uterus-contracting drug, e.g.,
  oxytocin, within one minute of birth.
• Applying controlled cord traction and counter
  traction to the uterus.
• Massaging uterus after delivery of the placenta,
  as appropriate.

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Variations of the definition of AMTSL

• Uterotonic drug some specify oxytocin (drug of
  choice), other drugs have been used in the
  literature (ergometrine, syntocinon,
  syntometrine, prostaglandins).
• Early or immediate cord clamping not
  recommended by ICM/FIGO.
• But for descriptive purposes we should collect
  data on what is being done.
• Some studies have omitted uterine massage.
• No studies to date looking at effectiveness of
  the individual components of AMTSL.

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What does AMTSL do for a woman?
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Evidence on AMTSL

• Reduces incidence of postpartum hemorrhage by up
  to 60 percent.
• Reduces the quantity of blood lossthereby
  decreasing incidence and severity of anemia.
• Reduce emergencies and related cost, transport.
• Reduces the use of blood transfusion.

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To date, there has only been one study to
document AMTSL practices internationally
Bulletin of the World Health Organization (WHO),
2003
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Source Festin et al. 2003 Bulletin of the WHO
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However, these data

• Are only from university teaching hospitals.
• (one health facility in each country, so this is
  not a representative sample of deliveries in a
  country)
• Suggest that practices vary widely. People say
  they are doing active management, but many of
  them are using different definitions.
• Do not tell us WHY providers do or do not use
  AMTSL routinely.

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Our study wants to describe

• How different providers/facilities define AMTSL.
• The barriers (and the facilitators) to routine
  use of AMTSL.

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Determinants of the 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
Provider
Knowledge, skills in AMTSL
Implementation
Motivation to use
Proper storage
Sufficient availability of oxytocics, needles, syr
inge on site
Logistics
Amount procured
Transport issues
Procure- ment at hospital level
Uterotonics included on Essential Drug
List (oxytocin drug of choice)
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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)
Provider
Implementation
Skills in AMTSL
Know- ledge
Motivation to use
Proper storage
Sufficient availability of oxytocics, needles, syr
inge on site
Logistics
Amount procured
Transport issues
Procure- ment at hospital level
Uterotonics included on Essential Drug
List (oxytocin drug of choice)
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We have divided our data collection so that

• The quantitative data has already been collected
  analysis is underway.
• This will be the qualitative part of the study
  during which
• You will interview health care providers about
  their attitudes and practices in AMTSL.
• You will interview community leaders, traditional
  birth attendants, and community members about
  PPH.

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Remember your job is only to ask questions and
record responses

• You should NOT express your opinion about the use
  of AMTSL.
• You should NOT discuss the details of our study
  with health care providers or other professionals
  in health care facilities.
• Simply say that this study is to document how the
  third stage of labor is managed. We are simply
  documenting common practices.