9 July, 2008 AED, Washington, DC Holley Stewart

1. International survey of the active management of the 3rd stage of labor:Results from Ethiopia,Tanzania & Uganda 9 July, 2008AED, Washington, DC Holley Stewart

2. Acknowledgements • 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

3. The Lifetime Risk of Maternal Death in Africa is Staggering 1:2,800 1:94 1:16 1:160 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

4. 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. 4

5. What is AMTSL: The ICM/FIGO 2003 Joint Statement • Prophylactic administration of a uterotonic drug • Controlled cord traction (CCT) • Uterine Massage

6. 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)

7. 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

8. 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) Implementation Motivation to use Know- ledge Skills in AMTSL Provider Proper storage Logistics Sufficient availability of oxytocics, needles, syringe on site Amount procured Transport issues Procure- ment at hospital level Uterotonics included on Essential Drug List (oxytocin= drug of choice)

9. 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?

10. 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)

11. 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

12. Survey countries: maternal health profiles

13. Methods - Data Collection

14. Selected Results

15. Availability of uteronics & related issues

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

17. 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

18. Maternal Deaths and Correct Use of AMTSL

19. Use of AMTSL in Uganda

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

21. Potentially harmful practices, Tanzania

22. Qualitative findings

23. Percent of providers with knowledge on various components of AMTSL: Tanzania

24. Percent of providers making correct statements on components of AMTSL, Ethiopia

25. Factors identified as barriers to AMTSL use • 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

26. TBAs and Mx of the 3rd Stage of Labor 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)

27. PPH according to TBAs (Uganda) • 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

28. Constraints TBAs face in case of PPH • 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

29. Community involvement in PPH prevention/MX • 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

30. Role of communities from H/W perspective 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

31. Conclusions • 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.

32. Recommendations • 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

33. Next steps • 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 http://www.pphprevention.org/Surveytools.php

34. Thank you