PPPH, The Ethiopian Experience

Abstract:- Presented At The 6^th Regional Conference Of East Central And South African Societies Of Obstetrician And Gynecologists.

Title:- Introducing the practice of active management of the third stage of labor for all of vaginal deliveries in a low resource setting, an Ethiopian experience.

Authors:- Ashebir Getachew (MD), Biruk Tafesse (MD), Mulu Muleta (MD, MPH)

Background

It is a hard fact that 99% of global maternal deaths takes place in developing countries. Ethiopia is among the eight countries with high maternal mortality rates contributing to 50% of the world’s maternal deaths and postpartum hemorrhage is estimate to account for 25% of the deaths (’94-’00/USAID health and population).

In response to a request by the United States Agency for International Development, the Ethiopian society of obstetricians and gynecologists, PRIME II, and ministry of health Ethiopia have been working with collaboration in an effort to reduce maternal deaths secondary to postpartum hemorrhage through introduction of an evidence based practice, active management of the third stage of labor for all vaginal deliveries.

Objectives

General objectives: - To evaluate the feasibility of implementing the practice of active management of the third stage of labor for all vaginal deliveries (AMTSL) widely through a small scale pilot project at selected sites.

Specific objectives: -

• Determine current practices regarding AMTSL knowledge, availability of skilled attendants, supplies and favorable policy environment,

• Formulate appropriate interventions and evaluate the adequacy of interventions (change in performance, effectiveness, safety and acceptability),

• Identify programmatic and administrative factors that have facilitated or hindered project implementation and

• Formulate lessons learned and made recommendations for wide extension of the practice to other sites

Methods

The study was conducted from February 2003 up to April 2004 in 24 health institutions of different strata involving 79 skilled birth attendants. A base line assessment was done to asses current practices, results based interventions designed (trainings, distribution of job aids and supportive supervision) and implemented, project outputs and out comes were assessed at different times. Data were collected using pre-tested instruments to include interviews, observations and record reviews, data entry and analysis were performed using SPSS (version 8) statistical package.

Results

90% of vaginal deliveries are currently receiving AMTSL as compared to only 1% at base line. Increased knowledge in key steps of AMTSL 12% baseline v 72% final evaluation, increased provider performance skills 80% baseline v 86% final evaluation (average score) and increased provider performance in managing third stage complications were observed. Low number of PPH cases (1.5%) and low number of referrals and blood transfusions due to PPH were found as compared to the base line findings. oxytocic storage condition showed notable improvements. a positive provider response as well as a favorable policy environment were achieved.

Mixed pictures of shortage of oxytocic drugs in some institutions as compared to oversupplies in others and low institutional delivery rate were observed to be major obstacles

Conclusion

The findings of this pilot project have shown that AMTSL is effective, safe and acceptable. In other words wide scale introduction of AMTSL in our set-up and most probably also in other similar low resource areas is programmatically feasible. A rational drug management system should be practiced in order to correct the irregularities in oxytocic availability.

Recommendations

1. There are enough evidences both locally and world wide on the effectiveness and safety of universal application of AMTSL for all of vaginal deliveries and it is time to replicate the practice widely.

2. Developments of a national guideline and Incorporating AMTSL into the pre-service teaching curricula are important next steps ensuring rapid scale up.

3. Improvements in all aspects of the drug management information system specially of rational distribution of drugs is recommended

4. Consideration should be given to introduce AMTSL at the community level in the future when the use of Misoprostol in this regard is well established. This will enable us to reach the majority who are delivering at home and are dying of PPH