Experiencing challenges when implementing Active Management of Third Stage of Labor (AMTSL): a qualitative study with midwives in Accra, Ghana

BMC Pregnancy and Childbirth

Karen Odberg Pettersson⁴  Gladys Brew³  Amna Elyas¹  Stina Mannheimer Schack² 

[1] Region Skåne, Skånehuset i Kristianstad, J A Hedlunds väg, Kristianstad, Sweden;Capio S:t Göran Hospital, Stockholm, Sweden;Safe Mother Care Programme, Ghana Health Service, Accra, Ghana;Social Medicine and Global Health, Lund University, Malmö, Sweden

关键词: Task shifting;    Ghana;    Uterine massage;    Controlled Cord Traction;    Oxytocin;    Post-partum hemorrhage (PPH);    Active management of the third stage of labor (AMTSL);   

Others  :  1127245
DOI  :  10.1186/1471-2393-14-193

 received in 2014-03-09, accepted in 2014-05-21,  发布年份 2014

【 摘 要 】

Background

Post-partum hemorrhage (PPH) is the major cause of maternal mortality in Ghana and worldwide. Active management of the third stage of labor (AMTSL) is a globally recommended three-step method that in clinical trials has been proven effective in prevention of PPH. The AMTSL guidelines were introduced in 2003, modified in 2006, and has been part of the national guidelines in Ghana since 2008. In 2012, the guidelines were modified a second time. Despite its positive effects on the incidence of PPH, the level of adherence to the guidelines seems to be low in the studied area. This appears to be a problem shared by several countries in the region. An in-depth understanding of midwives’ experiences about AMTSL is important as it can provide a basis for further interventions in order to reach a higher grade of implementation.

Methods

Twelve in-depth interviews were conducted with labor ward midwives who all had previous training in AMTSL. The interviews took place in 2011 at three hospitals in Accra Metropolis and data was analyzed using qualitative latent content analysis.

Results

Our main finding was that the third step of AMTSL, uterine massage, was not implemented, even though the general attitude towards AMTSL was positive. Thus, despite regular training sessions, the midwives did not follow the Ghanaian national guidelines. Some contributing factors to difficulties in providing AMTSL to all women have been pointed out in this study, the most important being insufficiency in staff coverage. This led to a need for delegating certain steps of AMTSL to other health care staff, i.e. task shifting. The fact that the definition of AMTSL has changed several times since the introduction in 2003 might also be an aggravating factor.

Conclusions

The results from this study highlight the need for continuous updates of national guidelines, extended educational interventions and recurrent controls of adherence to guidelines. AMTSL is an important tool in preventing PPH, however, it must be clarified how it should be used in countries with scarce resources. Also, considering the difficulties in implementing already existing guidelines, further modifications must be made with careful consideration.

【 授权许可】

   
2014 Schack et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]WHO: Maternal Mortality. Fact sheet N°348. Geneva: WHO; 2012.
• [2]WHO: WHO guidelines for the management of postpartum hemorrhage and retained placenta. Geneva: WHO; 2009.
• [3]Ghana Statistical Service (GSS), Ghana Health Service (GHS), and Macro International: Ghana Maternal Health Survey 2007. Calverton, Maryland, USA: GSS, GHS, and Macro International; 2009. http://pdf.usaid.gov/pdf_docs/PNADO492.pdf webcite
• [4]WHO: Care in Normal Birth: a practical guide. Geneva: WHO; 1996.
• [5]Enkin M, Keirse MJNC, Renfrew M, Neilson J: Third Stage of Labor. In A Guide to: Effective Care in Pregnancy & Childbirth. 2nd edition. New York: Oxford University Press; 1995:236-242.
• [6]International Federation of Gynaecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM): Joint Statement Management of the Third Stage of Labor to Prevent Post-partum Hemorrhage. London: FIGO, ICM; 2003. http://www.pphprevention.org/files/ICM_FIGO_Joint_Statement.pdf webcite
• [7]Prendiville WJ, Elbourne D, McDonald S: Active versus expectant management of the third stage of labor. Cochrane Database Syst Rev 2000, 3:000007.
• [8]Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W: Active versus expectant management for women in the third stage of labor. Cochrane Database Syst Rev 2010, 7:007412.
• [9]WHO: Department of Reproductive Health and Research. Managing Complications in Pregnancy and Childbirth. A guide for midwives and doctors. Geneva: WHO; 2000. Reprinted 2007
• [10]WHO: Recommendations for the Prevention of Postpartum Hemorrhage. Geneva: WHO; 2007. http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf webcite
• [11]WHO: Recommendations for the prevention and treatment of postpartum hemorrhage. Geneva: WHO; 2012. http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf webcite
• [12]Gulmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel-Aleem H, Festin M, Carroli G, Qureshi Z, Souza JP, Bergel E, Piaggio G, Goudar SS, Yeh J, Armbruster D, Singata M, Pelaez-Crisologo C, Althabe F, Sekweyama P, Hofmeyr J, Stanton M, Derman R, Elbourne D: Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012, 379:1721-1727.
• [13]Sheldon WR, Durocher J, Winikoff B, Blum J, Trussel J: How effective are the components of active management of the third stage of labor? BMC Pregnancy and Childbirth 2013, 13:46. BioMed Central Full Text
• [14]USAID: Prevention of Postpartum Hemorrhage Initiative (POPPHI). Rational Pharmaceutical Management Plus Program. Active Management of the Third Stage of Labor in Health Care Facilities: Results of a National Study in Ghana 2007. Arlington, Virginia, USA: USAID, POPPHI; 2008:2008. Available at: http://www.pphprevention.org/files/GhanaAMTSLSurveyReport.pdf webcite
• [15]POPPHI: Active Management of the third stage of Labor. Data Obtained from National Survey in Uganda. Washigton DC: POPPHI; 2007. http://www.path.org/publications/files/MCHN_popphi_amtsl_rpt_uganda.pdf webcite
• [16]Oladapo OT, Fawole AO, Loto OM, Adegbola O, Akinola OI, Alao MO, Adeyemi AS: Active management of third stage of labor: a survey of providers’ knowledge in southwest Nigeria. Arch Gynecol Obstet 2009, 280(6):945-952.
• [17]POPPHI: Facility-based Management of the Third Stage of Labor and Community Perceptions and Actions on Postpartum Hemorrhage; Findings from a National Survey in Tanzania. Washington DC, USA: POPPHI; 2006. http://www.path.org/publications/files/MCHN_popphi_amtsl_rpt_tanz.pdf webcite
• [18]Asare G: Multiple ways to scale up PPH prevention in Ghana. In Meeting on Tackling the biggest maternal killer: Progress and challenges in preventing postpartum hemorrhage. Washington DC, USA: USAID; 2009.
• [19]Tsu VD, Levin C, Tran MP, Hoang MV, Luu HT: Cost-effectiveness analysis of active management of third-stage labour in Vietnam. Health Policy Plan 2009, 24(6):438-444.
• [20]Fullerton J, Frick KD, Fogarty LA, Fishel JD, Vivio DM: Active Management of Third Stage of Labour Saves Facility Costs in Guatemala and Zambia. J Health Popul Nutr 2006, 24(4):540-551.
• [21]Dahlgren L, Emmelin M, Winkvist A: Qualitative methodology for international public health. Umeå, Sweden: Umeå University; 2007.
• [22]Ghana Health Service (GHS): Greater Accra Region. http://www.ghanahealthservice.org/region.php?dd=4®ion=Greater%20Accra%20Region webcite
• [23]Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 2004, 24:105-112.
• [24]WHO: Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva: WHO; 2008.
• [25]Pettersson KO, Svensson ML, Christensson K: The lived experiences of autonomous Angolan midwives working in midwifery-led maternity units. Midwifery 2001, 17:102-114.
• [26]Pettersson KO, Johansson E, Pelembe MF, Dgedge C, Christensson K: ‘Mozambican midwives’ views on barriers to providing quality perinatal care”. Health Care Women Int 2006, 27(2):145-168.
• [27]United Nations (UN): Millennium Development Goals (MDG) Goal 5: Improve maternal health. New York: UN; 2000.