In many developing countries, the majority of women who give birth in a health facility do not receive proper care during the last stages of labor, according to a study in which researchers observed deliveries in Benin, El Salvador, Ethiopia, Honduras, Indonesia, Nicaragua and Tanzania.1 The International Federation of Gynecologists and Obstetricians (FIGO) and the International Confederation of Midwives (ICM) recommend that vaginal singleton births routinely receive active management during the third stage of labor: Birth attendants should administer the correct dose of a uterotonic drug within one minute of fetal delivery, provide controlled traction of the umbilical cord and fundal massage after delivery of the placenta, and perform uterine palpations every 15 minutes for two hours afterward. This set of techniques, aimed at preventing postpartum hemorrhage, was used correctly in only 1–32% of deliveries in the seven study countries, while potentially harmful practices occurred in 48–94% of deliveries. From these results, the investigators estimate that 1.4 million facility-based deliveries in these countries are mismanaged annually.
Between October 2005 and December 2006, the researchers observed nationally representative samples of vaginal deliveries in health facilities in the seven countries, ranging from 192 deliveries in 25 facilities in El Salvador to 408 deliveries in 27 facilities in Indonesia. At each facility, the investigators generally observed all deliveries that occurred within two eight-hour periods, although in Indonesia deliveries were observed 24 hours per day for five days to obtain the desired sample size. Only public facilities were included, except in Benin and Tanzania, where both public and private facilities allowed observation. With the exception of deliveries in Africa, some of which occurred at health centers, deliveries were observed at district or higher-level hospitals.
The researchers recorded the age and parity of women whose labors they observed, as well as the type of provider assisting with delivery. They interviewed midwives, nurses and doctors about any training they had received in the previous year on active management of the third stage of labor. The researchers also interviewed officials and examined documents to determine national policies on active management.
The seven countries were selected to reflect diversity in maternal health and health infrastructure. Maternal mortality ratios varied from 71 maternal deaths per 100,000 live births in El Salvador to 637 deaths per 100,000 in Ethiopia. The proportion of deliveries occurring in public health facilities ranged from fewer than 5% in Ethiopia to 60–65% in Benin, Honduras and Nicaragua. Per capita spending on health in 2005 ranged from $6 in Ethiopia to $91 in Honduras.
Most of the deliveries observed by the researchers were by women aged 20–34 (61–85%). In Benin, Tanzania and Indonesia, midwives performed the largest proportions of deliveries (94%, 71% and 45%, respectively), whereas physicians were generally in attendance in the Central American countries (58–73%). In Ethiopia, nurses performed most deliveries (61%).
In-service training for active management of the third stage of labor was frequently provided at the facilities where deliveries occurred. Such training was most prevalent in Benin, where 61% of deliveries occurred in facilities that trained midwives, 98% in those that trained nurses and 82% in those that trained doctors. However, the personnel targeted for training were not always the ones who managed the most deliveries. For instance, although facilities in Benin were more likely to provide training in management of the third stage of labor to doctors and nurses than to midwives, the latter performed 94% of deliveries.
Overall, active management of the third stage of labor, as defined by FIGO and ICM, was correctly carried out in only a small minority of deliveries: 32% of those in Indonesia, 18% of those in Benin and 1–5% of those in the remaining five countries. The proportion of deliveries that met the less stringent Cochrane definition of correct active management (use of a uterotonic, controlled cord traction, and cord clamping or cutting within one minute of delivery) was somewhat greater (45% in Benin, 41% in Indonesia), but remained below 10% in El Salvador, Nicaragua and Tanzania. These findings suggest that 1.4 million facility-based deliveries are mismanaged annually in the seven countries, even according to the standards of the less rigorous Cochrane definition.
The use of uterotonics was nearly universal (>95% of deliveries), except in El Salvador (60%). The prevalence of correct use, however, was substantially lower, varying from 7% in Tanzania to 61% in Benin. Use of other elements of active management also varied widely: Controlled cord traction was used in just 26% of deliveries in El Salvador, but in 70% or more of those in the African nations and Indonesia. Correctly timed fundal massage and subsequent palpations of the uterus—actions that indicate close observation of mothers in the risky postpartum period—were performed in 71% of deliveries in Indonesia, but in only 6–35% elsewhere.
In all study countries, the lack of correctly employed active management techniques was accompanied by the use of potentially harmful practices. In 12–81% of deliveries, researchers observed providers performing cord traction without supporting the uterus; in 10–73%, providers performed fundal massage after fetal (rather than placental) delivery. The proportion of deliveries that involved either of these harmful practices ranged from 48% in Tanzania to 94% in Nicaragua.
A multivariate analysis revealed that correct use of active management (using the Cochrane definition) was often less common in lower-level facilities than in national referral hospitals; the odds of correct use were particularly low in Beninese health centers (odds ratio, 0.2), Ethiopian regional hospitals (0.2), and Honduran regional and district hospitals (0.2 and 0.4, respectively), relative to those countries' national referral hospitals. Staff training in active management of the third stage of labor was generally not associated with increased odds of correct use.
The review of labor management policies revealed that all seven countries had at least two uterotonics on their essential drug list, and six had standard treatment guidelines that included some definition of the active management of the third stage of labor. However, all but Indonesia had conflicting active management guidelines.
The researchers conclude that in the seven study countries, "health systems do not appear to have actively targeted reduction in postpartum haemorrhage as an achievable goal." To improve use of active management of the third stage of labor—and thus to protect the health and lives of more women in labor—they propose that "behavior change interventions should be targeted to the cadres responsible for the most deliveries." The researchers also support ongoing research into the relative contribution of each component of the active management regimen.—H. Ball
1. Stanton C et al., Use of active management of the third stage of labour in seven developing countries, Bulletin of the World Health Organization, 2009, 87(3):207–215.