Overcoming provider barriers to
introduction and sustainability of
AMTSL at facilities
Susheela M. Engelbrecht
PATH / Oxytocin Initiative
Objectives
• List determinants of the use of AMTSL in a
facility
• Describe three interventions that address
facility-based provider-related barriers to
introduction and/or sustainability of AMTSL
in facilities
• Develop ideas for improving sustainability of
AMTSL in facilities in your country
AMTSL defined:
1. Administration of a uterotonic drug within 1 minute of
birth of the baby (oxytocin 10 IU IM is the uterotonic
of choice; in its absence, use 0.2 mg ergometrine IM
or 1 mL syntometrine IM or 600 mcg misoprostol po)
2. Controlled cord traction with counter-pressure to
support the uterus
3. Immediate uterine massage following delivery of the
placenta w/ evaluation of uterine contractedness and
repeat massage every 15 minutes for at least 2 hrs
NOTE: early cord clamping (defined as clamping
immediately after birth of the baby) is not part of the
ICM/FIGO definition
AMTSL coverage was low in facilities – 2007 national surveys
Percent of observed deliveries w/ uterotonic given during 3rd/4th stages of labor
and correct use of AMTSL (uterotonic administration within 1 minute)
100.0
99.7
100.0
97.6
95.6
100.0
95.6
92.6
89.2
90.0
86.7
80.0
70.0
60.0
% of deliveries
60.0
50.0
40.0
31.8
29.0
30.0
20.0
17.0
10.0
6.7
7.1
5.4
3.0
4.5
2.6
0.3
0.0
Indonesia
Benin
Ethiopia
Ghana
Tanzania
Uganda
Received uterotonic 3rd/4th stage
El
Salvador
Guatemala Honduras Nicaragua
AMTSL (1 min)
Why don’t providers consistently use
AMTSL in facilities? (1)
• Policies may prevent certain cadres from
applying active management of the third
stage of labor
• Providers may either not be trained or not
be consistently trained
• AMTSL may not be integrated into
supportive supervision activities
• There may not be indicators for AMTSL and
uterotonic drugs to monitor progress
Barriers to the use of AMTSL in a facility
(2)
• Uterotonic drugs may not be consistently
available due to logistics problems
• Uterotonic drugs may not be stored
correctly, making them less effective, which
has a negative effect on use of AMTSL
What will address provider-related barriers to
sustainability of AMTSL in the facilities?
• Policies that promote application of AMTSL
by all birth attendants in the facility
• Training activities that ensure that at least
80% of the population of birth attendants
apply AMTSL consistently and competently
• Internal and external supervisory systems
that monitor the practice
• Indicators to follow progress
Intervention 1: Changing AMTSL Behavior in
Obstetrics (CAMBIO)
• Developing evidence-based guidelines with
providers
• Peer election of a facilitator for each facility
• Training elected facilitators in each facility to
disseminate guidelines
• Training all providers in AMTSL
• Use of the oxytocin-Uniject device
• Use of reminders
Results of implementing CAMBIO in
Argentina
Belizán and Althabe (2009)
Intervention 2: Self and Individual learning
(SAIN)- 1
• Training of clinical instructors (“mentors”) for each
facility
• Clinical instructors guide all providers through
blended learning materials:
• Self-directed learning
• Clinical practicum
• Clinical instructors work with pharmacy managers
to ensure availability and correct storage of
uterotonic drugs
• Clinical instructors work with facility managers to
ensure availability of essential equipment, supplies,
and consumables
Intervention 2: Self and Individual
learning (SAIN)- 2
• Additional interventions:
• Posted job aids
• Additional columns to
track AMTSL in the
delivery log
• Wall charts to follow
progress
• Follow-up and supportive
supervision
Results of implementing SAIN –
Ghana (1)
• Baseline use in Ghanaian Hospitals of the complete AMSTL
interventions: 3,0% (2007)
• Intervention: June – October, 2009 / Evaluation: November 2009
• There were adequate stocks of oxytocin, ergometrine, and
misoprostol in all of the facilities at the time of visit
• Coverage:
• By report: 100% coverage of AMTSL
• Observation of the delivery register: 91-100% was actually
recorded
• In most cases when AMTSL was not checked, oxytocin
was documented, indicating that there is most likely 100%
coverage but not 100% documentation
• Anecdotal decrease in cases of PPH and retained
placenta, and reduced need of uterotonic drugs for
management of PPH
Results of implementing SAIN –
Ghana (2)
Findings on evaluation: Percentage of observed providers
practicing selected components of third stage management to
standard (Ghana)
Results of implementing SAIN –
iLembe district, South Africa (1)
Results of implementing SAIN –
iLembe district, South Africa (2)
Results of implementing SAIN –
iLembe district, South Africa (3)
Intervention 3: Intensive post-training
supervision
• Competency-based training for providers in
integrated maternal and newborn care
• Supervisors included in training activities
• One to two providers trained per site in off-site
training
• Providers returned to worksites to “brief” other
providers
• Trainers made up to 3 post-training follow-up visits to
assess practice and provide refreshers as needed
• Additional interventions:
• Posted job aids
• Delivery logs and partograph revised to include
tracking AMTSL
Intensive post-training supervision DRC
Peer training - DRC
Lessons learned
• Mentors / Clinical instructors can help
introduce and ensure sustainability
• Monitoring provides incentives
• Supervision assures quality and
sustainability
• Informal peer training works
PPH Prevention and Treatment Website
• www.pphprevention.org