Abstract
BackgroundActive management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants.MethodsA systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool.ResultsOf 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n = 15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n = 6083) and 63 to 100% (9 studies, n = 8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n = 6445); 80 to 99.4% (5 studies, n = 2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n = 6090).ConclusionTask shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users.In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended.
Highlights
Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH)
In the prevention of PPH as major contributor to maternal mortality, the efficacy and safety of task shifting of all elements within AMSTL should be evaluated in future studies
Task shifting of AMSTL to community health workers, traditional birth attendants or selfadministration has been explored in response to the shortages in skilled birth attendants and facility-based deliveries in low- and middle income countries
Summary
Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). Active management of the third stage of labor (AMTSL) describes a set of interventions aimed at the prevention of PPH [3, 4]. AMTSL includes the administration of uterotonics (for example oxytocin or misoprostol) preferably within 1 min after delivery to all women, controlled cord traction (CCT) to stimulate placental delivery, uterine massage to activate uterine contraction and assessment of uterine tonus every 15 min during 2 h postpartum to early identify uterine atony [1, 4,5,6]. CCT is considered optional in settings with skilled birth attendants, continuous uterine massage is not recommended if prophylactic oxytocin is provided and uterine tonus surveillance is recommended for all delivered women [4, 7,8,9]
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