pilot study: the safety and feasibility of midwifery assistants (matrones) using active management...
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Pilot Study: The safety and feasibility of midwifery assistants (Matrones) using active management of the third stage of labour (AMSTL)
Presentation to the PPH Working Group
March 20, 2008
Washington, DC
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Introduction of AMTSL in Mali
• Introduction of AMTSL in Mali:
• Pilot project in 2002/2003 demonstrated the feasibility and acceptability of applying AMTSL by skilled birth attendants in Mali
• Scale-up in progress for skilled birth attendants (physicians, midwives, and obstetrical nurses)
• Challenge for scale-up:
• The availability of personnel trained in practicing AMSTL is critical to its widespread use
• Matrones (midwifery assistants) attend the majority of normal spontaneous vaginal births but are not authorized to apply AMTSL or administer uterotonic drugs
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Objectives of the study
3 districts (Koulikoro, Sikasso, and Gao), 3 Reference Health Centers (CS Référence), 15 Community Health Centers (CSCOM)
• Demonstrate the safety and feasibility of midwifery assistants (matrones) to practice AMTSL for the prevention of PPH ;
• Demonstrate the feasibility of supplying and stocking uterotonic drugs at the CSCOM level
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Background
• MMR (DHS 2007): 464 / 100,000 live births
• Estimated population (2007) for the three districts: 1,013,714
• This represents 8.5% of the total population of Mali estimated at 11,987,735
• The births that took place at the study sites represented 16.8% (8,512/50,596) of all births recorded in the three districts
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Intervention
• Training conducted in AMTSL, supportive supervision, and utilization and storage of uterotonic drugs
• The following cadres were trained:
• Matrones
• Skilled birth attendants and in-charges of the CSCOM
• Pharmacists and pharmacy managers
• Regular follow-up and supervision
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Test of feasibility and safety of introducing oxytocin in UnijectTM
• 15,000 units of Oxytocin in UnijectTM were introduced in August 2007 to:
Pilot sites from initial study in Bamako
Matrone study sites in Koulikoro and Gao
• Providers and pharmacy managers were trained in utilization and storage of units
• Data have been entered and validation of data entry and analysis are now being completed
• Oxytocin in UnijectTM is now being requested from providers, MOH and USAID for national use
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Study design
XIntervention
Sept 06 - December 07
O1
BaselineAugust /
October 2006
O2
Evaluation
November 07 /
January 08
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Percentage of birth attendants able to cite the three elements of AMTSL
SBA Matrones
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Performance - AMTSL
Average scores during observation of the application of AMTSL
N=6
n=41
65.4 66.5 66
97.4 96.3 96.8
0
10
20
30
40
50
60
70
80
90
100
Baseline Evaluation
SBA
Matrones
Total
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Percentage of birth attendants performing AMTSL to standard (>=80%)
16/37
10/28
26/65
39/40
38/38
77/78
0
10
20
30
40
50
60
70
80
90
100
Baseline Evaluation
Matrones
SBA
Total
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Number and Percentage of women who had a vaginal birth and had AMSTL performed during the last 12 months (data being verified)
1
97
47.4
99.1
1.6
100
23.9
98.6
0
10
20
30
40
50
60
70
80
90
100
Koulik
oro
Sikas
so Gao
Total
Baseline
Evaluation
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Safety of training matrones to apply AMTSL
• Indicators still being analyzed:
• Number and proportion of cases of postpartum hemorrhage in the past year
• Number of cases of selected obstetric complications (ruptured uterus and retained placenta) in the past year
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Availability of oxytocin and ergometrine at study sites
44.4 38.9
88.9
11.1
0
10
20
30
40
50
60
70
80
90
Baseline Evaluation
Oxytocin
Ergometrine
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Preliminary conclusions (1)
• Matrones and SBAs have similar scores on knowledge questions about AMTSL
• Matrones can apply AMTSL according to standards
• If safety data show no increase in selected obstetric complications, a reasonable assumption will be that matrones can safely apply AMTSL and administer uterotonic drugs
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Preliminary conclusions (2)
• Training in AMTSL is accompanied by an increase in availability of oxytocin and a decrease in availability of ergometrine
• Supportive supervision contributed to effective transfer of skills to the workplace after training and maintenance of quality of skills for up to 12 months post training
• Given the preference for using oxytocin in Uniject, the availability of the device may also increase use of oxytocin and thus AMTSL
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Preliminary conclusions (3)
• Training all cadres of health workers attending births will vastly increase the number and percentage of women who have a vaginal birth and AMSTL performed
• MOH and partner coordination and commitment is essential to ensure training in AMTSL for all current birth attendants and for integration into pre-service training programs
• Including AMTSL in matrones’ scope of work will require MOH authorization
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Thank you!