Impacting safe delivery in Mali: From study to action and policy change

Background: Until recently, training in active management of the third stage of labor (AMTSL) did not include matrones, who attend most vaginal births in Mali. Through USAID's Capacity Project and Prevention of Postpartum Hemorrhage Initiative, with assistance from USAID bilateral projects and local partners, IntraHealth International studied the feasibility and safety of training matrones in AMTSL.

Design: Feasibility of AMTSL practice by matrones was evaluated using a design based on historical controls. Statistical analysis involved a weighted average of a simple "before" versus "after" comparison of obstetric complications (potentially related to AMTSL practice) from each medical facility, adjusted for change in AMTSL availability. The Ministry of Health chose three districts; six health facilities per district participated. In each district, one facility was the district health center; five were community health centers with high patient volume where matrones attended births. Experienced midwives collected data on 12 indicators—four directly related to the feasibility and safety of training matrones.

Results:

• 90% coverage for AMTSL in demonstration project facilities • Reduction in postpartum hemorrhage (PPH) rates overall • No proportionate increase in obstetric complications for women attended during childbirth by matrones who performed AMTSL.

Conclusions: Because evidence shows matrones can safely perform AMTSL, recommendations were to: 1) change policy, allowing matrones to practice AMTSL nationally; 2) continue making uterotonics more available; and 3) improve monitoring systems to include AMTSL indicators.

Mali's Ministry of Health subsequently authorized matrones to practice AMTSL nationally. AMTSL use—and resulting PPH reduction—encourages women to utilize health centers for birth.