CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Globally, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality worldwide, contributing to approximately 25% of maternal deaths annually, with an estimated 70,000 deaths per year (World Health Organization [WHO], 2020). The global incidence of PPH is about 5%-10% of all live births (WHO, 2019). Active Management of the Third Stage of Labor (AMTSL) has been shown to reduce PPH by up to 60%, and is recommended globally as a key intervention to prevent excessive bleeding after childbirth (Leduc et al., 2019). This approach includes the administration of uterotonic drugs, controlled cord traction, and uterine massage, all of which have proven efficacy in reducing maternal morbidity. Despite the global recommendations, adherence to AMTSL protocols varies significantly across countries, particularly between high-income and low-resource settings, due to factors such as training gaps, resource limitations, and healthcare infrastructure.

In the United States, PPH contributes to 11% of maternal deaths annually, with over 4,000 deaths linked to hemorrhage (Centers for Disease Control and Prevention [CDC], 2021). Despite the high healthcare standards, studies indicate that aproximately 60-70% of hospitals adhere to AMTSL protocols, with significant variability across different states and healthcare settings (Callaghan et al., 2019). While adherence to AMTSL has been associated with a decrease in PPH-related deaths, the U.S. still faces challenges in achieving consistent implementation of AMTSL, especially in rural hospitals and community settings, where training may not be as frequent or comprehensive. Additionally, institutional factors such as policies, staff shortages, and patient overload continue to undermine efforts to standardize AMTSL practices across all healthcare facilities.

In Europe, PPH remains a significant cause of maternal morbidity, although the rates of maternal death are lower than in low-resource settings. In France, for example, PPH is responsible for around 25% of maternal deaths, but the country has significantly reduced the incidence of PPH by implementing AMTSL protocols consistently across healthcare facilities (Deneux-Tharaux et al., 2017). Studies show that in Sweden, AMTSL adherence is nearly 100%, contributing to lower maternal mortality rates and a 15% reduction in PPH over the past two decades (Sujan et al., 2021). In contrast, Eastern Europe and some parts of Southern Europe still experience challenges in fully adopting AMTSL due to regional disparities in training and healthcare resources. However, standardized protocols in countries like the United Kingdom and France have led to significant improvements in maternal outcomes, reducing the global burden of PPH in these regions.

In Africa, PPH remains a primary contributor to maternal mortality, with rates of maternal deaths from hemorrhage ranging from 30% to 50% in some countries (WHO, 2020). The maternal mortality rate in sub-Saharan Africa is significantly higher than in other regions, with an estimated 500 deaths per 100,000 live births. In countries like Cameroon, PPH is responsible for approximately 30% of maternal deaths (Kouam et al., 2021). Although AMTSL has been identify as a critical intervention, adherence is notably low, often below 50% in rural and resource-limited areas (Mbangue et al., 2020). Factors contributing to poor adherence include inadequate training of midwives, insufficient resources such as uterotonic drugs, and high workload. In rural areas, lack of skilled birth attendants and delayed access to emergency obstetric care further exacerbate the situation, making it difficult to implement evidence-based protocols consistently.

1.2 Statement of the problem

Failure to properly implement Active Management of the Third Stage of Labour (AMTSL) significantly increases the risk of postpartum haemorrhage (PPH), which remains the leading cause of maternal mortality worldwide (WHO, 2012).When uterotonic drugs such as oxytocin are not administered correctly, uterine atony may occur, leading to severe and uncontrolled bleeding after childbirth (WHO, 2014).Globally, PPH accounts for approximately 25% of all maternal deaths, most of which are preventable with correct AMTSL practice (WHO, 2012).Evidence shows that proper AMTSL can reduce the incidence of PPH by about 60% to 70%, highlighting its life-saving importance (WHO, 2014).Poor adherence to AMTSL also increases the likelihood of severe maternal anaemia, shock, and the need for blood transfusion (WHO, 2012).In many low-resource settings, failure to follow AMTSL protocols contributes to delayed recognition and management of excessive bleeding (WHO, 2014).This leads to higher rates of emergency surgical interventions such as hysterectomy and increased maternal morbidity (WHO, 2012).In addition, inadequate implementation of AMTSL places a heavy burden on health systems through increased hospital stay and treatment costs (WHO, 2014).Studies indicate that gaps in midwives’ knowledge and practice are key contributors to poor AMTSL adherence and adverse outcomes (WHO, 2012).Therefore, strengthening AMTSL implementation is essential for reducing preventable maternal deaths and improving childbirth outcomes globally (WHO, 2014).

The failure of Active Management of the Third Stage of Labor (AMSTL) significantly increases the risk of postpartum hemorrhage (PPH). To mitigate the effects of AMSTL failure, several interventions are crucial. The administration of utero tonic drugs, such as oxytocin, is essential during the third stage of labor to promote uterine contractions and reduce the risk of hemorrhage (Linne et al., 2020). In addition, uterine massage plays a vital role in stimulating uterine contractions post-delivery, which helps prevent uterine atony, a major cause of PPH (Lortie et al., 2018). Controlled cord traction, when performed appropriately, assists in the smooth delivery of the placenta, minimizing the risk of retained placenta and subsequent hemorrhage (El-Gilany et al., 2020). Furthermore, ensuring that healthcare providers adhere to AMSTL protocols, including timely uterotonic administration and proper techniques for uterine massage and cord traction, is crucial. Regular training and updates for midwives and healthcare professionals on these procedures can enhance outcomes and reduce complications (Chawla et al., 2021). Finally, continuous monitoring during and after delivery, including observation of bleeding levels and uterine tone, allows for early detection of issues such as uterine atony, facilitating prompt intervention and minimizing risks (Hawes et al., 2022). Strengthening these preventive measures and ensuring their proper execution can significantly reduce the likelihood of severe postpartum hemorrhage following delivery.

During my clinical internship in the maternity unit, I witnessed a sad case of early postpartum hemorrhage after a normal vaginal delivery. The mother delivered a healthy baby successfully and appeared stable immediately after birth. However, active management of the third stage of labor (AMTSL) was not properly practiced, as uterotonic drugs were delayed, uterine massage was not effectively done, and close monitoring was inadequate.A few minutes later, the mother started bleeding excessively. Her uterus became soft, she became weak and unconscious, and despite emergency interventions, her condition worsened rapidly. Unfortunately, she died from severe postpartum hemorrhage shortly after delivery.This experience made me ask my self is there a relationship between adherence to active management of third stage of labour and prevention of post partum hemorrhage?, ,are they factors influencing adherence to active management of third stage of labour in preventing post partum hemorrhage?  like in this case stock  availability.

1.3 Research Objectives

1.3.1 Main objective

To asses midwives adherence and practice to active management of third stage of labor in preventing post partum hemorrhage at District hospital Obala

1.3.2 Specific objectives

1. To identify factors that influence adherence of health personnel in the prevention of postpartum hemorrhage at district hospital Obala
2. To Asses the practice of health personnel in the prevention of post partum hemorrhage at district hospital Obala

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