Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands.
Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
BMC Pregnancy Childbirth. 2018 Feb 6;18(1):47. doi: 10.1186/s12884-018-1677-5.
Active 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.
A 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.
Of 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).
Task 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.
积极的第三产程管理（AMTSL）描述了干预措施，其共同目标是预防产后出血（PPH）。在中低收入国家，由于熟练的接生员短缺以及高比例的家庭分娩，AMTSL 的实施受到阻碍。将特定的 AMTSL 组成部分转移给非熟练的接生员或自我管理可能是增加潜在救生干预措施获取途径的一种策略。本研究旨在评估将特定的 AMTSL 方面的任务转移给非熟练的接生员的效果、接受程度和安全性。
2015 年 9 月，在五个数据库中进行了系统检索，以确定由非熟练的接生员或孕妇自己实施的 AMTSL 干预研究。使用经过改编的 Cochrane 协作评估工具评估研究质量。
在筛查的 2469 项研究中，有 21 项被纳入。所有研究均评估了在产前（家庭）就诊或分娩时，由社区卫生工作者（CHWs）、辅助助产士、传统助产士（TBAs）或自我管理，为产妇使用宫缩剂（米索前列醇片或催产素注射剂）的实施情况。没有报告其他 AMTSL 组成部分的任务转移情况。与标准护理相比，提供宫缩剂的任务转移（RR 0.16 至 1）可降低 PPH 的风险（13 项研究，n = 15197）。报告的正确剂量和时间分别为 83.4%至 99.8%（5 项研究，n = 6083）和 63%至 100%（9 项研究，n = 8378）的妇女。80%至 99.7%（7 项研究，n = 6445）的妇女向他人推荐宫缩剂；80%至 99.4%（5 项研究，n = 2677）的妇女在下一次分娩时会使用该药物。对宫缩剂的支付意愿从 54.6%至 100%不等（7 项研究，n = 6090）。
迄今为止，AMTSL 的任务转移已针对宫缩剂（由 CHWs 和辅助助产士注射的米索前列醇片和催产素）的管理进行了评估，这降低了 PPH 的发生率，提高了使用者的适当使用率和满意度。为了增加低人员配备的卫生设施中的 AMTSL 覆盖率，可以考虑将子宫按摩或产后张力评估的任务转移给非熟练的助产士或产妇。目前不建议将控制性脐带牵引的任务转移。
