1. 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

2. 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

3. 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

4. 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

5. 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

6. Test of feasibility and safety of introducing oxytocin in Uniject TM 15,000 units of Oxytocin in Uniject TM 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 Uniject TM is now being requested from providers, MOH and USAID for national use

7. Study design X Intervention Sept 06 - December 07 O 1 Baseline August / October 2006 O 2 Evaluation November 07 / January 08

8. Percentage of birth attendants able to cite the three elements of AMTSL SBA Matrones

9. Performance - AMTSL Average scores during observation of the application of AMTSL N=6 n=41

10. Percentage of birth attendants performing AMTSL to standard (>=80%)

11. Number and Percentage of women who had a vaginal birth and had AMSTL performed during the last 12 months (data being verified)

12. 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

13. Availability of oxytocin and ergometrine at study sites

14. 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

15. 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

16. 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

17. Thank you!