Human resources for maternal health: multi-purpose or specialists?

A crucial question in the aim to attain MDG5 is whether it can be achieved faster with the scaling up of multi-purpose health workers operating in the community or with the scaling up of professional skilled birth attendants working in health facilities. Most advisers concerned with maternal mortality reduction concur to promote births in facilities with professional attendants as the ultimate strategy. The evidence, however, is scarce on what it takes to progress in this path, and on the 'interim solutions' for situations where the majority of women still deliver at home. These questions are particularly relevant as we have reached the twentieth anniversary of the safe motherhood initiative without much progress made

How effective are the components of active management of the third stage of labor?

BACKGROUND: Active management of the third stage of labor is recommended for the prevention of post-partum hemorrhage and commonly entails prophylactic administration of a uterotonic agent, controlled cord traction, and uterine massage. While oxytocin is the first-choice uterotonic, it is not known whether its effectiveness varies by route of administration. There is also insufficient evidence regarding the value of controlled cord traction or uterine massage. This analysis assessed the independent and combined effectiveness of all three interventions, and the effect of route of oxytocin administration on post-partum blood loss. METHODS: Secondary data were analyzed from 39202 hospital-based births in four countries and two clinical regimens: one in which oxytocin was administered following delivery of the baby; the other in which it was not. We used logistic regression to examine associations between clinical and demographic variables and post-partum blood loss ≥ 700 mL. RESULTS: Among those with no oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by nearly 50% as compared with expectant management (P < 0.001). Among those with oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by 66% when oxytocin was intramuscular (P < 0.001), but conferred no benefit when oxytocin was intravenous. Route of administration was important when oxytocin was the only intervention provided: intravenous administration reduced hemorrhage risk by 76% as compared with intramuscular administration (P < 0.001); when combined with other interventions, route of administration had no effect. In both clinical regimens, uterine massage was associated with increased hemorrhage risk. CONCLUSIONS: Recommendations for active management of the third stage of labor should account for setting-related differences such as the availability of oxytocin and its route of administration. The optimal combination of interventions will vary accordingly