Active management of the third stage of labor and eclampsia management as critical components of skilled care during birth in Cambodia

For 10 years the level of maternal mortality in Cambodia has remained at approximately 470 maternal deaths per 100 000 live births. The 2 primary causes of maternal death in Cambodia are postpartum hemorrhage and eclampsia which together account for more than 50% of maternal deaths. A situational analysis was conducted regarding the current practice of active management of the third stage of labor (AMTSL) and the management of eclampsia. The assessment of these procedures was carried out in a sample of 30 of the 42 busiest public birthing facilities in Cambodia. Questionnaires used in the assessment were adapted from those developed by the USAID-supported Prevention of Postpartum Haemorrhage Initiative. At each of the 30 facilities a trained team of 2 external midwives observed all vaginal births during a defined time period (2 3 or 4 days as predetermined by the birth caseload). The assessment teams observed 141 consecutive deliveries and completed structured interviews with chief midwives facility pharmacists private pharmacists and new mothers/new mothers’ family members. All women provided informed consent. In total AMTSL was correctly carried out in only 22 of the 141 deliveries. After taking into account weights related to the sampling strategy the nationally representative percentage for use of AMTSL among public facilities with 400 or more annual deliveries was 17.1% (95% confidence interval 10.9-23.3). The component of AMTSL most commonly missing was uterine massage and monitoring of the uterus in the 30 minutes after birth. The only uterotonic drug used routinely was oxytocin and several significant stock-outs of this drug were encountered. Magnesium sulfate was not used according to the WHO guidelines in Cambodia. The treatment regimens for eclampsia reportedly included the use of magnesium sulfate but never in the doses recommended by the WHO. Magnesium sulfate was usually available at the hospitals assessed but its use was at best suboptimal. Thus 2 of the most important evidence-based simple and affordable interventions to save mothers’ lives were practiced irregularly incorrectly or not at all. The barriers to correct use included staff competence use of competing non-evidence-based practices and national policies. After the assessment results were publicized the official Cambodian policy on magnesium sulfate was changed to the regimen recommended by the WHO; such treatment will also be delegated to midwives at the health center level. With the current surge toward institutional births in Cambodia such efforts can be expected to improve maternal survival significantly. Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.