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Saving Women's Lives One Birth at a Time

Scaling Up of a Best Practice in Obstetrical Care Makes a Difference in Benin!

Post-partum hemorrhaging is the single most significant cause of maternal mortality in the world, accounting for half of all maternal deaths that occur after childbirth, and about one-fourth of maternal deaths overall. In Benin, post partum hemorrhages contribute significantly to the high maternal mortality rate.

Unlike other causes of maternal death, post-partum hemorrhages can be easily prevented through the systematic application of "active management of the third stage of labor" (AMTSL) recognized by the World Health Organization as a best practice to be replicated. This practice has three main components: use of uterotonic drugs within one minute after birth of the newborn, controlled cord traction and counter-traction to the uterus, and massage of the uterine fondus through the abdomen. The practice shortens the time it takes to deliver the placenta and significantly reduces the chances of severe bleeding following delivery.

Thanks to the efforts of the Ministry of Health and its partners-and USAID's support-more and more women in Benin are benefiting from the application of this life-saving practice.

In September 2002, USAID launched a special initiative to reduce postpartum hemorrhage. In Benin, IntraHealth (a U.S. non-profit organization) worked in collaboration with the Ministry of Health and professional associations to demonstrate the feasibility of introducing AMTSL. AMTSL was introduced in seven pilot sites in three regions and 121 providers were trained in the AMTSL practice, as well as counseling and other skills.

Following this successful pilot experience, the Ministry of Health advocated scaling up the practice-and, with support from IntraHealth, other donors (such as the World Bank, UNFPA and the Swiss Cooperation) got involved. AMTSL was eventually introduced in 70 health facilities (in four regions), with more than 120 additional providers trained.

Follow-ups conducted in some pilot sites in October 2003 and in July 2004 revealed a decrease in the number of cases of hemorrhaging during delivery in the sites visited. Dramatic decreases occurred in the numbers of cases that needed to be evacuated to a referral facility. For instance, before the AMTSL training, 19 hemorrhage cases were recorded at the Akassato Health Center and six of these cases were evacuated (January through April 2004). After the training, only two cases of hemorrhaging occurred-and no evacuation was needed.

The impact of AMTSL practice on the number of hemorrhage and maternal death cases is more difficult to document from records. Information on delivery practices is not always properly documented, and the data are not always reliable. Nevertheless, data indicate that AMTSL is having a positive impact. Some data collected for the period of April thru September 2004 show that at the national university gynecologic and obstetrical clinic where AMTSL is hardly applied (14%), 4.6% of post partum hemorrhages where recorded for 926 deliveries and 3 maternal deaths due to a post partum hemorrhage (0.3%). On the other hand, at one of the biggest maternity hospitals in Benin, where more than 80% of vaginal deliveries are performed with AMTSL, there were only 0.4% of post partum hemorrhages for 2027 vaginal deliveries and only one maternal death was recorded (0.05%) .

The systematic application of AMTSL not only contributes to preventing maternal morbidity and mortality-it is also a practice greatly appreciated by health care providers themselves. Providers in Benin said that AMTSL is safer, cleaner, faster and often less expensive than the other methods, both for the health facility and for the client herself! Providers also are exposed to less blood (thus reducing risk of infections), are using less blood and other supplies and do not have to spend as much time waiting for the delivery of the placenta-leaving them more time to attend to the mother, the newborn and other clients, and for the mother to rest and to hold her baby immediately after birth.

Information gathered to date, though not yet complete, clearly shows the benefits of using AMTSL in health facilities. However, additional efforts are needed to ensure the quality of service provision for emergency obstetrical and neonatal care, and to ensure that all providers are actually trained in AMTSL so that a maximum number of women in Benin can benefit from it.

The Ministry of Health in Benin is committed to a long-term vision of a significant and lasting reduction in maternal mortality that includes ensuring the availability, accessibility and utilization of high quality family health. By supporting the prevention of post-partum hemorrhages, improved emergency obstetrical and neonatal care, and a strengthened health care system, USAID and its partner agencies are working to support the MOH in achieving this vision.

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