Midwives’ experiences with implementation of active management of third stage of labor in Sub-Saharan Africa : a systematic review

Abstract

Background: Globally, post-partum hemorrhage (PPH) remains the leading cause of maternal mortality, and active management of the third stage of labor (AMTSL) serves as an effective solution to this critical childbirth and maternal health issue. However, adherence to AMTSL guidelines remains low in Sub-Saharan Africa (SSA): thus, midwives' experiences are essential for interventions aimed at scaling-up AMTSL use. In this study, we identify, appraise, synthesize, and evaluate empirical qualitative evidence on midwives’ experiences with AMTSL implementation in SSA. Methods: The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was conducted across multiple databases, including PubMed, CINAHL, and Scopus, focusing on qualitative studies published between 2003 and 2021, which examined midwives' experiences with the implementation of AMTSL. Keywords such as "active management of the third stage of labor," "postpartum hemorrhage," "maternal mortality," "experiences of midwives," and "sub-Saharan Africa" helped us retrieve 450 articles, which were scaled down to four after applying the inclusion criteria. The thematic analysis, thus reports findings from the four papers. Findings: Five key themes emerged, namely: familiarity with AMTSL; benefits of AMTSL; experiences of midwives with the application of AMTSL; barriers to the implementation; and how to improve implementation. These themes reveal nuances regarding how midwives come to know, apply, and navigate the execution challenges as well as how to promote AMTSL implementation. For illustration, training in AMTSL improves knowledge, yet skepticism persists despite its importance in preventing PPH. Many midwives do not consistently follow all procedures due to barriers like heavy workloads and the unavailability of oxytocin. To enhance AMTSL use, teamwork, delegation, communication, and ensuring oxytocin availability were recommendations proffered. Conclusion: Midwives’ implementation of AMTSL reduces PPH and enhances maternal outcomes, despite the lingering implementation challenges they encounter, especially in low-resource settings. Policies must encourage its use by ensuring the availability of high-quality oxytocin, including proper storage conditions to address shortages, and in addition, priority be assigned to in-service training on its implementation. Finally, ensuring flexible work routines and effective teamwork can also help scale up AMTSL administration and compliance.