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Integration of the Practice of Active Management of the Third Stage of Labor Within Training and Service Implementation Programming in Zambia


  • Donna Vivio CNM, MPH, MS,

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    • Donna Vivio, CNM, MPH, MS, FACNM, was Senior Reproductive Health Advisor to the Health Services and Systems Program (HSSP) in Zambia and was on the staff of Jhpiego, a partner in the HSSP. She is currently with the World Health Organization in Bangladesh.

  • Judith T. Fullerton CNM, PhD,

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    • Judith T. Fullerton, CNM, PhD, FACNM, is an international consultant in women's reproductive health, measurement, research, and evaluation.

  • Rosha Forman CNM, MSN,

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    • Rosha Forman, CNM, MSN, is a graduate of the Yale University midwifery program where she received the Down's Fellowship for international research. She is currently working as a midwife at Boston University Medical Center, Boston, MA.

  • Reuben Kamoto Mbewe MD,

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    • Reuben Kamoto Mbewe, MD, is a specialist in obstetrics and gynecology. He is Deputy Director of Public Health for Reproductive and Child Health and spokesperson for the Ministry of Health of Zambia.

  • Masuka Musumali MD, DRH,

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    • Masuka Musumali, MD, DRH, is a medical doctor working in the area of reproductive health, and a masters student in public health. She is currently employed as the Reproductive Health Specialist in the HSSP in Lusaka, Zambia.

  • Patrick M. Chewe MA

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    • Patrick Mumba Chewe, MA, is an economist/statistician. He is currently working for the HSSP as a monitoring and evaluation technical advisor.

Address correspondence to Judith T. Fullerton, CNM, PhD, 7717 Canyon Point Ln., San Diego CA 92126.


Introduction: Postpartum hemorrhage (PPH) is the leading cause of pregnancy-related mortality (cited at 591 per 100,000 Zambian women), and is responsible for up to 60% of maternal deaths in developing countries. Active management of the third stage of labor (AMTSL) has been endorsed as a means of reducing the risk of PPH. The Ministry of Health/Zambia has incorporated the use of AMTSL into its reproductive health guidelines.

Methods: Midwives employed in five public hospitals and eight health centers were interviewed (N = 62), and 82 observations were conducted during the second through fourth stages of labor.

Results: Data from facilities in which oxytocin was available (62 births in 11 settings) indicated that a uterotonic was used in 53 of the births (85.5%); however, AMTSL was conducted in strict accord with the currently recommended protocol (a time-specific use of the uterotonic, controlled cord traction, and fundal massage) in only 25 (40.4%) of births.

Discussion: Midwives have concerns about risks of maternal to newborn HIV blood transfusion; it is doubtful that they will adopt the currently recommended practice of delayed cord clamping and cutting. Infrastructure issues and supply shortages challenged the ability to correctly and safely implement the AMTSL protocol; nevertheless, facilities were generally ready to support it.