Voices from the Capacity Project

Health worker Berthé Aissata Touré is dedicated to helping women deliver their babies safely, but in a large country like Mali with vast rural areas, birth complications are especially risky. “When we had cases of hemorrhage we referred them to the district referral center,” Touré explains. “Often the trip is very long and there is too much time to lose blood on the way. Even once you get there it can take a while to have blood available. Many women were lost.”

Touré is among a group of auxiliary midwives called matrones who attend the majority of births in Mali. Pregnancy- and delivery-related mortality remains the primary cause of death among women of reproductive age. Although postpartum hemorrhage—the leading cause of maternal mortality—cannot be predicted, it can be avoided with appropriate measures. The World Health Organization recommends using a technique known as active management of the third stage of labor (AMTSL) to prevent excessive blood loss after delivery. AMTSL also helps decrease other complications that can occur, including retained placenta. Matrones, however, were not authorized to administer uterotonic drugs, a critical component of AMTSL, and thus couldn’t be trained in the lifesaving practice.

Addressing this issue, the Capacity Project partnered with the Ministry of Health, the Prevention of Postpartum Hemorrhage Initiative and USAID-funded bilateral projects (Assistance Technique Nationale and Keneya Ciwara) on a pilot study to demonstrate the efficiency and the safety of matrones using AMTSL. The study compared matrones’ use of AMTSL with skilled birth attendants who were authorized to perform the practice, and assessed factors that could affect matrones’ ability to perform AMTSL.

Diarra Djeneba is a matrone who participated in the pilot. “Before we had AMTSL training we had a lot of cases of retained placenta or incomplete placenta,” she recounts. “We needed to find a motorbike to go get the midwife and that took a long time. Since we started practicing AMTSL we haven’t had to go get a midwife because the placenta is immediately delivered, within three to five minutes. Cases of hemorrhage are also decreased.”

Djeneba shares an example. “A woman who usually gives birth with me lost a lot of blood at each delivery. Often we had to do a transfusion, and she would have to stay at the health center for three to four days because of anemia. After we started practicing AMTSL, this woman had a delivery here and coincided with my shift. I correctly practiced AMTSL and the woman was very surprised because she didn’t bleed or have anemia. And she was even more surprised when she was told she could go home the same day! I explained that we’ve been trained to practice this different method, AMTSL. The woman thanked me and said she would advocate for more women to come deliver at this health center.”

After training, the study assessed matrones on the skills and techniques involved in AMTSL. They scored 96%, essentially the same as the skilled birth attendants’ score of 97%. Matrones’ scores in recognizing and handling delivery complications were virtually identical to those of skilled birth attendants.

Data from the final assessment showed that almost all vaginal deliveries in the study’s health facilities had occurred using AMTSL. Matrones attended an important number of these births, and the postpartum hemorrhage rate decreased from 1.9% (93 cases) in the baseline survey to 0.13% during the final assessment (11 cases).

Dr. Mahamadou Traoré is head of the health division in Koulikoro. “Since this is a technique that enables decreasing cases of postpartum hemorrhage and therefore maternal mortality,” he says, “we have to involve matrones in this strategy because 80-90% of deliveries are done by matrones. So if you really want to bring down the number of postpartum hemorrhage cases and maternal mortality cases,” he continues, “we really have to involve matrones and ensure a supportive supervision system.”

Presented with the study’s promising results, Minister of Health M. Oumar Ibrahim Touré promptly authorized matrones to practice AMTSL and requested a commission to develop an action plan for training all matrones throughout the country.

“With AMTSL our work has been made easier,” Berthé Aissata Touré adds, “and I can say that it has allowed us to save many women’s lives.”

[June 2009. Print a PDF version.]

The Capacity Project, funded by the United States Agency for International Development (USAID) and implemented by IntraHealth International and partners (IMA, Jhpiego, LATH, MSH, PATH, TRG), helps developing countries strengthen human resources for health to better respond to the challenges of implementing and sustaining quality health programs.

The Voices from the Capacity Project series is made possible by the support of the American people through USAID. The contents are the responsibility of IntraHealth International and do not necessarily reflect the views of USAID or the United States Government.