Maternal Safety First: Study Exploring Midwives' Experiences with Active Management of Third Stage of Labor

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality, making the implementation of Active Management of the Third Stage of Labor (AMTSL) critical. Recent systematic review synthesizes qualitative evidence regarding midwives' experiences with AMTSL, highlighting both their knowledge and barriers to effective application. Results indicate that while midwives acquire AMTSL knowledge mainly through education and on-the-job training, consistent application of its protocols varies. Midwives recognized the importance of AMTSL, composed of administering uterotonics, controlled cord traction (CCT), and uterine massage, to prevent PPH. However, hesitation often preceded its incorporation, stemming from a lack of in-service training and varying personal experiences. Participants indicated that while knowledge was adequate, those newly graduated found implementation easier due to recent training on current evidence-based practices (EBP). The review elucidates that hands-on experience plays a crucial role in overcoming initial skepticism about the effectiveness of AMTSL.

Barriers to Effective Implementation

Significant barriers to AMTSL implementation emerged from the findings, including excessive workloads and understaffing within healthcare facilities. Many midwives reported challenges in adhering to the recommended protocols due to time constraints, wherein they often focused on immediate needs, such as the health of the newborn, during high-pressure birth scenarios. Moreover, crowded labor environments impeded the execution of AMTSL due to simultaneous births. A common sentiment expressed by midwives was that PPH was often perceived as an inevitable consequence of childbirth rather than a preventable condition.

Recommendations for Improvement

The findings highlight the necessity for improved working conditions, including adequate staffing and timely access to essential medications like oxytocin, to facilitate effective AMTSL practices. Continuous professional development through structured mentorship and in-service training is crucial for bridging the knowledge gap among midwives. Notably, fostering open communication and collaboration among staff could also enhance knowledge-sharing and adherence to AMTSL best practices.

Research Gaps and Future Directions

The review identifies a significant research gap, emphasizing the need for more qualitative studies on midwives' experiences with AMTSL to inform midwifery practice and policy. Recommendations include establishing supportive environments that prioritize training and adherence to protocols, as well as standardized monitoring systems. Ultimately, prioritizing these initiatives may advance maternal health in Sub-Saharan Africa and significantly reduce the incidence of PPH-related maternal mortality.

Key Points

- Postpartum hemorrhage (PPH) is a major cause of maternal mortality in Sub-Saharan Africa, highlighting the need for effective Active Management of the Third Stage of Labor (AMTSL) protocols among midwives to mitigate this issue.

- Midwives acquire their knowledge of AMTSL primarily through educational programs and on-the-job training, yet their ability to consistently implement AMTSL protocols is influenced by various factors, including personal experience and in-service education.

- The components of AMTSL—administering uterotonics, controlled cord traction (CCT), and uterine massage—are recognized by midwives as essential measures to prevent PPH, although they often experience hesitation in applying these techniques due to insufficient training and previous experiences.

- Barriers to implementing AMTSL include excessive workloads, understaffing, and high-pressure situations during labor, which lead midwives to prioritize immediate newborn health concerns over adherence to AMTSL protocols.

- Improvements in AMTSL implementation can be achieved through enhanced working conditions, such as better staffing ratios and timely access to necessary medications, along with ongoing professional development and mentorship for midwives.

- There is a pressing need for further qualitative research to explore midwives' experiences with AMTSL, which could inform midwifery practice and policy changes. Advocating for supportive training environments and standardized monitoring may also significantly improve maternal health outcomes and reduce PPH-related mortality rates in the region.

Reference –

Esther Danquah & Anthony Kwame Morgan (2025). Midwives’ Experiences With Implementation Of Active Management Of Third Stage Of Labor In Sub-Saharan Africa: A Systematic Review. *BMC Pregnancy And Childbirth*, 25. https://doi.org/10.1186/s12884-025-07331-7.