CLINICAL ARTICLE Reduced postpartum hemorrhage after implementation of active management of the third stage of labor in rural Honduras Lisa Kane Low a, b, ⁎, Joanne Motino Bailey c , Emma Sacks d , Chayla Robles b , Lilian Medina e a Women's Studies Department, University of Michigan, Ann Arbor, USA b School of Nursing, University of Michigan, Ann Arbor, USA c University of Michigan Health System, Ann Arbor, USA d Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA e Negrito Health Center, Yoro, Honduras abstract article info Article history: Received 30 March 2012 Received in revised form 5 July 2012 Accepted 15 August 2012 Keywords: Active management of third stage labor AMTSL Honduras Intramuscular oxytocin Postpartum hemorrhage Safe Motherhood Skilled birth attendants Objective: To assess outcomes after auxiliary nurses were trained and given resources to use active manage- ment of the third stage of labor (AMTSL) for all women giving birth in a low-resource, low-risk, rural, public birth center setting in northern rural Honduras. Methods: Auxiliary nurses received training on estimation of blood loss before the preintervention phase of the study (July 2004 through April 2005) and AMTSL, including use of intramuscular oxytocin, and estimation of blood loss prior to the intervention phase (July 2007 through June 2008). Preintervention and intervention data on use of oxytocin, blood loss postpartum, hemorrhage rates, and management interventions were collected and compared. Results: After nurses received training on AMTSL using intramuscular oxytocin, the use of intramuscular oxytocin during the third stage of labor increased from 63.8% to 96.5%. Postpartum hemorrhage rates decreased from 14.8% to 5.9% (P = 0.001). Use of intrapartum oxytocin, which can have adverse effects, also increased: from 6.1% to 22.7% (P b 0.001). Conclusion: Training auxiliary nurses to perform AMTSL using oxytocin in this birth center setting was effective in reducing the rate of postpartum hemorrhage; however, increased use of intrapartum oxytocin may be an unintended outcome of the increased accessibility of oxytocin. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide and accounts for 25% of all maternal deaths [1]. Active management of the third stage of labor (AMTSL) is an evidence-based strategy to reduce the incidence of uterine atony, which is the primary cause of PPH [2]. Components of AMTSL include admin- istration of uterotonic medications to the mother within 1 minute after delivery, use of controlled cord traction in delivery of the placenta, and uterine massage following placental delivery [1]. The use of AMTSL can reduce the risk of PPH (blood loss greater than 500 mL) and severe PPH (blood loss greater than 1000 mL) and decrease the need for blood transfusion or additional uterotonic medications [2]. The International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) issued a joint statement in 2003 and reinforced it in 2006, recommending routine use of AMTSL in all vaginal births as the optimal standard of maternity care in all settings [1]. However, implementation of AMTSL requires training and resources [3]. Implementation challenges in low-resource countries include variations in curricula, conflicting policies, insufficient training, and variable access to uterotonic agents. Honduras currently has a maternal mortality rate of 110 per 100 000 live births [4], which represents a decrease from 186 per 100 000 during the 1990s [5]. Successful efforts to reduce maternal mortality in Honduras have focused on increasing the number of births attended by skilled birth attendants in hospitals and free-standing birth centers [6]. In 2004, the Honduran Ministry of Public Health officially endorsed the universal application of AMTSL as a standard of maternity care in all settings as a means of continuing to reduce maternal morbidity and mortality. Clínica Materno-Infantíl (CMI) is a free-standing, public birth cen- ter located in northern rural Honduras in the district of Morazán. The clinic offers pregnancy and delivery services to low-risk women from the surrounding area, including rural communities located as much as 4 hours away. It is the site of previous maternal health research [7], is staffed by auxiliary nurses, and is administratively supervised by a professional nurse and a general medicine physician who are normally available on-call. The auxiliary nurses attend most births alone without other immediate help. The Honduran auxiliary nurse curriculum is a 1-year program that includes prenatal care knowledge and experience, but not care during childbirth. Prior to staffing at CMI, an auxiliary nurse must observe and perform supervised births International Journal of Gynecology and Obstetrics 119 (2012) 217–220 ⁎ Corresponding author at: 400 N, Ingalls, Suite 3320, Ann Arbor, MI 48109, USA. Tel.: +1 734 647 0136. E-mail address: kanelow@umich.edu (L.K. Low). 0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.007 Contents lists available at SciVerse ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo