title: Experiencing challenges when implementing active management of third stage of labor (AMTSL): a qualitative study with midwives in Accra, Ghana.
abstract: BACKGROUND
  Post-partum hemorrhage (PPH) is the major cause of maternal mortality in Ghana and worldwide. Active management of the third stage of labor (AMTSL) is a globally recommended three-step method that in clinical trials has been proven effective in prevention of PPH. The AMTSL guidelines were introduced in 2003, modified in 2006, and has been part of the national guidelines in Ghana since 2008. In 2012, the guidelines were modified a second time. Despite its positive effects on the incidence of PPH, the level of adherence to the guidelines seems to be low in the studied area. This appears to be a problem shared by several countries in the region. An in-depth understanding of midwives' experiences about AMTSL is important as it can provide a basis for further interventions in order to reach a higher grade of implementation.
  
  
  METHODS
  Twelve in-depth interviews were conducted with labor ward midwives who all had previous training in AMTSL. The interviews took place in 2011 at three hospitals in Accra Metropolis and data was analyzed using qualitative latent content analysis.
  
  
  RESULTS
  Our main finding was that the third step of AMTSL, uterine massage, was not implemented, even though the general attitude towards AMTSL was positive. Thus, despite regular training sessions, the midwives did not follow the Ghanaian national guidelines. Some contributing factors to difficulties in providing AMTSL to all women have been pointed out in this study, the most important being insufficiency in staff coverage. This led to a need for delegating certain steps of AMTSL to other health care staff, i.e. task shifting. The fact that the definition of AMTSL has changed several times since the introduction in 2003 might also be an aggravating factor.
  
  
  CONCLUSIONS
  The results from this study highlight the need for continuous updates of national guidelines, extended educational interventions and recurrent controls of adherence to guidelines. AMTSL is an important tool in preventing PPH, however, it must be clarified how it should be used in countries with scarce resources. Also, considering the difficulties in implementing already existing guidelines, further modifications must be made with careful consideration.
authors.forename: Stina Mannheimer
authors.initials: SM
authors.lastname: Schack
authors.forename: Amna
authors.initials: A
authors.lastname: Elyas
authors.affiliation: Safe Mother Care Programme, Ghana Health Service, Accra, Ghana. gbrew2001@yahoo.co.uk.
authors.forename: Gladys
authors.initials: G
authors.lastname: Brew
authors.forename: Karen Odberg
authors.initials: KO
authors.lastname: Pettersson
mesh_terms: D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000592:standards*; D005260:Female; D005869:Ghana; D019983:Guideline Adherence / Q000458:organization & administration; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D007749:Labor Stage, Third; D008405:Massage / Q000592:standards; D008880:Midwifery / Q000458:organization & administration / Q000592:standards*; D006473:Postpartum Hemorrhage / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D036301:Qualitative Research; D014599:Uterus; D016526:Workload