Editor's comment

The two safe motherhood papers featured in the December issue both address the implementation of well-known interventions in low resource contexts—the continuing challenge to averting maternal death and disability. One of the interventions, active management of the third stage of labor (AMTSL), concerns the prevention of one of the most common complications (postpartum hemorrhage) [1]. The other intervention, cesarean delivery [2], is in response to several complications. While both these interventions are widespread and relatively safe in countries with well-developed health systems, in settings where health systems are less well developed, both have the potential to do harm.

The issues surrounding cesarean delivery are well known and numerous—access to care, late presentation, prompt and correct diagnosis, prompt response, human resources, presence of protocols and adherence to them, surgical technique, pre- and postoperative care, and overuse. Yet the intervention has received a fair amount of attention, and progress has been and continues to be made in increasing its availability and quality.

Although, for several decades, some have recommended making uterotonics available at the lowest levels of the health system (even traditional birth attendants), the potential for dangerous misuse has largely discouraged this. Perhaps because of this, AMTSL has received less attention as the paucity of research shows. Furthermore, research in low-income countries has suffered from unclear detail and weakness of design. An exception is the recent work in India [3].

The issues surrounding the use of uterotonics differ from those around cesarean delivery. While they have in common the availability of human resources and presence or absence of protocols, practical details also matter such as which uterotonic drugs are available and in what dose and form (tablet, liquid, suppository etc), by what means can they be administered (regulatory infusion pump for example), and what adjunct nonpharmaceutical techniques can and should be used. Although much work remains to be done in this area—from well designed research to adjustments in essential drug policy—the potential public health benefit is great.