Table 4.

Representative quotes regarding facilitators and barriers to the use of prophylactic uterotonics during the third stage of labor

Facilitators

Providers who understood the value of prophylactic uterotonics as a life saving drug purchased oxytocin when the government supply was inconsistent.

• “Because oxy is an emergency drug it is very important for delivery. Sometime it is short, but I buy and keep it in the cupboard. Yea but sometime government have shortage and don’t give us, but we buy.” – Clinical Health Officer  • “I want to save life, I’m not going to depend on government to give me oxy, so that’s why we usually buy it, whenever we have a case. “– Midwife

Established protocols in facility for preventing PPH

• “One of the protocols is that when the woman has delivered we give oxytocin.... All of this management is an attempt to prevent PPH.” – Clinical Health Officer

Providers who understand the importance of oxytocin as a life saving drug strongly encouraged patients to purchase oxytocin when it was unavailable

• “When we are short of oxytocin, we buy. If there is nothing, we tell them [patients], when they are term, birth preparedness, this will one of the things that will be in the kit. You bring this, you bring this, and you bring this. The nurses write for them to bring. But normally it is around. For those who can’t afford, we give. “– Clinical Health Officer  • “We ask them [patients], we force them to buy it because you know after delivery we need to help them with oxytocin.” – midwife

Providers purchase oxytocin out of fear of being audited

• “They order it so that we can save our own selves, because if you have a maternal death and you are on duty, they will query you. They will judge you and you have to prove yourself, you have to take all of your documents and explain what happened and what did not happen. So you will not allow that. So even if the midwife is not around, we have to take it out of [our own money].” – Maternal and Child Health Aid

Barriers

Providers reported giving uterotonics when it was available, but during shortages managed the third stage expectantly.

• “We give oxytocin if we have, but if we don’t have then we express normal procedures [expectant management].” – MCHA

Misconceptions about the universal indication of uterotonics – such as prolonged labor or if there is difficulty delivering placenta - prevented providers from giving routinely

• “At times – we do not give oxytocin if the placenta comes out easily. There is no need to give oxytocin.”  • “Only when it is difficult labor we are told to give. But we haven’t had any yet.

Some providers report learning that uterotonics should be given to all patients but believe that it is not required unless the mother is bleeding

• “Well because we are supposed to give, but when we don’t have the case and we are not seeing enough profuse bleeding, I do not see justification to give. So normally we do fundal massage for contractions to take place, and if there are clots then we expel. We check for tear, perineal, cervical and we see how best – based on that if there is no profuse bleeding we don’t give.” – Clinical Health officer

Belief that prophylactic oxytocin is not needed if a patient delivers normally

• “After the delivery I didn’t give oxytocin because she delivered normally. Only if she is bleeding. Because some of them they deliver normally, no problem.” – MCHA  • “After delivery I do not give any oxytocin because she delivered normally. Later on after 30–40 min {inaudible} so I had to set my normal saline with 20 IU oxytocin and the woman was still bleeding so I called for sister to help me.” - MCHA