Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador

Objective: To analyze the Ecuadorian experience regarding the adoption, scale-up, and institutionalization of active management of the third stage of labor (AMTSL) for prevention of postpartum hemorrhage via continuous quality improvement (CQI) processes. Methods: Average AMTSL implementation rates for women with vaginal deliveries were compared using unweighted provincial aggregate data from facilities participating in 3 phases of AMTSL programming. Months taken to implement AMTSL at 80% or more and 90% or more compliance were compared across phases. Results: Rate of oxytocin administration during the first 3 months was 5.0% in phase 1, 9.8% in phase 2, and 72.2% in phase 3 (P <= 0.001 vs phases 1 and 2). The average number of months provinces took to increase oxytocin administration to 80% or more and 90% or in more women with vaginal deliveries was, respectively, 21.6 +/- 18.7 and 30.6 +/- 16.4 in phase 1, 23.5 +/- 15.1 and 30.1 +/- 14.9 in phase 2, and 4.7 +/- 4.9 (P <= 0.01 vs phase 1; P <= 0.001 vs phase 2) and 4.0 +/- 3.4 (P <= 0.001 vs phases 1 and 2) in phase 3. By December 2009, AMTSL implementation was sustained at 90% or more in all provinces. Conclusion: CQI processes identified resistance and operational barriers, and developed mechanisms to overcome them. (C) 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.