A behavioral intervention to improve obstetrical care.
BACKGROUND
Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.


METHODS
We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.


RESULTS
The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention.


CONCLUSIONS
A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720 [ClinicalTrials.gov]; Current Controlled Trials number, ISRCTN82417627 [controlled-trials.com].).
Althabe
Fernando
F
Institute of Clinical Effectiveness and Health Policy, Buenos Aires, Argentina. althabef@gmail.com
Buekens
Pierre
P
Bergel
Eduardo
E
Belizán
José M
JM
Campbell
Marci K
MK
Moss
Nancy
N
Hartwell
Tyler
T
Wright
Linda L
LL
D000328:Adult; D001118:Argentina; D004502:Education, Medical, Continuing; D004841:Episiotomy / Q000193:education / Q000592:standards* / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006771:Hospitals, Maternity / Q000592:standards; D006801:Humans; D007749:Labor Stage, Third / Q000187:drug effects; D009774:Obstetrics / Q000193:education / Q000592:standards*; D010121:Oxytocin / Q000627:therapeutic use*; D006473:Postpartum Hemorrhage / Q000453:epidemiology / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D014583:Uruguay
D010121:Oxytocin