title: Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador.
abstract: 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.
  
  
  CONCLUSIONS
  CQI processes identified resistance and operational barriers, and developed mechanisms to overcome them.
authors.affiliation: University Research Co., LLC, Bethesda, MD 20814, USA. jhermida@urc-chs.com
authors.forename: Jorge
authors.initials: J
authors.lastname: Hermida
authors.forename: Bernarda
authors.initials: B
authors.lastname: Salas
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Sloan
mesh_terms: D004484:Ecuador; D005260:Female; D006801:Humans; D007749:Labor Stage, Third; D010120:Oxytocics / Q000627:therapeutic use*; D010121:Oxytocin / Q000627:therapeutic use*; D006473:Postpartum Hemorrhage / Q000517:prevention & control*; D011247:Pregnancy; D058996:Quality Improvement; D013997:Time Factors
chemical_list: D010120:Oxytocics; D010121:Oxytocin