title: A multifaceted intervention to increase prophylactic oxytocin use during the third stage of labor and to reduce routine episiotomies in Nicaragua.
abstract: OBJECTIVE
  To assess the effect of a multifaceted intervention among skilled birth attendants on the use of oxytocin during the third stage of labor, the active management of the third stage of labor (AMTSL), and the rate of routine episiotomy during vaginal births in two health districts in Nicaragua.
  
  
  METHODS
  An uncontrolled before-and-after study design was used. The rates of oxytocin use in the third stage of labor, AMTSL, and episiotomy were measured for vaginal births occurring in eight hospitals and health centers during 2011-2012, before and after implementation of a multifaceted facility-based intervention. The intervention involved the use of opinion leaders, interactive workshops to develop and implement evidence-based guidelines, academic detailing, the use of reminders, and feedback on the rates of oxytocin use and episiotomy.
  
  
  RESULTS
  Oxytocin use during the third stage of labor increased significantly from 95.3% to 97.4% (P=0.003). The episiotomy rate dropped significantly from 31.2% to 21.2% overall, and from 59.6% to 40.5% in primiparous women (P<0.001 for both comparisons).
  
  
  CONCLUSIONS
  The multifaceted intervention improved the targeted care practices during childbirth. However, a further decrease in the routine use of episiotomy would be desirable.
authors.affiliation: Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. Electronic address: egarciaelorrio@iecs.org.ar.
authors.forename: Ezequiel
authors.initials: E
authors.lastname: García-Elorrio
authors.affiliation: Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay.
authors.forename: Alicia
authors.initials: A
authors.lastname: Aleman
authors.affiliation: Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay.
authors.forename: Maria L
authors.initials: ML
authors.lastname: Cafferata
authors.affiliation: Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Colomar
authors.affiliation: Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay.
authors.forename: Giselle
authors.initials: G
authors.lastname: Tomasso
authors.affiliation: Program for Appropriate Technology in Health (PATH), Managua, Nicaragua.
authors.forename: Yann
authors.initials: Y
authors.lastname: Lacayo
authors.affiliation: Program for Appropriate Technology in Health (PATH), Managua, Nicaragua.
authors.forename: Henry
authors.initials: H
authors.lastname: Espinoza
authors.affiliation: Program for Appropriate Technology in Health (PATH), Seattle, WA, USA.
authors.forename: Shirley
authors.initials: S
authors.lastname: Villadiego
authors.affiliation: Program for Appropriate Technology in Health (PATH), Seattle, WA, USA.
authors.forename: Susheela
authors.initials: S
authors.lastname: Engelbrecht
authors.affiliation: Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
mesh_terms: D000293:Adolescent; D000328:Adult; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D004841:Episiotomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007749:Labor Stage, Third; D008297:Male; D009527:Nicaragua; D010120:Oxytocics / Q000627:therapeutic use*; D010121:Oxytocin / Q000627:therapeutic use*; D006473:Postpartum Hemorrhage / Q000517:prevention & control*; D011247:Pregnancy; D011446:Prospective Studies; D055815:Young Adult
chemical_list: D010120:Oxytocics; D010121:Oxytocin
keywords: Active management of third stage of labor (AMTSL); Multifaceted intervention; Nicaragua; Oxytocin; Postpartum hemorrhage; Professional behavior change; Selective episiotomy; Uniject