Abstract
BackgroundA significant proportion of the health care administered to women in Latin American maternity hospitals during labor and delivery has been demonstrated to be ineffective or harmful, whereas effective interventions remain underutilized. The routine use of episiotomies and the failure to use active management of the third stage of labor are good examples.Methods/DesignThe aim of this trial is to evaluate the effect of a multifaceted behavioral intervention on the use of two evidence-based birth practices, the selective use of episiotomies and active management of the third stage of labor (injection of 10 International Units of oxytocin). The intervention is based on behavioral and organizational change theories and was based on formative research. Twenty-four hospitals in three urban districts of Argentina and Uruguay will be randomized. Opinion leaders in the 12 intervention hospitals will be identified and trained to develop and implement evidence-based guidelines. They will then disseminate the guidelines using a multifaceted approach including academic detailing, reminders, and feedback on utilization rates. The 12 hospitals in the control group will continue with their standard in-service training activities. The main outcomes to be assessed are the rates of episiotomy and oxytocin use during the third stage of labor. Secondary outcomes will be perineal sutures, postpartum hemorrhages, and birth attendants' opinions.
Highlights
A significant proportion of the health care administered to women in Latin American maternity hospitals during labor and delivery has been demonstrated to be ineffective or harmful, whereas effective interventions remain underutilized
The caesarean section rate in Latin American countries is above 25% for the region as a whole, resulting in approximately 850,000 unnecessary cesarean sections performed each year [3]
Among the trials considered in the above reviews were strategies directed at behavior change of birth attendants in North America and Europe, including distribution of educational materials, employing local opinion leaders, and the use of audits and feedback directed at increasing the number of vaginal births after cesarean section [15]; nurse opinion leaders to reduce rates of epidural analgesia by increasing the amount of support to women in labor [16]; educational outreach visits to introduce Cochrane Reviews to facilitate evidence-based use of specific birth practices [17]; employing local opinion leaders, grand round lectures, chart reminders, group interactive discussions, and audits to increase the use of corticosteroids for enhancing fetal lung maturation prior to a preterm birth [18]
Summary
In Latin American maternity hospitals, a significant proportion of the health care administered to women during labor and delivery has been demonstrated to be ineffective or harmful, whereas proven effective interventions are underutilized. Among the trials considered in the above reviews were strategies directed at behavior change of birth attendants in North America and Europe, including distribution of educational materials, employing local opinion leaders, and the use of audits and feedback directed at increasing the number of vaginal births after cesarean section [15]; nurse opinion leaders to reduce rates of epidural analgesia by increasing the amount of support to women in labor [16]; educational outreach visits to introduce Cochrane Reviews to facilitate evidence-based use of specific birth practices [17]; employing local opinion leaders, grand round lectures, chart reminders, group interactive discussions, and audits to increase the use of corticosteroids for enhancing fetal lung maturation prior to a preterm birth [18]. Secondary objectives are to evaluate the effect of the intervention on rates of post-partum hemorrhage, use of perineal sutures and to document readiness to change among birth attendants Through this process we intend to improve the research capacities of a network of Latin American hospitals, and increase their ability to perform quality local and collaborative research studies
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