Ministry of Health of Ecuador Adopts Guidelines for Active Management of the Third Stage of Labor and Scales up its Implementation

by Cecilia Moya and Luis Vaca

Health providers were trained in AMTSL procedures using anatomical models

As part of a regional Essential Obstetric Care (EOC) Improvement Collaborative supported by USAID in Ecuador, Honduras, and Nicaragua, in August 2003, QAP began supporting the Tungurahua Provincial Health Directorate and teams in the province’s hospital and seven health centers to introduce a number of evidence-based obstetric care practices in the province’s health facilities. One of these practices was the active management of the third stage of labor (AMTSL), which reduces the occurrence of maternal death by preventing post-partum hemorrhage.

The third stage of labor is the period between the birth of the child and the expulsion of the placenta. In passive management of this stage of labor, the health provider attending the delivery only intervenes if there is a problem. In contrast, active management is a preventive intervention aimed at avoiding post-partum hemorrhage by means of three concrete actions:

• Application of 10 IU of oxytocin immediately after the birth of the child
• Controlled traction of the umbilical cord
• Uterine massage after the expulsion of the placenta

At the time the collaborative started, AMTSL was rarely practiced in Ecuador, mainly because it was not part of the Ministry of Public Health’s (MOH) technical guidelines for maternal care, which had last been updated in 1999. Indeed, many MOH authorities were not convinced of the efficacy of AMTSL in preventing post-partum hemorrhage, and as a result, some were hesitant about its use in Ecuador as part of the EOC Collaborative. It was in that context that the leadership of the EOC Collaborative began an intense effort of information dissemination, training, monitoring, and advocacy vis-à-vis AMTSL with MOH officials, beginning in Tungurahua.

Through the learning sessions of the EOC Collaborative, teams of healthcare practitioners in Tungurahua’s facilities had access to high quality international literature which demonstrated the efficacy of AMTSL in preventing post-partum hemorrhage. They were also trained in its application and shared their experiences with other practitioners through several meetings and, more recently, through the collaborative’s website (www.mortalidadmaterna.org), which allows healthcare providers from Ecuador, Nicaragua, and Honduras to share their experiences on improving maternal care.

In early 2004, another two Ecuadorian provinces joined the collaborative, and by mid-2004, another eight provinces followed suit, such that by 2005, half of Ecuador’s 22 provinces were participating in the EOC Collaborative, including facilities in some 70 districts. Because of the rapid expansion of the work of the collaborative, the practice of AMTSL experienced fast growth in public healthcare facilities.

As a result of advocacy efforts and what was taking place at the operational level in so many facilities, MOH authorities agreed to adopt the use of oxytocin as one of the indicators of quality obstetric care, although they abstained from promoting AMTSL as an officially sanctioned procedure. In 2005, most facilities participating in the collaborative in each province were reporting on oxytocin use for each attended delivery.

The following graph shows the increase in the use of oxytocin as a proxy measure for active management of the third stage of labor in 11 of Ecuador’s 22 provinces between July 2003 and December 2005. It is notable that the practice of AMTSL increased from 0% to 70% of attended normal deliveries in a 30-month period.

According to María Elena Robalino, M.S., nurse at the Riobamba General Teaching Hospital and an active participant in the collaborative, the application of oxytocin in vaginal births increased in Riobamba hospital from zero to 100% in less than a year. She feels that this was possible due to the leadership of the Chief of the Ob-Gyn ward and the commitment of the staff of the Obstetric Care Center to the implementation of the following actions:

• Review and discussion of evidence-based literature on AMTSL.
• Placing of posters in the delivery room detailing the AMTSL procedure.
• Assigning responsibility to the medical staff attending the delivery for administering or prescribing oxytocin.
• Assigning responsibility to the nursing staff for administering oxytocin and its registration in the patient’s medical record.
• Training and supervision of each physician in the Obstetric Care Center in AMTSL.

As the practice of AMTSL expanded in the provinces participating in the collaborative, advocacy efforts with central MOH authorities were intensified in order to achieve the necessary legitimacy for the practice, to continue the spread of active management throughout the entire country. While ideally this legitimacy should be reflected in a complete revision of the current maternal care guidelines, given the difficulty of achieving such a revision in a short time, it was decided instead to work toward an addendum to the guidelines which would endorse the practice of AMTSL.

The restructuring process that has been underway within the MOH, coupled with the country’s political instability, have led to frequent changes in key MOH staff and resulted in delays in efforts to formalize AMTSL within the national maternal care guidelines. However, in December 2005, MOH representatives and QAP staff resumed discussion on the subject, and the MOH decided to move ahead with the addendum. In January 2006, the MOH convened a working group of expert obstetrician-gynecologists with QAP support to write the addendum, which was completed in February and is now scheduled to be officially launched at a national meeting on April 20, 2006. This meeting will be attended by national and regional public health authorities and will initiate the distribution of 1,500 copies of the addendum to healthcare personnel throughout Ecuador.

The collaborative approach supported by QAP and the MOH in Ecuador, which promotes continual sharing of information by peers, allowed for the introduction and rapid expansion of a key internationally accepted best practice to safeguard maternal health. The changes in clinical practice triggered in health facilities in the provinces participating in the collaborative fueled and reinforced the advocacy efforts carried out at the highest levels of health policy decision-making. The important national policy change that has been achieved in Ecuador with respect to active management of the third stage of labor will now legitimize a trend that continues to gain strength in clinical practice and that will benefit the health of women of reproductive age in the entire country.

 For more information on QAP’s work in Ecuador, contact QAP Deputy Director Dr. Jorge Hermida at jhermida@urc-chs.com.

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(Note: The provinces that joined the EOC Collaborative were those in which the QAP team was already introducing continuous quality improvement methodologies within the National Free Maternity Program.)