Journal Article Reports Ecuador’s Adoption of Clinical Practice to Improve Maternal Health

An article by public health specialists at University Research Co, LLC (URC) describes how Ecuador successfully introduced a modern delivery practice nationwide within six years, transforming its approach to maternal health in the process. The article provides a compelling model for countries seeking to reduce the number of women who die each year during childbirth, estimated at nearly 400,000 globally. Co-authored by Dr. Jorge Hermida, Director of Latin America for the US Agency for International Development (USAID) Health Care Improvement Project (HCI), the article appears in the June issue of the International Journal of Gynecology and Obstetrics.

As in many other developing countries, the primary cause of maternal death in Ecuador results from severe bleeding in childbirth, or postpartum hemorrhage. Research shows that postpartum hemorrhage rates drop by more than half when health workers perform a clinical practice called active management of the third stage of labor (AMTSL) immediately after delivery. AMTSL involves three steps: injecting a drug that induces contractions, carefully pulling out the umbilical cord, and massaging the woman’s abdomen.

Most women in Ecuador go to health facilities to deliver, but most health facilities did not apply AMTSL until HCI and the Ministry of Health introduced the practice in 2003. The article describes the introduction and rapid expansion of AMTSL in Ecuadoran health facilities, health centers, and hospitals. 

“Together with the Ministry of Health, we introduced one of simplest, low-cost, high-impact clinical practices that can significantly reduce the preventable deaths of women during childbirth,” said Dr. Hermida. “Through this process, we learned that scaling up AMTSL nationally is both feasible and affordable.”

At the same time, HCI Ecuador staff advocated for including AMTSL in national health care guidelines with ministry officials. Using this twofold approach—facility-level implementation and national-level advocacy—the project galvanized support and impetus for action at both grassroots and national levels. The project’s initial success convinced ministry decision makers to approve and include the contraction-inducing drug oxytocin in the ministry’s obstetric care standards in 2006.

“This project helped transform the ministry’s approach to maternal health care, prompting us to prioritize and launch a national plan to reduce maternal deaths in childbirth,” said Bernarda Salas, co-author of the paper and National Director of Standardization at the Ecuadorian Ministry of Health from 2007 to 2009. “Because of this, we are saving more mothers’ lives and improving the livelihoods of families around the country.” 

By the project’s end, 138 health facilities, 37 health centers, and 101 hospitals applied AMTSL to women who delivered under their care at least 90% of the time. Even as donor support waned in late 2008, this rate remained constant, demonstrating that health facilities had institutionalized the practice.

Applying Continuous Quality Improvement for Better Care

To achieve these results, HCI applied a process called continuous quality improvement (CQI). Through CQI, facility-based teams of health care workers adapt, integrate into their regular work, and disseminate one or more best practices (in this case, AMTSL) by testing innovative ways to overcome any obstacles they encounter in trying to implement the practice. The teams regularly measure and evaluate their progress in complying with the practice to determine when it is not used and why. The interaction of teams within and among facilities fosters innovation and motivates health workers to strive for improvement.

The ministry gathered and synthesized lessons learned during the CQI teamwork and incorporated them into a National Campaign to Reduce Maternal Mortality.

The article suggests that public health practitioners and ministries of health can use CQI to introduce and scale up AMTSL and other best practices that would improve the health and welfare of people worldwide. 

Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador” is available online. An author-accepted manuscript is available in English and Spanish.

About URC 
Established in 1965, URC is a global company dedicated to improving the quality of health care, social services, and health education worldwide through programs in over 40 countries, including the global USAID Health Care Improvement Project. With its non-profit affiliate, the Center for Human Services, URC is based in Bethesda, Maryland, USA and has over 850 employees around the world.

About HCI 
HCI is a USAID-funded project that supports countries in improving the quality and impact of health services. The project assists national and local programs to scale up evidence-based interventions and improve outcomes in child health, maternal and newborn care, HIV/AIDS, tuberculosis, malaria, and reproductive health.


June 29, 2012
Regions/ Countries