Intensive Training for Medical Staff in Latin
American Hospitals Reduces
Serious Complication of Pregnancy
An intensive educational program for physicians and midwives involving
19 hospitals in Argentina and Uruguay dramatically reduced the
rate of postpartum hemorrhage, according to researchers from the
National Institutes of Health and other institutions.
Postpartum hemorrhage is excessive bleeding experienced by the
mother after she gives birth. It results from failure of the uterus
to contract after detachment of the placenta, or from ruptures
or tears in the uterus and other tissues. The intensive educational
program stressed giving the drug oxytocin to all women just after
vaginal delivery, to contract the uterus and stop uterine bleeding.
The educational program also resulted in many fewer episiotomies
being performed at the participating hospitals, especially among
women delivering their first infant. An episiotomy is an incision
in the skin between the vagina and anus. The procedure was thought
to prevent tearing of the vagina during the birth process. Although
many studies have shown that episiotomies are not beneficial, they
are still performed in many hospitals worldwide.
"It can be difficult to change accepted medical practices," said
Duane Alexander, M.D., director of the NIH’s Eunice Kennedy Shriver
National Institute of Child Health and Human Development (NICHD). "This
successful intervention offers an effective model that can be translated
into education programs suitable for interventions throughout the
United States and Latin America."
The report of the large randomized controlled trial appears in
the May 1 New England Journal of Medicine.
The study was funded by the Global Network for Women's and Children's
Health Research, a public-private partnership between the NICHD
and the Bill and Melinda Gates Foundation. The NICHD Global Network
for Women's and Children's Health Research supports studies seeking
to improve treatments, procedures and preventive measures that
will reduce death and disability in women, infants, and children
in resource poor-countries. For information on the Global network
for Women’s and Children’s Health Research, see http://www.nichd.nih.gov/research/supported/globalnetwork.cfm.
Additional funding for the study was provided by the National
Institute of Diabetes and Digestive and Kidney Diseases.
The study’s first author was Fernando Althabe, M.D., of the Institute
of Clinical Effectiveness and Health Policy, in Buenos Aires, Argentina.
The study also included researchers from the School of Public Health
and Tropical Medicine at Tulane University, Louisiana; the Research Triangle Institute International, North Carolina; the University of North Carolina
at Chapel Hill; the World Health Organization; and the NICHD.
To conduct the study, the researchers distributed questionnaires
to birth attendants in 10 public maternity hospitals in Argentina
and Uruguay. The birth attendants were asked to identify opinion
leaders at their hospitals — physicians, midwives, and residents
to whom the other birth attendants at the hospitals looked for
Three to six opinion leaders were selected from each hospital.
They attended a five-day workshop on how to develop and carry out
guidelines for physicians and midwives based on the best scientific
evidence available. The guidelines focused on limiting the use
of episiotomy at delivery, and the management of the third stage
of labor — the period after birth of the baby, and before
expulsion of the placenta.
At the workshop, the opinion leaders were instructed in how to
find, evaluate and summarize the research findings on the management
of the third stage of labor. Based on that evidence, they developed
guidelines recommending administration of oxytocin to all women
just after a vaginal birth. They also were taught techniques for
stimulating expulsion of the placenta and for inducing the uterine
contractions that stop uterine bleeding after detachment of the
The opinion leaders also developed evidence-based guidelines recommending
against the routine use of episiotomy. The procedure poses such
risks as blood loss, infection, and subsequent impairment of sexual
functioning. The opinion leaders also were taught how to effectively
communicate what they had learned at the workshop to their fellow
The remaining nine hospitals served as controls for the study.
Birth attendants at those hospitals did not receive any instruction
in labor management techniques or for communicating with their
At the end of 18 months, the researchers compiled data on a total
of 5,466 vaginal births. The researchers found that oxytocin use
increased from 2.1 percent of births before the trial began to
83.6 percent at the 10 intervention (instruction) hospitals. By
comparison, oxytocin use increased from 2.6 percent to 12.3 percent
at the control hospitals.
Episiotomies decreased from 41.1 percent of births to 29.9 percent
at hospitals receiving the staff instruction and increased slightly
at control hospitals, from 43.5 percent to 44.5 percent.
The hospitals where the staff received the instruction also had
a 45 percent reduction in postpartum hemorrhages of 500 milliliter
(2 cups) or more and a 70 percent reduction on postpartum hemorrhage
of 1000 milliliter (4 cups) or more.
After one year, oxytocin use remained high at the hospitals receiving
the instruction (73.4 percent) and low in the control hospitals
(7.1 percent.). Similarly, after a year, the episiotomy rate at
hospitals receiving the instruction was 28.1 percent and 45.1 percent
in the control hospitals.
Because the change in oxytocin use was much larger than the change
in episiotomy use, the researchers suggested that getting health
professionals to adopt a new practice may be easier than getting
them to eliminate an established practice.
The NICHD sponsors research on development, before and after birth;
maternal, child, and family health; reproductive biology and population
issues; and medical rehabilitation. For more information, visit
the Institute’s Web site at http://www.nichd.nih.gov/.
The National Institutes of Health (NIH) — The Nation's
Medical Research Agency — includes 27 Institutes and
Centers and is a component of the U.S. Department of Health and
Human Services. It is the primary federal agency for conducting
and supporting basic, clinical and translational medical research,
and it investigates the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov.