Apr. 30, 2008 Relatively inexpensive interventions were effective in helping health care providers in Latin America improve the way they treat mothers during labor and delivery, reducing bleeding and sometimes saving lives of women during childbirth, according to a University of North Carolina at Chapel Hill School of Public Health study released April 30 in the New England Journal of Medicine.
Using teaching techniques that employed behavioral change strategies aimed at modifying practices, researchers were able to reduce the number and severity of episiotomies, a surgical procedure in which a doctor or midwife makes an incision in the tissue between the mother's vagina and rectum during childbirth.
They were also able to increase the use of the hormone oxytocin -- which is given to mothers to make their uterus shrink and bleed less -- to manage the third stage of labor, when the placenta detaches and passes from the uterus and hemorrhaging may occur.
At the start of the study, public hospitals in Argentina and Uruguay had very high rates of routine episiotomy and low rates of actively managing the third stage of labor. In the randomized trial of 20 hospitals, 10 received the intervention and the rest received clinical practice guidelines via seminars.
The intervention included identifying and training small teams of respected medical "opinion leaders" at several hospitals. These teams then trained their peers, and provided their colleagues with ongoing reminders and feedback regarding progress.
Researchers found that these evidence-based behavioral approaches proved to be far more effective than knowledge alone in getting public hospital physicians and midwives to adopt clinical practice guidelines that can save lives.
The results showed that just receiving the information had little effect on practice. Oxytocin use increased from 2.1 percent before the study began to 83.6 percent after the end of the intervention. At control hospitals, the rate increased from 2.6 percent to 12.3 percent. The rate of episiotomies decreased from 41.1 percent to 29.9 percent at hospitals receiving the intervention, but remained the same at control hospitals.
"We saw significant improvements, with a reduction of unnecessary episiotomies and an increase of active management -- and most remarkably, these effects were maintained one year after the intervention ended," said Marci Campbell, Ph.D., a professor in the UNC School of Public Health whose research focuses on health interventions. "Both of these changes greatly reduced the amount of blood mothers lost during childbirth, with mothers in the intervention hospitals losing 44 percent less blood."
Campbell said hemorrhage and blood loss are a major cause of death and disability for women throughout the world during childbirth.
"These techniques for teaching better ways of managing labor and delivery could be used in many part of the world, leading to similar improvements in labor and delivery care," she said. "The result could be improved health for mothers and infants everywhere."
Participating hospitals were part of the Global Network for Women's and Children's Health Research. The study was implemented between September 2003 and December 2005 at 19 public maternity hospitals that had at least 1,000 vaginal deliveries each year, and no explicit policy for episiotomy or active management of the third stage of labor.
"This randomized trial showed that knowledge alone does not change behavior," Campbell said. "It takes the combination of opinion leaders, personal visits, reminders, and support to change behavior. This change is especially important for developing countries where maternal hemorrhage is a major health threat. However, the intervention also could be beneficial in developed countries, including many parts of the United States, where rates of routine episiotomy are still above optimal."
Other authors of the study were Dr. Fernando Althabe and Dr. José M. Belizán from the Institute of Clinical Effectiveness and Health Policy in Buenos Aires, Argentina; Dr. Pierre Buekens from the School of Public Health and Tropical Medicine at Tulane University, New Orleans; Eduardo Bergel, Ph.D. from the United Nations, the World Health Organization and the World Bank; Nancy Moss, Ph.D., and Dr. Linda L. Wright from the National Institute for Child Health and Human Development in Bethesda, Md.; and Tyler Hartwell, Ph.D. from Research Triangle Institute International, Research Triangle Park, N.C.
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