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Abstract: Objective: To analyze the Ecuadorian experience regarding the adoption, scale-up, and institutionalization of active management of the third stage of labor (AMTSL) for prevention of postpartum hemorrhage via continuous quality improvement (CQI) processes. Methods: Average AMTSL implementation rates for women with vaginal deliveries were compared using unweighted provincial aggregate data from facilities participating in 3 phases of AMTSL programming. Months taken to implement AMTSL at 80% or more and 90% or more compliance were compared across phases. Results: Rate of oxytocin administration during the first 3months was 5.0% in phase 1, 9.8% in phase 2, and 72.2% in phase 3 (P ≤0.001 vs phases 1 and 2). The average number of months provinces took to increase oxytocin administration to 80% or more and 90% or in more women with vaginal deliveries was, respectively, 21.6±18.7 and 30.6±16.4 in phase 1, 23.5±15.1 and 30.1±14.9 in phase 2, and 4.7±4.9 (P ≤0.01 vs phase 1; P ≤0.001 vs phase 2) and 4.0±3.4 (P ≤0.001 vs phases 1 and 2) in phase 3. By December 2009, AMTSL implementation was sustained at 90% or more in all provinces. Conclusion: CQI processes identified resistance and operational barriers, and developed mechanisms to overcome them. [Copyright &y& Elsevier]