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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 3 months 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 © 2012 International Federation of Gynecology and Obstetrics. All rights reserved.)

Objective: Working with a multidisciplinary team of Ecuadorians, Bangladeshis and Americans, we developed a simple protocol for community-based implementation of kangaroo mother care (CKMC) that does not require birth weight or clinical judgment to identify which newborns should receive CKMC. CKMC could stabilize newborns and possibly reduce neonatal mortality where there is little medical care for newborns and low birth weight (LBW) is common., Study Design: During their CKMC training, community-based workers identified 35 expectant or recently delivered women in the pilot study area and taught them about CKMC. Women were interviewed at 1 month postpartum to evaluate their experience with CKMC., Results: In all, 77% of mothers initiated skin-to-skin care and 85% with LBW babies did so (37% were LBW). CKMC mothers delayed newborn bathing. Few slept upright with their newborns., Conclusions: CKMC was quickly and popularly adopted. A randomized controlled cluster trial is planned to determine whether CKMC reduces neonatal mortality.

Objective: This quasi-experimental study tested a method to safely reduce the rate of cesarean delivery in Ecuador., Method: Hospital policy was modified to provide co-management for cesarean candidates at the major maternity hospital in Quito. Cesarean rates before (n=14743) and after (n=12351) the intervention were compared by chi-square and multiple logistic regression with other major maternity hospitals (before, n=12514; after, n=9590). Characteristics of cesarean candidates who had vaginal or cesarean deliveries in the intervention hospital were compared by chi-square (n=1584)., Result: Cesarean rates declined by 4.5% (P<0.001) in the intervention hospital. A smaller (2.1%, P<0.01) reduction occurred in the other major public hospital in Quito where students of the co-principal investigator attempted to reduce cesarean delivery. Cesarean rates were unchanged in the public maternity hospitals of other major cities., Conclusion: Case co-management, a simple, locally appropriate, and inexpensive intervention, safely reduced surgical delivery, hospital stay and cost of care.

Because resources for care of low-birthweight (LBW) infants in developing countries are scarce, the Kangaroo mother method (KMM) was developed. The infant is kept upright in skin-to-skin contact with the mother's breast. Previous studies reported several benefits with the KMM but interpretation of their findings is limited by small size and design weaknesses. We have done a longitudinal, randomised, controlled trial at the Isidro Ayora Maternity Hospital in Quito, Ecuador. Infants with LBW (< 2000 g) who satisfied out-of-risk criteria of tolerance of food and weight stabilisation were randomly assigned to KMM and control (standard incubator care) groups (n = 128 and 147, respectively). During 6 months of follow-up the KMM group had a significantly lower rate than the control group of serious illness (lower-respiratory-tract disorders, apnoea, aspiration, pneumonia, septicaemia, general infections; 7 [5%] vs 27 [18%], p < 0.002), although differences between the groups in less severe morbidity were not significant. There was no significant difference in growth or in the proportion of women breastfeeding, perhaps because the proportion breastfeeding was high in both groups owing to strong promotion. Mortality was the same in both groups; most deaths occurred during the stabilisation period before randomisation. KMM mothers made more unscheduled clinic visits than control mothers but their infants had fewer re-admissions and so the cost of care was lower with the KMM. Since the eligibility criteria excluded nearly 50% of LBW infants from the study, the KMM is not universally applicable to these infants. The benefits might be greater in populations where breastfeeding is not so common.