RESUMEN
OBJECTIVE: To assess the effect of a multifaceted intervention among skilled birth attendants on the use of oxytocin during the third stage of labor, the active management of the third stage of labor (AMTSL), and the rate of routine episiotomy during vaginal births in two health districts in Nicaragua. METHODS: An uncontrolled before-and-after study design was used. The rates of oxytocin use in the third stage of labor, AMTSL, and episiotomy were measured for vaginal births occurring in eight hospitals and health centers during 2011-2012, before and after implementation of a multifaceted facility-based intervention. The intervention involved the use of opinion leaders, interactive workshops to develop and implement evidence-based guidelines, academic detailing, the use of reminders, and feedback on the rates of oxytocin use and episiotomy. RESULTS: Oxytocin use during the third stage of labor increased significantly from 95.3% to 97.4% (P=0.003). The episiotomy rate dropped significantly from 31.2% to 21.2% overall, and from 59.6% to 40.5% in primiparous women (P<0.001 for both comparisons). CONCLUSION: The multifaceted intervention improved the targeted care practices during childbirth. However, a further decrease in the routine use of episiotomy would be desirable.
Asunto(s)
Atención a la Salud/estadística & datos numéricos , Episiotomía/estadística & datos numéricos , Oxitócicos/uso terapéutico , Oxitocina/uso terapéutico , Hemorragia Posparto/prevención & control , Adolescente , Adulto , Femenino , Humanos , Tercer Periodo del Trabajo de Parto , Masculino , Nicaragua , Embarazo , Estudios Prospectivos , Adulto JovenRESUMEN
To explore attitudes of physicians attending births in the public and private sectors and at the managerial level toward cesarean birth in Nicaragua. A qualitative study was conducted consisting of four focus groups with 17 physicians and nine in-depth interviews with decision-makers. Although study participants listed many advantages of vaginal birth and disadvantages of cesarean birth, they perceived that the increase in the cesarean birth rate in Nicaragua has resulted in a reduction in perinatal morbidity and mortality. They ascribed high cesarean birth rates to a web of interrelated provider, patient, and health system factors. They identified five actions that would facilitate a reduction in the number of unnecessary cesarean operations: establishing standards and protocols; preparing women and their families for labor and childbirth; incorporating cesarean birth rate monitoring and audit systems into quality assurance activities at the facility level; strengthening the movement to humanize birth; and promoting community-based interventions to educate women and families about the benefits of vaginal birth. Study participants believe that by performing cesarean operations they are providing the best quality of care feasible within their context. They do not perceive problems with their current practice. The identified causes of unnecessary cesarean operations in Nicaragua are multifactorial, so it appears that a multi-layered strategy is needed to safely reduce cesarean birth rates. The recent Nicaraguan Ministry of Health guidance to promote parto humanizado ("humanization of childbirth") could serve as the basis for a collaborative effort among health care professionals, government, and consumer advocates to reduce the number of unnecessary cesarean births in Nicaragua.