Volume 114, Issue 2 p. 184-189
Averting maternal death and disability
Free Access

Using Uniject to increase the use of prophylactic oxytocin for management of the third stage of labor in Latin America

Fernando Althabe

Fernando Althabe

Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

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Agustina Mazzoni

Agustina Mazzoni

Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

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María L. Cafferata

María L. Cafferata

Clinical and Epidemiological Research Unit, Montevideo, Uruguay

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Luz Gibbons

Corresponding Author

Luz Gibbons

Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

Corresponding author at: Dr Emilio Ravignani 2024, Buenos Aires C1414CPV, Argentina. Tel./fax: + 54 11 47778767.Search for more papers by this author
Ariel Karolinski

Ariel Karolinski

Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

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Deborah Armbruster

Deborah Armbruster

Program for Appropriate Technology in Health (PATH), Washington, USA

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Pierre Buekens

Pierre Buekens

Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA

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José M. Belizán

José M. Belizán

Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

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Oxytocin in Uniject Study Group

Oxytocin in Uniject Study Group

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First published: 21 June 2011
Citations: 19

Abstract

Objective

To evaluate a multifaceted intervention for effectiveness in increasing the use of prophylactic oxytocin by birth attendants (obstetricians, midwives, and nurses) working in small maternity hospitals in Argentina.

Methods

A before-and-after quasi-experimental study was conducted in 5 small maternity hospitals. The study intervention consisted of training birth attendants in the active management of the third stage of labor, distributing oxytocin in Uniject (Hipofisina BIOL Uniject; Laboratorios BIOL, Buenos Aires, Argentina), and using posters as reminders. The primary outcome was the rate of prophylactic oxytocin use in the 6 months before and the 6 months of the intervention period. Secondary outcomes included use of controlled cord traction and uterine massage, and birth attendants' acceptance of the use of oxytocin in Uniject.

Results

The use of prophylactic oxytocin showed a median rate of 14.6% at baseline and 85.6% during the intervention period. 96% of birth attendants reported that the Uniject device facilitated oxytocin 1administration.

Discussion

Prophylactic oxytocin in the third stage of labor is a beneficial intervention with current low use, particularly in low- and middle-income countries. If the results shown in the present study were further replicated, this strategy could be an effective method for improving prophylactic oxytocin use in other similar Latin American hospitals.

1 Introduction

Postpartum hemorrhage (PPH), defined as more than 500 mL of vaginal blood loss after birth, is the leading cause of maternal mortality worldwide and the second in Latin America [1,2]. WHO and an ICM/FIGO joint statement on managing the third stage of labor to prevent PPH recommend universal use of active management of the third stage of labor (AMTSL) [3,4], which includes the administration of uterotonic agents, controlled cord traction (CCT), and uterine massage after delivery of the placenta. The recommendation is based on evidence from 5 hospital-based randomized controlled trials in which AMTSL reduced the risk of mild and severe PPH by approximately 65% compared with expectant management [5]. The prophylactic administration of uterotonic drugs alone has also been shown to reduce the risk of PPH by 40%–60% [6]. Oxytocin is the agent of choice at health facilities where skilled birth attendants are available because of its benefit-to-risk ratio [4,7]. Despite its demonstrated effectiveness and its availability, prophylactic oxytocin is still underused or incorrectly used in the third stage of labor in Latin America. Surveys on the management of the third stage of labor in El Salvador [8], Guatemala [9], Honduras [10], and Nicaragua [11] showed correct use of prophylactic uterotonics to be only 10%–20%.

The situation in Argentina varies. Whereas several large maternity hospitals have incorporated AMTSL as standard care [12], others still show very low use [13]. Limited access to information, resistance to change, and lack of skills, medical resources, and explicit guidelines are reported as main barriers in large maternity hospitals [14]. At small maternity hospitals, one of the barriers to the adoption of prophylactic oxytocin may be the scarcity of human resources. Birth attendants are frequently alone caring for the mother after delivery. Although a nurse is usually present, she attends the newborn. The timely administration of prophylactic oxytocin with conventional vials/syringes could be difficult in this situation.

Uniject (BD, Franklin Lakes, NJ, USA) is a single-dose, pre-filled injection device that simplifies intramuscular (IM) delivery of drugs, including oxytocin [15–18]. Because it eliminates the need for dosage estimation and minimizes wastage and contamination, it is ideal for use by unskilled individuals or in settings with scarce personnel.

The main aim of the present study was to evaluate whether a multifaceted intervention—including the distribution of oxytocin in Uniject devices (Hipofisina BIOL Uniject; Laboratorios BIOL, Buenos Aires, Argentina [referred to as “oxytocin in Uniject” from here]), training on AMTSL, and use of reminders—was effective at increasing the administration of prophylactic oxytocin and other components of AMTSL by birth attendants working in small maternity hospitals in Argentina.

2 Methods

2.1 Design and population

A clinical trial was conducted using a before-and-after quasi-experimental design with no control group in 5 small (300–600 deliveries per year) non-randomly selected maternity hospitals in Corrientes, Argentina, in which the use of prophylactic oxytocin for the management of the third stage of labor was not standard care (< 25% use in vaginal deliveries, as reported verbally by the heads of the maternity units). Rates of prophylactic oxytocin use were measured in the 6-month pre-intervention period (June–November 2008) and compared with the 6-month intervention period (December 2008–May 2009).

2.2 Study interventions

To explain the study and to ensure that birth attendants at all hospitals had similar knowledge at baseline, 1-day workshops were conducted in each of the hospitals before the pre-intervention data collection period. The workshops included evidence-based information about AMTSL, objectives of the study, and how to implement pre-intervention data collection.

After the 6-month pre-intervention data collection period, an intervention was conducted consisting of: training for birth attendants and nurses in the 3 AMTSL components (prophylactic oxytocin, CCT, and uterine massage); distribution of packages of oxytocin in Uniject; and use of posters as reminders to practice AMTSL.

A half-day training session was conducted at each hospital, with the participation of most of the health providers (obstetricians, midwives, and nurses) involved in labor and delivery care. The training included evidence supporting the benefits of AMTSL, presentation of oxytocin in Uniject, and a practical session using anatomic models for all components of AMTSL. At the practical session, health providers were trained in the administration of prophylactic oxytocin using both Uniject and vials/syringes. Participating health providers replicated the training at the hospital for the 10% of birth attendants and nurses who did not attend.

Uniject (1 mL) devices containing 10 IU of oxytocin were distributed and provided to the hospitals during the 6-month intervention period. Oxytocin in vials/syringes was also available in all participating hospitals during both study periods.

Posters in a clear and simple format explaining how to put the 3 components of AMTSL into practice were placed in labor and delivery wards at each hospital. The posters were designed by the Prevention of Postpartum Hemorrhage Initiative [19].

2.3 Outcomes measured

The primary outcome was the rate of prophylactic oxytocin use (a single 10-IU injection via either Uniject or vials/syringes) for the management of the third stage of labor in vaginal deliveries. The secondary outcomes were the use of CCT, uterine massage, and oxytocin through Uniject. Other outcomes were number of maternal admissions to intensive care unit (ICU), blood transfusions, retained placenta, manual removal of the placenta, and postpartum interventions (curettage, hysterectomy, and laparotomy). Birth attendants’ views and perceived barriers were also measured with regard to implementation of AMTSL, acceptance of the use of oxytocin in Uniject compared with vials/syringes, accessibility of uterotonic drugs within each hospital, control and storage conditions, and hospitals’ clinical guidelines regarding labor and delivery recommendations. Clinical outcomes were measured in all vaginal deliveries attended during the 12-month period at each hospital. Trained in-hospital data collectors abstracted clinical variables from the clinical records and completed paper data forms daily. As a second source of information related to the management of the third stage of labor, data collectors also completed forms with the variables reported verbally by the birth attendants. Digital pictures of the forms were taken and transmitted electronically to an independent data center (UNICEM, Montevideo, Uruguay) for data entry. All cases in which inconsistent reports of the primary outcome were found between the 2 sources of data (clinical record and verbal report) were revised and discussed with the birth attendants.

Providers’ opinions regarding AMTSL and barriers to its implementation were measured in both the pre-intervention and the intervention periods. All birth attendants—obstetricians, midwives, and nurses—who attended deliveries completed anonymous self-administered questionnaires to describe their opinions and knowledge about the effectiveness of each AMTSL component and barriers to its implementation, in addition to the acceptability of Uniject for administering oxytocin. The questionnaires were collected in opaque envelopes and sealed boxes at each hospital.

2.4 Statistical analysis

The percentages of use for all primary and secondary outcomes by hospital and by month were calculated. The primary source was the data extracted from the clinical records (considered the most reliable source). The median use rates for the 5 hospitals in each period were also calculated, in addition to the difference between the intervention rate and the baseline rate for each hospital. Finally, the median value of the differences between the pre-intervention and the intervention periods for the 5 hospitals was calculated. The Wilcoxon rank test was used to test the hypothesis that the intervention would increase the use of oxytocin, owing to the small number of hospitals and the unlikelihood of a normal distribution of the rates.

Providers’ responses to the questionnaire were analyzed; only the frequency of responses in the entire sample of birth attendants in each period is reported. No statistical inferences were made for this outcome.

2.5 Ethics approval

Approval for the study was obtained from 3 Institutional Review Boards (IRBs): the Program for Appropriate Technology in Health (PATH) Research Ethics Committee and the Tulane Office of Research Protection IRB in the USA; and the Medical Education and Clinical Investigation Center IRB in Argentina. Hospital authorities provided written consent for their participation.

Because outcome data were routinely collected at hospitals and no personal identifiers were transmitted, all IRBs requested verbal consent from women for the use of clinical data regarding their pregnancy, labor, delivery, and puerperium, and written informed consent for women under 18 years of age, with parents’ or guardians’ signatures. Birth attendants were asked for signed informed consent for their participation in the survey.

The Uniject device was approved by Administración Nacional de Medicamentos, Alimentos y Tecnología Médica.

3 Results

3.1 Participating hospitals

Of the 11 maternity hospitals attending between 300 and 1000 deliveries per year in the province of Corrientes, 5 that reported prophylactic oxytocin use below 25% and had previous research collaboration with the Institute for Clinical Effectiveness and Health Policy (IECS) were invited. One hospital was excluded in the first month of data collection because it was partially closed, and was replaced by another eligible hospital. All hospitals completed the study: 4 collecting data for 12 months and 1 for 11 months.

3.2 Maternal and childbirth characteristics

Data were collected on 942 and 951 vaginal births in the pre-intervention and intervention periods, respectively (median number of deliveries by hospital, 178 and 194, respectively). Maternal age, parity, and operative vaginal delivery rate were similar in both periods. Only doctors worked as birth attendants in the participating hospitals and, in the vast majority of deliveries, they were assisted by a nurse. No differences between periods were observed (Table 1). The use of an intravenous (IV) line during delivery was 57.5% and 51.3%, at baseline and during the intervention period, respectively. Labor augmentation was 51.1% in the pre-intervention period and 34.6% in the intervention period. It should be noted that, for both practices, the range of use across the 5 hospitals was very wide: whereas 1 hospital had rates of 13.8% for labor augmentation at baseline, another had rates of 82.4%. Similar ranges were observed for IV infusion lines at both periods (Table 1).

Table 1. Characteristics of women undergoing vaginal delivery at the 5 participating hospitals at baseline and follow-up.a
Characteristic Baseline (n = 942) b Intervention (n = 951) c
Age, y 24.1 ± 6.6 24.0 ± 6.7
Parity
  Nulliparous 29.2 (28.0–40.0) 33.5 (30.2–37.8)
  Multiparous (3 or more) 22.7 (12.9–23.8) 20.6 (15.1–24.4)
Operative delivery 0.6 (0.0–1.0) 0.0 (—)
Type of birth attendant
  Any physician/resident 92.3 (82.2–98.9) 95.0 (88.5–100.0)
  Midwife, nurse, or other 11.1 (1.1–17.8) 5.7 (0.0–11.5)
Aid during delivery
  By another doctor 0.9 (0.0–41.0) 0.0 (0.0–4.4)
  By midwife, nurse, or other 98.9 (89.7–100.0) 99.2 (95.0–100.0)
  None 0.6 (0.0–10.3) 0.8 (0.0–3.1)
Intravenous infusion to the mother during delivery 57.5 (19.2–88.7) 51.3 (19.0–98.1)
Oxytocin for labor augmentation 51.1 (13.8–82.4) 34.6 (5.7–56.5)
  • a Values are given as mean ± SD or median percentage (range) of the 5 hospitals.
  • b Median, 178 women (range, 107–320) per hospital.
  • c Median, 194 women (range, 119–270) per hospital.

3.3 Management of the third stage of labor

There was a median rate of 14.6% for the use of prophylactic oxytocin in the pre-intervention period, compared with 85.6% in the intervention period (median of the differences, 71.0%; range, 6.0%–97.0%) (Table 2). During the pre-intervention period, 4 hospitals used prophylactic oxytocin 20% of the time or less, whereas 1 had a rate of 77.8%. During the intervention period, all hospitals increased their use of prophylactic oxytocin to more than 80%. Oxytocin use in vials/syringes decreased from 14.6% to 7.0% (median of the differences, −8.2%; range, −70.0% to 2.4%). The use of oxytocin in Uniject (not available in the pre-intervention period) was 73.4%, 76.0%, 77.3%, 85.6%, and 97.0% in the 5 hospitals in the intervention period. The use of other prophylactic uterotonics or oxytocin doses lower than 10 IU was rare at baseline and nonexistent during the intervention period.

Table 2. Use of AMTSL in the 5 participating hospitals, Argentina 2008–2009.a
Baseline (n = 941) Intervention (n = 951) Median of the differences b P value c
Prophylactic oxytocin (10 IU) 14.6 (0.0–77.8) 85.6 (80.4–97.0) 71.0 (6.0–97.0) 0.043
  In vials/syringes 14.6 (0.0–77.8) 7.0 (0.0–11.8) –8.2 (− 70.0 to 2.4) 0.144
  In Uniject 0.0 (—) 77.3 (73.4–97.0)
Prophylactic oxytocin (< 10 IU) 0.0 (0.0–14.3) 0.0 (0.0–1.0) 0.0 (− 14.3 to 1.0) 0.655
Other prophylactic uterotonics 0.0 (—) 0.0 (0.0–0.6) 0.0 (0.0–0.6) 0.317
Controlled cord traction 7.0 (0.5–73.1) 47.8 (0.6–98.5) 25.4 (− 1.7 to 41.9) 0.080
Uterine massage 6.3 (0.0–90.7) 48.9 (0.6–100.0) 9.4 (− 2.2 to 42.6) 0.090
  • Abbreviation: AMTSL, active management of the third stage of labor.
  • a Values are given as median percentage (range) of the 5 hospitals unless otherwise indicated.
  • b Calculated based on the difference between the intervention rate and the baseline rate for each hospital.
  • c P < 0.05 was considered statistically significant.

According to the verbal reports from birth attendants, there was a median rate of prophylactic oxytocin use of 28.6% and 84.9% in the pre-intervention and intervention periods, respectively. The difference in the pre-intervention rate between the 2 sources was audited; we concluded that verbal reports overestimated the use of prophylactic oxytocin owing to a misinterpretation of the correct definition of prophylactic oxytocin (data not shown).

Fig. 1 shows the rates of prophylactic oxytocin use by month and by hospital. During the pre-intervention period, 4 hospitals showed monthly values between 0% and 30%. In the intervention period, the monthly use of oxytocin in these 4 hospitals was always above 80%. One hospital showed a stable pattern of high use across both periods, with rates higher than 70% for all months but 1.

Details are in the caption following the image

Use of prophylactic oxytocin in 5 small maternity hospitals in Argentina. The intervention began in month 6 and continued until month 12.

The median rate for CCT was 7.0% and 47.8% in the pre-intervention and intervention period, respectively (median of the differences, 25.4%; range, −1.7% to 41.9%). Comparing the intervention period with the pre-intervention period, 2 hospitals showed a constant low use below 5% and 3 increased their use.

For uterine massage, the median rates were 6.3% and 48.9% for the pre-intervention and intervention periods, respectively (median of the differences, 9.4%; range, −2.2% to 42.6%). Three hospitals increased their use in the intervention period, whereas 2 showed use rates below 6% in both study periods.

3.4 Maternal outcomes

Admission to ICU and blood transfusions were similarly low in both periods. Postpartum interventions and manual removal of the placenta together showed similar numbers of events in both periods. Fewer women received additional postpartum uterotonics during the intervention period (Table 3).

Table 3. Maternal clinical and healthcare outcomes at the 5 participating hospitals following administration of prophylactic oxytocics, Argentina 2008–2009.
Outcome Baseline (n = 942) Intervention (n = 951)
No. No.
Admission to intensive care unit 1 1
Blood transfusion 2 3
Postpartum interventions
  Curettage 1 1
  Hysterectomy 1
  Laparotomy
  Drainage of vulvar hematoma 1
Retained placenta 7 5
Manual removal of placenta 14 11
Additional uterotonics postpartum 605 366

3.5 Survey of birth attendants

Thirty and 32 birth attendants responded to the survey in the pre-intervention and intervention periods, respectively. The characteristics of the birth attendants were similar in both periods (Table 4).

Table 4. Characteristics of birth attendants interviewed at the 5 participating hospitals, Argentina 2008–2009.a
Characteristic Baseline (n = 30) Post-intervention (n = 32)
Age, y 40.3 ± 1.8 40.3 ± (1.7)
Male 10 (33.3) 10 (31.3)
Profession
  Physician 26 (86.7) 25 (78.1)
  Midwife 2 (6.7) 2 (6.3)
  Nurse 2 (6.7) 5 (15.6)
Years since graduation 14.4 ± 1.7 13.5 ± 1.7
Years since started attending deliveries 13.8 ± 1.7 13.3 ± 1.6
Deliveries performed by month during entire practice
  0 0 (0.0) 0 (0.0)
  1–5 4 (13.3) 9 (28.1)
  6–10 6 (20.0) 8 (25.0)
  11–20 11 (36.7) 12 (37.5)
  21–30 5 (16.7) 1 (3.1)
  31–40 0 (0.0) 0 (0.0)
  41 or more 3 (10.0) 0 (0.0)
  • a Values are given as mean ± SD or number (percentage).

More than 90% of birth attendants reported they had heard about AMTSL and knew its components (Table 5). Regarding prophylactic oxytocin, more than 90% answered that they considered the intervention effective and that it was either very easy or not difficult to implement. In the pre-intervention period, 73.3% reported ever administering prophylactic oxytocin, whereas all had used it in the intervention period.

Table 5. Birth attendants’ responses about active management of the third stage labor, Argentina 2008–2009.
Baseline (n = 30) Post-intervention (n = 32)
Active management of the third stage labor
  Have you ever heard about active management of the third stage of labor? [Proportion answering “yes”] 28 (93.3) 32 (100.0)
  Do you know what it consists of? [Proportion answering “yes”] 28/28 (100.0) 26/28 (92.9)
Prophylactic oxytocin
  Did you ever administer prophylactic oxytocin for the management of the third stage of labor? [Proportion answering “yes”] 22 (73.3) 32 (100.0)
  What is your opinion about its effectiveness? [Proportion answering “effective” or “effective but it may present some adverse effects”] 29 (96.7) 29 (90.6)
  What is your opinion about the level of difficulty in its implementation while attending a birth? [Proportion answering “very easy to implement” or “little bit difficult to implement”] 29 (96.7) 30/30 (100.0)
Controlled cord traction
  Did you ever use controlled cord traction for the management of the third stage of labor? [Proportion answering “yes”] 27 (90.0) 31/31 (100.0)
  What is your opinion about its effectiveness? [Proportion answering “effective” or “effective but it may present some adverse effects”] 29 (96.7) 31/31 (100.0)
  What is your opinion about the level of difficulty in its implementation while attending a birth? [Proportion answering “very easy to implement” or “little bit difficult to implement”] 29 (96.7) 31 (96.9)
Uterine massage
  Did you ever use uterine massage for the management of the third stage of labor? [Proportion answering “yes”] 25/29 (86.2) 31 (96.9)
  What is your opinion about its effectiveness? [Proportion answering “effective” or “effective but it may present some adverse effects”] 28 (93.3) 31/31 (100.0)
  What is your opinion about the level of difficulty in its implementation while attending a birth? [Proportion answering “very easy to implement” or “little bit difficult to implement”] 27 (90.0) 31 (96.9)
Uniject
  Did you use Uniject to administer prophylactic oxytocin? [Proportion answering “yes”] 31 (96.9)
  Do you think the use of Uniject facilitates the administration of prophylactic oxytocin as part of the active management of the third stage of labor? [Proportion answering “yes”] 31 (96.9)
  When comparing Uniject with the use of ampoules and syringes, in your opinion, the use of Uniject is:
  Simpler 27/31 (87.1)
  Equally simple or complex 4/31 (12.9)
  Complex 0/31 (0.0)
  If Uniject were not available, do you think that the prophylactic administration of oxytocin would be reduced? [Proportion answering “yes”] 14 (43.8)
  • a Values are given as number (percentage).

Regarding CCT, more than 90% of the respondents answered that they had used CCT, that it was effective, and that it was very easy or only somewhat difficult to implement. The rates were similar in both periods. Similar responses were observed for uterine massage (Table 5).

Questions regarding Uniject were asked only after the intervention period. Overall, 96% of the respondents answered that they had used Uniject for administration of prophylactic oxytocin and that the device facilitated its administration. In total, 54.8% answered that using Uniject was much simpler than administration through vials/syringes. Finally, 43.8% responded that the use of prophylactic oxytocin would decrease if Uniject were not available.

4 Discussion

The present study showed that an intervention consisting of providing oxytocin in Uniject, training birth attendants working in maternity hospitals in AMTSL, and using posters as reminders to birth attendants may increase the use of prophylactic oxytocin, with no increase in maternal complications. It also showed birth attendants’ high level of use and acceptance of oxytocin in Uniject, and their opinion that it is a valuable device for facilitating the use of prophylactic oxytocin. The study was conducted in district hospitals in one of the most deprived regions of Argentina, implying that this strategy could be replicated in first- and second-level hospitals of similar urban and semi-urban Latin American settings.

The main limitations of the study were the before-and-after quasi-experimental design without a control group and the small number of hospitals included. Such a design cannot exclude the possibility that secular trends or the effect of other simultaneous interventions could be alternative explanations of the findings. Furthermore, the small sample size means that chance cannot be excluded as a likely explanation. However, two facts strengthened the likelihood that the intervention was the cause of the observed improvement. First, the major increase seen just after the implementation of the intervention—the use of prophylactic oxytocin in the 6 months before the intervention was 20% maximum in 4 of 5 hospitals, increasing to more than 80% in all of them only 2 months after the implementation. Second, there were no simultaneous active interventions occurring in either the country or the region that could explain such an increase. The Corrientes Ministry of Health distributed national guidelines recommending the use of AMTSL in 2005, and dissemination of the guideline occurred in the following years; however, no specific active promotion was carried out subsequently. In addition, the birth attendants' responses regarding the use of Uniject showed that they believed that the device facilitated the administration of prophylactic oxytocin, and that if the device were not available oxytocin use could decrease. In the hospital with high rates of prophylactic oxytocin use throughout the study, it is possible that the initial discussion reinforced an existing positive behavior, which was maintained throughout the study period. Fourth, the present findings are consistent with those from a qualitative study in Argentina and Uruguay reporting that negative attitudes toward changes in practice, lack of skills in performing the practice, and lack of medical resources and explicit guidelines were among the barriers to AMTSL in maternity hospitals [20]. The intervention components were designed to overcome most of these factors.

No relevant effects on CCT or uterine massage use can be inferred from the present study. The change between baseline and intervention was very heterogeneous among the hospitals, and overall the use of both components during the intervention period did not exceed half of the deliveries. Moreover, a direct observation of the deliveries as a validation of what was recorded was not conducted.

Regarding the acceptability of Uniject by birth attendants, the present findings are consistent with those from previous studies of midwives in Indonesia and Vietnam reporting that Uniject was easier to use and preferable to vials/syringes for the administration of prophylactic oxytocin [21,22]. A cluster randomized trial is now ongoing to determine the effect of prophylactic oxytocin in Uniject on PPH at community level in Ghana and India (Cynthia Stanton, PhD, personal communication, May 2010).

The present study should be seen as an exploratory investigation because the limitations described preclude reliable inferences. Our conclusions are that, in small maternity hospitals in Argentina, a multifaceted intervention comprising short training on AMTSL using anatomic models, oxytocin in Uniject, and the use of reminder posters is likely to increase the use of prophylactic oxytocin for management of the third stage of labor.

Prophylactic oxytocin in the third stage of labor is a beneficial intervention with current low use, particularly in low- and middle-income countries. If the results from the present study were further replicated, the strategy could be an effective method for improving the use of prophylactic oxytocin in management of third stage of labor in other similar Latin American hospitals.

Acknowledgments

This study was funded by PATH (grant number GAT.5001-06-07392-SUB). We thank BIOL (Instituto Biológico Argentino) for kindly donating the oxytocin in Uniject devices needed to conduct the study. Members of the Uniject Group include: E. Montenegro (Regional Coordinator), C. Cappara, and M. Brambilla in Monte Caseros Hospital; M. Velazquez and T. Etcheverría Lima in Mercedes; C. Ganduglia and A. González in Virasoro Hospital; L. Ramirez, S Navarro, and L Velázquez in Esquina Hospital; and H. Zambrana and R. Guardini in Saladas.

Conflict of interest

The authors have no conflicts of interest.