An education and motivation intervention to change clinical management of the third stage of labor - the GIRMMAHP Initiative

Birth. 2008 Dec;35(4):283-90. doi: 10.1111/j.1523-536X.2008.00255.x.


Background: Hemorrhage and hypertensive disorders are major contributors to death after delivery in developing countries. The GIRMMAHP Initiative was designed to describe the actual delivery care in five Latin American countries and to educate and motivate clinical staff at 17 hospitals with the purpose of implementing their own clinical practice guidelines to prevent postpartum hemorrhage.

Methods: A multicountry education intervention was developed in four consecutive stages, using two analyses: (a) an observational study of the clinical records in eight teaching and nine nonteaching hospitals and (b) a study of the long-term changes measured 12 months after completion of an education intervention and writing a local clinical guideline.

Results: Data from 2,247 pregnant women showed that only 23.3 percent had an active management of the third stage of labor and that 22.7 percent received no prenatal care visit. These data were used to prepare local clinical practice guidelines in each participant hospital. The proportion of active management increased to 72.6 percent of deliveries at 3 months and 58.7 percent 1 year later. Use of oxytocin during the third stage of labor increased to 85.9 percent of included deliveries. The proportion of women who had postpartum hemorrhage decreased from 12.7 percent at baseline to 5 percent at 1 year after the intervention.

Conclusions: An education intervention and discussion of actual clinical practice problems with health professionals and their involvement in drafting clinical guidelines helped improve health care quality and practitioners' adherence to these guidelines.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Delivery, Obstetric / methods
  • Delivery, Obstetric / statistics & numerical data*
  • Education, Medical, Continuing
  • Evidence-Based Medicine / methods
  • Female
  • Guideline Adherence
  • Hospitals
  • Humans
  • Labor Stage, Third / drug effects*
  • Latin America
  • Obstetrics / education*
  • Obstetrics / standards
  • Oxytocics / therapeutic use
  • Oxytocin / therapeutic use
  • Postpartum Hemorrhage / prevention & control*
  • Practice Guidelines as Topic*
  • Pregnancy
  • Teaching / methods


  • Oxytocics
  • Oxytocin