To conduct the study, the researchers distributed questionnaires to birth attendants in 10 public maternity hospitals in Argentina and Uruguay. The birth attendants were asked to identify opinion leaders at their hospitals - physicians, midwives, and residents to whom the other birth attendants at the hospitals looked for professional guidance.

Three to six opinion leaders were selected from each hospital. They attended a five-day workshop on how to develop and carry out guidelines for physicians and midwives based on the best scientific evidence available. The guidelines focused on limiting the use of episiotomy at delivery, and the management of the third stage of labor - the period after birth of the baby, and before expulsion of the placenta.


At the workshop, the opinion leaders were instructed in how to find, evaluate and summarize the research findings on the management of the third stage of labor. Based on that evidence, they developed guidelines recommending administration of oxytocin to all women just after a vaginal birth. They also were taught techniques for stimulating expulsion of the placenta and for inducing the uterine contractions that stop uterine bleeding after detachment of the placenta.

The opinion leaders also developed evidence-based guidelines recommending against the routine use of episiotomy. The procedure poses such risks as blood loss, infection, and subsequent impairment of sexual functioning. The opinion leaders also were taught how to effectively communicate what they had learned at the workshop to their fellow birth attendants.

The remaining nine hospitals served as controls for the study. Birth attendants at those hospitals did not receive any instruction in labor management techniques or for communicating with their peers.

At the end of 18 months, the researchers compiled data on a total of 5,466 vaginal births. The researchers found that oxytocin use increased from 2.1 percent of births before the trial began to 83.6 percent at the 10 intervention (instruction) hospitals. By comparison, oxytocin use increased from 2.6 percent to 12.3 percent at the control hospitals.

Episiotomies decreased from 41.1 percent of births to 29.9 percent at hospitals receiving the staff instruction and increased slightly at control hospitals, from 43.5 percent to 44.5 percent.

The hospitals where the staff received the instruction also had a 45 percent reduction in postpartum hemorrhages of 500 milliliter (2 cups) or more and a 70 percent reduction on postpartum hemorrhage of 1000 milliliter (4 cups) or more.