ALSO in Ecuador:Teaching the Teachers



Lee T. Dresang, MD

Assistant Professor, University of Wisconsin Medical School

Faculty, St. Luke’s Family Practice Residency

Medical Director, Mitchell Point Family Health Center


Wm MacMillan Rodney, MD

Adjunct Professor

Department of Family and Community Medicine

Meharry Medical College


Larry Leeman, MD, MPH

Assistant Professor, Family and Community Medicine

Assistant Professor, Obstetrics and Gynecology

University of New Mexico School of Medicine


Jason Dees, DO

Medicos para la Familia

Department of Family and Community Medicine

Vanderbilt University School of Medicine


Paul Koch, MD, ScM

Assistant Professor, University of Wisconsin Medical School

Faculty, St. Luke’s Family Practice Residency


Mauricio Palencia, MD

Assistant Professor, University of Wisconsin Medical School

Faculty, St. Luke’s Family Practice Residency


Date of submission: May 16, 2003; Accepted for publication August 2003


Word count (excluding abstract, table and references): 1912


Key words: OBSTETRICS, international, FAMILY PRACTICE,


ALSO in Ecuador:Teaching the Teachers





The Advance Life Support in Obstetrics (ALSO) course is designed to help maternity care providers prepare for emergencies arising at the time of delivery. A team of twelve US physicians and a medical interpreter recently taught the ALSO course in Ecuador, with the goal of addressing Ecuador’s high maternal and infant mortality rates. In order to have a greater impact, a teach-the-teacher model was used so that Ecuadorian physicians can now hold their own ALSO courses. In the process of implementing the courses, valuable lessons were learned which can be applied to future ALSO courses in developing countries.
Teaching the Teacher ALSO



Give someone a fish and you feed them for a day; teach someone to fish and you feed them for a lifetime.” Following this proverbial advice, a teach-the-teacher model was employed when twelve physicians and a medical interpreter went to Ecuador in February, 2003 to teach the Advanced Life Support in Obstetrics ALSO course. This article will describe perinatal health in Ecuador, provide background on the ALSO course, discuss implementation of the ALSO courses in Ecuador and offer suggestions for future international ALSO courses.


Perinatal health in Ecuador


The decision to teach the ALSO courses in Ecuador was based in part on a desire to address Ecuador’s high maternal and infant mortality rates. Every minute, on average, somewhere in the world, a woman dies as a consequence of complications of pregnancy, and one hundred women suffer from pregnancy-related complications.1 Approximately 23,000 women die every year in Latin America and the Caribbean from pregnancy- related causes. Bolivia, Brazil, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Paraguay, Peru and the Dominican Republic are the 11 countries in the region with the highest maternal mortality rates.2 The adjusted maternal mortality in Ecuador in 1995 was 210 per 100,000 live births, greatly outnumbering the 12 per 100,000 live births in the United States.3 The infant mortality rate in Ecuador in 1999 was 27 per 1,000 live births, in contrast to the 7 per 1,000 in the United States.4

The leading causes of maternal mortality in the Americas are hemorrhage, pre-eclampsia, infection, septic abortion, and delivery complications such as labor dystocia or malpresentation. The leading cause of maternal mortality in Ecuador is pre-eclampsia. It is estimated that over half of maternal deaths could be prevented by access to high-quality health care services.1


Background on the ALSO course


The ALSO course was designed to prepare maternity care providers for obstetrical emergencies. It was developed by two Wisconsin Family Physicians -- Dr. James Damos and Dr. John Beasley -- in 1991, following targeted action through the establishment of a task force on obstetrics.5,6,7 The course was obtained by the American Academy of Family Physicians (AAFP) in 1993. The curriculum is modeled after the Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS). Now in its fourth edition, the ALSO course is evidence-based, categorizing its recommendations according to the strength of supporting evidence. The course uses an adult learning model, with much of the instruction taking place in interactive workshops utilizing mannequins and competency-based testing.


The ALSO course has been taught outside of the United States since 1995. Recent courses were held in Uzbekistan and China. In Latin America and the Caribbean, courses have been taught in Haiti and Paraguay. The Ecuador courses were the first courses to use the Spanish translation of the fourth edition of the ALSO syllabus.



Implementation of the “teach-the-teacher” model in Ecuador


In Ecuador, the teach-the-teacher method was completed within five days, from February tenth through fourteenth, 2003. According to ALSO rules, at least half of the faculty for each ALSO course must have ALSO Instructor or Instructor Candidate status, and each course must have an ALSO Faculty Advisor. First, thirty-four Ecuadorian practitioners participated in a two-day ALSO provider course. Then, thirty three completed a one-day ALSO instructor course. Finally, twenty nine taught an ALSO provider course to an additional thirty-three Ecuadorian practitioners. Twenty eight of the twenty nine were approved as ALSO instructors and five were given honorary ALSO Faculty Advisory status. By the end of the week, enough Ecuadorian practitioners were certified to hold their own officially approved ALSO courses after we left. They are planning a course for February, 2004.


The ALSO courses in Ecuador were taught to family practice residents, family physicians, obstetrician/gynecologists, certified midwives (obstetrices) and lay midwives. The majority of the ALSO course participants were family practice residents. The national academy of family practice in Ecuador will coordinate future courses in Ecuador. Studies have demonstrated the positive effect of improving perinatal skills among community based family physicians.9,10,11,12 


The Ecuadorian family physicians who will be teaching future ALSO courses have been encouraged to extend their work beyond other family physicians by continuing to work with obstetrices, lay midwives and others providing maternity care. Obstetrices are certified nurse midwives who have had five years of university-level education. In 1998, Ecuador had approximately 16,000 physicians and 900 obstetrices attending deliveries.8


So that the courses could be carried on after we left, we donated six mannequins, five Kiwi vacuums, an infant intubation mannequin, manual vacuum aspiration demonstration supplies, and a pair of Tucker-McClaine forceps. The donated supplies will be stored in the office of the Ecuadorian Association of Family Medicine when they are not in use.


The implementation of the course was facilitated by a host institution, Hospital Vozandes, with a history of supporting medical education from its hospital and community base. Hospital Vozandes has had a family medicine residency since 1986. The hospital provided housing, meals and administrative support for the US instructors. The course facilitators reserved ample rooms for workshops and provided audiovisual aids. Snacks were provided for instructors and course participants. Two administrative aides were available at all times to address any glitches, such as technical problems with audiovisual equipment or a need for additional photocopies. In addition, excursions were planned for US instructors when they were not teaching. The process of teaching the ALSO courses would have been much more challenging without such extensive support from the sponsoring institution.


Ecuadorian participants adapted quickly to the adult-learning and evidence-based aspects of the ALSO course. At first, resistance was encountered to the interactive nature of the ALSO course and to the use of mannequins. One participant noted that most Ecuadorian medical education is taught in a paternalistic manner where the professor imparts their knowledge through lectures and is not to be questioned, nor challenged. Another participant noted an initial preference to learn on live patients rather than mannequins. By the end of the courses, the Ecuadorian providers were enthusiastically leading discussions and teaching and learning using the mannequins.


Similarly, the evidence-based nature of the course was quickly adapted by course participants. The lack of evidence-based practice in Ecuador was illustrated by a question regarding a supervising obstetrician who recommended a C-section prior to the onset of labor because he felt a woman was carrying her baby too high. In addition, in Ecuador, bilateral mediolateral episiotomies are routine for all primagravida women and many others. Remarkably, by the end of the course, a few students were bringing in relevant articles for discussion.


Photos from first provider course


















Review and exam






Ecuadorian physicians teaching the second provider course




















Suggestions for how to improve the process


From our experience in Ecuador, we have suggestions for future international ALSO courses. First, we suggest the development of a pre-course survey. Some questions to include in such a survey are included in Table 1. A completed survey could be required of the host institution three to four months prior to international courses. This would allow time to adjust the course structure accordingly and to obtain approval from the ALSO Advisory Board for any major adjustments.


Table 1: Pre-Course Survey Questions


1)             Nationally, who are the maternity care providers and what is their level of training?

2)             Who will be attending the ALSO course? Where are they from and what is their level of training?

3)             Where are births occurring -- hospitals, homes, birth centers -- and what is the level of care at each site (i.e. what proportion of rural hospitals can perform a c section)?

4)             What are culturally-specific attitudes and practices relevant to the birthing process?

5)             What are the rural and urban C-section rates?

Ecuadorian hospitals have rates of 50%, which usually means any woman with a mildly concerning strip, need of operative vaginal delivery or prior c-section is delivered by cesarean. The talk on dystocia may need to be reformulated into a discussion on advantages of vaginal vs. cesarean delivery, issues of patient choice cesarean, etc.

6)             What is C-section availability in rural and urban areas?

7)             What are local practices regarding breech delivery? If vaginal breech delivery is the norm, this becomes a more important focus. ALSO materials could be supplemented with video footage of breech deliveries.

8)             What are the leading causes of maternal and infant mortality? How common are perinatal conditions such as preeclampsia, preterm delivery, Group B strep infection, HIV and other STDs? 

9)             Which of the optional ALSO workshops will be most useful?

10)           Are newborn resuscitation program (NRP) courses available?

                A Spanish-translation of the NRP manual and CD are available. Offering this course before or after the ALSO courses may amplify the potential of the courses to reduce perinatal mortality. 

11)           What is the availability of and experience with different technologies including:

                manual vacuum aspiration for first trimester loss, prenatal ultrasound, vacuum, forceps and fetal monitoring

12)           What is the availability of medicines including:

                magnesium sulfate, terbutaline, hemabate, misoprostol and methergine

13)           What is the cost and availability of laboratory testing?

                The recommendations for universal testing for Group-B Streptococcus and HIV testing may be reconsidered. Recommendations for Kliehauer- Betke testing may not be realistic.

14)           What audiovisual aids and equipment are available?



Consideration may be given to the development of a supplementary manual to the ALSO instructor syllabus for use in developing countries. The manual would address many of the technology and resources issues raised in the pre-course survey. The manual would also include strategies and resources for fundraising and obtaining donations for the courses.


Our experience in Ecuador identified a host of technology and resource-related issues which might be included in a supplementary manual. For example, in developing countries, septic abortion is often a significant cause of maternal morbidity and mortality. A workshop on manual vacuum for management of first trimester pregnancy loss may be particularly useful.13 Also, electronic fetal monitoring may not be universally available in developing countries. In this setting, it makes sense to emphasize intermittent auscultation skills. Another common issue in developing countries is the lack of access to C-section capabilities. An ALSO addendum could include a section with more detailed guidelines on when and how to transport a patient to a facility with operative services. In addition, changes in drug recommendations may be indicated for courses in developing countries. For example, because it is inexpensive and easily stored, misoprostil for postpartum hemorrhage may deserve special attention.14 Also, for maternal cardiac resuscitation, the use of vasopressin and amiodarone could be deemphasized when epinephrine and lidocaine are less expensive, more available, and similarly effective.


Other areas for improvement in the course include local expertise, course timing, test preparation and translation issues. Local expertise in maternity and infant care can be assessed prior to and during the course. Without sufficient expertise, instructors from the host institution may have difficulty answering questions, and future courses may lack depth. Course participants with extensive knowledge and skill may be granted honorary ALSO Faculty Advisor status. If no one can be identified, the US Faculty Advisor and Course Director may decide to require that an outside Faculty Advisor return for future courses by the host institution until an appropriately trained local leader can be identified.


In addition to training issues, scheduling logistics need consideration. For both US and Ecuadorian participants, teaching three courses in five days was quite draining. This has to be balanced alongside the need for US instructors to minimize time away from their practice and family. A day off between the instructor course and the second provider course would allow for a needed break and better preparation for the second provider course, yet still enable the complete process to be completed in a timely manner. Not all US instructors are needed for evaluation and supervision during the second provider course.  


In countries outside the US, testing issues deserve special attention. The testing methods of the ALSO course may be unfamiliar. A higher test failure rate may have more to do with difficulty with the testing methods than with the testing material. Consideration may be given to allocating time for demonstration and practice of the megadelivery, a part of ALSO course testing in which participants must manage an assisted delivery, shoulder dystocia and post-partum hemorrhage.


Finally, translation issues should be addressed when the course is not given in English. Mnemonics pose a special challenge for translation. For the Spanish-translation, the mnemonics were not modified. When a Spanish word beginning with the same letter as the English word could not be substituted into the mnemonics, the English word was taught with the meaning written in Spanish in parentheses.


Once the ALSO syllabus is translated, it will require multiple revisions. Input from participants and instructors has been applied to improve the translation quality. Wording may vary depending on regional idiomatic differences: what is correct in one Spanish-speaking country may be confusing in another. Ongoing feedback can be encouraged to further fine tune the provider syllabus translation. The Spanish translation is available for future courses through the national ALSO office.




In an attempt to decrease the high maternal and infant mortality rates in Ecuador, the ALSO course was taught utilizing a teach-the-teacher method. Within five days, twenty-eight Ecuadorian physicians were trained to hold their own ALSO course. Course modification, including a pre-course survey and an addendum to the ALSO syllabus, may improve the process of introducing ALSO to other developing countries.



1.         Safe motherhood. Pan American Health Organization. 1998.


2.         Pan American Health Organization.


3.         WHO, UNICEF, UNFPA estimates.


4.         Infant mortality in developing countries.


5.         Rodney WM. A personal reflection from the AAFP task force on obstetrics.  Tenn Fam Physician 1990; 1(3):4-5.


6.         Rodney WM.  Obstetrics enhanced family practice:  an endangered species worth saving!  Florida Fam Phys 1993; 43(1):8-9.


7.         Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in FP J Am Board Fam Pract 2002;15:255-56.


8.         Coury JP, Lafebre A. The USAID Population program in Ecuador: a graduation report 2001;


9.         Allen DI, Kamradt JM.  Relationship of infant mortality to the availability of obstetrical care in Indiana.  J Fam Pract 1991; 33(6):609-613.


10.       Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA.  Access to obstetrical care in rural areas: Effect on birth outcomes.  Am J Public Health 1990; 80:814-818.


11.       Foster DC, Guzick DS, Pulliam RP.  The impact of prenatal care on fetal and neonatal death rates for uninsured patients:  a "natural experiment" in West Virginia.  Obstetrics & Gynecology 1992; 79:49-5.


12.       Larimore WL, Davis A.  Relation of infant mortality to the availability of maternity care in rural Florida.  JABFP 1995; 8:392-9.


13.       Mahomed K, Healy J, Tandon S. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion. Int J Gynaecol Obstet 1994; 46:27-32.


14.         Caliskan E, Meydanli MM, Dilbaz B, Aykan B, Sonmezer M, Haberal A. Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. Am J Obstet Gynecol 2002; 187:1038-45.