Obstetric care providers' knowledge, practice and associated factors towards active management of third stage of labor in Sidama Zone, South Ethiopia

Active management of the third stage of labor and associated factors among maternity care providers in public health facilities in Eastern Ethiopia: a multi-center study

INTRODUCTION

The third stage of labor is the shortest, most critical, and hazardous stage as it is linked with postpartum hemorrhage, the leading cause of maternal mortality and morbidity. Postpartum hemorrhage can be prevented by 60% with active management of the third stage of labor (AMTSL). Few studies have been conducted in different parts of Ethiopia showing rates of AMTSL ranging from 16.7% to 43.3%. Limited information, however, exists about its practice in our study area. Thus, we aimed to assess the practice of AMTSL and associated factors among maternity care providers in public health facilities in eastern Ethiopia.

METHODS

An institution-based cross-sectional study design was used among 270 maternity care providers in public health facilities in eastern Ethiopia. They were recruited using cluster sampling techniques in their health facilities from July 15-October 30/2021. Pretested self-administered questionnaires and an observational checklist were used to collect data. Descriptive, binary, and multivariable logistic regression analyses were performed. Adjusted odds ratios with 95% confidence intervals were used for statistically significant associations.

RESULTS

Good practice of AMTSL occurred in 40.3% (95% CI: 34.5%-46.1%) of births. Being trained (aOR 3.02; 95% CI 1.60-5.70); presence of birth assistance (aOR 2.9; 95% CI 1.42-6.04); having the highest educational level (aOR 4.21; 95% CI 1.08-16.40); and having good knowledge (aOR 3.00; 95% CI 1.45-6.20) were factors statistically associated with maternity care providers' good practice of AMTSL.

CONCLUSION

Active management of the third stage of labor was practiced with low rates in the study area. Therefore, we suggest that the stakeholders could enhance the presence of birth assistance during all births and provide education to attain higher educational levels and continuously update the maternity care providers' level of knowledge through comprehensive and on-the-job training to increase the good practice of the third stage of labor.

Knowledge of immediate newborn care and management of complications among midwives in Ghana

OBJECTIVE

Midwives are instrumental in improving maternal/newborn health outcomes. Since complications after childbirth are leading causes of maternal deaths, midwives' knowledge of how to manage complications and care for the newborn is important. This study assessed midwives' knowledge of immediate newborn care and management of postpartum complications.

DESIGN

A cross-sectional descriptive survey design was used.

SETTING

Four hospitals that provide inpatient maternity services in Tamale, Ghana.

PARTICIPANTS

245 midwives who worked in the four hospitals.

MEASUREMENTS

Data were collected in December 2018 using an electronic survey questionnaire by the Johns Hopkins Program for International Education in Gynecology and Obstetrics, and analyzed using descriptive, bivariate, and multivariate statistics.

FINDINGS

About 98% of midwives were female. The mean age of midwives was 31.87 years. The percentage of midwives who responded correctly to questions on newborn care and management of postpartum complications ranged from 29.80% to 89.39%, and 32.17% to 91.43% respectively. Midwives were most knowledgeable about breastfeeding and immediate hemorrhage intervention, and least knowledgeable about cord care, thermal protection, newborn resuscitation, contraindications for vacuum extraction, treating metritis, and performing a cervical repair. Years of experience and age are predictive factors of midwives' knowledge.

CONCLUSION/IMPLICATIONS

There remains the opportunity for continuing education on complication management. Additional training of midwives on newborn resuscitation is recommended.

Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study

Background

Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases.

Methods

This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression.

Results

We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores.

Conclusion

We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05128-6.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study

Background

Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda.

Methods

We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH.

Results

The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80–6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11–3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00–2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78–9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87–6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49–3.09, P<0.001). Coagulopathy was not prevalent in primary PPH.

Conclusion

Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.

Knowledge and skills on active management of third stage of labor for prevention of post-partum haemorrhage among health care providers in Lake Zone, Tanzania: a cross sectional study

Background

Health care providers (HCPs) knowledge and skills are both crucial in saving the lives of mothers and their newborns during childbirth. This study aimed to assess the knowledge and skills of HCPs on active management of third stage of labor (AMTSL) for prevention of PPH in Lake Zone Tanzania.

Methods

A cross-sectional analytical hospital-based study which included 340 HCPs who were randomly selected, the study was conducted from March to May 2019 in lake zone, Tanzania. Data were collected using standardized questionnaire and observational checklist. Predictors of knowledge and skills on AMTSL were determined using binary logistic regression under multivariable analysis using SPSS version 23.0. p-value less than 0.05 was considered significant.

Results

Most 200 (58.8%) of the participants were aged between 25 and 34 years with mean age 31.4 ± 6.26 years. Majority 240 (67.6%) were females. Of all HCPs, 171 (50.3%) had adequate knowledge whereas 153 (45.0%) had adequate skills on AMTSL. Males (AOR = 1.96, 95% CI 1.18–3.26), HCPs with University education (AOR = 3.29, 95% CI 1.19–9.13) and previous BEmONC training (AOR = 2.20, 95% CI 1.24–3.91) were found to be the predictors of adequate knowledge on AMTSL. HCPs aged ≥ 45 years (AOR = 9.35, 95% CI 1.74–10.28) and HCPs working at a hospital (AOR = 1.78, 95% CI 1.12–2.82) were associated with having adequate skills on AMTSL.

Conclusion

HCPs included in this study demonstrated low skills on AMTSL as compared to knowledge which needs immediate attention. We recommend continuous in-service training and supportive supervision among HCPs working in labour wards for improving their knowledge and skills on AMTSL. This will help to reduce maternal morbidity and mortality related to PPH.

Active Management of Third Stage of Labor: Practice and Associated Factors among Obstetric Care Providers in North Wollo, Amhara Region, Ethiopia

Background

World Health Organization strongly recommends that every obstetrical provider at birth needs to have knowledge and skills on active management of the third stage of labor and use it routinely for all women. However, implementation of this lifesaver intervention by skilled birth attendants is questionable because 3% to 16.5% of women still experience postpartum hemorrhage. Even though coverage of giving births at health facilities in Ethiopia increases, postpartum hemorrhage accounts for 12.2% of all maternal deaths occurring in the country. Lack of the necessary skills of birth attendants is a major contributor to these adverse birth outcomes.

Objectives

This study aimed to assess the active management of the third stage of labor practice and associated factors among obstetric care providers.

Methods

An institution-based cross-sectional study design was applied from March 15 to April 15, 2020. Multistage sampling techniques were used to get 254 participants, and data were collected using self-administered structured questionnaires and an observation checklist. Data were entered into EpiData version 3.1 and exported to Statistical Package for the Social Sciences (SPSS) version 23.0 for analyses. The multivariable logistic regression model was used at 95% confidence interval with P value <0.05. Among the 232 providers participating in the study, only 75 (32.3%) of respondents had a good practice. The practice of the provider was significantly associated with work experience (adjusted odd ratio 0.206 (95% confidence interval, 0.06–0.63)), knowledge (adjusted odd ratio (2.98 (95% confidence interval, 1.45–6.14)), the presence of assistance (adjusted odd ratio 2.04 (95% confidence interval, 1.06–3.93)), and time of uterotonic drug preparation (adjusted odd ratio 4.69 (95% confidence interval, 2.31–9.53)).

Conclusion

Only one-third of obstetric care providers had good practice during active management of third stage of labor. Practice was significantly associated with work experience, knowledge, the presence of assistance during third-stage management, and time of uterotonic drug preparation. Consistent and sustainable on job training and clinical audit should be applied in all facilities with regular supportive supervision and monitoring. Furthermore, team work and adequate preparation should be done to facilitate the management of active third stage of labor.

A descriptive study of healthcare-providers' experiences with the use and quality of oxytocin for the prevention of post-partum hemorrhage in Nigeria: A nation-wide survey

Background

Oxytocin is recommended as an affordable and effective drug in the prevention of postpartum hemorrhage—one of the leading causes of maternal morbidity and mortality in low- and middle-income countries, however, there are concerns about its proper use and quality. This study builds on earlier work conducted in a South-Western state in Nigeria.

Objective

The study assessed the knowledge around oxytocin, usage, storage practices and perceived quality of oxytocin used by healthcare providers that directly administer oxytocin for the prevention of postpartum hemorrhage across Nigeria.

Methods

This was a descriptive cross-sectional study that surveyed a representative sample of 6,299 healthcare providers who offer obstetrics and gynecological services and recruited from 1,894 healthcare facilities in Public and Private sectors in 12 states across Nigeria. Data were collected using an electronic questionnaire, analyzed using SPSS, and presented in frequencies and percentages.

Results

Only forty-six percent of respondents (52.8% in private; 40.0% in public sector) had proper knowledge that oxytocin storage is in the refrigerator. Proper knowledge also varied by professional cadre, doctors (71.2%); nurses (46.6%); Community Health Workers (28.4%) and by years of experience, less than 10 years (51.4%); more than 10 years (40.8%). Only 34% of the respondents (41% in private and 27.5% in public sector) reported good practices that oxytocin is stored in the refrigerator in their facilities. Most healthcare providers used oxytocin for prevention of PPH (77.9%). Oxytocin was also used for augmentation (66.7%) and induction of labor (52.6%). Half of respondents used above the WHO-recommended oxytocin dose of 10IU for prevention of PPH. Twenty-three percent of respondents reported experiencing oxytocin failure in PPH prevention of whom, 54.3% changed to another uterotonic and 37.1% doubled the dose of oxytocin for their patients.

Conclusion

Our study findings should be used to establish clinical guidelines and trainings for healthcare providers to improve their knowledge and storage practices and use to safeguard the quality of these lifesaving medicines.

Factors that influence management of postpartum hemorrhage among midwives in a rural setting in Kenya

Background

Postpartum hemorrhage is the cumulative blood loss of 500 milliliters or more in a spontaneous vaginal delivery and approximately 1,000 milliliters or more for caesarean section birth and a leading cause of maternal mortality1.

Objective

The overall aim of the study was to determine midwives' factors that influence the management of PPH.

Methods

A descriptive cross-sectional study that employed a quantitative approach through the use of a research self- administered questionnaire and an observational checklist targeting midwives were used. 85 midwives filled the questionnaire and 71 were observed respectively. The study was hospital- based conducted in Muranga County, Kenya. Convenience sampling technique was used to select the midwives in the study sites.

Results

The following factors were statistically significant in influencing management of postpartum hemorrhage; age (P-value = 0.021). professional qualification (P= 0.047), experience in management of PPH (P= 0.032) and training on emergency PPH (P= 0.010), knowledge factors that were found to influence the management of PPH positively include knowledge on; prevention of PPH (p value-0.000), correct use of prophylactic uterotonic agents (P= 0.000), uterotonics use (P= 0.043), uterine massage during 3^rd stage of labour (P= 0.012), examination of the placenta (P= 0.034), management of PPH (P= 0.028), causes and diagnosis of PPH (P= 0.001), (Fischer's exact value= 0.043).

Conclusion

Results of the study indicate a statistical association between midwives' factors and management of PPH.

Knowledge and barriers on correct use of modified guidelines for active management of third stage of labour: a cross sectional survey of nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania

Background

Despite the fact that it is possibly preventable, postpartum haemorrhage (PPH) is the global most deadly form of obstetric bleeding, mainly sub-Saharan Africa with at least one-fourth of maternal deaths in East African regions. Active management of third stage of labour (AMTSL) is recommended to prevent PPH. However, AMTSL guidelines have been revised since 2006.

Objectives

To examine the current status of nurse-midwives' knowledge on modified AMTSL guidelines and highlight barriers to AMTSL correct use.

Method

Descriptive cross sectional survey was conducted to 160 nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania. One-way, interactive modes ANOVA and Chi square (χ2) test were run in SPSS 21 version to compare the association of independent and dependent variables.

Results

Virtually all nurse-midwives knew the first recommended uterotonic (99.4%) and delayed cord clamping (98.8%) protocols as modified. Knowledge was significantly contributed by multiple factors; p=0.001. Reported correct AMTSL use was 46.8% which was significantly affected by AMTSL training (χ2 = 6.732, p = 0.009) and prioritizing atteding an asphyxiated baby (χ2 = 5.647, p = 0.017).

Conclusion

Regardless of high nurse-midwives' AMTSL knowledge; it is imperative that responsible authorities plan appropriate strategies to solve reported barriers affecting correct AMTSL use.

Assessment of Midwife Knowledge, Practice, and Associated Factors towards Active Management of the Third Stage of Labor at Governmental Health Institutions in Tigray Region, Northern Ethiopia, 2018

Introduction

Globally, postpartum hemorrhage is the most common cause of maternal mortality and morbidity, and it accounts for more than 25% of all maternal deaths. The majority of death due to postpartum hemorrhage is caused by uterine atony. Routine and correct usage of active management of the third stage of labor decreases the occurrence of postpartum hemorrhage by 60% when compared to expectant management of the third stage of labor. The purpose of this study was to assess midwife knowledge, practice, and associated factors towards active management of the third stage of labor at governmental health institutions in the Tigray region, 2018.

Results

These study results showed that from the total study participants (N = 278), 170 (61.2%) were good in knowledge and 121 (43.5%) were good in practice towards active management of the third stage of labor. Training related to active management of the third stage of labor (AOR = 2.119, 95%CI = 1.141, 3.3937) and practice level of midwives (AOR = 8.089, 95%CI = 4.103, 15.950) became significantly associated with the knowledge level. The educational level of midwives (AOR = 3.811, 95%CI = 2.015, 7.210), training related to active management of the third stage of labor (AOR = 2.591, 95%CI = 1.424, 4.714), and knowledge level of midwives towards active management of the third stage of labor (AOR = 7.324, 95%CI = 3.739, 14.393) were significantly associated with the practice level. This study showed that training related to active management of the third stage of labor was significantly associated with the knowledge and practice level of midwives. The educational level and knowledge level of midwives were significantly associated with the practice level of midwives towards active management of the third stage of labor. Therefore, midwives should update their academic level and knowledge. Health institutions in collaboration with the Tigray Regional Health Bureau should arrange training for all midwives to bring change.

Predictors of change of health workers' knowledge and skills after the Helping Mothers Survive Bleeding after Birth (HMS BAB) in-facility training in Tanzania

BACKGROUND

Our study aimed to assess the effect of Helping Mothers Survive Bleeding after Birth on knowledge and skills of health workers and whether such effect varies by health workers characteristics.

METHODS

Nested in a cluster-randomised trial to assess the effect of the training on health outcomes, we assessed changes in knowledge and simulated skills in 61 facilities. The assessments were done i) before, ii) immediately-after training session and iii) at 10-month follow-up for subset of health-workers of implementation facilities as defined by the trial. We used a self-administered questionnaire and Objective Structures Clinical Examinations to assess three skill sets: Active Management of Third Stage of Labour, removal of retained placenta and management of severe postpartum haemorrhage. We computed summary statistics and used the paired t-test to assess change of knowledge and skills immediately post-training and at 10-month follow-up. Linear regression was done to assess association of scores and health worker characteristics.

RESULTS

Of the 636 health workers included, 606 (96.7%) and 591 (91.4%) completed the knowledge and skills assessments, respectively. Majority of the participants (68%) were nurse-midwives. Knowledge scores increased by 15 percentage-points from 77.5% to 93% (95% CI 14.3, 16.3, p-value <0.000), and skills scores by 47 percentage-points (95% CI 46.5, 49.2, p-value <0.000) from 37.5% to 83%. There was a 4.0% decline of skills at 10-month follow-up. The decline was higher in auxiliary staff (-11.8%) and least in nurse-midwives (-2.1%) p-value <0.001. Health workers who assisted less than 5 deliveries in the last month, those who never attended postpartum haemorrhage in-service training and profession experience >8 years were associated with lower mean skill change immediately post-training.

CONCLUSION

Our study supports the potential of the Helping Mothers Survive Bleeding after Birth training to increase knowledge and skills of postpartum haemorrhage among all professional groups. Auxiliary staff benefited most from the training but also showed higher skill decline at 10-month. Our study highlights the importance to disaggregate knowledge and skills by health workers characteristics.

Practice and factors associated with active management of third stage of labor among obstetric care providers in Amhara region referral hospitals, North Ethiopia, 2018: A cross sectional study

BACKGROUND

Active management of third stage of labor is the most indispensable intervention to avert post-partum hemorrhage which is one of the typical causes of maternal morbidity and mortality. Therefore, the aim of the study was to assess practice and factors associated with active management of third stage of labor among obstetric care providers in referral hospitals.

METHODS

Institution based cross-sectional study design was conducted from April 1-30, 2018. Simple random sampling technique was used to select a total of 356 obstetric care providers. Data were collected using pretested, structured and self-administered questionnaires. Data were entered to Epi data version 3.1 statistical software and exported to SPSS 23 for analysis. Bivariate and multivariate logistic regression analyses were performed to identify associated factors. P value <0.05 with 95% confidence level were used to declare statistical significance.

RESULT

This study revealed that practice of active management of third stage of labor was 61.2%. Age group of 20-30 years [AOR = 1.95 (95%CI;1.13-3.38)], Being male obstetric care provider [AOR = 1.74 (95%CI;1.03-2.94)], having work experience ≥2 years [AOR = 1.95(95%CI;1.13-3.38)], availability of oxytocin [AOR = 5.46 (95%CI; 2.41-12.3)], having exposure to manage third stage of labor [AOR = 2.91(95%CI; 1.55-5.48)], and having good knowledge [AOR = 2.67 (95%CI; 1.46-4.90)], were the factors associated with practice.

CONCLUSION

This study showed that practice of active management of third stage of labor was high. Age group between 20-30 years, being a male obstetric care provider, having ≥2years work experience, availability of oxytocin, exposure to third stage management and having good knowledge were factors associated with practice. Therefore, all referral hospitals and concerned bodies need efforts to focus on providing training to increase health care provider's knowledge so as to sustain good practice through appropriate interventions.