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

BMC Pregnancy and ChildbirthBMC series – open, inclusive and trusted201717:292

https://doi.org/10.1186/s12884-017-1480-8

Received: 6 September 2016

Accepted: 1 September 2017

Published: 7 September 2017

Abstract

Background

Active management of third stage of labor played a great role to prevent child birth related hemorrhage. However, maternal morbidity and mortality related to hemorrhage is high due to lack of knowledge and skill of obstetric care providers ‘on active management of third stage of labor.

Our study was aimed to assess knowledge, practice and associated factors of obstetric care providers (Midwives, Nurses and Health officers) on active management of third stage of labor in Sidama Zone, South Ethiopia.

Methods

An institution based cross sectional study design was conducted from December 1–30 /2015 among midwives, nurses and health officers. Simple random sampling technique was used to get the total of 528 participants. Data entry was done using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. The presence of association between independent and dependent variables was assessed using odds ratio with 97% confidence interval by applying logistic regression model.

Results

Of the 528 obstetric care providers 37.7% and 32.8% were knowledgeable and skilled to manage third stage of labor respectively. After controlling for possible confounding factors, the result showed that pre/in service training, being midwife and graduation year were found to be the major predictors of proper active management of third stage of labor.

Conclusion

The knowledge and practice of obstetric care providers towards active management of third stage of labor can be improved with appropriate interventions like in-service trainings. This study also clearly showed that the level of knowledge and practice of obstetric care providers to wards active management of third stage of labor needs immediate attention of Universities and health science colleges better to revise their obstetrics course contents, health institutions and zonal health bureau should arrange trainings for their obstetrics care providers to enhance skill.

Keywords

Active management of third stage of labor Ethiopia Knowledge Practice Third stage

Background

Active management of third stage of labor played a great role to prevent childbirth related hemorrhage. Proper practice of active management of third stage of labor is a novel method to alleviate postpartum hemorrhage [1, 2].

Hemorrhage is the leading cause of maternal death, especially in developing countries including Ethiopia. Maternal mortality ratio in Ethiopia per 100,000 live births were 676 in 2012 and 420 in 2014. A 2015 estimate puts the maternal mortality ratio in Ethiopia 353 /100,000.

Worldwide, maternal morbidity and mortality is alarmingly decrease, however in developing countries, especially sub-Saharan Africa frontline maternal death is caused by hemorrhage due to infrastructure limitation, lack of skill birth attendants, inappropriate management of active third stage of labor, [2].

Third stage of labor is the period after the fetus is delivered until the placenta completely removed. It is the easiest and shortest time, but dangerous as most maternal deaths were occurred [3].

Active management of third stage of labor involves the obstetric care providers to carry out three interrelated but independent processes: - Prophylactic administration of an uterotonic agent, Controlled cord traction and uterine massage. Active management of third stage of labor is an interventions needed to reduce maternal death due to PPH [4].

FIGO–ICM Recommends to use uterotonic drugs immediately following delivery of the fetus, controlled cord traction and uterine massage immediately after delivery of the placenta, followed by massage of the uterus every 15 min for 2 h to assess the continued need for massage [5].

Active management of third stage of labor is a proven solution to prevent unnecessary procedures and complications, such as manual removal of the placenta and postpartum hemorrhage [6].

Since all parturient women are at risk for PPH, obstetric care providers need to possess the necessary knowledge and skills of active management of the third stage of labor properly to prevent PPH [7].

The WHO technical update, assures that now a days the most effective approach to prevent PPH is active management of the third stage of labor (AMTSL) [8].

Effective use of AMTSL in reducing PPH and the need for PPH treatment has been investigated by a number of large trials. The Hinchinbrook 12 randomized control trials provided evidence that AMTSL significantly reduces postpartum hemorrhage, decreases blood loss and decreases the need for blood transfusions [2].

The AMTSL practice of obstetric care providers in developing countries is not in line with what is recommended by FIGO because of certain factors like knowledge, qualification, training, and other demographic factors. The practice of AMTSL according to the FIGO/ICM recommendations in Ethiopia was only 5% of all observed deliveries [5].

The aimed of this study is to assess knowledge, practice and associated factors of obstetric care providers (amongst midwives, nurses and health officers) on active management of third stage of labor in Sidama Zone, South Ethiopia.

Methods

An Institution based cross-sectional study was conducted among obstetric care providers in Sidama Zone from December 1–30, 2015. Sidama zone is one of the zone found in southern nation’s nationalities and peoples region (SNNPR) of Ethiopia.

According to Sidama zone health department, the total population in 2014/2015 is expected to be 3,676,576. The health institutions which are found in the zone include three governmental hospitals, 130 governmental health centers, 524 posts. Regarding human resource for health, the zone has 1857 obstetrics care providers.

Out of 19 Woredas (districts), from the Zone seven were selected by simple random sampling techniques [9]. The study population was randomly selected obstetric care providers. The sample size was determined using single population proportion formula at 95% of confidence interval with assumption of prevalence of AMTSL practice in Ethiopia 5% [5] with (α = 0.05), 3% marginal error (d = 0.03).

Multistage stage sampling method was employed by using design effect of 2 and 10% non-response response. The final sample size was 528 obstetric care providers. To collect the data, initially all public health institution in Sidama zone from selected Districts were listed and identified. The participants were allocated proportionally to each public health institution and were selected by using simple random sampling technique from each public health institution. Obstetric care providers who had service greater than 6 month were participated in the study.

The structured interviewer administered questionnaires were included sociodemographic characteristics, personal characteristics and knowledge while observational checklist for skill part assessment were used as data collection instruments.

Obstetric care provider who knew all AMTSL components, right time of oxytocin administration and cord clamping were considered as knowledgeable and the obstetric care provider who administered oxytocin with in 1 min, apply CCT and perform uterine massage considered as skilled.

Pretest was done on 5% obstetric care providers working out of the selected health to check clarity, length and completeness of the questionnaires and observation check list. Based on this necessary correction was done accordingly.

Data was collected by face to face interview using a structured and pre-tested questionnaire to assess knowledge and observation check lists for practice assessment.

Both interview and observation were used for the same participant, interview was administered to assess the sociodemographic characteristics and knowledge of the participant. After interview, verbal consent was obtained from the parturient mothers, and the participant was observed while managing third stage of labor.

Interview and observation were performed by obstetric care provider data collectors. Both sexes were participated in data collection. Seven (07) obstetric care providers who have BEmONC training were recruited and training was given for 01 days on the objective, relevance of the study, confidentiality of information, respondent rights, informed consent, and technique of interview, 02 Health professional who have 1st degree (BSC nurse, midwife or HO) were trained and supervise the data collection. Data entry was done by using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. The presence of association between independent and dependent variables was assessed using odds ratio with 97% confidence interval by applying logistic regression model.

Ethical clearance was obtained from College of Medicine and Health Sciences ethical review committee, Hawassa University. Formal letter of cooperation was written for Sidama Zone Health Department and Sidama zone selected District Health Offices. After informing the objective of the study, consent was obtained voluntarily from each study subject.

Results

Socio-demographic characteristic and experiences of obstetric care providers

A total of 528 obstetric care providers were participated in the study, with 96.4% response rate. Out of the total respondents, 75.4% (n = 398) were females and the age of participants were from 22 to 45 years old. The mean age of the study population was 26.4 with SD 3.05 years. Sidama was a dominant ethnic group, which accounted for 49.6% (n = 262) (Table 1).
Table 1

Socio-demographic characteristics of the obstetric care providers

Variables

 

Frequency

(n = 528)

Percentage

Sex

Male

130

24.6

Female

398

75.4

Age

20–30

461

87.3

31–40

57

10.8

41–50

10

1.9

Marital status

Single

258

48.9

Married

249

47.2

Divorced

16

3

Widowed

5

0.9

Ethnicity

Sidama

262

49.6

Amhara

104

19.7

Oromo

125

23.7

Tigre

20

3.8

Others®

17

3.2

Religion

Protestant

216

40.9

Orthodox

233

44.1

Muslim

38

7.2

Catholic

41

7.8

Work place

Health center

483

91.5

Hospital

45

8.5

Profession

Health officer

30

5.7

BSc midwife

66

12.5

Diploma midwife

330

62.5

BSc Nurse

40

7.6

Diploma Nurse

61

11.6

Others➲

1

0.2

AMTSL related In/pre service training

Yes

374

70.8

No

154

29.2

Conduciveness of delivery room

Yes

467

88.4

No

61

11.6

Adequate oxytocic drugs

Yes

488

92.4

No

40

7.6

Others®: Wolayta, Hadya, Kembata

Others➲ Public Nurse

Knowledge of obstetrics care providers on active management of third stage of labor

The knowledge of the obstetrics care providers towards active management of third stage of labor were 37.7%(n = 199) (Table 2).
Table 2

Knowledge of the obstetric care providers on active management of third stage of labor

Variables

 

Frequency

Percent

Uterotonic drugs know

Oxytocin

439

83

Ergometrine

57

10.8

Misoprostol

18

3.4

All

15

2.8

Dose of oxytocin know

0.5 mg

6

1.0

10 IU

492

93.2

10 mg

26

4.9

0.5 IU

5

0.9

Recommended rout of oxytocin know

IV

34

6.4

IM

494

93.6

Time of uterotonic drug administration know

After the delivery of anterior shoulder

33

6.2

Within one minute after delivery of baby

451

85.3

Within three minutes

45

8.5

Mentioned essential components of active management of third stage of labor

Administer uterotonic drugs

61

11.5

Apply counter cord traction

102

19.3

Uterine massage

59

11.2

All

307

58

 

Knowledgeable

199

37.7

Knowledge

Not knowledgeable

329

62.3

Practice of obstetrics care providers on active managements of third stage of labor

The practice of the obstetrics care providers towards active management of third stage of labor were 32.8%(n = 173) (Table 3).
Table 3

Practices of the obstetric care providers on active management of third stage of labor

Variables

 

Frequency

Percent

Abdomen palpated to rule out the presence of second baby

Yes

331

62.7

No

197

37.3

Uterotonic drugs given

Oxytocin

432

81.8

Ergometrine

61

11.6

Misoprostol

30

5.7

Not given

5

0.9

Dose of uterotonic drugs given

0.5 mg

24

4.5

10 IU

486

96.6

0.5 mg

12

2.3

Others

6

1.1

Route of uterotonic drugs given

IM

519

97.2

IV

9

1.7

Oral

6

1.1

Wait uterine contraction 2–3 min to apply CCT

Yes

243

46

No

285

54

Wait gush of blood

Yes

283

53.6

No

245

46.4

Counter cord traction applied

Yes

472

89.4

No

56

10.6

Placenta supported by two hands during placenta delivery

Yes

421

79.7

No

107

20.3

Membrane extracted gently with lateral movement

Yes

293

55.5

No

235

44.5

Uterine massage immediately after delivery of placenta

Yes

227

43

No

301

57

Uterine relaxation ensured

Yes

161

30.5

No

367

69.5

Inform and demonstrate the mother massage uterus

Yes

196

37.1

No

332

62.9

Skill

Skilled

173

32.8

 

Not skilled

355

67.2

Factors associated with obstetric care provider’s knowledge to wards AMTSL

Profession and year of graduation were factors which associate with knowledge of obstetric care provider’s towards active management of third stage of labor (Table 4).
Table 4

Factors associated with obstetrics care providers’ knowledge on active third stage management of labor

Characteristics

AMTSL knowledge

OR(97% CI)

P value

Yes

No

Crude

Adjusted

 

Sex

Female

154

244

1.2 (0.75–1.88)

0.86(0.54–1.34)

0.47

Male

45

85

1.00

  

Age

20–30

171

289

1.14 (0.64–2.04)

0.90 (0.50–1.62)

0.70

>30

28

40

1.00

  

Marital status

Single

114

144

1.72 (0.65–1.42)

0.92 (0.61–1.40)

0.66

Married

85

185

1.00

  

Work place

Hospital

22

23

0.55 (0.28–1.08)

0.60 (0.30–1.24)

0.13

Health center

307

176

1.00

  

Profession

Midwife

259

167

1.37 (1.07–2.60)*

1.76 (0.33–0.87) a

0.007

Others Θ

70

62

1.00

  

Year of graduation

2005–2007

136

193

1.55 (1.00–2.29)*

0.67 (0.46–0.98) a

0.036

Before 2005

62

136

1.00

  

Year of experience

½-2 years

105

159

1.19 (0.80–1.76)

0.84 (0.56–1.27)

0.36

>2 years

94

170

1.00

  

Receiving training

Yes

59

95

1.04 (0.63–1.48)

0.86(0.46–1.58)

0.58

No

140

234

1.00

  

Trained topic related to AMTSL

Yes

96

151

1.10 (0.75–1.62)

0.99 (0.56–1.76)

0.96

No

103

176

1.00

  

*P-value <0.05,

a Adjusted for socio demographic characteristics and some concepts of AMTSL

Others Θ: Health officers, BSc/diploma nurses, public nurse

Factors associated with obstetric care provider’s practice to wards AMTSL

Pre/in service training was associated with the practice of obstetric care providers to wards active management of third stage of labor (Table 5).
Table 5

Factors associated with obstetrics care providers’ practices on active third stage management of labor

Characteristics

AMTSL Practice

OR (97% CI)

P-value

Yes

No

Crude

Adjusted

 

Sex

Male

45

85

1.12 (0.70–1.78)

1.30 (0.78–2.16)

0.27

Female

128

270

1.00

1.00

 

Age

20–30

157

303

1.68 (0.29–1.09)

1.75 (0.89–3.43)

0.07

>30

16

52

1.00

1.00

 

Marital status

Single

108

191

1.43 (0.46–1.06)

0.73 (0.48–1.11)

0.10

Married

65

164

1.00

  

Profession

Midwives

125

271

0.81 (0.78–1.96)

0.73 (0.45–1.18)

0.15

Others

48

84

1.00

1.00

 

Conduciveness of delivery room

Yes

147

320

0.62 (0.34–1.13)

0.66 (0.35–1.25)

0.15

No

26

35

1.00

1.00

 

Place of work

Hospital

20

25

1.73 (0.29–1.15)

0.55 (0.27–1.10)

0.06

Health center

153

330

1.00

1.00

 

Year of graduation

2005–2007

102

227

0.81 (0.54–1.22)

1.28 (0.84–1.95)

0.21

Before 2005

71

128

1.00

1.00

 

Experience Year

½-2 year

87

177

1.02 (0.68–1.41)

0.97 (0.67–1.42)

0.91

>2 year

86

178

1.00

1.00

 

Receiving training

Yes

143

231

2.56 (1.56–4.20)*

2.67 (1.60–4.50) a

000

No

30

124

1.00

1.00

 

Training topic related to AMTSL

Yes

98

183

1.23 (0.82–1.84)

1.28 (0.84–1.95

0.20

No

75

172

1.00

1.00

 

*P-value <0.05,

aAdjusted for socio demographic characteristics and some concepts of AMTSL

In this study 11.4% (n = 60) of the obstetric care providers were clamp the cord within the recommended time which is within 2–3 min (Fig. 1).
Fig. 1

Practice of cord clamping time of obstetrics care providers (N = 528)

Eighty eight point 4 % (n = 467) of the delivery rooms were conducive to apply active third stage management (Fig. 2).
Fig. 2

Conduciveness of delivery room

Discussion

The available reports and this study showed that in Ethiopia the knowledge and practice of obstetric care providers towards active management of third stage of labor is unsatisfactory. Among the participants 37.7% (n = 199) of the obstetric care providers were knowledgeable on managing of third stage of labor actively. This finding is higher than the study conducted in south Nigeria and Tanzania 28.3% and 9% respectively [10, 11]. Profession and year of graduation were the factors which associate with obstetric care provider’s knowledge towards active management of third stage of labor. Even observational studies are exposed to observational bias, utilization of both structured interviewer administered questionaries and observation check list is considered as strength of this study. This study is the first of its kind in southern Ethiopia which includes observational check list to assess the actual practice of obstetric care providers towards active management of third stage of labor. Based on the observation the practice of obstetric care providers were not satisfactory in this study even it is better from the previous findings in Ethiopia and Nigeria [5, 9]. Almost all the obstetric care providers were rid of the placenta after administration of uterotonic drugs, like that of Australia, Holland and United Kingdom practice, but different from some United States and Canada which advocates withholding uterotonic administration until the placenta is delivered [12]. All obstetric acre providers were used oxytocin as an uterotonic drug for AMTSL which is slightly different from a study conducted in Istanbul, Turkey [6]. Most of the obstetric care providers check presence of second twine before administration of oxytocin which is better than Istanbul Turkey practice [6]. Majority of the participants were observed while correctly apply counter cord traction practice but half of them were not wait uterine contraction like that of Nepal [13] Practice. Participants who got pre/in service training were observed while correctly practicing AMTSL than who did not have training which indicates AMTSL related training is needed.

In this study majority of the obstetric care providers were midwives which is totally different from a study conducted in Ethiopia, which concludes nurses performed most (61%) in Ethiopia [5]. Physicians were not observed during active management of third stage of labor, this might be due to Physicians tend to manage more complicated third stages. Most of our participants were not clamp the cord with the recommended time which is within 2–3 min. In Albanian maternity hospital the practice is within 20 s [14]. There was no problem on delivery room conduciveness and availanlity of oxytocic drugs to practice AMTSL in our study area.

Conclusion and recommendation

The knowledge and practice of obstetric care providers towards active management of third stage of labor can be improved with appropriate interventions like in-service trainings. This study also clearly showed that the knowledge and practice of obstetric care providers to wards AMTSL which needs immediate attention of Universities and health science colleges better to revise their obstetrics course contents, health institutions and zonal health office need to arrange trainings for their obstetrics care providers to enhance skill.

Abbreviation

AMTSL: 

Active management of third stage of labor

AOR: 

Adjusted odds ratio

BEmONC: 

Basic emergency obstetrics and newborn care

E.C: 

E Ethiopian calendar

FIGO: 

Federation of international gynecology and obstetrics

ICM: 

International cooperation of midwifery

PPH: 

Postpartum hemorrhage

SNNPRS: 

Southern nation nationalities people regional state

WHO: 

World health organization

Declarations

Acknowledgements

We are very grateful to Hawassa University for approval of ethical clearance, technical and financial support of this study. Then, we would like to thank all obstetrics care providers who participated in this study for their commitment in responding to our interviews and consent for observations. Finally, we are also grateful to the Sidama zone health department and Sidama zone selected District health offices for their assistance and permission to undertake the research.

Competent interests

The authors declare that they have no competing interests.

Funding

This research were funded by Hawassa University for academic staff.

Availability of data and materials

We send all which is available as, there is not remaining data and materials.

Authors’ contributions

ZT wrote the proposal, participated in data collection, analyzed the data and drafted the paper. ZY and AA approved the proposal with some revisions, participated in data analysis and revised subsequent drafts of the paper. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board of the Hawassa University. Communication with the different District health office administrators were made through formal letter obtained from the Hawassa University. After the purpose and objective of the study have been informed, written and verbal consent was obtained from each study participant. Participants were also be informed that participation was on voluntary basis and they can withdraw from the study at any time if they were not comfortable about the questionnaire. In order to keep confidentiality the information was maintained throughout by excluding names as identification in the questionnaire and kept their privacy during the observation by observing them alone.

Consent for publication

Not applicable.

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Authors’ Affiliations

(1)
School of Nursing and Midwifery, College of Medicine and health sciences, Hawassa University
(2)
School of Public and Environmental Health, College of Medicine and health sciences, Hawassa University

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Copyright

© The Author(s). 2017