ABSTRACT

Background: Postpartum hemorrhage is leading cause of maternal death worldwide, with an estimated mortality rate of 140000 per year accounting for approximately one maternal death every 4 minutes

Aim: The aim is to identify those factors that may negatively influence the practice of AMTSL amongst obstetric care providers in the Buea Regional Hospital.

Materials and methods: Quantitative cross-sectional study was carried out from February to March 2022, data was collected using a well-structured questionnaire (Parted in three sections in accordance with specific objective) and administered through face to face interview. The questionnaire consisted of a close ended questions. A total of 96% participants were enrolled into this study.

Result: Finding of this study shows that 21(70.0%)workload, lack of knowledge on the components of active management of third stage of labour 28(66.7%)and being a less experienced midwives 28(66.7%)The least cited factors were inadequately equipped hospital 10(33.3%)and lack of oxytocin 11(36.7%);majority of 29(96.7%)participants knew that massage or palpation is done immediately after the birth of the baby to check if there is another baby in the uterus Nurses and midwives demonstrated 30(100%)awareness and 27(90.0%)knew oxytocin  as first recommended uterotonic including it’s does 29(96.7%)route 28(93.3%) injection timing 29(96.7%)and timing for cord clamping 28(93.3%).majority 27(90.0%)knee that ignoring the assessment of uterus tonus, placenta completeness, cervical and vaginal tears of repair are harmful practices during AMTSL.

Conclusion: Base on the findings, it shows that majority of nurses and midwives have adequate knowledge on Active management of third stage of labour.

CHAPTER ONE

INTRODUCTION

1.1 Background

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, with an estimated mortality rate of 140 000 per year accounting for approximately one maternal death every 4 minutes (Leduc et al., 2009). The prevalence of PPH has been estimated to be 5.7% of all delivery and responsible for 27% of all maternal deaths worldwide (Lubaki et al., 2010). Severe bleeding in the postpartum period is the single most important cause of maternal deaths worldwide and more than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive blood loss (AbouZahr, 2013).

Post-partum haemorrhage (PPH) is the single largest cause of maternal death particularly in developing countries (Lubaki et al., 2010). In Africa the situation is worse as 33.9 % of maternal deaths are due to PPH (Zubor et al., 2014). In Cameroon the maternal mortality ratio was 467 deaths per 100,000 live births according to the Cameroon Demographic and Health Survey (CDHS, 2018). According to Tebeu et al., (2015), the main cause of maternal mortality was PPH (38.0%).  Gilda et al., (2007) reported that a clinical guideline for the prevention of post-partum hemorrhage widely recommend provision of a package of interventions known collectively as Active Management of the Third Stage of Labor (AMTSL). Sheldon et al. (2013) discovered that PPH has been shown to be effectively prevented by the use of active management of the third stage of labour (AMTSL). WHO Making Pregnancy Safe Technical Update (2006) also revealed that AMTSL is intended to reduce post-partum blood loss through expediting placental delivery and preventing uterine atony.

Active management of the third stage of labor (AMTSL) is a feasible and inexpensive intervention that can help to save millions of women’s lives especially in a poor resource setting. Active management of the third stage of labour (AMTSL) is a combination of actions performed during the third stage of labor to prevent PPH, the components of AMTSL are administration of a uterotonic drug within one minute after the baby is born, controlled cord traction (CCT) and uterine massage immediately after delivery of the placenta (WHO, 2006).  Based on an extensive review of the literature, the WHO recommends that active management of third-stage of labour be offered to all women, because the presence of risk factors cannot be used to predict postpartum hemorrhage, Active management has been proved to reduce the incidence of postpartum hemorrhage, the quantity of blood loss, and the use of blood transfusions (Sheldon et al., 2013.).The Prevention of Postpartum Hemorrhage Initiative (2013) reported that Postpartum hemorrhage (PPH) is commonly defined as blood loss > 500ml in the first 24 hours after delivery and severe PPH is loss of 1000mL or more. The use of active management of the third stage of labor (AMTSL), has been associated with nearly 60% reduction in PPH occurrence and that universal use of AMTSL will prevent 27% of deaths from PPH (POPPHI, 2013). A retrospective study from Ghana compared active versus expectant management in a rural setting at Holy Family Hospital in Berekum, the findings show that PPH occurred less often in the actively managed group compared with the expectant management group (Miller et al., 2004). Miller et al. (2004) found that despite the fact that several studies have shown that AMTSL, is an effective evidence-based intervention for the prevention of uterine atony and PPH, the knowledge, correct and timely practice in most developing countries including Cameroon are still very low. A study done in Ghana elucidated some factors as being responsible for low utilization of AMTSL during delivery including inconsistent guidelines on AMTSL, lack of adequate staff and inability of the old midwives to adapt to the new guidelines (Hammah and Donkor, 2013).

In a qualitative study conducted in Accra metropolies, It was discovered that some of the difficulties in implementing AMTSL are insufficiency in staff coverage leading to task shifting and the frequent change in the definition of AMTSL since its introduction in 2003 (Schack et al., 2014). Lack of training was seen as a barrier to the implementation of AMTSL (POPPHI, 2007). The aim of this study was to assess the factors influencing the practice of AMTSL among nurses and midwives in the Buea Regional Hospital.

1.2 Statement of the Problem

In 2015 approximately 14 million women suffered from postpartum hemorrhage worldwide resulting into 287 000 women dying while pregnant or giving birth (WHO, 2015). Carroli et al. (2008) reported that postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%. Africa has the highest prevalence rate of about 10.5%. In Africa and Asia, where most maternal deaths occur, PPH accounts for more than 30% of all maternal deaths. PPH is the leading cause of maternal death in low-income countries and is the primary cause of approximately one-quarter of global maternal deaths (Fawole et al., 2013).  The most common cause of PPH is uterine atony, a condition in which the uterus failed to contract after delivery of the fetus and/or placenta (Carroli et al., 2008). Among PPH survivors, an estimated 12% will suffer from the consequences of severe anemia (AbouZahr, 2003). Annually, an estimated 467 per 100,000 Cameroonian women die from pregnancy related complications (CDHS, 2018). PPH is the leading cause of maternal mortality in Cameroon accounting for 38% of the mortality.During our internship at the RHB,I realized that  post partum women suffer from PPH due to poor management of third stage of Labour,reasons why I decided to carry out a research on Active management of third stage of labour.

1.3 Rationale

Despite the fact that maternal mortality resulting mainly from PPH is high in Cameroon and that various studies have consistently demonstrated poor knowledge, attitude and practice for the effective use of AMTSL by the skilled birth attendants (CDHS, 2018; Naamala, 2007; Mfinanga et al., 2009), very limited research has been carried out in Cameroon to address the challenges and barriers to the effective use of AMTSL by nurses and midwives.  Following the continuous modification of the AMTSL guideline in 2012, it is important to examine the knowledge and highlight factors contributing to the correct use of this modified AMTSL guidelines. Therefore this study aims to assess the factors that influence the AMTSL among nurses and midwives working at the Buea Regional Hospital. These findings are going to help health planners develop a strategies to improve on the effective AMTSL and infant and maternal health as a whole.

 1.4 Research Questions

1. What is the level of knowledge of nurses and midwives on active management of third stage of labour (AMTSL)at the Buea Regional Hospital?
2. What are the factors that negatively influence the practice of active management of third stage of labour (AMSTL)among nurses and midwives working at the Buea Regional Hospital?
3. What challenges do nurses and midwives face in the active management of third stage of labour at the Buea Regional Hospital?

1.5 Research Objectives

1.5.1 General Objective

The general objective of this study was to assess the factors that influence the active management of third stage of labour (AMTSL) among nurses and midwives at the Buea Regional Hospital.

1.5.2 Specific Objectives

1. To assess the level of knowledge of nurses and midwives on active management of third stage of labour (AMTSL)at the Buea Regional Hospital
2. To identify the factors that negatively influence the practice of active management of third stage of labour (AMTSL)among nurses and midwives working at the Buea Regional Hospital
3. To identify the challenges faced by nurses and midwives in the active management of third stage of labour(AMTSL)at the Buea Regional Hospital