Obstetric Care Providers Knowledge and Practice towards Active Management of Third Stage of Labourat Hawassa City, SNNPRS, Ethiopia

Background: Active management of third stage of labour properly is frontline to prevent post-partum haemorrhage related maternal morbidity and mortality. 99% of the maternal deaths take places in developing countries. The majority causes of death occur within 4 h after delivery because of haemorrhage. Clinical trial suggests that Routine practice of active management third stage of labour dramatically reduce haemorrhage by 60%. Active management third stage of labour can help to save thousands of women life with low cost. The aims of this study to assess Obstetric care providers Knowledge and Practices o n active management of third stage of labour at Hawassa city, South Ethiopia 2015. Methods: An institutional based cross sectional study was conducted to health institution in Hawassa city, from April to May 2015. By using pretested structured questionnaires for knowledge assessment and observation checklists for practice. Simple random sampling technique was used to select 76 obstetric care providers. Data were entered using Epi Info version 3.5.1 was coded, edited, exported and analyzed by SPSS version 20. Bivariate and multivariate logistic regressions were used to identify independent predictors of knowledge and practice of obstetric care providers. Results: 24 ( 33.3%) of obstetric care providers had knowledgeable about active management third stage of labour and 16.7 % obstetric care providers was applied correctly active management of third stage of labour. Obstetric care providers who took pre/in-service training were 7.4 times was done correctly active management of third stage of labour than didn’t take training [AOR=7.4, 95% CI, (1.07-51)]. Conclusion and recommendation: In this study knowledge and practice of obstetric care providers towards active management of third stage of labour is still low. T he governmental and non-governmental organization which works in health related activities plan to give trainings on active management of third stage of labour.


Introduction
Every year worldwide and in Ethiopia 515,000 and 20,000 women, die respectively due to complications of pregnancy and childbirth. 99% of the maternal deaths take place in developing countries. The majority causes of death occur within 4 h after delivery because of haemorrhage [1][2][3] . A total of deliveries 5% women may develop postpartum haemorrhage; this is an accountable for a main part of maternal mortality and morbidity. Clinical trial suggests that Routine practice of active management third stage of labour dramatically reduce haemorrhage by 60%. Active management third stage of labour can help to save thousands of women life with low cost. However, the majority causes of death occur within 4 h after delivery because of haemorrhage and mismanagement third stage of labour 3,4 . There are 14 million women were suffered postpartum haemorrhage annually. Third-stage labour is the period during which the placenta is completely expelled by cord control traction to prevent uterine agony and bleeding 5 . There are two contrasting approaches to the clinical management of the third stage of labour: active and expectant (sometimes referred to as physiological or passive) management. Expectant management is a noninterventionist approach 6 . In contrast, active management involves the clinician intervening in the process through three interrelated but independent processes, Prophylactic administration of an uterotonic agent, Controlled cord traction to aid the delivery of the placenta and uterine massage 7 . These three interventions hasten placental delivery by increasing uterine contractions, decreasing blood loss and preventing postpartum haemorrhage by averting uterine agony. Active management of third-stage of labour is currently recommended as protection against postpartum haemorrhage 8 . So the aims of this study to assess obstetric care provider's knowledge and practices o n active management of third stage of labour.

Study area and period
The study was conducted at Hawassa city from April to May 2015. Hawassa city is located in the Southern part of the country and 273 km away from Addis Ababa and the capital of SNNPRS.

Obstetric Care Providers Knowledge and Practice towards Active Management of Third Stage of Labourat Hawassa City, SNNPRS, Ethiopia
There are seven urban sub cities and 1 rural sub city. According to Hawassa city administration health department, the total population in 2014/2015 was expected 351,567. Out of the total population 170,510 (48.5%) were females and the rest (51.5%) were males. The numbers of women who were in childbearing age group (15-49) were 69,769, from this, 12,167 were pregnant. The health institutions were found in the city includes one governmental referral and one primary hospital, three private primary hospitals, nine governmental and two private health centres.

Study population
The study population was all obstetric care providers who can manage active third stage of labour during the study period.

Inclusion criteria
All obstetric care providers who were available at the time of data collection were included in the study.

Exclusion criteria
Those who were unavailable and having less than half year experience were excluded from the study.

Operational definitions
Third stage management: The third stage of labour is the time from the delivery of the foetus until delivery of the maternal placenta.
Active management of third stage of labour: AMTSL involves interventions to assist in expulsion of the Placenta with the intention to prevent or decrease blood loss. Which has the following components (based on FIGO guidelines): Administration of 10 IU oxytocin intramuscularly immediately within 1 min of delivery of foetus, apply Controlled cord traction and uterine massage after delivery of the placenta.
Obstetric care providers: are professionals who are learned and qualified to give obstetric care in this study those who have the capacity to manage third stage of labour.
Knowledge: The level of knowledge was determined on a knowledge index. Knowledgeable obstetric care provider is those who were known all AMTSL components and right time of oxytocin drug administration. Active management of third stage of labour. Knowledge was categorized as knowledge able and not knowledgeable.
Practice: The overt behaviour, habit or custom that people does, or carry out in his/her daily life. In this study it was measured based on question which measure the actual practices of study subjects based on predefined parameters like (time, dose of oxytocin's, CCT, uterine massage) and the results was added to classify obstetric care providers as skilled or not skilled.

Study design and sample size determination
An institution based cross sectional study was employed. Sample size was determined by using single population proportion formula by considering assumptions of P value 5% as prevalence of active management of third stage of labour practice in Ethiopia 9 desired precision of 5%, 95% confidence level. 5% for non-response rate, a total of 76 obstetric care providers were required for the study.

Sampling procedure
Systematic random sampling techniques were used to select the study subjects. The city had 4 hospitals and 12 health centres which gave labour and delivery services. Two hospitals and four health centres have selected by high case follow at least four per day. Seventy six obstetric care providers were selected by simple random sampling technique and a frame was used employer register.

Data collection
Structured questionnaires and observation check lists were used. It was prepared in English and then translated to local language Amharic. The main contents of questionnaires were socio demographic characteristics, oxytocin drug utilization, knowledge, and observation about AMTSL practices based on FIGO guide line. The questionnaires were developed after reviewing different literatures [8][9][10] .

Data quality control
Data were collected by eight BSc midwives who took BEmONC training, the data collects work area were out site of Hawassa city. Data collectors were trained for two day on the objectives of the study. Questionnaires were pre-tested at Yirgalem hospital to assess clarity, flow and consistency and revised prior to start data collection.

Data analysis
To ensure the quality of data, all filled questionnaires were checked incompleteness and inconsistency. Data were entered using Epi Info version 3.5.1 and exported to SPSS version 20.0 for statistical analysis. Descriptive statistical analysis was used to compute frequency, percentage and mean for independent and dependent variables. Binary logistic regression analysis was used to ascertain the association between explanatory variables and outcome. Variables with significant association in the bivariate analysis were entered into multivariate analysis to determine knowledge and practice about obstetric care providers. Variables with P value less than 0.05 was considered as statistically significant. Finally the results were presented in texts, tables and graphs.

Ethical consideration
Ethical approval and clearance was taken from institutional review board of AAUMF and then formal letter was written by the department of nursing to the concerned office. Regional Health Bureau gave permission to conduct the study in each selected health institution in the study area. After explaining the purpose of the study, verbal informed consent was obtained from respondents before data collection. The right to withdraw the study at any time was also assured. Coding was used to eliminate names and other personal identification of respondents throughout the study process to ensure participants confidentiality.

Socio-demographic characteristic and experiences of obstetric care providers
A total of 72 obstetric care providers were participated in the study, with 95% response rate. Among the total study subjects 75% (n=54) were diploma midwives followed by 22% (n=16) B.Sc. midwives ( Table 1).

Knowledge of obstetric care providers on active management of third stage of labour
Respondents were knew the uterotonic drugs 4.2% (n=3) .The majority of the respondents 86.1% (n=62) were known the dose of oxytocin is 10 IU ( Table 2).
Only 33.3% (n=24) of the respondent had knowledgeable on three components, i.e., administering uterotonic drugs, apply control cord traction and uterine massage (Figure 1).

Practices of obstetric care providers on active management of third stage of labour
More than half of 65.3% ( n=47) the obstetric care providers were examined the abdomen to rule out the presence of another baby before administering oxytocin drugs. Only 31.9% (n=23) of the obstetric care providers gave the uterotonic drugs within one minute (Figure 2).

Factors associated with knowledge and practice about obstetrics care providers
Male obstetrics care providers were 29. 8

Discussion
This study has tried to assess knowledge and practice active management of third stage of labour among obstetric care providers in Hawassa city, sidama zone of SNNPRS. In this study showed that more than half of the respondents didn't know all the three components of active management of third stage of labour. Only 33.3% had knowledge on three components, i.e., administering uterotonic drugs, apply control cord traction and uterine massage and know the right time of oxytocin drug administration. These findings is higher than on obstetric care provider's knowledge on Active management of third stage of labour in south Nigeria 28.3% and Tanzania 9% 11-13 . Male obstetric care providers were 29.8 times have knowledge than female [AOR=29.78, 95% CI: (2.56, 345)]. This might be due to females have additional home activities and difficult to update their knowledge's and also the number of male and female participants were not proportional to compare, so it needs further investigation. Obstetrics care providers who got pre/in service training were 7.4 times practice than who did not get training [AOR=7.4, 95% CI: (1.07, 51)]. This is in line with the study done in the Tanzania 3 .
In this study practice of the obstetric care providers on active management of third stage of labour 15.7% of the study subjects was correctly practice. Which is higher than the study conducted in Ethiopia and in south Nigeria 5% and 7% respectively 12,14 . This might be due to the time of the research conducted. In this study 96.1% of the respondents had rid of the placenta after the administration of uterotonic drugs. It is coincide to studies conducted in Australia and United Kingdom 6 . According to this study, 100% of the obstetric care providers were provides oxytocin drugs for active management of third stage of labour. This is slightly higher than a study done in Istanbul, Turkey which is 95% 12 . This study also showed that 64.7% of the obstetric care providers ruled out the possibility of second twin before administration of oxytocin drugs. This finding is very

Strengths and Limitation of the Study
The strength of this study was used observational check list. However, it has limitations that it was based on small sample size. Analytical study design is recommended for further study.

Conclusion and Recommendation
The knowledge and practice of obstetrics care providers towards of active third stage management of labour was s very low. Obstetric care providers who receive pre/in-service training are seven times skill full than those who did not receive training (AOR=7.4, 95% CI=1.07-51). The obstetric care providers update themselves and perform correctly active management of third of labour and accept as norm active management of third of labour. The health bureau employee midwives and trained components of active management of third of labour. The health institutions also prepare morning session every day and mentorship. The health institution put guideline in the labour ward and put poster on the wall of labour ward to show AMTSL.