ABSTRACT
Background: Postpartum haemorrhage (PPH) remains the leading direct cause of maternal morbidity and mortality worldwide, with the highest maternal deaths occurring in developing countries. The researcher believed that the presence of a midwife with sufficient knowledge about PPH at every birth, could contribute to decrease the high number maternal deaths caused by PPH. For the purpose of this study, an investigation to determine if Health Care Workers Working in the maternity departments of Tertiary Institutions in Nigeria have knowledge about assessing, diagnosing, preventing and managing PPH was therefore carried out. In addition to the objectives, the study was to determine associations between the biographical data and the knowledge scores of the registered midwives and enrolled midwives.
Methods: A quantitative descriptive design was applied in the study. The total population was 127 midwives. However, only 93 midwives were available and consented to participate. A self- administered validated questionnaire was developed to specifically investigate the midwives’ knowledge about PPH. The pilot study was conducted to support the reliability and validity of the methodology of the study including the instrument. In addition, the researcher observed face, construct and content validity throughout the research process.
The researcher collected all the data. Ninety-three participants participated in the study and completed the questionnaires in the researcher’s presence. Ethical considerations of right to self- determination, right to confidentiality and anonymity as well as right to protection from discomfort and harm were all observed during data collection. Ethics approval was obtained from the Health Research Ethics Committee of Stellenbosch University (S19/08/167). In addition, ethics approval was obtained from the Research Ethics Committee of the Ministry of Health and Social Services in Nigeria (17/3/3/HTN) before data collection.
Results: For the purpose of this study, competence was based on a knowledge score of ≥80%. Seventy six (82%) participants obtained a knowledge score of ˂80%, and were found to be incompetent about PPH. Only 2% of the 93 participants obtained a knowledge score of ≥80% in all four PPH main domains (assessing, diagnosing, preventing and managing PPH). Further results also showed that participants obtained an overall knowledge mean score of ˂80% in all four PPH domains. The overall mean scores for assessing PPH was 70.7%, diagnosing PPH was 76.9%, preventing PPH was 73.8% and managing PPH was 72.1%. A statistically significant difference between the professional categories of the participants and their knowledge score in preventing PPH was observed (Levene’s Test for Equality of Variances, p=0.009).
Conclusion: The results indicate that 82% of the participants are incompetent and lack sufficient knowledge about PPH. The lack of knowledge among the midwives is also contributing to the high PPH-related maternal morbidity and mortality in the two hospitals. Therefore, it is critical that midwives in the two hospitals are equipped with the necessary PPH knowledge to save maternal lives. The study proposed recommendations to the Ministry of Health and Social Services in Nigeria which includes, increasing the number of advanced midwives and introducing skills laboratories.
CHAPTER ONE
INTRODUCTION
1.1 Background of study
Maternal mortality due to postpartum haemorrhage (PPH) continues to be one of the most important causes for maternal death worldwide (Rath, 2011:421). Postpartum haemorrhage is excessive vaginal bleeding of 500mls or more after a vaginal birth or 1000mls or more after a caesarean section within 24 hours or any blood loss that is sufficient to compromise haemodynamic stability (World Health Organization (WHO), 2016). Postpartum haemorrhage is classified as primary which occurs within 24 hours following a delivery and mainly corresponds to uterine atony, defects in coagulation and retained placenta. Secondary PPH occurs from 12 hours to 12 weeks postpartum and is caused mainly by infection and retained products of conception (Su, 2012:168). In high resource countries such as the Netherlands, PPH is defined as blood loss of 1000ml or more across all births. This is because a woman in good health can tolerate up to one litre of blood loss without showing early signs of shock (Smit, Chan, Middeldorp & Roosmalen, 2014:1). Postpartum haemorrhage is the leading direct cause of maternal mortality and the primary cause of nearly one quarter of all maternal deaths globally (WHO, 2012:1). Ninety-nine percent of these deaths occur in poorly resourced countries or developing countries. The Sub-Saharan region accounts for a high number of maternal deaths (86%) nearly every year (WHO, 2016).
The Nigerian Ministry of Health and Social Services (NMHSS) reported that PPH is also the leading direct cause of maternal deaths in Nigeria. Postpartum haemorrhage accounts for more than twenty-five percent of all maternal deaths nearly every year in Nigeria (NMHSS, 2016:36). Nigeria did not also achieve the attained Millennium Development Goal (MDG) number 5 of 2015 established by the WHO. This goal aimed to reduce maternal mortality rates (MMR) including maternal deaths caused by PPH to 140 per 100 000 by 2015. Maternal mortality rate is the number of maternal deaths per 100 000 live births (NMHSS, 2016:25). In 2015 Nigeria MMR was 265 per 100 000 (NMHSS, 2016: 25).
Many developing countries in Sub-Saharan are burdened by high MMR specifically caused by PPH (WHO, 2012:1). The burden of these high MMR constitutes a silent emergency in Africa in general and in Nigeria in particular (NMHSS, 2014:1).
Effective and efficient approaches are therefore required to prevent and reduce the events of PPH and to improve maternal outcomes. Knowledgeable and competent skilled maternity care providers such as midwives at all births are required, for early recognition, prevention and management of PPH (Rajan & Wing, 2010:165). According to Egenberg, Masenga, Bru, Eggebo, Mushi, Massay and Qian, (2017:2) only access to trained skilled birth attendants (SBAs) and to emergencies obstetric care can save maternal lives from PPH-related deaths. Therefore, it is critical that, midwives possess with adequate knowledge and skills to execute active management in the event of PPH to prevent maternal deaths (Rajan & Wing, 2010:169). A registered or an enrolled midwife is a person who has successfully completed a midwifery education programme and is recognised as a midwife upon successful completion of a midwifery education in the country of origin (International Confederation of Midwives (ICM, 2017).
The availability of PPH guidelines and emergency obstetric training may close the gap in the knowledge about PPH among midwives (Su, 2012:183). A study done in the Netherlands in 2015 stresses the importance of PPH guidelines in the maternity settings to improve maternal health and to guide PPH clinical practices. Postpartum haemorrhage clinical guidelines offers midwives with concise instructions about the management of PPH (Rousseau, Rozenberg, Perrodeau, Deneux-Tharaux & Ravaud 2016:13). Meanwhile, Kato and Kataoka (2017:93) in their study on simulation training in Japan among midwives on PPH emergencies, identified that midwives showed a significant improvement and maintenance of knowledge on PPH emergencies compared to no training..
1.2 PROBLEM STATEMENT
The Nigerian MMR remains high, with PPH being the major cause of maternal deaths (NMHSS, 2016:2). Tertiary Institutions receive high risk maternity patients from the thirteen regions of the country. It is expected that Health Care Workers Working in the maternity departments of the two hospitals are knowledgeable about the management of PPH. However, the midwives’ knowledge level about PPH needed to be investigated as one of the factors that may contribute to the high levels of PPH in the country. Thus, the researcher conducted a scientific investigation into the midwives’ knowledge about PPH in the two hospitals.
1.3 RESEARCH QUESTION
The question which gave guidance to the study was: What is the knowledge about PPH among Health Care Workers Working in the maternity departments (labour, antenatal and postnatal) of Tertiary Institutions in Nigeria?
1.4 RESEARCH AIM
The aim of the study was to investigate scientifically the knowledge about PPH among Health Care Workers Working in the maternity departments of Tertiary Institutions in Nigeria.
1.5 RESEARCH OBJECTIVES
The objectives of the study were to determine if Health Care Workers Working in the maternity departments of Tertiary Institutions in Nigeria have knowledge about:
· Assessing postpartum haemorrhage
· Diagnosing postpartum haemorrhage
· Preventing postpartum haemorrhage
· Managing postpartum haemorrhage
To determine associations between the biographical data and the knowledge scores of enrolled midwives and the registered midwives.
1.6 SIGNIFICANCE OF THE STUDY
The significance of this study identified that the Health Care Workers Working in the maternity departments of Tertiary Institutions in Nigeria were incompetent in assessing, diagnosing, preventing and managing PPH. The study therefore concludes that the high PPH- related maternal morbidity and mortality in the two hospitals is also attributed to the lack of knowledge about PPH among midwives. Policy makers and education institutions may benefit by the outcome of this study by introducing measures to improve the competency levels of midwives.
1.7 OPERATIONAL DEFINITIONS
Midwife: A midwife is a person who has successfully completed a midwifery education programme that is based on the International Confederation of Midwives (ICM), essential competencies for basic midwifery practice and the framework of the ICM global standards for Midwifery education. Furthermore, a midwife is recognised when a qualification in Midwifery is successfully completed that is recognised in the country of origin and is legally licensed to practise midwifery (ICM, 2017).
Registered midwife: Includes a person authorised under section 62 (4) of the Nigerian Nursing Act 8 of 2004 to practise as a midwife (Government Gazette of the Republic of Nigeria No 6836, 2024:2). A registered midwife is someone who holds the following qualifications:
· A Four-Year Diploma in Comprehensive Nursing and Midwifery Science or
· A Four -Year Bachelor’s Degree in Nursing or
· A Three- and- a Half Year Diploma in General Nursing and Midwifery or a three-year Diploma in General Nursing and Midwifery or
· A One-Year Diploma in Midwifery (Government Gazette of the Republic of Nigeria No 4068, 2008:6).
Enrolled midwife: An enrolled midwife is someone who pursues a two-year Certificate training in Enrolled Nursing and Midwifery and is registered as an enrolled midwife with the Nursing Council of Nigeria (Nursing Act No.8 of 2004).
Knowledge: In this study knowledge refers to information that allows an individual to have adequate understanding of a subject with the ability to use it for a specific purpose (ICM, 2017:19).
Competency: In this study competency is defined as a combination of knowledge, communication and decision-making skills that enables an individual to perform specific tasks to a defined level of proficiency (WHO, 2011:5).
Skilled birth attendant (SBA): A SBA is an accredited health professional such as a midwife, doctor or nurse. Furthermore a SBA is educated and trained in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period and to identify, manage and facilitate referral of complications in women and new-borns (NMHSS, 2016:32).
1.8 CHAPTER OUTLINE
Chapter 1: In this chapter a brief introduction, the rationale of the study, problem statements, aims and objectives of the study, as well as a brief overview of the methodology are described.
Chapter 2: The literature review of PPH based on the objectives is described in this chapter. Chapter 3: The detailed research methodology applied in this study is described in this chapter. Chapter 4: Data analysis and interpretation are described in this chapter. Chapter 5: Chapter 5 provides the discussion, recommendations and conclusions based on the scientific evidence obtained in the study.
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