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CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Pregnancy and delivery are supposed to be a safe process when well-managed, but a number of times it involves major health risks, even to women with no pre-existing health problem. Thousands of women die all over the world from issues directly associated with pregnancy, delivery and its complications (Maya, Buntugu, Lovelace, Emmanuel, & Srofenyoh, 2015). According to World Health Organization, (2012) Sub-Sahara Africa is responsible for approximately 60% of maternal deaths with total lifetime risk as high as 1 in 39 pregnancies when compared with 1 in 2900 in Europe. Although Postpartum haemorrhage affects about 4% of all pregnancies (Combs, Murphy, & Laros, 1991), making it the leading cause of maternal death all over the world.

Recent evidence from World Health Organization, (2008) estimated that postpartum haemorrhage of all etiologies accounts for 25% of the maternal deaths worldwide. However, statistics from the same organization showed disparity in the documentation of findings as record could reach as high as 40% in South East Asia, Latin America and some countries in Africa. Postpartum haemorrhage is responsible for about 50% of maternal mortality in Guatemala and Afghanistan (Miller & Martin, 2008). Every year, a total number of 529,000 women died due to complications of pregnancy and childbirth (Ojengbede, Morhason, Galadanti, Meyer, Nsima, & Gamin, 2010). Similarly, statistics has shown that 358,000 women lose their lives due to negative outcome of pregnancy and delivery (WHO,2010).

According to Adesokan (2010), PPH is excessive bleeding from the genital tract after the birth of a baby up to 6 weeks which is in excess of 500mls or any amount sufficient enough to cause cardiovascular collapse which is dangerous to the life of the woman. According to Reynders Sentennm, Tjalma and Jacquemyn, (2006) majority of these maternal deaths occur within the first four hours after birth. They occur as a result of either lack or poor management of the stage three of labour by skilled midwives and birth attendants, most pregnant women are liable postpartum haemorrhage. Therefore midwives need to possess the knowledge and skill in third stage management of labour, recognize asses, treat excessive blood loss and prevent postpartum haemorrhage.

Postpartum haemorrhage is a killer, and also one of the obstetric complications with established and effective intervention through the use of a low technology device referred to as Non-Pneumatic Anti-Shock Garment or life wrap. NASG is a device in form of a lower bottom suit of an articulated neoprene with Velcro parts which gives lower body circumferential counter pressure that supplies blood to the vital organs of the body, thus reversing hypovolemic shock and decreasing postpartum haemorrhage. Evidence suggests that this promising technology helps overcome further damage and plays a part in sophisticated modern care units by stabilizing women whilst waiting for definitive haemorrhage therapies such as blood transfusion and surgeries.

Uterine atony is the inability of the uterine muscle to effectively contract after delivery which can be managed with the use of appropriate of uterotonic drugs like misoprostol (International Confederation of Midwives and International Federation of Gynecology and Obstetrics, 2007). Misoprostol is a prostaglandin based drug that has aroused the interest of significant others as an effective uterotonic agent due to its ease of administration, safety profile, cost and ease of storage. Though, studies on use of misoprostol as auterotonic agent in management of postpartum haemorrhage have been conducted in many centres (El-Refaey & Templeton, 2006).

Besides, the Nursing and Midwifery Council of Nigeria in the recent past organized workshops and training on the use of NASG for midwives and nurses in Nigeria both in the clinical setting and academia to educate them on the availability and the use of the garment in the control of PPH. However, there is paucity of literature on the appropriate application of their skills on the use of NASG in the Secondary Health Care Facilities in Ondo State. Hence, this study seeks to assess the skills of midwives on the utilization of Anti Shock Garment and administration of misoprostol in the management of postpartum hemorrhage in selected Secondary Health Facilities in Ondo State, Nigeria.

1.2 Statement of the Problem

Postpartum haemorrhage (PPH) is rated among the five leading factors responsible for maternal mortality constituting about 25% of maternal deaths worldwide. Out of these maternal deaths, 99% occurred in developing which is an average of 290 deaths per 100,000 deliveries in contrast to 14 deaths per 100,000 live births in developed countries with uterine atony been responsible for 80-90% of haemorrhage (WHO, 2007).

Nigeria, as a country, constitutes the 4^th largest country with highest maternal mortality rate worldwide (The World Bank & United Nations Population Division, 2014). The  Millennium Development Goals (MDGs) performance track in Nigeria, 2015 also reported that maternal death rate was 350 per 100,000 deliveries as at 2013 which was still 40 % short of the 250 maternal deaths per 100,000 deliveries as  projected for Nigeria in 2015 (Nigeria MDG 2013 Report, 2015) 

Postpartum haemorrhage is one of the few obstetric complications with established and effective interventions to reduce maternal death. The midwife require skills in the use and application of non-pneumatic Anti-shock garment, the garment reverses the hypovolemic shock and requires knowledge in the use of misoprostol which is effective in managing post-partum haemorrhage. Despite the introduction of this evidence based and low cost first aid device into Nigeria in 2008, there has not been a significant reduction in maternal morbidity and mortality as both India and Nigeria is rated third worldwide with former at 19% (56,000), and later at 14% (40,000), (United Nations, Population Fund, WHO, UNCF and World Bank 2012), with postpartum haemorrhage still the leading cause of maternal mortality. Thus, Nigeria as a nation has the highest maternal mortality ratios (MMR) with national figure officially at 814 maternal deaths/100,000 live births (United Nations Population Division, 2014).

 Evidence also suggests that Non pneumatic Anti shock garment and misoprostol are not been effectively utilized by midwives  in the course of managing clients with  postpartum haemorrhage in many health care center’s as investigated by Onasoga, Awhanaa,  &Amiegheme, (2012), as maternal mortality indices are still very poor. Hence, this study seeks to assess the midwives skills in the application of Anti-shock garment as well as their knowledge and utilization of misoprostol as a measure of controlling postpartum haemorrhage in selected health facilities in Ondo State.

1.3 Significance of the Study

The findings of this study reveals the level of knowledge, utilization and if midwives have the skills in the application of Anti-shock garment and the use of misoprostol management of PPH, thereby reducing maternal morbidity and mortality. Furthermore, the available information would be made available in developing the curriculum for students in training midwives, policy makers and other health workers in planning strategies and intervention to improve midwifery practice as well as promoting the utilization of this low technology, evidence-based and low cost strategy to reduce maternal morbidity and mortality from postpartum haemorrhage. It would also provide data for further studies

1. Scope of the Study

The researcher studied on nursing intervention on midwives’ skill in the management on postpartum haemorrhage. The study was limited to midwives working in the Labour and Postnatal ward of State Specialist Hospital Akure and Ondo, Ondo State, Nigeria.

1. Objective of the Study   

The main objective of the study is to determine the effects of nursing intervention on midwives skills in the management of postpartum haemorrhage in Ondo State, Nigeria.

The specific objectives are to:

1. determine the pre intervention knowledge level of midwives on misoprostol in the management of PPH
2. determine the pre intervention knowledge level of midwives on NASG in the management of PPH
3. determine the effect of nursing intervention on midwives knowledge in the use of misoprostol in the management of PPH
4. determine the effect of nursing intervention on knowledge of midwives in the use of NASG in the management of PPH
5. determine the effect of nursing intervention in the application of NASG in the management of postpartum hemorrhage
6.  determine the effect of nursing intervention in the removal of NASG in the management of postpartum hemorrhage
   1. Research Questions
7.  What is the pre intervention knowledge level of midwives on misoprostol in the management of PPH?
8. What is the pre intervention knowledge level of midwives on NASG in the management of PPH?
9. What is the effect of nursing intervention on knowledge of midwives in the use of misoprostol in the management of PPH?
10. What is the effect of nursing intervention on knowledge of midwives in the use of NASG in the management of PPH?
11. What is the effect of nursing   intervention in the application of NASG in the management of postpartum hemorrhage?
12. What is the effect of nursing   intervention in the removal of NASG in the management of postpartum hemorrhage?
    1.  Hypotheses

H₀1_: There is no significant difference in the pre intervention knowledge of misoprostol    

         and NASG in the management of PPH in the experimental group and the control  

         group.

H₀2: There is no difference in the post intervention   knowledge of misoprostol and

          NASG in the management of PPH in the experimental and control groups. 

H₀3: There is no difference in the pre and post   intervention knowledge of midwives in

         the use of Misoprostol in the management of PPH.

H₀4: There is no difference   in the pre and post intervention skills of midwives in the use

         of NASG in the management of PPH in the experiment group.

1.  Operational Definition of Terms
2. Knowledge: Ondo State midwives understanding of midwives on the use of misoprostol and anti-shock garment as measures of managing postpartum haemorrhage.
3. Knowledge level of Misoprostol: A score of 0-6 on the misoprostol knowledge scale is regarded as low knowledge; 7-12 as moderate knowledge while 13-18 as high knowledge respectively. Total mark obtainable is 18.
4. Knowledge level of NASG: A score of 0-7 on the Anti-shock knowledge scale is regarded as poor knowledge, 8-12 moderate knowledge and 13-22 as high knowledge. The total mark obtainable is 22
5. Knowledge level of practice: A score of 0-13 on the Anti-shock practice of skill scale is regarded as poor knowledge, 14-25 moderate knowledge and 26-38 as high knowledge. The total mark obtainable is 38.
6. Postpartum Haemorrhage: Is the loss of blood after delivery that is sufficient enough to cause cardiovascular collapse which is detriment to the life of a woman.
7. Anti-Shock Garment: Is a form of lower bottom suit used in the management of postpartum haemorrhage.
8. Midwives skills: Ability to use and administer misoprostol and anti-shock garment in the control of postpartum hemorrhage.
9. Nursing Intervention: is the approach utilize by the researcher to give information on knowledge on use of Misoprostol and Anti-shock garment and demonstration on the use Anti-shock garment.
10. Management of postpartum haemorrhage: the use of Misoprostol and NASG in the control postpartum haemorrhage.