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KNOWLEDGE AND USE OF MISOPROSTOL IN THE PREVENTION AND TREATMENT OF POST PARTUM HAEMORRHAGE AMONG PRIMARY HEALTH CARE WORKERS

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CHAPTER ONE

INTRODUCTION

Background to the Study

Maternal mortality has been and still continues to be a public health problem particularly in developing countries. It is made more tragic because women die in the process of performing the essential physiologic function of childbearing and in efforts to fulfill their natural role of perpetuating the human race. According to WHO (2005), maternal mortality is the death of a woman while pregnant or within 42 days of termination of a pregnancy irrespective of the duration or site of the pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental causes. Globally, an estimated 287 000 maternal deaths occurred in 2010, Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of the global burden (245 000 maternal deaths) in 2010. At the country level, two countries account for a third of global maternal deaths: India at 19% (56 000) and Nigeria at 14% (40,000) (WHO,UNFPA, UNICEF & World Bank, 2012).

In Nigeria, the maternal mortality is estimated to be 545/100,000 live births (National Demography & Health Survey 2008). Indeed, the country has been ranked as the number two country (after India) with the highest absolute number of maternal death in the world. The causes of maternal mortality were reported in percentages as post partum haemorrhage (23%), infections (13%), unsafe abortion (13%), eclampsia (12%),obstructed labour (8%), other direct causes (8%) and indirect causes 20% (FMOH, 2007). Indirect causes such as malaria, anaemia, HIV/AIDS and cardiovascular disease complicate pregnancy or are aggravated by it (WHO, 2005).

Postpartum hemorrhage (PPH) is the common cause of obstetric haemorrhage and the leading cause of maternal death in Nigeria, as one in four maternal deaths is due to it (FMOH, 2007).According to the World Health Organization (WHO, 2000), PPH is defined as bleeding from the genital tract of 500 ml or more within the first 24 hours of delivery of the baby. Bleeding after delivery is normal; however excessive bleeding is often fatal. Uterine atony, which is the failure of the uterus to properly contract after delivery, is the commonest cause, accounting for about 90% cases of PPH (Chelmow, 2008). Other causes of PPH include tear in the cervix or vaginal tissue, uterine rupture, retained placenta or membrane, blood clotting disorders such as disseminated intravascular coagulation accounting for 10% of cases (FMOH, 2007).

The International Federation of Obstestrics and Gynaecology/International Council of Midwives (FIGO/ICM, 2006) recommended the use of active management of the third stage of labour (AMTSL) to prevent post partum haemorrhage. It involves the administration of a drug that causes the uterus to contract known as uterotonics, controlled cord traction only when a skilled attendant is present at birth and uterine massage after delivery of the placenta. Injectable uterotonics, which include ergometrine, oxytocin and syntometrine are the conventional drugs used and also remain the first line drug for prevention and treatment of PPH. However, these drugs are heat-sensitive when exposed to hot climates over long period of time which means they need to be refrigerated in order to maintain their potency. This may be difficult in low-resource settings or rural areas where electricity supply is very erratic and may be ineffective at preventing PPH and maternal mortality, sufficiently for Nigeria’s quest to accelerate pace towards MDG-5 target (FMOH, 2007).

Misoprostol, another uterotonic that is available in tablet form, was thus approved by the Federal Ministry of Health in 2007 for the prevention and treatment of PPH (FMOH, 2007). It has since been in increased use in obstetric and gynaecological practice, including the treatment of post partum haemorrhage. This is because it is relatively inexpensive, has alternative routes of administration (rectally, orally, and sublingually), is easy to store and is stable in field condition, has long shelf life of about 3 years and is easy to use with or without a skilled attendant (Prata, 2005). These characteristics make it very important and useful in rural settings where the efficacy of the other uterotonics (and injection safety) are not assured and the skilled birth attendants to administer the latter are even in short supply.

FIGO and ICM (2005), jointly recommend that in the absence of safe injection, oral misoprostol should be administered to prevent and treat post partum haemorrhage by a skilled birth attendant especially in rural areas. Therefore, there is need to promote misoprostol as an effective and easily administered drug for the prevention of PPH, and to ensure its ready availability in all settings where deliveries take place in the country especially in Primary health care facilities. This is because Primary Health Centres (PHCs) are the basic health care units in the country, and are located mainly in the rural communities where other categories of health facilities are few. Women needing delivery care first present in PHCs, and only when they experience severe complications are they referred to secondary or tertiary levels of care (Okonofua, 2010).

However, referral mechanisms between the different levels of care are not well developed in Nigeria and PPH being a rapidly developing phenomenon, may not be amenable to resolution even by prompt referral (Okonofua, 2010). Therefore, an effective approach to preventing maternal mortality associated with PPH is to ensure that efforts are put in place to effectively prevent or treat PPH in a timely fashion at childbirth. Thus the knowledge and use of misoprostol among nurses, midwives and community health workers, who are the principal delivery care providers of maternal health services at the primary level of care become necessary. This study is aimed at determining the knowledge and use of misoprostol in the prevention and treatment of post partum among primary health care workers in Zaria metropolis.

 

Statement of Problem

The Federal ministry of health, as part of her commitment to reducing maternal mortality due to PPH, trained selected health professionals fraom the 36 states and the FCT in the use of misoprostol for the reduction of maternal mortality (FMOH, 2011). Also, the department  of Obstestrics and Gynaecology, Ahmadu Bello University Zaria  in 2009 and 2010 in collaboration with University of California, Bekerley, trained primary health care providers in Zaria metropolis on the use of this drug in the prevention and treatment of post partum haemorrhage (Population & Reproductive Health Initiative, based at  ABUTH, Zaria 2010).

The trainings   were informed by the result of a community based study which showed that less than 5% of primary health care workers in the country have knowledge of the drug (Okonofua, 2008). Another study conducted in Benin revealed that only 24.2% of primary health care workers indicated that they had heard about misoprostol. However, when asked the route of administration and the dose for the prevention of PPH, only 5 (15.1%) respondents indicated correctly. Similarly, only 3 respondents   correctly mentioned the route of administration of misoprostol for treatment of PPH but none could mention the correct dose for this purpose.  Also, available records from primary health care facilities in Zaria metropolis showed that majority of the maternal deaths were as a result of PPH caused   by uterine atony (Sabon-Gari Health Department, 2011). The researcher also observed that during the course of her practical experiences with students in the facilities that misoprostol was not commonly used by the health workers rather oxytocin and ergometrine were the commonly used drugs, despite the advantages of misoprostol (ease of storage, can be administered through multiple sites without the use of injection and has lower tendency to lose potency in tropical climate). Also, the researcher observed that primary care health workers do not use the correct recommended dose. The questions being raised in this study are how knowledgeable are the primary health workers in the use of misoprostol in the prevention and treatment of PPH and furthermore, does knowledge of misoprostol influence its use among primary health care workers? This study is geared towards finding answers to these questions.

Purpose of the Study

The purpose of this study was to determine the knowledge and use of misoprostol for the prevention and treatment of post partum haemorrhage among primary health care providers in Zaria metropolis.

Objectives of the Study

Specifically, the objectives of this study include to:-

  1. Determine the level of   knowledge of misoprostol as a drug used in the prevention and treatment of PPH among primary health care workers in Zaria metropolis.
  2. Determine how primary health care workers use misoprostol in the prevention and treatment of post partum haemorrhage
  3. Identify factors influencing use of misoprostol for the prevention and treatment of post partum haemorrhage.
  4. Determine the relationship between knowledge of Misoprostol and the use of Misoprostol among the primary health care workers.
  5. Determine the relationship between some demographic characteristics such as age of respondents ,qualification, and years of experience and the knowledge of misoprostol.

Research Questions

  1. What is the level of knowledge of misoprostol in the prevention and treatment of post partum hemorrhage among primary health care workers in Zaria metropolis?
  2. How do Primary health care workers use misoprostol in the prevention and treatment of post partum hemorrhage?
  3. What are the factors influencing use of this drug?
  4. What is the relationship between knowledge of misoprostol and the practice of its use among the respondents?
  5. What is the relationship between some demographic characteristics of the respondents and their knowledge of misoprostol

Significance of the Study

The study is significant because it will provide information on the knowledge and use of misoprostol in the prevention and treatment of post partum haemorrhage among primary health care workers. The findings from the study when communicated will inform stakeholders thereby making a case for proper training of primary health care workers. Also  such capacity  building for primary health care workers on misoprostol use has the potential of preventing PPH, reducing complications of PPH, reducing  number of referrals, especially in this setting where referral is weak  and consequently reduction of maternal mortality. The result will be useful in promoting use of misoprostol for the prevention and treatment of post partum haemorrhage. The findings from this study will equally provide information on the factors influencing the use and non use of the drug among primary health care workers in the prevention and treatment of post partum haemorrhage. The identified factors when communicated will assist health policy makers, ministry officials, local government health officials, local and international organization and other government agencies in taking the proper steps to resolve the problems thus making the use of misoprostol correctly.

Finally information gathered from this study will serve as a source of literature and guide for future research and as well serve as empirical reference for further studies.

Scope of the Study

The study is limited to primary health care workers (Nurses, Midwives and community health extension workers) providing delivery services in Zaria metropolis. Specifically it is limited to Knowledge and use of misoprostol among primary health care workers in the prevention and treatment of post partum in Zaria metropolis .It is also confined to factors influencing use  of misoprostol in the prevention and treatment of post partum haemorrhage among primary health care workers in Zaria Metropolis.

Operational Definition of Terms

Level of  knowledge of Misoprostol: Refers to the respondents understanding of the class of the drug, routes of administration and dosages of the drug for both prevention and treatment of PPH, when the drug is administered, mechanism of action and side effects associated with the use of the drug. For the purpose of this study, knowledge of the respondents will be categorized in to three levels. Respondents scoring 80-100% will be graded as having high level of   knowledge,50-79% as moderate level of Knowledge and 49% and below will be regarded as low level of  knowledge.

Use of misoprostol for prevention and treatment of PPH: Refers to whether they have used the drug, how they used it, when they gave the drug, the dosage they administered for both prevention and treatment of post partum haemorrhage. It also refers to the correct use of misoprostol as stipulated by guidelines of the federal Ministry of health. For the purpose of this study respondents that have used misoprostol will be deemed to have used the drug correctly if the dosage and route of administration, timing for administration for prevention and treatment were accurately documented.

Factors influencing use: These refer to factors such as availability, supply, previous experience with the use of the drug, cost of the drug, health workers perception of effectiveness of the drug, e.t.c which can enhance or inhibit its utilization in the prevention and treatment of postpartum haemorrhage.

Primary Health care workers refer to nurses, midwives and community health workers who provide maternal and child health care delivery services in primary health care facilities.

Socio-demographic variables of the respondent: This refers to the age, qualification and years of working experience of the respondents.

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