Active Management of Third Stage of Labor: Practice and Associated Factors among Obstetric Care Providers in North Wollo, Amhara Region, Ethiopia

Background World Health Organization strongly recommends that every obstetrical provider at birth needs to have knowledge and skills on active management of the third stage of labor and use it routinely for all women. However, implementation of this lifesaver intervention by skilled birth attendants is questionable because 3% to 16.5% of women still experience postpartum hemorrhage. Even though coverage of giving births at health facilities in Ethiopia increases, postpartum hemorrhage accounts for 12.2% of all maternal deaths occurring in the country. Lack of the necessary skills of birth attendants is a major contributor to these adverse birth outcomes. Objectives This study aimed to assess the active management of the third stage of labor practice and associated factors among obstetric care providers. Methods An institution-based cross-sectional study design was applied from March 15 to April 15, 2020. Multistage sampling techniques were used to get 254 participants, and data were collected using self-administered structured questionnaires and an observation checklist. Data were entered into EpiData version 3.1 and exported to Statistical Package for the Social Sciences (SPSS) version 23.0 for analyses. The multivariable logistic regression model was used at 95% confidence interval with P value <0.05. Among the 232 providers participating in the study, only 75 (32.3%) of respondents had a good practice. The practice of the provider was significantly associated with work experience (adjusted odd ratio 0.206 (95% confidence interval, 0.06–0.63)), knowledge (adjusted odd ratio (2.98 (95% confidence interval, 1.45–6.14)), the presence of assistance (adjusted odd ratio 2.04 (95% confidence interval, 1.06–3.93)), and time of uterotonic drug preparation (adjusted odd ratio 4.69 (95% confidence interval, 2.31–9.53)). Conclusion Only one-third of obstetric care providers had good practice during active management of third stage of labor. Practice was significantly associated with work experience, knowledge, the presence of assistance during third-stage management, and time of uterotonic drug preparation. Consistent and sustainable on job training and clinical audit should be applied in all facilities with regular supportive supervision and monitoring. Furthermore, team work and adequate preparation should be done to facilitate the management of active third stage of labor.


Introduction
Active management of the third stage of labor (AMTSL) is a combination of intervention performed by skilled birth attendant designed to facilitate the delivery of the placenta by increasing uterine contraction during the third stage of labor and also used to prevent postpartum hemorrhage (PPH) by averting uterine atony [1,2].
According to FIGO-ICM and WHO, the usual components of AMTSL are the use of uterotonic agent in the first steps, preferably IM 10 IU oxytocin immediately within 1 min of delivery after ruling out the possibility of second baby to all births. en, applying controlled cord traction (CCT) with the clamping of the cord within 1-3 minutes after birth is the second step for delivery of the placenta [3,4]. e global target for ending preventable maternal mortality by 2030 recommends that every country should reduce its MMR by at least two-thirds from the 2016 baseline, and no country should have an MMR higher than 140 deaths per 100,000 live births (twice the global target) [5,6]. In Ethiopia, the maternal mortality ratio was 412/ 100.000 live births in 2016 [7]. is number showed that MMR in our country is six times higher than the baseline, 140 deaths/100,000 live births [8].
Maternal mortality has sharply decreased by 43% worldwide [9,10]. AMTSL plays an important role in preventing 27% of maternal deaths, 60% of PPH, and the use of blood transfusions [11,12]. However, about 3% to 16.5% of women still experience PPH and require treatment [13][14][15]. Every pregnant woman may face life-threatening blood loss during delivery. FIGO-ICM strongly recommends that every obstetrical provider at birth needs to have knowledge, skills, and critical judgment to carry out AMTSL [1,3].
PPH is one of the leading causes of maternal death worldwide. It occurs in 25% of all maternal deaths worldwide [4,5], 34% in Africa [16], and 12.2% in Ethiopia [17], especially in settings where there are no birth attendants or where they lack the necessary skilled birth attendants and equipment to prevent and manage PPH and shock [12]. e majority of these deaths are preventable by adopting simple, effective, and safe strategies such as AMTSL [9,16,18].
Routine use of AMTSL by skilled birth attendants at health facilities for all vaginal singleton birth is recommended by the IFGO-ICM and WHO [3,19]. All laboring women are at risk for PPH, so all obstetric care providers should have knowledge and skills regarding AMTSL intervention to prevent PPH [20]. e implementation of AMTSL intervention by skilled birth attendants is questionable because the incidence of PPH keeps rising [4,13,21]. However, studies have identified a gap in the use of AMTSL. In a global survey, it was found that only 16 (43%) of 37 investigated countries included the administration of a uterotonic/AMTSL in their national health management information systems [22]. A study conducted in seven Sub-Saharan countries reported that the AMTSL was only implemented correctly in 0.5-32% of the observed deliveries [23] whereas only 47% in Ethiopia [24].

Study Design and
Setting. An institutional-based crosssectional study design was conducted from March 15 to April 15, 2020, at governmental health facilities of Northeastern, Ethiopia.

Source Populations.
e study included all obstetric care providers working in the maternity unit at North Wollo Health Facilities.

Study Populations.
e study included all obstetric care providers working at selected health facilities.

Inclusion and Exclusion Criteria
2.3.1. Inclusion Criteria. All obstetric care providers working in the maternity unit were included in this study.

Exclusion Criteria.
Obstetric care providers who were not volunteers and those on annual leaves were excluded from the study.

Sample Size Determination.
For two outcome variables, the sample size was determined using single population proportion formula by considering the following assumptions: where n � sample size required for the study and p � the proportion of practice (32.8%) on AMTSL in Sidama Zone, South Ethiopia [14]. Z � Zα/2 � 1.96, corresponding to a 95% confidence level. d � the margin of error � 0.05. For practice, where n � 338.7 approximately 339. However, only 268 obstetric care providers were working at the selected health facilities. Because the population is less than 10,000, the study considered correction formula by taken 361 to get the maximum sample size: Since multistage sampling technique was used, the sample size was multiplied by the design effect of 1.5: For possible none response rate, the final sample size was increased by 10% to n � 254.
(5) e sample size for associated factors was determined using Epi Info 7 as shown in Table 1.

Sampling
Techniques. Multistage sampling technique was used. Initially, out of 14 districts of the zone, five were selected using simple random sampling techniques (lottery methods): Lalibela districts, Wolidya districts, Mersa town, Wadila woreda, and Bugina woreda. ere were 17 health facilities at the selected districts with a total of 268 obstetrics care providers. All the health institutions were included in this study. en the final sample size was allocated proportionally for each health facility based on their number of obstetrical care providers. Respondents were selected by simple random sampling technique using the list of the professionals working in the delivery ward from the human resource management as a sampling frame, as shown in Figure 1.

Data Collection Tool and Data Quality Assurances.
A standard questionnaire was adapted from the ICM and FIGO guidelines (1). It was prepared in English. Self-administered structured questionnaires and observation checks lists were used separately. Self-administered structured questionnaires have four parts: sociodemographic characteristics (9 items), training factors (7 items), health facility factors (7 items), and knowledge assessment (11 items). Moreover, the observation checklist part has 16 items. e level of knowledge was determined using 11 questions. Participants who scored below the median were considered to have poor knowledge. In contrast, participants who scored equal or above the median score were considered to have good knowledge. e level of practice was measured based on a series of 16 steps. Good practice: those who followed 16 steps of the checklist correctly while conducting AMTSL. Poor practice: those who did not follow at least one step of the checklist correctly.
A pretest was conducted on 5% of the sample size other than the study area. To minimize the effect of personal and professional relationships, observers were selected from outside of the study facilities. Cronbach's alpha was done to check the reliability. It was 0.84 for knowledge and 0.77 for practice. Eight data collectors and four supervisors who had Basic Emergency Obstetric and Neonatal Care (BEmONC) and Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) training were recruited, and two days of training were given for both. Providers were not aware of the contents and items on the checklists. To minimize the effect of observation on the provider behavior (hawthorn effect), providers were assured the data collected were anonymous and individual performance would not be reported to their supervisors or shared publically (published reports only refer to aggregate data). e birth attendants were observed while conducting the third stage of labor using the observational checklist. en, self-administered structured questionnaires were distributed to respondents who participated in the observational part of the study. Data were collected and signed by supervisors after checking the filed questionnaire for any missing items and correctness. Besides, there was continuous follow-up and supervision by the principal investigator throughout the data collection period, and also necessary feedback was provided for supervisors and data collectors. All questionnaires and observation checklists were kept under lock and key for security and confidentiality of obtained information.

Sociodemographic Characteristics of Respondents.
From a total of 254 obstetric care providers included in the study, about 232 participated with an overall response rate of 91.3%. One hundred thirty-five (86%) participants were found in the age group of 25-30 years with a mean age of 28.7 years and a standard deviation (±SD) of 4.069, as shown in Table 2.

Health Institution and Training Information of
Respondents. More than half (68.1%) of the participants were working at the health center, and almost all 229 (98.7%) and 226 (97.4%) of them had adequate oxytocin drugs and refrigerators in their workplace, respectively. About 35.3% of providers have in-service training as shown in Table 3.

Practice Obstetric Care Provider on AMTSL.
Only 32.3% of providers had a good practice on AMTSL in Figure 2. Moreover, the three components of AMTSL were more practiced among midwives compared to other professions as indicated in Table 4.  Sudan (26.7%) [25] and (16.7%) Hawassa city [26], and lower than the studies conducted in Addis Ababa (47%) [24], Nigeria (78%) [27], and Netherlands (48%) [25]. e discrepancy might be due to knowledge gap, variation in study setting (in this study, both hospital and health center were included), and study participants (different disciplines included in this study).
Preloading uterotonic drugs before the third stage of labor, having assistant during third stage management, inservice training, work experience, and knowledge on Others * such as Afar, Gurage. Diploma * * : certificate given after two years of higher education training. Advanced diploma * * * : type of diploma given after three years of higher education studies, just below the achievement of bachelor's degree. Degree * * * * : bachelor's degree. Obstetrics and Gynecology International  AMTSL had a significant association with the provider's proper application of AMTSL. Considerable studies and different organizations indicate that team work and preparation to attend childbirth is mandatory to manage labor effectively and prevent unpredicted complications [1,8]. In line with this, the present study also shows that providers who preloaded uterotonic drugs were 4.6 times more likely to practice AMTSL appropriately than those who did not preload. However, only 57.8% of care providers prepared uterotonic drugs before they started to attend labor. It is  Obstetrics and Gynecology International 7 lower than the study done in Nepal, which was 99.3% [28]. e possible justification for this difference might be variation in study design (single-blind) and study setting. e study done in Nepal included only one training center hospital. is gives enhanced chances for the providers to access different on-the-job training that might have helped to update their knowledge. Moreover, providers working in the hospital mostly get experience from a gynecologist and other senior staff. Furthermore, providers who managed the third stage of labor with assistance were 2.0 times more likely to practice AMTSL appropriately compared to those who managed 3 rd stage of labor alone. However, still more than half of the providers (about 53.4%) managed the third stage of labor without the presence of assistance. is is higher than the study conducted in Nigeria, which is 23.7% [27].
e reason behind this result may be due to patient load and busy clinics. Nevertheless, due to the unpredicted nature of labor, having an assistant is a must.
Providers who had work experience <12 months were 79.4% less likely to practice AMTSL than those who had >36 months. is finding has a discrepancy with the study done in Indonesia, which indicates that participants who have less work experience practiced well. e variation might be due to the difference in study participants (research in Indonesia includes only midwives) and providers' burnout (due to workload and little benefits, some providers may develop burnout syndrome and do not do their work properly) [29]. On the contrary, Providers who received in-service training were 7.4 times more likely to practice AMTSL than those who did not. is finding is also supported by the study conducted in Tanzania [30]. In fact, providers who have been taken on in-service training might have better motivation and get practical training. Furthermore, those who had good knowledge of AMTSL were 2.9 times more likely to practice AMTSL than those who had poor knowledge. Similar to the studies conducted in Tanzania, Finfine area Special Zone, Nigeria, and Ghana [27,30,31]. e reason might be because knowledge brings a change in practice.

Limitation of the Study.
Even if the different technique was carried out to minimize hawthorn effects, direct observations may change the provider's behaviors, so this could affect the results of the study.

Conclusions
Only one-third of obstetric care providers had good practice during active management of the third stage of labor. Practice is significantly associated with work experience, knowledge, the presence of assistance during third-stage management, and time of uterotonic drug preparation. e federal and regional health biro of the country should focus on updating the obstetric care provider's knowledge and skill by providing consistent and sustainable practice-based AMTSL training if a possible clinical audit should be applied in all facilities with regular supportive supervision and monitoring. Furthermore, the ministry of education should assess the quality of preservice training among health care providers.

AMTSL:
Active management of the third stage of labor AOR: Adjusted

Data Availability
e data used to support the finding of this study are available from the corresponding author upon request.

Ethical Approval
Ethical clearance was obtained from Jimma University Institutional Review Board (IRB). A formal letter of permission was obtained from Zonal Health Offices.

Consent
Written informed consent was obtained from all providers, and verbal consent was obtained from each mother during data collection.

Conflicts of Interest
e authors declare that they have no conflicts of interests.

Authors' Contributions
WM conceptualized and designed the study; collected, analyzed, and interpreted the data; and contributed to the drafting of the manuscript. MT designed the study; analyzed and interpreted the data; and contributed to the drafting the manuscript and advising the whole research paper. AD designed the study; analyzed and interpreted the data; and contributed to advising the whole research paper. 8 Obstetrics and Gynecology International