TABLE OF CONTENTS
Title page – – – – – – – – – i
Certification – – – – – – – – – ii
Declaration – – – – – – – iii
Dedication – – – – – – – – – iv
Acknowledgement – – – – – – – v
Table of contents – – – – – – vi
List of tables – – – – – – – – – ix
List of figures- – – – – – – – x
List of Appendices – – – – – – xi
Abstract – – – – – – – – xii
Chapter One: Introduction – – – – – 1
Background to the Study – – – – – – – 1
Statement of Problem – – – – – 4
Purpose of the Study – – – – – – – 5
Objectives of the Study – – – – – – – 5
Research Questions – – – – 5
Significance of the Study – – – – – 6
Scope of the Study – – – – – – – 6
Operational Definition of Terms – – – 7
Chapter Two: Literature Review – – – – 9
Overview of Maternal Mortality and Post Partum Haemorrhage – 9
Prevalence of Post Partum Haemorrhage – – – 12
Overview of Anatomy and Physiology of the Uterus – – 14
Uterine and Cervical Coats – – – – – 15
Uterine Blood Supply – – – – – 16
Pathophysiology of Post-Partum Haemorrhage – 18
Causes and Risk factor of Post Partum Haemorrhage – – 18
Management of Post-Partum haemorrhage – – – 19
Misoprostol in the Prevention and
Treatment of Post Partum Haemorrhage 20
Advantages of misoprostol over other conventional uterotonic drug in prevention and management of post-partum haemorrhage – 21
Steps in Misoprostol Administration for the prevention of postpartum haemorrhage – – – – – – – 22
Side effects of misoprostol in the
prevention and management of PPH – 23
Health workers responsibility in administration of misoprostol in prevention and treatment of PPH – – – 23
Factors influencing Use and Non – Use of this drug – 23
Theoretical Review – – – – – – 24
Empirical Review – – – – – – – 33
Summary – – – – – – – 39
Chapter Three: Research Methods – – – – 41
Research Design – – – – – – 41
Area of the Study – – – – – – 41
Population of study – – – – – 42
Subjects of Study – – – – – – – 42
Instrument for data collection – – – – 43
Validity of the research instruments – – – – 43
Reliability of the research instrument – – – – 43
Ethical Consideration – – – – 44
Procedure for data collection – – – – 44
Method of data analysis – – – – – 45
Chapter
four: Presentation Of Results
Presentation of data – – – – – – 46
Summary of major findings – – – – – 58
Chapter
five: Discussion Of Findings
Discussion of findings – – – – – 59
Implication for Nursing – – – – – 62
Limitations of the Study – – – – – 63
Suggestion for further studies – – – – – 63
Summary – – – – – – – 64
Conclusion – – – – – – – 65
Recommendations – – – – – – 66
References – – – – – – 67
Appendices – – – – – – 70
Questionnaire- – – – – – Appendices A
Distribution of Respondents- – – – Appendices B
Reliability- – – – – – – Appendices C
Ethical Clearance- – – – – Appendices D
Letter of permission to carry out research- – Appendices E
Letter of introduction- – Appendices F
Inform consent sheet- – – – Appendices G
LIST OF TABLES
TABLE NO
TITLE PAGE
Table 1 Dosage of Misoprostol for Prevention
and treatment of PPH 21
Table 2 Socio-Demographic Characteristics of
the Respondents. – 45
Table 3 Level of knowledge of misoprostol for the prevention
and treatment of post partum haemorrhage – 49
Table 4 Use of Misoprostol in the prevention and
treatment of PPH – 50
Table 5
Correct
use of misoprostol for prevention and treatment
of postpartum Haemorrhage – – – 52
Table 6 Factors influencing use and nonuse of
Misoprostol for the prevention and treatment of post partum haemorrhage.- 53
Table
7 Chi-square showing the relationship between knowledge
of misoprostol and the use of misoprostol for
Prevention of PPH 55
Table
8 Chi-Square showing relationship between the knowledge of misoprostol and use of
misoprostol for treatment of PPH – 56
Table 9 Chi-square
showing the relationship between professional cadre and knowledge of
misoprostol for prevention and treatment of PPH 57
Table 10 Chi-square showing the relationship between years of experience and knowledge of misoprostol- – – – 58
LIST OF FIGURES
FIGURES TITLE
PAGE
Figure 1: Health Belief Model – – – – 27
Figure 2: Conceptual model for knowledge and use
of misoprostol – 29
Figure
3: Conceptual model of the study – – – – 30
ABSTRACT
Postpartum haemorrhage (PPH) is the common cause of obstetric haemorrhage and the leading cause of maternal deaths in Nigeria. 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 is very erratic.Misoprostol, another uterotonic that is available in tablet form, was thus approved by the Federal Ministry of Health. The purpose of this study was to determine the knowledge and use of misoprostol in the prevention and treatment of Post-Partum haemorrhage. The research design was a descriptive survey method and one hundred and fifty six primary health care workers that met the inclusion criteria across the twenty five facilities of Sabon Gari and Zaria local government area were included for the study. A validated questionnaire constructed by the researcher based on the guidelines on the use of misoprostol in the prevention an d treatment of Post-Partum haemorrhage was used for data collection. Information derived from the questionnaire was subjected to descriptive statistics and chi-square test of association. The findings from the study showed that only 31.3% of the respondents had high level of knowledge of misoprostol in the prevention and treatment of PPH and only 38.3% of the respondents had used misoprostol correctly for the prevention of PPH .For the treatment of PPH, findings revealed that only 16.3% of the respondents had used misoprostol correctly. Only about a quarter of the respondents (23.3%) had received training on the use of misoprostol and (27.3%) of the respondents claimed that the drug was always available in their facility. Knowledge of misoprostol was associated with the correct use of misoprostol for the prevention and treatment of PPH. Based on the findings the following recommendations were made; investment in training and retraining of primary health care workers on the use of misoprostol in the prevention and treatment of post-partum haemorrhage, monitoring and supervision of primary health care workers on the use of the drug and frequent supply and sustainable commodity management will be good mechanisms to improve availability of the drug and thus promote the frequent use of the drug.
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
KNOWLEDGE AND USE OF MISOPROSTOL IN THE PREVENTION AND TREATMENT OF POST PARTUM HAEMORRHAGE AMONG PRIMARY HEALTH CARE WORKERS IN ZARIA METROPOLIS, KADUNA STATE,NIGERIA
