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

                                                      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

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