musa halima abdul - university of nigeria
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Ugboaku, Edith J
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY
DEPARTMENT OF NURSING SCIENCES,
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
MUSA HALIMA ABDUL
REG. NO. PG/MSC/08/53033
ii
TITLE PAGE
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
M.Sc. DISSERTATION
BY
MUSA HALIMA ABDUL
REG. NO. PG/MSC/08/53033
PRESENTED TO
DEPARTMENT OF NURSING SCIENCES,
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY,
UNIVERSITY OF NIGERIA ENUGU CAMPUS
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF
MASTER OF SCIENCE DEGREE IN MATERNAL AND CHILD NURSING
SUPERVISOR: Dr. (Mrs.). I.L Okoronkwo
DATE: March 20-14
iii
CERTIFICATION PAGE
This Dissertation Titled “ 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’’ is the original research work of HALIMA
MUSA ABDUL, with Registration Number PG/M.Sc./08/53033, a post graduate student in
the Department of Nursing Sciences, Faculty of Health Sciences and Technology, University
of Nigeria Enugu Campus.
--------------------------------------------------- ---------------------------------------
Halima Abdul Musa Date
--------------------------------------------------- ---------------------------------------
Dr. I.L Okoronkwo Date
SUPERVISOR
iv
APPROVAL PAGE
This dissertation has been approved for the award of Master of Science Degree in Nursing in
the Department of Nursing Sciences, Faculty of Health Sciences and Technology, University
of Nigeria, Enugu Campus.
------------------------------------------------ ---------------------------------------------------
Dr I.L Okoronkwo Date
------------------------------------------------ ---------------------------------------------------
Dr. Uche Okolie Date
Head of Department
------------------------------------------------ ---------------------------------------------------
Prof Obinna Onwujekwe Date
Dean of the Faculty
------------------------------------------------ ---------------------------------------------------
External Examiner Date
v
DEDICATION
To all the women who had become incapacitated and those who had lost their lives as a result
of Post-Partum Haemorrhage.
vi
ACKNOWLEDGEMENTS
All praises to Almighty Allah, for his protection and guidance throughout this programme.
My profound gratitude goes to my great supervisor Dr I.L Okoronkwo, for her unflagging
encouragement and constructive critiquing necessary to improve the quality of this study.
My sincere gratitude goes to the Head of Department Dr Okolie .U. who inspired me towards
completion of this study.
To my distinguished and acclaimed scholars, Prof Okafor C, Dr (Mrs.)Ehiemere I.O, Dr
(Mrs.)Anarado, A,N, Dr (Mrs.)N.P Ogbonnaya, Dr.Nwaneri A, Dr Nwonu. E, Mrs.
Iheanacho. P. Dr (Mrs.) Chinweuba, A, I would say thank you for all the Knowledge and
inspiration you gave to me during the course of this programme.
To the love of my life, my pillar, my guiding light “My husband” Prof. M.A Abdul whose
unwavering support and confidence in me kept me going. I remain eternally grateful.
The patience and understanding of my children, Mustapha, Muaz, Hamza, Bilal and
Haneefah are deeply appreciated. Thank you for all your prayers.
I also extend my gratitude to my Parents, In-laws, brothers and sisters for their moral support
and unending prayers.
I would like to acknowledge the efforts of Prof. Shittu. O of Department of Obstetrics and
Gynaecology, Ahmadu Bello University Zaria for his useful suggestions and guidance
throughout this study.
To my colleagues, classmates and friends: Sani, Idris, Ladan, Isah, Addakano, Sheidu,
Fatima B, Fatima A, Fatima L, Masa, Ifeanyi, thank you for making this study a success.
Finally to the Head of health and primary health care workers of Sabon Gari and Zaria local
government area, Thank you for making this dream a reality!
vii
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
viii
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
ix
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
x
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
xi
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
xii
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.
1
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
2
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
3
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.
4
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
5
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?
6
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
7
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.
8
Socio-demographic variables of the respondent: This refers to the age, qualification and
years of working experience of the respondents.
9
CHAPTER TWO
LITERATURE REVIEW
The chapter dealt with the review of relevant literature. The relevant literature discussed were
conceptual, theoretical and empirical review. The literature was concluded with a summary
of the reviews.
OVERVIEW OF MATERNAL MORTALITY AND POST PARTUM HAEMORRHAGE
Maternal mortality also known as ‘maternal death’ or ‘obstetric death’ is the death of a
woman during or shortly after a pregnancy. According to world Health Organization (WHO
2005), maternal mortality is defined as the death of a woman while pregnant or within
forty-two days after the termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management
but not from accidental or incidental causes.
Globally, an estimated 287,000 maternal deaths occurred in 2010 (WHO, UNFPA, UNICEF &
World Bank, 2012).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). The global MMR in 2010 was 210 maternal deaths per 100,000 live births, down from
400 maternal deaths per 100,000 live births in 1990. The MMR in developing regions (240)
was 15 times higher than in developed regions (16). Sub-Saharan Africa had the highest
MMR at 500 maternal deaths per 100,000 live births, while Eastern Asia had the lowest
among MDG developing regions, at 37 maternal deaths per 100,000 live births. The MMRs
of the remaining MDG developing regions, in descending order of maternal deaths per 100
000 live births are Southern Asia (220), Oceania (200), South-eastern Asia (150), Latin
America and the Caribbean (80), Northern Africa (78), Western Asia (71) and the Caucasus
and Central Asia (46) (WHO, UNFPA, UNICEF & World Bank, 2012).
10
This implies that more maternal deaths occur in countries in sub-Saharan Africa. This is
because women in developing countries have many pregnancies on the average; their lifetime
risk more accurately reflects the overall burden of these women (WHO, 2010). Lifetime risk
is the probability that a woman will die from complications of pregnancy and childbirth over
her lifetime; it takes into account both the maternal mortality ratio and the total fertility rate
(probable number of births per woman during her reproductive years). Thus in a high-fertility
setting a woman faces the risk of maternal death multiple times, and her lifetime risk of
death will be higher than in a low-fertility setting. The lifetime risk of maternal death in the
developing world in 2008 was 1 in 120, compared with industrialized regions with an
estimated 1 in 4300 (WHO, 2010). Among the regions, women in sub-Saharan Africa faced
the highest lifetime risk – 1 in 31 – followed by , South Asia – 1 in 110.
Post-partum hemorrhage was the leading cause of maternal mortality worldwide, accounting
for about 34% of deaths, hypertension 18%,sepsis 8%,abortion 10%, embolism 1%, other
direct causes 11% and indirect cause’s accounts for about 18% (WHO, 2010). According to
the Kinney, Kerber, Black et al(2010) the picture in sub-Saharan Africa is similar to the
global distribution of causes of death with haemorrhage accounting for about 34% of all
maternal deaths.
Nigeria is the most populous country in Africa, 2% of the world’s population but contributes
about 14% (40,000 maternal deaths) to the global estimates of maternal mortality (UNPA,
WHO, 2012). The World Health Organization and the Federal Ministry of Health of Nigeria
report that about 145 women died everyday in Nigeria as a result of causes related to
childbirth and in terms of absolute numbers, Nigeria ranked second globally to India in
number of maternal deaths. The risk of a woman dying from child birth was 1 in18 in
Nigeria, compared to 1 in 61 for all developing countries, and 1 in 29,800 for Sweden
(Nwosu, Odubanjo & Osinusi, 2009). The proportions of maternal deaths attributable to PPH
11
varied considerably between developed and developing countries, suggesting that deaths
from PPH are preventable.
Interventions to prevent PPH in developing countries are therefore pivotal in the global effort
to achieve by 2015 the Millennium Development Goal of reducing maternal mortality ratio
by three-quarters (from 1990 levels).
According to the NDHS (2008) maternal mortality ratio in Nigeria was 545/100,000 live
births, with a wide regional variation. The MMR in Northern Region was consistently over
1,000 per 100,000 live birth compared to the MMR in the Southern Region, which was
frequently below 300 per 100,000 live births (Northwest-1025,Northeast-1549,Southwest-
165,Southeast-285). Also, MMR in rural areas was higher than that of the urban areas (Centre
for reproductive rights, 2009). The wide regional variation is attributed to differences in a
range of factors such as wealth indices, educational level, cultural practices, health care
coverage and utilization (Ozumba, 2009). The main causes of maternal mortality in Nigeria
are post- partum haemorrhage, accounting for 23% of deaths, post-partum infections
accounting for 17%, and the trio of eclampsia, obstructed labour and complications of
abortion each accounting for about 11% of deaths. Other indirect causes of maternal deaths
include malaria and anaemia in pregnancy (FMOH, 2007).
Prevalence of Post Partum Haemorrhage
According to World Health Organization (WHO, 2000), PPH is defined as bleeding from the
genital tract of 500 mls or more within the first 24 hours of delivery of the baby. PPH is the
most common life- threatening complication of the third stage of labour. It can also be a
cause of long-term severe morbidity, and approximately 12% of women who survive PPH
will have severe anemia (Abou-Zahr, 2003; WHO, 2006). Additionally, women who have
severe PPH and survive (“near misses”) are significantly more likely to die in the year
following the PPH (Carrolli, 2007).
12
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide with a
prevalence rate of approximately 6%; Africa has the highest prevalence rate of about 10.5%
Considerable variations were also recorded for different regions of the world ranging from
2.55% in Asia to 10.5% in Africa although the rates were comparable for Europe (6.38%),
Latin America and the Caribbean (8.90%), Northern America (6.37%) and Oceania (7.68%).
However, these regional differences are not a direct reflection of the magnitude and risk of
PPH-related maternal death which are largely determined by the availability of skilled birth
attendants and facilities needed to save women’s lives. The risk of maternal death from PPH
in developing countries is estimated to be one in 1000 deliveries compared with developing
countries such as the UK, where the risk is estimated to be less than one in 100,000 deliveries
(CMACE, 2011).
In Nigeria, PPH is the most common cause of maternal deaths accounting for about 23% of
all maternal deaths (FMOH, 2007). Thus, efforts to achieve the fifth Millennium
Development Goal must therefore include aggressive interventions to reduce PPH-related
death. Although specific studies on postpartum haemorrhage in Nigeria are scanty, the
contribution of postpartum haemorrhage to maternal mortality is well documented.
Balachandran (2005) in Kaduna, Northern Nigeria documented postpartum haemorrhage as
the most common cause of maternal mortality, accounting for 25% of all maternal deaths.
Adewunmi’s (1986) reported that postpartum haemorrhage contributed to 18.7% of maternal
mortality in Ibadan.
Another study from Eastern Nigeria reported 2.72% incidence and a case fatality rate of
3.25% for postpartum haemorrhage (Anya, 1999) .A study conducted in Jos revealed post
partum haemorrhage to be the leading cause of maternal deaths accounting for about 34% of
all the cases (Ujah, Aisien, Mutihir, Vanderjag, Glew & Uguru, 2005).
13
Morbidity and mortality due to PPH are largely preventable through skilled care during
childbirth. However, delays in identifying haemorrhage, delays in transport to the appropriate
point of care, and delays in receiving the recommended treatment all contribute to high rates
of maternal mortality and morbidity due to PPH (Okonofua, 2010). In some cases, women
may give birth in facilities where skilled birth attendants lack the necessary skills, equipment,
or supplies to prevent and manage PPH and shock, thus leading to increase in the cases of
PPH. Hence if health workers especially those working in the primary health facility are
equipped with evidenced based knowledge on the prevention and treatment of post partum
haemorrhage there will be less need for referral to secondary or tertiary health care facility
(Okonofua,2010).
OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE UTERUS
Anatomically, the uterus consists of three divisions: the body or corpus, the isthmus, and the
cervix. The body of the uterus is the uppermost part and forms the bulk of the organ. The
lining of the cavity is continuous with that of the fallopian tubes, which enter at its upper
aspects (the cornua). During pregnancy, the body of the uterus is the portion of the structure
that expands to contain the growing fetus. The portion of the uterus between the points of
attachment of the fallopian tubes is termed the fundus.
The fundus is also the portion that can be palpated abdominally to determine the amount of
uterine growth occurring during pregnancy, to measure the force of uterine contractions
during labor, and to assess that the uterus is returning to its non pregnant state after
childbirth. The isthmus of the uterus is a short segment between the body and the cervix. In
the non pregnant uterus, it is only1 to 2 mm in length. During pregnancy, this portion also
enlarges greatly to aid in accommodating the growing fetus. It is the portion of the uterus that
is most commonly cut when a fetus is born by a cesarean birth.
14
The cervix is the lowest portion of the uterus. It represents approximately one third of the
total uterus size and is approximately2 to 5 cm long. Approximately half of it lies above the
vagina and half extends into the vagina. Its central cavity is termed the cervical canal. The
opening of the canal at the junction of the cervix and isthmus is the internal cervicalos; the
distal opening to the vagina is the external cervical os. The level of the external os is at the
level of the Ischia spines (an important relationship in estimating the level of the fetus in the
birth canal).
Uterine and Cervical Coats
The uterine wall consists of three separate coats or layers of tissue: an inner one of mucous
membrane (the endometrium), a middle one of muscle fibers (the myometrium), and an outer
one of connective tissue (the perimetrium).The endometrium layer of the uterus is the one
that is important for menstrual function. It is formed by two layers of cells. The layer closest
to the uterine wall, the basal layer, remains stable, uninfluenced by hormones. In contrast, the
inner glandular layer is greatly influenced by both oestrogen and progesterone. It grows and
becomes so thick and responsive each month under the influence of estrogen and
progesterone that it is capable of supporting a pregnancy. If pregnancy does not occur, this is
the layer that is shed as the menstrual flow. The mucous membrane lining the cervix is
termed the endocervix.
The endocervix, continuous with the endometrium, is also affected by hormones, but changes
are manifested in a more subtle way. The cells of the cervical lining secrete mucus to provide
a lubricated surface so that spermatozoa can readily pass through the cervix; the efficiency of
this lubrication increases or wanes depending on hormone stimulation. At the point in the
menstrual cycle when oestrogen production is at its peak, as much as 700 mls of mucus per
day is produced; at the point that oestrogen is very low, only few millilitres are produced.
Because mucus is alkaline, it helps to decrease the acidity of the upper vagina, aiding in
15
sperm survival. During pregnancy, the endocervix becomes plugged with mucus, forming a
seal to keep out ascending infections (the operculum).The lower surface of the cervix and the
lower third of the cervical canal are lined not with mucous membrane but with stratified
squamous epithelium, similar to that lining the vagina.
The myometrium, or muscle layer of the uterus, is composed of three interwoven layers of
smooth muscle, the fibers of which are arranged in longitudinal, transverse, and oblique
directions. This network offers extreme strength to the organ. The myometrium serves the
important function of constricting the tubal junctions and preventing regurgitation of
menstrual blood into the tubes. It also holds the internal cervical os closed during pregnancy
to prevent a preterm birth. When the uterus contracts at the end of pregnancy to expel the
fetus, equal pressure is exerted at all points throughout the cavity because of its unique
arrangement of muscle fibers. After childbirth, this interlacing network of fibers is able to
constrict the blood vessels, thereby limiting the loss of blood in the woman (McCance &
Heuther, 2007).
The perimetrium, or the outermost layer of the uterus, serves the purpose of adding strength
and support to the structure (Pelliteri, 2006).
Uterine Blood Supply
The large descending abdominal aorta divides to form two iliac arteries; main divisions of the
iliac arteries are the hypogastric arteries. These further divide to form the uterine arteries and
supply the uterus. Because the uterine blood supply is not far removed from the aorta, it is
copious and adequate to supply the growing needs of a foetus. As an additional safeguard,
after supplying the ovary with blood, the ovarian artery (a direct subdivision of the aorta)
joins the uterine artery as a fail-safe system to ensure that the uterus will have an adequate
blood supply. The blood vessels that supply the cells and lining of the uterus are tortuous
against the sides of the uterine body in non-pregnant women.
16
As the uterus enlarges with pregnancy, the vessels “unwind” and so can stretch to maintain
an adequate blood supply as the organ enlarges. The uterine veins follow the same twisting
course as the arteries; they empty into the internal iliac veins.
After the baby is born, the muscles of the uterus contract, helping the placenta to separate
from the uterine wall. The amount of blood lost depends on how quickly this happens, since
the uterus can contract more effectively after the placenta is expelled. If the uterus does not
contract normally (such as in uterine atony), the blood vessels at the placental site stay open
and haemorrhage results. Because the estimated blood flow to the uterus is 500 to 800
mls/minute at term, most of which passes through the placenta, severe post partum
haemorrhage can occur within just a few minutes. The muscle fibers of the uterus are in a
crosshatch (criss-cross) pattern surrounding maternal blood vessels (Figure 1). After the birth
of the baby, these muscle fibers begin to contract and retract. Oxytocin, a hormone secreted
by the posterior pituitary gland, stimulates uterine contents of the placenta to separate from
the uterine wall. Placental separation occurs by contraction and retraction of the uterine
muscles, reducing the size of the placental area. This reduction in size of the uterus is caused
by retraction of the uterine muscles, a unique characteristic that helps maintain its shortened
length after each contraction.
As the placental area becomes smaller, the placenta begins to separate from the uterine wall
because, unlike the uterus, it is not elastic and cannot contract and retract. At the area where
the placenta separates from the uterus a clot forms. This clot - known as a retro placental clot
- collects between the uterine wall and the placenta and further promotes separation.
Additional uterine contractions complete the separation of the placenta from the uterine wall.
The placenta descends into the lower uterine segment and into the vagina where it is
expelled.
17
After separation:
• The placental site is rapidly covered by a fibrin net and clots form.
• The muscle fibers of the uterus compress the blood vessels where the placenta was
attached, helping to control bleeding at the placental site.
• The uterus continues to contract, forcing the placenta and membranes to fall into the
lower uterine segment. With the delivery of the placenta, the uterus is able to contract
completely (Pelliteri, 2006).
PATHOPHYSIOLOGY OF POST-PARTUM HAEMORRHAGE
At term, the uterus and placenta receive 500-800 mls of blood per minute through their low
resistance network of vessels. This high flow predisposes a gravid uterus to significant
bleeding if not well physiologically or medically controlled. By the third trimester, maternal
blood volume increases by 50%, which increases the body's tolerance of blood loss during
delivery. Following delivery of the fetus, the gravid uterus is able to contract down
significantly given the reduction in volume. This allows the placenta to separate from the
uterine interface, exposing maternal blood vessels that interface with the placental surface.
After separation and delivery of the placenta, the uterus initiates a process of contraction and
retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic
sutures or "living ligatures".
If the uterus fails to contract, or the placenta fails to separate or deliver, then significant
haemorrhage may ensue. Uterine atony, or diminished myometrial contractility, accounts for
90% of postpartum hemorrhage (Pelliteri, 2006).
Causes and Risk factor of Post Partum Haemorrhage
18
According to Ujah & Ejeh (2005) post partum haemorrhage is most commonly caused by
uterine atony in Nigeria as in other parts of the world. It accounts for 70-80% of the cases
(FMOH, 2011).
Koh, Devendra & Tan (2009) report that there are several possible reasons for severe
bleeding during and after the third stage of labour which includes uterine atony (failure of the
uterus to contract properly after delivery), trauma (cervical, vaginal, or perineal lacerations),
retained or adherent placental tissue, clotting disorders, and inverted or ruptured uterus. More
than one of these can cause postpartum haemorrhage in any given woman.
Recognised risk factors to uterine atony include pre-eclampsia, prolonged or augmented
labour, large baby or multiple foetuses, high parity and use of halogenated anaesthetic agents
prior to delivery (Tsu, 2004). An important predisposing factor that cuts across all causes of
PPH is anaemia in pregnancy and labour. Anaemia increases the risk of dying from PPH
because blood loss that could readily be tolerated by women with normal haemoglobin levels
could be fatal for an anaemic woman. In spite of the long list of risk factors in the literature,
most PPH cases occur in women without any identifiable risk factors and thus preventive
measures are recommended for all women giving birth (WHO, 2005).
Management of post partum haemorrhage
The specific time at which PPH occurs is during the third stage of labour (after delivery of
the baby and until complete delivery of the placenta), when the uterus may suddenly lose its
ability to contract. Indeed uterine atony is the biggest cause of PPH worldwide (WHO, 2007).
Also, predicting who will have PPH based on risk factors is difficult because two thirds of
women who have PPH had no preceding risk factors (JHPIEGO, 2001). Therefore, all
women are considered at risk and PPH prevention must be incorporated into care provided at
every birth.
19
An evidence based intervention that is universally recommended for PPH prevention is active
management of third stage of labour (AMTSL) (WHO, 2007 and FMOH, 2011). The World
Health Organization (WHO, 2007) currently recommends that AMTSL should be performed
only by skilled attendants and offered to all women who are giving birth.
It is a set of inter locking intervention that includes the administration of an uterotonic one
minute after birth, control cord traction and uterine massage (Fawole, Awolude, Adenija &
Onafowokan, 2010). It shortens the duration of the third stage of labour, thus decreasing
blood loss after delivery and should be performed by a skilled birth attendant. It also helps in
preventing about 60% of PPH as a result of uterine atony (FMOH, 2011).
Uterotonics are pharmacological agents that help to induce contraction of the uterus.
According to Okonofua (2011), administration of a potent uterotonic drug will prevent severe
haemorrhage and reduce the likelihood of maternal mortality when uterine atony occurs.
WHO (2005) also recommends the use of intravenous oxytocin or ergometrine as first or
second line drugs, respectively for the prevention and treatment of uterine atony that leads to
PPH.
However, there are limitations to the routine in all settings especially in primary health care
setting. Firstly they can only be administered by parenteral injections and may be expensive
especially when the cost of purchasing syringes, needles and antiseptics are added to the
computations. Secondly, the drugs have short half lives as 80% of their potency could be lost
by inappropriate storage especially in low resource settings. It is within this context that
misoprostol, an analogue of prostaglandin, has advantages over oxytocin and ergometrine
(Okonofua, 2010).
20
Misoprostol In The Prevention And Treatment Of Post Partum Haemorrhage
Misoprostol is a synthetic prostaglandin E1 analog (cytotec) that causes powerful
contractions of the uterus when the uterus is fatigued (uterine atony) (Okonofua, 2010).
Misoprostol has an excellent safety profile with over 1500 studies published on its use. It has
been widely used in obstetrics for decades and is a proven, evidence-based drug that reduces
postpartum blood loss as a result of uterine atony (Alfirevic et al, 2007). Studies have shown
that misoprostol, aprostaglandin-E1 analogue, is effective in causing the uterus to contract; it
stops PPH within minutes (Goldberg et al, 2001; Lokugamage et al, 2001).
WHO (2009) recommends the use of misoprostol in the prevention and treatment of PPH in
settings where it is not possible to use oxytocin or another injectable uterotonic .In addition, it
is recommended that health workers who will administer misoprostol should be trained in its
correct use after birth of the baby in order to avoid its administration before birth at incorrect
doses, and in identifying and managing its side-effects. This means this drug will be of great
importance in primary health care settings where it is difficult to maintain the efficacy of
injectable uterotonics (oxytocin and ergometrine). Studies have also documented the
effectiveness of misoprostol in the prevention and treatment of post partum haemorrhage. In
India, a trial found that misoprostol reduced bleeding after child birth by 5.6% and severe
bleeding by 11% (Derman, Kodkary & Goudar, 2006). A recent study on the cost
effectiveness of misoprostol at the community level also in India estimated that it reduced
maternal mortality by an estimated 70% when given sublingually to treat severe bleeding and
when given orally to prevent severe bleeding, the reduction was 81% (Suther, 2010).
Advantages of misoprostol over other conventional uterotonic drug in prevention and
management of post-partum haemorrhage
The FMOH (2007) outlined the following advantages of misoprostol over other uterotonic
drug like oxytocin and ergometrine which includes:-
21
• It acts faster about 3-5 minutes following oral administration
• Misoprostol is inexpensive,
• easy to store,
• widely available,
• stable in field temperature (does not require refrigeration)
• Misoprostol does not required an injection and it can be used in women with
hypertensive disorders in pregnancy, in contrast to its ergot-based counterpart.
Use of Misoprostol in the Prevention and Treatment of Post-Partum Haemorrhage
In Nigeria, misoprostol was approved in 2006 for the prevention and treatment of postpartum
haemorrhage. Following the approval, a clinical guideline was developed to guide health care
workers on the use of this drug in 2007 (FMOH, 2011). The drug has also been added to the
country’s essential drug list in 2011 showing its significance in the prevention and treatment
of PPH.
The dosage and route of administration of misoprostol for PPH depend on its indication
either for prevention or treatment. The different routes of administration are oral, under the
tongue (sublingual), vaginally and rectally. The table below gives the recommended dosage
for the two indications.
Table 1: Dosage of Misoprostol for Prevention and treatment of PPH
Indication Dosage
(a) Prevention of post-partum
haemorrhage.
600ug orally within one minute of delivery
(b) Treatment of post-partum
haemorrhage
1000mcg rectally
Source FMOHN 2011: clinical guideline on use of misoprostol
22
Steps in Misoprostol Administration for the prevention of post partum haemorrhage
According to FMOH, (2011) the steps in misoprostol administration for prevention of PPH,
are ensure three tablets of Misoprostol (3x200mcq) are at hand at the second stage of labour,
Palpate the uterus for any more foetus(es).If yes, complete delivery of the fetus.
If no, Administer 600mcq (3x200mcq) sublingually to the patient immediately after delivery
of the baby before the placenta is delivered.
For the treatment of post partum haemorrhage, 1000mcq (5x200mcq) tablets should be
inserted rectally after blood loss exceeding 500mls. If bleeding persists, do not repeat dose
refer to nearest hospital (FMOH 2011).
Side effects of misoprostol in the prevention and management of PPH
According to the FMOH (2011), the side effects of misoprostol includes headache, nausea,
vomiting and diarrhoea when administered orally, transient increase in body temperature,
shivering and lower abdominal pain from uterine contraction.These side effects, particularly
fever and shivering, are dose-related, self-limiting and do not require any medication
(Okonofua, 2010).However, Federal Ministry of Health Nigeria (2006) advocates the use of
analgesia like paracetamol in case of fever and shivering.
Health workers responsibility in administration of misoprostol in prevention and
treatment of PPH
The Federal Ministry of Health (2007) opined that nurses should ensure the five right of drug
administration, watch out for symptom of side effect, treat as appropriate any side effect, as
well as to document and report any side effect to the appropriate authority
Factors influencing Use of Misoprostol.
Some of the factors that may enhance or inhibit the use of misoprostol are:-
Policy
23
Misoprostol was approved in 2006 for the prevention and treatment of postpartum
haemorrhage among providers trained for its use. It was also included in the country’s
essential drug list in March 2011 validating its safety and efficacy in the prevention and
treatment of postpartum haemorrhage. In order to promote correct use at primary health care
level, primary health care workers within 36 states of Nigeria were trained on the knowledge
and use of this drug (FMOH, 2011). In turn, such training is expected to influence facility
policies and practices.
Availability of misoprostol
The sufficient availability of Misoprostol, at national and local levels is essential for routine
use of the drug for the prevention and treatment of post partum haemorrhage. A 2006
Nigerian study on the availability of misoprostol indicated that only two percent and five
percent of pharmacies, in the cities of Lagos and Abuja respectively, had misoprostol in stock
(Akiode et al. 2008).This raises the crucial concern about the importance of ensuring
universal availability of the medication to ensure sustainability (Westheimer & Blum, 2004;
Prata et al. 2009).
Effectiveness of the drug
Providers’ previous experiences with the drug will influence the use of the drug if the
providers experience was positive (Westheimer & Blum 2004; Prata et al. 2009).
THEORETICAL REVIEW
For the purpose of this study the Health promotion model was utilized as a working
framework. The health promotion model (HPM) proposed by Nola Pender (1982; revised,
1996) was designed to be a “complementary counterpart to models of health protection”. It
defines health as a positive dynamic state not merely the absence of disease. Health
promotion is directed at increasing a client’s level of wellbeing. The model focuses on the
following three areas:
24
• Individual characteristics and experiences
• Behaviour-specific cognitions and affect
• Behavioural outcomes
The health promotion model notes that each person has unique personal characteristics and
experiences that affect subsequent actions. The set of variables for behavioural specific
knowledge and affect have important motivational significance. Health promoting behaviour
is the desired behavioural outcome and is the end point in the HPM. Health promoting
behaviours should result in improved health, enhanced functional ability and better quality of
life at all stages of development. The final behavioural demand is also influenced by the
immediate competing demand and preferences, which can derail intended health promoting
actions.
ASSUMPTIONS OF THE HEALTH PROMOTION MODEL
The HPM is based on the following assumptions, which reflect both nursing and behavioural
science perspectives:
1. Individuals seek to actively regulate their own behaviour.
2. Individuals in all their biopsychosocial complexity interact with the environment,
progressively transforming the environment and being transformed over time.
3. Health professionals constitute a part of the interpersonal environment, which exerts
influence on persons throughout their lifespan.
4. Self-initiated reconfiguration of person-environment interactive patterns is essential to
behaviour change.
The major concepts and definitions of the health promotion model
• Individual Characteristics and Experience
• Prior related behaviour
25
• Frequency of the similar behaviour in the past. Direct and indirect effects on the
likelihood of engaging in health promoting behaviours.
Personal factors
Personal factors categorized as biological, psychological and socio-cultural. These factors are
predictive of a given behaviour and shaped by the nature of the target behaviour,being
considered.
Personal biological factors
• Include variable such as age, gender, body mass index, pubertal status, aerobic
capacity, strength, agility, or balance.
Personal psychological factors
• Include variables such as self esteem, self motivation, personal competence perceived
health status and definition of health.
Personal socio-cultural factors
• Include variables such as race ethnicity, acculturation, education and socioeconomic
status.
• Behavioural Specific Cognition and Affect
Perceived benefits of action
• Anticipated positive outcomes that will occur from health behaviour.
Perceived barriers to action
• Anticipated, imagined or real blocks and personal costs of understanding a given
behaviour.
Perceived self efficacy
26
This is the judgment of a person’s capability to organise and execute a health-promoting
behaviour. Perceived self efficacy influences perceived barriers to action. So higher efficacy
result in lowered perceptions of barriers to the performance of the behaviour.
Activity related affect
Activity-related affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of efficacy
can generate further positive affect.
Interpersonal influences
This has to do with cognition concerning behaviours, beliefs, or attitudes of the others.
Interpersonal influences include: norms (expectations of significant others), social support
(instrumental and emotional encouragement) and modelling (vicarious learning through
observing others engaged in a particular behaviour). Primary sources of interpersonal
influences are families, peers, and healthcare providers.
Situational influences
Personal perceptions and cognitions of any given situation or context that can facilitate or
impede behaviour and includes perceptions of options available, demand characteristics and
aesthetic features of the environment in which given health promoting is proposed to take
place. Situational influences may have direct or indirect influences on health behaviour.
Behavioural Outcome:
Commitment to plan of action
The concept of intention and identification of a planned strategy leads to implementation of
health behaviour.
Immediate competing demands and preferences
27
Competing demands are those alternative behaviours over which individuals have low control
because there are environmental contingencies such as work or family care responsibilities.
Competing preferences are alternative behaviour over which individuals exert relatively high
control.
Health promoting behaviour
Endpoint or action outcome directed toward attaining positive health outcome such as
optimal well-being, personal fulfilment, and productive living.Community health care setting
is the best avenue in promoting health & preventing illnesses. Using Pender’s Health
Promotion Model, community program may be focused on activities that can improve the
well-being of the people.
Figure 1: Health Belief Model (Pender, 1982)
Application of the health promotion model
28
Theoretical statements derived from the model provide a basis for investigative work on
health behaviours. The HPM is based on the following theoretical propositions:-
1. Prior behaviour (knowledge and use of misoprostol in the prevention and treatment of
PPH).
2. Personal factors: Training on the knowledge and use of misoprostol in the prevention
and treatment of PPH will enhance commitment to the action.
3. Perceived benefits: These are the benefits of a particular action that will likely
influence the use of a particular health intervention. (What are the primary health care
providers perceived benefits on the use of misoprostol in the prevention and treatment
of PPH).
4. Perceived barriers can constrain commitment to action, a mediator of behaviour as
well as actual behaviour.(regular supply of the drug, availability of misoprostol in
primary health care centres )
5. Perceived competence or self-efficacy to execute a given behaviour increases the
likelihood of commitment to action and actual performance of the behaviour.(Do the
primary health care workers see themselves competent enough in overcoming those
barriers).
6. Greater perceived self-efficacy results in fewer perceived barriers to a specific health
behaviour.
7. Activity related affect: Positive affect toward a behaviour results in greater perceived
self-efficacy, which can in turn, result in increased positive affect. When positive
emotions or affect are associated with a behaviour, the probability of commitment and
action is increased. (What are the providers’ experiences with the use of misoprostol
for the prevention and treatment of PPH).
29
8. Situational influences in the external environment can increase or decrease
commitment to or participation in health-promoting behaviour.(Policy on the use of
the drug, increased cases of PPH).
9. The greater the commitments to a specific plan of action, the more likely health-
promoting behaviours are to be maintained over time
10. Commitment to a plan of action is likely to result in the desired behaviour. (Correct
use of misoprostol for the prevention and treatment of PPH).
30
Figure 2: Conceptual model for knowledge and use of misoprostol in the prevention and
treatment of post partum haemorrhage among primary health care providers in
Zaria metropolis, Kaduna state: adapted from the Health Promotion Model
(Pender, 1996)
31
Figure 3: Conceptual model of the study developed using the Pender Health
Promotion Model (Musa, 2012)
The independent variables are training on use of misoprostol in the prevention and treatment
of post-partum haemorrhage and knowledge of misoprostol in the prevention and treatment
of PPH. The intervening variables are the providers previuos experiences with the use of the
drug for the prevention and treatment of PPH, number of cases of post-partum haemorrhage,
competency of primary health care provider on the use of the drug, availability of the drug,
perceived benefits of the drug by the primary health care workers. The intervening variables
are expected to influence the degree to which the independent variables will determine the
correct use of misoprostol in the prevention and treatment of postpartum haemorrhage.
The dependent variables are described as the expected outcome of the intervention. They
include training on use of misoprostol and Knowledge of misoprostol based on the
recommended guidelines in the prevention and treatment of post partum haemorrhage. The
researcher conceptualizes that providing knowledge of misoprostol through training will
promote knowledge and thus influences clinical practice (correct use of misoprostol for
prevention and treatment of PPH).
- Training on use of misoprostol - Knowledge of misoprostol for prevention and treatment of PPH
- Previous experience of primary healthcare provider on the use of drug. - Number of PPH cases - Competency of primary health care workers - Availability of Misoprostol - Perceived benefits of the drug by the providers
Use of misoprostol for the prevention and treatment of PPH as recommended by the National Guideline
Independent Variable
Intervening Variable
Dependent Variable
32
Also availability of misoprostol in the health facilities will ensure easy access thereby
promoting the use of the drug. This will prevent complications of post partum haemorrhage
and thus promoting health, wellbeing and good maternal outcome
EMPIRICAL REVIEW
A study conducted in Ethiopia by the Federal Ministry of Health Ethiopia (FMOHE) on
provider’s knowledge and practice of AMTSL using misoprostol in primary healthcare
facilities revealed the following: 103 health extension workers(HEW) and 73 midwives and
nurses (HCW) were included in the study. The researcher employed both quantitative and
qualitative methods including key informant interview and focus group discussion. Results
from the quantitative methods revealed that none of the health extension worker one hundred
and three (100%) and healthcare providers (73 midwives and Nurses) could state the correct
components of active management of third stage of labour.
Additionally, only eighty (80.5%) of the health extension workers and sixty eight (93.1%) of
the healthcare providers knew that the purpose of AMTSL was to prevent PPH .Sixty seven
(65.0%) of HEW and fifty nine (81.9%) HCW indicated that they practice AMTSL.
However, ninety four (91.3%) of HEW and forty three (59.7%) of HCW had used
misoprostol as a uterotonics while only nine (8.7%) of HCW and twenty nine (40.3%) of
HCW had never used the drug as a uterotonic. Eighty-four (74.5%) of the HEW and thirty six
(83.7%) of HCW stated that they administer the drug immediately after childbirth before
separation of placenta while ten (10.6%) of HEW and seven (16.3%) of the HCW stated they
administer the drug after placenta has been delivered. Fifty-six (54.4%) of HEW and twenty-
one (48.8%) of HCW stated that they have encountered side effects related to misoprostol.
Forty-three (41.7%) of the HCW and twenty-two (50.3%) of the HCW stated that they have
never encountered side effects related to misoprostol. Ninety-two (97.9%) of the HCW and
all forty-three (100%) of the HCW stated that from their experience, misoprostol effectively
33
managed PPH. Regarding availability of misoprostol, fifty-six (54.4%) of the health workers
and twenty-one (48.8%) of HCW stated that the drug is sometimes available while forty-three
(41.71%) of the HCW and twenty-two (48.3%) of the health workers stated that it is always
available in their facility. Only one (2.0%) of the HCW stated that the drug is never
available. All the respondents stated that the major source of supply is from donations by
Non- governmental Organizations. The study concluded that the providers’ knowledge of
AMTSL is poor and that misoprostol can be safely and effectively administered by health
extension workers if preceded by proper training and supervision. The study recommended
that there should be routine training of healthcare workers and health extension workers on
AMTSL using misoprostol in primary healthcare level.
In another study conducted by Wassberg (2004) in Uganda on Use & Availability Of
Misoprostol In Three Primary Health Centres Mulago, Nsanbya and Jinga in Uganda
revealed the following
In Mulago, eleven midwives and six senior health officers were included for the study. In
Nsanbya eleven midwives and one junior health officer were included while in Jinja, only
one midwife was included in the study making a total of thirty respondents. In Mulago, the
study revealed that only three (27%) of the midwives have used misoprostol in the
prevention and treatment of PPH, none of the senior health officers have ever used the drug
for the treatment of PPH. In Nsanbya and Jinja, none of the midwives or health officer had
ever used the drug in the prevention and treatment of PPH. Regarding dosage and route of
administration, 33% of the respondent stated 600mcq (x3tabs) for the treatment of PPH
while 66.6% indicated 400mcq(2tabs) orally and rectally for the treatment of PPH. From the
overall assessment of correct use of misoprostol, only 40% and 20% had used misoprostol
correctly for the prevention and treatment of post partum haemorrhage respectively.
34
Regarding experience of side effect due to treatment with misoprostol all the respondents
indicate hyper stimulation of the uterus as the common side effect related to the use of the
drug. Regarding where patient gets misoprostol from, two (18%) of the midwives indicated
that the hospital provides the drugs to them and eight (72%) of the respondents stated that
they purchase the drug in a pharmacy outside the facility, only 9% of the midwives stated
donations from Non-governmental organization. Regarding availability of misoprostol,
86.4% of the respondents indicated that the drugs are never available, 9% stated that the drug
is rarely available and 54.5% stated that the drug is occasionally available.
Regarding the present availability of misoprostol in Mulago ten (90%) of the respondents
stated that the drug misoprostol is not sufficiently available in Uganda and only one (10%) of
the respondents agreed that the drug is available. The main reason for the insufficient
availability mentioned were cost, insufficient availability in pharmacy, lack of knowledge
and fear of its side effects such as uterine rupture.
Regarding source of information about Misoprostol, four (36%) of the respondents’ stated
scientific report and seven (63%) indicated from colleagues. Regarding overall experience
from using misoprostol in the prevention and treatment of PPH, one (33%) of the
respondents stated that they had a very good experience with using the drug for the treatment
of PPH and two (66.6%) stated they had a good experience with the use of the drug.
The study concluded that misoprostol is not sufficiently available in Kampala and clinics in
rural areas and there is wide variety in dosage routines and preferred route of administration
among health workers. The study also recommended that more education and training is
required in order to make health staff confident in using misoprostol and minimizing the risk
of severe side effect which is dose-dependent.
35
In another study in Nigeria conducted by Okonofua (2010) on knowledge and correct use of
misoprostol in active management of third stage of labour and treatment of PPH in four local
government area in Ondo state using forty nine (49) PHC facilities revealed the following
when asked whether they encounter deliveries that are complicated by PPH, fifteen out of the
forty-nine PHC facilities (30.6%) reported that they do. It was not clear why the others did
not report cases of PPH as PPH is the most common delivery complication which ought to
have been encountered and reported. None of the PHC facilities kept accurate records of the
number of deliveries or complications of pregnancies and none had clear procedures or
guidelines for managing pregnant women which could explain the lack of data and
information on PPH. With regard to prevention of primary postpartum, none of the PHC
workers could accurately describe AMTSL and none had clear guidelines located in its
facility on methods of preventing and treating PPH. When asked what drugs they administer
for the prevention of PPH, the most frequently mentioned drug was ergometrine indicated by
twenty three out of the fourty-nine PHC locations; this was followed by oxytocin, indicated
by twenty-one PHC locations. By contrast, none of the PHC location reported that they use
misoprostol for the prevention of PPH. When asked the timing of the drug administration for
the prevention of PPH, the result showed a propensity by PHC worker to administer
uterotonics after the delivery of the placenta. For the treatment of PPH, twenty two PHC
facilities in the four locations reported the use of ergometrine as compared to thirteen that
reported use of oxytocin. None of the PHC locations in the four LGAs visited reported the
use of misoprostol for the treatment of PPH. Twenty-three out of the fourty-nine PHC
facilities sampled had no stock of any uterotonics at the time of the needs assessment study.
Regarding knowledge and current use of misoprostol, only four (8.2%) of the forty
respondents indicated that they have heard of misoprostol (3 in Owo and 1 in Akure South
LGA). However, when asked route of administration of misoprostol and the dose for the
prevention of PPH, only four (8.2%) could mention the correct dose or route of
36
administration. Only 10 % of the respondents had a high level of knowledge of misoprostol
for the prevention and treatment of post partum haemorrhage.None of the respondents had
ever misoprostol for the prevention or treatment of PPH. Also, none of the PHC workers had
ever stocked the drug in the pharmacy.
The study concluded that there is poor knowledge in the use of evidence-based methods for
the prevention and treatment of PPH in PHC setting in the four LGAs. In particular, there
was evidence of poor use of AMTSL for the prevention of PPH, poor knowledge and use of
misoprostol in the prevention and treatment of PPH and inadequate supplies of available
uterotonics especially misoprostol in PHCs in the selected four(4) LGAs of Ondo state. The
researcher therefore concluded that there is need to target capacity building of primary health
worker’s as an approach to improve the management of the third stage of labour and
treatment of PPH using misoprostol thereby reducing maternal mortality from PPH in rural
communities. The researcher recommended that there is the need to improve the drug supply
mechanism and availability in the LGA’s and intensify public health education and advocacy
to increase women’s access to essential services (Okonofua, 2010).
Another study on knowledge and correct use of misoprostol in active management of third
stage of labour and treatment of PPH was conducted by Okonofua (2010) in three (3) LGA’s
in Edo state. These include sixteen PHC facilities in Esan West, thirteen in Esan Central
and 10 in Igueben LGA. Thirty three midwives were included from the three local
governments, 14 in Esan West, 9 in Esan Central, 10 in Igueben LGA. When asked whether
they encountered deliveries that are complicated by PPH, eleven out of the thirty-three (33)
PHC facilities (33.3%) reported that they do. It was not clear why others did not report cases
of PPH as PPH is the most commonest delivery complication which ought to have been
encountered and reported. None of the PHC workers could accurately describe the active
management of the third stage of labour (AMTSL) and none had a clear guidelines located in
37
its service facilities on methods for preventing and treating PPH. Regarding drugs they
administer for prevention of PPH, twenty three out of the thirty-three PHC facilities indicated
ergomentrine and twenty-one PHC facilities stated oxytocin/pitocin. By contrast, only two
PHC facilities mentioned that they use misoprostol for the prevention of PPH and nine (8 in
Esan West and one in Esan Central) reported that they administer Vit K, which is not a
known uterotonic for the prevention of PPH but is known to regulate blood coagulation.
When asked the timing of the drug administration for the prevention of PPH, the result
showed a propensity by PHC workers to administer uterotonics after the delivery of the
placenta. This confirms a tendency towards passive management of the third stage of labour
rather than active management that is more likely to reduce the risk of PPH.This result
showed that none of the PHCs workers could correctly describe AMTSL for the prevention
of PPH. For the treatment of PPH, 24 PHC facilities reported use of oxytocin/pitocin, twenty-
four(24) reported ergometrine, while thirteen(13) reported use of Vit. K .Only one PHC
facility in Esan West reported that they use misoprostol. Also ten out of the thirty-three (33)
PHCs sampled had no stock of any uterotonic at the time of this study. Regarding knowledge
and use of misoprostol, eight (24.2%) of the respondents indicated that they have heard of
misoprostol. However, when asked the route of administration and the dose for the
prevention of PPH, only five (15.1%) respondents indicated correctly. Similarly, only three
respondents (2 in Esan West and 1 in Igueben LGA) correctly mentioned the route of
administration of misoprostol for treatment of PPH but none could mention the correct dose
for this purpose. Additionally none of the respondent could indicate the multiple routes of
administration of misoprostol. Majority(90%) of the respondents had a low level of
knowledge of misoprostol for the prevention and treatment of post partum haemorhage and
10% had high level of knowledge. Regarding source of supply of misoprostol to PHC
facilities, only one of the respondent indicated that they obtain their supplies from a nearby
pharmacy. The others did not know their sources of supply. As for the cost of misoprostol,
38
among respondents who had heard of misoprostol (n=8), the answers ranged from N300 –
N400, with a median of N350.0 (N1=US$ 1.15). Thus, the estimated reported cost of
misoprostol in the LGAs was US$2.5 per tablet.
The study concluded that there is poor knowledge on the use of evidence-based method in
prevention and treatment of PPH. It concluded that there is need for capacity building
workshop aimed at improving the knowledge and skills of primary healthcare workers on
prevention and management of PPH, knowledge and correct use of misoprostol in the
prevention and treatment of PPH, establishment of misoprostol drug revolving fund,
advocacy/public health education on creating public knowledge about maternal mortality and
PPH and increasing official commitment to providing resources, including misoprostol to
reduce maternal mortality associated with PPH in the LGA’s in Edo state (Okonofua, 2010).
Summary of literature review
The literature review provided an overview of the maternal mortality and post partum
haemorrhage, overview of Anatomy and Physiology of the uterus, pathophysiology of PPH,
causes and risk factors, treatment of PPH, Advantages of misoprostol over other conventional
uterotonic drug in the prevention and treatment of PPH .Use of misoprostol, and factors
influencing use of misoprostol.
Health promotion model was used as a working framework for the study. According to the
empirical review, only few studies have been conducted on this subject matter. However the
few studies available showed that the earlier researchers in this area basically looked on
knowledge, use and availability of misoprostol in the prevention and treatment of post partum
haemorrhage. They failed to look into factors influencing use of the drug in the prevention
and treatment of PPH despite its advantages over other conventional uterotonics. These may
be the reasons why the drugs are not commonly used in some facilities. This is considered a
39
serious gap as factors influencing use of the drug will help in identifying the specific
problems.
Therefore, there is a great need for more studies to be carried out on knowledge and correct
use of misoprostol as well as factors influencing its use in the prevention and treatment of
post partum haemorrhage. Hence in an attempt to bridge the gap, the present study was set to
determine knowledge and use of misoprostol as well as identify factors influencing use of
misoprostol in the prevention and treatment of post partum haemorrhage.
40
CHAPTER THREE
RESEARCH METHODS
This chapter dwelt with the procedure adopted for the investigation under the following sub-
headings: research design, area of study, target population, subjects of study, instrument for
data collection, validity and reliability of the instrument, ethical consideration, procedure for
data collection and method of data analysis.
Research Design
This study adopted a cross-sectional descriptive design to describe the knowledge and use of
misoprostol in the prevention and treatment of post partum haemorrhage among primary
health care workers in Zaria metropolis. This design was chosen because ,according to
Fajonmi(2003) survey is used for descriptive, explanatory purposes ,and of course this
survey is descriptive in nature and therefore is more appropriate for this study. However,
cross sectional descriptive design is considered appropriate because it allows for collection of
data from a group of people at the same time for the purpose of describing a phenomena
under study .Descriptive study also allows the investigator to discuss the phenomena under
study as it exists at the time of study.
Area of the Study
The study was carried out in health facilities within Zaria metropolis which comprised of two
LGA (Zaria and Sabon-Gari LGAs). There are nine (9) primary health care facilities in
Sabon-Gari local government and a total of fifteen (15) primary health care facilities in Zaria
local government providing maternal health services (Sabon-Gari and Zaria Local
Government Health Department Record). Majority of the clients attending the primary health
care facilities are women from the rural communities. Zaria is located at some eighty three
kilometer (83km) to the north of Kaduna. It is located on a Plateau at a height of about 2200
feet above sea level, in the centre of Northern Nigerian (Mortimore, 1979). Formerly known
41
as Zazzau, Zaria was one of the original seven states of the old Hausa Kingdom founded in
the early 15th century that rose to prominence in the early 16th century under the leadership of
Queen Amina. It has a total population of 408,198 (NPC, 2006). The inhabitants are
predominantly Hausa-Fulani, with a significant representation of the Yorubas and Ibos from
the southern part of the country
Population of study
The study population includes all the nurses, midwives and community health workers
working in the primary health care facilities that provide maternal health services in Zaria
metropolis. As at the time of the study, there were one hundred and fifty six workers
distributed across the twenty four primary health care facilities in the Zaria and Sabon-Gari
LGA and they form the population of the study (Appendix B)
Subjects of Study
The subjects of the study consisted of all the one hundred and fifty –six primary health care
providers providing delivery care services in the twenty four facilities in the two local
government area. Due to the small population size, the entire health workers were used for
the study. This is in line with Fisher (1983) and Shelly (1984), in their studies involving
small population that all elements can and should be included in the study, hence no sampling
is needed.
Inclusion Criteria
• All trained primary health care workers (Nurses, Midwives and Community health
extension workers) working in antenatal wards, postnatal wards & labour room in the
two local government areas
• Willingness to participate in the study.
• Present at the time of data collection.
42
Instrument for data collection
The instrument used for data collection was a questionnaire (Appendix A) designed by the
researcher based on guidelines on the use of misoprostol for the prevention and treatment of
post -partum haemorrhage according to the FMOH( 2011). The questionnaire was made up of
thirty-two items based on the objectives of the study. It consisted of four parts: Section
A,B,C,D. Section A, consisted of four questions to describe the socio-demographic
characteristics of the respondents. Section B was made up of thirteen questions to measure
the respondents knowledge of misoprostol in the prevention and treatment of PPH . Section C
consisted of nine questions to measure the use of misoprostol among the primary health care
workers. Section D consisted of eight questions to elicit factors influencing use of
misoprostol for the prevention and treatment of post partum haemorrhage.
Validity of the research instrument.
Face validity of the instrument (questionnaire) was determined by the judgment of the
supervisor . For the content validity, the instrument, and research objectives were submitted
to the project supervisor, a clinical expert, a Professor in Obstetrics & Gynecology ABUTH
and a Professor of Maternal and Newborn nursing in the Department of Nursing Sciences
ABU, Zaria to critically assess for relevance of the content, clarity of statements and logical
accuracy of the instrument. Their suggestions and corrections were effected thus increasing
the items from 28 to 33.
Reliability of the research instrument
The stability of the instrument was determined using a test – retest reliability. A pilot study
was conducted using twenty health workers that met the inclusion criteria and not part of the
study population in Giwa local Government. The instrument was administered twice to the 20
health workers at 2 weeks interval. The scores from the two administrations were correlated
using the Pearson Product moment correlation coefficient method. A correlation co-efficient
43
of 0.98 was obtained. According to Tuckman, (1999), the nearer to 1 the co-efficient of
reliability of an instrument the more reliable the instrument, thus the instrument was
considered to be reliable.
Ethical consideration
Ethical approval was obtained from the health research ethical committee of Ahmadu Bello
University Teaching Hospital Zaria(Appendix D).All respondents were fully informed of the
objective and design of the study and written consents were obtained from each of the respondents
(Appendix E).
Procedure for Data Collection.
With the ethical approval and letter of introduction, from the head of department of Nursing
Sciences University of Nigeria Enugu Campus(Appendix G), permission to carry out the
study in the local government area was obtained from the Head of Health of the two
LGA’s(Appendix Eand F) .Four research assistants who were trained on the purpose of the
study and how to collect data from the respondents were utilized for the study.The training
involved discussion of objectives of the study, contents of the instruments and how to
administer the instrument. Objectivity and confidentiality on information gathered were
emphasized. The researcher and research assistants visited the head of each facility for self
introduction before the collection of data. Upon accepting to participate in the research, and after
signing the informed consent sheet(Appendix H) those who met the inclusion criteria had a copy of
the instrument administered to them, after the purpose of the study had been explained to them. They
were asked to read the contents as carefully as possible and respond to each item as applied to them.
The researcher and two research assistants administered questionnaires to all respondents in
fifteen primary health care facilities of Zaria local Government while the other two research
assistants administered questionnaires to respondents in Sabon Gari Local Government with
nine facilities. The questionnaires were administered each day between 2nd December 2012
to 31st January 2013 and data collection ended 6th febuary 2012.
44
Method of data analysis
Descriptive statistics including frequencies (f), percentages, were used to present the data
on socio-demographic variables, knowledge of misoprostol,use of misoprostol and factors
influencing use. Inferential statistic was used to test for relationship among variables using
Pearson Chi square test. The level for statistical significance was set at p < 0.05. For the
purpose of this study, knowledge of the respondents was categorized in to three levels .To
achieve this, a scoring system was developed. There was a total of 13 questions on
knowledge of which five were rated 10mrks and the remaining eight where rated 6.25 mrks
each making a total of 100%.. Respondents scoring 80-100% was graded as having high level
of knowledge,50-79% as moderate level of Knowledge and 49% and below was regarded
as having low level of knowledge of misoprostol for the prevention and treatment of
postpartum haemorrhage.
The analysis was done using Statistical Package for Social Sciences (SPSS) version 16.0.
45
CHAPTER FOUR
PRESENTATION OF RESULTS
A total of 156 questionnaires were administered to the respondents and 150 were completely
filled and retrieved giving a response rate of 96.2%.
Table 2: Socio-Demographic Characteristics of the Respondents
Table 2 above reveals that 40.7% of the respondents are between 20-30 years of age, 37%
were between 31-40yrs, 20% are between 41-50yrs while only 2% of the respondents are
between 51years and above. Also the table reveals that 29 (19.3%) .With regards to the
professional cadre of the staff, 26(17.3%) of the respondents where registered Nurses,
44(29.3%) were Nurse midwives, 47(31.3%) were senior community health extension
F (%)
Age 20-30 61 40.7
31-40 56 37.3
41-50 30 20.0
51 and above 3 2.0
Total 150 100
Sex Male 29 19.3
Female 121 80.7
Total 150 100
Prof. cadre Nurse 26 17.3
Nurse/Midwife 44 29.3
SCHEW 47 31.3
JCHEW 20 13.3
CHO 13 8.7
Total 150 100.0
Years of work
experience
0-5yrs 51 34.0
6-10yrs 50 33.3
11-15yrs 26 17.3
16-20yrs 13 8.7
Above 20 yrs 10 6.7
Total 150 100
46
workers, 20(13.3%) were junior community health extension workers while 13(8.7%) were
community health officers
Table 3: Level of knowledge of misoprostol for the prevention and treatment of
post partum haemorrhage
Level of knowledge Frequency(percentage)
High 47(31.3)
Moderate 27(18.0)
Low 76(50.6)
Total 150
The table above shows that only 31.3% of the respondents had high level of knowledge of
misoprostol for the prevention and treatment of postpartum haemorrhage.
47
Table 4: Use of Misoprostol in the prevention and treatment of PPH
Variables Response F (%)
Have you ever used misoprostol for the prevention of PPH
Yes 101 67.3
No 49 32.7
Total 150 100
If yes what dose did you administer?
Correct 55 54.5
Incorrect 46 35.5
Total 101 100
What was the route of administration?
Correct 66 65.3
Incorrect 35 34.7
Total 101 100
When did you administered the drug?
Correct 56 55.4
Incorrect 45 44.6
Total 101 100
Have you used Misoprostol in the treatment of PPH.
Yes 99 66
No 51 34
Total 150 100
If yes, what dosage did you administered?
Correct 28 28.3
Incorrect 71 71.7
Total 99 100
What is your most frequent route of administration?
Correct 28 28.3
Incorrect 71 71.7
Total 99 100
Have you witnessed any of your patients with any side effect of misoprostol?
Yes 61 61.6
No 38 38.4
Total 99 100
If yes what are the side effect?
Hyperpyrexia 30 49.2
Rigors and chill Headache
20 11
32.8 18.0
Total 61 100
Table 4 above shows that 101(67.3%) of the respondents had used misoprostol before.
55(54.5%) of the respondents administered the correct dose of misoprostol for the prevention
of PPH. Furthermore, only 66(65.3%) of the respondents administered the drug through the
correct route. The table also shows that only 56(55.4%) of the respondents administered the
drug at the correct time. About 99 (66%) of the respondents have used misoprostol for the
treatment of PPH, only 28(28.3%) of the respondents used the correct dosage of misoprostol
for the treatment of PPH. While only 28(28.3%) of the respondents administered the drug
48
through the correct route for the treatment of PPH and only 61(61.6%) of the respondents had
witnessed the side effect of misoprostol.
Table 5: Correct use of misoprostol for prevention and treatment of post partum
haemorrhage
Use of
Misoprostol
Use of misoprostol for prevention
of PPH(Frequency/percent)
Use of misoprostol for the
treatment of PPH
(frequency/percent)
Correct use 39(38.6) 16(16.2)
Incorrect use 62(61.4) 83(83.8)
Total 101 99
Table 5 above shows that only 39 (38.6%) of the respondents had used misoprostol correctly
for the prevention of PPH while only16 (16.2%) had used misoprostol correctly for the
treatment of PPH.
49
Table 6: Factors influencing use of Misoprostol for the prevention and treatment of post
partum haemorrhage.
Table 6 reveals that only 35(23.3%) of the respondents had received training on the use of
misoprostol. Also only 41(27.3%) of the respondents stated that the drug is always available
in their facility. Out of the 41 respondents who stated the drug is always available in their
facility, 23(56.1%) of the respondents stated local government store as the source of their
supply of the drug while 4.5% do not know the source of their supply. Also 24(58.5%) of the
Variables/ factors Response Frequency Percent (%)
Received formal training on use of misoprostol
Yes 35 23.3
No 115 76.7
Total 150 100
Misoprostol always available in your facility?
Yes 41 27.3
No 109 72.7
Total 150 100
If yes, what is the source of supply
LGA store 23 56.1
state MOH 4 9.8
NGO 1 2.4 open market 11 25
Don’t know source 2 4.5
Total 41 100
Regularity of Supply Yes 24 58.5 No 17 41.5
Total 41 1000
Where do patients in your facility get misoprostol from (if not available in your center)
Outside pharmacy/chemist
101 100
Others 0 0
Total 60 100
Effective for prevention and treatment of PPH.
Yes 53 52.5 No 38 47.5
Total 101 100 Misoprostol too expensive? Yes 49 49
No 52 52
Total 101 100
50
respondents stated that the supply is regular. 101(100%) of the respondents stated that their
patient get their drug in pharmacy/chemist outside the facility if not available in the centres.
The table also reveals that 53 (52.5%) of the respondents stated that from their experience
misoprostol effectively prevent and treat PPH. Furthermore,49 (49%) of the respondents
considered misoprostol as expensive when compared to other uterotonics.
Table 7: Relationship between knowledge of misoprostol and the use of
misoprostol for Prevention of PPH
Use of misoprostol for prevention of PPH
Level of Knowledge misoprostol Correct use Incorrect use Total High 24 12 36
Moderate 5 14 19
Low 10 36 65
Total 39 62 101
χ2 =18.572 df=2 p-value < 0.0001
Table 7 shows that there is a significant relationship between knowledge of misoprostol and
the use of misoprostol for the prevention of post-partum haemorrhage
51
Table 8: Relationship between the level of knowledge of misoprostol and use of
misoprostol for treatment of PPH
Use of misoprostol for treatment of PPH
Level of Knowledge misoprostol Correct use Incorrect use Total High 15 16 31
Moderate 0 13 13
Low 1 54 68
Total 16 83 99
χ2 = 34.591 df=2 p-value = 0.0001
Tables 8 shows that there is a significant relationship between knowledge of misoprostol and
the use of misoprostol for the prevention/treatment of PPH, More respondents with high level
of knowledge of misoprostol use the drug correctly. .
Table .9: The relationship between professional cadre and knowledge of misoprostol for
prevention and treatment of PPH
Knowledge of misoprostol
Professional Cadre High Moderate Low Total
Nurse 3 5 15 23
Nurse-midwife 11 4 9 24
SCHEW 22 11 34 67
JCHEW 5 4 13 22
CHO 6 3 5 14
Total 47 27 76 150
χ2 =7.613 df=4 p-value = 0.107
Table 9 shows that there is no relationship between professional cadre and knowledge of
misoprostol. The level of knowledge of misoprostol of the respondents is not influenced by
professional cadre of the respondents.
52
Table 10: The relationship between years of experience and knowledge of misoprostol
Knowledge of misoprostol
Years of working experience High Moderate Low Total
0-5yrs 6 14 26 46
6-10yrs 15 6 17 38
11-15yrs 17 4 21 42
16-20yrs 5 2 8 15
above 20yrs 4 1 4 9
Total 47 27 76 150
χ2 = 10.701 df=4 p-value = 0.030
Table 10 revealed that respondents that had worked between 6-15 had more knowledge of
misoprostol than other groups. There was a significant relationship between knowledge of
misoprostol and years of working experience.
Summary of Major Findings
-About 31.3% of the respondents had high level of knowledge of misoprostol for the
prevention and treatment of post-partum haemorrhage.
- Only 38.3% and 16.3% of the respondents had used the drug correctly in the prevention
and treatment of PPH respectively
- Only 23.3%, had received training on use of misoprostol for the prevention and treatment of
postpartum haemorrhage
- 27.3% of the respondents stated that the drug is always available in their facility.
- 0nly 52.5% of the respondents stated that misoprostol effectively prevents and treats PPH.
53
- Almost half of the respondent (49%) considered misoprostol as expensive when compared
to other uterotonics.
- There was a significant relationship between knowledge of misoprostol for the prevention and
correct use of misoprostol.
-There was no significant relationship between knowledge of misoprostol and professional cadre.
- There was a significant relationship between knowledge of misoprostol and years of experience .
54
CHAPTER FIVE
DISCUSSION OF FINDINGS
This chapter presents discussion of the major findings, implications of the findings, , limitations of
the study, suggestions for further studies, summary, conclusion and recommendations of the study .
Discussions of major findings
Level of knowledge of misoprostol for the prevention and treatment of PPH among
primary health care workers
Level of knowledge of misoprostol for the prevention and treatment of post partum
haemorrhage revealed that only (31.3%) had high level of knowledge . This is surprising as
training on the use of the drug among primary health care workers were organized following
the approval of the drug by the Federal Ministry of Health for the prevention and treatment of
post partum haemorrhage. In addition, Department of Obstestrics and Gynaecology, Ahmadu
Bello University Zaria 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 in 2009 and 2010 (Population & Reproductive
Health Initiative, based at ABUTH, Zaria 2010). This finding is higher than that of
Okonofua ( 2010) where only 10% of the respondents had a high level of knowledge of
misoprostol for the prevention and treatment of post partum haemorrhage. Differences in
methodology including sample size (one hundred and fifty six respondents of this study was
much higher than that of the fourty respondents of Okonofua) and the permeating effect of
ABU-university of California project on community use of misoprostol as mentioned above
may accounts for the differences in the level of knowledge in this study.
55
Use misoprostol by primary health care workers for the prevention and treatment of
PPH?
About (67.3%) of the respondents had used misoprostol for the prevention of PPH. This is in
contrast to the findings of Wassberg (2004) where only (27%) of the primary health care
workers had ever used the drug for the prevention of PPH .The reason for the high percentage
in this study may also be attributed to the fact that some of the primary health care workers
had received training on the use of misoprostol for the prevention and treatment of PPH.
However, only (54.5%) of the respondents who stated that they have ever used the drug for
the prevention of PPH administered the correct dose. This is in constrast to the findings of
Wassberg (2004) where only 27% of the respondents that had used the drug in the prevention
of PPH administered the correct dose.
Findings showed that 65.3% of the respondents administered the drug through the correct
route; while 55.4% of the respondents administered the drug at the right time (immediately
after childbirth before separation of placenta). This does not support the findings of FMOHE
(2008) where 83.7% of the HCW stated that they administered the drug at the right time
(immediately after childbirth before the separation of the placenta) and through the correct
route.. The study revealed that only (66% )of the respondents had used misoprostol for the
treatment of PPH. This is in contrast to the finding of Okonofua (2010) where none of the
respondents reported that they had used misoprostol for the treatment of PPH. Furthermore,
only (38.6%) of the respondents had used misoprostol correctly for the prevention of PPH
and only (16.5%) of the respondents had also used misoprostol correctly for the treatment of
PPH. These findings have a significant implications as incorrect use of the drug may lead to
complications like uterine rupture when an overdose is administered as well as poor
management of post partum haemorrhage if an under-dose is given or if the drug is not
given at the right time. This will invariably lead to poor maternal outcome and thus
contributing to maternal mortality which is unacceptably high. However, this findings
56
supports the study of Wassberg (2004) where only 40% and 20% of the respondents had used
the drug correctly for the prevention and treatment of post partum haemorrhage.
Factors influencing use of misoprostol for prevention and treatment of PPH
Only 23.3% of the respondents had received formal training on use of misoprostol in the
prevention and treatment of postpartum haemorrhage. The study revealed that only 27.3% of
the respondents stated that misoprostol was always available in their facility. This may also
influence the use of the drug as the more available the drug is, the more the respondent may
likely use it in the prevention and treatment of postpartum haemorrhage. This is related to the
finding of Wassberg (2004) where only 10% of the respondents stated that the drug was
always available in their facility. The lack of availability of the drug may not be unconnected
to the fact that in Nigeria only one pharmaceutical company (Emzor) is into production of
this drug. More than half of the respondents 52.5% of the respondents admitted that from
their experience, misoprostol effectively prevented and treated PPH. This may be connected
to the fact that only few of the respondents had used the drug correctly for the prevention and
treatment of post partum haemorrhage. This is incongruous to the finding FMOHE (2008)
where 97% of the respondents stated that from their experience, misoprostol effectively
prevented and treated PPH. This implies that if correct use of misoprostol is promoted by
increasing knowledge of PHCW on the use of misoprostol through training and retraining,
it will go a long way in reducing the number of deaths from PPH and thus reducing maternal
mortality in North-West Nigeria.
Relationship between Knowledge and use of Misoprostol in the Prevention and
Treatment of Post-Partum Haemorrhage
Findings from the study revealed that there was a significant association between knowledge
and correct use of misoprostol. Respondents with higher level of knowledge of misoprostol
tend to use the drug correctly. This is in agreement with the observation that
57
knowledge/training influences clinical practice and thus reaffirming the appropriateness of
our theoretical framework (Pender Model of Health Promotion). This findings supports the
study of Wassberg (2004) where there was a relationship between knowledge of misoprostol
and use of misoprostol for the prevention and treatment of post partum haemorrhage.
Relationship between Knowledge of Misoprostol and Socio-Demographic Variables
From findings, years of experience of the respondents were associated with knowledge of
misoprostol. Majority of respondents with years of experience between 6-15 years had high
level of knowledge of misoprostol. This may not be unconnected to the fact that these groups
of respondents are very enthusiastic and are more likely to explore training opportunities.
Implication for Nursing
Since the level of knowledge of misoprostol for the prevention and treatment of PPH is low
among the respondents and also only few respondents had used the drug correctly, the
implication is that mothers may be exposed to complications of PPH or death. Furthermore,
only few of the respondents had used the drug correctly for prevention or treatment of
Postpartum haemorrhage. The implication of this is that an overdose of the drug may be
given for either prevention or treatment of Post –Partum haemorrhage which may lead to
further complications like ruptured uterus . This may lead to further bleeding, leading to
death of the mother and thus increasing the maternal morbidity and mortality rate which is
already unacceptably high.
Furthermore only few of the respondents had received training on the knowledge and use of
misoprostol in the prevention and treatment of post-partum haemorrhage. The implication of
this is that, lack of training among the majority of the respondents may lead to poor
knowledge of the drug which may invariably lead to incorrect use leading to poor maternal
outcome. More so lack of availability of the drug may lead to non-use of the drug among the
primary health care workers.
58
Limitations of the Study
The major constraints of this study were paucity of literature. Secondly some of respondents
felt reluctant to fill the questionnaire even after they had signed the informed consent form as
they thought that the researcher may disclose what is happening in the North to people of the
East and as such it took the researcher many visits to same respondents to retrieve the
completed questionnaire. Also there was difficulty assessing some of the facilities due to
poor transport network.
Suggestions for further studies
Similar studies should be carried out in other primary health care facilities in the State and
other States especially in the North east where maternal mortality is exceptionally high to
ascertain their knowledge and correct use of misoprostol in the prevention and treatment of
Postpartum haemorrhage.
Summary of the study.
The study was conducted to assess the level of knowledge of misoprostol and its c use among
primary health care workers in Zaria metropolis. The objective of the study were to determine
the level of knowledge of misoprostol for prevention and treatment of postpartum
haemorrhage, to examine the use of misoprostol in the prevention and treatment of PPH
among primary health care workers; to determine factors influencing use and non-use of the
misoprostol; to determine the relationship between knowledge and use of misoprostol for the
prevention and treatment and to determine the relationship between knowledge and some
socio-demographic variables.
A descriptive cross-sectional survey was used for the study. . The subjects of the study consisted
of all the one hundred and fifty –six primary health care providers providing delivery care services in
the twenty four facilities of the two local government area. Due to the small population size, the
59
entire health workers were used for the study, hence no sampling was made. A researcher
constructed questionnaire according to the national guidelines on the use of the misoprostol
for the prevention and treatment was administered to Primary health care workers and 150
questionnaires were retrieved. Data was analyzed using descriptive statistics- frequency and
percentages. Pearson chi-square was used to test for relationship between knowledge of
misoprostol for prevention and treatment of PPH and use of misoprostol for the prevention
and treatment of PPH and also the relationship between knowledge of misoprostol for the
prevention and treatment of PPH and some socio-demographic variables. The study showed
that only 31.3% of the respondents had high level of knowledge of misoprostol for the
haemorrhage. Also, the study revealed that only 38.3% of the respondents had used the drug
correctly in the prevention of PPH and 16.3% of the respondents had used misoprostol
correctly for the treatment of PPH. Furthermore, only about a quarter of the respondents,
23.3%, had received training on the use of misoprostol for the prevention and treatment of
postpartum haemorrhage and only 27.3% of the respondents stated that the drug is always
available in their facility. Moreover, more than half of the respondents 52.5% admitted that
from their experience misoprostol effectively prevented and treated post partum haemorhage
However,49% of the respondents stated misoprostol as expensive when compared to other
uterotonics. There was a significant relationship between knowledge of misoprostol for the
prevention and treatment of postpartum haemorrhage and use of misoprostol. There was no
statistical relationship between knowledge of misoprostol and professional cadre but there there was
significant relationship between knowledge of misoprostol and years of experience .
Conclusion
Based on the findings of this study the following conclusions were made.
• Level of knowledge of misoprostol for the prevention and treatment among primary
health care workers in Zaria metropolis was low.
60
• Only few of the primary health care workers had used misoprostol correctly in the
prevention and treatment of postpartum haemorrhage.
• Only few of the primary health care workers had been trained on the knowledge and
correct use of misoprostol for the prevention and treatment of PPH.
• Majority of the respondents stated that the drug is not available in their facility.
• More than half of the respondents that had used misoprostol stated that the drug is
effective in the prevention and treatment of PPH..
• Almost half of the respondents considered misoprostol expensive when compared to
other uterotonics
• There was a significant relationship between knowledge of misoprostol and use of
misoprostol for the prevention and treatment of PPH.
• That there was no relationship between knowledge of misoprostol and professional
cadre
• That there was relationship between knowledge of misoprostol and years of
experience.
Recommendations
Based on the finding from the study, the following recommendations are made to improve the
knowledge and use of misoprostol for the prevention and treatment of PPH:
(1) Investment by State Ministry of health, National primary health care development
Agency and Nursing and Midwifery council in training and retraining of primary
health care workers in evidence-based method in the prevention and treatment of
postpartum, in order to promote their knowledge especially in the use of
misoprostol as it will definitely reduce number of deaths from PPH which is the
biggest cause of maternal mortality worldwide.
61
(2) Monitoring and supervision by Federal Ministry of Health and Nursing and
midwifery on the correct use of the drug for the prevention and treatment of PPH.
(3) Frequent supply and sustainable commodity management by the state and local
government and also establishment of misoprostol revolving fund in the health
facilities will be a good mechanism to improve the availability of misoprostol and
thereby promoting it’s use among the primary health care workers in the
prevention and treatment of postpartum haemorrhage.
62
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65
APPENDICES
APPENDIX I (QUESTIONNAIRE)
DEPARTMENT OF NURSING SCIENCES
FACULTY OF HEALTH SCIENCES
UNIVERSITY OF NIGERIA
ENUGU CAMPUS
ENUGUSTATE
Dear Respondent
The researcher is a Post graduate student of the above department and is carrying out a
research which is mainly for academic purpose. The questionnaire is designed to determine
the “Knowledge and use of Misoprostol in the prevention and treatment of postpartum
haemorrhage among primary health care workers in Zaria metropolis.
Your honest response will be highly appreciated and no more is needed as information
obtained from you will be strictly confidential.
Thank you for your cooperation.
Yours faithfully,
Musa Halima, A.
SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS
1. Age: ___________
2. Sex; (i) Male [ ] (ii) Female [ ]
3. Professional cadre; (i) Nurse [ ] (ii) Nurse/Midwife [ ] (iii) SCHEW [ ]
(iv) JCHEW [ ] (v) CHO [ ]
4. Years of working experience: ______________
KNOWLEDGE OF MISOPROSTOL IN THE PREVENTION AND TREATMENT OF
POSTPARTUM HAEMORRHAGE.
(5) Misoprostol is a synthetic prostaglandin analogue YES [ ] NO [ ]
(6) Misoprostol comes in both tablet and injectable form YES [ ] NO [ ]
(7) Misoprostol comes only in a tablet form YES [ ] NO [ ]
(8) Misoprostol is administered orally only YES [ ] NO [ ]
(9) Misoprostol can be administered sublingually YES [ ] NO [ ]
66
(10) Misoprostol can be administered rectally YES [ ] NO [ ]
(11).What is the recommended dose of Misoprostol for the prevention of PPH? (i)400mcq (2
tablets) [ ] (ii) 600mcq (3 tablets) [ ] (iii) 800mcq (4 tablets) [ ]
(iv) 1000mcq (5 tablets) [ ].
(12) When is the drug administered for the prevention of PPH?
(i) Immediately after delivery of the baby [ ] (ii) Immediately after delivery of the placenta [ ] (iii) Before delivery of the baby [ ] (iv) Anytime at your discretion [ ]
(13).What is the recommended route of administration of misoprostol for the prevention of
PPH (i) Orally/Sublingually [ ] (ii) Vaginally [ ] (iv) Rectally [ ]
(14). In the treatment of PPH, what is the recommended dose? (i) 400mcq [ ]
(ii) 600mcq [ ] (iii) 800mcq [ ] (iv) 1000mcq.
(15).What is the recommended route of administration of misoprostol for the treatment of
PPH
(16).The mechanism of action of misoprostol includes:(Tick the correct option.)
(a)Initiates and sustains the contraction of the smooth muscle fibres of the myometrium [ ]
(b)Stimulates the posterior pituitary gland leading to the release of oxytocin [ ]
(c) Closes the cervix thereby reducing the bleeding [ ]
(17). Which of the following are the common side effects of misoprostol in the prevention
and treatment of PPH? (You may tick more than one)
(i)High temperature [ ] (ii)Hypothermia [ ] (iii)hypotension [ ] (iv)Rigors and chills [ ]
USE OF MISOPROSTOL FOR PREVENTION AND TREATMENT OF
POSTPARTUM HAEMORRHAGE
(18) Have you used misoprostol for the prevention of PPH? (i) Yes [ ] (ii) No [ ]
IF‘NO’ Move to question 22
(19). If yes, how many tablets did you administer for prevention of PPH?
(i) 200mcq x 2 tabs [ ] (ii) 200mcq x 4 tablets [ ] (iii) 200mcq x 3 tabs [ ]
(iv) 200mcq x 5 tablets [ ]
(20) What was the route of administration? (i) Orally/Sublingually [ ] (ii) Vaginally [ ]
(iv) Rectally [ ]
(21) When do you administer the drug? Tick the correct option (i) Immediately after delivery of the baby [ ]
67
(ii) Immediately after delivery of the placenta [ ] (iii) Before delivery of the baby [ ] (iv) Anytime at your discretion [ ]
22. Have you used misoprostol in the treatment of PPH? (i) Yes [ ] (ii) No [ ]
If NO, move to question to question 27
23. If yes, what dosage did you administer for the treatment of PPH?
(i) 40mcq (2 tablets) [ ] (ii) 600mcq (3 tablets) [ ] (iii) 800mcq (4 tablets) [ ]
(iv) 1000mcq (5 tablets) [ ]
24. What is your frequently used route of administration of misoprostol for the treatment of
PPH? (i) Rectally [ ] (ii) Orally [ ] (iii) Vaginally [ ] (iv) Sublingually [ ]
25. Have you experienced/witnessed any side effect following the use of misoprostol?
Yes [ ] No [ ]
26. If Yes what were the side effects experienced? (List)
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………….………
FACTORS INFLUENCING USE OF MISOPROSTOL
27 Have you ever received any formal training on the knowledge and use of misoprostol?
(i) Yes [ ] (ii) No [ ]
28 .Is misoprostol always available in your facility? (i)Yes (ii)No
29. If yes what is the source of suppy? (i) LGA [ ](ii) State MOH [ ] (iii) NGO
(iv) Open market [ ] (v) Other (specify)…….
30 Is the suppy regular? (i)Yes (ii)No
31.Where do patients in your health care unit get misoprostol from?
(i) Your clinic [ ] (ii) Pharmacy/Chemist Shop [ ] (iii) Others (specify) ---
32. From your experience, does misoprostol effectively prevent and treat postpartum
haemorrhage? (i) Yes [ ] (ii) No [ ]
33. Compared to other uterotonics, do you consider misoprostol expensive Yes [ ] No [ ]
Thank You
68
APPENDIX II
Distribution of health care workers in primary health care facilities in Sabon-Gari Local Government Area Zaria SNO HEALTH
FACILITY NURSE MIDWIFE
MIDWIFE ONLY
NURSE ONLY
COMMUNITY HEALTH EXTENSION WORKER (CHEW)
1 PHC BASAWA 1 0 0 2
2 PHC SAKADADI 1 0 2 3
3 PHC H ANWA 2 0 0 3
4 PHC MUCHIYA 2 0 0 12
5 PHC KWATA 3 1 0 9
6 PHCABDU KWARI 1 1 0 8
7 PHC CHIKAJI 1 0 0 4
8 PHC JAMAA 1 2 0 5
9 PHC SAMARU 1 0 0 7
TOTAL 13 4 2 53
Source: Sabon-Gari Health Department, 2011
69
Total population of primary health care workers in Zaria Local Government
SNO HEALTH FACILITY NURSE MIDWIFE
MIDWIFE ONLY
NURSE ONLY
COMMUNITY HEALTH EXTENSION WORKER (CHEW)
1 PHC WUCICIRI 0 0 2 4
2 PHC DAMBO 0 0 2 3
3 PHC DAKACE 0 0 0 3
4 PHC GYELLESU 0 0 0 5
5 PHC TUKUR-TUKUR
2 0 0 5
6 PHC ANGUWAN DANKALI
0 0 2 2
7 PHC JAKARA 0 0 0 5
8 PHC RIMIN DOKO 0 0 0 6
9 PHC DAN DUTSE 0 0 0 2
10 PHC DUTSEN ABBA
0 0 0 4
11 PHC PANMADINA 0 0 0 0
12 PHC SALAMANDUNA
1 0 0 2
13 PHC KWARBAI 1 0 0 5
14 PHC TUDUN WADA
0 0 0 13
15 PHC BABAN DODO
1 0 0 14
TOTAL 5 0 6 73
Source: Zaria health department, 2011
70
SPSS-16 RESULTS: Test –retest Reliability Estimate for knowledge and use of misoprostol
in the prevention and treatment of Post-partum haemorrhage questionnaires.
A test- retest reliability estimate was carried out to ensure the reliability of the instrument.
The questionnaire has a re-test reliability estimate (two weeks interval) of r=0.981 showing
that the questionnaire is reliable and can be used for the study.
Test-retest reliability estimate
Retest
Test_1 Pearson Correlation 0.981
Sig. (2-tailed) 0.000
N 40