Active management of third stage of labor practice and associated factors among skilled birth attendants in Gamo and Gofa zone, Southern, Ethiopia

Background Active management of third stage of labour is evidence based inexpensive and effective intervention for the prevention of postpartum hemorrhage which is the leading cause of maternal mortality in low and middle income countries. In spite of this technique being espoused in Ethiopia and internationally, its actual practice and factors inuencing its practice were yet to be established.Objective The aim of this study was to assess status of active management of third stage of labor practice and associated factors among skilled birth Attendants in public health facilities of Gamo and Gofa zone, southern Ethiopia Methods Facility based cross-sectional study design was employed on 356 skilled birth attendants working in public health facilities of Gamo and Gofa zone. Semi- structured questionnaire with observational checklist was used to collect the data. Data was checked and entered into Epi info version 7 then exported to statically package for social science version 24 for analysis. Univariate, Bivariate and multivariable analysis with 95% CI was carried out. Result The nding of the study revealed that 48.1% of the skilled care providers were good practice towards active management of third stage of labour with 95% CI (43-53). Skilled birth attendants having clinical experience of 7 years and above were 2.52 times more likely performed good practice than others [AOR=7.00(95%CI, 1.82,7.75)] and those skilled birth attendants taken in service training were 2.55 times more likely performed good practice than others [AOR=2.55(95%CI, 1.99,6.56)]. In addition to this those skilled birth attendants who were working in favorable delivery rooms were 1.86 times more likely performed good practice than others [AOR= 1.86(95%CI, 1.32-2.24)] study active third of labour poor. Clinical year experience, having conducive room taking in training active third labour good

room and taking in -service training on active of third management of labour were some of the factors associated with good practice. So crating satisfactory delivery room and providing training on active of third management of labour is very important to enhance their knowledge and skill of birth attendant.

Background
Postpartum hemorrhage and its related complications constitute one of the most common causes of maternal mortality and morbidity (1). Active management of the third stage of labor (AMTSL) is a feasible and inexpensive intervention that can help to save thousands of women's lives (2).It involves; three interrelated but independent components such as, prophylactic administration of an uterotonic drugs, controlled cord traction and uterine massage (3). Currently, World Health Organization recommends active management of the third stage of labour as a critical intervention for postpartum hemorrhage (PPH) prevention (4).
More than half, of direct maternal deaths are due to hemorrhage, typically in the postpartum period and most maternal deaths due to PPH happen in low-income countries.
Besides the death, PPH also causes serious morbidities such as respiratory distress syndrome, coagulopathy, shock, loss of fertility, pituitary necrosis and anemia in the mother (5).
An estimated half million women die as a result of pregnancy and childbirth related complications in the glob (6). Over 50% of direct maternal deaths are due to hemorrhage, typically in the postpartum period (7,8).
In Africa, obstetrics hemorrhage is responsible for 30% of the total maternal deaths (9).
Sub-Saharan Africa alone accounts nearly 66% of maternal death. In Ethiopia, about 412/100,000 women die as a result of complications related to pregnancy and child birth (10).
Study showed that majority of women who gave birth in a health facility particularly in most of developing countries does not receive appropriate care during third stage of labor (9).
Since all laboring women were at risk for PPH health care providers need to possess the knowledge and skills to practice active management of the third stage of labor so as to prevent maternal mortality and morbidity (11) Currently in low resource setting countries like Ethiopia AMTSL is considered an important tool for prevention of postpartum hemorrhage (12). So it is important to assess the existing practice of AMTSL and associated factors among skilled birth Attendants.

Study area and period
The study was conducted in selected public health facilities in Gamo and Gofa zone in south Ethiopia. In Gamo and Gofa Zone there are a total of four public hospitals and seventy seven health centers. The study was conducted among randomly selected 33 health center and 4 hospitals from September 15-May 30, 2018/2019 Study design Institutional based cross sectional study design was employed Study population All skilled care providers who were working in public health institution of Gamo and Gofa zone Sample size determination The sample size was determined by using Epi Info 7 menu StatCalc, by considering the following assumptions: confidence level 95%, power 80% and exposed to unexposed ratio of 1:1Finally, the required sample size for this particular study was decided by taking the maximum sample size from the calculation results and by adding 5% non-response rate the final sample size was 356 Sampling procedure In this study area there are a total of 81 public health facilitates which gave delivery service. The study was conducted on those randomly selected 37 public health facilitates.
The allocation of the sample to health facilities was made proportionally based on the number of health care providers. Individual participants in each of the health facilities were selected by using simple random sampling until the required sample size at each Data collection tool Both interview and observational cheek list was used. The questionnaire was designed in English. All skilled attendants who were working in labour wards of selected public health facilitate and who fulfilled eligibility criteria was included. Data was collected by using pretested and semi-structured questionnaires with observational checklists to assess the practice. Nine data collector was recruited and investigators supervised the data collection process.

Data quality control
Before data collection data Collectors and supervisors was trained on the objective, benefit of the study, individual's right, Informed consent and techniques of the interview for two days.
Than to assure the data quality the questionnaire was pre-tested on 5% of sample size outside the study area. After pre-testing further adjustments to the data collection tool was made to improve clarity, understandability, and simplicity of the messages. All of the questionnaires were checked for completeness and accuracy before, during and after the period of data collection. Throughout the course of the data collection, interviewers were supervised; regular meetings were held between the data collectors and the investigators together. The collected data was again reviewed and checked for completeness before data entry.

Data analysis and interpretation
Data was cleaned and stored for consistency and entered in to Epi info version 7 software.
For analysis the data was exported to SPSS version 24.0 software. Descriptive statistics was carried out and the finding was presented using tables and figures. Bivariate logistic regression was carried out to see the association of each of the independent variables with the outcome variables. Thereafter, the multivariable logistic regression method was used. P-Value of <0.05 and 95% confidence level was used as a difference of statistical significance.

Ethical Consideration
Ethical clearance was obtained from Arba Minch University College of medicine and health science institutional review board. An official letter of cooperation was written by the College of Medicine and Health Sciences to Gamo Gofa Zone and Zonal health department, and administrators of each hospital and health centers. Informed consent was obtained from each study participant and each study participant was informed about the objective of the study and confidentiality of the information she/he is giving. Moreover, the confidentiality of information was guaranteed by using code numbers rather than personal identifiers and by keeping the data locked.

Results
Socio-demographic characteristic of obstetric care providers A total of 356 obstetric care providers were participated in the study, with 97% response rate. Mean age of the respondents was 25.8 SD± 3.54) years. Almost above the half of respondents were midwife 251(72.8%) followed by health officers 57(16.7%), Majority of the study participants 137 (39.7%) were from the Gamo ethnic group and 179 (51.9%) were Orthodox Christianity religion followers. Regarding the marital status of respondents 229(66.4%) was married ( Table 1)

Discussion
The result of this study presented that 94.2 % of health care provider provides 10 IU of oxytocin with one mint, CCT 75.4% and uterine massage 83.8% respectively. It is comparable with the study conducted in Tanzania which revealed that 87.4% of health care provider provides 10 IU of oxytocin within one mint, CCT 92% and uterine massage 72.4% respectively (13). The finding is also similar with study conducted in Addis Ababa, Ethiopia which showed that 77.9% had given oxytocin with in the first minute, 89% used controlled cord traction, and 86% performed uterine massage with in the first minute after delivery (14).
The finding of this study revealed that the overall practice of Active management of 3 rd stage of labour was 48.1% with [95 % CI (43-53)]. The finding of this study is higher than the study conducted in Hawassa, Ethiopia, which showed that 15.7% study participant had good practice on active management of third stage of labors (15). The discrepancy might be due to the presence of updated guide line and improvement of hospital infrastructures which is necessary or input for the provision of active management of third stage of labour. But the finding of this study is comparable with other study conducted in Addis Ababa, Ethiopia which showed that 47% of health care provides had good practice towards Active management of third stage of labour (14). It is also lower than study conducted in Maternity hospital in Albania which showed that 78% of health care provider practice active management of third stage of labour (16). The discrepancy might be due to the difference in knowledge and skill of health care provider or it might be due to the difference in study period and methods of data collection because this study used three observations to know the status of AMTSL practice. The finding of this study is higher than study conducted in Kenya and Nigeria which showed that 31.5% and 28.3%of health care providers use Active management of third stage of labour practice respectively (17,18).

The most communally mentioned components of third stage of labour in this study was
Administration of oxytocin 72.2%, Apply control cord traction 94.2, uterine massage 76.2% and all components 67.2%. The finding of this study is lower than study conducted in Kenya which showed that the most commonly mentioned components of active management of third stage of labour was administration Oxytocin 76.9% and controlled cord traction 96.5% (17). The discrepancy might be due to the difference in health care providers' knowledge and attitude to utilize active management of third stage of labour.But the finding of this study is somewhat comparable with study conducted in Nigeria which exhibited that the most communally mentioned component by respondents included administration of prophylactic oxytocic 88.4%, controlled cord traction 74.5% and Uterine massage following placental delivery 61.2% (18).
The result of multivariable analyses showed that respondents with clinical experience of 7 years and above were 2.52 times more likely performing good practice than others and respondents taken in service training on active management of third stage of labour were 2.55 times more likely performing good practice than others. In addition to this those health care providers who were working in favorable delivery rooms were 1.86 times more likely perform good practice than others.
The finding of this study was the same as the study conducted in Kenya which showed that, availability of a fridge, availability of standards documents, training, type of training and knowledge of health care on AMTSL was some of the factors associated with practice of AMSTL (17). Similarly the finding of this study is in line with the study conducted in others part of Ethiopia which presented that the obstetric care providers who had taken pre/in-service training were more skill full than non-trained obstetric care providers to practice active management of third stage of labour(20).

Conclusions
As we know that Obstetric hemorrhage is the world's leading cause of maternal mortality, causing 24% of maternal deaths annual. Active management of third stage is simple and practical intervention to reduce the incidence of PPH. It is globally endorsed, and widely promoted for more than a decade as part of programs to reduce maternal mortality.
In this study, the practice of obstetric care providers towards active management of third stage of labor is still low. Since absence of taking training, short years of working experience and having Absence of favorable labour and delivery room was associated with the obstetric care provider's poor practice, the governmental and non-governmental  T a b l e 5. Bivariate and multivariable logistic regression analysis of practice of AMTSL among obstetric care providers in Gamo and Gofa zone public health facility, south, Ethiopia,