Active management of the third stage of labour: knowledge and challenges of obstetric caregivers in selected health facilities in Fako Division, Cameroon

Background: In Cameroon, the decrease in MMR (Maternal Mortality Ratio) from PPH (Postpartum Haemorrhage) despite reported use of the Active Management of the Third Stage of Labour (AMTSL) is slower than required to achieve the Third Sustainable Development Goal (SDG3) hence the need to question obstetric caregivers’ competence in AMTSL, as well as the factors hindering its proper use We therefore aimed to assess obstetric caregivers’ knowledge about AMTSL, as well as the determinants and barriers of AMTSL in selected hospitals in Fako Division, Cameroon. Methods: This was a hospital-based cross-sectional study of 150 participants recruited in 27 health facilities in Buea, Limbe and Tiko health districts from January 15, 2020, to March 31, 2020. Participants’ socio-demographic and qualication characteristics, knowledge and challenges, and the references guiding their practice of AMTSL were collected using a structured questionnaire. AMTSL knowledge was categorized as poor or good and the determinants of good AMTSL knowledge were evaluated. The data was analyzed in SPSS version 25.0. Results: Of the 150 caregivers interviewed, only 48.7% had good knowledge of AMTSL. In logistic models, participants’ use of AMTSL increased Good knowledge of AMTSL (AOR: 12.96, CI: 1.12 -150.3, p=0.04). Unavailability of drugs and/or equipment, insucient staff coverage and lack of knowledge and training of the staff were the major challenges reported. Conclusion: Obstetric caregivers in Fako have face in AMTSL which account Filling this gap and mitigating towards the SDG3.

prevalence's of PPH displays slow progress towards achieving the Third Sustainable Development Goal (SDG3). However, it has been shown that the AMTSL practice of obstetric caregivers in Cameroon and other low and middle-income countries is not consistent with the recommendations of the International Federation of Obstetrics and Gynaecology (FIGO), especially keeping in mind that a satisfactory level of knowledge and skills, a critical judgment and access to good equipment are mandatory for every birth attendant to perform AMTSL [1]. Moreover, studies conducted in Ethiopia, Nigeria and Ghana highlighted inadequate knowledge, lack of training, communication di culties between more-and less-experienced caregivers, inadequate staff coverage and other socio-demographic factors as some of the causes of these lapses [8][9][10]. This, together with the high MMR and prevalence of PPH in Cameroon despite reported AMTSL use, therefore, raised the argument that AMTSL may not be properly done by the obstetric caregivers. We thus hypothesized that the knowledge and practice of AMTSL by caregivers is low while the challenges are numerous in selected hospitals in Fako Division, Cameroon. This highlighted the necessity to study AMTSL knowledge, practice and challenges of obstetric caregivers in some selected hospitals in Fako Division, Cameroon.
This study aimed to assess obstetric caregivers' knowledge about AMTSL, as well as the determinants and barriers of AMTSL in selected hospitals in Fako Division, Cameroon

Materials And Methods
This was a hospital-based cross-sectional study carried out from January 15, 2020, to March 31, 2020.
Obstetric caregivers in selected health facilities in Buea, Tiko and Limbe health districts were enrolled in the study. The selection criteria were as follows; health facilities with a maternity unit, health facilities with registered information at the District Health O ces and health facilities with greater numbers of obstetric caregivers.
Those who gave written consent lled a self -administered semi-structured questionnaire to collect data on their knowledge of AMTSL, the challenges they faced concerning its use, the recommendations they had for better AMTSL practice and the references guiding their practice of AMTSL. The questionnaire was adapted from similar studies carried out in Nigeria (2015, 2018) and Ethiopia (2015, 2018) [9][10][11][12][13] and the standardized KAP (Knowledge, Attitude and Practice) questionnaire from KAP manual published in 2014 by Food and Agricultural Organization (FAO) [14]. The criteria for scoring obstetric caregivers' knowledge of AMTSL was adapted from a similar study in Ethiopia [10]. The maximum score was 25, and the knowledge was categorized as good or poor. (Table 1)

Fig 1: Study Consort
Participants' age ranged from 21 to 67 years with a mean age of 34.19 ±9.27 years. Most of the participants, 76 (50.7%) were in the age group 21 to 30 years. A great majority of the participants were females, 121 (80.6%). The mean work experience was 7.77 (±7.52) years with 50 (33.3%) caregivers having between one to two years of work experience and 43 (28.7%) having more than 10 years of work experience. Furthermore, a majority of the caregivers, 91 (60.7%) worked in unclassi ed healthcare facilities (Health centres), 46 (30.7%) in Primary healthcare facilities (District hospitals) and 13 (8.7%) in a (Secondary healthcare facilities) Regional Hospitals. (Table 2) (Fig 2), of whom 22.7% (34/150) were midwives, 12% (18/150) were general medical practitioners, 12% (18/150) were nurses and 2% (3/6) were Obstetricians (Fig 3). Only 45.3% of the caregivers knew all the three components of AMTSL (66.7% of obstetricians, 55.4% of midwives, 46.2% of general medical practitioners and 33.9% of nurses). However, up to 94.6% of the caregivers knew of oxytocin as the rst line uterotonic drug recommended for AMTSL, 91.1% knew that the recommended dose of the uterotonic of choice for AMTSL was 10 IU (of oxytocin) and 77.9% of them reporting IM route as the recommended route to administer the drug during AMTSL (Table 4). Caregivers who reported using AMTSL were 13 times more likely to have good knowledge of AMTSL compared to those who reported not using it (AOR: 12.96, 95%CI: 1.12 -150.3, p=0.04). The profession and training on AMTSL were confounders ( Table 5).  Organization of training programs, seminars and workshops on AMTSL following the standard and updated guidelines was the major recommendation proposed by caregivers, 61 (45.9%). Provision of an adequate supply of oxytocin and other delivery equipment, 21 (15.8%) as well as improvement in staff coverage, 21 (15.8%) were both greatly recommended too (Table 7). The use of Standard Operating Procedures (SOPs), charts and/or posters on AMTSL, 76 (69.7%) pasted on the walls in the maternity ward was the main reference guiding the caregivers' practice of AMTSL.
Only six per cent of caregivers reported using WHO or evidence-based practice guidelines to guard their practice of AMTSL. That notwithstanding up to 12 (11%) of respondents did not have any reference guide of their practice of AMTSL (Table 8).

Discussion
Knowledge of caregivers on AMTSL In our study, we observed an overall good knowledge level on AMTSL in 48.7% of caregivers. This was very high compared to 7.0% and 10% of caregivers reported in separate studies in Tanzania and 37.7% reported in Ethiopia [10,11,13]. Our nding was, however, lower than the 51.5% reported in Ethiopia and 57.8% and 66.7% reported in studies carried out in Nigeria [9,10,15]. In that line, midwives were the most knowledgeable group with 22.7% of them with good knowledge of AMTSL. They were followed by general medical practitioners (12%), nurses (12%) and lastly obstetricians (2%). Despite having comparable MMRs to, and better MMRs than some of the countries in the studies aforementioned, this low knowledge level of caregivers on AMTSL is worrisome indicating that AMTSL practice may not be adequate. A possible explanation could be the lack of workshops on AMTSL and/or inadequate preservice and/or in-service training on AMTSL. Also, the studies carried out in Nigeria, Ethiopia and Tanzania [9,10,11,13,15] principally assessed midwives and nurses, meanwhile our study assessed physicians, midwives and nurses. Besides, physicians in the studied health facilities are usually called up to manage complicated third stages of labour and hence take less part in uncomplicated deliveries [16].
When assessing the caregivers' knowledge of the components of AMTSL, we observed that less than half of the caregivers (45.3%) knew all the three main components of AMTSL. Our nding was higher than that reported in South Africa (36.0%) [17] but was however very low compared to ndings in Tanzania (70.1%), Ethiopia (63.2% and 58.0%) and Lesotho (62.2%) [10,11,16,18]. The majority of respondents were able to state at most 2 of the components correctly. A possible explanation could lie in the difference in the questionnaire used in our respective studies. Ours had open-ended questions while theirs had multiple choice questions for one to select the right answer. This reduced the chance of guess work.
The Guideline Development Group (GDG) of WHO considered the use of uterotonics as the main intervention within AMTSL, and, in our study, administration of uterotonics was the most frequently reported AMTSL component by the caregivers. This shows that despite not knowing all the components of AMTSL, many knew the most important component.

Determinants of knowledge of caregivers on AMTSL
The fact that caregivers' use of AMTSL was the only factor independently associated with good knowledge of AMTSL in our study contrasted with a similar study carried out in Ethiopia [16] where the profession of the caregivers was the only independently associated factor to a good knowledge of AMTSL. Caregivers who reported using AMTSL were more likely to have good knowledge on it as compared to those who reported not using it. This can be explained by the saying practice makes perfect, as their regular use of AMTSL has urged them to know all about it to ensure adequate practice and thus has improved their knowledge on the subject.

Challenges to AMTSL utilization
Insu cient staff coverage (22.8%) was the major challenge to the use of AMTSL faced by caregivers. This challenge was also reported by caregivers interviewed in similar studies carried out in Ghana and Tanzania [8,11]. Unavailability of drugs and equipment, as well as lack of knowledge and training on AMTSL, were also major challenges reported in Tanzania, Ghana and Nigeria [8,11,15].
The recommendations for better practice of AMTSL proposed by the caregivers under study were in line with the challenges they reported; with the organization of training programs, seminars and workshops on AMTSL following the standard and updated guidelines, provision of an adequate supply of oxytocin and other delivery equipment as well as improvement of staff coverage being the major recommendations they proposed.
Our study also revealed that 11% of caregivers did not have any reference guiding their practice of AMTSL. Moreover, only six per cent of the caregivers reported using guidelines from international bodies like WHO or evidence-based practice to guide their practice of AMTSL. The Majority of them used standard operating procedures (SOPs), charts and/or posters on AMTSL (69.7%) pasted on the walls in the maternity ward as the main reference guiding their practice of AMTSL con rming the hypotheses that most caregivers rely more on standard operating procedures (SOPs) (usually pasted on the walls of maternity units) rather than actual (updated) guidelines or directives on AMTSL [19]. Therefore, there was no scienti c backing of their practice [20].

Strengths and limitations
A qualitative arm of this study could enlighten us more on the challenges faced by caregivers on the practice of AMTSL.
Our study included physicians (obstetricians and general medical practitioners), which only a few studies in sub-Saharan Africa have done.
Finally, our study was the rst to assess obstetric caregivers' knowledge on AMTSL, the challenges they face in its use and the determinants of good knowledge on AMTSL in Cameroon.

Conclusion
There is a knowledge gap in AMTSL among obstetric caregivers in Buea, Limbe and Tiko health districts with less than half having good knowledge.
Caregivers' use of AMTSL was the only determinant of good knowledge of AMTSL identi ed in these health districts.
Challenges reported by the caregivers in the practice of AMTSL included the lack of training and workshops, insu cient staff coverage and the unavailability of drugs and/or equipment.
These challenges could account for the high MMR from PPH in Cameroon despite AMTSL use as well as the slow progress towards achieving SDG3. All eligible participants were informed on the aim and objectives of the study and possible adverse effects (time-consuming to ll questionnaires) after which the information sheet was given to each of them. Participants were given opportunities to ask questions for clarity. Participants who accepted to be part of the study gave written consent. No material or nancial incentives were given to encourage participation in the study. Con dentiality was ensured by coding and keeping the data collected very securely through the use of passwords only accessible to the principal investigator. No information on identi cation such as names was obtained from the participants, rather codes were used to make sure it could not be traced back to them

Consent for Publication
Not applicable

Availability of data and materials
The authors declare that data su cient to produce the presented results will be made available on reasonable request to the Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Buea. Data requests can be submitted through the corresponding author.

Con icts of interest
The authors declare having no con ict of interest.  Tables   Table 1: Criteria for scoring obstetric caregivers' knowledge on AMTSL [10] Caregivers' Knowledge Scoring(N) Aggregate score (%) Poor <20 <80 Good 20-25 ≥80         Distribution of good knowledge level on AMTSL per profession