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Active Management of Third Stage of Labour: Practice and Associated Factors

among Obstetric Care Providers’ at Health Facilities in KembataTembaro
Zone, Southern Ethiopia 2018

Article · March 2019

DOI: 10.4172/2376-127X.1000406

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 ncy an
gna d Wudneh et al., J Preg Child Health 2019, 6:2
Journal of P re

Ch
DOI: 10.4172/2376-127X.1000406
Journal of Pregnancy and Child Health
ISSN: 2376-127X ild Health

Research
Research Article
Article OpenAccess
Open Access

Active Management of Third Stage of Labour: Practice and Associated

Factors among Obstetric Care Providers’ at Health Facilities in Kembata-
Tembaro Zone, Southern Ethiopia 2018
Aregahegn Wudneh1, Merga Dheresa2, Melake Demena2 and Abebe Alemu3*
1
Department of Midwifery, Dilla University, Ethiopia
2
Department of Public Health, Haramaya University, Ethiopia
3
Department of Midwifery, Wachamo University, Ethiopia

Abstract
Introduction: Every year, more than half a million women die with complications related to child birth and pregnancy.
Worldwide, bleeding after child birth is the leading direct cause of approximately one third of maternal death. Practicing
good active management of third stage of labour prevents bleeding after child birth. But, it was estimated that annually
1.4 million deliveries didn’t get good active management of third stage of labour. Thus, this study was aimed to assess
obstetric care providers practice and associated factors in Kembata-Tembaro Zone, Southern Ethiopia 2018.
Methods: Institutional-based cross-sectional study design was used. One hundred seventy one study participants
were enrolled using simple random sampling technique. To collect data, questionnaires and checklists were used.
Descriptive statistic was used to describe study participants. Multivariate logistic regression analysis was carried out
to identify associated factors with practice of active management of third stage of labour.
Results: Magnitude of good practice of active management of third stage among respondents was 29.8% only.
The factors that significantly associated were, knowledge respondents on active management of third stage of labour
(AOR=4.88, 95%CI: 2.10-11.33), pre-service or in-service training (AOR=4.760, 95% CI: 1.89-11.96) and service year
(AOR=2.51, 95%CI: 1.07-5.92).
Conclusion: The magnitude of good practice of active management of third stage of labour among respondents’
was low. Thus, improving practice of active management of third stage of labour among obstetric care providers needs
great attention by all stakeholders. Proving in-service training to obstetric care providers may improve practice towards
active management of third stage labour.

Keywords: Obstetric care; Ethiopia; Logistic regression; Child birth; World Health Organization recommends that all women should get
Pregnancy appropriate active management of third stage labour administered by
skilled care provider [10].
Introduction
Preventing postpartum haemorrhage is a significant strategy to
Every year, more than half a million women die to pregnancy and reduce maternal morbidity and mortality. But, many obstetric care
child birth related complications worldwide [1]. Bleeding is a leading providers failed to appropriately practice active management of third
direct cause of maternal death, representing 27.1% of maternal death. stage labour.
More than two third of reported maternal death from bleeding was
classified as postpartum haemorrhage [2]. According to Ethiopian demographic health survey 2016, maternal
mortality rate was 412 per 100,00 live births [11]. the magnitude
In Africa 33.9% of maternal deaths are due to postpartum of deliveries that active management of the third stage of labour
haemorrhage [3]. In Ethiopia, twenty thousand women die due to appropriately practiced by obstetric care providers was only 4.5% which
pregnancy and child birth complications. The majority of the deaths needs serious attention to active management of third stage labour
occur due to excessive bleeding after child birth within first four hours practice [9].
[4-6].
As studies revealed that multiple factors affected appropriate
In low resources countries the most prominent challenges are, lack
of qualified health care providers, the insufficient or incorrect practice
of active management of the third stage of labour, the underestimation *Corresponding author: Abebe Alemu, Department of Midwifery, College of
of blood loss and also the impairment in communication and Health Sciences and Medicine, Wachamo University, Southern, Ethiopia, Tel:
+251913672730; Fax: +2514665540110; E-mail: [email protected]
transportation infrastructure [7].
Received: January 24, 2019; Accepted: March 20, 2019; Published: March 27,
Postpartum haemorrhage can be prevented by active management 2019
of third stage of labour. However about 10% of all maternal deaths were
Citation: Wudneh A, Dheresa M, Demena M, Alemu A (2019) Active Management
averted with full use of active management of third stage of labour [2,8]. of Third Stage of Labour: Practice and Associated Factors among Obstetric Care
The practice of active third stage labour management was very low in Providers’ at Health Facilities in Kembata-Tembaro Zone, Southern Ethiopia 2018.
African countries (Benin, Ethiopia and united republic of Tanzania), J Preg Child Health 6: 406. doi:10.4172/2376-127X.1000406
which ranges from 0.5-17.6% [9]. Copyright: © 2019 Wudneh A, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
Annually, it was estimated that 1.4 million deliveries didn’t unrestricted use, distribution, and reproduction in any medium, provided the
practice appropriate active management of third stage labour [9]. But, original author and source are credited.

J Preg Child Health, an open access journal

ISSN: 2376-127X Volume 6 • Issue 2 •1000406
Citation: Wudneh A, Dheresa M, Demena M, Alemu A (2019) Active Management of Third Stage of Labour: Practice and Associated Factors
among Obstetric Care Providers’ at Health Facilities in Kembata-Tembaro Zone, Southern Ethiopia 2018. J Preg Child Health 6: 406.
doi:10.4172/2376-127X.1000406

Page 2 of 5

practice of active management of third stage of labour [9]. Those Data quality control
factors significantly associated were: Lack of training, absence of fridge,
sex of care providers, year of experience, knowledge towards active Reliability test was done for data collection tools by using coronach
management of third stage labour, availability of standard document alpha (0.85). A pre-test was done at health facilities in Hosana town,
and other health facility factors [1,12]. Hadiya Zone. Training was given for data collectors and supervisor
regarding data collection tools. All filled checklist and questionnaires
Determining the level of practice of active management of third were checked for completeness and consistency before data entry.
stage labour and its associated factors among obstetric care providers
is significantly important to tackle bleeding after child birth that highly Data analysis
contributing for maternal morbidity and mortality in the study area. Data was entered using the Epi-data version-4.2 and exported to
Therefore, this study was aimed to access practice of active the SPSS version-20 for analysis. Frequencies, proportion and summary
management of third stage labour and its’ associated factors of among statistics were used to describe the study population. Binary logistic
obstetric care providers in the Kembata-Tembaro Zone, Southern regression was carried out to identify variables that are significantly
Ethiopia 2018. associated with practice of active management of third stage labour. The
variables with p-value less than 0.25 (p<0.25) on bivariate analysis were
Method and Materials candidate for multivariate logistic regression. Finally, variables with
p-value less than 0.05 in multivariable logistic regression were declared
Study design, period and area as significantly associated factors with active management of third stage
Facilities-based cross-sectional study design was conducted from labour.
January 20 to February 28, 2018 in Kembata-Tembaro Zone Southern
Operational definitions
Ethiopia.
Active Management of Third Stage Labour (AMTSL): Is
Source population administration of oxytocin within 1 min of delivery of the baby,
All obstetric care providers at health facilities in Kembata-Tembaro clumping and cutting of the cord within 2-3 min of delivery of baby,
Zone, Southern Ethiopia assisted delivery of the placenta through controlled cord traction and
massaging of the uterus immediately after delivery and subsequent
Sample size determination massage every 15 min for the first 1-2 h
Single population formula was used to compute the sample size by Controlled cord traction: The application of gentle traction of the
considering the assumptions, 95% confidence interval, 5% margin of umbilical cord with upward manual support of uterus as a means of
error, p=15.7%, practice of active management of third stage of labour delivery of the placenta.
study southern Ethiopia [13]. Sample size coreection formula was
conscidered, because the total health care providers in the Zone was Practice: Refers to the ability of obstetric care providers to carryout
less that 10,000. Finally, considering 10% non-response rate, the total active management of third stage of labour correctly.
sample size was 180. Third stage of labour: Refers to the stage of labour starts at the
birth of the baby and finished with the expulsion of the placenta and
Sampling techniques
membranes
All health centers and hospitals where obstetrics care service given
Good practice: A care giver who performed at least all of the
were included in the study. Sample size was proportionally allotted to
following during observation: Administered right dose of oxytocin
each health facility. To enrol study participant simple random sampling
within one minute of child birth, deliver the placenta using controlled
was used.
cord traction, massage the uterus immediately and massage uterus
Data collection procedure and tool every 15 min for the first 1-2 h after delivery were said to have good
practice on AMTSL otherwise poor practice.
Structured self-administered questionnaire was used to collect
data on knowledge of study participants on active management of Obstetric care provider: Is a person who is trained, qualified
third stage of labour. The questionnaire was adopted from published professional and have been giving obstetric care in the health
literatures and prepared in English. Observational checklist was used facilities.
collect information on practice of active management of third stage of
labour care providers and that was adopted from FIGO/ICM guideline
Ethical consideration
[14,15]. The questionnaire had three sections: Socio-demographic Ethical approval was obtained from the Haramaya University,
characteristics, facility factors and knowledge on active management College of Health and Medical Sciences Institutional Health Research
of third stage of labour. Ethics Review Committee. Letter of support was obtained from
Kembata Tembaro Zone, health Bureau. The informed consent from
Data collection procedures the labouring mother was obtained.
The birth attendants were observed during active third stage of
labour and finally self-administered questionnaire filled by the birth Results
attendant. But, obstetric care providers didn’t know the specific skill Socio-demographic characteristics
being observed. Finally, the observational checklist and the self-
administered questionnaire of each study participants were combined The mean age of the study population was 30.6 (SD ± 4.95) years.
according to the coded information on the questionnaires. The response rate was 95% (Table 1).

J Preg Child Health, an open access journal

ISSN: 2376-127X Volume 6 • Issue 2 •1000406
Citation: Wudneh A, Dheresa M, Demena M, Alemu A (2019) Active Management of Third Stage of Labour: Practice and Associated Factors
among Obstetric Care Providers’ at Health Facilities in Kembata-Tembaro Zone, Southern Ethiopia 2018. J Preg Child Health 6: 406.
doi:10.4172/2376-127X.1000406

Page 3 of 5

Practice of active management of third stage of labour management of third stage of labour was significantly associated with
health care providers’ pre-service or in-service training (AOR=4.76,
From all of the respondents, 51(29.8%) of obstetric care providers had
95%CI: 1.89-11.97), year of work experience (AOR=2.5, 95%CI: 1.07-
good practice in active management of third stage of labour (Table 2).
5.9) and knowledge of health care providers on active management of
Among the four components of active management of third stage of third stage of labour (AOR=4.88, 95%CI: 2.1-11.34).
labour outlined by FIGO/ICM standard’s documents, controlled cord
traction was the most correctly practiced component which accounted The obstetric care providers who had been trained on active
81.3% of the obstetric care providers (Figure 1). management of third stage of labour were 5 times more likely to
practice good as compare to those who didn’t’ have training. Obstetric
Factors associated with the practice of active management of care providers with year of work experience 6-10 years were 2.5 more
third stage of labour likely to practice good active management of third stage of labour than
those with ≤ 5 years of work experience. Regarding to the obstetric care
On multivariate logistic regression analysis, practice of active
providers knowledge on active management of third stage of labour,
those who had good knowledge were five times more likely to practice
Variables Category Frequency Percent
good management of third stage of labour as compared to that of those
Sex Male 56 32.7
who had poor knowledge (Table 3).
  Female 115 67.3
Age in years 20-30 87 50.9 Variables Frequency Percentage (%)
  31-40 71 41.5
Yes 109 63.7
  ≥ 41 13 7.6 Rule out the presence of second baby
No 62 36.3
Religion Protestant 119 69.6
Uterotonic drug given within first one Yes 125 73.1
  Orthodox 34 19.9
minute after baby delivered No 46 26.9
  Muslim 18 10.5
Ethnicity Kembata 110 64.3 Yes 139 81.3
Controlled cord traction applied
  Hadiya 21 12.3 No 32 18.7
  Tembaro 25 15.7 Yes 147 86
  Other* 15 6.7 Placenta supported by two hands
No 24 14
Profession Midwife 126 73.7
Membrane extracted gently with later Yes 132 77.2
  Nurse 28 16.4
movement No 39 22.8
  Health officer 17 9.9
Uterine massage immediately after Yes 116 67.8
Educational level Diploma 115 67.3
delivery of placenta No 55 32.8
  Degree 56 32.7
Work place Health center 115 67.3 Subsequent massage within 15 min Yes 69 40.4
  Primary hospital 43 25.1 for the first hour No 102 59.6
  General hospital 13 7.6 Good practice 51 29.8
Practice on active third stage of
*
Tembaro, Gurage, Amhara and Silte. labour Poor practice 120 70.2
Table 1: Socio-demographic characteristics of respondents at health facilities in Table 2: Respondents’ practice of active third stage of labour at health facilities in
Kembata-Tembaro Zone, Southern Ethiopia 2018. Kembata-Tembaro Zone, Southern 2018.

90.00%
81.30%
80.00%
73.70%
70.00% 67.80%
59.60%
60.00%

50.00%
40.40%
40.00% practiced
32.20%
30.00% 26.30% did not practiced
18.70%
20.00%

10.00%

0.00%
correct correct CCT Immediate subsequent
oxytocine uterine uterine
adminstration massage massage
Figure 1: Practice of respondents on individual components of active management of third stage of labour at health facilities in Kembata-Tembaro Zone, Southern
Ethiopia 2018.

J Preg Child Health, an open access journal

ISSN: 2376-127X Volume 6 • Issue 2 •1000406
Citation: Wudneh A, Dheresa M, Demena M, Alemu A (2019) Active Management of Third Stage of Labour: Practice and Associated Factors
among Obstetric Care Providers’ at Health Facilities in Kembata-Tembaro Zone, Southern Ethiopia 2018. J Preg Child Health 6: 406.
doi:10.4172/2376-127X.1000406

Page 4 of 5

OR (95% CI)
Variable Category Good practice Poor practice
Crude Adjusted
Profession Midwifery 41 (32.6%) 85 (67.4%) 1.688 (.762-3.740) 1.707 (0.604,4.821)
  Other* 10 (22.2%) 35 (77.8%) Ref
Educational level Degree 20 (35.7%) 36 (64.3%) 1.505 (.759-2.985) 2.211 (0.886,5.518)
  Diploma 31 (26.9%) 84 (73.1%) Ref
Work Experience 0-5 years 16 (19.7%) 65 (80.3%) Ref
  6-10 years 28 (36.4%) 49 (63.6%) 2.321 (1.13-4.7) 2.514 (1.067,5.927)
  Above 10 7 (53.8%) 6 (46.2%) 4.740 (1.39-16.0) 3.575 (0.861,14.840)
Training Trained 42 (44.2%) 53 (55.8%) 5.899 (2.64-13.19) 4.760 (1.89, 11.96)
  Untrained 9 (11.8%) 67 (88.2%) Ref
Knowledge on AMTSL Good 39 (48.1%) 42 (51.9%) 6.036 (2.8-12.7) 4.882 (2.103,11.336)
  Poor 12 (13.3%) 78 (86.7%) Ref
*
Nurses, health officers.
Table 3: Factors associated with practice of active management of third stage of labour among respondents’ at health facilities in Kembata-Tembaro Zone, Southern
Ethiopia 2018.

Discussion providers with length of work experience (≥ 6 years) was higher than
those with <6 years of work experience. This study finding was in line
In this study, 29.8% of obstetric care providers had good practice with the study conducted in Addis Ababa but contradicts with the study
on active management of third stage of labour. This finding is in line conducted in Nigeria in which the birth attendants with less experience
with the finding of studies done on practice on active management found to be good in practice than those with high experience [16,21].
third stage of labour among obstetric care providers at Nigeria (31.5%) This finding discrepancy might be due difference in study population,
and Ethiopia (29%) respectively [16,17]. But the finding of this study is study time and sample size.
higher than studies done in Tanzania (15.7%) and Ethiopia (7%) and
lower than the study conducted in Nigeria (41.7%) [13,18,19]. This Conclusions and Recommendations
finding inconsistency might be due to difference in time of research
Good practice of active management of third stage labour among
studied, study population and variation of tools and parameters used to
obstetric care providers was low (29.8%) in Kembata-Tembaro Zone,
determine good practice of active management of third stage of labour.
Southern Ethiopia. The factors significantly associated were pre-service
Totally, the result of all studied had shown that there are huge gap of
or in-service training, years of work experience and care providers’
good practice of active management of third stage of labour among knowledge on AMTSL.
obstetric care providers that needs serious attention to improve quality
care and client satisfaction in delivery care service. Updating obstetric care provider’s knowledge through consistent and
sustainable trainings, advancing practice of graduates on active management
Administration of oxytocin within one minute of delivery of the of third stage of labour via organizing objective structure competency
baby through intramuscular injection (73.7%) and controlled cord evaluation session and proper monitoring of obstetric care providers in their
traction (81.3%) were the most correctly practiced components of active practice to establish compliance with standards is necessarily important to
management of third stage of labour among obstetric care providers. have good active management of third stage of labour.
Good practice of active management of third stage of labour was
significantly associated with having of pre-service or in-service training
Study Limitation
by obstetric care providers. This study finding is consistent with findings As cross-sectional study, the response biases are the potential
of studies conducted in Ethiopia, Kenya and Tanzania [13,16,20]. This limitation of this study and it was not appropriate to determine causality.
might be due to the fact that providing training for obstetric care providers
towards active management of third stage of labour help them to practice Declarations
it while working their routine activities as per the standards. Moreover, Competing interests: All authors declare that they have no
training might update knowledge of obstetric care providers regarding the competing interests.
components of active management of third stage of labour.
Author’s contributions: All authors equally contributed for this
Obstetric care providers’ knowledge on active management of third research work.
stage of labour significantly associated with good practice on AMTSL. Also
previous studies suggested that there was strong association between level Ethics approval and consent to participate: Ethical approval was
of obstetric care provider’s knowledge and practice active management of gotten from Haramaya University, research ethical committee which
third stage of labour. This finding is similar with previous studies findings was dedicated to evaluating ethical consideration of researchers and
in Addis Ababa, Kenya, Tanzania and Nigeria [15,16,20,21]. This implies informed written consent was obtained from study participants during
that obstetric care providers’ knowledge on definition of AMTSL and its data collections.
components was found to be vitally important to have good practice on Consent for Publish: Not applicable.
active management of third stage of labour.
Availability of data and materials: All data necessary will be
In this study, obstetric care providers’ years of work experience was availed on request.
significantly associated with the good practice of active management of
Funding: Not applicable.
third stage of labour. The level of good practice among obstetric care

J Preg Child Health, an open access journal

ISSN: 2376-127X Volume 6 • Issue 2 •1000406
Citation: Wudneh A, Dheresa M, Demena M, Alemu A (2019) Active Management of Third Stage of Labour: Practice and Associated Factors
among Obstetric Care Providers’ at Health Facilities in Kembata-Tembaro Zone, Southern Ethiopia 2018. J Preg Child Health 6: 406.
doi:10.4172/2376-127X.1000406

Page 5 of 5

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