“At least three Vacuum Extractionsare possible every day!”: A questionnaire study in two hospitals inTanzania.By: Elsa

(1)

Läkarprogrammet, självständigt arbete (30 hp) Institutionen för kvinnor och barns hälsa

“At least three Vacuum Extractions are possible every day!”

A questionnaire study in two hospitals in Tanzania.

By: Elsa Georgsson

Supervisor: MD Johanna Belachew Date: 2018-01-08

(2)

Populärvetenskaplig sammanfattning (Swedish)

Många kejsarsnitt i låginkomstländer görs på felaktiga grunder där förlossningen hade kunnat ske vaginalt med hjälp av instrumentella hjälpmedel. Det vanligaste är sugklocka, där en sugkopp sätts fast på barnets huvud och med hjälp av ett yttre drag kan barnet förlösas vaginalt. Sugklocka är en

kostnadseffektiv och relativt enkel metod med gott resultat som dessvärre knappt används i dessa länder. Tanzania är ett exempel. Kejsarsnitt har revolutionerat förlossningsvården men har också flera risker och en vaginal förlossning har, när den är möjlig, en bättre långsiktig prognos. Framförallt ger en vaginal förlossning bättre förutsättningar inför framtida graviditeter och i ett land som Tanzania där varje kvinna i genomsnitt föder 5 barn är detta en viktig faktor. Skulle användandet av sugklocka öka, skulle onödiga kejsarsnitt kunna minska.

En teori till den låga användningen av sugklocka är att sjukvårdspersonalen saknar tillräcklig kunskap och utbildning. Denna studie har delat ut enkäter till förlossningspersonal på två olika sjukhus i Dar es Salaam; Muhimbili National Hospital och Temeke Regional Hospital. Enkäterna undersöker

personalens utbildning och kunskapsnivå för att se ifall detta kan kopplas till den låga användningen.

Totalt har 104 vårdgivare svarat på enkäten, jämt fördelat mellan barnmorskor och läkare. Resultat från studien visar att många vårdprofessioner saknar utbildning i användning av sugklocka. De personer som däremot har fått utbildning verkar vara mer benägna att använda metoden. Sjukvårdspersonalen själva anser att utbildning och utrustning är de två viktigaste faktorerna för att öka användandet av sugklocka och nästan alla anser att de får för lite utbildning. Resultatet tolkas som att det finns goda möjligheter till att öka användandet av sugklocka genom att utbilda personalen och således minska onödiga kejsarsnitt med ett förbättrat utfall för både mödrar och barn.

(5)

Abstract

Background: At Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania, the rates of Caesarean Sections (CS) 2016 was as high as 56% (1). The most common indication for CS at MNH is “Previous scars”, meaning that CS leads to more CS. Vacuum Extraction (VE) is an effective and evidence based method to treat prolonged second stage of labour (2,3) but the use in Tanzania is low (1, 45). If VE could increase, the rate of unnecessary CS could decrease, with improved outcome for both mothers and babies.

Objective: This study investigates the healthcare professionals’ education in, and knowledge about, VE to see if that can explain its low use.

Method: One questionnaire composed of twelve multiple choice questions was answered by 104 healthcare professionals working with obstetric care at MNH and Temeke Hospital in Dar es Salaam.

Results: There was a general lack of education and training in VE among the healthcare professionals and those who had received some training in VE were more likely to perform it.

Conclusion: Many healthcare professionals at both hospitals lack adequate education and training in VE which is a possible explanation for its low use.

(6)

Abbreviations

Caesarean Section……….………CS Dar Es Salaam..………DAR Emergency Obstetric and Neonatal Care.……….………EmONC Muhimbili National Hospital...……….MNH Maternal Mortality Rate………MMR Temeke Regional Referral Hospital ……….………TMH Vacuum Extraction..……….……….………VE

(7)

Background

Global maternal mortality

Around 99% of all maternal deaths occur in low resourced countries (4,5) and the highest maternal mortality rates (MMR) are found in the poorest communities where access to family planning, antenatal care and emergency obstetric and neonatal care (EmONC) is limited. One of the main strategies for reducing maternal morbidity and mortality is to ensure qualified and trained staff for all women in labour (6). The introduction of high quality EmONC in developing countries has rapidly decreased the number of maternal deaths and between 1990 to 2015 the MMR in Sub-Saharan Africa fell with 44% (5). This is often seen as the introduction of safe Caesarean Section (CS) and after its establishment, the CS-rates have steadily risen (7,8). Nevertheless, there are many different

emergencies in labour and not all of them need to be treated with CS.

Haemorrhage, infections, unsafe abortions, hypertensive disorders and obstructed labours are the five most common causes of maternal mortality worldwide and counts for about 70% (9–12).

Sub-Sahara Africa, Tanzania and maternal deaths

Tanzania is one example of a low-resourced country in Sub-Saharan Africa with both high CS rates and high MMR (7,13–15). The rates of births assisted by trained professionals differ between rural and urban areas with a span from 42% in rural, up to 95% in urban areas (13). In Dar es Salaam (DAR), 78% of all women deliver in a health facility with full access to EmONC (14). Nevertheless, the MMR has over the past years been around 400 deaths per 100,000 live births (9,13,16) which represents almost a fifth of all deaths of women in the age between 15-49 years (11,16). In Tanzania, an

approximate estimation of 6% of all maternal deaths are due to deficient labour care (14,17). Most of the maternal deaths occur within the maternity facility, meaning that the women are present and seeking help and that their deaths occur while waiting. Concluding that a lot of improvements need to be done within the hospitals (18).

Prolonged Labour

Prolonged labour is referred to as “failure to progress”. This can be caused by several reasons although the most common is loss of power in the uterine contractions. When the woman gets into the active phase of labour, a primi-gravida is in a prolonged stage if there has been no dilation of the cervical os after 2 hours without an epidural anaesthesia (EDA) or after 3 hours with an EDA. For a multipara the

(8)

labour is considered to be prolonged if there is no dilation after 1 hour without an EDA or after 2 hours with an EDA. However, there is not only the dilation of the cervical os that is important but also the descent of the foetal head. Prolonged labour is the most common indication for instrumental delivery such as VE (3).

A prolonged second stage of labour is associated with a higher morbidity and mortality for the mother, with complications such as increased blood loss, endometritis, choriamnionitis, uterine atony, postpartum haemorrhage and infection due to prolonged rupture of membranes (3,19–23). There are studies pointing towards a relatively small neonatal risks with a prolonged second stage of labour (20,21,24), while other studies have shown associations with different severity; higher frequency of brachial plexus injuries (22), birth asphyxia (25–29), neurological sequelae (27,30), low Apgar score (5 min.) (19,27,30,31), higher admission to a neonatal intensive care unit (19,22,30) and even perinatal mortality (19,24,26,30,31).

Since it is more common for primi-gravidas to get into a prolonged stage, most women that undergo VE are primi-gravidas (32). If a prolonged labour is due to a disproportion or mal-presentation, one should be cautious with instrumental vaginal deliveries and it could even be contraindicated (3).

Obstructed labour

During obstructed labour, the foetus can not progress into the birth canal despite the uterus trying to contract. The most common reasons are disproportion between the foetal head and the mother’s pelvis or that the child’s position is not adequate for a normal delivery (32,33). The diagnosis differs in frequency between different healthcare facilities and sometimes between factors in the individual socio-demographic status (34), showing the diversity in its interpretation. The prevalence of obstructed labours in sub-Saharan Africa is around 10% (34) and worldwide it is estimated to cause around 8% of all maternal deaths (35).

Caesarean Section

WHO’s statement from 1985 is the current leading guidance and the recommended rate of CS in a population is between 10-15% (36). This recommendation can not be adapted into a particular hospital since the individual need is different and therefore differs from hospital to hospital. CS is considered to be part of the comprehensive emergency obstetric care and is therefore not available everywhere (37).

Both MNH and TMH in DAR possess CS but since MNH is the national referral hospital, the most

(9)

complicated patients will be referred to them and they are therefore expected to have a higher rate of CSs. Based on a population level, WHO claims that maternal and neonatal deaths decrease with an increasing rate of CS up to 10%, but no benefits are seen with CS rates above 15% (38). Summing up that CSs should only be used when medically needed (38). As for all surgical interventions, CS has complications such as post-operative infections, excessive haemorrhage and increased pain postpartum (39,40). WHO estimated 2008 a cost of 6,2 billions US$ for unnecessary CS, and thereby being more than four times more expensive than the cost of the global needed (41). Doubtful indications are believed to be a major cause of the unnecessary CSs (15,42). In countries already struggling with low recourses, the expensive, unnecessary CSs do not only effect the patients but also the development of the healthcare facilities (43).

Vacuum Extraction, VE

VE is an effective evidence-based method to treat prolonged second stage of labour (2,3) and is

considered to be an essential part of the Basic obstetric care (37). The most commonly used extractor is the metal cup which was first invented by the Swedish professor Tage Malmström in the late 1950s (44,45). The frequency of VE varies worldwide; 7-8% in Sweden (46), 12-13% in the UK (47,48) and around 3% in the United States (49). In sub-Saharan African countries the frequency of VE ranges between 1-3% and it seems to be decreasing (45,50–52).

The two most common indications for VE are “failure to progress” and foetal asphyxia (2). To perform VE the foetus head has to be sufficiently descended and VE is usually preferred when the foetal skull is in at least stage 0, the lower the baby’s head has reached when the extractor cup is placed, the better outcome (53).

VE is associated with an increased risk, by approximately 2-5% (3), of intracranial haemorrhages, cephalohematomas and subgaleal hematomas for the baby (2,3,54–56). The alternatives such as CS or doing nothing, do however also come with severe complications, sometimes even more severe. At least two studies have investigated the long-term neurological sequels for the babies without any significant difference from the control groups (3,57).

In Tanzania, VE is being performed by both doctors and midwifes. With two professionals performing VE and with more midwifes than doctors in clinic, VE could have a very good accessibility.

(10)

VE or CS?

In many Sub-Saharan countries, some women who could deliver vaginally with VE, are instead undergoing CS (1,14,15) and the belief is that some unnecessary CS could be reduced if the use of VE would increase (45,50). A mother who almost dies during labour is called a “maternal near miss” and CS is associated with both a higher rate of maternal near miss and maternal deaths than assisted vaginal deliveries (39,40). The risks with CS are even higher in low-resourced settings (15,58). A prolonged labour is sometimes mixed up with an obstructed labour and CS is performed in situations where VE could have been possible (59,60). To succeed with reducing the number of CS, not only do the indications for it need to be looked over, but other options such as VE, need to be implanted in the daily procedures and guidelines (61). VE could have a higher accessibility, not only because both midwifes and doctors perform it, but it also requires less equipment and less staff in comparison to CS which needs full surgical preparations including staff from other specialities, e.g. anaesthetic

professionals (62). This also makes VE more cost beneficial (45,50,62).

As for the mother, she will generally have a quicker and better recovery with VE compared to CS (63–

65). One very important advantage of using VE instead of CS concerns future pregnancies. Previous CS have an increased risk of placenta accreta/-increta/-percreta, placenta praevia (66–72), placental retention (73) and postpartum haemorrhage for the next pregnancy (74–76). There is also an increased risk of uterine rupture (76–78), ectopic pregnancy and even infertility (72). If the woman for her next pregnancy aims for a vaginal delivery, the possibility for a spontaneous vaginal delivery increases by five times if the first child was delivered with VE instead of CS (79). A lot of women also report increased chronic pain long time after CS (72).

This concludes that an assisted vaginal delivery most often is preferable, given that the right indications are present.

Aim of the study

The study aims to investigate the knowledge and education in VE among healthcare professionals in two hospitals in Tanzania and see if that could explain its low use.

Study question

Do the healthcare providers at MNH and TMH lack education and knowledge in the use of VE which could explain its low use?

(11)

Method

Design of the study

This is a descriptive, quantitative study including a total number of 104 participants. A questionnaire with twelve questions (see appendix) was handed out to each participating staff-member at MNH and TMH in DAR. The participants had the option to choose between an English version or a Swahili version.

The questions in the questionnaire

Two questions evoked basic knowledge about VE, two were presented as clinical cases, one asked about how comfortable they felt in performing VE and one about comfortableness in other methods for treating prolonged labour. One question was about how often they have used VE, one asked about received training/education in VE, another about the established guidelines, one investigated what could be hindering its current use, one asked about what types of vacuum extractors they were familiar with and the last question was about if they thought they would need more education/training in VE.

The questions were constructed by looking at a similar study done in a hospital in Uganda with a similar setting (51). Every question was answered by circling one of multiple choices and some questions could be answered with several options. The complete questionnaire is included in the Appendix.

Study settings

The data collection was obtained at MNH and TMH in DAR, Tanzania.

Muhimbili National Referral Hospital

The highest tertiary referral hospital in DAR is MNH which also is the largest Hospital in Tanzania (80). They handle the most complicated cases with around 9000-10,000 deliveries a year. The MMR at MNH has the past years been around 300 per 100,000 live births (14). MNH distributes two Vacuum extractors, both of them are manually operated metal cups (14). The patients are mostly public patients who do not pay for their healthcare except for necessary materials such as cotton pads, knife for the umbilical cord and gloves for the professionals et cetera (81). MNH does however accept private patients and for them, the insurance company will pay for the healthcare and reimburse the doctors more if CS has been performed (81).

(12)

The CS rate at MNH have risen rapidly over the past years from an average of 20% in 2005, to 55% in 2015 and 56% in 2016 (1).

Temeke Regional Referral Hospital

TMH is dealing with around 12-15,000 deliveries every year, handling some complicated cases but referring the most complicated once to MNH. TMH distributes one Hand pump/Kiwi as equipment for VE (82). Only public patients go to TMH (81).

The situation at MNH, TMH and Uppsala Akademiska hospital.

Table 1. Comparison between MNH, TMH and Uppsala Akademiska referral hospital.

Hospital and year Numbers of deliveries

CS rates VE rates Number of healthcare professionals

Muhimbili National Hospital 2016 ¹

9 241 56% 0,7% 27 Specialists

50 Residents (in clinic) 0 Registrars

20 Midwifes 58 Nurses

53 Ward Attendants Temeke Regional

Hospital. 2016 ²

12 515 13,9% 4,5% 1 Specialist

12 Registrars 50 Midwifes Akademiska hospital,

Uppsala. 2016 ³

4 271 18,8% 6,9% 17 Specialists

14 Registrars 50 Midwifes

Looking at the numbers in Table 1, one can see that TMH’s rates of both CSs and VEs are similar to those from Uppsala Akademiska hospital, whereas the rates at MNH stand out.

1 Reference (1)

2 Reference (82)

3 Reference (46)

(13)

Study population

The study population includes the healthcare professionals working in labour ward; Midwifes, nurse- midwifes and medical doctors (interns, residents/registers, specialists and assistant medical officers).

The participants were distributed between the two hospitals in relation to their individual size and importance; MNH has more healthcare professionals, a higher CS-rate and a lower VE-rate and contains therefor 70 participants. TMH as a comparing hospital has 34 participants. The participants were equally distributed between midwifes and doctors.

Table 2: Study population

Variable Total number Per cent*

Participants 104 100 %

Hospital

Muhimbili 70 67 %

Temeke 34 33 %

Working experience

0-1 years 40 39 %

2- 5 years 31 30 %

5-10 years 14 14 %

>10 years 19 18 %

Cadre

Midwife/regular nurse 51 49 %

Medical doctors 52 50%

Missing 1

*The per cent column is based on the total number of participants from both hospitals.

Information to the participants and anonymity

All persons answering the questionnaire were informed about the study and that participation was voluntary and anonymous. This information was done orally and an informative document was also distributed to all participants who wanted. The document included more descriptions about the study and information about who to contact if they had any questions.

(14)

Statistics

The analyses were done in IBM SPSS Statistics version 23, by using crosstabs, chi-square tests and student’s t-test. The questions with multiple choices with linear values, were modified into two variables, similar to a “yes” and “no” answer. For example; the question about how often they have used VE was in the original form quantified into values; “not at all”, “once”, “1-2 times”, up to “ten times”. This was modified into two variables; “not at all” and “once or more”. The questions about education and the use of VE were modified similarly. The original question about education included different types of education whereas the analyse used only two variables; “No education” and “some education”. These two questions were put together into one crosstab with two variables at each side.

One side: “No education” and “some education”, versus the other side: “Have done VE” and “Have not done VE”. The same procedure was done for all similar questions.

The one question which has answers in quantitative linear values was analysed with independence samples t-test in SPSS.

Ethical consideration

The study is approved by the National Institute of Medical Research in Tanzania and has the Muhimbili National Hospital’s Ethical clearance certificate.

(15)

Results

Current knowledge and use among healthcare professionals

Most healthcare professionals included in the study answered correctly to the first two questions (see appendix) about basic knowledge. The first question asked about name of the stage in labour when the bony part of the baby’s head is at the level of the ischial spines and 78% answered “stage 0” which is the correct answer. 6% did not answer at all, leaving 16% wrong answers. Concerning the second question about the positioning of the VE-cup; 69% answered “over the posterior fontanelle” which was considered to be the correct answer. There was no statistical significant difference between midwifes and doctors, although 5 doctors answered: “over the anterior fontanelle”, compared to zero midwifes.

The use of VE

45,2% of all participants, have not used VE at all during the past three months [Figure 1].

No difference between professionals was found, but a difference between the two hospitals, where 59,4% at MNH have not used VE at all during the past three months, compared to 17,6% at TMH where the most frequent answer was “3-5 times” which counted for 35,3% of all answers.

Figure 1. How often have you used Vacuum Extraction during the last three months?

A comparison between the two hospitals.

Total amount of answers.

41

13

10

4

1 0

6

3

9 12

2 2

0 5 10 15 20 25 30 35 40 45

Not at all Once 1-2 times 3-5 times 5-10 times >10 times Muhimbili National Hospital Temeke Hospital

(16)

Methods for treating prolonged labour and comfortableness

CS is the method which was the most frequent answer circled when asked about which methods the healthcare professionals were comfortable with (53,5%). Followed by stimulation of contractions and 19% circled VE. When asked directly about VE without other options [Figure 2], 71% at TMH answered that they felt comfortable with VE as a method to treat prolonged labour, whereas at MNH, there was an equally amount of healthcare providers who felt comfortable with VE as there were providers who did not feel comfortable. The difference between the two hospitals is statistical significant with a p-value of 0,042. No difference was seen between the cadres.

Figure 2. Do you feel comfortable in using VE as a method for treating prolonged labour?

A comparison between the hospitals.

The more frequent use of VE, the more comfortable?

Among those who have used VE once or more the past months, a majority feel comfortable with the method [Table 3], but this was not statistically significant.

29 28

11 24

9

1 0

5 10 15 20 25 30 35

Yes No No opinion

Muhimbili Temeke

(17)

Table 3: Comparison between comfortableness in VE and how often they have used VE.

Professionals who are comfortable with VE

Have you used VE the past three months?

Number (n=53) Per cent (%) P-value

Not at all 19 49 %

0,066

Once or more 34 68 %

Established procedures and guidelines

91% of the healthcare professionals at TMH feel comfortable with the established procedures and guidelines for treating prolonged labour, compared to 73% at MNH.

Figure 3. Do you feel comfortable with the established procedures and guidelines for treating prolonged labour?

A comparison between the two hospitals. Total amount of answers.

49

5

13 31

2 1

0 10 20 30 40 50 60

Yes No No opinion

Muhimbili National Hospital Temeke Hospital

(18)

The education among healthcare professionals

Figure 4.1 How much training have you received in VE? A comparison between the hospitals.

Figure 4.2 How much training have you received in VE? A comparison between the cadres.

76,5% at TMH compared to 64,8% at MNH claims having received some kind of training [Figure 4.1]

but it is not statistically significant, p = 0,167. Within the cadres [Figure 4.2], almost half of the midwifes, 46%, have not been given any education at all in the use of VE, whereas more than half of the doctors are given both theoretical and practical training. There are also more doctors than nurses who have received theoretical education only; 26%, compared to 8% of the midwifes (p <0,0001).

24

11

4

29

2

6 6 6

16

0 0

5 10 15 20 25 30 35

None Theoretical

only Practical only Theoretical

and Practical No answer Muhimbili Temeke

7

13

4

26 23

4 4

19

0 5 10 15 20 25 30

None Theoretical only Practical only Theoretical and practical Doctors Midwifes

(19)

The more education in VE, the more use of VE

The professionals who have theoretical and practical training were overrepresented among those who had done VE once or more the past three months (table 4), and among those without training; 79% had not done VE at all during the past three months.

Table 4: Comparison between those who have done VE once or more the past three months and if they have received training in VE or not. p<0,0001.

Professionals who have done VE, once or more the past three months:

P-value

The amount of

training/education received

Number (n=55) Per cent (%)

No training received 6 21%

< 0,0001

Training received 49 68%

Case scenarios

The case scenario one [Figure 5.1]:

“A Primi-Gravida is in second stage; the bony part of the skull is 3 cm below the level of the spines.

There is foetal distress. What would you do?”

The right answer is VE, which 60% answered, versus 26% who answered emergency CS.

Figure 5.1 Case scenario one. A Primi-Gravida is in second stage, the bony part of the skull is 3 cm below the level of the spines. There is foetal distress. You would do?” Total amount of answers.

27

10

61

4 Emergency CS Episiotomy and

fundal expression

Vacuum

Extraction Continue pushing 0

10 20 30 40 50 60 70

(20)

The case scenario Two [Figure 5.2]:

“A Primi-Gravida has been in second stage for an unknown period of time and is exhausted. The foetal skull is 2 cm below the level of the spines. Occiput posterior. You would do?”

This second case scenario in a setting of DAR would be managed by CS, which 51% answered, compared to 42% who answered that they would do VE.

Figure 5.2 Case scenario two: “A Primi-Gravida has been in second stage for an unknown period of time and is exhausted. The foetal skull is 2 cm below the level of the spines. Occiput posterior. You

would do?” Total amount of answers.

Correlations between the answers in Case scenario one [Figure 5.1] and other questions.

The use of VE, compared to the answers in case scenario one.

There is a positive correlation between those who have done VE once or more the past three months and those who answered VE when VE is the correct answer. 68% among the healthcare professionals who answered that they would do CS in case scenario one which should be managed by VE, had not performed VE at all the past three months. Whereas 82% of those who had performed VE once or more the past three months chose VE in the same case scenario. If the professionals have not done VE it is more likely that they will go for CS in a scenario similar to the case scenario one in the questionnaire, which should be managed by VE (p=0,001).

The other two options, episiotomy + fundal pressure and continue pushing, were excluded in the analysis since so few professionals answered these options and the interesting comparison is between CS and VE.

52

5

42

2 0

10 20 30 40 50 60

Emergency CS Episiotomy and

fundal pressure VE Contiue pushing

(21)

Received training, compared to the answers in Case scenario one.

The professionals who answered that they would do VE in case scenario one [Figure 5.1], are more likely to have received some kind of training. 79 % of those who have received some training in VE chose to do VE in case scenario one. p=0,001.

Figure 6.1 Answers to case scenario one, Figure 6.2 Answers to case scenario one, from the professionals who have not from the professionals who have received

received training in VE. training in VE.

Obstacles for using VE more often

Figure 7: What (if any) is hindering/stopping you from using VE more often?

A comparison between the hospitals. Total amount of answers.

CS 58%

VE 42%

CS VE

CS 21%

VE 79%

CS VE

5

22 22

21

14

5 1

12

5

9

3

9

0 5 10 15 20 25

Support from

collegues Equipment Experience Training Established

guidelines Patient's refusual Muhimbili National hospital Temeke Hospital

(22)

The participants could give multiple answers to the question about what is stopping them from using VE more often [Figure 7].

“Equipment”, “Experience” and “Training” count for 71% of all answers. “Equipment” and “Training”

are the two leading reasons for the low use of VE and together they count for half of the answers. 31%

at TMH thinks that equipment is hindering the use of VE compared to 25% at MNH.

The main difference is concerning Patient’s refusal. 23% of all the answers from TMH said that

“Patient’s refusal” is one of the main reasons not to do VE, whereas only 6% answered “Patient’s refusal” at MNH. A comparison between the two cadres [Figure 8], shows that 19% of all nurses answered that “patients’ refusal” is hindering the current use of VE, whereas only 3% among the doctors. p = 0,001.

Figure 8: What (if any) is topping/hindering you from using VE more often?

A comparison between cadres. Total amount of answers.

94% of all the healthcare professionals who participated in the study think that they need more training in the use of VE.

5

23

15

13

8

1 2

11 12

17

9

12

0 5 10 15 20 25

Support from

collegues Equipment Experience Training Established

guidelines Patient's refusual Doctors Nurses

(23)

Discussion

There is a general lack of education and training in the use of VE among the healthcare providers at MNH and TMH which can be one of the causes to its low use. Both hospitals hold many healthcare professionals who have not received any education/training in VE, but those who have, are more likely to perform it when the right indications are present. The healthcare providers at TMH perform more VE and they feel more comfortable with the method compared to the professionals at MNH, who did not perform VE as much and did not feel as comfortable. Concluding that VE is more integrated and more used at TMH than at MNH.

An important big majority of the professionals at MNH have not used VE at all during the past three months and since both hospitals deal with over 20 deliveries every day, this is surprisingly low.

Professionals at both hospitals, think that they need more training/education in VE. They also underline the importance of experience. Experience that is the result of more training and more use. The result from this study also shows that if the healthcare professionals have more recently performed VE, they are more likely to perform it again if the right indications are present. The more training in VE the healthcare providers get, the more VE they perform.

Comparison between MNH and TMH Received training

There are just slightly more professionals answering that they have received some kind of training at TMH compared to MNH. The Comprehensive Community Cased Rehabilitation in Tanzania (CCBRT) is the largest provider of disability and rehabilitation services in Tanzania (84) and they are currently doing regular interventional training for the staff at TMH (81). Although the result in this study could only show a small difference between the two hospitals. This might be a fault of definition where education/training could have different meanings for different professionals and between different hospitals. It is however unlikely that such a difference would exist between these two hospitals. It might also reflect the providers’ thoughts about our study. During the visit at TMH, the healthcare professionals were showing positive attitudes towards the study, expressing their will of wanting to learn. One midwife explicitly said; “We are ready! We want to learn!”. If the professionals think their answers could facilitate the possibility of receiving more training, they might have answered that they have not received enough. It is also possible that the professionals at TMH underestimate the training

(24)

that they have received, or they thought that the training was not sufficient. One personnel from CCBRT said that he reminded the staff regularly about how often they can do VE; “Every day at least three vacuums are possible!”.

Another likely possibility is the aspect of money. CCBRT has given the participants a salary to compensate for their participation off-duty (81). Money has a great power and if they think their answers could have some influence, this is an aspect to have in mind. Although the question only evoked the received training and there was nothing pointing towards that they will receive more training if they answered in a certain way.

Patients’ refusal

The professionals at TMH circled “patient refusal” more frequently than those at MNH (P<0,0001).

The difference between hospitals is interesting and could reflect the different categories of patients.

TMH has less complicated cases which might make the women more empowered to speak out their opinion. Those who answered; “Patient’s refusal”, were in a higher extent midwifes and one

explanation could be that midwifes spend more time with the patients and might develop a closer understanding compared to the doctors. Due to limited pain-relief during vaginal deliveries in

Tanzania, the women are more likely to fear VE than CS. This could also reflect that the possible closer bond between midwifes and patients are more present at TMH.

Education and training Untrained staff performs VE

The healthcare providers who have not received any training in VE are over-represented among those who have never used VE, which is reassuring since untrained staff should not perform VE. Our data, however, indicates that VE is sometimes performed by a doctor or a midwife who has not received any training on its use. Midwifes are given surprisingly poor education in VE. This result is most likely reflecting the actual situation, but it might as well be a fault of definition. Independently, if the nurses are given less education or not, the important thing is that they answered that they did not receive any, which strengthen that they are not given sufficient.

The case scenarios

Looking at the case scenario two [Figure 5.2], the right answer in this particular study setting is CS, which 51% answered. Nevertheless, it is as many as 42% who answered VE. If one compares that to

(25)

the actual low use of VE, they do not correlate. This makes the results at both scenarios harder to trust.

Although, there is one important difference between them; the first case scenario is easier and thus makes it more reliable.

The most interesting finding concerning the case scenario one is that the professionals who have

performed VE more frequently, were also more likely to choose the correct answer VE in that scenario.

This concludes that training has a big importance for the use of VE. Experienced professionals choose more often to use VE in cases where VE is the right method to use.

The importance of education/training

Education and training among healthcare professionals are associated with better outcome for both mother and child (2,85). In many low-resourced countries education in instrumental vaginal deliveries can be an economical challenge in the start, but it can be motivated by a more cost beneficial result (52) and better outcomes (51).

Other influences

Almost a third of those who have received training, have not used VE at all the past three months (32%). This points towards additional parameters that influence the use of VE and not only the education and training.

Attitude towards CS and VE

The attitudes have not been investigated in this study. Although, an overall uncritical attitude toward CS among healthcare professionals has been observed. Several voluntary comments were written on the questionnaires saying that CS is the best method with the best outcome for both mother and child.

Other studies have also found the same uncritical attitudes towards CS (14,15). Attitudes towards VE need to be investigated more in future studies.

Economic factors

This study has not been investigating the economic factors linked to VE. Previous studies have investigated the reasons for the high rates of CS in other settings and in relation to socio-economical factors (8,42,86,87), showing an adverse position for VE with potential profits with CS. Few studies have focused on VE alone as a central factor that can reduce the high rates of CS which has been the focus in this study.

Established guidelines

At TMH, 7,7 % answered that the established guidelines are hindering the use of VE, compared to

(26)

professionals to perform it. This result is a possible reflection of the impact of CCBRT and their work at TMH. The most common indication for CS at MNH is “Previous scars” (1) which shows the viscus circle that CS leads to more CS. VE need to be better implemented in the hospitals’ guidelines.

According to the obstetrics’ database from both hospitals very few VEs are being performed, supposing that the established guidelines do not include VE that well.

What role do forceps have?

It has been a general shift from forceps towards VE the past decades (54) and in many low-income countries forceps are used even less than VE (50,52,88). Although forceps are less likely to fail compared to VE (53,89), they are associated with higher mortality and morbidity for the mother (53,54,88–91) and it also requires more experience to use (52).

Equipment

When asked about what is hindering the use of VE, “equipment” and “training” were the two most circled options. This result is interpreted as the importance of having sufficient equipment available in the facilities since the accessibility of vacuum extractors today is poor with only one respectively two vacuum extractors. Whether or not there is any preference in the type of VE has not been investigated.

The soft cup is associated with more failures compared to the metal cup, but the soft cup does also have less foetal scalp injuries (89,92). MNH uses a vacuum extractor with a metal cup whereas TMH uses a kiwi-soft-cup. If the metal cup is associated with more foetal scalp injuries, this could be one aspect that affects the use at MNH since they are performing less VEs. Although this is speculations and whether or not this has influenced the result can not be said. According to one retrospective cohort study published 2014, both Malmström’s metal cup and the Kiwi OmniCup are equally safe and good to use if the right indications are present (91).

Similar studies

An interventional study done in Uganda was able to increase the use of VE after the implementation of a training program in 2012. They developed standard operating procedures for the use of VE and for the sterilization o Kiwi-cups and could thereby increase the use of it and improve their outcomes. Less stillbirths, less uterine ruptures and a reduced time, by four hours, for delivering with VE instead of CS (51). The setting in DAR is similar to the one in Uganda, pointing towards that the same improvements could be seen in DAR.

Another study published 2013, investigated the relation between VE and CS in a low-resourced setting in Nigeria. The study concluded that VE has an important role in low-resourced settings where CSs are

(27)

not always available or include higher risks and complications. They also underlined that VE needs to be promoted if one wants to reverse the trend of the increasing CSs (45).

Strengths and Limitations I was there

A strength of the study is that the author has participated and contributed from the start to the end. The author chose the questions, distributed the questionnaires and visited the hospitals. By being there and talking to the healthcare professionals, the study setting was experienced on place. The study has been analysed and criticized through-out the whole process and the author has a good insight in the whole process of the study.

Representative study population and different settings

The study includes a relatively large study population for being healthcare professionals with 104 participants, equally distributed between both midwifes and doctors and thereby representative for the population studied. The study also includes two different hospitals and any difference between them can be linked to the difference in settings. At the same time, this is also what makes the results that points towards the same conclusion a higher external validity. Meaning that if the majority from both settings have answered in one way, it is likely to be valid also over a broader population.

Language barrier

Swahili is the spoken language in Tanzania but English is the used language in all professional settings and for practically all healthcare terms. Almost no-one of the healthcare professionals did know the Swahili word for VE. There should not be any limitation as for the medical terms, but as for the reading comprehension, misunderstanding can not be excluded.

Pleasing bias

The fact that the study is about VE and its low use in Tanzania could have had some impact on the participants answers. It is possible that some participants answered VE because they thought that it would be the right answer.

Few specialists

A large part of the participating doctors were Residents (28%). This is motivated by the fact that most doctors working in the wards are Residents/Registers, but it is also a limitation in the study since they do not have the same experience in the field as a specialist. Although, the registers are reflecting the

(28)

training in VE twenty years ago, if that is not the case today.

Reliability in the questionnaire

The first few questions evoked basic knowledge for professionals working in the field and is expected to be seen in the result. Nevertheless, there are faults which need to be discussed.

First of all, there is a mistake in the questionnaire which was discovered after that it had already been distributed. Concerning the positioning of the VE-cup. The correct answer: “Just in front of the posterior fontanelle” was unfortunately missed in the questionnaire and leaves the option: “Over the posterior fontanelle” as the most correct one. This is very unfortunate. Although, among the three answers possible, it is only that one option that fits since the other two are completely wrong. We advised the participants to take the answer they thought suited the best. Comments were possible to make and two participants added the comment: “just in front”.

The amount of wrong answers can be due to some kind of careless mistake where the participants did not read carefully. Although, this does not explain why such a relatively big part of the doctors answered: “Over the anterior fontanelle” and another 20% answered that they would put the VE-cup

“just in front of the anterior fontanel”. This points most likely towards a lack of knowledge.

More than a fifth (22%) of the healthcare professionals did not name stage 0 correctly. This basic question can be compared to another interesting finding from the question about available methods in their facility where only 85,4% answered that CS is available. If we would have asked the question:

“Do you perform CS here?”, most likely 100% would have answered “yes”. Can this be seen as a lack of reliability to other questions too or is 85,4% a good amount of correct answers? Only 13,6% did miss CS as one available method. It might also be a misunderstanding of the question. They were asked about methods in “their” facility, which might have been misunderstood as the ward in which they were currently working. CSs are not performed in the labour ward but in the operating theatres.

Future studies

These results point towards a lack of knowledge and experience in the use of VE. Future studies including deeper interviews to evaluate and ensure the result from this study is recommended. It would also be interesting to furthermore proceed with controlled interventions to educate the professionals in VE, similar to what has been done in Uganda, to see if the use of VE could increase.

(29)

Conclusion

Many healthcare professionals at both hospitals lack adequate education and training in VE.

Professionals who have received some training in VE are more likely to perform it compared to professionals without training. If the professionals have performed VE at least once during the past three months, they are more likely to perform VE again if the right indications are present, compared to the professionals without recent practice who were more likely to choose CS in a similar case. This shows that training and experience are connected to the performance of VE, which could be one explanation of its low use in this particular setting.

(30)

Acknowledgements

I wish to thank each and every one of the 104 healthcare professionals who participated in the study. A special thanks to the administration at MNH for facilitating in the data collection and also a great special thanks to MD Andrew Mgaya at MNH and Dr. Muzdalifat Abeid at TMH for helping out so nicely at both hospitals. Of course, also a big thanks to my supervisor MD Johanna Belachew for great support, patience, guidance and time during my work. Thanks also to my co-supervisors MD Helena Litorp and Dr. Henrik Sandell for invaluable knowledge about Tanzania and quick and supportive feedback. Last but not least, thanks also to Maria Öhman for great teamwork during the data collection.

(31)

References

1. Muhimbili National Hospital Obstetric database records. 2016.

2. Operative Vaginal Delivery. Royal College of Obstetricians & Gynaecologists. Green-top Guideline No.26. Jan 2011.

3. Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Rev Obstet Gynecol.

2009;2(1):5–17.

4. WHO. Trends in Maternal Mortality: 1990 to 2008. Geneva 2010.

http://apps.who.int/iris/bitstream/10665/44423/1/9789241500265_eng.pdf

5. WHO | Maternal deaths fell 44% since 1990 – UN. WHO. 2015. Report from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Devision highlights progress.

6. Stanton C, Blanc AK, Croft T, Choi Y. Skilled care at birth in the developing world:

progress to date and strategies for expanding coverage. J Biosoc Sci. 2007 Jan;39(1):109–20.

7. Harrison MS, Goldenberg RL. Cesarean section in sub-Saharan Africa. Matern Health Neonatol Perinatol. 2016 Jul 8.

8. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS One.

2016;11(2).

9. Maternal Mortality. MMR_Matdeaths_LTR trend estimates 1990 -2015. UNICEF DATA. Updated Nov 2017.

10. WHO | Maternal mortality. WHO. Updated November 2016.

http://www.who.int/mediacentre/factsheets/fs348/en/

11. WHO | Tanzania. WHO.

http://www.who.int/pmnch/activities/countries/tanzania/en/index1.html

12. WHO, UNICEF, UNFPA and The World Bank, Trends in Maternal Mortality: 1990 to 2015, WHO, Geneva, 2015.

13. UNICEF Tanzania - Maternal & child health - The situation.

https://www.unicef.org/tanzania/maternal_child_health.html

14. Mgaya AH. Improving the quality of caesarean section in a low-resource setting. PLoS One. 2016 Nov 28;11(11)

15. LITORP H. What about the mother? Midwifery. 2015 Jul;31(7):713-20.

16. WHO_Tanzania_maternal_health.pdf.

http://www.who.int/gho/maternal_health/countries/tza.pdf

17. Sorensen BL, Elsass P, Nielsen BB, Massawe S, Nyakina J, Rasch V. Substandard emergency obstetric care - a confidential enquiry into maternal deaths at a regional hospital in Tanzania. Trop Med Int Health TM IH. 2010 Aug;15(8):894–900.

18. Pembe AB, Paulo C, D’mello BS, van Roosmalen J. Maternal mortality at muhimbili national hospital in Dar-es-Salaam, Tanzania in the year 2011. BMC Pregnancy Childbirth. 2014 Sep 13

19. Sandström A, Altman M, Cnattingius S, Johansson S, Ahlberg M, Stephansson O.

Durations of second stage of labor and pushing, and adverse neonatal outcomes: a population-based cohort study. J Perinatol. 2017 Mar;37(3):236–42.

20. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes? Am J Obstet Gynecol.

2004 Sep 1;191(3):933–8.

21. Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman MK. Neonatal and Maternal Outcomes With Prolonged Second Stage of Labor. Obstet Gynecol. 2014 Jul;124(1):57–67.

(32)

labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol. 2009 Oct;201(4):357.

25. Vacuum Extraction: Introduction and History, Prerequisites for Vacuum Extraction, Indications for Vacuum Extraction. 2017 Jan 27. https://emedicine.medscape.com/article/271175- overview

24. Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with a prolonged second stage of labor. Obstet Gynecol. 2003 Jul;102(1):52–8.

25. Herrera-Marschitz M, Morales P, Leyton L, Bustamante D, Klawitter V, Espina-

Marchant P, et al. Perinatal asphyxia: current status and approaches towards neuroprotective strategies, with focus on sentinel proteins. Neurotox Res. 2011 May;19(4):603–27.

26. Li W, Zhang H, Ling Y, Jin S. Effect of prolonged second stage of labor on maternal and neonatal outcomes. Asian Pac J Trop Med. 2011 May 1;4(5):409–11.

27. Hunt JC, Menticoglou SM. Perinatal Outcome in 1515 Cases of Prolonged Second Stage of Labour in Nulliparous Women. J Obstet Gynaecol Can. 2015 Jun 1;37(6):508–16.

28. Muraca GM, Sabr Y, Lisonkova S, Skoll A, Brant R, Cundiff GW, et al. Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station.

CMAJ Can Med Assoc J. 2017 Jun 5;189(22):E764–72.

29. Nauman Kiyani A, Khushdil A, Ehsan A. Perinatal Factors Leading to Birth Asphyxia among Term Newborns in a Tertiary Care Hospital. Iran J Pediatr. 2014 Oct;24(5):637–42.

30. Allen VM, Baskett TF, O’Connell CM, McKeen D, Allen AC. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol. 2009

Jun;113(6):1248–58.

31. Altman M, Sandström A, Petersson G, Frisell T, Cnattingius S, Stephansson O. Prolonged second stage of labor is associated with low Apgar score. Eur J Epidemiol. 2015 Nov 1;30(11):1209–

15.

32. Författarna och Studentlitteratur 2008. Obstetrik. 1:1. Vol. 2008. Författarna och Studentlitteratur.

33. WHO Obstructed labour

http://www.who.int/healthinfo/statistics/bod_obstructedlabour.pdf

34. Kabakyenga JK, Östergren P-O, Turyakira E, Mukasa PK, Pettersson KO. Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda. BMC Pregnancy Childbirth. 2011 Oct 14;11:73.

35. Make every mother and child count. WHO. WHO/RHR/04.10.

http://apps.who.int/iris/bitstream/10665/68863/1/WHO_RHR_05.01.pdf 36. WHO Statement on Caesarean Section Rates.

http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf?ua=1 37. WHO Monitoring basic emergency obstetric care.

http://apps.who.int/iris/bitstream/10665/44121/1/9789241547734_eng.pdf

38. WHO | Caesarean sections should only be performed when medically necessary.

http://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/

39. Litorp H, Kidanto HL, Rööst M, Abeid M, Nyström L, Essén B. Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania. BMC Pregnancy Childbirth. 2014; 14: 244.

40. Nelissen EJ, Mduma E, Ersdal HL, Evjen-Olsen B, van Roosmalen JJ, Stekelenburg J.

Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study. BMC Pregnancy Childbirth. 2013 Jul 4;13:141.

41. WHO healthreport 2010. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Persormed per Year: Overuse as a Barrier to Universal

(33)

Cogerage. http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf 42. Litorp H, Kidanto HL, Nystrom L, Darj E, Essén B. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania. BMC Pregnancy Childbirth. 2013 May 8;13:107.

43. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet. 2006 Oct 28;368(9546):1516–23.

44. Rydén G. Vacuum extraction or forceps? Br Med J Clin Res Ed. 1986 Jan 11;292(6513):75–6.

45. Okeke T, Ekwuazi K. Is there Still a Place for Vacuum Extraction (Ventouse) in Modern Obstetric Practice in Nigeria. Ann Med Health Sci Res. 2013;3(4):471–4.

46. Statistikdatabas för graviditeter, förlossningar och nyfödda. [cited 2017 Oct 17].

http://www.socialstyrelsen.se/statistik/statistikdatabas/graviditeter-forlossningarochnyfodda 47. Royal College of Obstetricians & Gynaecologists.

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-an- assisted-vaginal-birth-ventouse-or-forceps.pdf

48. Hoapital Episode Stastistics Analysis, Health and Social Care Information Centre.

Hospital Episode Statistics: NHS Maternity Statistics - England. Hospital Episode Statistics Analysis, Health and Social Care Information Centre; 2015 Jan p. 30. http://digital.nhs.uk/catalogue/PUB16725 48. National Vital Statistics Reports.

https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf

50. Bailey P e. The disappearing art of instrumental delivery: Time to reverse the trend. Int J Gynecol Obstet. 2005 Oct 1;91(1):89–96.

51. Nolens B, Lule J, Namiiro F, van Roosmalen J, Byamugisha J. Audit of a program to increase the use of vacuum extraction in Mulago Hospital, Uganda. BMC Pregnancy Childbirth. 2016 Sep 2

52. Ameh C, Weeks A. The role of instrumental vaginal delivery in low resource settings.

BJOG Int J Obstet Gynaecol. 2009 Oct 1;116:22–5.

53. Al-Kadri H, Sabr Y, Al-Saif S, Abulaimoun B, Ba’Aqeel H, Saleh A. Failed individual and sequential instrumental vaginal delivery: contributing risk factors and maternal-neonatal

complications. Acta Obstet Gynecol Scand. 2003 Jul;82(7):642–8.

54. Ekéus C, Högberg U, Norman M. Vacuum assisted birth and risk for cerebral

complications in term newborn infants: a population-based cohort study. BMC Pregnancy Childbirth.

2014 Jan 20;14:36.

55. Werner EF, Janevic TM, Illuzzi J, Funai EF, Savitz DA, Lipkind HS. Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury. Obstet Gynecol. 2011 Dec;118(6):1239–46.

56. Mesleh RA, Al-Sawadi HM, Kurdi AM. Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Saudi Med J. 2002 Jul;23(7):811–3.

57. Ngan HYS, Miu P, Ko L, Ma H k. Long-term Neurological Sequelae Following Vacuum Extractor Delivery. Aust N Z J Obstet Gynaecol. 1990 May 1;30(2):111–4.

58. Kamilya G, Seal SL, Mukherji J, Bhattacharyya SK, Hazra A. Maternal mortality and cesarean delivery: An analytical observational study. J Obstet Gynaecol Res. 2010 Apr 1;36(2):248–53.

59. Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as

indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG Int J Obstet Gynaecol. 2012 Apr;119(5):605–13.

60. Maaløe N, Bygbjerg IC, Onesmo R, Secher NJ, Sorensen BL. Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion- based audit. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1069–76.

61. De Muylder X, Amy JJ. Caesarean section rates in an African country. Paediatr Perinat

(34)

Epidemiol. 1993 Jul;7(3):234–44.

62. Allen VM, O’Connell CM, Farrell SA, Baskett TF. Economic implications of method of delivery. Am J Obstet Gynecol. 2005 Jul 1;193(1):192–7.

63. Kealy MA, Small RE, Liamputtong P. Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy Childbirth. 2010 Aug 18;10:47.

64. Zakerihamidi M, Roudsari RL, Khoei EM. Vaginal Delivery vs. Cesarean Section: A Focused Ethnographic Study of Women’s Perceptions in The North of Iran. Int J Community Based Nurs Midwifery. 2015 Jan;3(1):39.

65. Kasai KE, Nomura RMY, Benute GRG, de Lucia MCS, Zugaib M. Women’s opinions about mode of birth in Brazil: a qualitative study in a public teaching hospital. Midwifery. 2010 Jun;26(3):319–26.

66. Zaideh SM, Abu-Heija AT, El-Jallad MF. Placenta praevia and accreta: analysis of a two- year experience. Gynecol Obstet Invest. 1998 Aug;46(2):96–8.

67. Kamara M, Henderson JJ, Doherty DA, Dickinson JE, Pennell CE. The risk of placenta accreta following primary elective caesarean delivery: a case-control study. BJOG Int J Obstet Gynaecol. 2013 Jun;120(7):879–86.

68. Sumigama S, Sugiyama C, Kotani T, Hayakawa H, Inoue A, Mano Y, et al. Uterine sutures at prior caesarean section and placenta accreta in subsequent pregnancy: a case–control study.

BJOG Int J Obstet Gynaecol. 2014 Jun 1;121(7):866–75.

69. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section.

Obstet Gynecol. 1985 Jul;66(1):89–92.

70. Sumigama S, Itakura A, Ota T, Okada M, Kotani T, Hayakawa H, et al. Placenta previa increta/percreta in Japan: a retrospective study of ultrasound findings, management and clinical course.

J Obstet Gynaecol Res. 2007 Oct;33(5):606–11.

71. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226–

32.

72. Clark EAS, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol. 2011 Dec 1;205(6, Supplement):S2–10.

73. Belachew J, Cnattingius S, Mulic-Lutvica A, Eurenius K, Axelsson O, Wikström A. Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study. BJOG Int J Obstet Gynaecol. 2014 Jan 1;121(2):224–9.

74. Belachew J, Eurenius K, Mulic-Lutvica A, Axelsson O. Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study. Ups J Med Sci. 2017 Aug;122(3):185–9.

75. Kramer MS, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol. 2013

Nov;209(5):449.e1-7.

76. Taylor LK, Simpson JM, Roberts CL, Olive EC, Henderson-Smart DJ. Risk of

complications in a second pregnancy following caesarean section in the first pregnancy: a population- based study. Med J Aust. 2005 Nov 21;183(10):515–9.

77. Guise J-M, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section.

BMJ. 2004 Jul 3;329(7456):19–25.

78. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001 Jul 5;345(1):3–8.

79. Elvander C, Cnattingius S. Outcome of attempted vaginal delivery after a previous vacuum extraction: a population-based study. Acta Obstet Gynecol Scand. 2016 Mar 1;95(3):362–7.

(35)

80. Muhimbili National Hospital website. [cited 2017 Nov 1]. http://www.mnh.or.tz/index.php/our- profile

81. Henrik Sandell. Information confirmed by Dr. Henrik Sandell.

82. Temeke Hospital Database 2016.

83. MD Johanna Belachew. Information from MD Johanna Belachew at Akatemiska hospital.

Akademiska hospital, Uppsala; Sweden.

84. CCBRT Vision & Mission. [cited 2017 Dec 1]. http://www.ccbrt.or.tz/about/vision- mission/

85. Cheong YC, Abdullahi H, Lashen H, Fairlie FM. Can formal education and training improve the outcome of instrumental delivery? Eur J Obstet Gynecol Reprod Biol. 2004 Apr 15;113(2):139–44.

86. Litorp H, Mgaya A, Mbekenga CK, Kidanto HL, Johnsdotter S, Essén B. Fear, blame and transparency: Obstetric caregivers’ rationales for high caesarean section rates in a low-resource setting.

Soc Sci Med. 2015 Oct;143:232–40.

87. Long Q, Klemetti R, Wang Y, Tao F, Yan H, Hemminki E. High Caesarean section rate in rural China: is it related to health insurance. Soc Sci Med 1982. 2012 Aug;75(4):733–7.

88. Aliyu L, Kadas A, Hauwa M. INSTRUMENTAL VAGINAL DELIVERY IN BAUCHI, NORTHEAST NIGERIA. J West Afr Coll Surg. 2011;1(4):18–27.

89. O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery.

In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2010

90. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994 Apr 2;308(6933):887–91.

91. Turkmen S. Maternal and neonatal outcomes in vacuum-assisted delivery with the Kiwi OmniCup and Malmström metal cup. J Obstet Gynaecol Res. 2015 Feb 1;41(2):207–13.

92. Johanson R. Menon V. Soft versus rigid vacuum extractor cups for assisted vaginal delivery.

Cochrane Database Syst Rev. 2000;(2):CD000446.

(36)

Appendix

The questionnaire:

Participant number: ____________

Health providers education and knowledge about the use of Vacuum Extraction

Instruction: Please circle your answer. DO NOT write your name.

Gender: 1. Female. 2. Male Age: _________

A) I work at:

1. Muhimbili National Hospital 2. Temeke Hospital

B). Number of years working with obstetrics:

1. 0-1 years 2. 2-5 years 3. 5-10 years 4. >10 years

C). In which cadre do you belong?

1. RN/midwife

2. Medical doctor: intern

3. Medical doctor: registrar/resident 4. Medical doctor: specialist

4. Assistant medical officer

D). What of the following methods of treating prolonged labour are available at your facility?

Please circle all methods that are available.

1. Augmentation of labour with Oxytocin infusion 2. Foreceps

3. Vacuum extraction 4. Cesarean section

5. Episiotomy and fundal pressure

Comment: _______________________________________________________________________

“At least three Vacuum Extractionsare possible every day!”: A questionnaire study in two hospitals inTanzania.By: Elsa