Effect of Flexible Sacrum Position on Maternal and Neonatal Outcomes in Public Health Facilities, Amhara Regional State, Ethiopia: A Quasi-Experimental Study

Restricting women giving birth in health care facilities from choosing the most comfortable position during labor and birth is a global problem. This study was aimed to examine the effect of flexible sacrum birth positions on maternal and neonatal outcomes in public health facilities in Ethiopia’s Amhara Region. A non-equivalent control group post-test-only design was employed at public health facilities from August to November 2019. A total of 1048 participants were enrolled and assigned to intervention or control groups based on their choice of birth position. Participants who preferred the flexible sacrum birth position received the intervention, while participants who preferred the supine birth position were placed in the control group. Data were collected using observational follow-up from admission to immediate postpartum period. Log binomial logistic regression considering as treated analysis was used. Of the total participants, 970 women gave birth vaginally, of whom 378 were from the intervention group, and 592 were from the control group. The intervention decreased the chance of perineal tear and poor Apgar score by 43 and 39%, respectively. The flexible sacrum position reduced the duration of the second stage of labor by a mean difference of 26 min. Maternal and newborn outcomes were better in the flexible sacrum position.

Non-equivalent control group post-test-only design was conducted in public health facilities of the Amhara region in Ethiopia, from August to November 2019. Ethiopia is located at the horn of Africa, and is bordered by Eritrea, Djibouti, Somalia, Kenya, South Sudan, and Sudan. It encompasses about 1.1 million square kilometers area of land and is characterized by varied topography and different climatic conditions. The estimated population is more than 107 million, the average life expectancy is 64.6 years, and the growth rate is 2.6% per year, making Ethiopia the second most-populous country in Africa. The present study was conducted in the Amhara region which is about 784 km from Addis Ababa. The study was conducted in public health facilities of four towns (Debark, Debretabor, Weldia and Finoteselam) found in Amhara region. Amhara region is the second most-populous region in Ethiopia with over 20 million people. There are 55 hospitals (5 referral hospitals, 2 zonal hospitals and 48 district hospitals). Four district hospitals and six health centers were selected for the study. Participants: All pregnant women who came for labor and birth services with low-risk pregnancy to the selected public health facilities during the study period were included in the study population. The inclusion criteria were women in the active phase of first stage of labor with spontaneous onset, singleton fetus, live, cephalic presentation, and gestational age between 37 and 42 weeks. Pregnant women with obstetric and medical difficulties were excluded, as were women with communication problems or hearing difficulties. The sample size was estimated using Epi Info 7.2.1.0 software with the assumption of a 5% level of significance (2-sided) and power of 80%, experimental to the non-experimental ratio of 1:1 with the proportion of second-degree perineal tear 70.7% among the intervention group and 78.3% among the control group [37]. The minimal sample size needed was 1190 individuals, of whom 530 were in the intervention group (FSPs) and 660 were in the control group (SP), considering a non-response rate and loss to follow-up of 10%. A two-stage random sampling technique was utilized to select the study participants. First simple random sampling was used to select ten public health facilities. Second, a systematic random sampling technique was used to determine the study participants. The sample size was proportionally allocated based on the average number of laboring mothers attending for labor and birth at the selected health facilities in the previous three months; this was as determined from the monthly report from each facility. At the time of allocation women were allowed to choose position and based on that preference the selected mothers were assigned either to the intervention group (FSPs) or to the control group (SP). Intervention group: comprised the study participants who preferred the flexible sacrum position (FSPs) and received the intervention. If the study participants chose either of the FSPs such as kneeling, standing, squatting, all-fours, lateral, or the birth seat positions, reported as FSPs. Control group: comprised the study participants who preferred the supine position (SP) and received the routine care. If the laboring mother liked either of the SP such as lithotomy, semi-sitting, recumbent, or semi-recumbent positions, they were reported as SP (NFSPs). First, there was information creation session (about different types of birth positions, so that they can make informed decision to choose between the FSP and supine). This was done for all mothers when they came for labor to the health facilities. The only chance given to the control group was to choose between the FSP or SP (supine position), but nothing was said about which group would be the intervention or the control. Intervention package: To apply the new birth position (FSP) in Ethiopia, the following activities were provided. Midwives were trained to attend to the participants who choose the flexible sacrum position (FSP). The primary outcome variable in this study was a perineal tear, which is classified into four types: first-degree perineal tears with injury to perineal skin and/or vaginal mucosa; second-degree perineal tears with injury to the perineum involving perineal muscles but not involving the anal sphincter [38]; third-degree perineal tears with an injury to the perineum involving the anal sphincter complex; and fourth-degree perineal tears with an injury to the perineum involving the anal sphincter complex, external anal sphincter, and internal anal sphincter and anorectal mucosa [39]. Perineal tears were measured: if the study participants developed first, second, third or fourth-degree perineal tears that fulfill the above definition and need to be sutured and labial tear sutured, the perineal tear was recorded as “Yes”. If the study participants developed abrasion but not sutured and intact perineum, the perineal tear was recorded as “No” [40]. Secondary outcome variables: duration of the second stage of labor, instrumental delivery, mode of delivery, low Apgar score (Appearance, Pulse, Grimace, Activity and Respiration) score and sent to NICU were examined as a secondary variable. Duration of second stage: this was defined as the time from fully dilated cervix when peaked till the birth of the baby. A prolonged second stage of labor was recorded if first-time mothers (primigravida mothers) were in that stage for >3 h and for experienced mothers(multi gravid mothers > 2 h) [41]. APGAR score: was defined as the 5th minute APGAR score of <7 [42,43,44,45] and neonate sent to NICU for neonatal asphyxia. Midwives at the study’s public health facilities were trained, with a total of 104 midwives receiving the professional training for two days of theory and three days of clinical practice (in the skills lab and clinical settings). The training was about the types of birth positions that can be used during labor and birth, their advantage and disadvantage, and how to assist and provide pain relief methods for participants who preferred the FSPs. Midwifery experts provided the training, which was needed because the midwives had no prior experience of attending women giving birth in the FSPs. The trained midwives working in maternal health care units in the study area could educate pregnant women at ANC and when they came for labor and attend birth in FSPs. After the training they continued to practice for one month with follow-up supervision per week before beginning to attend participants in the study and before the actual data collection. Two expert midwives did the follow-up supervision. After a practical follow-up supervision period, the data collection team of six first degree midwives and two MSc midwives (for supervision) were assigned to each hospital. Two first degree midwives and one MSc midwife were assigned for the data collection and supervision at each health center. The test instrument was validated content wise. Before the actual data collection began, the supervisors and data collectors received two days training on how to approach and interview laboring mothers, on the questionnaires, understanding the checklists, and when and how to record the outcomes at the time of observation. The pre-tested and semi-structured questionnaire was used by the data collectors and supervisors to collect the data, after they had been provided with data collection guidelines. The questionnaires have socio-economic, demographic and obstetric variables, and there were also checklists for the outcome variables. The trained midwives informed the study participants about the types of various birth positions after collecting baseline socio-demographic and obstetric data from the chosen study participants, and they advised them to occupy whatever positions felt natural to them. The intervention and control groups were then created based on the women’s indicated preferences for birth positions. However, the study participants did not know which group would receive the intervention. Observational follow-up was maintained from admission until the immediate postnatal period, and information on the positions taken during the second stage of labor and the exact times of delivery was gathered. Additionally, the peak time when the cervix was fully dilated, the time when passive pushing started, the time of active pushing (expulsive pushing), and the actual time of birth were all recorded to measure the duration of the second stage of labor. Data were also collected on the perineal tears and other maternal and neonatal outcomes on direct observation, drawn from the maternity clinical charts, delivery charts and by asking the midwives who attended the labor and delivery. This helped the data collection team to maintain a consistent method for conducting the interviews, hence avoiding the possible introduction of bias during data collection [46]. Data were analyzed according to required standards: data were cleaned, coded, and entered by Epi-info version-7 and stored in a Microsoft Access database file format, before being exported to STATA version-14 for analysis. Data management for all fields was conducted by looking at data ranges as well as looking for missing data. Descriptive analysis was done using frequencies and percentages. The chi-square test for categorical and independent t-test for continuous variables were employed to compare the intervention and control groups. The results were presented using texts, tables, and figures. Bi-variable log-binominal regression analysis was used to estimate the effect of FSP on the maternal and neonatal outcomes with relative risk at 95% confidence interval. A p–value of ≤ 0.05 was considered statistically significant. There was no need to fit multi-variable log-binominal regression analysis since the explanatory variables were uniformly distributed between the intervention and control groups.

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• Dima Health