Management of third stage of labour by midwives and maternity nurses in Oman: a mixed methods study

Background: Women's health throughout pregnancy and childbirth is greatly influenced by midwives and maternity nurses, who manage the third stage of labour and guard against postpartum haemorrhage occurrences. Postpartum haemorrhage is the biggest cause of maternal death worldwide and in Oman in 2017, there were over 20 cases per 100,000 live births. The World Health Organisation (WHO) proposal to follow active management of the third stage of labour guideline (AMTSL) for all women at birth is a crucial policy to avoid maternal mortality from PPH. Aim: To investigate and explore the current knowledge, practice and attitude of midwives and maternity nurses toward management of the third stage of labour and the professional and institutional variations/barriers and the influencing factors that affect adherence to the WHO guidelines of AMTSL in Oman. Methods: This study employed a pragmatic sequential mixed-methods explanatory design, which entailed the collection and analysis of quantitative and qualitative data in two sequential phases. The framework of Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS), a theory of implementation, was used to structure the research design, results and discussion. The study began with a cross-sectional survey of 300 (national and non-national) midwives and maternity nurses working in childbirth wards in six hospitals in Oman, followed by 18 semi-structured in-depth interviews with the same group of midwives and maternity nurses. Data were collected over six months, from July 2019 to February 2021. Using a validated questionnaire, quantitative data were collected and analysed using descriptive statistics and binary logistic regressions. Online, through Zoom, semi-structured interviews were conducted and analysed inductively using thematic analysis of the interview transcripts. Lastly, integration of data (Quantitative + Qualitative) was performed using side-by-side display and a statistics-by-themes comparison to interpret and report the mixed methods study's key findings. Results: The survey achieved a response rate of 80% (n=240; 231 midwives and 9 maternity nurses) and fourteen midwives and four maternity nurses participated in the semi-structured interviews. The quantitative data revealed that knowledge (55%, n=132) and practice (62.1%, n=149) related to WHO guidelines of AMTSL were at low levels. Additionally, a relatively small percentage of participants correctly identified specific components of AMTSL, such as the administration of oxytocin, cord clamping and cutting, CCT and no uterine massage. The qualitative data corroborated the findings of low and outdated knowledge among the participants. They provided detailed descriptions of how midwives and maternity nurses managed TSL differently, prioritizing hospital guidelines over the WHO guidelines, even when the guidelines were not based on current evidence. Among the participants, those in tertiary hospitals demonstrated higher adherence to AMTSL compared to those in primary and secondary hospitals (57.7% vs. 51.8%). The qualitative interviews revealed that primary and secondary hospital participants prioritized birthing the baby and placenta over administering oxytocin and delaying cord clamping and cutting. Conversely, the majority of older respondents (45+ years) with at least 5 years of experience in birthing wards (70.4%) exhibited strong knowledge and adhered to the WHO guidelines of AMTSL, in contrast to younger respondents (