Assessments of midwives’ knowledge and practice toward postpartum hemorrhage management and associated factors at selected public hospitals in Addis Ababa, Ethiopia, 2023

Abstract

BACKGROUND

Postpartum hemorrhage as the primary cause was associated with 41% to 51% of all maternal deaths in Ethiopia between 2013 and 2018. The majority of postpartum hemorrhage–related deaths can be avoided by using efficient therapies and having midwives with good knowledge and skills.

OBJECTIVE

This study aimed at determining the knowledge and practices of midwives related to postpartum hemorrhage management and associated factors at selected public hospitals in Addis Ababa, Ethiopia.

STUDY DESIGN

An institutional-based, cross-sectional study design was employed from March 15 to April 15, 2023. A simple random sampling technique was used to select the 207 sampled participants. Data were collected using a pretested, structured, self-administered questionnaire. Data coding and cleaning were done before data analysis. Variables with a P value <.25 in the bivariate logistic regression analysis were entered and checked for association in a multivariable logistic regression model so as to not miss an important variable. The finding was expressed as the adjusted odd ratio with 95% confidence interval and a variable at a P value of <.05 was declared as statistically significant.

RESULTS

In this study, 34.3% (95% confidence interval, 28–41) of the study participants had good knowledge, whereas 65.7% (95% confidence interval, 59–72) had poor knowledge. Participants who had received job training in the labor ward had 3 times better knowledge than those who did not receive it (adjusted odds ratio, 3.386; 95% confidence interval, 1.427–8.033). In total, 30.4% (95% confidence interval, 24.6–37.6) of the participants had good practice, whereas 69.6% (95% confidence interval, 62.4–75.4) had poor practice.

CONCLUSION

The participant responses showed that the majority of midwives lacked adequate knowledge of and practice related to postpartum hemorrhage management. All stakeholders should consider on-job training for participants, improving educational levels, and continuous screening and identification of institutional needs.

AJOG Global Reports at a Glance.

Why was this study conducted?

This study laid the groundwork for improving the quality of care provided by midwives by focusing on modifiable knowledge, practices, and associated factors related to the treatment of postpartum hemorrhage (PPH). It gave insight into ways to reduce maternal death, morbidity, family problems, and country crises and formed the basis for recommendations to close the gap. It will also serve as a baseline for future research in the region and will be used by various governmental and nongovernmental institutions with obstetrics and gynecology specialties.

Key findings

This study indicates that 65.7% and 69.6% of midwives employed in public hospitals of Addis Ababa have inadequate knowledge of and practices related to the treatment of PPH, respectively. The associated factors that had statistically strong significant associations with knowledge were work experience, guidelines, job training, and educational level. In addition, the factors associated with practice were age, job training, the use of an ambulance for transportation, blood storage, and blood.

What does this add to what is known?

Several studies have examined midwives’ knowledge of and practices related to PPH management across various Sub-Saharan settings, however, there is limited research that specifically focused on public hospitals in Addis Ababa. Our study identified significant associations among age, work experience, training, educational level, availability of supplies, and adherence to protocols for PPH management, which are in contrast with the findings of other studies. This study was carried out in a multicenter setting as opposed to the other studies that were carried out in single center.

Introduction

Postpartum hemorrhage (PPH) is defined by the World Health Organization (WHO) as blood loss exceeding 500 mL for vaginal delivery (or more than 1000 mL following a cesarean delivery) within the first 24 hours after delivery and after 24 hours for up to 6 weeks after delivery.¹ Every year, more than 14 million people worldwide are affected by PPH, and the case mortality rate is estimated at 1%.² However, a different estimate places the number of maternal deaths at 25% worldwide, and PPH is widely regarded as the primary cause of mortality in nations with low incomes. The mortality rate is likely lower in economically developed countries than in developing countries.² In Sub-Saharan Africa, the majority of maternal deaths take place within 4 hours of delivery and are caused by issues in the third stage of labor.³

The WHO estimated that 99% of deaths caused by PPH occurred in low- and middle-income nations, and Nigeria reported an estimated 814 maternal deaths per 100,000 live births.⁴ According to recent statistics, Tanzania’s total maternal mortality rate (MMR) was estimated to be 410 per 100,000 live births and 7900 overall, and PPH alone accounted for 25% to 28% of all maternal deaths in Tanzania.⁵ Despite the significant contribution made over the years by active management of the third stage of labor (AMTSL) to lower the burden of PPH and the maternal mortality ratio in Cameroon, 467 deaths per 100,000 live deliveries were recorded in 2018.⁶

According to a 2015 estimate, Ethiopia’s maternal death rate was 353 per 100,000 people.^7,8 There are approximately 4 maternal deaths in Ethiopia for every 1000 births as a consequence of bleeding after childbirth. Hemorrhage, primarily PPH, was to blame for 41% to 51% of all maternal deaths in Ethiopia between 2013 and 2018.⁹ PPH is linked to both long-term and short-term health issues, including chronic illness, disability, higher mortality risk, stunted infant growth, and organ failure. Because the majority of nonsevere types are not typically reported in databases or studies, focusing only on the number of fatalities or complications may understate the impact of PPH.⁹

Although lowering maternal mortality remains the most difficult challenge for Ethiopia’s health system, there are initiatives to address the grave disparities in maternal and perinatal health. The majority of these deaths take place within 4 hours of delivery and are caused by issues in the third stage of labor. Early, aggressive, and well-coordinated therapies can both prevent and treat PPH. Thus, it has been a welcome development to adopt life-saving techniques (LSTs) to lower maternal mortality and morbidity caused by these disorders.

Active treatment of the third stage of labor and quick and efficient administration of the first response bundle could prevent the majority of PPH deaths.¹⁰ The majority of PPH-related deaths can be avoided by using efficient therapies.¹¹ Standard care for PPH includes both nonsurgical and surgical interventions carried out in accordance with WHO guidelines, the International Federation of Gynecology and Obstetrics (recommendations, or locally tailored PPH treatment protocols. Midwives play an important role during delivery, childbirth, and the first few weeks after giving birth. The midwife’s attention should be focused on supporting, defending, standing up for, and empowering women during this time. To know when to act and when to make precise observations and administer midwifery interventions, midwives must possess the necessary knowledge and skills. Furthermore, midwives must be qualified and able to pursue further education and training to offer extended care.¹² In Addis Ababa, Ethiopia, there is a lack of published literature regarding midwives’ knowledge of and practice related to PPH management and associated factors. Therefore, this study investigated midwives’ knowledge of and practice related to PPH management and associated factors in an attempt to fill the gap.

Materials and methods

Study design and period

This was an institutional-based, cross-sectional study design that was employed from March 15 to April 15, 2023.

Study area

The study was conducted in selected public hospitals in Addis Ababa, Ethiopia. Addis Ababa is the capital city of Ethiopia, which is located in the central part of Ethiopia. There are a total of 13 public hospitals in Addis Ababa. The study was conducted at 7 selected public hospitals found in Addis Ababa, namely Tikur Anbessa Specialized Hospital (TASH), Ras Desta Hospital, Gandhi Memorial Hospital, Zewditu Memorial Hospital, Yekatit 12 Hospital Medical College, Menelik Referral Hospital, and St. Peter Referral Hospital.

Study participants

The source population comprised all midwives who were working in Addis Ababa health facilities.

Eligibility criteria

Inclusion criteria

Midwives who were currently working in the gynecology and obstetrics wards of the selected hospitals and who were directly involved in conducting deliveries were included.

Exclusion criteria

Midwives who were on annual leave, maternal leave, sick leave, or severely sick during the study period were excluded.

Sample size determination

The final sample size was calculated using a single population proportion formula to estimate the sample size, and a proportion of 0.43 was taken from research done on the knowledge and competency of midwives in the implementation of active management in the third stage of labor.¹³ Therefore, this study used this value to obtain the minimum sample size at 95% certainty and a maximum discrepancy of 5% between the sample and the population. Contingency of 10% was added to compensate for possible incomplete data. Thus, 207 study participants were determined to be the final sample size.

Sampling procedure and technique

Using the lottery method, the 7 hospitals were selected from a total of 13 public hospitals in Addis Ababa. The study population number was allocated proportionally to the selected hospitals. Using simple random sampling, the study participants from an allocated sample of respective hospitals were included in the study until the calculated final sample size was obtained. The hospitals included were Tikur Anbessa Specialized Hospital, Ras Desta Hospital, Gandhi Memorial Hospital, Zewditu Memorial Hospital, Yekatit 12 Hospital Medical College, Menelik Referral Hospital, and St. Peter Referral Hospital. These hospitals were chosen because they provide maternal healthcare services and handle a high volume of deliveries, thereby making them suitable for assessing midwives’ knowledge of and practice related to PPH management (Figure 1).

Figure 1.

Sample size allocation

H, Hospital; MCH, Medical College Hospital; MH, Memorial Hospital; RH, Referral Hospital; TASH, Tikur Anbessa Specialized Hospital.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Operational definitions

Knowledge was defined as midwives’ intellectual thinking around the management of PPH and key factors related to its management, including, uterotonics, controlled umbilical cord traction, uterine massage, fluid resuscitation, and nonsurgical measures (such as bilateral compression, intrauterine balloon insertion, nonpneumatic anti-shock garments, and aortic compression).⁸

Good was defined as a respondent score of 60% or more for the questions on knowledge of instructions on how to prevent and handle PPH.¹

Poor was defined as a respondent score of less than 60% for the questions on the knowledge guide on the prevention and management of PPH.¹

Practice was defined as how midwives who worked in several public hospitals in Addis Ababa dealt with the management of PPH as defined in the National Obstetrics Guidelines; specific advice on safe motherhood.¹

Good was defined as a respondent rating of at least 60%, which showed that their practices had a positive effect on the prevention and management of PPH.¹

Poor was defined as a respondent score of less than 60%, which showed that their practices had a negative impact on the prevention and management of PPH.¹

Data collection tool and techniques

A pretested, validated, semi-structured questionnaire was adopted from relevant literature¹³ and tailored to the study variables to collect data. The tools were prepared in English. The tool had 4 parts. Part 1 was for the collection of demographic data, part 2 comprised the questionnaire on the knowledge of midwives, part 3 questionnaire to collect data on the associated factors, and part 4 comprised the practice questionnaire. Data were collected by 6 trained data collectors and 2 supervisors. Clarification was done for all areas of concern for the questions and checklist.

Data quality control

A pretested, validated, semi-structured data collection tool was adopted after a review of related literature to ensure data quality. Two days training were provided to data collectors and supervisors on the objectives of the study, the contents of the data collection tools, and how to collect and record data appropriately. In addition, the quality of the data was ensured by using a properly designed extraction checklist. A pretest was conducted on 5% of the sample at the Alert Hospital. Charts of the study’s sample population were assessed for completeness. Cronbach alpha was used to check for the internal consistency of the questionnaire with the value of 0.63. The filled checklists were checked daily for completeness by the supervisors and principal investigator.

Data processing and analysis

The data that were collected using the Kobo toolbox were exported into SPSS, version 27, and then coded, cleaned, and stored. Texts, tables, and figures were used to display the descriptive and summary statistics. To evaluate sample suitability and to pinpoint explanatory factors connected to the outcome variable, a binary logistic regression analysis was conducted. For multiple logistic regression models, all covariates with P values <.25 in the bivariate analysis became candidate variables. The adjusted odds ratio (AOR) and 95% confidence interval (CI) were used to determine the strength of the relationship between independent predictors and the outcome variable. The observed correlations were deemed statistically significant at a P value of ≤.05. The assumption of multicollinearity was evaluated using the variance inflation factor (VIF) with values of 1.2 to 3.9, and the adequacy of the final model was checked using the Hosmer and Lemshew goodness of fit test at a P value of >.05 showed that the final model fitted the data well. The results were presented using frequency tables, graphs, charts, and narration through text.

Ethical consideration

Ethical clearance was obtained from the research committee of the Department of Emergency Medicine, College of Health Science, Addis Ababa University. An official letter was submitted to the Tikur Anbessa Specialized Hospital, St. Paul’s Hospital Millennium Medical College, Gandhi Memorial Hospital, Zewditu Memorial Hospital, Yekatit 12 Hospital Medical College, Menelik Referral Hospital, and St. Peter Referral Hospitals. Written informed consent was obtained from the study participants after clearly explaining the purpose of the study. Confidentiality was maintained. This study was conducted in accordance with the Declaration of Helsinki.

Results

Sociodemographic characteristics of the study participants

A total of 207 participants were included in the study with a response rate of 100%. The normality test status for age had a P value of <.05. More than half of the participants were in the age group of 20 to 29 years with a median (range) of 28 (26–30) years. More than half (53.6%) of the participants were male. In terms of educational attainment, the majority (84.1%) of the respondents had a BSc degree. Nearly 60% of respondents had less than 5 years of professional work experiences (Table 1).

Table 1.

Sociodemographic characteristics of study participants in selected Hospitals, Addis Ababa, Ethiopia, 2023

Variables	Frequency	Percentage
Age group
20–29	143	69.1%
30–39	64	30.9%
Sex
Female	96	46.4%
Male	111	53.6%
Level of education
Diploma	2	1%
BSc degree	174	84.1%
Master’s and above	31	15%
Work experience (in years)
<5	124	59.9%
5–10	82	39.5%
>10	1	0.5%

The data for n=207 midwifes are displayed.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Institutional-related supplies availability

In this study, from all hospitals that were the target of this study, the availability of supplies were identified (Table 2).

Table 2.

Institutional-related supply availability in selected public hospitals in Addis Ababa, Ethiopia, 2023

Variable	Frequency	Percentile
Fluid availability	203	98.1
Blood and drug storage availability (refrigerator)	128	61.8
Drugs availability	159	76.8
Blood availability	151	72.9
Adult ventilator	189	91.3
Ambulance	128	61.8
Human resource	188	90.8
Guidelines or protocol	106	51.2
Suturing material	200	96.6
Surgical glove	161	77.8
Job training received	99	47.8

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Knowledge on the management of postpartum hemorrhage

In this study, more than one-third (34.3%) of the respondents had good knowledge of PPH management, whereas 65.7% of the respondents had poor knowledge (Table 3).

Table 3.

Knowledge level of midwifes in selected hospitals in Addis Ababa, Ethiopia, 2023

Knowledge outcome	Frequency	Percentage	95% Confidence interval
			Lower	upper
Poor	136	65.7	59	72
Good	71	34.3	28	41

The data for n=207 midwives are shown.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

On the specific knowledge-based questions, nearly three-quarters (74.9%) of the respondents knew that oxytocin and controlled cord traction (CCT) can be used after delivery in the case of cesarean delivery. More than half (51.7%) of the respondents knew the clinical diagnosis of PPH, whereas more than two-thirds (74.9%) of the respondents knew the pharmacologic management of PPH with oxytocin, both in spontaneous and cesarean deliveries. In this study, the majority (96.6%) of participants knew that obstetrical care providers demonstrated correct AMTSL. Similarly, 81.6% of the respondents knew the most commonly recommended drug to manage PPH. Less than half (41.1%) of the participants responded to the question on the treatment option for PPH when uterotonics and other conservative interventions fail. More than half (56%) of the respondents knew the steps of managing a patient with PPH. Two-thirds (66.6%) of the respondents did not know the common route of administration of misoprostol to manage PPH. More than two-thirds (68.6%) of the respondents did not know the length of time required to complete AMTSL clinical indicators of PPH (Table 4).

Table 4.

Level of midwives’ knowledge on the management of postpartum hemorrhage in selected hospitals in Addis Ababa, Ethiopia, 2023

Variable	Correct response (%)	Incorrect response (%)
Clinical diagnosis of PPH	107 (51.7)	100 (48.3)
In settings where skilled birth attendants are unavailable, CCT is recommended or not	69 (33.3)	138 (66.7)
Whether or not oxytocin and CCT be used in cesarean delivery after delivery	155 (74.9)	52 (25.1)
The most effective protocol for managing PPH	137 (66.2)	70 (33.8)
The most recommended drug to manage PPH	169 (81.6)	38 (18.4)
The recommended minimum dose of oxytocin	163 (78.7)	44 (21.2)
The route of administration of oxytocin	188 (90.8)	19 (9.2)
The common route of administration of misoprostol to manage PPH	69 (33.3)	138 (66.6)
Duration of time to complete AMTSL clinical indicators of PPH	65 (31.4)	142 (68.6)
Steps of managing a patient with PPH in AMTSL	116 (56)	91 (43.9)
Treatment option for PPH when uterotonics and other conservative interventions fail.	85 (41.1)	122 (58.9)

The data for n=207 midwives are shown.

AMSTL, active management of third stage labor; CCT, controlled cord traction; PPH, postpartum hemorrhage.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Practice on the management of postpartum hemorrhage

In this study, less than one-third (30.4%) of the study participants had good practice of PPH management, whereas 69.6% had poor practice (Table 5).

Table 5.

Practice outcome of study participants on the management of PPH in selected hospitals in Addis Ababa, Ethiopia, 2023

Practice outcome	Frequency	Percentage	95% Confidence interval
			Lower	Upper
Poor	144	69.6	62.4	75.4
Good	63	30.4	24.6	37.6

The data for n=207 midwives are shown.

PPH, postpartum hemorrhage.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

In the assessment of individual variables related to practice among midwives on the management of PPH, the majority of midwives demonstrated good practice in several items, including the 3 key AMTSL components with 99%, 99%, and 82.1% correctly performing the administration of oxytocin, CCT, and knew what to do to aid uterine contraction, respectively. More than two-thirds (76.3%) of the respondents performed timely administration of drugs after delivery of the baby. In total, 87% of the respondents supported the placenta during expulsion. The majority (89.4%) of the participants were performing cord clamping close to the perineum (Table 6).

Table 6.

The practice of study participants on the management of PPH in selected hospitals in Addis Ababa, Ethiopia, 2023

Variable	Correctly (%)	Incorrectly (%)
Presence of another fetus before continuing with oxytocin administration after delivering the first baby	201 (97.1)	6 (2.9)
Administration of 10 IU of IM oxytocin after delivery of baby.	205 (99)	2 (1)
Applying CCT	205 (99)	2 (1)
Pulls the cord gently, firmly, and uniformly downward to deliver the placenta	199 (96.1)	8 (3.9)
Supports the placenta during expulsion	180 (87)	27 (13)
Extracting membranes gently with lateral movement	194 (93.7)	13 (6.3)
What we do to aid uterine contraction	170 (82.1)	37 (17.9)
Complete expulsion of placenta	201 (97.1)	6 (2.9)
Examines woman for cervical tears or episiotomy to be repaired	203 (98.1)	4 (1.9)
Practicing of active management of third stage of labor	200 (96.6)	7 (3.4)
Time of administration of drug after delivery of baby	158 (76.3)	49 (23.6
Administration within 3 min if oxytocin is unavailable.	192 (92.8)	15 (7.2)
Report of uterine contraction every 15 min in the first hour then twice hourly,	190 (91.8)	17 (8.2)
Time of cord clamping	207 (100)	000
Clamping cord close to perineum	185 (89.4)	22 (10.6)
Supplies used to clamp the cord	188 (90.8)	19 (9.2)
Check to see uterus contracted after uterine massage	202 (97.6)	5 (2.4)
Waiting for strong uterine contraction 2–3 min	198 (95.7)	9 (4.3)
Examine the tissue to see if completely expelled	201 (97.1)	6 (2.9)

The data for n=207 midwives are shown.

CCT, controlled cord traction; IM, intramuscular; IU, international unit; PPH, postpartum hemorrhage.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Obstetrics-related training

In this study, 10.6% of the respondents trained in AMTSL, 25.1% trained in Basic Emergency Obstetrics and Neonatal Care (BEmONC), 29.5% completed Comprehensive Emergency Obstetrics and Neonatal Care (CEmONC) training, and 11.6% completed other training (Figure 2).

Figure 2.

Obstetrics-related training taken by study participants at selected public hospitals in Addis Ababa, Ethiopia, 2023. (n = 207)

AMSTL, active management of third stage labor; BEmONC, Basic Emergency Obstetrics and Neonatal Care; CEmONC, Comprehensive Emergency Obstetrics and Neonatal Care.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Obstetrics guideline or protocol availability

Of all the participants in this study, 28% used the International Conference of Midwives guidelines, 15.9% used the FIGO guidelines, 8.2% used the WHO guidelines, and 2.4% used others guidelines (Figure 3).

Figure 3.

Types of guidelines available in selected public hospitals in Addis Ababa, Ethiopia, 2023

FIGO, International Federation of Gynecology and Obstetrics guidelines; ICM, International Conference of Midwives guidelines; WHO, World Health Organization guidelines.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Factors associated with knowledge of postpartum hemorrhage management among study participants

In the multivariable logistic regression, educational level, work experience, training, and the presence of guidelines were significantly associated with knowledge of PPH management at a P value of <.05. The odds of having poor knowledge were 3.7 times higher among those who had less than 5 years of work experience (AOR, 3.7; 95% CI, 1.5–8.8; P=.0001) than those who had between 5 and 10 years of work experience. The odds of having poor knowledge were 3.4 times higher among those who did not have guidelines (AOR, 3.4; 95% CI, 1.4–8; P=.010) than those who had guidelines. The odds of having poor knowledge were 3.4 times higher among those who did not take training (AOR, 3.4; 95% CI, 1.4–8; P=.012) among those who completed training. The odds of having good knowledge were 7.8 times higher among those who had a master’s degree compared to those with a diploma-level education (AOR, 7.8; 95% CI, 2.1–2356.3; P=.017) (Table 7).

Table 7.

Factors associated with midwives' knowledge towards management of PPH at selected public hospitals in Addis Ababa, Ethiopia, 2023

Variables	Category	Knowledge level		COR 95% CI	AOR 95% CI	P value
		Poor	Good
Work experience	<5	104 (50.2%)	10 (4.8%)	1	1
	5–10	49 (23.7%)	2 (1%)	4.2 (1.8–9.8)	3.7 (1.4–9.9)	.009a
	>10	2 (1%)	22 (10.6%	114.4 (23.4–558.9)	344.7 (32.4–3671.1)	.001b
Guidelines or protocol availability	Yes	70 (33.8%)	36 (17.4%)	2.7 (1.4–5.3)	3.4 (1.4–7.9)	.010 a
	No	85 (41.1%)	16 (7.7%)	1	1
Job training received	Yes	64 (30.9%)	35 (16.9%)	3.2 (1.5–5.7)	3.4 (1.4–8.0)	.012a
	No	91 (44.0%)	17 (8.2%)	1	1
Educational level	Diploma	15 (7.2%)	1 (0.5%)	1	1
	BSc degree	134 (64.7%)	40 (19.3%)	4.5 (0.6–34.9)	3.8 (1.2–823.2)	.037c
	Master’s and above	6 (2.9%)	11 (5.3%)	27.5 (2.9–262.3)	7.8 (2.1–2356.3)	.017c

The data for n=207 midwives are shown.

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.

^aP≤.01;

^bP≤.001;

^cP≤.05.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Factors associated with practices of postpartum hemorrhage management among study participants

In the multivariable logistic regression, age, training, the availability of an ambulance for transportation, blood storage, and blood availability were significantly associated with practice related to PPH management at a P value of <.05. The odds of having poor practice were 3.7 times higher among those aged between 20 and 29 years (AOR, 3.7; 95% CI, 1.6–8.6; P=.002) than those aged between 30 and 39 years. The odds of having poor practice were 4.9 times higher among those who did not have blood storage available (AOR, 4.9; 95% CI, 1.3–18.1; P=.017) than those who had blood storage available. The odds of having poor practice were 14.8 times higher among those who did not have blood available (AOR, 14.8; 95% CI, 3.5–65.1; P=.034) than those who had blood available. The odds of having poor practice were 24.4 times higher among those who did not have an ambulance (AOR, 24.4; 95% CI, 5.7–103.6; P=.035) than those who had an ambulance. The odds of having poor practice were 3.5 times higher among those who did not take job training (AOR, 3.5; 95% CI, 1.8–6.5; P=.001) than those who took job training (Table 8).

Table 8.

Factors associated with midwives' practice towards management of PPH in selected public hospitals in Addis Ababa, Ethiopia, 2023

Variable	Category	Practice level		COR 95% CI	AOR 95% CI	P value
		Poor	Good
Age	20–29	113 (54.6%)	30 (14.5%)	1	1
	30–39	31 (15%)	33 (15.9%)	4.01 (2.1–7.6)	3.7 (1.6–8.7)	.002a
Blood storage availability	Yes	109 (52.7%)	31 (15.0%)	1.6 (4.8–53.4)	4.9 (1.3–18.1)	.017b
	No	46 (22.2%)	21 (10.1%)	1	1
Blood availability	Yes	97 (46.9%)	61 (29.5%)	4.9 (1.3–18.1)	14.7 (3.4–63.1)	.034b
	No	47 (22.7%)	2 (1.0%)	1	1
Ambulance for transportation	Yes	80 (38.6%)	61 (29.5%)	5.4 (1.1– 26.1)	24.4 (5.7– 103.6)	.035b
	No	64 (30.9%)	2 (1.0%)	1	1
Job training	Yes	30 (14.5%)	30 (14.5%)	6.0 (2.0–17.6)	3.5 (1.8–6.5	.001c
	No	114 (55.1%)	33 (15.9%)	1	1

The data for n=207 midwives are shown.

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.

^aP≤.01

^bP≤.05

^cP≤.001.

Bidiru. Knowledge of and practices related to postpartum hemorrhage management among midwives in Addis Ababa. Am J Obstet Gynecol Glob Rep 2025.

Discussion

In this study, only 34.3% (95% CI, 59–72) of midwives demonstrated good knowledge of PPH management. This rate is comparable with those in some Sub-Saharan settings (eg, the Free State district hospitals in South Africa where significant knowledge gaps were noted), yet, it is lower than those noted in studies from regions such as the Lake Zone in Tanzania where midwives showed higher competence in identifying clinical indicators of and implementing management protocols for PPH.^14,15 The discrepancy may be owing to differences in training programs, continuous professional development initiatives, and institutional support across settings.

In this study, 66.6% of the respondents did not know the typical route for administering misoprostol for the treatment of PPH. This finding is in line with studies done in the Meru county of Kenya.¹ A possible reason for this could be that participants across the 2 studies used similar guidelines and standards.

In this study, less than half (43.9%) of the respondents did not specify the 3 key sequential steps of AMTSL used to manage a woman once PPH has been identified. This study finding is in contrast with the findings of the study done in Wad Medani Hospital, Gezira State, Sudan.¹⁶ The discrepancy could be because of the small sample size in the current study and the absence of adequate training.

In this study, 51.7% of respondents knew the clinical diagnosis of PPH. This rate is higher than the rate in the study conducted in Sidama, South Ethiopia.⁵ This discrepancy might be because of the methodologic differences of the studies. In this study, the majority (96.6%) of the participants knew that obstetrical care providers demonstrated correct AMTSL, which is in contrast with another study done at Adama, Oromia, Ethiopia. In that study, only 30% of the obstetrical care providers exhibited correct AMTSL technique.¹⁷ This discrepancy might be because of the sociodemographic factors and the method of data collection. The odds of having poor knowledge were 3.7 times higher among those who had less than 5 years of work experience than those who had more than 10 years of work experience. The tendency was for those with 5 to 10 years of work experience to have superior knowledge than those with fewer than 5 years of experience, suggesting that all midwives could benefit from extended exposure in the work setting. Therefore, it seems that midwives with more work experience have a higher level of knowledge on the management of PPH (3.7; 95% CI, 1.520–8.826). The findings of this study differ from other studies conducted in Dar es Salaam.⁵ The reason for this variation could be due to the differences in the sampling method used.

In this study, the level of knowledge was significantly associated with educational status. Those study participants with a master's degree or higher education were 7.8 times more likely to have better knowledge than those with a diploma or BSc degree. Similarly, a study from Lake Zone, Tanzania showed that the level of knowledge was strongly associated with the level of education.¹⁵ This could be because of a number of reasons, such as long periods of training, being in the field for more than 5 years, and in-service training on PPH management, which might help them have adequate knowledge. The availability of guidelines for midwives is increasing the level of knowledge on the management of PPH. This translated into a tendency that those who had guidelines were more likely to have better knowledge than those who did not have guidelines. Participants who had guidelines or protocol on PPH management had 3 times greater odds of having good knowledge of PPH management than those who did not have guidelines. In addition, those who received job training with specific focus on PPH were more likely to have better knowledge than those who did not receive job training. Participants who received job training in the labor ward were 3 times more likely to have good knowledge on PPH management than those who did not receive training in the labor ward. It was supported by a descriptive study done at the Benha University Hospital.¹⁵ Human resources, referral, and other logistic material did not significantly affect the level of knowledge on the management of PPH among midwives studied based on the P values that were more than .05.

Overall, a significant proportion of midwives (69.6%; 95% CI, 62.4–75.4) exhibited poor practice in managing PPH in this study, indicating that only 30.4% demonstrated good practice. These findings differ from those of previous studies conducted in Hawassa City.¹⁸ This difference might be because of the method of data collection.

In the multivariable regression, age, job training, blood storage, and blood availability were found to be significant determinants of practice among midwives. Midwives between the ages of 30 and 39 years seemed to do better compared to other age groups. Participants aged between 30 and 39 years had 3.7 times greater odds of performing good practices related to PPH management than those in other age groups. The findings of this study are in contrast with another study done in Ondo state, Nigeria, which revealed that respondents with effective practices for PPH management were primarily between the ages of 18 and 30 years.¹⁹ This disparity might be because these participants had recent training from midwifery schools or may still be undergoing education in the form of seminars, workshops, in-service training, etc. Participants who received job training related to PPH were more likely to have better practice than those who did not receive job training. According to the multivariable regression, participants who had received job training in the labor ward had 3.5 times higher odds of good practice related to PPH management than those who did not receive training in the labor ward. According to this study, another study, conducted in the Anambra State of Nigeria, showed that BEmONC, CEmONC, and AMTSL training, as well as the length of training, were all factors related to the outcome.²⁰ This similarity could have been contributed by the study design and tools used to collect data.

Our study identified significant associations among age, work experience, training, educational level, the availability of supplies, and the adherence to protocols in PPH management. In contrast, an evaluation conducted in a resource-limited setting that used a self-administered questionnaire highlighted the importance of factors such as the availability and storage location of uterotonics, maintaining a controlled temperature in the ward, efficient transport for referrals, and a sufficient staff-to-patient ratio.²¹ Although several studies have examined midwives’ knowledge of and practices regarding PPH management across various Sub-Saharan settings, there remains limited research that specifically focussed on public hospitals in Addis Ababa.

Conclusion and recommendation

In this study, the majority of the respondents had inadequate knowledge on the treatment of PPH and had poor practice related to PPH management. Based on the quantitative analysis, participant responses showed that the majority of midwives employed at Addis Ababa’s public hospitals lacked adequate training, guidelines, blood, blood storage, and ambulance transportation required for the treatment of PPH. There were statistically significant correlations among knowledge, the availability of guidelines or protocols, job training, work experience, and educational level. Similarly, there were significant statistical correlations among practices, age, job training, the availability of ambulance services, blood, and blood storage but not among the other tested variables, such as sex and other institutional characteristics.

Better training of and more experience among healthcare workers play a crucial role in improving the labor and delivery outcomes. Regular hands-on training (eg, BEmONC, CEmONC, AMTSL) ensures that midwives and obstetrical care providers stay updated on evidence-based practices. Simulation-based training improves decision-making skills in emergency situations. Protocol-based education helps to standardize care and reduce medical errors. Healthcare workers with more years of experience develop better clinical intuition to identify and manage complications early. Experienced midwives are more confident in handling emergencies, such as uterine atony, retained placenta, and severe bleeding. Exposure to diverse cases improves critical thinking and adaptability in the labor room.

In fact, it would be ideal if midwives had knowledge and practice levels even higher than those now observed, because this would reduce the risk that they would make mistakes and increase the likelihood that they would provide high-quality treatment, preventing maternal deaths from PPH.

Based on this conclusion, the Addis Ababa health bureau should consider providing participants with on-job training and improving educational levels. Hospital management should establish an operational team to evaluate the current protocols and to ensure the use of the available PPH management protocols or guidelines. This will help to improve the quality of care. All hospitals should be continuously screening institutional needs, like blood, blood storage, and ambulance availability, and should fulfil the need on time.

CRediT authorship contribution statement

Ashenu Bidiru: Writing – original draft. Heyria Hussein: Project administration. Tola Getachew Bekele: Data curation. Tilahun Teshager: Formal analysis. Fenta Wondimneh: Methodology. Indeshaw Ketema: Resources. Beyene Feleke: Conceptualization. Lema Daba: Funding acquisition. Merga Shelema: Validation.