In total, 83/134 (61.9%) participants returned the questionnaires, including 22/43 nurse-midwives, 32/45 residents in training and 29/46 consultant obstetricians.
Reasons for (previously) low vacuum extraction use
The most frequently mentioned reasons for low vacuum extraction use before the start of the programme were lack of vacuum extraction skills amongst doctors and midwives (60/83, 72.3%,), no vacuum extractor available (59/83, 71.1%), not enough opportunities for practice and training of staff (30/83, 36.1%), concerns of trauma to the neonate (29/83, 34.9%) and concerns related to mother to child transmission of HIV (27/83, 32.5%) (Table 1).
Table 1
Reason | N (%) of health workers who found this a reason for (previously) low vacuum extraction use |
| All (83) |
| N (%) |
Lack of skilled staff | 60 (72.3%) |
No vacuum extractor available | 59 (71.1%) |
No training opportunities | 30 (36.1%) |
Concern trauma to baby | 29 (34.9%) |
Concern HIV transmission | 27 (32.5%) |
No VE if CS is possible | 4 (4.8%) |
CS safer for mother | 3 (3.6%) |
Should be done by specialist | 3 (3.6%) |
Obsolete | 0 (0.0%) |
Other | 7 (8.4%) |
| * N = number %= percentage of health workers |
Concerns regarding trauma to the neonate were more frequently reported by midwives (13/22, 59.1%) as compared to obstetricians (4/29, 13.8%). The majority of consultant obstetricians (15/29, 51.7%) reported concerns about HIV transmission, as compared to 8/32 (25.0%) of residents and 6/22 (27.3%) of midwives.
Recommendations to increase vacuum extraction use
The most frequently reported suggestions for increasing the use of vacuum extraction were organizing more skills training (61/83, 73.5%) and increase the availability of equipment (38/83, 45.9%) (Table 2). It was furthermore suggested by a few participants (3/83, 3.6%) to raise awareness about the procedure.
Table 2
Option | N (%) of health workers that recommended this option to increase the use of vacuum extraction (open question) |
| All (83) |
| N (%) |
Vacuum extraction skills training | 61 (73.5%) |
Increase availability of equipment | 38 (45.9%) |
Supervision and feedback | 7 (8.4%) |
Present evidence | 5 (6.0%) |
Need for local protocol | 4 (4.8%) |
Raise awareness | 3 (3.6%) |
No recommendation | 32 (16.9%) |
| * N = number %= percentage of health workers |
Preference of health worker for herself or his partner/sister
In the event of a prolonged second-stage of labour, 57/83 (68.8%) would choose vacuum extraction as preferred mode of birth, compared to 21/83 (25.3%) who would choose CS (Table 3). Especially consultant obstetricians preferred vacuum extraction over CS (25/29, 86.2%). On the other hand, many midwives were in favour of CS (9/22, 40.9%).
Table 3
Option | N (%) of health workers that would choose this option for oneself or family member |
| Midwife (22) | Resident (32) | Obstetricians (29) | All (83) |
| N (%)* | N (%) | N (%) | N (%) |
Vacuum extraction | 13 (59.1%) | 19 (59.4%) | 25 (86.2%) | 57 (68.8%) |
Caesarean section | 9 (40.9%) | 11 (34.4%) | 1 (3.4%) | 21 (25.3%) |
No preference | 0 (0.0%) | 2 (6.3%) | 3 (10.3%) | 5 (6.0%) |
| * N = number %= percentage of this type of health professionals |
Contra-indications for using vacuum extraction
Face and brow presentations were perceived by the majority of the participants as absolute contra-indications (Table 4), also considered as such in international guidelines. (1)
Table 4
Indication | N (%) of health workers (midwives/ residents/ obstetricians) who considered this a relative or absolute contra-indication |
| N (%)* | N (%) | N (%) |
| Absolute contra-indication | Relative contra-indication | Blanc |
Face presentation | 73 (87.9%) | 4 (4.8%) | 6 (7.2%) |
Brow presentation | 66 (79.5%) | 10 (12.0%) | 5 (6.0%) |
Big baby | 42 (50.6%) | 33 (39.6%) | 3 (3.6%) |
Previous caesarean section | 33 (39.8%) | 40 (48.2%) | 3 (3.6%) |
HIV without medication | 28 (33.7%) | 39 (46.9%) | 2 (2.4%) |
HIV with HAART | 7 (8.3%) | 38 (45.8%) | 6 (7.2%) |
Caput succedaneum | 25 (30.1%) | 41 (49.4%) | 7 (8.4%) |
IUFD | 22 (26.5%) | 16 (19.3%) | 5 (6.0%) |
Occiput posterior | 17 (20.5%) | 38 (45.8%) | 8 (9.6%) |
Moulding | 10 (12.1%) | 45 (54.2%) | 12 (14.5%) |
| * N = number %= percentage of health workers HIV = human immunodeficiency virus. IUFD = intra-uterine fetal death. HAART = highly active antiretroviral therapy. |
Big baby, moulding and caput succedaneum were perceived as absolute contra-indications by 42/83 (50.6%), 25/83 (30.1%) and 10/83 (12.1%) of the health workers, respectively. Few participants (7/83, 8.3%) perceived a woman with HIV receiving antiretroviral therapy as an absolute contra-indication for vacuum extraction. When it concerned a woman not receiving antiretroviral therapy, 28/83 (33.7%) considered this an absolute contra-indication.
Who should be allowed to perform vacuum extraction?
When asked which type of health worker would be suited to perform vacuum extraction, obstetricians were unanimous (32/32, 100%) that obstetricians, residents and interns should be entitled to perform it. Overall, the majority found that obstetricians, residents, midwives and interns would be suited to perform vacuum extraction after having received appropriate training (Table 5).
Table 5
Type of health worker | N (%) of health workers that indicated a trained of a specific discipline with appropriate training as being entitled to perform a vacuum extraction |
| All (83) |
| N (%)* |
Obstetrician | 76 (91.6%) |
Residents | 81 (97.6%) |
Interns | 61 (73.5%) |
Midwives | 60 (72.3%) |
Nurses | 15 (18.1%) |
Blanc | 0 (0.0%) |
| * N = number %= percentage of health workers |
Comments mentioned by participants:
Category
|
Reasons for low use
|
Suggestions to increase use
|
Logistical organization
|
“Vacuum extraction should be performed if CS is available in case of failed attempt”
|
“Decongest (operating) theatre, so that it is ready in case of failed vacuum”
|
“Simply because donation of vacuum extractors was irregular”
|
“Provide vacuum sets and make them available for use and provide regular periodic training for all doctors in the department”
|
“Satisfactory resuscitation of babies not guaranteed in labour ward”
|
|
Implementation
|
“Low number of cases for vacuum extraction on the day of duty”
|
“Do hands-on training to increase confidence of health workers to do this procedure”
|
“There are few indications for vacuum extraction”
|
|
Perception
|
“Attitude towards vacuum extraction: people just don’t want to do it!!!”
|
“Perform evidence-based studies on vacuum extraction in Uganda and present evidence of success”
|
|
“Sensitize mothers about this procedure”
|
|
“Increase knowledge, train medical workers and dispense myths about the risks for the babies”
|