EVALUATION OF THE CLINICAL DIFFICULTIES ASSOCIATED WITH PROLONGED LABOUR IN NIGERIA

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Prolonged labour, commonly known as labour dystocia, represents a critical obstetric complication that presents considerable clinical challenges in maternal healthcare globally, especially in developing nations such as Nigeria. Labour is characterised as a duration exceeding 20 hours for first-time mothers or surpassing 14 hours for those who have previously given birth (World Health Organisation, 2018). Extended labour heightens the likelihood of maternal fatigue, postpartum bleeding, uterine rupture, and infection. For the foetus, it may result in birth asphyxia, neonatal infection, or potentially fatal outcomes (Oladapo et al., 2016). In Nigeria, maternal mortality rates rank among the highest globally, with prolonged labour significantly impacting maternal and neonatal outcomes, especially in environments where access to prompt medical interventions is restricted (Fawole et al., 2018). In light of the significant implications associated with the management of prolonged labour, it is evident that healthcare providers in Nigeria encounter a range of obstacles. These include insufficient medical infrastructure, a lack of skilled healthcare professionals, and delays in the delivery of emergency obstetric care.

The challenges associated with managing prolonged labour in Nigeria are significantly shaped by shortcomings within the healthcare system, especially in rural and underserved regions. Numerous hospitals and healthcare facilities are deficient in crucial medical apparatus, including cardiotocography machines for foetal heart monitoring, which are vital for identifying indicators of foetal distress during extended labour (Adegoke et al., 2017). Moreover, the scarcity of crucial medications like oxytocin, utilised to enhance labour, adds another layer of complexity to the clinical management of labour dystocia (Ogunjimi, Ibe, & Ikorok, 2019). In the absence of sufficient monitoring tools and medications, healthcare professionals frequently find themselves dependent on manual techniques, which tend to be less effective and heighten the risk of complications (Thaddeus & Maine, 1994) cited in Fawole et al., (2018). Moreover, inadequate access to surgical procedures, such as caesarean deliveries, intensifies the dangers linked to extended labour. In rural regions where surgical resources are frequently lacking, women in labour may face critical delays that could jeopardise their lives before being moved to a facility capable of managing emergency obstetric situations (Aluko & Oyetunde, 2017).

A notable challenge in addressing prolonged labour in Nigeria is the insufficient number of qualified healthcare practitioners, especially midwives and obstetricians equipped to manage labor-related complications. In numerous healthcare environments, particularly in rural and resource-limited regions, there exists a deficiency of sufficiently trained individuals who can identify and address labour dystocia proficiently (Oladapo et al., 2016). In Nigeria, particularly in rural areas, midwives play a crucial role in providing essential maternity care. Nonetheless, a significant number of midwives lack sufficient training to manage intricate labour scenarios, and frequently, there are no obstetricians available to offer assistance or execute emergency procedures (Fatusi & Ijadunola, 2018). The deficiency of proficient birth attendants is intensified by substandard working conditions, insufficient remuneration, and lack of adequate support, all of which lead to elevated turnover rates within the healthcare workforce. Consequently, numerous women in Nigeria, especially those in rural regions, lack access to essential medical care during extended labour, which heightens the likelihood of negative maternal and neonatal results (Oladapo et al., 2016).

Prolonged labour in Nigeria presents significant clinical challenges, particularly due to delays in seeking care, receiving care, and accessing the appropriate level of care. The model of three delays elucidates the factors that lead to unfavourable maternal health outcomes: the hesitation to seek medical assistance, the challenges in accessing healthcare facilities, and the lag in receiving appropriate care upon arrival at the facility (Thaddeus & Maine, 1994). The delays present significant challenges in the context of extended labour, where prompt medical intervention is essential to avert complications. A significant number of women in Nigeria postpone pursuing medical care as a result of cultural beliefs, apprehension regarding medical interventions, or financial obstacles (Ogunjimi et al., 2019). Even when women choose to pursue care, inadequate transportation infrastructure, especially in rural regions, results in additional delays. When women finally arrive at a healthcare facility, they frequently encounter further delays in obtaining care, attributed to insufficient staffing, bureaucratic hurdles, and shortages of medical supplies (Gyang et al., 2018). The systemic delays present considerable risks linked to extended labour, especially for women with preexisting conditions like hypertension or diabetes.

The significant occurrence of extended labour in Nigeria is associated with various socio-demographic and medical risk factors. Individuals at the extremes of reproductive age, specifically those younger than 18 or older than 35, exhibit a heightened likelihood of encountering labour dystocia. This is also true for those presenting with conditions such as foetal macrosomia, cephalopelvic disproportion, and multiple gestations (Oladapo et al., 2016). Inadequate nutritional status, prevalent in economically disadvantaged regions, plays a significant role in insufficient pelvic development, thereby heightening the likelihood of obstructed labour (Adegoke et al., 2017). Furthermore, factors like maternal obesity, which is increasingly prevalent in Nigeria, have been linked to extended labour and higher incidences of caesarean sections (Olusola, 2020). It is essential to tackle these risk factors through prenatal education and enhanced healthcare services to diminish the occurrence of prolonged labour and its related complications.

In light of the difficulties associated with prolonged labour, Nigeria’s healthcare system has undertaken initiatives to enhance maternal health services. Initiatives like the Midwives Service Scheme (MSS) and the National Health Insurance Scheme (NHIS) were established to enhance access to skilled care and decrease maternal mortality (UNFPA, 2019). Nonetheless, these initiatives encounter challenges related to sustainability, especially concerning financial support, training opportunities, and the fair allocation of resources (Fatusi & Ijadunola, 2018). Moreover, the persistent political instability and corruption within the healthcare sector have significantly obstructed the successful execution of these programs across various regions of the country, especially in rural areas where maternal health services are critically required (Ogunjimi et al., 2019).

In summary, the challenges related to extended labour in Nigeria are complex, encompassing deficiencies within the healthcare system, a lack of qualified personnel, as well as socio-economic and cultural obstacles. Confronting these challenges necessitates a thorough strategy that encompasses enhancing healthcare infrastructure, augmenting the presence of qualified birth attendants, and guaranteeing prompt access to emergency obstetric care. Moreover, focused strategies to tackle socio-demographic risk factors and the delays in both seeking and receiving care are crucial for enhancing the management of prolonged labour and for decreasing maternal and neonatal mortality rates in Nigeria (Fawole et al., 2018; Oladapo et al., 2016). This research aims to assess the clinical challenges, providing a deeper understanding of the particular obstacles encountered by healthcare professionals and patients in the management of prolonged labour within Nigeria's healthcare framework.

1.2 Statement of the Problem

In light of the progress made in maternal healthcare, the ongoing issue of prolonged labour remains a significant factor in the elevated rates of maternal and neonatal morbidity and mortality in Nigeria. The challenges encountered in Nigerian hospitals during extended labour encompass delays in intervention, insufficient medical resources, and restricted availability of qualified healthcare practitioners. The World Health Organisation (WHO) indicates that complications arising from prolonged labour are a significant contributor to obstructed labour, potentially leading to severe conditions like uterine rupture and postpartum haemorrhage (WHO, 2018). In numerous instances, extended labour results in caesarean deliveries, which, while essential for averting complications, entail their own set of risks, particularly in resource-limited environments (Fawole, 2020). The difficulties are intensified by the scarcity of healthcare resources and inadequate referral systems, especially in rural regions where prompt interventions frequently prove impractical (Adeniran et al., 2017).

A significant concern is the insufficient training of healthcare professionals in the effective management of prolonged labour. Studies indicate that midwives and nurses in Nigeria often face challenges in recognising and addressing prolonged labour situations, primarily stemming from inadequate training and a deficiency in ongoing professional development (Okafor et al., 2021). A significant number of healthcare facilities lack the necessary instruments for tracking labour progression, including partographs, which are crucial for the timely identification of labour complications (Ekanem & Ekwempu, 2020). In the absence of adequate labour monitoring, the likelihood of delayed interventions increases, thereby exacerbating the complexities involved in the clinical management of these cases. Furthermore, cultural and social influences frequently hinder women from pursuing medical assistance, as certain women choose traditional birth attendants who may lack the ability to manage complications such as prolonged labour (Onwudiegwu, 2019). The intricate challenges present impede the effective management of extended labour and play a significant role in the elevated maternal mortality rates observed in the nation.

The absence of adequate guidelines and uniform protocols for addressing prolonged labour contributes to the intricacies of clinical practice in Nigeria. Healthcare institutions frequently function without well-defined protocols for addressing labour complications, resulting in providers depending on obsolete or variable methods (Adamu & Salihu, 2016). Consequently, significant differences exist in the approach to managing prolonged labour across various regions and healthcare environments within the nation. In rural regions, where the healthcare infrastructure is notably deficient, women face a heightened risk of negative outcomes stemming from extended labour, as healthcare facilities frequently lack the necessary resources to address complications (Tukur et al., 2019). The variation in access to quality care highlights the necessity for thorough investigation into the clinical challenges linked to extended labour, as well as the formulation of strategies to tackle these concerns throughout all healthcare environments in Nigeria. Thus, this investigation is warranted.

1.3 Objectives of the study

The primary objective of this study is to critically evaluate the clinical difficulties associated with prolonged labour in Nigeria. Specific objectives of this study are to:

1. To examine the prevalence of prolonged labor in healthcare facilities across different regions in Nigeria

2. To determine the risk factors associated with prolonged labor in Nigeria

3. To identify the clinical challenges faced by healthcare professionals in managing cases of prolonged labor

4. To investigate the consequences of clinical challenges on mother and foetal wellbeing in Nigeria.

1.4 Research Questions

The following research questions which are in line with the objectives of this study will be answered in this study:

1. 1. 1. What is the prevalence of prolonged labor in healthcare facilities across different regions in Nigeria?

      2. What is the risk factors associated with prolonged labor in Nigeria?

      3. What are the clinical challenges faced by healthcare professionals in managing cases of prolonged labor?

      4. What are the consequences of clinical challenges on mother and foetal wellbeing in Nigeria?

1.5 Research Hypotheses

To determine the effectiveness of this study, the following research null hypotheses will be formulated to guide the study and it will be tested at 0.05% levels of significance.:

Ho: Healthcare professionals face no significant clinical challenge in managing cases of prolonged labor in Nigeria

Ha: Healthcare professionals face significant clinical challenge in managing cases of prolonged labor in Nigeria.

1.6 Significance of the study

This study on the clinical challenges related to prolonged labour in Nigeria holds considerable importance, tackling essential gaps in healthcare, maternal outcomes, and the advancement of professional skills. This research offers significant insights into the difficulties encountered by healthcare professionals in handling prolonged labour, especially in settings with limited resources. The study will provide a foundational reference for decision-makers and midwives.

The findings of this study offer valuable insights for healthcare administrators and policymakers, presenting evidence-based strategies aimed at enhancing maternal health services and mitigating the incidence of maternal and neonatal complications associated with prolonged labour. This will be especially beneficial in informing health policies, protocols, and clinical guidelines aimed at improving the management of childbirth complications in both urban and rural healthcare environments.

This study will be of great importance to midwives, nurses, and obstetricians, as it will illuminate the particular challenges they face in clinical practice while managing prolonged labour. Comprehending these challenges can facilitate focused strategies such as enhanced training, optimised resource distribution, and augmented assistance for healthcare professionals. Improved training initiatives derived from the insights of this research will not only elevate the competencies of healthcare practitioners but also result in enhanced patient outcomes. This investigation could encourage hospitals and healthcare organisations to implement innovative labour management strategies that may alleviate the dangers linked to extended labour periods.

This study will provide significant advantages to individuals engaged in the exploration of maternal and child health. This investigation aims to enhance the current understanding and establish a robust basis for subsequent enquiries into labour complications and maternal healthcare in Nigeria. This study will provide students with a foundational understanding of the complexities surrounding labour management, maternal health policies, and the obstacles encountered by healthcare professionals. This work will serve as a valuable foundation for additional exploration into interconnected domains, including the provision of healthcare in rural settings, the education of healthcare professionals, and the outcomes related to maternal health.

1.7 Scope of the study

Broadly, this study focus is to critically evaluate the clinical difficulties associated with prolonged labour in Nigeria. Empirically, the study will explore the prevalence of prolonged labor in healthcare facilities across different regions in Nigeria, the risk factors associated with prolonged labor in Nigeria, the clinical challenges faced by healthcare professionals in managing cases of prolonged labor and the consequences of clinical challenges on mother and foetal wellbeing in Nigeria

Geographically, the study will be carried out in General Hospital, Kubwa, Abuja.

1.8 Limitations of the study

During the examination, the researchers carefully examined the inherent limitations that are present in all human behaviours. One of the main challenges we faced was the lack of extensive scholarly research on the subject. A notable factor that contributed to the issue was the limited data available regarding an Evaluation of the clinical difficulties associated with prolonged labour in Nigeria. Given the task at hand, it was quite demanding to find the required materials, books, or information and organise the data, requiring a significant investment of time and effort.

In addition, the study's findings may be constrained by the small number of participants and the limited scope of the research, which mainly revolves around General Hospital, Kubwa, Abuja. Therefore, the findings of the study have limited practical implications, highlighting the need for further research.

In addition, the individual experienced significant constraints due to financial constraints. As a student with limited financial resources, they had to carefully navigate these constraints throughout their study. The exorbitant transportation fees at the research site proved to be a significant hindrance in meeting the financial obligations tied to travel expenses.

Furthermore, the person had a packed schedule due to their scholarly obligations, including attending lectures and participating in a range of educational pursuits.

1.9 Definition of terms

Prolonged labor: Prolonged labor also known as Labor dystocia is a labor complication common in nulliparous women that may disrupt the process of vaginal delivery making it a major indication for instrumental deliveries or/ and cesarean section. Prolonged labor is labor that has slow progression — whether in the first or second stage. 

Risk factor: A risk factor or determinant is a variable associated with an increased risk of disease or infection

---

---