Prevention and Control of Postpartum Hemorrhage: Validation of Rangel’s Technology for Huambo, Angola ()
1. Introduction
Hemorrhage and hypertensive disorders of pregnancy are the leading causes of maternal morbidity and mortality in developing countries. Hemorrhage is the leading cause of maternal death in Africa (33.9%) and Asia (30.8%) and the second leading cause in Latin America and the Caribbean (20.8%) [1] . Globally, 35% of maternal deaths are associated with PPH [2] . Mortality from hemorrhage for developed countries was much lower, 13.4% [1] , but studies have warned of a trend towards increasing incidence of PPH as a cause of severe maternal morbidity (near miss) in developed countries, such as Australia, Canada, the United Kingdom and the United States, especially those related to uterine atony [3] [4] .
Women in the immediate postpartum period needs observation of the volume of blood loss, the height of uterine contraction, recognition of the causes of hemorrhage and identification of risk factors, where warning signs are essential to prevent and control PPH. The major focus of health care is to do good to the patient, considering the scientific and technological advances involved in this process. Care defines the essence of nursing, and this occupation has socially conquered a space of trust, protection, hope and capacity for solidarity with patients, families and communities [5] . Therefore, nursing must be reinterpreted from scientific knowledge, in order to generate theories, concepts, methods, hypotheses and technological innovations [6] . Thus, nursing care in PPH must be based on observation and evidence-based protocols for the prevention, early detection and control of PPH.
The uterine contractions following delivery separate the placenta from the uterine wall completely, and it descends into the lower uterine segment and then into the vagina, where it is expelled. There are four most frequent signs in the first five minutes after delivery that indicate placental separation: firm globular uterus, gushing or trickling blood (depending on the insertion), lengthening of the cord and enlargement of the uterus in the abdomen [7] .
At the placental site, 500 to 800 ml of blood flows every minute. If there is no mechanism after expulsion to control the hemorrhage, the woman will lose blood at that rate. She will bleed to death in a matter of minutes. With an average of five liters of blood in circulation, a woman can lose all her blood in six to ten minutes [8] .
Due to the urgency and importance of PPH, professionals must act quickly before it becomes an irreversible condition that can lead to serious harm and even death [9] . In these conditions, it is important to estimate blood loss as accurately as possible and to watch carefully for signs and symptoms of hypovolemia and/or shock, recording them correctly and taking appropriate control and treatment measures.
Therefore, nursing care that prevents and/or controls PPH requires techniques and technologies based on scientific evidence. Thus, among the various requirements for institutional management, the organizational infrastructure, number and preparation of adequate professionals, protocols, guidelines and instruments that support the intervention stand out. Accordingly, with the aim of contributing to the reduction of maternal mortality due to hemorrhage, the following objective was defined.
2. Objective
To validate Rangel’s instrument with its application in the Maternity Ward of the General Hospital of Huambo, Angola.
3. Methodology
This is a descriptive study with a quantitative approach. This is the sixth stage of the Translation and Cultural Adaptation process [10] [11] .
3.1. Ethical Aspects
The study was submitted to the Research Ethics Committee of the Instituto Superior Politécnico da Caála Huambo, Angola, opinion number 027/2021. Authorization was also previously requested from Dr. Rita de Cássia Teixeira Rangel, author of this instrument, who gave her written answer. Authorization was also requested from the Maternity Ward Directorate of the General Hospital of Huambo (HGH) in Angola.
3.2. Study Site
The study was conducted at the Maternity Ward of the General Hospital of Huambo (HGH), in Angola. This unit was chosen because it is the one that cares for the largest number of births, and it is also defined as high complexity in Huambo Province.
HGH was inaugurated on October 19, 1956, and is governed under the terms of Presidential Decree 260/10, dated November 19 [12] [13] and according to the Basic Law of the National Health Service, according to Decree-Law 21-B/92 [13] [14] , which contains the references of the first level cases. Currently, HGH has an installed capacity of 820 beds and operates on a 24-hour basis.
Following the guidance of the National Directorate of the Ministry of Health, it is becoming a Regional Hospital. It has 402 Angolan doctors and 62 foreigners of various nationalities such as: Cuba, Russia, Egypt, Brazil, Senegal, Ethiopia, Portugal, among others. It has 810 nursing workers, 609 of whom are nurses (with university education), i.e., 82.2%; and of these, 20 have joined the Committee of Experts.
In addition to patients from Huambo Province, HGH also cares for populations from different provinces such as: Bié and Kuando Kubango, besides neighboring municipalities, such as: Waco Kungo, Quibala, Cassongue and Ganda (Table 1).
3.3. Study Population and Sampling
The study population consisted of women who had children born in the Maternity Ward of HGH, regardless of the type of delivery (vaginal or cesarean section) who presented PPH in the third stage of birth, whose hemorrhage was controlled and were able to answer the instrument after ten hours of controlled hemorrhage.
As a preliminary procedure, the year 2019 was defined, prior to the COVID-19 pandemic. Therefore, considering that the Maternity Ward of HGH presented the highest number of births, it was identified that there was representativeness for Huambo (Table 2). Therefore, 12,294 births occurred in this institution were considered as the study population. After these definitions, the LabStat system of the Federal University of Santa Catarina, a free and easily accessible platform for various statistical calculations, was applied to calculate the sample (http://sestatnet.ufsc.br) [14] [15] . Considering a case frequency hypothesis of 10%, with a confidence interval of 95%, an estimated sample of 102 puerperal women was obtained.
3.4. Data Collection
The application of Rangel’s Instrument in clinical practice with the Maternity Ward of the General Hospital of Huambo was carried out in the months of January and February 2023, until the number of puerperal women was completed, observing the characteristics defined in the study population. The collection was carried out by the nurses who composed the Committee of Experts, together with the main researcher, since the instrument, after adjustments due to translation into Angolan Portuguese, underwent evaluation in the following aspects: clarity, coherence, relevance to clinical practice, scientific updating and reliability.
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Table 1. Distance between Huambo and the provinces that receive care at the General Hospital of Huambo. Florianópolis - SC, Brazil, 2023.
Source: Systematized by the author, with data provided by the General Hospital of Huambo, 2021.
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Table 2. Number of deliveries and live births per institution in Huambo, Angola. Florianópolis-SC, Brazil, 2023.
Source: Systematized by the author, with data collected at the Municipal Health Department of Huambo, 2021.
Each nurse performed an average of five applications, which was also performed by the main researcher. Thus, answers were obtained to proceed with the evaluation of the validity and reliability of the instrument in the field of clinical practice.
3.5. Statistics
Rangel’s instrument translated into Angolan Portuguese remained with the 5 axes, 20 domains and 92 care actions. In this phase, sixth in the conception of Beaton [10] [11] , the instrument was applied by the nurses who were members of the Committee of Experts and the main researcher, accompanied by a seven-point Likert-type evaluation scale, in order to evaluate each care proposed in each domain, in terms of content validity for the Angolan reality. Scale scores: 1 = Inadequate and incomplete; 2 = Needs major revision to be adequate and complete; 3 = Needs minor revision to be adequate and complete; 4 = Neither inadequate nor adequate; 5 = Adequate and complete; 6 = Very adequate and complete; 7 = Totally adequate and complete.
Once this step was completed, the answers were recorded in a Microsoft Excel (2010) spreadsheet, in order to verify the scores assigned to each item. The relevance of the items was obtained by interobserver agreement using Cronbach’s Alpha coefficient and Content Validity Index (CVI).
According to Freitas and Rodrigues [15] [16] , the Cronbach’s alpha index [16] [17] is satisfactory when α ≥ 0.70 is obtained. In this adopted process, the acceptance of the care action was evaluated as valid and applicable in the Angolan reality when the care action obtained a score above 5 (five) on the Likert scale, with the CVI also being higher than 0.77 [17] [18] . The Kappa Coefficient shows the ratio of the proportion of times that raters agreed (corrected for chance agreement) to the maximum proportion of times that raters could agree (corrected for chance agreement) [18] [19] .
4. Results
The understanding of Rangel’s instrument was demonstrated by the nurses who made up the Expert Committee after applying it to 102 puerperal women, who then stated that it was easy to understand and apply. The statistical results showed reliable measures for the adapted version, with the reliability value allowing us to infer that the instrument is able to measure the proposed clinical competences. The clinical competences integrated into the planned care actions include, among others, taking an anamnesis, as shown in Table 3, and were evaluated from clarity to scientific updating, as shown in Table 4.
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Table 3. Evaluation of Rangel’s instrument for the reality of Huambo, Angola, for the prevention and control of hemorrhage in the third stage of birth. Florianópolis-SC, Brazil, 2023.
Source: Systematized by the author, 2023.
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Table 4. Content validation by reliability measures with Cronbach’s Alpha, Average and Content Validity Index (CVI) of Rangel’s instrument for the reality of Huambo, Angola, for the prevention and control of hemorrhage in the third stage of birth. Florianópolis-SC, Brazil, 2023.
5. Discussion
Content validation is based on the opinion of experts on the theme to be studied. Therefore, the identification and choice of these professionals becomes the core in investigations using this methodological approach. The inadequate choice of selection criteria for experts (nurses with clinical practice) may interfere with the reliability of the results, since these professionals will be responsible for judging the validity of each item described in the instrument [19] [20] .
Obtaining these professionals is a difficulty in translation and adaptation studies, since there is no consensus in the literature as to the defining characteristics for their selection. The lack of uniformity in the criteria for considering a professional as an expert is described in the literature as generating varied discussions and suggestions about his/her profile. For example, one could ask about years of experience; time since graduation; degree level; experience with research; publications on the studied theme and place of work. In this context of vagueness, in order to enable the identification of experts, Melo et al. refers that each researcher elaborates his/her own criteria as a way of directing them to the study objectives, respecting the necessary requirements to consider a professional as an expert [20] [21] . In any case, the criteria should be clear, justifying the choices of the researcher, in order to increase the credibility of future investigations.
In this study, the following criteria were adopted: to be a nurse, a native of Angola, to read and write Portuguese, to have at least one year of experience in caring for during and after the birth process, to work at the Maternity Ward of the General Hospital of Huambo, to be willing to participate in the research by applying the instrument with the puerperal women under the face-to-face observation of the native Angolan researcher.
Therefore, the act of inviting nurses as experts from other countries also requires taking into consideration the linguistic and cultural aspects of each.
The content validity of an instrument is necessarily based on judgment [21] [22] . There is no known set of objective methods to ensure the adequacy of the content coverage of an instrument, but content validity involves critical examination of the basic structure of the instrument, as well as its applicability to the research question [22] [23] .
The values found for Cronbach’s Alpha (α) and Content Validity Index (CVI) exceeded the cutoff values established in the research method, which were Cronbach’s Alpha ≥ 0.70 and CVI ≥ 0.80 [23] [24] . They were also higher than those adopted by Yamada for excluding items from the instrument [24] [25] .
Rangel’s instrument applied in the Maternity Ward of the General Hospital of Huambo, Angola, presented an adequate internal consistency (α = 0.77) in the 20 evaluated domains. The averages were close to the highest score, between 6.3 and 7.0, which reflects the positive direction of the attitude of the respondents towards each statement. The CVI and Kappa tests showed values of 0.99 and 1.0. Accordingly, the instrument is considered recommendable for clinical practice, with agreement and validity (Table 3).
Table 4 shows the content validation, by reliability measures with Cronbach’s Alpha and Content Validity Index (CVI) of Rangel’s instrument for the prevention and control of hemorrhage in the third stage of birth [25] [26] , according to the composition of 10 items (coverage; clarity; coherence; item criticality; objectivity; scientific writing; relevance; sequence; uniqueness and updating). After the evaluation with 102 puerperal women, the averages of each item varied from 6.62 to 6.81. The validation measures were adequate, with the agreement of the answers obtained being between 97.1% and 100%; the CVI varied between 0.97 and 1.00; and Cronbach’s Alpha was 0.91.
The validated instrument, with evaluations of the items proposed by Pasquali obtained values varying with maximum and minimum [26] . The items evaluated with the highest Cronbach’s Alpha value, with 0.96, referring to the reliability of the instrument data, were: clarity; coherence; scientific writing; relevance; sequence; uniqueness and updating. The items related to coverage, item criticality and objectivity reached a Cronbach’s Alpha of 0.95, all considered by the judges with reliability. The results of the evaluation attest to the reliability, internal consistency of the instrument and the estimation of reliability among judges, as well as content validity. Overall, the instrument evaluated by nurses showed reliability in the axes, domains and actions and is therefore recommended for clinical practice, with a view to preventing and controlling hemorrhage in the third stage of birth.
6. Conclusions
The validation of instruments with care actions is a contribution to the adequate performance of procedures in clinical nursing practice.
Rangel’s instrument, translated into Angolan Portuguese, for nursing care aimed at preventing and controlling hemorrhage in the third stage of birth, was considered reliable and necessary for clinical nursing practice in Huambo, Angola, based on the statistical results obtained during validation.
Most causes of maternal mortality are considered preventable with the proper care. Therefore, the translated and validated instrument in the clinical nursing practice in Huambo, Angola, will contribute to the prevention and control of hemorrhage in the third period of birth and, consequently, will contribute in terms of reducing maternal mortality from this cause.