Obstetric competence among primary healthcare workers in Mali

Factors influencing pregnancy care and institutional delivery in rural Mali: a secondary baseline analysis of a cluster-randomised trial

OBJECTIVE

The vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali.

METHODS

A baseline household survey of Malian women aged 15-49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester.

RESULTS

Of the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business.

CONCLUSION

The findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context.

TRIAL REGISTRATION NUMBER

NCT02694055.

Self-perceived competence in managing obstetric emergencies among recently graduated physicians from Lima, Peru

OBJECTIVE

This study aimed to examine the self-perception of competencies in obstetric emergencies among recently graduated physicians from universities in Lima, Peru; and to identify its associated factors.

METHODS

An analytical study was conducted, with the study population comprising newly graduated doctors who attended the "VI SERUMS National Convention" in 2017. We used Poisson regressions to assess the factors associated with the self-perception of competencies in obstetric emergencies, calculating prevalence ratios (PR) and their 95% confidence intervals (95% CI).

RESULTS

We analyzed a population of 463 newly graduated physicians (mean age: 25.9 years), of which 33.3% reported feeling competent in obstetric emergencies. In the adjusted analyses, we found that having a previous health career (PR: 1.77, 95% CI: 1.12-2.81), having completed the internship in EsSalud hospitals (PR: 1.48, 95% CI: 1.31-1.68), and completing a university externship (PR: 1.62, 95% CI: 1.34-1.96) were associated with a higher prevalence of self-perceived competence in obstetric emergencies.

CONCLUSION

Our findings suggest that certain academic factors, such as completing an externship and internship in specific hospital settings, may enhance the competencies or competence self-perception of recently graduated physicians in obstetric emergencies. Further studies are needed to confirm these results and identify other factors that may impact physicians' competencies in this field.

Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015)

Background

Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania.

Methods

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance.

Results

Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=−12.66 [95% CI −14.15 to −11.16]), those whose mothers were uneducated (PAF=−9.11 [95% CI −13.41 to −4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=−66.51 [95% CI −79.25 to −53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban–rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period.

Conclusions

The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.

Healthcare workers' clinical knowledge on maternal and newborn care in Ethiopia: findings from 2016 national EmONC assessment

Background

Improving maternal and newborn health indicators are key if Ethiopia is to achieve the Sustainable Development Goals. To do so, women need access to skilled attendance at birth and emergency obstetric and newborn care. To maximize their impact, understanding gaps in workers’ knowledge is required to remedy the weakness. This assessment determines knowledge levels of clinical management of maternal and newborn healthcare and factors that influence knowledge.

Methods

This study used data from the National Emergency Obstetric and Neonatal Care assessment conducted in 2016. Provider knowledge for MNH was assessed by interviewing providers. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible answers, and standardizing this to a scale of 100. Mixed linear regression was used to determine individual and contextual factors associated with the score.

Results

A total of 3800 interviews with complete data were included in this study. Most respondents were diploma midwives (73%), BSc midwives (11%) and diploma nurses (10%). On average, midwives scored 60 out of 100 on the question regarding the primary aspects of focused antenatal care and elements of a birth plan. Half of the midwives and health officers, and one-third of nurses knew to provide a loading dose of magnesium sulphate. Midwives scored 90% on the steps of active management of third stage of labor. In the mixed linear regression, working in a private for profit facility, health center/clinic, rural area, or in a facility with a protocol on referral/counter referral predicted lower knowledge scores. More positive scores were associated with work environments that had a computer, internet, and protocols on safe abortion care, management of selected obstetric topics, integrated management of pregnancy, childbirth, postnatal, and newborn, care for low birth weight including kangaroo mother care, and treatment of infection in young infants.

Conclusion

With regard to most knowledge related questions, health officers and midwives scored similarly. Providers scored substantially better on routine intrapartum and newborn care than on aspects related to care for complications. A substantial proportion of providers indicated that they would never give a loading dose of magnesium sulphate.

Assessment Of Maternity Staff Training And Knowledge Of Obstetric Care In Burkina Faso: A Repeated Cross-Sectional Study

Background and aim

The quality of maternity care in low-income countries has often been questioned. The objective of this study was to describe the trend of the percentage of staff trained on selected obstetric care topics and their level of knowledge of maternal care over a 5-year period in Burkina Faso.

Methods

We conducted a secondary analysis of data from two national emergency obstetric and newborn care (EmONC) needs assessments. Staff members’ knowledge scores were determined at the facility level for 2010 and 2014 and were further categorized into low (less than 50%), medium (50 to 74%) or high (at least 75%) levels. We used McNemar’s test with a 5% significance level to compare the distribution of the proportions in 2010 versus 2014.

Results

Out of 789 facilities surveyed in the 2014 assessment, 736 (93.3%) were eligible for this study. Most of them were primary healthcare centers (87.2%). Overall, 21.6% (n=197) of health workers in 2010 and 39% in 2014 were midwives. The proportions of staff who received training on focused antenatal care (FANC) and on how to perform active management of the third stage of labor (AMSTL) have increased by 15.8% and 14.7%, respectively. A significant proportion of facilities had health workers with a low level of knowledge of FANC (p<0.001), the parameters that indicate the start of labor (p<0.001), the monitoring of labor progress (p<0.001) and AMSTL (p<0.001). There was no significant change in staff knowledge in hospitals over the 5-year period.

Conclusion

From 2010 to 2014, the proportion of staff trained in obstetric care has increased. Their level of knowledge also improved, except in hospitals. However, further efforts are needed to reach a high level of knowledge.

Nursing knowledge of essential maternal and newborn care in a high-mortality urban African setting: A cross-sectional study

Aims

To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya.

Background

The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low‐resource settings.

Design

Cross‐sectional survey.

Methods

Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015–2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed.

Results

Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case‐load facilities had lower average knowledge scores compared with better‐resourced and busier facilities.

Conclusion

Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6).

Relevance to clinical practice

Focus on periodic training, ensuring retention of knowledge and skills among health workers in low‐case load setting, and bridging the know‐do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.

Assessment of clinical decision-making among healthcare professionals performing caesarean deliveries in Burkina Faso

OBJECTIVE

To identify the factors associated with quality decision-making of healthcare professionals in managing complicated labour and delivery in referral hospitals of Burkina Faso.

METHODS

We carried out a six-month observational cross-sectional study among 123 healthcare professionals performing caesareans in 22 hospitals. Clinical decision-making was evaluated using hypothetical patient vignettes framed around four main complications during labour and delivery and developed using guidelines validated by an expert committee. The results were used to generate a quality decision-making score. A multivariate linear regression analysis was used to identify the factors independently associated with the score.

RESULTS

Out of 100, the mean ± SD quality decision-making score was 63.84 ± 7.21 for midwives, 65.58 ± 6.90 for general practitioners (GPs), and 71.94 ± 6.70 for gynaecologist-obstetricians (p < 0.001). Quality decision-making score was higher among professionals with more than seven years' work experience and those with the highest level of professional qualification. Working in a service where partograms are regularly reviewed by peers dramatically increased the skills of professionals.

CONCLUSION

The simple dissemination of written clinical guidelines is not sufficient to maintain high-quality decision-making among healthcare professionals in Burkina Faso. Midwives may have some better scores than GPs if duly retrained and supervised. Increasing in-service training and supervision of both junior staff and lower-qualified healthcare professionals might help to improve obstetric practices in referral hospitals of Burkina Faso.

Competency of peripheral health workers in detection & management of common syndromic conditions under surveillance, North 24 Parganas, West Bengal, India, 2016: a cross-sectional study

Background

Competency of peripheral health workers in the detection and management of common syndromic conditions is crucial as they are the first point of contact for the majority of the Indian population.

Methods

We measured the competency of auxiliary nurse midwives (ANMs), and factors associated with inadequate competency, in the detection and management of common conditions-diarrhoea, acute respiratory tract infection, fever, malaria-through a cross-sectional study using condition specific validated clinical vignettes and structured questionnaires.

Results

Out of 272 selected ANMs, 68% (95% CI 62–74%) were adequately competent. Factors independently associated with inadequate competency were unavailability of essential drugs in preceding month [adjusted odds ratio (AOR) = 1.95; 95% CI 1.1–3.5] and ever trained in integrated management of childhood illness (AOR = 2.4; 95% CI 1.4–4.1).

Conclusion

More than two third of the peripheral health workers were adequately competent to detect and manage common conditions. Ensuring uninterrupted drug availability and improved quality in service trainings might facilitate competency levels.

Healthcare workers' behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review

BACKGROUND

Healthcare workers may affect the utilization of sexual and reproductive healthcare (SRH) services, and quality of care thereof, for example by their behaviours or attitudes they hold. This can become a hindrance to accessing and utilizing SRH services, particularly by young people, and thus a better understanding of these behaviours and associated factors is needed to improve access to and utilization of SRH services.

METHODS

A systematic review of literature was conducted to identify studies focusing on healthcare workers' behaviors and personal determinants associated with providing adequate SRH services in sub-Saharan Africa (January 1990 - October 2015). Five databases were searched until 30th October 2015, using a search strategy that was adapted based on the technical requirements of each specific database. Articles were independently screened for eligibility by two researchers. Of the 125-screened full-text articles, 35 studies met all the inclusion criteria.

RESULTS

Negative behaviours and attitudes of healthcare workers, as well as other personal determinants, such as poor knowledge and skills of SRH services, and related factors, like availability of essential drugs and equipment are associated with provision of inadequate SRH services. Some healthcare workers still have negative attitudes towards young people using contraceptives and are more likely to limit access to and utilization of SRH by adolescents especially. Knowledge of and implementation of specific SRH components are below optimum levels according to the WHO recommended guidelines.

CONCLUSIONS

Healthcare workers' negative behaviours and attitudes are unlikely to encourage women in general to access and utilize SRH services, but more specifically young women. Knowledge of SRH services, including basic emergency obstetric care (EmOC) is insufficient among healthcare workers in SSA.

TRIAL REGISTRATION

A protocol for this systematic review was registered with PROSPERO and the registration number is: CRD42015017509 .

Predictors of nurses' and midwives' intentions to provide maternal and child healthcare services to adolescents in South Africa

Background

Adolescent mothers are at a much higher risk for maternal mortality compared to mothers aged 20 years and above. Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects such as early onset of adult diabetes than newborns of older mothers. Few studies have investigated the determinants of adequate quality maternal and child healthcare services to pregnant adolescents. This study was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa.

Methods

A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Pearson’s correlation analysis was conducted to determine the association between knowledge, attitude, subjective norms, self-efficacy, and intention variables for FP and MCH services. A 2-step linear regression analysis was then conducted for both FP and MCH services to predict the intentions to provide FP and MCH services to adolescents.

Results

Self-efficacy to conduct MCH services (β = 0.55, p < 0.01) and years of experience as a nurse- midwife (β = 0.14, p < 0.05) were associated with stronger intentions to provide the services. Self-efficacy to provide FP services (β = 0.30, p < 0.01) was associated with stronger intentions to provide FP services.

Conclusions

Self-efficacy has a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. There is a need to improve and strengthen nurses’ and midwives’ self-efficacy in conducting both MCH and FP services in order to improve the quality and utilization of the services by adolescents in South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1901-9) contains supplementary material, which is available to authorized users.

Obstetric competence among referral healthcare providers in Mali

OBJECTIVE

To determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali.

METHODS

The present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score.

RESULTS

Out of 100, the mean±SD score was 57.8±11.2 for obstetric nurses, 66.4±14.7 for midwifes, and 78.6±13.4 for physicians (P<0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers.

CONCLUSION

Increasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes.