Knowledge and Skills of Basic Emergency Obstetrics Care Among Healthcare Providers in Selected Primary Health Centres in Ibadan, Southwest Nigeria.

Esther Oluwatoyin Famutimi ¹, Timothy A.O. Oluwasola², Funmilayo A. Okanlawon³

1. Department of Clinical Nursing, University College Hospital, Ibadan. Email – famutimiesther@yahoo.com; Telephone +2348032379954; 2. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan and College of Medicine, University of Ibadan. Email – sesanoluwasola@gmail.com; Telephone +2348033384064; 3. Department of Nursing, College of Medicine, University of Ibadan. Email – funmilayookanlawon@yahoo.com; Telephone +2348167223644

Introduction: Healthcare providers (HCPs) need to be adequately informed and experienced in Basic Emergency Obstetric Care (BEmOC) techniques to effectively manage obstetric and neonatal emergencies. This study evaluated the knowledge and skills of HCPs in selected Primary Health Centres (PHCs) in Ibadan Metropolis, Nigeria. Method: This was a cross-sectional study comprising 319 HCPs working in 6 Local Government Areas within the Ibadan metropolis. A structured, self-administered questionnaire was used to collect data on their knowledge and skills regarding BEmOC. Both self-reported as well as demonstrated knowledge and skills were considered while comparisons were made among various HCPs. The knowledge scores were categorized as good (≥85.0%) and poor (<85.0%), and Skills as good (≥ 75th percentile) and poor (<75^thpercentile). Statistical analysis was done using Statistical Package for Social Sciences (25.0) with a p-value set at <5%. Results: The mean age of participants was 47.0±6.5 years with more than four-fifths, 261(81.8%), being Community Health Workers. Of all the participants, 228(71.5%), have been practicing for over 10 years while only about one-quarter, 83(26.1%), had ever been trained on BEmOC. Among those ever trained, 45(54.2%) had the training within the last five years. Overall, only 1.3% and 1.8% of the participants demonstrated good knowledge and skills of BEmOC respectively. Both self-reported and standard scores were statistically similar regarding knowledge (p=0.54) and skills (p=0.08). There was no statistically significant difference between the level of education and knowledge of BEmOC, (aOR=0.52; 95% CI 0.26-1.05), but those in practice for more than 10 years were less likely to have good knowledge (aOR=0.54; 95% CI 0.45- 0.65). Conclusion: There is an urgent need for periodic training and re-training of HCPs especially at PHCs to improve their knowledge and skills of BEmOC to make a positive impact on improving maternal and neonatal outcomes.

Keywords: knowledge, skills, basic emergency obstetric care, primary health centres, healthcare providers.

Correspondence:

Famutimi, Esther Oluwatoyin PhD

Department of Clinical Nursing, University College Hospital, Ibadan

Email – famutimiesther@yahoo.com Telephone +2348032379954

Nigeria remains one of the countries in sub-Saharan Africa with high maternal mortality ratios. An important strategy in

minimizing avoidable complications from pregnancy and childbirth is the availability of Skilled Birth Attendants (SBA) ¹. Prompt management of most obstetric problems by Healthcare Providers (HCPs) can significantly reduce maternal and perinatal mortality. Emergency Obstetric Care (EmOC) is among the crucial strategies for enhancing maternal health and achieving the Sustainable Development Goal (SDG) 3. Given the unpredictability of pregnancy outcomes, mothers and infants need to have access to EmOC throughout pregnancy and delivery to lower maternal and neonatal mortality /morbidity. HCPs need to be knowledgeable and proficient in in-service delivery to women during pregnancy and labour. Unfortunately, most women, especially those in remote areas in Nigeria, lacked access to obstetrics care ². World Health Organization and World Bank Group reported that both the quantity and quality of health personnel are grave issues in many nations ³. The resultant burden of this preventable death among mothers continually remains high in developing nations and this can be tremendously reduced by utilising the two types of EmOC: basic (BEmOC) and comprehensive (CEmOC), the former is recommended at the grass root while the latter is often practiced at the secondary and tertiary facilities ⁴.

In 2020, Daniels and Abuosi documented that prompt access to BEmOC is crucial to preventing fatalities associated with unpredictable pregnancy outcomes, although such prompt access to care has proven difficult in Sub-Saharan Africa, particularly Nigeria ⁵. The bulk of HCPs at the Primary Health Centres (PHCs) are Community Health Workers (CHWs), thus they must be extremely knowledgeable and skillful in the prevention, and/or stabilisation of complex cases as well as coordinating the transfer of care to functional higher referral levels ⁶. Regrettably, healthcare professionals in Nigeria, particularly those in PHCs, continue to exhibit poor knowledge and skills in the management of obstetric emergencies^2,7. Comprehensive evaluations of the accessibility and distribution of EmOC have revealed that, in many situations, there are modalities in place, as well as equipment and consumables, but personnel are unable to deliver all the signal functions of EmOC because of inadequate knowledge and skills ⁸. Unfortunately, most of the previous studies on EmOC focused on secondary & tertiary levels of care which necessitated the design of this study to evaluate the knowledge and skills of healthcare providers at PHCs on BEmOC in the Ibadan metropolis.

This was a descriptive cross-sectional study comprising 319 consenting HCPs working in PHCs in 6 purposefully selected Local Government Areas (LGAs) within the Ibadan metropolis, Oyo state, Nigeria and it lasted for 12 weeks. Ibadan is made up of 11 LGAs; 5 urban and 6 semi-urban, out of which 3 LGAs were purposively selected from each region. Overall, the 6 LGAs utilised for this study were Lagelu, Oluyole, Ibadan North, Ibadan Northeast, Ibadan Southeast, and Egbeda. All HCPs from PHCs under each of the selected LGAs were considered eligible for the study except for those who were unavailable for official reasons. Ethical approval was obtained from the Ethical Review Committee of the Oyo State Ministry of Health, Ibadan. Permission to conduct research was also sought from the Oyo State Primary Health Care Board and all the coordinators of each of the PHCs used for this study.

The targeted HCPs were the Nurses, Midwives, Community Health Officers (CHOs), and Community Health Extension Workers (CHEWs). Six research assistants were recruited for this study and using a structured, self–administered questionnaire, information on respondents’ socio-demographic characteristics, whether ever received training on EmOC, availability of EmOC signal function and various sources of information, self-reported knowledge and skills, actual knowledge of BEmOC were obtained. Meanwhile, the demonstrated skills were assessed through an Objective Structure Clinical Examination (OSCE).

The information obtained was cleaned, processed, and verified for accuracy, completeness, and consistency. Normality tests done using Kolmogorov Smirnov and Shapiro Wilk test showed that both knowledge and skills of BEmOC scores were not normally distributed, hence nonparametric tests were utilized for analysis. Statistical analysis was done using the Statistical Package of Socio Sciences Version 25.0 and the p-value was set at <5%. The knowledge scores were categorised as good (≥85.0%) or poor (<85.0%) while skills were described as either good (if ≥75^th percentile) or poor (if < 75^th percentile).

The socio-demographic characteristics of 319 participants used for this study are shown in Table 1. The mean age of the participants was 47

6.5years, and about two-thirds 228(71.5%), have been practicing for over 10 years with a little above one-quarter 83(26.1%) of all the participants being previously trained on BEmOC. Although only 45(54.2%) of participants previously trained had it within the last five years.

Overall, four-fifths, 257 (80.6%), of the participants reported non-availability of partographs in their respective facilities and 258 (80.9%) expressed their inability to even use partographs correctly. Only 37 (11.6%) of the participants reported that they usually perform the BEmOC signal function in their facilities. Considering various sources of information on EmOC in this study (Table 2), a little above half 162 (50.8%) reported professional training, followed by workshops/conferences 55 (17.2%).

The self-reported knowledge of EmOC among the HCPs, highlighted in Table 3, showed that almost three-fifths of the respondents, 59.6%, indicated a need for improvement in their knowledge of the management of obstetric hemorrhage while 56.4% required an update in the treatment of Preeclampsia/eclampsia. Overall, 53.6% reported the need for improvement in the management of EmOC signal functions. The highest-rated self-reported knowledge with excellent performance among participants was in the active management of the third stage of labour (AMTSL) – 21.6%. Concerning the self-reported skills of respondents, preeclampsia/eclampsia was noted to be the leading area in which participants need improvement among the signal functions, (45.5%), followed by sepsis (41.7%). However, the highest-rated self-reported skill of participants with excellent performance was neonatal resuscitation though very low (8.2%).

Table 2: Availability of EmOC signal functions and various sources of information

Table 3: Self-Reported Knowledge and Skills of BEmOC among Healthcare Workers on Selected Variables

Overall, a larger percentage, 98.7% and 98.2%, of health workers had poor knowledge and skills of EmOC respectively. Self-reported/standard scores were compared in terms of knowledge and skills of EmOC. Both self-reported and standard scores were statistically similar regarding knowledge (p=0.54) and skills (p=0.08). There was no statistically significant difference between the level of education and knowledge of BEmOC, (aOR=0.52; 95% CI 0.26-1.05), but years of experience were statistically significant; those in practice for more than 10 years were less likely to have good knowledge of BEmOC but those in practice for more than 10 years were less likely to have good knowledge ((aOR=0.54; 95% CI 0.45- 0.65) and (aOR= 0.64; 95% CI 0.45-0.90) for 11 to 20 and ≥ 21 years respectively.

Pregnancy and labour are natural processes but are associated with potential complications that necessitate the provision of lifesaving treatments for women during labour and delivery. This study assessed the knowledge and skills of EmOC among HCPs in six LGAs in Ibadan Metropolis, South-West Nigeria. The study compared both self-reported with demonstrated knowledge and skills and found that both were generally low among participants. The percentage of HCPs with poor knowledge and skills was disturbingly low for both self-reported and demonstrated knowledge and skills of EmOC. Although EmOC has been proven to be instrumental in rescuing women at risk of experiencing complications from labour, yet, demonstrated knowledge and skills of HCPs within Ibadan metropolis remain abysmally low as reflected in this study; only one-fifth of the study participants demonstrated good scores despite several awareness campaigns on EmOC. This is a likely contributory factor to the poor obstetric indices being recorded in most PHCs across Nigeria. This corroborates several assertions in the literature on the inadequacy of knowledge and skills of HCPs in the provision of EmOC.

Okonofua et al. in their study on the assessment of knowledge and skills of EmOC among HCPs in secondary healthcare centres in Nigeria reported that both the reported knowledge and skills were below average². Moreover, Du et al., (2019) in a multinational cross-sectional study on EmOC among HCPs in PHCs in SEANERN countries reported that the knowledge and skills seemed low and imbalanced ⁹. It is quite sad that HCPs in Nigeria still demonstrate inadequate knowledge and skills of EmOC despite several initiatives put in place to combat maternal mortality in the country ². These findings therefore call for urgent interventions in order to ensure full achievement of the SDG 3. Hence, providing short training for HCPs in the tertiary, secondary, and primary health centres in Nigeria will be of great significance at crucial times like this. Kabo et al.reported that intervention documented and implemented after their baseline study yielded positive results as most HCPs utilised for their study could provide necessary and adequate care during labour and delivery ⁴.

Moreover, it is of paramount importance to note that more than three-quarters of the HCPs in this study were CHWs who have a limited scope of training and are thus unable to provide EmOC services as would be expected of trained nurses and midwives. This is in tandem with similar studies whose findings show that the vast majority of HCPs in Nigeria's PHCs were CHWs and were unable to demonstrate good knowledge and skills in maternal health service ^10,11. Meanwhile, Olaniran et al., (2019) in their study asserted that CHWs are strategically and geographically located in Nigeria's PHCs to render maternal and neonatal health services and as such they need necessary help and assistance to provide such care ⁶. However, Ajisegiri et al., (2022) also asserted that CHWs are the bulk of HCWs in the PHCs in Nigeria and that these CHWs need motivation as well as necessary interventions that will boost their capacity to provide quality health services in their respective facilities ¹².Our study therefore recommends that necessary interventions are needed to improve the knowledge and skills of these categories of HCPs to improve service delivery at PHCs. Policy implementation on the need for further training of the CHWs will also go a long way to improve the status quo in Nigeria's health system.

The overall knowledge of EmOC among HCPs in this study was poor irrespective of cadre. This may reflect the small number of certified nurses and midwives that were available to function at the PHCs as most of the centres in Nigeria PHCs are currently being manned by CHWs. Notwithstanding, this is an important issue for consideration at the PHC levels because, according to the World Health Organization, nurses and midwives are expected to coordinate and practice more independently ¹³. Therefore, it is imperative to improve the quality and quantity of HCPs working at the PHCs especially as regards the number of certified nurses and midwives such that achievement of SDG 3 becomes less herculean.

In this study, the Chi-square analysis showed lack of statistical difference between self-reported/standard knowledge and skills of EmOC. This is at variance with the report by Esan et al., (2019) whose study affirmed that most of their HCPs perceived confidence in most of the skills assessed for maternal and newborn health ¹⁴. Yet, a larger percentage of their participants performed exceptionally low when faced with such tasks realistically. Hence, these categories of health workers need to be properly informed that what they assume might not be what they know in the real sense of it. They must be well equipped such that they will be able to identify potential complications in any woman during pregnancy and childbirth. Studies have shown that such HCPs will benefit from practical sessions, hands-on seminars, and workshops to be able to reduce the effects of such deficits ^2,15.

Professional training was found in this study to be the most mentioned source of information on EmOC among HCPs. Although, this is highly commendable, still, concerted efforts should still be made to raise more awareness of the need for EmOC in preventing and managing potential complications from pregnancy and childbirth⁴. It is of paramount importance to note that adequate training on EmOC should be conscientiously included in the curriculum of all health workers to minimize most complications from Obstetric care. Apart from this, the introduction and enforcement of necessary regulations to guide the conduct of HCPs at different levels will further reduce preventable complications and curtail excesses of some notorious health facilities. Replicating this study concurrently in the three tiers of health institutions in Nigeria could also provide useful insight into the way forward on this bottleneck.