Health providers´ knowledge on maternal and newborn care: Implications on health systems strengthening in Vihiga County, Kenya

  • Pan African Medical Journal, Volume 37, No. 73, Year 2020

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Study Justification:
– The study aims to investigate the knowledge of health providers on maternal and newborn care in Vihiga County, Kenya.
– This is important because pregnant women require skilled attendance at birth and emergency obstetric care to prevent maternal deaths.
– Inadequate knowledge of health providers may contribute to the high maternal mortality rate in the county.
– By assessing the knowledge levels of health providers, the study seeks to identify areas for improvement and inform strategies to strengthen the health system.
Highlights:
– The study was conducted in Vihiga County, Kenya, which has a high maternal mortality rate despite a relatively high percentage of women delivering in health facilities.
– A total of 55 nurses were interviewed, and their knowledge scores on maternal and newborn health were assessed.
– The overall knowledge score for maternal and newborn health among the providers was found to be adequate, with a score of 64%.
– Midwives and higher diploma nurses consistently scored higher than diploma nurses in all areas of maternal and newborn health.
– In-service training on emergency obstetric care for providers is identified as critical for reducing maternal mortality.
Recommendations:
– Provide in-service training on emergency obstetric care to health providers, with a focus on areas where knowledge scores were lower, such as care for complications.
– Strengthen the education and training of diploma nurses to improve their knowledge and skills in maternal and newborn care.
– Consider allocating resources for continuous professional development programs for health providers to ensure their knowledge remains up to date.
– Monitor and evaluate the impact of the training programs on the knowledge and practices of health providers to inform future interventions.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation of training programs for health providers.
– County Health Department: Oversees the implementation of health programs and can allocate resources for training initiatives.
– Health Training Institutions: Provide training and education for nurses and midwives, and can collaborate with the government to update curricula and improve the quality of education.
– Professional Associations: Play a role in advocating for the professional development of health providers and can support training initiatives.
Cost Items for Planning Recommendations:
– Training materials and resources: Including development or procurement of training modules, textbooks, and other educational materials.
– Trainers and facilitators: Budget for the recruitment or assignment of experienced trainers to conduct the in-service training programs.
– Venue and logistics: Allocate funds for training venues, equipment, refreshments, and other logistical requirements.
– Monitoring and evaluation: Set aside resources for data collection, analysis, and reporting to assess the impact of the training programs.
– Continuous professional development programs: Consider budgeting for ongoing training and capacity-building initiatives to ensure the sustainability of knowledge improvement among health providers.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. To improve the evidence, the study could have included a larger sample size and used a more diverse range of health care providers. Additionally, the study could have provided more details on the methodology used for data analysis. Overall, the evidence could be strengthened by conducting further research with a larger and more diverse sample, and by providing more transparency in the data analysis process.

Introduction: pregnant women need access to skilled attendance at birth and emergency obstetric care (EmOC) to avert maternal deaths. While poor EmOC services may explain the high maternal mortality, inadequate knowledge of providers is also part of the problem. This forms the basis of this paper, in a setting where 50.2% of women deliver in a health facility but maternal mortality remains high at 531/100,000 live births, compared to the national average of 362/100,000 in Kenya. Methods: a facility based cross-sectional survey was conducted in 2018 with a set of knowledge questions extracted from the averting maternal death and disability toolkit. Providers knowledge for maternal and newborn health (MNH) was assessed by interviewing nurses on duty in the maternity units. Data were entered in Ms Access and exported to R version 3.6.2 for descriptive and logistic regression analysis. Ethical clearance was obtained from Kenya Medical Research Unit. Results: a total of 55 nurses were interviewed. Majority (71%) of the respondents were diploma nurses. The overall knowledge score for MNH among the providers was adequate with a score of (64%). Generally, the midwives and higher diploma nurses consistently scored higher than diploma nurses in all the topic areas of MNH. In the mixed linear regression, determinants of knowledge score were seen in provider-level variables. Conclusion: overall, the providers scores were higher on intrapartum and newborn care compared to scores on care for complications. We conclude that in-service training on EmOC to providers is critical to reduction of maternal mortality.

Study setting: this study was conducted in Vihiga County in Kenya. Vihiga County is one of the 47 Counties located in the western region of Kenya and covers an area of 531 km2 [15]. The County has five administrative sub-Counties namely Hamisi, Emuhaya, Luanda, Sabatia and Vihiga. The total population in the County was 600,000 in 2019 [16]. The County has a total of 90 health facilities (public and private) [15]. From these 45 (50%) offer maternity services. For this study, 30 health facilities were selected on the basis of offering maternity services 24 hours a day, 7 days a week and had conducted a total of thirty (30) normal deliveries the previous three months (January – March 2018). Among them, one was the Vihiga County Referral Hospital. There were three level-4 facilities in Sabatia, Hamisi and Emuhaya sub-Counties. All the four facilities provided comprehensive EmOC while the remaining 25 facilities offered basic EmOC. The facility based cross-sectional survey was conducted in the maternity units of the 30 health facilities between April and May 2018. This study was part of a larger study reference number (KEMRI/CPHR/005/07/2015) that assessed the health systems readiness to offer emergency obstetric care (EmOC) in Vihiga County, Kenya. Study population: the participants in this study were the health providers, mainly nurses on duty in the maternity units at the time of the survey. All the 30 maternity units had three or fewer nurses on duty at the time of the survey hence all nurses were invited to partake in the survey. Knowledge questionnaire: a quantitative structured questionnaire was adopted from the Averting Maternal Death and Disability Emergency Obstetric and Newborn Care (EmONC) needs assessment toolkit [10]. The questionnaire determined the knowledge of health providers on routine and emergency care during pregnancy, intrapartum care, essential newborn care and care for sick newborns. A pre-test of the questionnaire was conducted in a facility outside of Vihiga County. Necessary changes to the tool were made and the final tool adopted for the study. The questionnaire was administered by an interviewer who read each question out loud in English to the participant and responded directly into the tool. Answer options were not provided to nurses; instead, nurses provided their own answers and the interviewer marked the multiple choice answers as appropriate. Because all participants were trained in English, they answered in English without a need to translate to the local language. Two interviewers conducted the survey and they were part of the research team members with extensive familiarity and training in the tool; they contributed to the design of the tool and led the piloting of the questionnaire. Data completeness and accuracy was checked on a daily basis by supervisors. Data analysis: data was entered in Ms Access and exported to R version 3.6.2 for descriptive and logistic regression analysis. Based on the questions administered to the health care providers, a knowledge level score was generated. Average summary scores were then calculated for each specific question included in the topic area. Each knowledge question had multiple correct answers; that is, answers that the respondents were expected to offer spontaneously. If a correct answer was not offered, the interviewer coded the response as “not mentioned”. If a spontaneous answer did not appear as one of the multiple choices, it was not taken into consideration for scoring purposes. Respondents were scored on each question by calculating the number of correct responses mentioned out of the total possible and standardizing this to a scale of 100. A mixed-effect linear regression model was used to identify determinants of health providers´ knowledge on maternal and newborn care. The regression coefficient informs us how much the summary knowledge score is expected to increase when the independent variable increases by one, holding all other independent variables constant. In addition to the uni-variate model, we fitted three models. Model I was fitted using provider level variables, model II using facility level variables and model III was fitted on a combination of both provider and facility level variables. Akaike´s information criterion (AIC) was run to measure the model fits and complexity. For the given models fitted on the same data, the model with the smallest value of the information criterion is considered to be the best. The knowledge scores were operationally defined as follows: adequate knowledge: if the health provider answers correctly more than 50% of the questions; inadequate knowledge: if the health provider answers correctly less than 50% of the questions. Ethical approval: ethical approval for this study was granted by the Kenya Medical Research Institute (SSC protocol No: KEMRI/SERU/CPHR/ 003/3277). Written informed consent to conduct this study was obtained from the director of health in Vihiga County prior to conducting the study. Written informed consent was obtained from individual participants before administering the questionnaire.

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Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. In-service training on emergency obstetric care (EmOC): Providing regular and comprehensive training programs for healthcare providers, specifically focusing on EmOC, can enhance their knowledge and skills in managing complications during pregnancy and childbirth.

2. Mobile health (mHealth) interventions: Utilizing mobile technology to deliver maternal health information, reminders, and guidance to pregnant women and healthcare providers can improve access to essential care and promote timely interventions.

3. Telemedicine services: Implementing telemedicine services can enable remote consultations between healthcare providers and pregnant women, especially in rural or underserved areas, ensuring access to timely and quality care.

4. Strengthening health systems: Investing in the improvement of healthcare infrastructure, staffing, and supply chain management can enhance the overall capacity of health systems to provide adequate maternal health services.

5. Community-based interventions: Engaging and empowering local communities through awareness campaigns, education programs, and community health workers can improve access to maternal health services, especially in hard-to-reach areas.

6. Task-shifting and delegation of responsibilities: Training and empowering non-physician healthcare providers, such as midwives and nurses, to perform certain tasks traditionally done by doctors can help alleviate the shortage of skilled birth attendants and increase access to maternal health services.

7. Quality improvement initiatives: Implementing quality improvement programs in healthcare facilities, focusing on maternal health outcomes and patient satisfaction, can enhance the overall quality of care and encourage more women to seek skilled attendance at birth.

These innovations, when implemented effectively and in combination, can contribute to improving access to maternal health and reducing maternal mortality rates.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. In-Service Training on Emergency Obstetric Care (EmOC): The study highlights the importance of improving the knowledge of health providers on maternal and newborn care. Inadequate knowledge among providers is identified as a contributing factor to high maternal mortality rates. Therefore, developing an innovative in-service training program specifically focused on EmOC can be implemented. This program should target nurses and other healthcare providers working in maternity units in Vihiga County, Kenya. The training should cover topics such as routine and emergency care during pregnancy, intrapartum care, essential newborn care, and care for sick newborns. By enhancing the knowledge and skills of healthcare providers, the quality of maternal and newborn care can be improved, leading to better health outcomes for pregnant women and their babies.

The innovative aspect of this recommendation lies in the development of a comprehensive and tailored in-service training program that addresses the specific knowledge gaps identified in the study. The program should utilize interactive and practical teaching methods, such as simulations and case studies, to ensure effective learning and retention of knowledge. Additionally, the program should be regularly updated to incorporate new evidence-based practices and guidelines in maternal and newborn care.

To implement this innovation, collaboration between the Vihiga County government, healthcare institutions, and relevant stakeholders is crucial. Adequate resources, including funding and training materials, should be allocated to support the implementation and sustainability of the program. Monitoring and evaluation mechanisms should also be established to assess the impact of the training program on healthcare providers’ knowledge and the quality of maternal and newborn care provided.

By investing in the continuous professional development of healthcare providers through innovative training programs, access to skilled attendance at birth and emergency obstetric care can be improved, ultimately reducing maternal mortality rates in Vihiga County, Kenya.
AI Innovations Methodology
Innovations for improving access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with access to information on prenatal care, nutrition, and emergency services. These apps can also send reminders for appointments and medication, and allow women to communicate with healthcare providers remotely.

2. Telemedicine: Implement telemedicine programs that connect pregnant women in remote areas with healthcare providers through video consultations. This allows for timely advice, monitoring, and diagnosis, reducing the need for travel and improving access to specialized care.

3. Community Health Workers: Train and deploy community health workers to provide education, support, and basic healthcare services to pregnant women in underserved areas. These workers can conduct home visits, offer antenatal care, and refer women to appropriate healthcare facilities when necessary.

4. Maternal Waiting Homes: Establish maternal waiting homes near healthcare facilities in rural areas. These homes provide accommodation for pregnant women in the weeks leading up to their due date, ensuring they are close to a facility when labor begins and reducing delays in accessing care.

Methodology to simulate the impact of recommendations on improving access to maternal health:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the percentage of pregnant women receiving antenatal care, the percentage of births attended by skilled health personnel, and the distance to the nearest healthcare facility.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area. This can be done through surveys, interviews, and existing health records.

3. Develop a simulation model: Create a simulation model that incorporates the recommended innovations and their potential impact on the identified indicators. This model should consider factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Adjust the parameters of the innovations, such as the coverage and effectiveness, to explore different scenarios.

5. Analyze results: Analyze the simulation results to determine the projected changes in the selected indicators. Compare the outcomes of different scenarios to identify the most effective combination of innovations for improving access to maternal health.

6. Validate the model: Validate the simulation model by comparing the projected results with real-world data, if available. This helps ensure the accuracy and reliability of the model’s predictions.

7. Refine and implement recommendations: Based on the simulation results, refine the recommendations and develop an implementation plan. Consider factors such as feasibility, cost-effectiveness, and sustainability when prioritizing and implementing the innovations to improve access to maternal health.

Statistics:
Authors: 3
Identifiers:
DOI: 10.11604/pamj.2020.37.73.24597
Research Areas:
Disability, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Kenya
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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