Immediate postnatal care guidelines implementation and associated factors among healthcare providers in East Shewa zone public health facilities, Oromia, Ethiopia, 2022: a multicentre cross-sectional study

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Direct observation of healthcare providers’ actual performance on implementing postnatal care guidelines.

  • The study was carried out in health facilities in levels, it is very important to put as a starting point for inference to another health facility.

  • This study was a cross-sectional study, it did not identify the temporal relationship between outcome and predictor variables.

  • As it is an observational study, it is susceptible to reactivity (hawthorn effects), demand characteristics of study participants and observer bias.

  • During actual data collection, one healthcare provider was observed only once, so implementation across checklist items may differ from client to client.

Introduction

Immediate postnatal care (PNC) refers to care given to mothers and newborns during the first 24 hours after childbirth when major physiological and anatomical changes start to return to prepregnancy states and major complications arise during this period determines the health of mothers and newborns. Yet, this period is the most neglected time for the provision of quality PNC services.1

Globally, the immediate postnatal period accounts for more than 45% of maternal and more than 40% of neonatal deaths.2 3 The majority of these deaths occurred in low-income and middle-income countries (LMICs) by which sub-Saharan Africa shared two-thirds of maternal mortality and above one-third of neonatal mortality.4 Meanwhile, this period in Ethiopia accounts for a large proportion of maternal and neonatal deaths.5 The majority of that death was prevented by immediate PNC6; however, global median coverage of PNC in LMICs remains below 80% of global targets in 2025.7 Whereas, Ethiopian Demographic Health Surveys in 2016 illustrate only 17% of mothers and 13.1% of newborns had a postnatal check-up in the first 2 days.8

To end preventable deaths, WHO recommends that health professionals examine a woman and her baby within 1 hour of birth, and once more before discharge from a facility; particularly institutional birth as possibilities are in place, this assessment could proceed up to 24 hours after delivery.4 However, in LMICs, only 66% of mothers who delivered in health facilities receive at least one postpartum check-up from healthcare providers before discharge from the health facility.9 Likewise, the practice of immediate PNC according to immediate PNC guidelines was very low, ranging from 6% to 37.5%.10–13 Serious gaps were identified in the practices of midwives in measuring maternal vital signs, assessing uterine contraction, conducting a physical examination at discharge, routine suctioning of the airway of newborns and immediate removal of the vernix caseosa with olive oil that has been deemed unhelpful and was not per WHO/UNICEF recommendations on immediate PNC.14–16

Previous studies in Ethiopia reveal a very low proportion of mothers (6.3%) and newborns (12.1%) received immediate PNC within the first 24 hours and the Oromia regional state of this study setting was where mothers received the lowest check-ups in the first days after delivery among other regions in the country.6 8 Furthermore, a study done in Mekele and Gondar found that 79.2% and 57.6% of healthcare providers have incomplete adherence to immediate PNC guidelines, respectively.17 18 Moreover, previous studies have shown that low monthly income, absence of postpartum care guidelines, have not received training on basic emergency obstetrics newborn care (BEmONC) and essential newborn care training (ENBC), a lack of essential equipment, workload from inadequate human and material resources for the provision of comprehensive and quality immediate PNC, which affect the ability of healthcare to follow guidelines and standards of care.15 18–20

Through the implementation of various reproductive, maternal, newborn and child health policies and strategies, Ethiopia has made substantial progress in reducing maternal and neonatal mortality rates in the 2000–2019 period.21 The estimated MMR has reduced from 1030 in 2000 to 401 per 100 000 live births in 2017, a 61% reduction.2 8 as well as Neonatal Mortality Rate (NMR) has declined from 49 in 2000 to 27 per 1000 live births in 2020, representing a decline of 45%.8 22 Key drivers for this success are good health governance and an evidence-driven programmatic approach, such as increased access to maternal and neonatal health service for all, reducing healthcare service inequalities, improving the availability and readiness of service provided in health facility: increasing the antenatal, delivery and PNC, promoting quality improvement within health facility.21

Despite the remarkable reduction of maternal and neonatal mortality in Ethiopia in the past 20 years, these indicators are still among the world’s highest and need more focused attention to address them by scaling up an evidence-based, high-impact intervention that saves the lives of mothers and newborns.21 When guidelines are implemented successfully, they have a positive effect on the quality of care given to women and babies.23 Therefore, failure to follow practice guidelines and recommendations reduces the quality of PNC and increases the risk of maternal and neonatal morbidity or mortality.4 24 When compared with previous studies conducted in Tigray17 and Gondar,18 this study was done by direct observation including details of care content and by the inclusion of health centre, which aimed to assess immediate PNC guideline implementation and its associated factors among healthcare providers in East Shewa zone public health facilities, Oromia, Ethiopia 2022.

Methods

Study design, area and period

A facility-based cross-sectional study was conducted in the East Shewa zone public health facilities from 13 September 2022 to 28 October 2022. East Shewa zone is located at the centre of Oromia; Adama is the zone capital, which far 100 km from Addis Ababa. The zone has a total population of 1 615 178, from them 791 437 are male and 823 741 are female according to the 2007 census. The zone has 6 public hospitals (1 tertiary-level hospital, which is called the comprehensive specialised and teaching hospital, 2 secondary-level hospitals and 3 primary-level hospitals), and 58 health centres where maternity care is given, 357 healthcare providers working in the maternity ward. A monthly average of 700, 350, 250 and 100 mothers gave birth per facility (tertiary, secondary and primary-level hospitals and health centres, respectively) from data taken from respective hospitals and East Shewa Zone health administration.

Patient and public involvement

None.

Population

All healthcare providers who work in the maternity ward of the East Shewa zone public health facilities were the source population while all healthcare provider who work in the maternity ward of the randomly selected East Shewa zone public health facilities were the study population. Randomly selected individual healthcare providers for data collection were study units. Healthcare providers who were assigned to the delivery and postnatal ward during data collection were included in the study. Healthcare providers who are not on duty for annual, maternity, sick and study leave were excluded from the study.

Sampling procedure

The sample size was determined by a single population proportion formula with the assumption of 95% (Ζα/2=1.96) confidence level, 5% marginal error, 10% non-response rate and 42.4% complete adherence of healthcare providers to immediate PNC guidelines in the Gondar zone.18 Hence, after using the correction formula and adding a 10% non-response rate, the final sample size was 202. East Shewa zone has 6 public hospitals and 58 health centres. All 6 public hospitals were included in the study purposely selected, and 19 health centres were randomly selected. The final calculated sample size was proportionally allocated to 6 hospitals and 19 health centres. Each study participant was selected by simple random sampling through the lottery method using his or her list from each hospital and health centre’s human resource department or matron office as a sampling frame. During actual data collection, one healthcare provider was observed only once, which means 196 healthcare providers per 196 mother and neonate pairs were observed.

Variables of the study

The dependent variable for this study was immediate PNC guidelines implementation whereas the independent variable was sociodemographic factors: age, sex, professional category, professional qualification, year of work experience, marital status and monthly income. Provider-related factors: having training on BEmONC, training on ENBC, midwife-led PNC, shortage of staff and recognition for performance, and facility-related factors: type of health facility, presence of maternal and newborn care guidelines, presence of PNC guideline, shortage of bed and vital sign equipment in the postnatal ward.

Data collection tool, procedure and quality control

A structured self-administered questionnaire was adapted from previous studies after reviewing different kinds of literature and standard observational checklists, which were adopted from the midwifery care process and modified according to consolidated new WHO recommendations consisting of 32 checklist items, was used to collect the data.25 A structured self-administered questionnaire was used to collect sociodemographic characteristics and provider-related and facility-related factors. An observational checklist, which consists of immediate newborn care and immediate postpartum care of a mother, was used to collect data via direct observation of the actual implementation of immediatePNC guidelines.

The questionnaire was designed in Kobo toolbox software and exported to Kobo and ODK android app for electronic data collection. Data were collected by six BSc midwives and supervised by two MSc holders. Before the actual data collection day, the questionnaires were pretested on 5% of the sample size in Turunesh Beijing, General Hospital to identify any ambiguity, in consistency and then necessary corrections were made. The investigator was provided with a 2-day training for the data collector and supervisor to help them understand the purpose of the study, how to collect data and conduct the observation. Selected study participants were checked for shifts they were assigned to the delivery and postnatal ward from tentative schedules of the ward head, and then data were collected when they were on the day shift. One data collector followed one healthcare provider until the mother was discharged from a health facility. According to the Ethiopia context after delivery, one mother stays in a postnatal ward for 6 hours before discharge.

To minimise observation bias from reactivity (Hawthorne effect) of healthcare providers, data collectors told the objective of the study but did not provide details of study procedures. The data collection process is mysterious and can no longer be disclosed to their close supervisors. Finally, the supervisor cross-checks the data for completeness and sends it to the investigator through the Kobo toolbox.

Data process and analysis

Data collected by Kobo and ODK android app were sent to the Kobo toolbox, then exported to Excel to check the completeness, and finally exported to SPSS V.25 for analysis. The questionnaire created in Kobo was must fill/enter data format, because of this data collector cannot proceed to the next without filling in the preceding question, which aimed to reduce missed data during data collection. Beyond this, if missed data occur, it is managed by hot deck imputation by which the modes of the healthcare provider performance on a specific item of the checklist were taken and filled for missed value on that specific checklist item. Descriptive statistics was used for determining the frequency, percentage, mean and SD. The factors associated with the outcome variable were found using binary logistic regression analysis. The multivariable logistic regression analysis included all explanatory variables in the bivariate analysis and had a significant association with the outcome variable at a p≤0.25. ‘It is a purposeful variable selection algorithm as proposed by Hosmer and Lemeshow 2000. This allows more variables in multivariate analysis by removing confounding variables above 25% to adjust for variables remaining in the model’. Crude and adjusted ORs (aORs) with their 95% CI constructed by robust SE were determined and a statistically significant association was declared based on p<0.05. There are no multicollinearity effects among independent variables as all variable Variance Infilation Factor (VIF) lies between 1 and 2.

Operational and term definition

Implementation of immediate PNC

Each observational checklist item has a ‘yes’ or ‘no’ response (ie, a score of 1 was given for a ‘yes’ and 0 for a ‘no’ response). Implementation of immediate PNC was dichotomised as good implementation if the healthcare providers performed, the task means and above (≥27.68) out of the overall checklist items and poor implementation, if the healthcare providers performed, the task below mean(<27.68) out of overall checklists items.11 We did not assess that all checklist item has equal difficulty in using Bloom’s cut-off point above 75% to say good implementation. In case of this, we prefer to use the average mean by looking distribution of the score.

Midwife-led model of care: When the midwifery team gives PNC.25

A shared model of care: When PNC is shared between different healthcare professionals.25

Result

Sociodemographic characteristics of the study participants

A total of 196 healthcare providers participated in this study making a response rate of 97.03% response rate. The median age of study participants was 28 years with IQR (27–31). More than half of the study participants 125 (53.1%) were female. Of the study participants, 188 (95.9%) were midwives and were the majority 155 (79.1%) first-degree (BSc) holders. Of the total participants, 85 (43.4%) of them have 3–5 years of work experience and 101 (51.5%) have a monthly income of ETB6001–ETB8000 (for more, see table 1).

Table 1

Sociodemographic characteristics of the healthcare provider in East Shewa Zone public health facility, Oromia, Ethiopia, 2022

Healthcare provider and facility-related factor

In study participants who received training related to immediate PNC, the majority 117 (59.7%) received BEmONC training. During the provision of immediate PNC, most of the healthcare providers 109 (55.6%) used midwife-led postcare whereas 87 (44.4%) healthcare providers used a shared model of PNC. About 121 (61.7%) participants of this study are hospital worker. About 111 (56.6%) participants responded that they have maternal and neonatal clinical guidelines in their hospitals and health centres. One hundred and thirty-four (68.4%) care providers responded that they have a shortage of beds and most care providers 136 (69.4%) responded that their facilities have a shortage of vital sign equipment, such as Blood Pressure (BP) apparatus (sphygmomanometers) and thermometers 50.7% and 42.4%, respectively (for more, see table 2).

Table 2

Provider and facility-related factors in public health facility of East Shewa zone, Oromia, Ethiopia 2022

Implementation of immediate PNC guidelines

The mean of the total score of 196 healthcare providers was 27.68±SD 11.4, the minimum score was 7, the maximum score was 55 and the modal score was 16, 23 and 38. The overall healthcare providers who implemented above the mean score considered as a good implementation of immediate PNC guidelines was 44.4% (95% CI 37.3% to 51.6%). For the distribution of scores, see figure 1. This study revealed that in immediate newborns care; ensuring thermal protection by putting them under a radiant warmer was 156 (80.6%), assessing Apgar score 158 (80.6%), checking cord for bleeding 163 (83.2%), vitamin K administration 169 (86.2%), application of tetracycline 175 (89.3%) and neonate weighing 157 (80.1%) were among frequently implemented immediate newborn care. Whereas, healthcare providers checked the mother for HIV tested or not 154 (78.6%), counselled on severe vaginal bleeding 130 (66.3%), and counselled severe headaches with the blurring of vision 120 (60.2%); checked vaginal bleeding during discharge 120 (61.2%) and uterus contracted or not during discharge 116 (59.2%) among frequently implemented immediate postpartum care of the mother (for more, see online supplemental table 1).

Supplemental material

Figure 1
Figure 1

The distribution of implementation scores among healthcare providers in East Shewa zone Oromia, Ethiopia, 2022.

Factor associated with the implementation of immediate PNC guidelines

Multivariable binary logistic analysis showed that receiving BEmONC training, the presence of maternal and newborn care guidelines in the delivery and postnatal ward, and working in a tertiary-level hospital (comprehensive specialised and teaching hospital) were significant factors associated with the good implementation of immediate PNC guidelines.

The odds of good implementation of immediate PNC guidelines by the healthcare providers who received BEmONC training were 3.72 times higher than those who did not receive BEmONC training (AOR 3.72 95% CI 1.7 to 8.1)). Likewise, the odds of good implementation of immediate PNC guidelines by healthcare providers working in a tertiary-level hospital (comprehensive specialised and teaching hospital) were 3.85 times higher than those working in health centres (AOR3.85, 95% CI 1.3 to 11.2). Moreover, the odds of good implementation of immediate PNC guidelines by a healthcare provider who had maternal and newborn care guidelines in their delivery and postnatal wards were 3.2 times higher than their counterparts (AOR 3.2 95% CI 1.5 to 6.6) (for more, see figure 2).

Figure 2
Figure 2

This figure shows an OR for factors of interest in multivariable logistic regression analysis. Error bars represent 95% CI. AOR, adjusted OR; BEmONCT, basic emergency newborn care training; BOR, bed occupancy rate; CSTH, comprehensive specialised and teaching hospital; ENBCT, essential newborn care training; GH, General Hospital; MI, monthly income; MNCG, maternal newborn care guideline; PH, primary hospital; PNCG, postnatal care guideline specifically; RFFP, received recognition recognition for performance; Ywe, Year of work experience.

Discussion

This study finding revealed that the overall good implementation of the immediate PNC guideline was 44.4%, which is consistent with a study conducted in Gondar (42.4%)18 and Egypt (37.5%).12 This consistency may be due to the similarity of study design, ways of measurement as healthcare providers observed only once, and the similarity of the study unit where they take data from a nurse in maternity wards. Whereas, the finding in this study was higher than the study conducted in Mekele (22.8%),17 Uganda (12%)10 and Iraq (6%).13 This disparity could be due to differences in measurement tools (observational checklist) to determine implementation status, and the difference in study design, and study setting as they include only hospital, study period, sample size and study participants, which includes students and charts.

This study revealed that the odds of having a good implementation of immediate PNC guidelines were 3.72 times higher among healthcare providers who received BEmONC training than healthcare providers who did not receive BEmONC training. This finding is similar to a study conducted in Gondar18 and Afar.26 This might be because training provided to obstetrics care providers related to basic emergency obstetrics and newborn care may enhance basic knowledge and skills about PNC in the management of complications that arise during the postnatal period, especially during the first 24 hours. This was supported by findings from previous studies revealed that training health professionals improve their adherence to available evidence or guidelines,27 and implementation framework combining training, mentoring, demonstrating and redemonstrating of the healthcare providers in the maternity ward on immediate PNC improves the performance of healthcare providers from preprograms to postprogrammes.12 28 29 Interactive and targeted education may be effective in developing clinical practitioner knowledge, skills and attitudes about a guideline’s recommendations.23 30

The odds of having a good implementation of immediate PNC guidelines were 3.2 times higher among healthcare providers who had maternal and newborn care guidelines in their maternity ward than those who did not have maternal and newborn care guidelines in their maternity ward. This finding is in line with a study done in Gondar18 and Kenya.31 This might be because the presence of guidelines in the work area may help healthcare provider easily recall what they have to do, retain their knowledge and demonstrate their skills proficiently, as well as guidelines given to trainers during training, may assist them in their long-term adherence to practice. This is supported by findings from previous studies, which revealed that besides training, availing evidence-based summaries or guidelines to healthcare providers improves their compliance with immediate PNC guidelines,27 and maternity nurse practice was improved after the implementation of educational guidelines regarding PNC of mothers and neonates.29 The use of guidelines ensures healthcare teams have a similar approach to care and most common implementation interventions such as distributing educational material plus educational meetings such as training and other interventions have improved the knowledge and practice of nurses and improved patient outcomes.30 32 33

Moreover, the odds of good implementation of immediate PNC guidelines by healthcare providers working in a tertiary level hospital (comprehensive specialised and teaching hospital) were 3.85 times higher than those working in a health centre. This finding was consistent with a study done in the eastern and central zones of the Tigray region,34 35 in Afar26 and in Kenya.31 This may be due to hospitals at higher levels having much more experienced and skilled healthcare providers from different disciplines, hospitals having standards of care, which is better than health centres, and the hospital may have a good supply of medical equipment when compared with the health centre.

Strength of the study

Direct observation of the actual performance of healthcare providers generates new knowledge regarding the implementation of immediate PNC guidelines. In addition, this study was carried out in health facilities in levels, it is very important to put as a starting point for inference to another health facility. Lastly, this study was based on the current guidelines of the midwifery care process recommended by the Ethiopian Federal Ministry of Health to midwives and other health professionals in collaboration to keep the health of mothers and newborns.

Limitations of the study

As this study was a cross-sectional study, it did not identify the temporal relationship between outcome and predictor variables. In addition, as it is an observational study, it is susceptible to reactivity (hawthorn effects), demand characteristics of study participants and observer bias; as observation was used for the data collection method. The healthcare provider was observed only once while providing care, so implementation across items of the checklist by the provider may differ from client to client. This study did not identify which training approaches were used while giving training for healthcare providers and it did not differentiate the contribution of facility-level factors from provider-level factors rather than taking individual variables as a factor. Finally, this study did not include private health facilities. Therefore, we cannot generalise it for private health facilities.

Conclusion

This study found only 44.4% of healthcare providers have a good implementation of immediate PNC guidelines. Receiving BEmONC training, having maternal and newborn care guidelines in their delivery and postnatal ward, and working in a tertiary-level hospital (comprehensive specialised and teaching hospital) were significantly associated factors with good implementation of immediate PNC guidelines. Therefore, this study suggests enhancing training for healthcare providers on PNC care, distributing updated maternal and newborn care guidelines to health facilities, and supplying primary-level health facilities with necessary medical equipment and human power may improve the implementation of immediate PNC guidelines, which aims to reduce maternal and newborn mortality during this neglected period of the first 24 hours, and plays a great role in achieving sustainable development goal.

Data availability statement

Data are available on reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and the proposal of the study was first submitted to Ambo University College of Medicine and health science, ethical review board for ethical approval (AU/PGC/408/2014). Then, an official letter was obtained from the ethical review board and taken to Oromia regional health bureau Health research ethical review committee (BFO/HBTFH/925), and then, an official letter from the Regional Health Bureau taken to the East Shewa Health office, hospitals and health centre for permission and cooperation. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

First, I would like to extend my thanks to Madda Walabu University for full sponsorship. Next, I would like to forward my thanks to Ambo University College of Medicine and Health Science for creating an opportunity to take my MSc programmes. In addition and foremost, I would like to extend my gratitude to my heartfelt friends, study participants, supervisors and data collectors who devoted their time to adding valuable information and assisting me in my research proposal and thesis.

This post was originally published on https://bmjopen.bmj.com