Research Article: Assessing the knowledge and skills on emergency obstetric care among health providers: Implications for health systems strengthening in Nigeria

Date Published: April 8, 2019

Publisher: Public Library of Science

Author(s): Friday Okonofua, Lorretta Favour Chizomam Ntoimo, Rosemary Ogu, Hadiza Galadanci, Mohammed Gana, Durodola Adetoye, Eghe Abe, Ola Okike, Kingsley Agholor, Rukiyat Adeola Abdus-salam, Abdullahi Randawa, Hauwa Abdullahi, Suleiman Muhammad Daneji, Blessing Itohan Omo-Omorodion, Olalekan Uthman.


To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria.

A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period.

Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country.

All skilled providers offering EMOC services in the hospitals during the study.

A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents’ knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall.

A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores.

The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country.

Nigeria Clinical Trials Registry 91540209.

Partial Text

Available evidence indicate that while 303,000 women died in 2015 from preventable causes related to pregnancy and childbirth, sub-Saharan Africa accounted for 66% of these deaths [1]. Within sub-Saharan Africa, nearly 29% of the maternal deaths occurred in Nigeria with an estimated 58,000 pregnant women dying annually in the country mainly from preventable obstetric causes [1, 2]. While many socio-economic and cultural factors have been put forward to explain the high rates of maternal deaths in Nigeria [3, 4], it is evident that the poor accessibility of pregnant women to quality emergency obstetric care (EMOC) is at the root of the problem. The WHO defines EMOC as “a list of live-saving services or signal functions that define a health facility with regard to its capacity to treat obstetric emergencies” [5]. Two types of EMOC services have been described: Basic EMOC (BEOC) and Comprehensive Emergency Obstetrics Services (CEOC). BEOC is offered in primary health care facilities and consists of skilled delivery care, the administration of antibiotics, manual removal of the placenta, removal of retained products of conception, assisted vaginal delivery possibly with a vacuum extractor, and basic neonatal care including neonatal resuscitation. In contrast, CEOC consists of all BEOC services as well as caesarean section, safe blood transfusion services and the treatment of the sick baby, and is offered mainly in referral Secondary and Teaching Hospitals by skilled medical and midwifery personnel. Although the Federal Ministry of Health of Nigeria recommends BEOC as the entry point to the health care system in order to generate universal health coverage for all citizens [6], it is evident that a large number of women require CEOC because of the complexity of their pregnancy complications.

The study was designed to investigate the knowledge and skills of health providers relating to EMOC practices in eight referral hospitals in Nigeria. We first studied the knowledge and use of standard procedures, guidelines and protocols for the management of obstetric complications and the involvement of the health providers in national and international safe motherhood movements. To assess the knowledge and skills of the health providers, we specifically asked questions about their knowledge and skills in managing primary post-partum haemorrhage, eclampsia and obstructed labour, which are the three leading emergency obstetric complications in Nigeria. We assessed these by asking questions on the availability and use of parthograph, which is a standard procedure recommended by the World Health Organization for the prevention of obstructed labour in developing countries [21], and on the respondents’ knowledge and use of the WHO guidelines for managing complications of pregnancy and childbirth [24]. Although a large proportion of the providers reported that they are aware of, and use parthograph for the management of labour, there was limited evidence to substantiate this. However, only a few of the respondents reported their use of the WHO standard guidelines for management of obstetric complications, and less than a quarter were active in national and international networks relating to the prevention of maternal mortality (safe motherhood). Also, they did not appear to use any specific protocols for the management of the leading pregnancy complications, neither was there evidence of regular reviews of maternal deaths and surveillance in the hospitals.

The results of this study indicate that the knowledge and reported skills on EMOC practices by health providers in referral facilities in Nigeria is lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country.




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