Mozambican Midwives' Views on Barriers to Quality Perinatal Care

Abstract

Our purpose in this study was to explore the midwives' perception of factors obstructing or facilitating their ability to provide quality perinatal care at a central labor ward in Maputo. In-depth interviews were undertaken with 16 midwives and were analyzed according to grounded theory technique. Barriers to provision of quality perinatal care were identified as follows: (i) the unsupportive environment, (ii) nonempowering and limited interaction with women in labor, (iii) a sense of professional inadequacy and inferiority, and (iv) nonappliance of best caring practices. A model based on the midwives' reflections on barriers to quality perinatal care and responses to these were developed. Actions aimed at overcoming the barriers were improvising and identifying areas in need of change. Identified evading actions were holding others accountable and yielding to dysfunction and structural control. In order to improve perinatal care, the midwives need to see themselves as change agents and not as victims of external and internal causal relationships over which they have no influence. It is moreover essential that the midwives chose actions aiming at overcoming barriers to quality perinatal care instead of choosing evading actions, which might jeopardize the health of the unborn and newborn infant. We suggest that local as well as national education programs need to correspond with existing reality, even if they provide knowledge that surpasses the present possibilities in practice. Quality of intrapartum and the immediate newborn care requires a supportive environment, however, which in the context of this study presented such serious obstacles that they need to be addressed on the national level. Structural and administrative changes are difficult to target as these depend on national organization of maternal health care (MHC) services and national health expenditures.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

“…In contrast, training allowed midwives to practice assisting women to deliver in non-supine positions and enabled them to get accustomed to this practice.Afsana 2001; Barua 2011; Blum 2006; DeMaria 2012; Fujita 2012; Graner 2010; Lester 2003; Mathole 2006High confidence-Health worker competencies and opportunities for on-the job training were sometimes limited by poor scheduling of in-service education sessions, high cost of continuing education for health workers, inequitable selection for professional development opportunities, lack of ongoing training and follow-up, and shortage of instructors for upgrading courses. In addition, the variation in quality of pre-service training resulted in varying levels of need for in-service training, and these needs were not always met, resulting in wide variation in proficiency among health workers.Fränngård 2006; Ith 2012; Pettersson 2006; Spangler 2012Moderate confidenceDue to minor concerns about methodological limitations and relevance; and moderate concerns about adequacyLearning through practical application facilitated acquisition of skills and confidence. The experience gained through, for example, internship, social service year, and working in the community, was identified as important for building doctors' and midwives' practical experience and confidence in providing care.DeMaria 2012Very low confidenceDue to moderate concerns about methodological limitations and relevance; and severe concerns about adequacyHealth workers reported several barriers to implementing recommended practice.…”

“…Secondly, health workers' flexibility, attitudes, and beliefs about medical knowledge and skills sometimes influenced their receptivity to new practice knowledge. For example, health worker attitudes did not view medical education as dynamic; held beliefs that no significant progress had been made and clinical practice was similar to techniques learnt many years ago; or were not flexible or willing to implement alternative positions of delivery, even though these were preferred by women.Conde-Agudelo 2008; Pettersson 2006; Pitchforth 2010Low confidenceDue to moderate concerns about relevance and adequacyLack of time, infrastructure, and skills limited health workers' ability to seek knowledge and practice new clinical skills. For instance, chronic staff shortages meant less time available for health workers to seek information.…”

“…Some studies described how health workers continued to practice ineffective procedures because they were considered routine; due to lack of time; because they lacked the autonomy to avoid using what they knew to be inappropriate care; because the resources at the institution were not aligned with the protocols for postpartum care; or when it was unclear who was professionally responsible, e.g. in using the partograph.Belizan 2007; de Carvalho 2012; Conde-Agudelo 2008; Molina 2011; Pettersson 2006Low confidenceDue to moderate concerns about methodological limitations, relevance, and adequacyHealth workers sometimes used unnecessary diagnostic tests and did not follow recommended practice when they feared malpractice suits. This fear could lead to practitioners retaining practices they believed were ‘safer’.Belizan 2007Very low confidenceDue to moderate concerns about relevance; serious concerns about adequacy; and minor concerns about methodological limitationsSome health workers did not use recommended interventions when delivering care because of concerns about negative outcomes for the baby or the mother.…”

“…Examples included the use of magnesium sulphate administered with anaesthesia during Caesarean sections or when monitoring of serum magnesium sulphate levels was not possible.Barua 2011Very low confidenceDue to moderate concerns about relevance; serious concerns about adequacy; and minor concerns about methodological limitationsHealth workers were sometimes reluctant to admit their lack of skills in delivering care for fear of blame and criticisms from managers . This fear of criticism could undermine health worker confidence and performance.Lugina 2001; Pettersson 2006; Thorsen 2012Low confidenceDue to minor concerns about relevance; and moderate concerns about adequacy COMMODITIES AND HEALTH SERVICES INFRASTRUCTURE Insufficient stock and/or lack of drugs such as hydralazine, magnesium sulphate, oxytocin, misoprostol, antiretrovirals, and supplies such as gloves, sometimes influenced the quality of care provided to mothers and their babies. For instance, health workers had to use less effective alternative drugs, e.g.…”

“…This sometimes led to wasted time in procuring the drugs and supplies and the creation of informal markets and corruption at health facilities.Barua 2011; Foster 2006; Fränngård 2006; Lester 2003; Pitchforth 2010; Spangler 2012; VSO 2012Low confidenceDue to moderate concerns about methodological limitations and adequacy; and minor concerns about coherenceLack of equipment limits health workers' ability to deliver quality care to mothers and their babies. As a result of this lack of equipment, mothers and their babies sometimes received poor quality care.Barua 2011; Fränngård 2006; Graner 2010; Lester 2003; Molina 2011; Penfold 2013; Pettersson 2006; Pitchforth 2010High confidence-Lack of blood or limited infrastructure to manage blood transfusion limited health workers from delivering appropriate care.Afsana 2001; Anwar 2009; Ith 2012Moderate confidenceDue to moderate concerns about adequacy; and minor concerns about relevanceLack of equipment, supplies, or drugs sometimes wasted health workers' time, increased their workload and risk of infection, and led to low morale.Belizan 2007; Bradley 2009; Foster 2006; Graner 2010; Lester 2003; Mathole 2006; Penfold 2013; Pitchforth 2010; VSO 2012Moderate confidenceDue to moderate concerns about methodological limitations; and minor concerns about coherencePoor, incomplete, and non-systematised patient information could lead to delayed or incorrect management of high-risk mothers, or interfered with continuity of care.Molina 2011; Pettersson 2006Low confidenceDue to serious concerns about adequacyLack of or unreliable supply of electricity, including a lack of fuel to run generators, and lack of water influenced health providers' ability to deliver quality care.…”