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Obstetric emergency: urban and rural comparison of knowledge, attitude and practice of health workers in river state of Nigeria -- impact on maternal health care in river state

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  • Save Clinical M edicine and Diagnostics 2013, 3(2): 29-51 DOI: 10.5923/j.cmd.20130302.03 Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for Maternal Health Care in Rivers State Ebuehi Olufunke Margaret1,*, Chinda Grace Nkechinyere2, Sotunde Oludolapo Muibat3, Oyetoyan Solomon Adeyanju4 1Reproductive and International Health Unit, Department of Community Health and Primary Care College of M edicine, University of Lagos, Lagos, Nigeria 2Rivers State M inistry of Health, Port Harcourt, Rivers State 3Primary Health Care Department, Local Government Secretariat, Lagos M ainland Local Government, Lagos State 4Primary Health Care Department, Local Government Secretariat, Badagry Local Government, Lagos State Abstract In Nigeria, an estimated 545 materna l deaths occur for every 100,000 live births. Within the country, gaps exist between urban and rural areas, with more maternal deaths occurring in the rural areas. The knowledge, attitude and practice (KAP) of Emergency Obstetric care (EmOC) among health care providers, are important determinants of the quality and outcome of care. The study determined and compared the KAP of EmOC among health care providers in urban and rural public secondary health facilities in River state, South-south Nigeria; and also assessed the availability of resources for EmOC p rovision.Informat ion was obtained from 304 doctors and nurses, using a pre-tested, self-ad min istered questionnaire and a facility checklist was used to obtain relevant informat ion about resource availability fo r EmOC in 13 health facilities. Data were analysed using EPI-INFO version 3.5.1. Findings showed that more (28.9%) res pondents from urban facilities had good knowledge of EmOC than their rural counterparts (16.4%). More respondents (96.1%) fro m ru ral facilities had positive attitude compared to the urban counterparts, (93.4%), however more urban respondents (77%) reported good practice compared to 40.8% in rural facilities. Approximately a third of respondents (urban: 28.5%, rural: 33.1%) reported having obstetric protocols in their facilities. A mean o f 7.5 obstetricians/gynecologists were employed in the 4 urban co mpared to 0.3 in the 9 rural facilities. More deficits in meeting the criteria for Co mprehensive Emergency Obstetric Care (CEmOC) were seen in the rural than the urban facilit ies; as at study time , all rural facilities neither had capacity for managing complications that could arise fro m pregnancy-induced hypertension nor a blood bank. Findings revealed that urban health workers demonstrated better knowledge and practices than their rural counterparts. Resources were inadequate in both areas albeit better in urban facilities. Regular train ing and re-training of staff on EmOC, with adequate and equitable d istribution of resources between urban and rural facilities is reco mmended. Keywords Emergency Obstetric Care (EmOc), Knowledge, Attitude, Pract ice, Urban and Rural 1. Introduction Co mbating maternal mortality and morb idity is a global problem that demands policies and political co mmit ments; strategy formu lation and implementation; and imp roved health care service delivery and management. There is now an international consensus that making pregnancy and delivery safer includes ensuring that women, who e xperience * Corresponding author: (Olufunke M. Ebuehi) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved obstetric comp licat ions, receive the medical care they need on time. The Un ited Nations Population Fund (UNFPA) has identified Emergency Obstetric Care (EmOC), to ensure timely access to care for wo men experiencing co mplications as one of the three strategies to reducing maternal mortality[1]. The other two strategies are family planning to ensure that every birth is wanted and skilled care by a health professional with mid wifery skills, for every pregnant wo man during pregnancy and childbirth. Emergency obstetric care (EmOC) is defined as a set of life saving services that must be available in health facilities to respond to emergencies that arise during pregnancy, delivery or postpartum.[2] Emergency services are needed to 30 Ebuehi Olufunke M argaret et al.: Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for M aternal Health Care in Rivers State handle potentially life-threatening, direct obstetric complications that affect an estimated 15% of wo men during pregnancy, at delivery, or in the postpartum period even in developed countries[3]. ‘About fifteen per cent of all pregnancies will result in comp lications. Most complications occur randomly across all pregnancies, both high- and low-risk. They cannot be accurately predicted and most often cannot be prevented, but they can be treated’[1] In 1987, the Safe Motherhood Initiative was launched; it sought to reduce the burden of maternal mortality especially in developing countries. In the application and implementation of these strategies, undue emphasis was placed on predicting and preventing obstetric comp licat ions, rather than effective and efficient management of these complications when they arise. While today, strategies are more appropriately focused. It is essential that pregnant wo men in who m co mplications develop have access to the med ical interventions of emergency obstetric care to ensure favourable maternal and foetal outcomes. Research has shown that for every maternal death, there is a potential death of a child, increase in child labour, illness, malnutrit ion, social isolation and poor hygiene[4],[5]. There is also, dissolution and reconstitution of the family unit, reduced productivity and loss of output.[4] An estimated figure of over five hundred thousand (>500,000) wo men d ie yearly fro m pregnancy related comp licat ions, about ninety nine percent (99%)[4] of these deaths take p lace in developing countries; where a wo man’s lifet ime risk of dying fro m pregnancy and related co mp licat ions is almost 40 times greater than that of her counterparts in developed countries.[4] It has also been noted that “for every wo man who dies, an estimated 15 to 30 wo men suffer fro m ch ronic illnesses or injuries as a result of their pregnancies”[1] all of these are preventable. Nearly all these lives could be saved if affordable, good-quality obstetric care were available 24 hours a day, 7 days a week.[1] The 2008 Nigeria Demographic and Health Survey estimated maternal mo rtality ratio to be 545 deaths per 100,000 live births.[6] These deaths are due to direct and indirect obstetric complications with the direct complications accounting for about seventy five percent (75%)[7] of maternal deaths in the developing countries. Eighty six percent (86%) of these direct obstetric deaths are caused by five major med ical co mp licat ions: haemorrhage (28%); co mplications of unsafe abortion (19%); pregnancy-induced hypertension (17%); obstructed labour (11%); and infection (11%).[7] A co mplication can be defined in pract ical terms as an event of sufficient severity that staff must respond with a life-saving procedure or referral to another facility. The response required for these direct obstetric comp licat ions have been identified as the “signal functions of emergency obstetric care”. The fifth (5th) M illenniu m Develop ment Goal is aimed at improving maternal health through reduction of maternal mortality and provision of universal access to reproductive health by 2015. It seeks to achieve a 5.5% annual decline in MMR fro m 1990 levels. Globally the annual percentage decline in MMR between 1990 and 2008 was only 2.3% thus ma king the attainment of the goal difficult.[5] The maternal mortality rat io in Nigeria is unacceptably high and should be a concern of every Nigerian at all levels of governance; policymaking and imp lementation; service delivery and management. Maternal mortality reduction has been described as a key developmental goal (M DG 5) and as a basic human right. If staff in a facility cannot recognize a condition that requires an emergency action, quality of care will be undermined;[2] it is worse tragedy if these conditions are identified and yet there is a “want” of skill or knowledge of what to do. 1.1. Review of Some Studies done in Nigeria A study done in Osun and Ekiti states in Nigeria, among primary and secondary levels obstetric care providers, revealed a poor knowledge of EmOC. An alarming 91% of providers had poor knowledge of the concept. The study also assessed the operatives’ preferred strategies and practices for safe motherhood and averting maternal mo rtality; 70% of respondents still preferred the strengthening of routine ANC services to the provision of access to EmOC for all pregnant wo men who need it. There was gross disparity in what is said to be practiced and what was actually practiced based on the structured observations done, 40% o f the staff reported counseling clients on complication readiness but the structured observation revealed no staff did. On ly 9% o f the staff had ever been trained in life saving skills.[8]In another study done also in South- West geo-political zone of Nige ria, only 32.3% of obstetric care providers used partograph in monitoring labour, and only 37.3% of obstetric care providers, who were predo minantly fro m tert iary level of care, could correctly mention at least one component of the partograph. The partograph is a cheap and efficient tool for monitoring active phase of labour, and aids early detection and prompt management of obstetric co mplications. It is a mandatory intra-partum tool for all health facilit ies providing matern ity services in the Women and Child Friendly Health Services (WCFHS) in itiat ive.[9] In yet another study done in the South-West region of Nigeria to assess the changing patterns of critical obstetric care, a two consecutive 3 year period retrospective study was done. In this study, the definition of near miss morbidity was based on validated disease-specific criteria. Results revealed 175 near misses and 27 maternal deaths in 1999– 2001 and 211 near misses and 44 maternal deaths in 2002–2004. The “critically ill obstetric patient”- cause specific case fatality rates (CIOP-CFRs) for the two periods showed a declining (but non-significant) trend in the standard of emergency obstetric care for life-threatening conditions (13.4% to 17.3%, P=0.250). The CIOP-CFR for postpartum hemorrhage significantly increased fro m 3.1% to 21.1% in the 2nd period (P=0.033), reflect ing a decline in the standard of care. Lack of blood fo r transfusion became a mo re significant ad ministrative problem in the 2nd period Clinical M edicine and Diagnostics 2013, 3(2): 29-51 31 occurring in 17.8% of all critically ill patients managed in 2002–2004. There was a notable though statistically insignificant increase in the non-adherence to treatment protocol among cases of maternal death in 2002–2004 compared with 1999–2001.[10] A nationwide survey of availability of basic emergency obstetric care (BEmOC) in primary healthcare centers with midwives service scheme (MSS) in rural areas in Nigeria revealed that a mean of 70% of the centers had access to antibiotics for the treatment of uncomplicated sepsis; 11% were conducting vacuum extraction; 21% were able to perform manual vacuum aspiration. Only 40% in itiated treatment for pre-eclampsia, and 28% for eclampsia. 36.8% had provision for post abortion care; South-south zone had only less than third of their PHC delivering post abortion care; 21% had a functional manual vacuum as pirator set. The south-south zone had the least of these devices. 30% of midwives service scheme PHC were not treating wo men with uncomplicated sepsis. 27% had magnesium sulphate (MgSO4) available; 30% had misoprostol tablets and 12% had anti-shock garment[11]. Similarly, a pre-intervention needs assessment done in a local government of South-West Nigeria revealed a want in skilled health wo rkers in health facilities. A good proportion of health facilit ies (46%) were manned by unskilled health workers, and there was wide spread lack of equip ment and supplies. No facility met the criteria for a basic essential obstetric care; only one private facility (3.8%) met the criteria for a co mprehensive essential obstetric care.[9] 1.2. Review of Some Studies done outsi de Nigeria A study done in Kenya, East Africa, which looked at health workers’ preparedness in the provision of EmOCexp loring the comprehensive knowledge of action to take in the event of retained placenta, unsafe abortion and postpartum haemorrhage. Findings revealed that Less than 25% (<1/4) had good knowledge on what to do in the event of retained placenta and there was great disparity between hospital-based health workers (40%) and clinic and dispensary health workers (6%). Similarly, there was poor knowledge on post abortion care, with only 14% of health workers samp led having good knowledge. There was fair performance on quality of care to be provided in the event of postpartum haemorrhage: 42% of hospital-based workers had good knowledge, 21.3% and 6.3% respectively of health center, and clin ic and dispensary workers had good knowledge.[12] In a study done in New South Wales to assess the availability of postpartum haemorrhage protocol in health facilit ies; 94% of facilit ies that provided maternity services had protocols. Of these 94% facilit ies, 22% of the facilities had protocols that contained incorrect definit ion of PPH. Only 71% of the respondents from small rural and urban facilit ies received a copy of the protocol.[13] Similarly, in Zambia few health facilities provided the complete BEmOC (12%) and qualified professionals available 24hours per day. There is an urban/rural disparity in the distribution of health professionals with the urban provinces having more doctors and mid wives, wh ile so me rural prov ince do not even have one health professional. Only 42% of the facilities employed more than two doctors in their facility[14]Of the 1131 Zambian delivery facilities, 135 (12%) were classified as providing EmOC. Zamb ia nearly met the UN EmOC density benchmarks nationally, but EmOC facilities and health professionals were unevenly distributed between provinces. Geographic access to EmOC services in rural areas was low; in most provinces, less than 25% of the population lived within 15 km o f an EmOC facility. In another study done in Zimbabwe, it was found that only 26.1% of the hospitals fulfilled the criteria for CEmOC. Main reasons found for non-fulfillment were: shortage of drugs (including blood and blood products) in 54.1% (20/53), unavailability of equip ment in 21.6% (8/53), and shortage of skills in 18.9% (7/53).[15] Malawi had similar pattern like other Southern African countries, the signal function which required specific manual skills and specific equip ment were the least available. On ly 3.3% (2/ 60) of health facilit ies could perform vacuum extractions, 3.1% (2/ 60) could perform manual vacuum aspiration for retained products of conception, and 35% performed manual removal of placenta.[16] 1.3. Justification for the Study The Nigerian Nat ional Reproductive Health Po licy of 2001 targeted a 50% reduction in maternal mo rtality fro m a national average of about 800 deaths to 400 deaths/100,000 live b irths between 2001 and 2006, a 50% increase in access to safe blood transfusion services, EmOC for wo men of reproductive age and reproductive health information and services. 17Nigeria is also a signatory to the Millenniu m Develop ment Goals (M GDs) of the Un ited Nat ions member countries, goal 5 of which targets the reduction of maternal morta lity by 75% between 1990 and 2015 18, and the African Road map for the accelerated achievement of this goal. However, the country has made insufficient progress in the reduction of maternal mo rtality, with an annual percentage decline of MMR of 1.5%,5 the attainment of 75% reduction of 1990 levels by 2015 is a dis mal goal. EmOC is an intra-partu m strategy developed to help developing countries improve maternal health; if properly imp lemented, it is estimated to reduce maternal mo rtality by a quarter. While innovative programmes are ongoing in a number of states and local government areas with the support of UN agencies, bilateral donors, non-governmental o rganizat ions and the private sector, there is little concomitant politica l will on the part of political leaders who control resources, especially with regards to the placement, train ing and retention of skilled staff in public health facilities.1 It is therefore difficult to translate globally proven and effective remedies and technologies into action. The United Nations process indicator for EmOC3 is a set of monitoring tool developed to 32 Ebuehi Olufunke M argaret et al.: Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for M aternal Health Care in Rivers State evaluate the progress of EmOC strategy. Availability of EmOC facilit ies involves: the structure, manpower, equipment, materials and supplies. If others are availab le and manpower of the right mix, with the right skill is not available, the quality of service delivered will be inadequate and the desired goal of the strategy will not be achieved. This study attempted to provide useful info rmation on the knowledge, attitude and practice of health care providers on EmOC and the availability of resources for the provision of these services in public secondary health facilit ies in Rivers State. This thus assesses the current situation of the implementation of the EmOC strategy in Rivers State viz a viz rural-urban co mparison and thus indirectly assessing the River state government’s efforts at meeting the MDG 5. 2. Methodology 2.1. Study Location The study was done in Rivers State, located in the South-South geopolitical zone of Nigeria. It was created fro m the then Eastern region by Decree No. 19 o f the 1967. Before then, the territory was referred to as Oil Rivers Protectorate; a name derived fro m its abundant wealth in o il and gas deposits. It accounts for over 48% of crude oil produced on-shore in the country, and 100% of the liquefied gas export for Nigeria. The strategic importance of Rivers state in the economy of Nigeria, earned it the name, the treasure base of the nation. The state is bounded on the south by the Atlantic Ocean; on the north by Anambra, Enugu, Ebonyi, Imo , and Abia states; on the east by AkwaIbo m and Cross River states; and on the west by Bayelsa and Delta states. With a tropical climate, nu merous rivers and vast area of land, the people of Rivers state have lived up to their tradition of agriculture, especially fishing and farming, co mmerce and industry.[20]The state has a population of about five (5) million people according to the National Populations Co mmissions, 2005.[21] Rivers state with twenty three (23) local government areas has thirty eight (38) public secondary health facilities with each LGA having at least one. Out of the 38 public secondary facilit ies, there are 15 in urban areas and 23 in rural. Four (4) of the secondary facilities in urban centers do not provide matern ity services; they are specialist centers and clinics, this brings the eligible facilities to a total of 34. There are a total of 183 doctors and 1,068 nurses/midwives in the eligible facilit ies, with the urban centers accounting for 121 doctors and 625 nurses/midwives; and the rural centers accounting for 62 doctors and 443 n u rs es /mid w iv es .[2 2] 2.2. Study Design A comparative cross sectional design, exploring the knowledge, attitude and practice of obstetric care providers about emergency obstetric care. 2.3. Study Population This consists of doctors and nurses/midwives in government owned public secondary facilit ies in rural and urban areas in Rivers State. 2.3.1. Inclusion Criteria All government owned public secondary health facilities offering maternity services were included in the study. All doctors, midwives, and nurses who have been in their present unit (i.e. mate rnity unit) or fac ility in the last one year prior to the study were included. 2.3.2. Exclusion Criteria All govern ment owned secondary health facilit ies not managed by the hospitals management board of the state were excluded All doctors and nurses on training course and have not worked in the matern ity unit for one comp leted year prior to the study. 2.4. Sampling Methodolog y Multi-stage sampling was e mployed to rec ruit respondents in this study as described: 2.4.1. Stage 1: Se lection of Facilities There are 34 public secondary facilities eligible for this study; 11 urban and 23 rural. So, the facilities were picked in an urban/rural ratio of 1:2. The average staff strength for the urban and rural health facilit ies were 40 and 20 respectively; therefore to obtain 152 respondents in both areas, a simple random samp ling method was used in the selection of 4 urban and 9 rura l fac ilit ies. An additional rural facility was selected to make up for the skewed distribution of health care p roviders in the rural s ettin gs . 2.4.2. Select ion of Respondents A simple random samp ling method was applied in the selection of respondents at each facility. The nu mber of respondents required for each urban facility was 38 (152/4) while for rural facilit ies it is appro ximately 17 (152/9) respondents per facility. At the facilities, a list containing the names of doctor and nurs es/midwives was obtained from the management and by balloting 38 respondents for each urban and 17 for each rural facility were selected for the study. A facility checklist was administered in every facility selected for availab ility of resources in the labour ward, theatre and pharmacy units. 2.5. Data Collection Tools and Techni ques The data was collected with two survey instruments: the health worker KAP questionnaire and a facility check list, fro m primary source by emp loying quantitative technique over an estimated three weeks period (March –April 2012) . The self- ad ministered, questionnaire (adapted fro m a similar Clinical M edicine and Diagnostics 2013, 3(2): 29-51 33 study done in South-West, Nigeria.[8]) was administered to the respondents while at work. The questionnaire had four sections – The first section obtained data on the socio-demographics of the respondents, section 2 on their knowledge, third section on their attitude, and the fourth on their practices regarding EmOC. There were a total of 34 questions, 9 on socio-demographics, 11 on knowledge, 6 on attitude, and 8 on practice. The eleven (11) knowledge questions required respondents to choose either “YES” or“NO” option on their awareness of EmOC, sub-types of EmOC, co mponents/ signal functions of EmOC, awareness of obstetric complications, the major direct and indirect obstetric complications, awareness of the term “life saving skills” (LSS) and if they have been trained on any of the skills, elements of prenatal care and how they are ran ked. There are six (6) attitude questions in which respondents were to choose whether a particular pract ice, intervention or strategy was “Not Effective”, “Barely Effect ive”, “Fairly Effective” or “Very Effect ive” in maternal health service delivery. The questions included: antenatal prediction and prevention of obstetric complications and death, EmOC in improving maternal health and reduction of maternal mortality, the effect of training and re-fresher courses on EmOC delivery, ad min istration of o xytocin, controlled cord traction and uterine massage are in the management of retained placenta, and referral of a co mplicated case by a skilled birth attendant with LLS training. The eight (8) practice questions required respondents to choose fro m options that were listed under various practices such as: routine use of partograph, availability and use of obstetric protocols, management of retained placenta and management of severe hypertension in pregnancy. Also, they were required to indicate interventions, or treatments they have performed in the last three months prior to the study fro m a list of interventions and treatments listed in the q u es tio n n aire. In addition, the facility checklist (adapted from UNFPA checklist for planners1 and supervision checklist of the Ministry of health, Malawi[24]) was used to collect informat ion on the availability of resources (human and material) in the thirteen facilit ies visited. This was applied in three areas: the labour ward, the theatre and the pharmacy units; using a walk-through- survey technique. The head of each unit or any person delegated by the head or the management of the facility took an interviewer through each unit, showing him/her the equipment and supplies itemized on the checklist. The interviewer indicated Yes or No, depending whether they were available or not and the number for hu man resources. The interviewer was also required to make remarks, fo r instance if an equipment is working or not; and any explanation provided by the guide. There were t wo sections: section A, human resource, had six (6) items; section B, material and supplies, had three sub-sections. B1 - labour ward with 31 items; B2 - theatre with 22 items and sub- items; and B3 – pharmacy unit with 12 items. 2.5.1. Pretest The questionnaire and facility checklist were pretested in two public secondary health facilit ies, one in each setting (urban/rural) in Lagos state to identify and correct possible flaws and ambiguity in the questionnaire. Twenty (20) respondents for each facility were randomly selected and questionnaires were ad ministered. The facility checklist was also admin istered in each of the facilities. 2.5.2. Training of Research Assistants Six research assistants were selected to assist in data collection: two med ical doctors, four field workers with minimu m of secondary education. They were trained on the use of the questionnaire and checklist and also practiced simp le random sampling for respondents at the facility level. 2.6. Data Analysis Co mpleted questionnaires were checked for co mp leteness, errors and inconsistencies. Errors and inconsistent entries detected were verified and corrected by the concerned interviewe rs . The Epi info statistical software; 2008 version was used for data entry, validation, cleaning and analysis.Data presentation was done in frequency tables, percentages, means and standard deviations (SD). Student’s T-test was used to compare means in the t wo groups. Ch i square and Fisher’s exact tests were used to determine significant association between variables. Statistical significance was set at P< 0.05. To assess the participants’ knowledge, att itude and practice of EmOC, relevant questions fro m the questionnaire had weight attached to them to create composite scores. 2.6.1. Scoring Method For every correct option in knowledge and practice, a score of one (1) was assigned and every wrong option was scored zero (0). Interpretation of scores will be based on an adapted and modified Generic Grading Scale for Higher Education.[25] Respondents whose scores translates to greater than 66% were classified as having good knowledge of EmOC; those who scored between 34% and 66% were classified as having fair knowledge; those who scored between 0% and 33% were classified as having poor knowledge. Similar scoring was applied for practice; scores >60% were classified as good practice and <60% was poor practice. For attitude questions, mod ified Likert scale 0-1 was applied in the attitude question. Scores 0%-60% was classified as negative attitude and scores greater than 60% as positive attitude. Checklist for human resources was used to obtain the numbers on obstetricians/gynecologists, anesthesiologists/a 34 Ebuehi Olufunke M argaret et al.: Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for M aternal Health Care in Rivers State nesthetic nurses, general practitioners with midwife ry skills, midwives, nurses, pharmacists/pharmacy technicians, laboratory scientist/technicians in each facility v isited. The mean and standard deviations for each staff type was calculated and the student’s T-test was used to compare means in urban and rura l fac ilit ies. Material resources were recorded as availab le or not available, the nu mbers of facilit ies where a particu lar item was availab le was used to calculate percentage availability of each item in urban and rural areas. Then Ch i-square was used to find the significance of association in the two settings. 2.7. Ethical Considerati ons Ethical clearance was obtained from the Health Research and Ethics Co mmittee, Lagos University Teaching Hospital. Permission was obtained fro m the Hospitals Management Board, Rivers state, before p roceeding to carry out this study. Confidentiality of respondents was ensured; names were not required on the questionnaires. A written consent form was administered to all respondents. 2.8. Li mitati on of the Study Only government secondary health facilit ies were used, so the study may not be a true p icture of all secondary health facilit ies in the study area. The study design did not include other health workers that are not doctors and nurses. 3. Results 3.1. Socio-Demographic and Occupational Characteristics of Res pondents The age range of the urban and rural respondents were between 23 and 63 years and between 24 and 62 years respectively. More than three quarters of the respondents (82%(urban) and 85.9% (rural)) in both areas, were below 50 years. The mean age of respondents in the urban and rural areas were 37.8 (+10.0) years and 37.5 (+ 8.7) years respectively. There is no statistically significant difference in the mean ages of the respondents fro m both areas (p-value=0.803). More than two thirds ((68.9%, [urban] and (72.2%, [rural]) of the respondents in both settings are females. There is no significant difference in the sexes of respondents in both settings (p-value= 0.528). Approximately seven out of ten respondents fro m both (70.4% [urban], (73.3%) [rural]) settings are married. There is no statistically significant difference in marital status among respondents in both urban and rural settings (p-value =0.570). All the respondents in both settings are Christians (Table 1). Table 1. Socio-demographic charact erist ics of respondent s So cio -demog ra phi cs Age (years) Age range(years) Age Group (years) <30 30-39 40-49 50 and above Mean Age (SD)(years) Sex Male Female Urban 23-63 N=150 42 (28.0) 42 (28.0) 39 (26.0) 27(18.0) 37.8 (10.0) N=151 47 (31.1) 104 (68.9) Rural 24-62 N=149 26 (17.4) 67 (45.0) 35 (23.5) 21 (14.1) 37.5 (8.7) N=151 42 (27.8) 109 (72.2) X2 0.203 P value 0.653 0.25* 0.398 0.803 0.528 Marital Status Married Single Sep arat ed Widowed N=152 107 (70.4) 37 (24.3) 2 (1.3) 6 (3.9) N=150 110 (73.3) 34 (22.7) 0 (0.0) 6 (4.0) 0.322 0.570 Eth nici ty Igbo Ijaw Ikwerre Ogoni Others N=144 21 (14.6) 49 (34.0) 29 (20.1) 14 (9.7) 31 (21.5) N=139 4 (2.9) 54 (38.8) 22 (15.8) 19 (13.7) 40 (28.8) 0.890 0.345 Reli gion Ch rist ian ity Islam Others *Student’s T-test N=151 151(100.0) 0 (0.0) 0 (0.0) N=152 152 (100.0) 0 (0.0) 0 (0.0) Clinical M edicine and Diagnostics 2013, 3(2): 29-51 35 Variable Profession Doctor Midwife/nurse Table 2. Occupat ional charact erist ics of respondent s Urban N=152 66 (43.4) 86 (56.6) Rural N=145 51 (35.2) 94 (64.8) X2 2.115 P value 0.146 De signation Medical officer Nursing officer Others* N=152 42 (27.6) 85 (55.9) 25 (16.4) N=152 58 (38.2) 94 (61.8) 0 (0.00) 3.815 0.051 Ye ars in practice Ye ars in practice (range) <20years >20years Mean no. of years in practice (SD) N=146 1-35 126 (86.3) 20 (13.7) 7.94 (8.71) N=140 1-32 124 (88.6) 16 (11.4) 8.09 (8.74) 0.14* 0.889 *Students’ T-test. *Others (consultant obstetricians & gynecologists) More than half of the respondents in both urban, (56.6%) and rural, (64.8%) areas are nurses while doctors constituted 43.4% and 35.2% in urban and rural areas respectively. There is no statistically significant difference in the profession of respondents in both settings (p-value = 0.146) More nursing officers than medical officers constituted respondents in both settings; urban (55.9%) and rural (61.8%). There is no statistically significant difference in the designation of respondents in both areas (p-value =0.051). Years in practice ranged between 1-35years and 1-32years among urban and rural respondents respectively. Majo rity of the respondents had spent<20years in service (86.3% and 88.6% urban and rural respectively). The means number of years in practice for urban (7.94+8.71 years) and rural (8.09+8.74years) respondents are comparable with no significant difference between the two setting (p value = 0.889) (Table 2). 3.2. Res pondents’ Knowledge of EmOC Table 3. Respondents’ Knowledge of EmOC Variable Awareness of EmOC Types of EmOC known Basic Emergency Obstetric Care (BEmOC) Comprehensive Emergency Obstetric Care (CEmOC) Complete Emergency Obstetric Care (CoEmOC) Urban N= 152 146 (96.1) N=145 129 (89.0) N=138 106 (76.8) N=133 50 (37.6) Rural N= 152 148 (97.4) N=134 115 (85.8) N=127 91 (71.7) N=119 61 (51.3) X2 0.412 0.628 0.922 3.186 P value 0.521 0.428 0.337 0.029 Aware of the term “components of EmOC” Components of EmOC known IV anticonvulsant IV Oxytocics Applying FundalPressure N=152 139 (91.4) N=141 133 (94.3) N=139 127 (91.4) N=137 33 (24.1) N=151 123(81.5) N=128 114 (89.1) N=133 116 (87.2) N=127 29 (22.8) 6.462 2.475 1.228 0.058 0.011 0.116 0.268 0.810 Removal of retained products of conception IT N at ANC N=143 133 (93.0) N=139 63 (45.3) N=133 121 (91.0) N=129 68 (52.7) 0.387 1.462 0.534 0.227 36 Ebuehi Olufunke M argaret et al.: Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for M aternal Health Care in Rivers State Majority of the respondents were aware o f EmOC in both urban (96.1%) and rural (97.4%) settings; there is no statistically significant difference in the level of awareness among urban and rural respondents (P-value 0.521). Subtypes of EmOC known by respondents in urban and rural areas respectively are: BEmOC (89% and 85.8%), CEmOC (76.8% and 71.7%), and Co EmOC (not a component of EmOC) (37.6% and 51.3%). There is no statistically significant difference in the awareness of the BEmOC and CEmOC subtypes among the respondents (P-value 0.428 and 0.337 respectively). However there was a statistically significant difference in the awareness of the Co EmOC subtype between the two groups. Awareness of the term “co mponents/signal functions” of EmOC was high among the respondents, (91.4%) urban and (81.5%) rura l respondents were aware of the term. There is a statistically significant difference in the level of awareness among respondents (p=0.011). More u rban than rural respondents were aware of the term, indicating a positive association of this awareness with wo rkers in urban setting. Co mponents of EmOC as identified by urban and rural respondents respectively are Intravenous anticonvulsant [(94.3%) urban and (89.1%) rural, p = 0.116); Intravenous oxytocic was correctly identified by (91.4%) urban and 116 (87.2%) ru ral, p=0.268). Removal o f retained products of conception (93%, urban and (91%) rural, p=0.534).Applying of fundal pressure to aid delivery and distribution of insecticide treated nets at antenatal clinics we re erroneously identified by(24.1%) and(45.3%) p=0.810, urban; and 22.8% and(52.7%), p=0.227 rural respondents as being components of EmOC (Tab le 3). 3.3. Respondents’ Knowledge of Obstetric Complications, Life Saving Skills and Elements of Prenatal Care The awareness of the term “obstetric co mplications” was very high among respondents both areas; Postpartum hemorrhage (PPH) and pregnancy-induced hypertension (PIH) were identified by majority of the respondents as major obstetric comp lication. More rural, 91 (65.5%) than urban, 68(46.3%), p =0.001) respondents erroneously identified pregnancy induced hyper-emesis as being a major direct obstetric co mplication. The knowledge of major indirect obstetric complications was similar in both settings except for mu ltiple gestations and female circu mcision that were wrongly identified as major obstetrics co mplications by more rural than urban respondents. There were significant differences in the knowledge of these complicat ions among respondents in urban and rural areas (p= 0.011 for mu ltip le gestations and p=0.022 fo r female circu mcision). More urban compared to rural respondents knew these were not major indirect obstetric comp licat ions, indicating a positive association of this knowledge with the urban areas (Table 4). The awareness of the term “life saving skills” (LSS) was high among the respondents, 143 (95.3%) urban and 142 (93.4%) ru ral were aware of the term. More rural, 53 (36.6%) compared to urban, 39 (26.0%) respondents reported to have been trained in (LSS) p=0.05). Majority of those that were trained in LSS had good knowledge of the components of LSS; 81.6% urban and 65.2% rural respondents p=0.094). Respondents were required to rank the elements of prenatal care, the most important as 1 and the next as 2. On ly 36 (64.3%) urban and 17 (34.7%) rural respondents ranked birth preparedness as 1 and this difference in ran king was statistically significant different (p=0.002), more urban compared to rural respondents ranked birth preparedness properly. Th irty-nine (75.0%) urban and 25 (67.6%) rural respondents ranked complication readiness as 2 (p=0.346). Good knowledge of EmOC was demonstrated by 44 (28.9%) urban and 25 (16.4%) rural respondents. More rural than urban respondents demonstrated fair knowledge of EmOC; while 48 (31.6%) of urban and 58(38.2%) of rural respondents demonstrated poor knowledge of the concept (Table 5). There is statistically significant difference in the level of knowledge of EmOC among urban and rural respondents (P = 0.027); more urban compared to rural respondents had good knowledge of EmOC. Good knowledge of EmOC is positively associated with urban areas (Table 5). 3.4. Res pondents’ Attitude towards EmOC Majority of the respondents felt prenatal care is very effective in predicting and preventing obstetric complications and death. More rural, 126 (82.9%) co mpared to urban, 99 (66.4%) respondents think in this manner, (P= 0.001*). Almost all the respondents, 148 (97.3%) u rban and 147 (98.0%) rural, felt EmOC is effective in improving maternal health. Similarly most respondents, 121 (81.2%) u rban and 124 (82.1%) rural, felt EmOC is very effective in reducing materna l deaths. In addition, almost all the urban respondents, 149 (98.7%) and all the rural respondents, 152 (100.0%), felt t rain ing and re-fresher courses will improve EmOC service delivery in their facilit ies (Table 6). Admin istration of o xytocics, controlled cord traction and uterine massage were perceived as very effective techniques in the management of PPH secondary to atonic uterus; 126 (85.9%) urban and 132 (86.6%) rural respondents thought this to be very effective. More rural, 48.0% co mpared to 38.7% o f urban respondents thought a skilled birth attendant with life saving skills training should always refer comp licated cases to other centers (p=0.051). Majority of the respondents demonstrated positive attitude towards EmOC, only 10 (6.6%) urban and 6 (3.9%) rural respondents showed negative attitude towards EmOC (Tab le 6). Clinical M edicine and Diagnostics 2013, 3(2): 29-51 37 Table 4. Respondents’ knowledge of obstetric complications Variable Aware of the term “obste tric complications” Major dire ct obstetric complications include Post Partum Hypertension Postpartum psychosis Pregnancy Induced Hypertension Pregnancy induced hyper-emesis Pre-partum migraine Major indire ct obstetric complications include Malaria Anaemia Multiple gestations Seizures Female circumcision Urban N=152 152 (100.0) N=152 151 (99.3) N=149 72 (48.3) N=151 140 (92.7) N=147 68(46.5) N=147 87 (59.2) N=146 102 (69.9) N=148 119 (80.4) N=143 83 (58.0) N=144 61 (42.4) N=146 93 (63.7) Rural N= 151 148 (98.2) N=148 148 (100.0) N=138 43 (31.2) N=143 137 (95.8) N=139 91 (65.5) N=138 73 (52.9) N=141 93 (66.0) N=141 108 (76.6) N=127 54 (42.5) N=135 43 (31.9) N=135 67 (49.6) X2 3.050 0.974 8.788 1.286 10.679 1.142 0.502 0.622 6.484 3.291 5.248 *Fisher’s exact P value Table 5. Respondents’ knowledge of life saving skills and elements of prenatal care Knowle dge of life saving skill (LSS) Aware of LSS Trained in any LSS Knowledge of component s of LSS Knowle dge of elements of prenatal care Birth preparedness Ranked as 1 Urban N= 150 143 (95.3) N=150 39 (26.0) 31 (81.6) N=56 36 (64.3) Rural N=152 142 (93.4) N= 145 53 (36.6) 30 (65.2) N=49 17 (34.7) X2 0.520 3.825 2.8 9.155 Complication readiness Ranked as 2 N= 52 39 (75.0) N=37 25 (67.6) 0.907 Knowle dge categories Poor Fair Good N=152 48 (31.6) 60 (39.5) 44 (28.9) N=152 58 (38.2) 69 (45.4) 25(16.4) 7.261 P value 1.000* 1.000* 0.003 0.257 0.001 0.285 0.479 0.430 0.011 0.070 0.022 P value 0.471 0.050 0.094 0.002 0.346 0.027 38 Ebuehi Olufunke M argaret et al.: Emergency Obstetric Care: Urban Versus Rural Comparison of Health Workers’ Knowledge, Attitude and Practice in River State, Nigeria- Implications for M aternal Health Care in Rivers State Table 6. Respondents’ attitude towards EmOC Variable Urban Rural X2 P value* Effe ctiveness of pre-natal care (PNC) in pre dicting & pre venting obstetric com pli cati ons Not effective Barely effective Fairly effective Very effective N=149 0 (0.0) 3 (2.0) 47 (31.5) 99 (66.4) N= 152 1 (0.7) 1 (0.7) 24 (15.8) 126 (82.9) 10.361 0.001 EmOC is very e ffe ctive in improving mate rnal heal th? Yes No N=148 144 (97.3) 4 (2.7) N=150 147 (98.0) 3 (2.0) 0.160 0.493 Effe ctiveness of EmOC in re ducing Maternal mortality Not effective Barely effective Fairly effective Very effective N=149 1 (0.7) 2 (1.3) 25 (16.8) 121 (81.2) N=151 1 (0.7) 0 (0.0) 26 (17.2) 124 (82.1) 0.042 0.478 EmOC training will improve se rvices and obstetri c outcomes in my facility Yes No N=151 149 (98.7) 2 (1.3) N=152 152 (100.0) 0 (0.0) 2.020 0.248 Effe ctiveness of oxytocics, CCT& uterine massage in PPHmgt Not effective Barely effective Fairly effective Very effective N=149 2 (1.3) 2 (1.3) 17 (11.4) 128 (85.9) N=152 0 (0.0) 2 (1.3) 18 (11.8) 132 (86.6) 0.056 0.473 A skilled birth attendant (SBA) with LSS training in an EmOC facility, should Always refer complicated cases Rarely refer complicated cases Refer if it is the best option in that circumstance Never refer complicated cases to avoid mismanagement N=150 58 (38.7) 2 (1.3) 90 (60.0) 0 (0.0) N=152 73 (48.0) 3 (2.0) 76 (50.0) 0(0.0) 3.056 0.051 Attitu de Po sit ive Negat iv e *Fisher’s exact P value N=152 142 (93.4) 10 (6.6) N=152 146 (96.1) 6 (3.9) 1.056 0.304 3.5. Res pondents’ Practices of EmOC Services More urban, 113 (74.8%) co mpared to rural, 86 (56.6%) respondents reported routine use of partograph for active management of labour. This observed difference was statistically significant and indicated a positive association of use of partograph with urban setting (P=0.001). Reasons for non use of partographs among non-users in urban and rural areas respectively include, non-availability(68.4%) and (83.1%), not trained in its use (21.1% and 9.2%), use of partograph is co mplicated (0.0% and 4.6%) p=0.085). Only 43 (28.5%) urban and 50 (33.1%) rural respondents reported having obstetric protocols in their facilities (p = 0.383). The obstetric protocols frequently reported by respondents are protocols for the management of Pregnancy induced hypertension (PIH), urban (48.5%) and rural (29.4%); and protocol for the management of obstetric heamorrhage, urban (48.9%) and rural (40.0%). There is no statistically significant d ifference in these practices between urban and rural respondents (P = 0.897 and 0.510) Majority of the respondents in urban, 141 (95.9%) and rural, 137 (93.8%) will manually remove placenta in a case of retained placenta (p= 0.419). Approximately 8 out of 10 respondents(82.6%, u rban, 84.6% rural), correctly identified that vacuum aspirator should not be used in the management of retained p lacenta (P = 0.658). More u rban 87 (62.1%) co mpared to rural 65 (45.5)

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