This study shows that the level of knowledge necessary to monitor and evaluate the labour process among skilled birth attendants in the study area is low. Younger age and higher levels of qualification were significantly associated with higher knowledge. Those who work in Kampong Cham scored significantly higher than those in the other two provinces. Previous training courses did not contribute to the current knowledge level.
The total number of deliveries in facilities of the study participants in 2017 were 8950, 12860, and 8509 in Phnom Penh, Kampong Cham, and Svay Rieng, respectively, which accounted for 22%, 47%, and 61% of all births in each province. This figure indicates that a substantial proportion of deliveries were conducted by trained health staff without a higher level of knowledge on monitoring the progress of delivery. Knowledge ensures quality of care through correct gathering and appropriate interpretation of information from parturient and foetus as well as translation of knowledge into practice. Sharing information on clinical course and its management plan facilitates practicing team medicine. Referring to the framework for quality maternal and newborn care proposed by Renfrew et al. [22], a lack of basic knowledge to monitor and evaluate the labour course hampers the ‘assessment of progress of labour’. Therefore, further practices will not be realised, including ‘promotion of normal processes and prevention of complications’ and ‘first-line management of complications’. Maintaining a sufficient level of knowledge is crucial to providing quality care, which contributes to reduce unnecessary morbidity and mortality both in mothers and babies.
This study has shown that age and qualification affected the level of knowledge. Cambodia experienced genocides during the Pol-Pot regime between 1975 and 1979 following a decade of civil conflict. Severe shortage of health care professionals and schools to provide appropriate training was a main issue in health service provision in Cambodia since the early 1980s. One-year training for ‘primary midwife’ and ‘primary nurse’ was created in 1989 to rapidly increase the number of health personnel, although the quality of the courses was untested and questionable [23]. A systematic review on the determinants of quality midwifery care has suggested that short-term training of birth attendants is far from the international standard [24]. However, the primary midwife course in Cambodia was maintained until 2015. Durations of undergraduate training are three and four years for secondary and bachelor midwives, respectively [25, 26]. This history and duration of education could be contributing factors for higher knowledge levels among bachelor and secondary midwives than for nurses and primary midwives.
Undergraduate training was observed to be insufficient, and the competency of health care professionals may be improved by the provision of postgraduate training. However, in this study none of the selected training courses has shown significant relationship with level of knowledge. Possible explanations for this finding are that the quality of the training was poor, or little effort was made to maintain knowledge after the training. Although it is difficult to evaluate the quality of the previous training retrospectively, we have confirmed that the selected courses contained appropriate modules for monitoring of labour and delivery. Trainers for the courses were experienced medical doctors or midwives from NMCHC; therefore, low quality of training was unlikely. Studies on training experience in neonatal resuscitation have shown that knowledge and skills deteriorate in the absence of active continuous education with mentoring [27, 28]. Studies on contributing factors of effective learning have shown that the learning environment in the work place and supportive supervision are key issues [29, 30]. Knowledgeable and skilled preceptors are required who can facilitate other staff members. However, in our study area the average number of birth attendants is 3.5 per facility (542 eligible persons in 157 facilities), and the number of bachelor holders is limited. Considering the shift work nature of health facilities, there would be little opportunity for birth attendants to share information on and discuss findings of labour courses with their colleagues. It implies that it is difficult to expect to conduct self-learning activities in each facility.
The Midwifery Coordination Alliance Team (MCAT) meeting, which was initiated in 2007 in Cambodia, is a mechanism to provide a link between midwives in health centres and hospitals as well as district staff. Its principle components are supervision and feedback for problem solving for common health centre issues, discussion on referred and complicated cases, and updating knowledge to refresh clinical skills [31–33]. Although a national plan intends to scale up the MCAT meetings to all districts [34], to date activities have been organised only in areas where external financial and technical supports are available. Of the three provinces in this study, currently only Kampong Cham has regular MCAT activity [35]. This may explain the higher knowledge level in Kampong Cham than in the other two provinces.
Substantial proportions of misclassification of monitoring items during labour were found in this study: 61% answered uterine contraction as a foetal condition; 44% answered foetal head descent and 26% answered foetal heart rate as maternal conditions; and 29% answered blood pressure as a progress of labour. The participants might have responded without due consideration and rather with an intention of increasing their score. If this is the case, it is a sign of lack of self-confidence, which is a part of professional wisdom of midwifery [36]. These findings also imply that their manner of comprehension was not well structured. As early as the year 1882, Lusk stated that midwifery practice should be based on physiological and pathological investigations, and as a natural outcome of scientific principles [37]. Science requires classification of a phenomenon to understand its background and nature. Important tools for classification in midwifery practice are basic medical sciences, namely physiology and anatomy. Therefore, the misclassifications of monitoring items during delivery imply a lack of understanding among the study participants of physiology and anatomy in pregnancy, labour, and childbirth.
Recall bias could influence the association between previous training experiences and the knowledge level. The study participants might not declare or even forget their previous attendance in training if it was more than several years prior. However, this potential bias would not affect much our findings. Those who did not declare previous training experience would have less knowledge due to a decline in their memory. Therefore, the direction of this potential bias would be to strengthen the relationship between the training experience and the score. However, our findings show that the experience has no significant relationship with the score.