Demographic information of the participants
A total of 26 nurses and midwives participated in the focus group discussions, 16 of whom were females and 10 males. More than a half were from Masaka district hospital (n = 14). The average age of participants was 32 years, ranging from 23 to 61 years. The level of education was predominantly the advanced diploma (A1) in midwifery with 14 of 26 participants having A1 level in midwifery. The majority of the participants had less than 10 years of experience in obstetric care (n = 18), and spent more than 10 hours per week providing obstetric care (n = 20). Table 1 shows the demographic characteristics of the participants.
Table 1
Participants characteristics ( N = 26)
| | | n (%) | |
Hospital Affiliation | | | |
| Masaka District Hospital | | 14 (54) | |
| Nyamata District Hospital | | 12 (46) | |
Gender | | | |
| Male | | 10 (38) | |
| Female | | 16 (62) | |
Education Level | | | |
| Midwife A0 | | 3 (11) | |
| Midwife A1 | | 14 (54) | |
| Nurse A0 | | 2 (8) | |
| Nurse A1 | | 5 (19) | |
| Nurse A2 | | 2 (8) | |
Years of experience in obstetrical care | | | |
| 1–5 | | 9 (35) | |
| 6–10 | | 9 (35) | |
| > 10 | | 8 (30) | |
Weekly workload in obstetrical care (hours) | | | |
| 0–5 | | 2 (8) | |
| 6–10 | | 4 (15) | |
| > 10 | | 20 (77) | |
Age, years, Mean (Range) | | 32 (23–61) | |
Abbreviations: % : Percentage | |
The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on their current practices, and (3) contextual factors influencing the delivery of BEmONC services. During the discussion of results, verbatim quotations were used to support the themes and provide evidence. More details on the main themes and sub-themes (Fig. 1) are presented in the text below, and are illustrated by quotations from the four focus group discussions.
Thematic framework
For each main theme, there were some associated key concepts that served as the sub - themes and resulted in the formation of the thematic framework shown in the Fig. 1.
Reflections to baseline research results
This was a reflection about the baseline survey findings on the knowledge and skills in the management of PPH and NR, and on a six months’ record review of the BEmONC outcomes - Apgar score and PPH progressions. The survey results indicated that the average knowledge score was 47.2% and the average skills score was 59.9% among 54 nurses and midwives interviewed for the survey [23]. The record review findings revealed an unstable newborn outcome (Apgar score < 7) following 10 minutes NR recorded in 62% (n = 78) newborn cases and an unstable maternal outcome (persistent bleeding ≥ 500mls) following PPH management recorded in 19% (n = 13) maternal cases. Under reflections to baseline research results, the sub-themes included reactions such as surprise, appreciation and shock, and explanations for the results which consisted of staff shortage, limited in-service training, lack of clinical guidelines, and lack of some essential materials.
Nurses and midwives admitted to being surprised by the survey and record review results. Some participants voiced appreciation of the research process, specifically receiving feedback on the baseline research results. They indicated that the research results presented to them, helped them reflect on their usual practice and to consider ways of improving the services that they provide.
“It is the first time we get access to the findings from all the surveys that have been conducted here by the research people, this is good even though our performance was not good, I think we need to improve on our knowledge, get refresher courses or read a lot” Midwife, Female.
Other participants said they were shocked by the realities of the performance of their departments, while others stated that they have always known that their performance was not optimum. The presented baseline results made some participants to consider ways to improve the situation.
“I know our department is not best performing due to some challenges we face here in district hospitals like the shortage of staff and lack of some essential materials, but these findings are not good at all. What can we do to address this issue? … I think the hospital administration need to take the lead to ensure safe environment of work here and help us get in-service trainings, it is really difficult to get them.” Midwife, Male.
Some participants thought that the reasons behind the low knowledge and skills scores was due to limited concentration while filling the survey questionnaires as they were thinking of the huge workload and this may have made them lose concentration.
“I think that the figures reflect the reality. But, I think the research was conducted while people were thinking of the work ahead. As a result of this, it is possible that some participants didn’t take time to answer the questions properly with enough concentration. They might simply have ticked the answers without thinking about them. That is my opinion” Midwife, Male.
Other possible explanations of the low knowledge and skills scores and the high records of unstable maternal and newborn outcomes, included staff related factors such as lack of skills where they describe the lack of in-service trainings as the main contributor.
“When we compare the knowledge and skills scores with the records, …. We can see that the figures from the records review also are too high (62% unstable newborn outcomes and 19% unstable maternal outcomes). It is still a fact that there is a serious problem regarding lack of skills or experience” Nurse, Female.
Another participant said:
“I think that the main reason is lack of regular and continuous trainings for us, … Continuous professional development is always needed not only to refresh but also to upgrade what one learnt at school, in other words, staff members regularly need training to get updates” Midwife, Female.
Another reason highlighted was the shortage of staff in the maternity department. According to nurses and midwives, the health system plays an important role in the provision of care which later affects patients’ outcomes. The unstable maternal and newborn outcomes were attributed to the health system structure with the main highlight on the insufficiency of staff.
“The biggest challenge is insufficiency of staff. Sometimes, you may need some assistance when dealing with newborn resuscitation or PPH and you fail to get someone to assist. In this case, you need to do everything by yourself and as a result you may not succeed in everything as it could have been if there were two of you” Nurse, Male.
Other participants voiced the need for adequate clinical guidelines that would be accessible and visible in the time of need, especially in case of emergencies, to help in decision making when dealing with birth complications such as PPH and NR.
“We need clinical guidelines to refer to regularly to provide better care to patients. The existing guidelines are not enough and not displayed in every labor room, … I think that the hospital should get more to have them displayed anywhere they may be needed” Nurse, Female.
The lack of essential materials was mentioned as another reason why there were high records of unstable maternal and newborn outcomes.
We might be in a situation where some materials, equipment and medicines are not available. Sometimes, there is a possibility of providing good service but when you fail to get what you need (materials) to provide such a service on time, there is a problem and you can’t succeed in your duties” Nurse, Female.
Self – reflection on their current practices
The participants’ narratives of lived experiences of providing obstetric care services in the study district hospitals revealed some insights into their current practices towards providing optimal BEmONC services. The discussions focused on team work, commitment to professional ethics, insufficient skills, learning opportunities and evidence-based clinical guidelines. Firstly, Participants discussed the importance of peer-support for improved BEmONC services provision, particularly with regard to the management of PPH and NR. They acknowledged the presence of a team work spirit among nurses and midwives.
“I am happy with the teamwork spirit in this hospital and I find this as motivation and support here. Though we have different tasks to perform here, I appreciate the way we work together” Nurse, Female.
Likewise, nurses and midwives indicated that sharing responsibilities is a significant enabler of good service provision. They link it to the issue of shortage of staff and high delivery loads. The mechanisms of supporting each other despite everyone’s allocated daily responsibility make the work possible with the support of good and timely communication.
“I like the fact that people working in maternity ward are good at communicating. I am saying this because when several deliveries are to take place at the same time, they would always call upon the coordinator to send in more staff members for support.” Midwife, Female.
In addition, Participants explained that their motivation which lead to their commitment to the professional ethics is a facilitator to better service provision. They discussed the value of wanting to save lives which keep them motivated to do whatever they can to care for women and newborns.
“I would like to say that we are motivated because we always wish to save lives. Of course, nobody would wish to experience newborn asphyxia. It is bad for any staff member. You would even get blamed for that. We are motivated and this has good impact on what we do. You can see that people like their job very much. You will see that we come not because we have to come but to save lives of mothers and newborns and to ensure that the work is properly done” Nurse, Female.
However, participants acknowledged the presence of insufficient skills to deal with birth complications among some nurses and midwives coupled with the lack of up to date clinical guidelines, which pose barriers to patient care. This was expressed as follows:
“The challenge I would raise is limited skills. Maybe it is not an issue for everyone but it is there. Among 5 team members, you may only find 2 with the skills that are required for newborn resuscitation” Midwife, Female.
Another participant stated that:
“Some nurses and midwives may not have enough skills to support the patients. For example, when it comes to cervical tear, they might fail to know how to suture the tear, thinking that it is only done by a doctor and remember that there is only one doctor assigned to maternity service” Midwife, Female.
Furthermore, nurses and midwives described the factors in respect of their professional development as significant contributors to the quality of obstetric care. The lack of in-service professional development courses was mentioned as a crucial barrier to quality BEmONC service provision. Participants stated a need to get access to regular in-service trainings and continuous learning opportunities to improve on their knowledge and skills which would positively affect patient outcomes. There was also a recommendation to promote the culture of reading among nurses and midwives.
“The big problem is that most of us do not have access to trainings and/or in -service professional development courses. Also, the culture of reading is not in us. We just keep doing things as we have always been doing.” Midwife, Male.
The study participants also mentioned the few learning opportunities that are available in the district hospitals which currently contribute to their continuous learning. These leaning opportunities include; mentorship sessions and clinical staff meetings. Participants agreed that those mentorship sessions improved their knowledge, skills and confidence, particularly with regard to maternal and child health care, and are key facilitators of evidence-based care provision.
“We nowadays have mentors from Rwanda Association of Midwives (RAM) and Ingobyi Project who give training to clinical staff. Trainings are provided to doctors, nurses and midwives working in maternity. Trainees meet and work with these mentors every month. They give training in obstetric care. Their support is essential and it has improved our ability in providing better services to mothers and newborns. Those from Ingobyi have given training to four staff members so far, two of these four cascade the training to staff in health centres. Those from RAM together with Rwanda Pediatric Association come here every month to train 3 people per month.” Midwife, Male.
In addition, several participants felt that nurses and midwives who have not yet participated in the mentorship program should be included in training when possible. For this to happen, the training frequency might be increased to reach more staff. Other related suggestions included pairing already trained staff with non-trained staff during work shifts to improve both care provision and learning. Participants also suggested that the mentorship sessions could focus more on birth complications such as PPH management and neonatal resuscitation.
“I would also like to say that a big number of staff members in maternity department have not yet participated in the mentorship program. The number is still too low. If the days of mentorship could be increased, everyone will get a chance to be trained. We need that the sessions focus more on PPH and neonatal resuscitation. Remember, some staff members are fresh graduates who only have knowledge without experience. I think they need a lot of continuous professional development trainings. Also having them on day or night shifts with the more experienced staff who have benefited from the mentorship would make the situation better” Midwife, Female.
Also, participants discussed the importance of clinical staff meetings that happen every morning to discuss obstetric care management. The meetings involve the presentation of cases of patients managed in the previous night as well as the hospitalized patients. The meetings also focus on the management of particular conditions in critical patients with senior staff advising junior staff. Nurses and midwives acknowledge these meetings as learning opportunities with real patient case presentations. Thus, helping them to improve the service provision. Participants also indicated that they have other educational meetings twice a week which are beneficial to their knowledge and skills refreshment.
“I think it is a good thing that we have staff meetings at hospital level to regularly discuss birth complications and related problems. We do not wait for these structured mentorship initiatives organized by external people. For example, in maternity ward, we also have educational meetings that are done on Wednesdays and Thursdays in addition to regular staff meetings that we have every morning. In these meetings, we talk about cases we have had and we thereafter have presentations about anything we think is useful. We often talk of PPH, eclampsia and helping baby breath. This is where emphasis is mostly laid to ensure that everyone working in maternity have basic skills in this. We also do some practices using the mannequins” Midwife, Female.
Further, nurses and midwives discussed the role of evidence-based clinical guidelines in continuous learning and in the provision of evidence-based obstetric care. Participants stated that they need clinical guidelines to support their service provision. However, they pointed out the insufficiency of clinical guidelines as an important barrier to quality service provision. They indicated that the few clinical guidelines available are not displayed wherever needed.
“I would like to add that clinical guidelines are important for us. Clinical guidelines are there but not enough. I think there is a need to have them available in more places including emergency area where we also have PPH cases to deal with. Those working with ambulance should also have the guidelines because they are the ones to take care of the PPH patient while being transferred. They should also be displayed in maternity, emergency and out-patient and even in surgery room and this should be done in a sufficient quantity. I don’t think they are available in health centres too. You may visit a place and notice that they don’t have a PPH guideline while they may have had 2 or 3 PPH cases in a month.” Midwife, Female.
Other participants indicated that the available clinical guidelines are not updated. They stressed that the availability of enough and up to date clinical guidelines would help them in clinical decision making while dealing with birth complications such as PPH and neonatal resuscitation.
“A staff member may not be in position to always remember what to do when there is a PPH or neonatal resuscitation. However, clinical guidelines are still few. Only one is displayed in the delivery room, it has been there for long ago and it is not updated.” Midwife, Female.
In addition, participants indicated the challenges with paper based clinical guidelines which are the only ones available. Participants cited the length, the difficulty to update and the deterioration with time as the main challenges of paper based clinical guidelines. They also stressed that it is hard for them to find time to read the non-summarized paper based clinical guidelines.
“There are few clinical guidelines: some are in file boxes and others are displayed on the walls…, it is hard to update these paper based-clinical guidelines and they could get deteriorated easily as time goes. The ones in file boxes are too long and it is unfortunate we do not read them- maybe reading is so difficult! People are too lazy to read or maybe don’t have time to read. You will hardly see someone reading the clinical guidelines in files boxes” Midwife, Male.
Finally, Nurses and midwives, in consideration of the evolving digital age, proposed to have the summarized electronic clinical guidelines which could be easily accessible and regularly updated.
“I have read on internet that in developed countries’ hospitals, there exist some form of electronic clinical guidelines that people consult on computers or smartphones. And, I think the easy way for us would be to have those electronic clinical guidelines that will be summarized, easily accessible for everyone and could be updated as science evolves.” Midwife, Female.
Contextual factors influencing the delivery of BEmONC services
Nurses and midwives indicated a number of context specific factors that influence the quality of care in BEmONC, particularly in the management of PPH and NR. Under contextual factors, the sub-themes included the realities of working in the context of district hospitals including the leadership and management, the staff shortage and heavy workload, the limited resources, the profile of their clients in relation to their socio-economic status as well as their socio-cultural beliefs and behaviors.
The participants highlighted the contribution of the leadership and management in ensuring the quality of obstetric care in the hospitals. Participants described hands on leadership, provided by departmental managers, ensuring that services were well organized and that staff were assigned to where they were most needed. The good organization of service within the maternity department was perceived as key to better service provision.
“We actually have a kind of task distribution and daily organization of the work by the maternity matron. When there is an emergency, for example in delivery room, those people in charge of different units get in touch and they may get support from each other by sending some members to help. The number of members to support will depend on the size of work to be performed. Such movements often happen between delivery room and hospitalization unit depending on cases.” Midwife, Female.
The participants described the support provided by the hospital management as enabling the service provision for the management of PPH and NR. They felt that the managers of the hospitals give a particular attention to maternal and child care which translate into more resources and supplies to the maternity department. They verbalized that:
“The maternity heads in collaboration with the hospital managers do all they can to have all we need in stock. This include also PPH and NR emergency kits and all other kits. We organize a morbidity day event in which we discuss birth complications and the Director General also attends the event. They take into consideration all our challenges in the provision of maternity care” Midwife, Male.
“What I can add is that we get a lot of support from the Hospital Management. Top management is very supportive and most importantly, the nursing leader is a midwife too. They are so sensitive about mothers. We usually get all equipments and drugs we need, even though sometimes, we run out of stock” Midwife, Female.
However, Participants described staffing shortages as a significant barrier to care provision. They explained it was common in district hospitals for two midwives or nurses to cover the waiting room, the emergency room, the labor room and the recovery room.
“There is a problem of workload. People here have too much to do. You may find two staff members in the maternity and when you have to attend to six mothers at once, you understand that it can’t work. As soon as a delivery has taken place, you immediately go to another mother without considering subsequent stages as you should and then monitoring PPH becomes hard. As a result, sometimes there may be some complications and you may fail to handle them on time” Midwife, Female.
Some participants stated that high number of deliveries per midwife made it difficult to perform well for every patient in need. They cited the poor staff/patient ratio, as an important barrier to good service provision in terms of dealing with birth-related complications. They stressed that the number of staff members is too low compared to the number of patients to take care of.
“I think there is a problem of staff/patient ratio. Monitoring also becomes very hard due to insufficient staff members. How can two midwives assist three deliveries at once? Who can meanwhile attend to those in the waiting room? Sometimes, you may end up finding the ones you left in waiting room suffering. The problem of insufficiency in staffing is crucial” Midwife, Male.
Then again, nurses and midwives stated that the low number of doctors assigned to the maternity department is a challenge to better service delivery. This is partly linked to the shortage of staffs in district hospitals.
“I think that availability of medical doctors is also a requirement for these cases of PPH and NR, however they are still few, one allocated to Maternity service daily” Nurse, Female.
Other participants felt that they need more specialist doctors like pediatricians when performing neonatal resuscitation and later for the recovery of the newborn.
“Another area to improve on is that we should also have a pediatrician to work with newborn resuscitation. The newborn resuscitation should not only be done by a midwife and a nurse. Sometimes, the newborn also needs antibiotics and a pediatrician would be in a better position to prescribe them. I think this is worth noting too” Nurse, Female.
Furthermore, participants highlighted the issue of staff rotations in different services and staff turnover as barriers to better service provision. They expressed concerns about staff rotations that is implemented by the health system in district hospitals of Rwanda. Staff, particularly nurses, are rotated to different clinical services such as maternity, pediatric, surgery and sometimes rotating to or from maternity. As a result, the rotating nurses, like new staff may not be familiar with dealing with birth complications and they may take time to get used to the routine work. Also, staff turnover was indicated as an important barrier in consideration of staff moving from one hospital to another hospital. When staff turnover takes place the origin hospital loses an experienced staff.
“We know well that we sometimes have staff rotations and staff turnovers in hospital- for example fresh graduates who have no experience and moving back and forth in different services. These new staff members might proceed with a given management of the birth complications without following the standard clinical guidelines” Nurse, Male.
Further, nurses and midwives discussed some of the resources challenge they face when dealing with obstetric emergencies. They cited lack of physical resources, including supplies and equipment, as a barrier to care provision. Resources such as oxygen cylinders, heating lamps for newborns, and suction bulbs were often unavailable or non-functional.
“…. We only have one suction bulb here, imagine if we have more than one neonatal who fails to cry after birth, what can we do with one piece only? When this happens, we face a serious problem. For the time being, we only have three penguins and one lamp…. These materials are not sufficient” Nurse, Female.
Another participant said:
“Another challenge is the problem related to availability and accessibility of some medications and materials. If I think of the number of deliveries we have here, they should match the quantity of equipment and materials needed for that purpose. I don’t understand how you can assist in 15 deliveries with only one heating lamp at night…. Sometimes, you may even fail to get oxygen cylinders because they are not there or not in sufficient quantities….” Midwife, Male.
Also, some participants described the persistent shortages of uterotonics, antibiotics and intravenous fluids. When medications were out of stock, patients or their family members were asked to purchase medications from outside pharmacies or, in emergency cases, nurses or midwives sometimes purchased medications for patients.
“We normally use oxytocin and cytotec. When we don’t have these drugs in our hospital pharmacy, the patient attendants go out to buy them in private pharmacy and it might be a bit too late to provide good service by the time they get back to us with these drugs” Nurse, Female.
Furthermore, nurses and midwives described the limited number of ambulances at the health centers level as an important barrier to better service provision. They highlighted that they receive some of the patients already in critical conditions due to travel delays related to the lack of transport/ambulances.
“The real problem starts at health centres because they may wish to transfer a mother with a complication but they fail to get transport for her. Some health centres do not have ambulances. You can see how much time it would then take for an ambulance to leave here and go to pick up that mother at a health centre. That ambulance will reach there when this mother is already in critical conditions” Midwife, Female.
Another contextual factor highlighted by nurses and midwives is the financial barrier among the patients. Participants described how financial barriers made service provision challenging for some patients. The lack of financial means for some mothers make them delay to present themselves to the hospital. And by the time they come, they are in a critical condition.
“Some patients are coming to hospital too late due to financial problems and in this case, both the mother and her baby have started to have some complications. It is a fact that sometimes, you fail to save a newborn’s life not because you didn’t have enough skills but because you started attending to the mother when the situation had gone beyond boundaries” Nurse, Male.
Participants also indicated that some patients cannot afford drugs and nurses and midwives cannot assist all of them with the emergency kits available which contain few emergency medications and materials. Other patients also get issues in transfer when they cannot afford the transfer fee.
“Another thing is lack of financial means by some patients to afford drugs. It is a fact that we have emergency kits to assist such patients but you may not get everything in those kits that is required for all the cases” Nurse, Female.
Another participant stated that:
“Sometimes we may have patients who cannot afford the services we provide. For instance, when we have a serious case to transfer, such a patient may not afford the transfer fee…When then time is being wasted discussing this, a patient might get in worse conditions” Midwife, Female.
On the other hand, nurses and midwives described low literacy and social-cultural and beliefs behaviors among mothers who visit the hospitals as contributing factors to the outcomes of delivery. Participants indicated that the use of traditional medications was prevalent in local communities. They indicated that most of the mothers coming to the hospitals for delivery, first take traditional medicines and these traditional medicines make the newborn suffer. As a result, the baby is born very weak and subject to neonatal resuscitation which is mainly hard to manage because the newborn in most cases has inhaled these traditional medicines.
“Nowadays, based on my personal observation, some mothers come to hospital after taking some traditional medicines and this leads to aspiration syndrome and make the resuscitation of a newborn difficult” Nurse, Female.
Another participant said that:
“I can add that there is a problem of literacy with the mothers we work with. They think that traditional healers help them to have live newborns. A large number of mothers who come here for delivery, they first take those traditional medicines. Such traditional drugs make the babies suffer a lot” Midwife, Female.
Other participants described an overall lack of awareness about the value of medical care during childbirth among some mothers who think that medical care is not enough that it has to be supplemented by traditional healers. There are misconceptions surrounding childbirth that mothers should take traditional medicines before delivery if they want to come up with a live newborn. Further, nurses and midwives expressed the need of health programs to increase the awareness of value of medical care during childbirth among the population.
“I think there should be initiatives to tell the mothers to stop taking traditional medicines. They should let these mothers know about the negative effects of these medicines and ask them to stop such practices. This is a common practice with mothers who come here and it really has a negative effect on the newborns they give birth to” Midwife, Female.