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Thesis Submitted As Partial Fulfilment of the Requirement for the Master of Philosophy Degree in International Community Health

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Thesis Submitted As Partial Fulfilment of the Requirement for the Master of Philosophy Degree in International Community Health AN EVALUATION OF THE QUALITY OF CARE MIDWIVES PROVIDE DURING THE POSTPARTUM PERIOD IN NORTHERN BOTSWANA. BY TAPIWA MAVIS KEBALEPILE Supervisor: DR M.D., PhD., Johanne Sundby (University of Oslo). Thesis submitted as partial fulfilment of the requirement for the Master of Philosophy degree in International Community Health. Institute of General Practice and Community Medicine, The Faculty of Medicine, University of Oslo. June/2001 Dedication Firstly, my dedication goes to my late father Mr W.L. Mabutho and my mother Mrs Balathi Mabutho, who found it necessary to give care, love and send me to school. To my dear husband Dennis Kebalepile and daughters Buthu, Kene and son Tinaye for according me the opportunity to go for further studies, and for their valuable support, encouragement and patience throughout my study period in Norway. ii Abstract Objective: To assess the quality of care midwives provide to clients during the postpartum period. Design: A cross sectional descriptive qualitative and quantitative survey among 65 practising registered nurse midwives. They were interviewed and observed in health institutions while examining the mother and baby prior to discharge. A convenient non- probability sampling was used to identify and select respondents from 14 primary health care facilities in northern Botswana, who were actively involved in provision of maternal health services. Method: Direct personal interviews using semi-structured questionnaires consisting of open and closed ended questions and non-participatory observations were used to collect data from informants at their respective places of work. Results: Of the 65 midwives interviewed, a majority were females aged between 30- 39 years. Age and length of service were not significant predictors for type of service provided. Most nurses provide quality care during immediate postpartum period. A majority of nurses have good knowledge and practice in management of postpartum activities but there are some areas that are not well done. Findings further show that 9% of clinic nurses have poor knowledge in management of post delivery severe anaemia. Almost all nurses have good knowledge in promotion of breastfeeding including its benefits to mother and baby. However, a majority of nurses have good knowledge in most postpartum activities but poor practice on the same area. Almost all nurses have good knowledge in management of breast engorgement, follow-up care, counselling on family planning and pelvic exercises but have poor practice on the same elements. Most nurses provide limited information to women on the importance of the 6-8 weeks assessment. Among all facilities, a majority had sufficient supply of equipment and consumables, but less than half had family planning packs. Most clinic nurses have poor practice on examination of the baby. Conclusion: Many nurses have good knowledge and practice, and provide quality care during immediate postpartum period but not all. The need to provide refresher courses on Safe Motherhood for all nurses involved in obstetric care to improve their skills in identified weak areas is obvious. With close supervision, in-service training and support, there is scope for improvement. With rapid trend of short hospital stay and the impact of HIV/AIDS, most mothers will most likely need follow-up care and advice on breast-feeding, safer sex, self and baby-care or other problems that may arise. This study therefore recommends the development of nursing standards, maternal health audits and re-introduction of domiciliary nursing along other strategies to improve the quality of care. iii Table of Contents No. Subject Page Dedication……………………………………………………... ii Abstract………………………………………………………... iii Table of Contents. iv List of Tables, Maps and Figures. vii Glossary of terms used ………………………………………... viii Acknowledgement. ix List of Appendices…………………………………………….. vii Chapter One: Introduction and Background 1.0 Introduction and Background………………………………. 1 1.1 Description of Postpartum care………………………………... 1 1.1.1 Postpartum services in Botswana……………………………… 1 1.2. Background of the study……………………………………… 2 1.2.1 Administration…………………………………………………. 2 1.3 Transport and Communication………………………………… 3 1.4 Referral System………………………………………………... 5 1.5 Population……………………………………………………... 6 1.5.1 Population Momentum ………………………………………... 7 1.6 Economy……………………………………………………….. 9 1.7 Socio-economic Status………………………………………… 9 1.8 Fertility Levels………………………………………………… 9 1.9 Postpartum Care……………………………………………….. 11 1.9.1 Professional / Modern Care……………………………………. 11 1.9.2 Traditional Care: A Setswana Perspective…………………….. 12 1.9.3 Postpartum Period………………….………………………….. 13 1.9.4 Need / Purpose for the Study…………………………………... 13 1.9.5 Statement of the problem (see 2.1)……………………………. 14 1.9.6 Research Question……………………………………………... 14 1.9.7 Broad Objectives………………………………………………. 14 1.9.8 Specific Objectives…………………………………………….. 15 1.9.9 Operational Definitions………………………………………... 15 Chapter Two: Literature Review 2.0 Introduction……………………………………………… 17 2.1 Literature Review and Conceptual Framework……………….. 17 2.2 Regional and Global Maternal Health Status…………………. 17 2.3 Maternal Mortality…………………………………………….. 18 2.4 Maternal Morbidity……………………………………………. 20 2.5 Barriers to Utilisation of Maternal Health Services…………… 22 2.6 Problems Encountered during postpartum period……………... 25 2.7 Quality of care ………………………………………………… 28 2.7.1 Client’s view of Quality of care……………………………….. 29 2.7.2 Various Criteria to Monitor Quality……………….…………... 30 2.7.3 Women’s Concerns about Postpartum Care…………………… 31 iv No. Subject Page 2.8 Relevance and importance of quality postpartum care………... 32 Chapter Three: Materials and Study Methods 3.0 Introduction…………………………………………………... 33 3.1 Study Design…………………………………………………... 33 3.1.1 Materials and Methods………………………………………… 33 3.1.2 Study Area…………………………………………………….. 35 3.2. Setting for the study………………………………………….... 36 3.2.1 Population……………………………………………………… 37 3.2.2 Exclusions……………………………………………………... 37 3.3 Sampling……………………………………………………….. 37 3.3.1 Sample size…………………………………………………….. 38 3.3.2 Sampling Error and Bias………………………………………. 38 3.4 Variables………………………………………………………. 39 3.5 Instrument Development (Questionnaire)……………………... 40 3.5.1 Data Collection Process. ……………………………………… 41 3.6 Reliability And Validity.………………………………………. 42 3.6.1 Reliability……………………………………………………… 42 3.6.2 Validity………………………………………………………… 43 3.6.3 Comments to internal validity…………………………….…… 44 3.6.4 Comments to external validity………………………………… 44 3.7 Data Handling 45 3.7.1 Data Analysis (Statistical Aspects) …………………………… 45 3.8 Limitations of the study. ……………………………………… 45 3.9 Ethical Consideration ………………………………………… 45 3.9.1 Informed Consent ……………………………………………. 46 3.9.2 Compensation ………………………………………………… 46 3.9.3 Potential Benefits and Dissemination of result………………... 47 Chapter Four: Data analysis and Results 4.0 Introduction…………………………………………………... 47 4.1 Study Constraints……………………………………………… 47 4.2 Background characteristics……………………………………. 48 4.3 Breastfeeding and Breast care…………………………………. 49 4.3.1 Breast examination…………………………………………….. 51 4.3.2 Postpartum infections………………………………………….. 52 4.3.3 Postpartum anaemia…………………………………………… 54 4.3.4 Summary of Management of Postpartum Activities………….. 56 4.4 Postpartum Assessment………………………………………. 57 4.4.1 Examination of the baby………………………………………. 58 4.4.2 Examination of the mother…………………………………….. 60 4.5 Postpartum Family Planning and Exercises…………………… 62 4.6 Follow-up Care (Home Visits)………………………………… 63 4.7 Advice, Information / Counseling and Support……………….. 64 4.7.1 The 6-8 week’s Assessment…………………………………… 65 v NO Subject Page 4.8 In-service Training and Support……………………………….. 65 4.9 Equipment, Drugs and Logistics………………………………. 66 4.9.1 Equipment…………………………………………………….. 66 4.9.2 Drugs…………………………………………………………... 66 4.9.3 Logistics……………………………………………………….. 67 4.9.4 Summary………………………………………………………. 67 Chapter Five: Discussion, Conclusion And Recommendations 5.0 Introduction……………………………………………………. 69 5.1 Management of Postpartum Activities………………………… 70 5.1.1 Breastfeeding and Breast Care………………………………… 70 5.1.2 Postpartum Infections including sepsis………………………... 72 5.1.3 Postpartum Anaemia…………………………………………... 73 5.2 Examination of the Baby………………………………………. 74 5.2.1 Examination of the Mother……………………………………. 75 5.3 Postpartum family Planning and Exercises……………………. 77 5.3.1 Postpartum Family Planning………………………………….. 77 5.3.2 Postpartum Exercises………………………………………….. 79 5.4 Follow-up Care (Home visits)…………………………………. 80 5.5 Advice, Counseling and Support………………………………. 81 5.6 The 6-8 weeks Assessment……………………………………. 84 5.7 Equipment and Consumables………………………………….. 86 5.7.1 In-service Training and Support…………………….………… 87 5.8 Conclusions……………………………………………………. 87 5.9 Recommendations……………………………………………... 89 References……………………………………………………... 91 vi List of Illustrations Page Tables 1. Referral System in Botswana…………………………………. 5 2. Mortality and Health Indicators for Botswana……………….. 6 3. Utilization of Maternal health services……………………….. 10 4. Postpartum care in Developed and Developing Countries…… 11 5. Distribution of Maternal Mortality…………………………… 19 6 Distribution of maternal Ratios………………………………. 21 7 Impact of user fees on obstetric admissions………………….. 24 8. Demographic distribution of informants………………….….. 48 9. Management of Breast engorgement…………………………. 49 10. Steps to successful breastfeeding……………………………... 50 11. Common breastfeeding problems…………………………….. 51 12. Advice on puerperal Sepsis…………………………………… 53 13. Management of postpartum Severe anaemia………………….
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