Demographic characteristics of health care workers
Participants were 12 midwives and four doctors including one specialized in obstetrics and gynaecology. Participants’ ages ranged from 23 to 48 years. All participants were trained in newborn resuscitation and 12 of them had received the training within less than six months from the interview. Thirteen of the health care workers had worked in a maternity unit for a period of more than a year. Details of the participants’ socio-demographic characteristics are shown in Table 1.
Table 1: Demographic characteristics of participants
Characteristics
|
Frequency
|
Age category
|
|
20-29
|
8
|
30-39
|
5
|
40-49
|
3
|
Sex
|
|
Male
|
4
|
Female
|
12
|
Health care workers’ qualification
|
|
Diploma Midwife/Nurse
|
6
|
Certificate Midwife
|
6
|
General Doctor
|
3
|
Specialist Doctor (Obstetrician/Gynaecologist)
|
1
|
Health care workers’ level of Health facility
|
|
Hospital
|
10
|
Health centre IV
|
1
|
Health Centre III
|
5
|
Years of Experience in Maternity care
|
|
Less than 1 year
|
3
|
1-5 years
|
8
|
6-10 years
|
3
|
More than 10 years
|
2
|
Time since training in neonatal resuscitation
|
|
Six months or less
|
12
|
7 months to 1 year
|
2
|
More than 1 year
|
2
|
Categories
In the following section, we present the main categories that emerged from the data and illustrate these with quotes from our interviewees. Data analysis yielded the following four categories: i) Understanding of and actions for foetal distress and BA, ii) Challenges of managing foetal distress and BA, iii) Expectations and blame from the community, and finally iv) Health care workers’ insights into the prevention of BA. A diagrammatic presentation of the analysis for one category is presented as Table 2 in Appendix 1.
Table 2: Analysis framework for the category “Understanding of and actions for Foetal distress and Birth asphyxia”
Open coding
|
Sub-categories
|
Category
|
Defining foetal distress
|
Knowledge of foetal distress
|
Managing foetal distress and birth asphyxia
|
Diagnosis of foetal distress
|
Confirmation of foetal distress
|
IV fluids/rehydration
|
Interventions for foetal distress
|
Lateral positioning and repositioning
|
Oxygen administration to mother
|
Referral to a higher level facility
|
Expediting delivery
|
Reassuring the mother
|
Consultation and team work
|
Failure to initiate breathing
|
Knowledge of Birth Asphyxia
|
newborn not breathing well
|
failure to gain normal respirations
|
newborn is blue, baby is floppy
|
Apgar score less than 7
|
Apgar score of 3 to 1 are difficult
|
Severity of birth asphyxia
|
Resuscitation
|
Interventions for Birth Asphyxia
|
Suctioning of the newborn
|
Using ambubag to resuscitate
|
Keep the newborn warm
|
Giving 10% dextrose
|
Using drugs like aminophylline
|
Giving oxygen
|
Referral to higher facility
|
Category 1: Understanding of and actions for foetal distress and birth asphyxia
Knowledge regarding foetal distress
Health care workers defined foetal distress according to the Ugandan guidelines. In some cases, different cut off values for the foetal heart rate were given such as above 150 or below 110 beats per minute. To confirm the signs of foetal distress, health care workers monitored foetal heart between and immediately after the contractions, and more frequently to ensure that the diagnosis was right.
“A normal foetal heart ranges from 120 to 160. So when the foetal heart is below or above that range then it means the foetus is going to distress. That’s why we always have to listen to the foetal heart the moment they come. And that’s why it’s important for us to count to know the normal from the abnormal one.” Midwife#14, Health Centre III
Interventions for foetal distress
Rehydrating mothers was the most common action that was taken to manage foetal distress by giving intravenous (IV) fluids such as Normal Saline and 5% Dextrose. Participants reported giving fluids as the first intervention because most mothers were thought to come to the facility dehydrated or very hungry. However, it was noted that some health care workers would delay to refer women for up to two hours while waiting for the foetal heart rate to normalise during intravenous fluid administration. Lateral positioning and giving oxygen were mentioned as other ways to manage foetal distress. Women were referred to the health centre IV or the hospital for a caesarean section when the initial interventions such as giving fluids and change of position failed to lead to normalisation of the foetal heart rate during the first stage of labour. During the second stage of labour, health care workers reported that they administer IV fluids, augment the labour with oxytocin and encourage the mother to push to enable quick delivery. Rarely, births were completed using vacuum extraction.
“…if you identify a mother who is having foetal distress you monitor more frequently like the foetal heart rate with your Pinard [Fetoscope] at the same time you start some other intervention and put on an IV fluid put the mother on the lateral side and then you start monitoring the foetal heart rate sometimes they improve depending on the cause.” Doctor#2, Hospital
Knowledge about birth asphyxia
Health care workers described BA as low Apgar scores of less than 7 or when the infant is born and does not cry. The timing when the Apgar score would be considered BA was rarely specified. Statements like “when the baby is not breathing well”, or even “failure to gain normal respiration” or “failure to initiate breathing” were used to define BA. Health care workers mentioned signs and symptoms such as chest in-drawing, nasal flaring, grunting, gasping, blue skin colour and lack of cord pulsations as indicators of BA. There was an attempt to classify the degree of severity of BA using the Apgar score. Generally, babies with Apgar scores of 3 or less were said to be difficult to resuscitate due to severity of BA.
“Birth asphyxia is when a baby is born then it is having a score of less than 7. A baby may come out and doesn’t cry immediately after birth, the baby is blue, the muscle tone is poor, doesn’t feel anything –if you touch it doesn’t feel-the senses are not there, definitely that baby will have asphyxia.” Midwife#5, Health Centre III
Interventions for birth asphyxia
Health care workers performed resuscitation using an ambu bag and bulb syringe to manage BA. Stimulating the newborn, suctioning, and positive pressure ventilation using the ambu bag were mentioned as aspects of resuscitation. In newborns with in meconium stained liquor, suctioning was said to be the first option while other health care workers prioritized providing warmth. There seemed to be a lack of clarity on how deep to suction during resuscitation.
The urgency of conducting the resuscitation to prevent severe asphyxia was expressed through the narratives of the health care workers.
“…the first thing you have to provide warmth to this baby, then you check the airway if it is meconium you suck it away. You do suction and normally during suction you have a stimulator to see if it can pick up, if after all this you fail then you start bagging [bag and mask ventilation] the baby. Another thing is to act as quickly as possible.” Midwife#13, Hospital
Giving 10% dextrose to newborns was said to help babies who are not breathing since they could be having hypoglycaemia. Using drugs including aminophylline, dexamethasone and atropine during resuscitation was frequently mentioned by midwives at the Health Centre III level. Oxygen was also considered helpful during resuscitation.
“Maybe if you do that and it fails maybe; it’s hypoglycaemia that is making the baby like that because with hypoglycaemia there will be reduced oxygen supply to the brains, so the moment you give dextrose it might also improve”. Midwife #12, Health Centre III
Category 2: Challenges of managing foetal distress and BA
Complexities of the referral system
One of the major challenges to managing both foetal distress and BA was the referral system. Health care workers called upon the sub-county ambulance based at the Health Centre IV to be available to transfer women. However, the one ambulance was not sufficient to serve all the health centres in the catchment area. In addition, lack of fuel, ambulance breakdown, and lack of drivers were commonly reported which lead to referral of women and newborns using motorcycles (boda-bodas). In other facilities, midwives waited for private or public transport vehicles on the road side to take the referred mothers to the next level of care and paid for transportation of the woman.
Health care workers did not have the possibility to escort the mothers when they worked alone at the facility or when the mother had to go by a motorcycle so they followed-up by phone. Due to the limited resources at the first level and other levels of referral, health care workers preferred to refer to the regional referral hospital directly.
“Sometimes you call the ambulance and they have no fuel so these mothers have to go on bodas (motorcycles)... You know it’s not easy in the darkness [at night]; those are challenges.” Midwife #15, Health Centre IV
Refusal of referral
Another challenge was that mothers with foetal distress themselves sometimes declined referral to higher level facilities. Therefore, health care workers had to convince and explain to the women that the lower health centre did not have the ability to manage foetal distress. Some of the reasons why mothers refused referral were; lack of money to cater for the personal costs of being admitted and having had an established relationship with their midwife at the lower level facility which lead to reluctance in being cared for by a different health care worker.
“First of all, mothers themselves are really an issue. Sometimes they refuse the referrals-they don’t want to go. So it makes us delay with the mother –convincing, delaying, talking… You find that a mother whom you have talked to about referring during antenatal; labour starts and she comes here, …like there was one who had previous uterine scar, she came here yet we had referred her. She told us [that] she wants us to first try…”. Midwife#14, Health Centre III
Lack of supplies and equipment
Limited resources made it difficult to offer appropriate care for foetal distress and BA. At the lower level facilities, participants mentioned lack of oxygen as a challenge during and after newborn resuscitation. This meant that midwives have to refer unstable newborns to a facility 20 -25 kilometres away to receive oxygen. At the Health Centre IV level, an oxygen concentrator was used to provide oxygen to newborns. This oxygen concentrator uses a solar power source, which is unreliable because its power gets depleted often especially at night. The inadequate power supply not only affected oxygen delivery but also there was no adequate lighting to perform other procedures at night such as emergency caesarean sections or inserting intravenous lines.
“I think, more so like in our case, we may have a gap in management of asphyxia like we don’t have oxygen, so for the babies we refer, if at all we had oxygen we could keep them here.” Midwife #5, Health Centre III
“Our theatre is there, fully functioning but there is no equipment. […] Here we have no blood bank and its risky. You can’t have an operation without a blood bank…” Midwife #15, Health Centre IV
Equipment for resuscitation were available but not always in condition for immediate use. Health care workers pointed out situations when all equipment was unsterile yet there was a newborn with BA. They perceived the lack of drugs such as aminophylline, dexamethasone and 10% dextrose as a barrier to effective care for babies with BA. A special room for neonatal care was said to be lacking in lower level facilities including the Health Centre IV. Because of this, sick babies were managed in the labour ward or postnatal ward with many other mothers around and no considerations for warmth which put the small for age and preterm babies at an increased risk of death. Continuity of care after resuscitation was inadequate and so some babies deteriorate even after successful resuscitation.
“There is need for a special place for babies with birth asphyxia during observation period. This is not available at most health centre IIIs.” Midwife #14, Health Centre III
“…because babies normally die after resuscitation you resuscitate a baby and comes up very well now the continuous care tend[s] to forget [be forgotten] ...” Doctor#2, Hospital
Human resources challenges
Health care workers talked about staff shortage and absence from duty as a barrier to appropriate care. Sometimes, they had to call upon other non-competent staff members to assist during neonatal resuscitation. For example, a midwife called upon a nurse or nursing assistant to help with newborn resuscitation while she managed postpartum haemorrhage. In cases where both the newborn and mother experienced complications the health care workers were in a dilemma to decide who would get attention first. Working alone was a recurring challenge at all levels of care. Team work was reported to be important, yet in many situations, participants said it was difficult to achieve due to understaffing or absence of responsible health care workers from the facility. Consultations were made by phone calls to seniors or colleagues sometimes using the health care worker’s personal phone and airtime. Health care workers sometimes had to independently make decisions to ensure quick interventions for mothers with emergencies.
“The number of staff; like if you are on duty and you are only one, so handling two people at ago because when the baby comes out with asphyxia the baby needs you and the mother still here also needs you so that is the main challenge.” Midwife#6, Health Centre III
Category 3: Expectations and blame from the community
Participants reported that the community’s expectation is for every pregnant woman to leave the hospital with a live infant despite the condition of the mother. Health care workers therefore felt under pressure from the community and caretakers to achieve this expectation. Ensuring that babies were born alive was described as hard work and a struggle by health care workers to save lives. Sometimes, health care workers were blamed by attendants and family members for causing the BA.
Therefore, they tried to have an effective and continuous communication with the attendants and the mother in order to create trust and reduce incidences of blame.
“They expect us to work so hard and deliver a live baby, they expect that we have to do something, and that if the baby comes out like that [with birth asphyxia] we have what it takes to save the baby.” Midwife#14, Health Centre III
“And sometimes when you leave the attendants out and you are alone with the mother and then the mother delivers and the baby has asphyxia they will blame you the midwife.” Midwife #5, Health Centre III
Participants reported that communities perceived BA to be caused by witchcraft or due to something wrong that the mother did during pregnancy. Therefore, the blame was apportioned to the mothers. The caretakers believe that if a mother does not push adequately, she is lazy or she was inactive during pregnancy; this could cause her infant to be born with asphyxia. Caretakers (mostly mothers’ in law) were said to abuse the mothers by slapping or threatening them that the infant will die if they do not push. Midwives reported that relatives can even ask for an episiotomy to be performed if they think the mother is not pushing adequately.
“If the mother was not pushing enough they will blame the mother directly and sometimes they even end up slapping the mother in the labour ward. ‘If you don’t push the baby, you end up going home with only clothes and the like and they don’t want that to happen so they encourage the mother to push harder… Sometimes they tell me[midwife] that if the mother is not pushing you cut her [do an episiotomy] ...” Midwife#5, Health Centre III
Category 4: Health care workers’ insights into prevention of foetal distress and birth asphyxia
To prevent BA, health care workers emphasized that mothers should be taught to come early in labour and not in second stage. Ensuring that mothers understand the signs of labour and when to seek health care was also mentioned to be important. Further, the study participants said that it is key to screen women from early on and to identify and manage risk factors for BA such as pre-eclampsia, malaria and anaemia. Health care workers strongly emphasised that adolescent pregnancies should be avoided since BA was more common among younger mothers.
“… only that we need to sensitize the community for early antenatal, strengthen school programs to adolescents to avoid early pregnancies…” Midwife#15, Health Centre IV
“Screening mothers with risk factors from antenatal and then when you get them, you have to explain to them the impact of child birth and then you make early referral to a higher level of management. Then we can also treat some conditions early; like pre-eclampsia…” Midwife#16, Health Centre III
Preventive measures suggested during labour included proper hydration of mothers by encouraging them to drink tea and other fluids. Proper labour monitoring, pelvic assessment and taking action in case of any abnormality was another way to prevent asphyxia. Companionship during labour was said to reduce stress and BA. Health care workers at the referral facility recounted that they had not been preventing BA but only fighting it after it has happened. This was due to the late referrals with already existing complications. At this level, skills in newborn resuscitation were said to be the only way to prevent complications of BA.