Elsevier

Social Science & Medicine

Volume 58, Issue 6, March 2004, Pages 1109-1120
Social Science & Medicine

Prospects of safe motherhood in Botswana: midwifery training and nurses’ ability to complete the Botswana obstetric record

https://doi.org/10.1016/S0277-9536(03)00281-8Get rights and content

Abstract

This paper examines several key factors that determine nurses’ ability to complete the Botswana Obstetric Record (BOR), an instrument that should help with early diagnosis of problems during pregnancy, labour, delivery and the puerperium. Using a national sample of 309 nurses working in hospitals, clinics and health posts under the local government authority in Botswana, the study found that a nurse's ability to complete the BOR was significantly related to midwifery training, level of basic nursing training, age group, level of income, job satisfaction, adequacy of equipment, attendance of refresher courses, overall level of in-service training, reliance on workshops and seminars, peer reliance and self-reliance for information on new nursing practices. Multivariate analyses indicated that the most competent nurse in completing the BOR was one trained as a midwife, working in an adequately equipped health facility, and who often consulted with peers as well as attended workshops and seminars. The study concludes that it is more important to train all nurses to become midwives than to upgrade enrolled nurses to become registered nurses if the plan for safe motherhood is to be advanced. Further research is needed to establish the objective competence of nurses who claim to be comfortable completing the BOR.

Introduction

Of the more than half a million pregnant women who die each year from complications of pregnancy, abortion attempts, labour and childbirth (Panos Institute, 2002; Weil & Fernandez, 1999), almost all (99 per cent) are in developing countries (Boerma, 1987; McCarthy & Maine, 1992; Paul, 1993; Seipel, 1992). In many of these countries, problems of pregnancy and childbirth cause more deaths among women of childbearing age than tuberculosis, suicide, war injuries, traffic accidents, and AIDS (Weil & Fernandez, 1999). Yet, as much as 75 per cent of maternal deaths result from direct obstetric causes such as haemorrhage, obstructed labour, infection, toxemia and unsafe abortion, that could have been prevented with timely medical treatment (Bhatia, 1993; Seipel, 1992; Thaddeus & Maine, 1994).

In 1987, a major step was taken by international development agencies to reduce maternal mortality in developing countries by launching the safe motherhood initiative (SMI), at a conference in Nairobi, Kenya. The development agencies involved included World Health Organisation, World Bank, United Nations Population Fund, United Nations Children Fund, International Planned Parenthood Federation and the Population Council (Graham, Filippi, & Ronsmans, 1996; Koblinsky, Tinker, & Daly, 1994; Thaddeus & Maine, 1994). The SMI identified a broad and multifaceted range of issues in the life and health of women, which needed to be addressed by developing countries with the hope of reducing the high maternal mortality rates by at least 50 per cent by the year 2000 and by 75 per cent by year 2015 (Panos Institute, 2002). The issues identified at the SMI conference included: overall gender equality; expanded female education; employment and improved socio-economic status of women; health education and community sensitisation; improving health and nutritional status of women who become pregnant; increasing access to prenatal care; improving women's access to health services during pregnancy; improving quality of medical care available to women experiencing complications during pregnancy and delivery; providing proper obstetrical care; teaching on risk signal awareness; providing safe abortion services; strengthening maternity care; increasing access to and effective use of family planning; limiting childbearing to ages 20–39; and eliminating fifth and higher-order births (Da-Silva, 1992; Graham et al., 1996; Kane et al., 1992; Khan, Rochat, Jahan, & Begum, 1986; Koblinsky et al., 1994; Mbizvo, Fawcus, Lindmark, Nystrom, & Maternal Mortality Study Group, 1993; Thaddeus & Maine, 1994; Trussell & Pebley, 1984; Ward, Maine, McCarthy, & Kamara, 1994).

The importance of monitoring and responding in good time to maternal danger signs during pregnancy, labour and delivery, and the puerperium, which has recently been highlighted, was not a priority item in the SMI agenda (Koblinsky et al., 1994; Maine & Rosenfield, 1999). In many developing countries, the methods of monitoring pregnancy and identifying risk signals in pregnant women were either not well developed or were used inconsistently (Maine & Rosenfield, 1999). Before the SMI was launched, few specific measures to reduce high maternal mortality rates in developing countries were known and proposed at national and international meetings (Maine, 1985). As a result, by the middle of the 1990s, evidence from many developing countries indicated that little progress had been made (Turmen & AbouZahr, 1994), and prospects for future results were not promising (Pradhan, Pittrof, & Johanson, 1995; Smyth, 1994).

The importance of maternal and obstetric care in Botswana was highlighted when the safe motherhood task force was set up in 1990. The Task Force recognised the issue of clinical skills of health workers in obstetric care as a priority item (Republic of Botswana, 1993). As a consequence, the midwifery curriculum at the Institute of Health Sciences was reviewed and more emphasis placed on clinical skills. Practising enrolled nurse-midwives were required to be upgraded in clinical skills and provision was made available to train doctors and midwives working in maternity units to improve their skills in obstetric care. A manual for basic service standards in antenatal care and the management of obstetric emergencies was developed in 1994 and later reviewed in 1997 (Republic of Botswana, 1997b). With as much as 72 per cent of the pregnancy-related mortality and morbidity due to preventable direct obstetric causes such as obstetric haemorrhage, sepsis, pregnancy-induced hypertension and abortion (Republic of Botswana (1997b), Republic of Botswana (1998)), monitoring of pregnancy became an important strategy of maternal care in Botswana.

Attempts at monitoring pregnancy and identifying risk signals in pregnant women date back to December 1983 with the development of the Ramotswa Antenatal Risk Card and Foetal Growth Graph at the Bamalete Lutheran Hospital, in Ramotswa, South Eastern Botswana, under the then superintendent, Dr. Ian Kennedy. The Ramotswa Antenatal Risk Card and Foetal Growth Graph represented the first “obstetric record” in Botswana. It was helpful in monitoring and assisting with the management of childbearing women during pregnancy, labour and the puerperium (Foetal Growth Watching Group, 1983). However, it did not capture enough information required for critical antenatal and postnatal interventions, and it was not used nationally. In 1984, Dr. Kennedy teamed up with Dr. Lake (an obstetrician working for the Princess Marina Hospital, the national referral hospital in the capital city, Gaborone) and developed a more comprehensive “obstetric record”, which was to be used nationally. As a result, it was officially named the Botswana Obstetric Record (BOR) and launched in 1984 (Republic of Botswana, 1984).

When the Botswana government adopted the SMI programme in 1990, its primary tool for monitoring pregnancy was the BOR. The BOR has continued to play an important role in the monitoring of maternal health during all the reviews and implementations of the various aspects of the SMI in Botswana. The BOR was reviewed in 1997 and made more comprehensive to include information on Human Immunodeficiency virus (HIV/AIDS), which further enabled nurses, midwives and doctors to identify additional life threatening conditions for pregnant women. When the Maternal Morbidity and Mortality (MM & M) monitoring system was developed in 1998 to address the causes of MM & M on a continuous basis, the BOR was identified as a key instrument to collect relevant information. In January 2000, the most up-to-date version of the BOR was ready for use in all health facilities.

The BOR is a 21-page instrument (in the form of a booklet) that records critical information about pregnancy, including a mother's history of antenatal care, labour and delivery, the puerperium, postnatal care and family planning. It is designed to also capture the history of medications used by the mother and infant. When completed properly, the BOR should provide valuable information that should enable nurses, midwives and doctors to make early diagnosis of problems during pregnancy, labour, delivery and the puerperium that might threaten the lives of both mother and baby. The information obtained through the BOR can further be used for completing questionnaires for the MM & M monitoring system (Republic of Botswana, 1997b).

The job of completing the BOR falls squarely on nurses, who form the core of reliable permanent staff for reproductive health services, particularly maternity care in the Botswana Primary Health Care system. A significant component of the BOR involves the nurse using relevant equipment to determine the appropriate information to fill in. Examples of this include equipment for testing blood pressure, laboratory facilities for testing urine samples, manuals and facilities for performing a caesarean section, as well as a supply of relevant drugs for obstetric complications. Since most of the information recorded on the BOR is obtained using a range of equipment, the availability of adequate equipment as well as the nurse's ability to use such equipment should enhance her confidence in completing the BOR.

Even in the best and well-staffed hospitals, the medical doctors are usually required only during emergencies and may be routinely present only at labour and delivery time. At all other times, it is the nurses or midwives who monitor pregnancies and identify complications for effective intervention. Adequate recording and interpretation of critical obstetric information is necessary for timely response to emergencies, which may include referral to other health workers and medical specialists.

Non-midwife nurses constitute two-thirds of the nursing force in Botswana. This makes them the most accessible health care workers, especially for the mothers who routinely visit relatively isolated health facilities that include an estimated 314 health posts and 689 mobile stops nation-wide (United Nations Development Programme, 1998:37). In these health facilities, every nurse—including non-midwives is expected to do everything including maternal care, childcare, family planning, health education and the work of pharmacy technicians (Akinsola & Ncube, 2000). As a result, non-midwife nurses play a vital role in the monitoring and identification of maternal danger signs by completing the BOR and by assisting pregnant women who experience pregnancy-related complications in relative isolation.

It is important to determine and document how competent various categories of nurses such as enrolled nurses, registered nurses (RNs), midwives and non-midwives feel about collecting diagnostic information through the use of the innovative BOR. It is also important to document the extent to which nurses who have no formal midwifery training are involved in completing the BOR, and to establish the extent to which they feel competent in doing so. This study, therefore, explores factors that may help explain the differences between those nurses that feel competent in completing the BOR and those that do not.

Unlike the situation in North America where obstetricians play a significant role, African countries have by and large adopted the historically British practice whereby the midwife is responsible for looking after pregnant women and handling all normal deliveries. The role of the African midwife in maternal health has been expanded to include the provision of primary health care services, the training of other midwives, supervision of other health workers, conducting of in-service training, providing health education to women, families and communities, and providing team leadership in safe motherhood, family planning, and on knowledge about sexually transmitted diseases including the HIV (Nasah, Mati, & Kasonde, 1994). However, the International Confederation of Midwives, the World Health Organisation and the United Nations Children's Fund have noted that there are not enough midwives to support primary levels and provide life-saving skills pertinent to achieving the goals of reducing maternal mortality by 50 per cent in the near future (Nasah et al. (1994)), or by 75 per cent by the year 2015 (Panos Institute, 2002). As a result, maternal mortality continues to be a significant problem in the African continent.

Prompt intervention by trained midwives is a key factor in the treatment of obstetric complications, the reduction of maternal mortality rates, and in the success of the SMI. Raleigh (2000) has noted that prompt access to emergency obstetric care helped reduce maternal mortality rates in England from 441 per 100,000 women in the mid-1930s to 40 by 1960. In South Africa, differential access to obstetric care accounts for the large difference in maternal mortality between black women (150–250 per 100,000) and white women (3–8 per 100,000) (Raleigh, 2000). Evidence suggests that while the vast majority of obstetric complications can neither be predicted nor prevented, they can be successfully treated (Maine & Rosenfield, 1999) by trained midwives. Trained midwives have the competence to intervene by first recognising maternal danger signs that warrant referral, and by using relevant equipment to serve as emergency surgeons able to perform caesarean sections (Sachs, Beard, Papiernik, & Russell, 1995) without help from obstetricians.

A midwife is trained to give the necessary care and advice to women during pregnancy, labour and the postnatal period, to conduct normal deliveries on her own responsibility, and to care for the newly born infant. A well-trained midwife is able to recognise imminent danger through correctly interpreting the warning signs of abnormal or potentially abnormal conditions, which necessitate emergency measures (Loudon, 1992; Towler & Bramall, 1986; World Health Organisation, 1966). It has been noted that with appropriate midwifery training, midwives in Britain have greatly contributed to the reduction of the maternal mortality rate and continue to play a central role in providing maternity services (Loudon, 1992). Significant reductions in maternal mortality ratios (from 800 per 100,000 live births in 1751 to 227 per 100,000 in 1990) due to the introduction of formally trained and licensed midwives (as well as the introduction of aseptic techniques in the late 1800s) have been noted (Sachs et al., 1995).

The importance of midwifery training has been highlighted by previous studies of nurses in Botswana. Fako and Linn (1994a) found that nurses with midwifery training provided their clients with a complete set of prenatal assessments and were involved in supervising both health facility and home deliveries. Those without midwifery training were minimally involved in performing blood and urine tests, and hardly ever involved in providing important prenatal services such as vaginal, pelvic, and foetal examinations. Nurses without midwifery training were predominantly involved in the checking of vital signs (blood pressure, heart beat and lungs) and somewhat involved in physical examinations such as weight, nutrition, hygiene and varicosity. Fako and Linn (1994b) found that nurses without midwifery training ranked “the lack of midwifery training to fit IUDs” second on the list of barriers to service delivery, while midwives ranked it seventh. Many non-midwives reported that without midwifery training, they could not attend to women who wanted IUDs or perform complete gynaecological examinations on clients seeking contraceptive methods or devices.

Fako and Forcheh (2000) found that midwifery training was the single most important factor that enhances the extent of nurse's involvement in antenatal health education. Midwifery training has also been found to be the most important factor determining productivity among nurses in Botswana (Fako, Forcheh, & Balogi, 2002). Midwifery training, adequate equipment, subsequent professional experience and in-service training should equip a nurse with knowledge to recognise obstetric complications and relevant skills to apply obstetrics first aid when needed (Fako & Linn, 1994a; Fako et al., 2002). Midwifery knowledge and skills should enable nurses to approach clinical, antenatal and postnatal care with more confidence.

It is hypothesised that nurses with midwifery training should feel more comfortable completing the BOR than nurses without midwifery training. It is also hypothesised that nurses who work with adequate equipment at their workplace should be more comfortable completing the BOR than those who work with inadequate equipment. A nurse who is experienced in using the necessary equipment should develop competence to complete the BOR, and make appropriate obstetric interventions. The more resources nurses have for routinely dealing with obstetric emergencies, the more knowledge they should eventually gain to complete the BOR and be effective in circumstances requiring obstetric interventions. Similarly, nurses with high levels of training and opportunities for subsequent in-service training should be more comfortable completing the BOR.

Section snippets

Methods

The data for this study are a sub-sample from a larger national survey of 325 nurses in Botswana. The target population for the national survey comprised all nurses working in local government health institutions, which include primary hospitals, clinics with and without maternity facilities, and health posts. Nurses who did not fall under the local government health authority, such as those working in referral hospitals, private hospitals and clinics, schools of nursing and the University of

Description of the sample

The nurses in the sample were all females aged between 20 and 66 yr and deployed across 15 health regions nation-wide. These nurses included 70 RN-midwives, 15 RNs, 37 enrolled nurse-midwives, and 160 enrolled nurses. There were 197 nurses with Junior Certificate (obtained after 3 years of secondary school), and 83 with higher academic qualifications, mainly a secondary school leaving certificate. The most common type of health facility in which nurses were based was a clinic without maternity

Discussion and conclusions

This study has contributed to the discourse on safe motherhood by confirming the importance of trained midwives in the identification of risk signals in pregnant women, the subsequent treatment of obstetric complications and the reduction of maternal mortality rates. The study should extend the body of literature that has underscored the importance of effective monitoring and responding in good time to maternal danger signs during pregnancy, labour and delivery, and the puerperium (Koblinsky et

References (40)

  • T.T Fako et al.

    Changes in the nursing curriculum in Botswana, Pula

    Botswana Journal of African Studies

    (1994)
  • T.T Fako et al.

    Family planning, midwifery training and nursing practices in Botswana, Mosenodi

    Journal of the Botswana Educational Research Association

    (1994)
  • Foetal Growth Watching Group. (1983). The Ramotswa antenatal risk card and fetal growth graph: Instructions and...
  • W.J Graham et al.

    Demonstrating programme impact on maternal mortality

    Health Policy and Planning

    (1996)
  • T.T Kane et al.

    Maternal mortality in Giza, EgyptMagnitude, causes, and prevention

    Studies in Family Planning

    (1992)
  • A.R Khan et al.

    Induced abortion in a rural area of Bangladesh

    Studies in Family Planning

    (1986)
  • M Koblinsky et al.

    Programming for safe motherhoodA guide to action

    Health-Policy and Planning

    (1994)
  • I Loudon

    Death in childbirthAn international study of maternal care and maternal mortality 1800–1950

    (1992)
  • D Maine

    Mothers in perilThe heavy toll of needless deaths

    People

    (1985)
  • D Maine et al.

    The safe motherhood initiativeWhy has it stalled?

    American Journal of Public Health

    (1999)
  • Cited by (0)

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