Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana

Abstract

ObjectivesTo assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities.DesignCross-sectional Health Facility Assessment linked to population-based surveillance data.Setting7 districts in Brong Ahafo region, Ghana.ParticipantsMost experienced delivery care providers in all 64 delivery facilities in the 7 districts.Primary outcome measuresHealth worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant.ResultsVignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores.ConclusionsLack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care.Trial registration numberNCT00623337.

Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

“…In conclusion, we provided evidence that facility birth alone, in a setting with low facility capability 40 and provider skill, 41 does not confer any survival benefit for women or babies. Encouraging women to deliver in facilities that are unable to safely manage routine deliveries and complications might actually cause harm and be unethical 12, 60.…”

“…Of the 64 facilities offering childbirth care, 24 were classified as capable of providing high-quality routine care, 12 as capable of providing emergency obstetric care (EmOC), of which eight were capable of providing CEmOC, and five were capable of providing emergency newborn care (EmNC) 40 . Detailed information on methods and findings of this comprehensive health facility assessment have been published elsewhere 40, 41. Briefly, we used information on key signal functions, availability of drugs, equipment, and trained health professionals to create quality scores of different dimensions of care, including routine childbirth care, CEmOC, and EmNC.…”

“…Two vignette cases tested ability to diagnose and manage conditions that threatened the lives of both mother and baby—pre-eclampsia and severe antepartum haemorrhage. On average, providers mentioned 11 of 20 necessary actions correctly, with the number of correct answers ranging from one to 15 41 …”

The influence of distance and quality of care on place of delivery in rural Ghana

“…Distance and quality were also modelled in several alternative ways (see supplementary files ): distance to the closest facility of a certain quality level (using categorization as described above) and the highest quality facility within a certain distance. Furthermore, two alternative quality measures were evaluated: a simple score counting one point per signal function, per doctor conducting cesarean sections (up to 3) and per health professional (up to 3) at each facility (total maximum 32 points), and health worker competence as evaluated with two clinical vignettes (total maximum 20 points, for details see 23 ).…”

'Going off track': The consequences of barriers to Ghanaian midwives’ ability to provide quality care.

“…In Ghana, Lohela, Nesbit, Manu et al (28), have indicated that, apart from medical doctors, midwives are the most capable professionals at providing su cient quality emergency obstetric and neonatal care.…”