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Citation: Mekni K, Aridhi A. Efficient maternal referral: Impact of maternity care providers conditions. Jr. med. res. 2023; 6(1):6-8.

Mekni et al © All rights are reserved. https://doi.org/10.32512/jmr.6.1.2023/6.8

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Background

High maternal referral rate from peripheral maternity units is related to the

unfavourable working conditions in these inconvenient and extremely busy

labor wards. Through our study, we examined the correlation of midwives

working conditions on the maternal referral rate and its impact on the

obstetric and fetal prognosis .

Methods

This was a four-months descriptive cross-sectional study using direct eight-

parts questionnaire among thirty-seven midwives working in the different

maternity hospitals in Jendouba, Tunisa. The study assessed midwives

working conditions and analysed the correlation with the referral rate.

Results

The (30-40) age group was the most represented in the study sample.

Midwives had more than ten years of experience in 38% of cases

(n=14/37). They lived far from workplace (> 5 kilometres) in 62% of cases

(n=23/37). Ain drahem’s maternity ward had the highest referral rate

(59%). A negative relationship was found between the average score of

midwives' working conditions and the maternal referral rate (p=0.03).

Tabarka Hospital (score=5.4) had the lowest maternal referral rate

(12.72%).

Conclusions

Significant correlation was noted between the score of midwives working

conditions and high maternal referral rate.

Key words

Midwife; rural maternity; referral; risk ; prognosis.

1: Department of Obstetrics and Gynaecology, Mahmoud El

Matri Hospital, Ariania, Tunisia

2: College of Medicine, Tunis, Tunisia Tunisia

3: Health sciences and techniques High school, Tunis Tunisia

* Corresponding author

Correspondence to:

Karima.mekni@fmt.utm.tn

Publication data:

Submitted: November 5, 2022

Accepted: December 30, 2022

Online: January 31, 2022

This article was subject to full peer-review.

This is an open access article distributed under the

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Share: copy and redistribute the material in any

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the work provided must be properly cited and

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Mekni Karima

1,2

*, Aridhi Amal

Abstract

Original Article

Efficient maternal referral: Impact of maternity care providers conditions.

Efficient maternal referral: Impact of maternity care providers

conditions

Citation: Mekni K, Aridhi A. Efficient maternal referral: Impact of maternity care providers conditions. Jr. med. res. 2023; 6(1):6-8.

Mekni et al © All rights are reserved. Submit your manuscript: www.jmedicalresearch.com

Introduction

Since its independence, maternal and neonatal health

(MNH) has been one of Tunisia’s public health priorities.

Several strategies and programs have been developed

Implementation of maternity units and regional hospitals

allowed the improvement of maternal and child health

indicators. However, interregional disparities still exist. In

some regions, establishment of peripheral maternity units

did not improve the quality of services with an objective

trend to abusive referral [1,2]. This study was conducted

among midwives working in several maternity hospitals of

Jendouba, Tunisia. The aim was to establish a score-

based assessment of the work conditions and to analyse

its interference with the decision making.

Table 1: Maternity units team composition

Maternity

unit

Jendouba

Tabarka

Gardimao

Fernana

Aindrahem

Boussalem

Midwives

Staff nurses

On call midwife

On call nurse

specialist doctor

Materials and methods

This was a four-months qualitative descriptive study

based on a questionnaire survey of midwives practicing in

maternity units of the governorate of Jendouba , Tunisia.

Questionnaires were directly delivered to the included

health practitioners after two random tests of readability

and comprehensibility. Data collected from the survey

performed in eight maternity units, referral logbook, and

the delivery registers of the regional maternity hospital.

To rule out correlation between midwives work conditions

and maternal referral rates, a "practice conditions" score

was developed and calculated for each midwife (ten items

scored1-0). For the referrals, the data included: age of

the parturient, the reason for transfer and the feedback

from referral hospital. Data was analysed using

IBM

SPPSS

26.0. effectiveness of the elaborated score

was tested using the ROC curve method. The study was

approved by the ethics committee.

Results

Midwives were aged 30 to 40 years old in 38% of cases ,

from Jendouba governorate in 86% of the cases and were

married in 89% of cases (n=34/37). Thirty seven percent

of the included midwives had more than ten years of

experience. The workplace was located more than 5

kilometres far in 62% of cases with no personal transport

in 89% of cases. Midwives were not satisfied with their

assignment in 67% of cases (n=25/37). They were not

satisfied with the salary in 94% of cases (n=35/37). No

internal promotion was noted in 81% of cases (n=30/37).

For usual obstetrics cases, all midwives are assigned to

perform deliveries, episiotomy and the first care of the

normal newborn in the delivery room. Experience with

perineal tears repair was noted in 64% of cases

(n=24/37). Midwives performed imminent and breech

deliveries while on call in 37% of cases. Forceps or

vacuum extraction were never applied.

Midwives have little or no supervision. No continuous

nursing education and workshops participation were noted

for more than 80% of cases. Only 11% of midwives were

up to date with the latest practice guidelines.

The work environment was considered satisfactory in only

25% of cases. They were able to plan their vacations

without problems in only 51% of cases(n=19/37). For job

stability, the assignment was fixed in only 10 cases, so that

midwives could work in the same year in different

establishments of the region: either in the peripheral

maternity hospital, in the mobile team, or in the maternal

and child protection centre. The composition of the team

was a source of unsatisfaction for 75% of midwives

(28/37). The lack of regular obstetrics and gynaecology

doctor was noted in 46% of the questioned staff (Table 1).

Lack in admission and monitoring basic equipment was reported by

54% of the interviewed midwives (20/37). The number of delivery

tables was insufficient in 27% of cases (10/37). Availability of

consumable materials ranged from 28 to 78%. For the newborn care,

94% of midwives stated having the necessary equipment (35/37).

The highest number of admissions was registered in the Ghardimao

maternity unit (508) followed by the Fernana unit (410). Maternal

referral rate in these units was 52.7% and 48.54% respectively.

Aindrahem unit had the highest referral rate (59%; 159 admissions).

(Table 2). In the unit of Jendouba , a triage is done and if needed, the

patients are referred to the capital. According to our survey, 65% of

the midwives (24/37) have preestablished systematic referral

checklist. Eight midwives did not find it applicable in all conditions.

Reasons for referral were variable. Fetal distress was found in 16% of

cases, preterm premature rupture of membranes(PPROM) in 15% of

cases, and a scarred uterus in 10% of cases. referred parturients were

in the first stage of labor in 50% of cases. 5% of them had reached

the third stage and 1% had given birth in the ambulance.

Table 2: Maternity units Workload.

Maternity

Admissions

Deliveries

Referral

Jendouba

Referral

Tunis

Jendouba

3021

2725

296

9.8%

Tabarka

330

288

12.72%

Fernana

410

211

188

48.54%

Aindrahem

195

59%

Boussalem

337

198

125

41.24%

Ghardimao

508

240

139

129

52.75%

Distance to the referral hospital was superior to 20 kilometres in 78%

of cases. The ambulance was well equipped for possible imminent

delivery in 81% of cases. However, it was not adapted for maternal and

neonatal resuscitation in 94% of cases. The parturient was

accompanied by a nurse or midwife in all cases. Administrative referral

difficulties were noted in more than 50% of cases. Based on the

information collected from surveyed midwives, a score of practice

conditions has been elaborated and calculated for each maternity unit.

The score value was variable. Mean individual score was 113.6. Mean

score per unit ranged between 2.5 and 5.4. Only one maternity out of 6

has reached the average (Tabarka unit). (Table 3).

Table 3: Maternity units practice conditions score.

Maternity

Practice conditions mean score

referral rate

aindraham

2.5

43%

Bousalem

3.8

37%

Fernana

46%

Ghardemao

2.4

27%

Jendouba

4.58

10%

Tabarka

5.4

Efficient maternal referral: Impact of maternity care providers

conditions

Citation: Mekni K, Aridhi A. Efficient maternal referral: Impact of maternity care providers conditions. Jr. med. res. 2023; 6(1):6-8.

Mekni et al © All rights are reserved. Submit your manuscript: www.jmedicalresearch.com

Table 4: Practice conditions score.

Criteria

Score calculation

Experience

<5years=0 ; >5years=1

Distance to Workplace

>5 km=0 ; <5km=1

Supplies

Insufficient=0 ; Sufficient=1

Available physician

No=0 ; yes=1

Satisfactory assignment

No=0 ; yes=1

Satisfactory salary

No=0 ; yes1

Satisfactory work atmosphere

No=0 ; yes=1

Need for workplace change

No=0 ; yes=1

Experience with neonatal death

No=0 ; yes=1

Adherence to perinatal national programs

No=0;yes=1

The analysis showed an objective influence of personal and

work-related factors on the maternal referral decision(p=0.03).

subjective factors that really interfere with the midwives decision

making in a measurable entity via the practice conditions score.

The results confirmed its correlation with the referral statistics.

The score could be used to assess healthcare practitioners

personal and work-related conditions to identify national public

health priorities.

Conflicts of interest: none

Discussion

The quality of services delivered in rural maternity units by

affiliated healthcare practitioners has been rarely studied in

literature. Our study conducted in six north-western Tunisian

units highlighted several difficulties. Results allowed the

analysis of working conditions on the midwives decision making.

Familial commitment,far work location and absence of assigned

transportation were the most previously cited professional

barriers [3,4]. Designated midwives for rural units are usually

fresh graduated or short experienced. In our study, more than

third of studied midwives have less than 5 years of experience.

This rate was 65% in the governorate of kef and 64.3% in

Ugandan study [5]. Unsatisfaction about work conditions and

allowances noticed in our study are cited in a Canadian which

identified insufficient remuneration as the main cause of

resignation of providers in peripheral units [6]. The difficult

access to the continuing nursing education and career

improvement was the other main reason according to some

other studies [7-9]. Placement in rural maternity units during

the training of students is not mandatory could create some

skill discordance between midwives of the same rural unit team

[10]. A Scottish study confirmed that working in the peripheral

units decreases professional development [11]. These

conditions can clearly explain the high rate of maternal referral

observed in rural maternity clinical practice. Concordant studies

results showed that personal unsatisfaction, the impossibility of

skills development and the absence of adequate technical

platform make the healthcare decision trend to the referral for

any reason [12-15]. In our study we tried to transform several

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Conclusions

Implementation of peripheral rural maternity units with the aim

of relieving obstetric departments in central hospital is curving to

fail. Challenging work conditions and the lack of adaptation of the

affiliated staff is objectively interfering with the decision making

and contributing to unjustified high maternal referral rate.