In South Africa, maternal healthcare guidelines are distributed to primary health care (PHC) facility for midwives to refer and implement during maternal healthcare services. Different training was offered for the use of maternal care guidelines. However, poor adherence and poor implementation of guidelines were discovered.
This study aimed to develop and prioritise strategies to improve the implementation of maternal healthcare guidelines at PHC facilities of Limpopo province, South Africa.
Strengths, weaknesses, opportunities and threats analysis and its matrix together with the nominal group technique were used to develop the current strategy. Midwives, maternal, assistant and operational managers from PHC facilities of the two selected district of the Limpopo province were selected. Criterion-based purposive sampling was used to select participants. Data collection and analysis involved the four steps used in the nominal group technique.
Strategies related to strengths and weaknesses such as human resources, maternal health services and knowledge deficit were identified. Opportunities and threats such as availability of guidelines, community involvement and quality assurance as factors that influenced the provision of maternal healthcare services were identified.
Researchers formulated actions that could build on identified strengths, overcome weaknesses such as human resources, explore opportunities and mitigate the threats such as quality assurance. Implementation of the developed strategies might lead to the reduction of the maternal mortality rate.
South Africa, like other countries, is utilising maternal healthcare guidelines derived from World Health Organization (WHO) to provide quality maternal healthcare to pregnant women.
In qualitative studies conducted by Ramavhoya
The quantitative descriptive cross-sectional study was conducted on 60 managers to determine the support offered to midwives in the implementation of maternal healthcare guidelines. The study revealed that staff shortage, material resources, inadequate supervision and monitoring of midwives by facility managers and district maternal health care managers (DMHCMs) and unsatisfactory facility visits by DMHCMs contributed to the substandard implementation of the guidelines. Although support through training was highly noted, it did not cover all midwives.
Talking about the studies conducted by Fulmer, Braddick indicated that unfair distribution of resources, infrastructure and capabilities, skills and competency levels of some midwives were amongst the aggravating factors influencing high maternal morbidity and mortality rate.
In developing the current strategies, researchers used the steps of Pearce,
The Nominal Group Technique (NGT) was utilised for the group to identify and prioritise strategies to address the issues from the SWOT analysis and to elaborate on the actions needed to implement these strategies (phase 2). During this process, the researchers collected both qualitative and quantitative data where ideas were brainstormed, listed and discussed followed by ranking through voting and agreed upon by all members of the group.
The population suitable for phase two were Provincial and District maternal healthcare managers, operational managers (OMNs), assistant managers and midwives working at the PHC facilities. The sampled members of NGT were given the SWOT matrix a week before the strategy development meeting to familiarise themselves with the matrix and for the group to have a voice in the development and prioritisation of the current strategies. This also ensured that participants had scientific evidence of phase one and their experiences in rendering maternal healthcare services played an essential role in developing the current strategies. Nominal Group Technique was appropriate for this study as it allows participants to participate without discrimination and intimidation from other participants, and the consensus is reached amicably.
This study was conducted in the PHC facilities of the Vhembe and Mopani districts in the Limpopo province, where maternal health guidelines should be implemented. The two districts form borders with neighbouring countries of Zimbabwe, Botswana and Mozambique and are experiencing a high influx of clients from Zimbabwe and Mozambique. Both districts are rural and consist of 223 PHC facilities including community health centres. Most of the PHC facilities consist of 4–7 professional nurses with 4 or 5 midwives and fewer advanced midwives. Fourty (40) to 50 pregnant women per month are seen in most clinics and 50–60 for community health centres. Deliveries at both levels of care range from 20 to 40 per month. Some facilities render 24-h services (call system) with community health centres operating day and night shifts, whilst others offer 12-h services. The PHC facilities use the supermarket approach to provide comprehensive PHC packages. Although, currently, the PHC facilities are using an ideal clinic realisation approach which involves three streams grouped as mother and child, minor ailment and chronic care streams.
The population consisted of OMNs, DMHCMs, provincial maternal health care managers, assistant managers (AM) and midwives of the two selected districts of the Limpopo province. The criterion-based purposive sampling method was used to select maternal healthcare services’ experts with more than five years of working experience in maternal healthcare and participated in phase one of the study.
One provincial maternal healthcare manager (MHCM) was selected as she oversee the programme within the province. Four midwives (two from each district) were selected as they are providers of maternal healthcare guidelines, two OMN (one from each district) as supervisors of midwives in PHC facilities. The two DMHCMs oversee maternal healthcare services within each district and two AMs (one from each district) as overall supervisors of PHC facilities. They also monitor maternal healthcare services in the local area. As the NGT usually involves the selection of 5–12 participants,
The researchers sent invitations to all who participated in the NGT. Eleven experts in maternal healthcare services met with the moderator and her assistant a week later on the date, time and place agreed with the group. Together with the researcher and her assistants, experts in maternal healthcare services worked as a team of researchers in developing the current strategies. The group was given the SWOT analysis matrix to familiarise themselves with the matrix’s content and help them make a final decision. On the meeting day, the researcher acted as the moderator and facilitated the group. The moderator welcomed the group and explained the purpose of the meeting, which was to develop and prioritise strategies that will improve midwives’ implementation of maternal healthcare guidelines by midwives based on the results of phase 1 inclusive of the five articles. The moderator presented the SWOT analysis matrix to the group clarifying any misunderstandings. The moderator then divided the group into four and instructed each group to discuss and write down their ideas following building on strength, overcoming weakness, exploring opportunities and minimising threats (BOEM) that can be used in the development of the current strategies. Participants were given 20 min to brainstorm the strategies using BOEM actions in silence. The moderator asked each group one by one the strategies that they wrote whilst the moderator’s assistant was jotting them down on the flip chart, for which no discussion occurred. This process was repeated until all the ideas were written down. Written ideas were discussed one by one so that group members get clarity of the listed ideas and add their inputs that will uplift the listed strategies.
Data analysis was performed simultaneously with data collection as the NGT allowed the process to be performed simultaneously.
Priority strategies to building on strength and overcoming weaknesses.
Ranking | Strategies on strength and weakness | Total scores | Actions to be taken to build on strength and overcome weaknesses |
---|---|---|---|
1 | Availability of human resources | 74 | MHCM to develop scheduled site visits to support PHC facilities Integration of programmes for OMNs to supervise and monitor the implementation of maternal healthcare services Filling of vacant posts and remunerations for seconded OMNs Hiring of more midwives who will support each other in managing pregnant women Clubbing of PHC facilities together to relieve the shortage of midwives |
2 | Knowledge deficit leading to difficulty and frustrations amongst midwives | 70 | Allocation of advanced midwives to each PHC facility Capacity building through various training programmes, including ESMOE Allocation of two midwives to manage pregnant women |
3 | Provision of maternal healthcare services | 69 | Referral of pregnant women for further management HIV counselling offered, need for human resource and test kit. Consolidation of registers to reduce the workload Purchasing of ambulances designated for maternal health Provision of anti-eclamptic drugs in facilities with shortages Inclusion of drugs that prevent eclampsia, magnesium sulphate and uterotonics on the reporting system To offer 24-h services to promote access to maternal healthcare services Designing maternal obstetric units and building maternity hospitals for high-risk women and those who are lost to follow-up and poor access. Provision of park homes in facilities with fewer consulting rooms |
MHCM, maternal health care manager; OMN, operational manager; ESMOE, essential management of obstetric emergencies; HIV, human immunodeficiency virus; PHC, primary health care.
Priority strategies to explore opportunities and minimising threats.
Ranking | Strategies | Total scores | Actions to be taken |
---|---|---|---|
4 | Quality assurance | 68 | Monthly facility assessment and peer reviews to be conducted Monthly perinatal meetings conducted Quarterly value clarification/workers for a change meeting Client satisfaction surveys to be conducted Clinical audits of records to be conducted Change attitude midwives and women to promote co-operation Incorporation of cell phone remainders in the Mom-Connect programme |
5 | Availability of PMTCT, maternity care guidelines and protocols | 66 | Positive attitudes of midwives towards guidelines Packaging all PHC guidelines electronically |
6 | Community involvement | 65 | Training of home-based carers and life orientation on maternal health issues Accompaniment of pregnant women to PHC facilities for delivery |
7 | Reduction of waiting times | 63 | Consolidation of registers to avoid duplications;
Use of appointment strategies Provision of park homes to communities without PHC facilities |
PMTCT, prevention of mother-to-child transmission; PHC, primary health care.
The strengths and opportunities were enablers for the organisation to achieve its objectives, whereas weaknesses and threats were regarded as harmful for the organisation to achieve its goals, and these must be manipulated.
From
The strengths and weaknesses were discussed together. To build on strengths and overcome weaknesses, the following strategies were indicated and ranked according to their priority: Availability of human resources, knowledge deficit and provision of maternal health services.
Successful implementation of maternal healthcare services needs appropriate structures, including MHCMs, OMNs, midwives and other support staff. In this study, researchers identified that MHCMs and OMNs were available as strengths although there was a lack of support to midwives who provide maternal healthcare services. To build on it, researchers will work with MHCMs in developing scheduled site visits that will enhance the support visits to midwives working at PHC facilities. This will enable managers to monitor the implementation of maternal healthcare guidelines. According to Roets,
The findings shown in
This study included the PMTCT guidelines assessment to guide midwives during maternal healthcare services. The findings of this study revealed the availability of HIV counselling services in all PHC facilities. As such, the Saving’s Mother Report of 2014–2016 reported a reduction in some maternal death caused by opportunistic infections related to HIV and acquired immune deficiency syndrome (AIDS).
Provision of maternal health services requires transferring pregnant women to the next level of care, which is the hospital, especially in obstetric emergencies such as PPH, pre-eclampsia or eclampsia. The barrier to facilitate this process was delayed ambulance response by ambulance services caused by the shortage of ambulances which was identified by researchers. One of the departmental core standards is for ambulance services to arrive at the PHC facilities within 60 min of being requested by midwives.
Hypertensive disorders in pregnancy were rated number one as the most common cause of maternal death in African countries.
The survey data are analysed and are used to formulate corrective measures. Researchers corroborated that failure of conducting surveys and clinical audits could be a threat.
Researchers identify the availability of maternal guidelines and protocols that guide midwives in caring for pregnant women – advising midwives to develop a positive attitude towards the guidelines as a tool that shows their management. In collaboration with the National Department of Health, they must ensure that all PHC guidelines are packaged electronically and made available to all midwives to facilitate their implementation and improve quality care. Other researchers also indicated the use of technologies such as e-learning as a strategy with effective results.
Community involvement is crucial in maternal healthcare service delivery; without the community, the facility will not function properly as its inputs play an essential role in community mobilisation. Most of the PHC facilities allow accompaniment of pregnant women by family members, especially during delivery. An action to facilitate and arrange meetings for traditional leaders, clinic committee members and home-based carers to influence the community on accompanying pregnant women to the PHC facilities, especially for delivery was indicated. This form of support by family members will enable midwives to implement the maternal guidelines with ease because some pregnant women when they experience labour pains, refuse to listen to the advice given by midwives. According to Ezeonwu,
One of the ministerial priorities is reducing the time where a patient is supposed to wait where the healthcare service is offered.
The developed strategies focus on the selected maternal health conditions and may not be applied to other medical conditions and other settings. The NGT process was completed in one day and some of the strategies might have been elaborated on further if more time was available.
This study aimed on developing and prioritising strategies to improve midwives implementation of maternal healthcare guidelines. The NGT group was invited to be part of the current strategies development. The strategies identified were rated according to their priorities following SWOT analysis. The researchers identified SWOT that influenced the provision of maternal healthcare services. The use of the SWOT analysis matrix and BOEM helped the NGT group as researchers to reach their goal of developing and prioritising the current strategies. Strategies such as the availability of human resources, knowledge deficit and provision of maternal health services were identified as both strengths and weaknesses. In contrast, quality assurance, lengthy waiting times, availability of maternal guidelines and community involvement were opportunities and threats. Researchers were able to formulate actions that could be used to build on identified strengths, overcome weaknesses, explore opportunities and mitigate the threats. Although experts in maternal healthcare services validated this strategy, it is yet to be implemented. Its implementation might lead to further refinement of the current strategies as such provision of maternal healthcare will improve which is anticipated to reduce the MMR. Researchers recommended that all the stakeholders involved in maternal healthcare services starting from MHCMs at the national, provincial, district office and District Executive Manager (DEM), OMNs and midwives at PHC facilities familiarise themselves and implement the developed strategies. To build on the strengths and overcome weaknesses, the DoH at national, provincial and district levels must provide resources for midwives. In turn, midwives must utilise the resources during the provision of maternal healthcare services, this will improve the implementation of maternal guidelines. Further research on the effectiveness of the implementation of the current strategies is recommended. The strategies could reduce MMR, hence achieving the third goal of Sustainable Development Goals by 2030.
The authors would like to acknowledge the South African Medical Research Council (SAMRC) for support. The authors would also like to acknowledge the University of Venda Research and Publication Committee, Limpopo Provincial Department of Health and the district executive officers who granted permission to conduct this study. The authors would like to thank all maternal healthcare managers, operational managers and midwives who participated in this study.
The authors declare that they had no financial or personal relationships that may have inappropriately influenced them in writing this article.
T.I.R. conducted the study and drafted this manuscript. M.S.M. and T.R.L. supervised and supported the study and made necessary corrections in the article.
Ethical principles were adhered to and ethical clearance reference number SHS/16/PBC/34/1910 was issued by the University of Venda Ethical Research Committee. The Limpopo Provincial Department of Health and the District Executive Officers of the two districts offered permission to conduct the study. Participants signed the informed consent form before the commencement of data collection. Participants were informed that participation was voluntary, and they could withdraw at any time without being prejudiced. To ensure confidentiality and anonymity, participants codes were used in each questionnaire and alphabets were used for the interviewed participants.
This research received financial assistance from the MRC and the University of Venda, National Research foundation [grant number S783].
The raw data used to support the findings of this study are included in the article and can be made available from the corresponding author, T.I.R., upon reasonable request.
The views and opinions indicated in this article are of the authors and do not reflect the official position of any affiliated agency of the authors.