research topics in midwifery in ghana

• Open access
• Published: 31 May 2022

Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana

• Veronica Millicent Dzomeku 1 ,
• Adwoa Bemah Boamah Mensah 1 ,
• Emmanuel Kweku Nakua 2 ,
• Pascal Agbadi 1 , 4 ,
• Joshua Okyere 1 , 3 ,
• Peter Donkor 5 &
• Jody R. Lori 6  

BMC Pregnancy and Childbirth volume  22 , Article number:  451 ( 2022 ) Cite this article

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Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility.

We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study.

The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO’s quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building.

We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

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Globally, maternal mortality is considered an important public health concern. While there has been substantial decline in maternal mortality rate across the globe, several countries including Ghana could not attain the targets of the Millennium Development Goal 5 which aimed at reducing global maternal mortality by 75% by the end of 2015 [ 1 ]. Nearly 810 women die every day from pregnancy and child birth related causes globally [ 2 ]. Low-and-middle-income countries contribute 94% to the global maternal mortality while sub-Saharan Africa accounts for nearly two-thirds of maternal mortality worldwide [ 2 ]. To further advance commitments towards reducing maternal mortality, there was the ratification of the Sustainable Development Goals, of which target 3.1 seeks to reduce maternal mortality rate to less than 70 per 100,000 live births by 2030 [ 3 ]. In Ghana, the introduction of the national health insurance scheme, free maternal health care, Safe motherhood, Prevention of mother to child transmission (PMCT) intervention for HIV, folic acid supplementation, coupled with an advocacy for skilled birth attendance and facility childbirth have led to significant improvement in pregnant women’s access to maternity care and reduced maternal mortality [ 4 ]. For instance, report from the 2017 Ghana Maternal Health Survey showed that Ghana’s maternal mortality has been improving over the years with a decline from 451 maternal deaths per 100,000 live births in 2007 to 343 maternal deaths per 100,000 live births in 2017 [ 5 ]. Notwithstanding, about one-third of pregnant and postpartum women do not access maternity care from health facilities [ 3 ]. This poses a significant threat to Ghana’s capacity to achieve the Sustainable Development Goals.

Available evidence suggests that women who do not receive maternity care have reported to have ever experienced or witnessed disrespectful maternity care at health facilities [ 6 , 7 , 8 ]. Hence, promoting respectful maternity care has become an important maternal health concern in Ghana. According to Freedman [ 9 ], disrespectful and abusive care is the “interactions or facility conditions that local consensus deem to be humiliating or undignified, and those interactions or conditions that are experienced as or intended to be humiliating or undignified” (p. 43). Therefore, it stands to reason that respectful maternity care (RMC) denotes the interactions or facility conditions that pregnant and postpartum women deem to be humiliating or undignified in the course of accessing maternity care.

To provide a more standardised definition, the World Health Organisation (WHO) refers to RMC as the organised care that is provided to all women in a manner that does not compromise on their confidentiality, dignity, and privacy while ensuring freedom from harm and mistreatment, as well as enabling women to make informed decisions and assuring them of continuous care from labour through to childbirth [ 10 ]. This implies that RMC should include all maternity care services that are devoid of any form of abuse including physical, emotional and psychological abuse [ 6 ]. RMC that focuses on individual, cultural, personal, and medical needs of women is vital to improving access to quality maternal healthcare. This is owing to the fact that when women are denied the respect that they deserve, they are less inclined to return to health facilities for future births [ 6 , 7 , 11 ]. The literature is replete with studies that show the existence of significant disparities with respect to who receives RMC [ 12 , 13 ]. For instance, younger women, unemployed women, and those who give birth in higher level facilities tend to have poorer experiences with respect to RMC [ 12 , 13 , 14 ]. Furthermore, most studies that have explored the phenomenon of RMC in Ghana have done so from the perspective of the client.

Respectful maternity care is supposed to be the normal maternity care practice for all healthcare workers. Nevertheless, earlier studies conducted in Ghana have found that disrespectful maternity care often manifested through acts of shouting, pinching, slapping, and physical restraint to a delivery bed, were commonly cited in the labour ward and often exhibited by midwives [ 6 , 7 , 13 , 14 ]. Evidence suggests that midwives who show acts of disrespect to women during childbirth do so on the premise of trying to save the mother or baby [ 6 , 15 ]. For instance, a qualitative study conducted in Ghana [ 6 ] and Guinea [ 15 ] have both shown that midwives often justified disrespectful care during childbirth when women were disobedient, uncooperative, or to save the life of the baby. Hence, justifying why the study is delimited to midwives. Moreover, with respect to RMC, to the best of our knowledge, there is no empirical evidence that describes the variation in RMC across different cadre of healthcare providers. Evidence available is shows the existence of disrespectful maternity care among midwives [ 6 , 7 , 13 , 14 ].

Implementing RMC can enable midwives’ better appreciate care for women in labour and subsequently reduce the incidence disrespectful maternity care [ 6 ]. As such, evidence-based research is needed to advance RMC adoption by midwives. Yet, only few studies have explored RMC from the service providers’ perspective, with those studies mainly focusing on midwives’ overall perspectives about the RMC [ 6 ]. To the best of the authors’ knowledge and after extensive literature search, no study in Ghana has explicitly focused on exploring the challenges that midwives face in attempting to provide RMC to women, neither has the existing studies explored the prospects and opportunities that exist to promote RMC in health facilities in Ghana. This paucity of literature informed the conceptualisation of our study.

We aimed to explore and document midwives’ perspectives concerning the challenges they face and prospects available for promoting RMC in a tertiary health facility in Ghana. The findings of this study will inform authorities in charge of managing health facilities and other relevant stakeholders about the existing challenges that ought to be addressed in order to improve women’s accessibility to RMC. It will also be important in raising stakeholders’ attention to current opportunities for RMC promotion that might be optimised and strengthened.

Methodology

Research team and reflexivity.

The research team consisted of midwives and nurses (VMD, ABBM, JRL), social scientists (JO), a surgeon (PD) and bio-statistician (PA, EKN). As such, they had no influence over the study participants and overall data collection dynamics. Moreover, interviewers who could speak both Twi and English language and had vast experience in qualitative research interviewing were recruited to support the data collection process. The research assistants were taken through intensive training for three days in order to deal with any conscious and sub-conscious biases that could have compromised the integrity of the study. The interviewers had no direct influence on the study site, methodological procedures, and findings of the study. As a result of this reflexivity exercise, all of the study authors were able to collaborate more effectively since they were able to grasp each other’s perspectives, which added to the study’s rigour.

Study design

The study adopted an exploratory descriptive qualitative approach. This design allowed us to explore midwives’ perspectives concerning challenges faced and prospects available for promoting RMC by gathering in-depth information through face-to-face interviews. Qualitative exploratory design served as the most appropriate design for this study since we were concerned about gaining broader and deeper insight about the phenomenon under study. Moreover, we adopted this study design because it allows us the flexibility to respond to varied research questions including questions that border on what, why and how the phenomenon under study happens [ 16 ].

Participant recruitment process and sampling

Purposive sampling technique was used to sample the participants who met the inclusion criteria. The inclusion criteria included the following: (a) participant should have participated in the RMC training, and (b) they should be providing maternity services and willing to participate in the study. In the year preceding the study, midwives at the study site undertook training on RMC. We trained 110 midwives on four separate training period. The training modules taught the trainees how to use effective, alternative birthing positions, focused antenatal care, empathetic and ethical communication with childbearing women, and demonstrating respect and dignity during intrapartum care provision to promote quality intrapartum care free of violence and abuse. Six months after the training, the research team visited the Obstetrics and Gynecology department of the hospital to discuss the study in detail. Two ward-in-charges volunteered as the study’s ‘recruitment links’ Trained research assistants (RAs) visited the hospital to meet with trained midwives through the ward-in-charge as the recruitment link. The study objective was explained to the participants who were eligible, and they were given a copy of the research’s information sheet. We granted prospective participants two-week window to read and review the information sheet in order to guide their decision to either participate or not participate in the study. Midwives with informed decision of participation contacted the RAs via phone for further arrangements on date, time and venue of the interview. Inform consent by writing ( n  = 11) and thumb printing ( n  = 1) were obtained prior to the interviews. It was only after the signed informed consent form had been received that our RAs proceeded to start the interviews.

The study was conducted in the maternity block of a tertiary hospital within the Kumasi Metropolis in the Ashanti region of Ghana. This facility is recognised as Ghana’s second largest hospital and the only tertiary hospital in the Ashanti region [ 17 ]. It provides healthcare to patients across the country but particularly serves the middle and savannah zones of Ghana. As such, it serves as the primary referral hospital for the Ashanti, Bono, Bono-East, Ahafo, Savannah, Northern and North-East regions as well as some neighbouring countries. The facility has a bed capacity of about 1200 and staff strength of about 3000. It has thirteen (13) clinical directorates (departments) one of which is the Obstetrics and Gynaecology (O &G) directorate, which has four labour wards. In 2018, the hospital recorded an estimated 4792 Spontaneous vaginal deliveries, an estimated 123 maternal deaths, and 61 neonatal deaths [ 14 ]. The midwife staff strength at KATH is 381. Table  1 provides statistics on the care provided between 2019 and 2021.

Data collection

ABBM, a qualitative researcher with clinical and academic experience in women’s health and maternal care worked collaboratively with three research assistants (RAs) who had undergone a two-days training about the objectives and procedures for data collection for this study, to conduct the face-to-face interviews with midwives. The interviews were conducted using semi-structured interview guide which was developed based on the WHO’s quality of care framework and an RMC module (RMC-M) developed by the first author in her preliminary studies. For each midwife, we approached them and discussed the objectives and procedures for the study. Additionally, their rights as participants were clearly stated to them as well as any possible discomfort, benefits and compensations. After all these have been explained to the midwife, their consent to voluntarily participate was obtained. All interviews were conducted were conducted as a one-off interview, and at a date, time and place of convenience to participants. The researcher and RAs asked probing questions in order to elicit rich qualitative data for analysis. Data collection began on May 1 through to August 9, 2021. On average, interviews lasted about 70 minutes. All interviews were audio recorded after seeking consent from the participants. In addition to the audio recording, the RAs captured other non-verbal cues and gestures through note taking and observation. By the 10th interview, we had reached saturation as no new analytical information was emerging from the interviews. We conducted additional two interviews to confirm that indeed we had gotten to the point of data saturation. We did not encounter any situation where participants refused to participate in the study. Also, none of the participants dropped out at any point in the study.

Ethical issues

Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics (CHRPE) at the Kwame Nkrumah University of Science and Technology (KNUST) (reference number: CHRPE/AP/181/18) and the Komfo Anokye Teaching Hospital (KATH) Institutional Review Board (reference number: RD/CR17/289). We anonymised information by giving pseudonyms to the participants in order to protect their identities and prevent third parties from tracing data back to participants. Written informed consent was sought from participants in order for them to voluntarily participate in the study after having read and understood the terms, risks and benefits associated with their participation. Also, the recorded interviews were encrypted to prevent third parties from having access to it. Interview venue (Office at KATH), date and time were determined by the participants. Interview language was Twi (local language). Both the interviewer and researchers could speak and understand Twi on a full professional competence level.

Data management and analyses

The audio files from the interviews were transcribed verbatim. ABBM proofread the transcribed interviews alongside listening to the audio files as a way of ensuring that, the transcripts reflected exactly what the participants stated. Two independent translators fluent in both the Twi and English languages then translated the twelve anonymised “Twi” transcripts using the process of back-back translation while maintaining confidentiality. Independent thematic coding analysis using QSR NVivo-12 was performed by two data analysts (PA and JO). Translated transcripts were imported into NVivo-12 for data management and analysis. Codes were generated through inductive analysis to create themes and sub-themes. This inductive analysis was done by reading the raw text data and discussing the emerging issues to form themes. Significant recurrent statements or phrases were retrieved as codes from participants’ transcripts to provide data that directly relate to the issue under research. The relevant statements or phrases were then used to develop formulated ‘meanings’ that described and illuminated the obstacles and opportunities for promoting RMC. Following that, themes were created based on various statements with comparable meanings. This process was repeated for all the 12 transcripts. Insights from the transcripts were broadly presented in line with the main questions in the semi-structured guide. To completely develop the ideas, the original themes were followed in subsequent interviews and validated using field notes. The initial analysis was performed by PA and JO, and later validated by the first, second, and third authors and through member checking with five participants. These participants reviewed the printed transcript so as to confirm the accuracy in the presentation of their views. Member checking allowed us to confirm the findings from our analysis. However, none of the issues changed after member checking.

Rigour and trustworthiness

Recognising the worth of rigour and trustworthiness in qualitative research, we ensured that our study and its methods adhered strictly to the principles of credibility, confirmability, transferability, and authenticity. Transferability was ensured by giving detailed description of the study objectives, research design, data collection procedures, study contexts and data analysis procedures. Confirmability was ensured by allowing five of the participants to review the printed transcript so as to confirm the accuracy in the presentation of their views. To authenticate the results, completed interviews were first reviewed by the interviewers. After that level of review, VMD, who is project lead and an experienced qualitative researcher together with ABBM and EKN validated the results. To ensure credibility, we adhered strictly to the study protocol and ensured that audio data were transcribed verbatim.

Demographic characteristics of participants

Table  2 shows the demographic characteristics of the sample. The ages of the participants ranged between 26 and 50 years, with the median age being 35 years. With the exception of participant 1 (P1), all the participants had attained a degree. Of the twelve participants interviewed, seven of them, representing 58.3% were married. Fifty percent of the participants had no child. Also, 67% of the participants sampled had between 1 and 5 years’ work experience as midwives.

Main findings

Midwives were expected to provide care to childbearing mothers in a supportive, respectful, and dignified manner. This type of care—respectful maternity care—is centred around three main themes in this study: emotional support, respectful communication, and respectful and dignified care. The provision of this care, like any other caregiving, requires both the expertise and the enabling environment for its sustainability. This study gave the opportunity to a handful of midwives to express their knowledge about specific respectful maternity care activities they are expected to implement and to equally detail any person-level or structural-level factors that may derail the performance of RMC activities. The findings are reported under the following categories: current actions undertaken, challenges and recommendations to improve RMC provision (see Table  3 ).

Providing emotional support

Actions implemented to provide emotional support, sacral massages and reassurance.

Emotional support can be provided in the following way: performing sacral massage, allowing birth companions, and responding timely to the needs of the childbearing women. Evidently, childbearing women are often plagued with many thoughts, including those of fears and anxiety. Thus, midwives are expected to reassure them of the childbirth process, by performing sacral massage on the woman in a comforting manner and counselling her to alleviate fears. From the responses on this theme, it was evident that the midwives involved family members of the childbearing women in the process of providing emotional support. For instance, one of the participants explain how she performs the sacral massages and the reassurances, highlighting family members involved in the process:

“Usually, women in labour are tensed and anxious. As such, it is critical to de-stress them and make them feel comfortable. So, what we do is that, we give them sacral massages (locally called apemfo amamia). In addition to that, we give them words of encourage so that they (woman) will feel reassured.” (P10, 35 years).

The involvement of family members was evident in the performance of sacral massage and reassurance activities. The participant said that, “at times we seek the support from the husbands to give them [their wives] the sacral massage, encourage and reassure them” (P3, 35 years).

One of the participants explained that first-time mothers are often afraid and anxious about the childbirth process because of what they heard from others about the birth pangs. In such situations, the midwife mentioned that describing the stages in the birthing process can help the childbearing women be at ease. She explained how she goes about this in the following way:

“Some of the patients are emotional. They are often fearful and anxious. Possibly, it is because they have not given birth before but may have heard that the process is painful. For some other clients, the way people may have described the process to them would have put a frightening aura around the birth process for the. In such instances, we try to calm the woman by encouraging and assuring her that she is in safe hand, and that everything is going to be alright. We keep her informed by describing the stages of labour to her. This helps us to calm the person and gain their cooperation because they are now aware of all the stages of birth and all other expectations.” (P4, 34 years).

Encouraging male involvement

Allowing birth companions enable the childbearing women to be comfortable given that they might find it easy to share their worries and concerns with these companions. Giving opportunity to childbearing women to be with birth companions of their choosing is another way to create an enabling environment for emotional support. The participants usually allow partners of the childbearing women to be with them during the birthing process. The midwives explained that they allow the men to be present so they can learn to provide compassionate care to their wives whiles they are in the hospital and when they return home after a safe childbirth.

“Over here, we try as much as possible to involve the males throughout the process. As such, we normally encourage them to come in and support the women. You know; women can be more cooperative when it is their husband who is giving them sacral massage or when it is their partner who is encouraging them to push the baby out. So, we encourage room-in and involve the men the birthing process” (P7, 32 years).

There are challenges to providing optimal emotional support to childbearing women. The challenges are related to inadequate staff, childbearing women attitudes, difficulty dealing with family members of the childbearing women, and hospital infrastructure deficits.

Inadequate staff

The midwives mentioned that a limited number of midwives resulting in unbearable workloads prevent them from providing emotional support in the best way they should. Regarding inadequate staffing and workload effect on the provision of emotional support, these midwives have the following to say:

“ … it got to do with the inadequate staff. If we’re not busy we can attend to the patient promptly but if we are two (2) on duty and we are all busy we can’t attend to the third person. We attend to the emergency cases and later to those that can hold on with their condition but if there were to be enough staff, we can attend to all” (P1, 34 years).

“… with respect to emotional support, it is quite challenging because of our staff strength. There could be more labour cases which makes it difficult to promptly attend to a patient’s emotional support one after the other but we reassure them” (P3, 35 years).

“… sometimes, here [referring to the hospital], we do seventeen (17) deliveries at night so in case there’s workload and you call we can’t attend to you; [this is] not intentional though, but the midwives [are] not enough” (P11, 26 years).

Non-cooperation from women

The next sets of challenges disabling midwives in their quest to provide emotional support to childbearing women include non-cooperation from women and partners’ lack of courage. Regarding the challenge of non-compliance, the midwives express their concerns as follows:

“Some patients don’t comply with instructions. How do we apply the massage? We do the sacral massage but some mothers don’t cooperate so we can’t do it” (P11, 26 years).

“Let’s say there are some patients, you approach them in this way: ‘Ma’am, the pain you are going through … . especially after labour has started …. that is what propels the baby down the birth channel to the outside, but no matter what you say to such a patient, she will ignore you. No matter what you say, she will ignore you. It is rather what your advice against that she will actually do …. And it seems like whatever you’ve been saying to her does not really register in her mind but rather passes over her ears. So, it can cause you to be reluctant: you can actually make up your mind not say anything further” (P5, 38 years).

“What I can say is, it is also their relatives. I don’t know, because this facility is a referral centre when they are being referred and then they come here, even when it is not labour, I mean it is a condition they came in with, the relatives don’t give us that space. You tell them to, maybe the patient is in pain, they are around, you tell them (relatives) to go, they (patients) are in your hands now, you are taking care of them, together with the doctors. Every point in time, you see a relative trooping in, especially when they see that the patient that they brought, the relative that they brought, the person is in pain, they (relatives) want to be involved in whatever is going on. I am not saying that they shouldn’t be involved, but I think so far as you’ve brought the patient into the facility, you’ve left her in the care of the doctor and the midwife or the nurse. So, whatever is going on, they should just allow us to do our job. Yeah, they should help us do it as they should just give us that space, that room to perform our jobs and after that, we will communicate whatever is going on to them” (P8, 28 years).

Partner’s lack of courage

Some of the participants mentioned that partners of childbearing women lack courage to provide emotional support as they often felt uncomfortable witnessing the pain their wives go through during the childbirth process.

“Many men don’t like it that way they don’t want to see their wife going through that pain. I remember I invited a husband and he even collapsed before seeing the baby’s head (laughs). Some will refuse if you offer the opportunity because he can’t watch. Few ones that are eager we have a way of letting them in. I gave some husbands the opportunity” (P2, 37 years).

Inadequate material resources and limited space

The other last set of challenges mentioned by the midwives are related to inadequate material resources and limited space. They mentioned that the hospital has no waiting area for relatives of childbearing women and there were only two delivery beds. These limitations prevent them from providing emotional support.

“So far, the hospital has no waiting room for relatives so if they come, they’ve to wait outside” (P1, 34 years).

“We have two (2) delivery beds in one room and two (2) women delivering at the same time with no curtains. Now here we have curtains. But the entrance is the problem where the husband will pass because the labour ward is connected to the theatre so entry is a problem ” (P2, 37 years).

“So, if two (2) or three (3) ladies become ‘full’ simultaneously, we will do the others on beds, and the others right here (indicating). Therefore, for the ones that we have to perform our duties on a bed, the husband cannot practically be there, because, right beside the wife, there will be another patient lying there. If you do that, you will be invading someone else’s privacy” (P5, 38 years).

Midwives’ recommendation for enhancing emotional support

The midwives suggested that the implementation of the following solutions will enable them to provide the necessary emotional support to childbearing women: increasing staff strength and logistical support for a timely response.

“More staff needs to be employed. We cannot have one (1) the patient is to one (1) midwife but at least there should be extra so that activities can be shared among us” (P1, 34 years).

We need to increase staff and some staff needs to change their attitude. We are not the same. Some will work hard others will not so mostly the patient expect the hard workers to treat them but you may be tired. We have to advise ourselves not all of us but at times we are the problem (P12, 30 years).

We need more equipment with foetal heart monitor we have two (2) so in case there are three (3) labour cases it means you’ve to use the manual one for the other patient which requires your presence but for the electric one you can listen to the feedback while doing other things. It will help us if we had enough and at times, we don’t get the number of consumables we request for. Meanwhile, the one been provided is not enough for the unit work (P3, 35 years).

Provision of dignified care: awareness, challenges, and recommendations

Actions implemented to provide dignified care, ensuring confidentiality.

Participants commented on how ensuring confidentiality was an integral way of promoting and providing dignified care to women in labour. The participants acknowledged that they asked sensitive questions only when they are alone with the client in their cubicle. This eased women and ensured that there is dignity and respect throughout the care process. In situations where it was almost impossible to ensure confidentiality, midwives reduced their tone in order for third parties not to reduce the possibility of accidentally disclosing information to third parties. This is reflected in the quotation below:

Oh, in such situations, I will be able to admit you and put you in a bed and then when I am taking the FH, your vitals and such inside, I can ask you that. It doesn’t exactly have to be at the time of admission that I have to get all the required information, for when I am taking the vitals, the relative is not with us. Uh huh, so I am alone with you in the cubicle, ‘OK, Sister, please, for the medications, have you started treatment? Have you done this or that?’ and when we get to such a stage, the client is capable of telling you everything, knowing it is just between the two of you (P4, 34 years).

If you can’t provide privacy, you have to talk in a lower tone because if it is abortion and you alarm it for relatives to hear they can divorce her. All you need is to talk under tone to prevent others from hearing (P9, 51 years).

Provide information and seek consent

In providing dignified care to women in labour, there should be absolute non-compulsion. The participants alluded to this as they revealed that in providing services and care to clients, they always provided them with sufficient information about that particular care in order for them to make an informed choice and consent to their participation. Below are direct quotations from the participants:

If it is MagSulf (magnezium sulphate) – MagSulf is given every four (4) hours – you tell the patient that …. they, the patients refer to MagSulf as ‘the needle that extremely burns’, so ‘Madam, I am about to give you the injection that is extremely painful or burns. You seek for their consent before you do that: everything you do for a patient; I think you have to explain and seek consent (P8, 28 years).

Like …. Mmmmm … … I see it that anything you have to do, you have to make the client aware, you have to tell her and explain what you are about to do and why you are to do it, if she will give you the permission (P10, 35 years).

Refer mothers who cannot pay bills to social welfare

The midwives indicated that there are times that women who come to deliver are unable to pay their bills. This makes it difficult for them to enjoy satisfaction of care. Hence, to ensure their dignity amidst their financial constraints, midwives refer the client to social welfare for further assistance to offset their bills. The quotes below are synopses of midwives’ account of referring mothers who cannot pay their bills to social welfare:

If a client cannot pay her bills, we turn her over to the social welfare department. Yeah. So, we no longer detain them as we use to … …. (P5, 38 years).

We come in when the patient tells us that maybe ‘I was charged a thousand cedis (1000GHC), I have five hundred (500GHC). So our new approach as midwives is to involve the social welfare department … … ’. So, we refer them to social welfare. Then they take it over from there. But before the RMC training, we use to detain them …… yes …. of course, because that is the hospital protocol (P8, 28 years).

Nevertheless, there some participants opined that there were times that they could not allow the women to leave the facility until they had an assurance of payment.

Hmmm right now if a patient delivers and she has no money to pay it is your shift that you’ve discharged her and the link system your name and everything is on it so if there’s any follow up, they’ll know you’re the one that didn’t collect money and the hospital will ask you to pay so a midwife won’t put herself in such situation so you pay before you leave (P2, 37 years).

In the quest to deliver dignified care to women in labour, midwives encounter some challenges ranging from logistical constraints on alternative birthing positions, facility environment limiting privacy and movements, and unavailability of drapes.

Logistical constraint on alternative birthing positions

From the accounts of the midwives, the hospital lacks the necessary logistics to support alternative birthing positions. This makes it difficult or impossible to explore and practice other birthing positions besides lithotomy. This is what some of them had to say:

We don’t have the necessary equipment and the way clients may behave, if we decide to improvise on the squatting, it is not going to go well. It will not work well at all (P7, 32 years).

There is position like the squatting position but here we don’t have the resources to support the squat birthing. We are used to the lithotomy and all the delivery beds are in that form. We would have adapted to patient’s preferred position such as squatting if we had the needed equipment (P2, 37 years).

For water birth, hmmmm … … we are aware of such position. However, we don’t have it [equipment] here. Nothing even shows that we are actually preparing ourselves to do water birthing! Should a patient request for this, then, hmmm …… we cannot meet this need. Let us see what the future holds for all other birthing positions. (P1, 34 years).

Facility environment limits privacy and movements

Ensuring privacy is extremely important for childbearing women. However, the midwives expressed their concern about the facility’s environment to ensure privacy and movements of women in labour. According to the midwives, they lacked the necessary logistics and environmental context to promote privacy of childbearing women. They asserted that the available space at the hospital was too small, and that women were housed in open labour wards.

… … ahaaa, so they are all bunched together inside and if you are working on a patient and you even use the screens, there are holes within the screens so someone can see through these (holes) and take a peep at naked patients. This too doesn’t help us (P5, 38 years).

the environment is not spacious enough to accommodate fee movement. There is always overcrowding due to the patient turn out. Hence, so we restrict walking around (P9, 51 years).

Closely tied to the issue of limited privacy is the unavailability of drapes. Some of the midwives mentioned that there were no drapes at the hospital to cover clients during childbirth. As such, they had to improvise by using the clients’ own clothes. This epitomised in the following quotes:

Ideally, the hospital has to provide drapes but we don’t have so we cover clients with their own sheet. Assuming the client comes in an emergency with no clothes, then ensuring privacy becomes a challenge (P3, 35 years).

As for the drapes, we don’t have any in this ward. So, the alternative we have here is the screen. So, we screen the patient and we do our thing (P5, 38 years).

The drape itself isn’t available (smiles) and let say the ward has only three (3) and it has been used. With my previous ward, the screens were scarce and even if it is available, it is faulty. Thus, providing privacy becomes a challenge (P1, 34 years).

Clients’ condition limits movement

Being able to move freely as one wishes to is fundamental to patients’ feeling of autonomy. Therefore, any restriction in the client’s movement could be viewed as limiting their dignity and autonomy. It emerged from our analysis that the condition of women in labour tends to limit their capacity to move about at the hospital. Specifically, women who had ruptured their membranes were restricted from moving for fear of cord prolapse and other complication. This was considered as a challenge to providing dignified care to childbearing women. The following quotes reflect the views of the midwives:

Yes, when the fluid comes out so you can’t allow her to move about with the fear that as the fluid leaks it could rupture for the cord to slip to cause cord prolapse that’s why we restrict them but if everything is fine without rupture, they’re allowed to move around because the force of gravity is even necessary so we encourage them to walk (P3, 35 years).

Well, when it comes to walking, you are allowed to walk but it depends on each stage and what you expect from the client. Let’s say the client is at eight cm (8 cm) … 8–9, at that stage, this is difficult. It is a transitional stage and she is traumatized and such, there is also the possibility of prolapse, and other complications too (P4, 34 years).

Midwives’ recommendation for improving dignified care

We sought to understand midwives’ perspectives about the essential recommendations necessary for improving dignified care. They recommended logistical support for alternative birthing, capacity building and trainings, logistical support for privacy, and motivation of midwives.

Logistical support for alternative birthing

To ensure the implementation of alternative birthing positions in order to improve dignified care for childbearing women, midwives recommended that the hospital must equip them with the necessary supportive logistics. The voices of the participants are captured in the following quotes:

The hospital has to acquire all the necessary equipment that will enable us to practice alternative birthing like the water birth (P1, 34 years).

We need the beds and the instruments they will use for those positions. As long as we have those, we will allow them to use them (P10, 35 years).

Oh OK, we have to get the different equipment performing those positions, like the birthing chair you talked about when we came (for the workshop) (P4, 34 years).

Capacity building and trainings

The midwives also recommended that in order to improve dignity of care, there is the need for the hospital management to organise workshops and training for them on alternative birthing positions.

Then, there should be a training on that [alternative birthing positions] for midwives. Though we’ve been taught about the new ones in school but we never practiced it so if the hospital is to provide it has to organise workshop for us (P1, 34 years).

when I had not yet come (to the workshop) to learn about respectful care, some of my attitudes and behaviours were not really optimal but once I came and got educated on these, things have changed. And a lot of things have changed. Therefore, we should go to the district, and other sectors and educate them the more, and even if it is possible, let us take the education to the schools so that by the time the person is coming (the healthcare worker is being sent to the ward), she would have picked it (the desirable concepts of respectful maternal care) already. And we need to continually re-educate, so our minds would be drawn to certain things all the time (P10, 35 years).

Logistical support for privacy and free movement

Given that midwives experienced challenges with ensuring the privacy and free movement of women in labour, they requested that the hospital management provide them with supportive logistics such as curtain, individual cubicles or rooms.

Yeah, when the screens are not enough, we can use the curtains. All you have to do is draw the curtains. So, if we were provided with more curtains or if they gave us more screens, we could ensure privacy. But albeit the problems, we do ensure privacy all the same (P6, 38 years).

Maybe in our ward, we should separate the labour cases from our ward to a different place, or let’s say for Cubicle One (1), let’s make it into a cubicle for only labour cases. So, we can use curtains to separate the place into individual rooms for each client that comes in. So, if you are in labour, your relative can stand beside you during the process (P5, 38 years).

Motivating midwives

The midwives also stated that in order for them to provide dignified care, there is the need for the hospital management to provide motivation to midwives.

Mm we have talked about all but I will add up that the hospital should add a bit of motivation to staffs although they are being paid for all they do but a bit of motivation will do to encourage us because at times you will realize they don’t appreciate what we are doing (P1, 34 years).

Provision of respectful communication: awareness, challenges, and proposed solution

Actions that promote respectful communication, ask relatives to excuse patient-provider conversations.

In describing actions that supported respectful communication, the midwives mentioned that they asked the woman’s relatives to excuse them whenever they had to discuss or solicit confidential information form women in labour.

When referrals come at the same time. Even if is second stage we attend to them first before we take other history, at times we ask other patient to excuse us if only the energy is there to wake and excuse us (P2, 37 years).

So, you just have to excuse the relatives … allow the relatives to excuse you so that the woman can be, the person can be truthful enough to tell you whatever (there is). Because, some people wouldn’t feel comfortable if their husbands or their spouses are around, or their family members, their relatives are around to tell you whatever, especially when they have their top-sending (P8, 28 years).

But if she sees a relative around … I walked up and told the relatives to excuse us for a while so we can get closer to the client and take better care of her, but they got offended even though I did not say it in a bad way (P4, 34 years).

Introducing ourselves as caregivers

From the midwives’ perspectives, introducing themselves as caregivers to women who are there to give birth was a way of promoting respectful communication. The following quotes exemplify this finding:

For communication we’re very good at it. After shift handing-over, we introduce ourselves to them so if they’ve problems they complain to us if we need to call a doctor we do if we can handle it, we do the needful (P3, 35 years).

Yeah. So, when we introduce ourselves to the clients, even if not by name, then when you go to perform a procedure for the client, she already knows you are part of the staffs and so she already has confidence in you. Then she goes like ‘Madam, what is your name?’ and you tell her your name and maybe she also says ‘I am also called this’. Ahaaa … .and then you proceed to conduct the care you have to give to her (P4, 34 years).

Poor attitudes of midwives

Some midwives revealed that the attitudes of their colleagues as a challenge to promoting respectful communication in the discharge of their service or care to women in labour. They mentioned that some midwives called clients by the name of their condition.

At times (laughs) let me say is their character or some encounter she had before come to work so it annoys her seeing you the patient. The moment you ask question she will scold you not really good but not all of us are like that so we have to advise ourselves (P12, 30 years).

Some midwives call patients by condition they have. Professionally it is not done. A patient has a real name and must be called by that not her condition. We have to put a stop to that it is a condition and won’t stay forever (P9, 51 years).

Language barrier

Also, the midwives indicated that language was a barrier in promoting respectful communication in delivering RMC.

In some cases, it is the language; there are situations in which the language being spoken by the client is not understood by me. She speaks a different language: she doesn’t speak Twi and neither does she speak English. In a scenario like that, it has to fall on the family member present who speaks the language (of the health worker). So, you speak to the relative, and the relative then translates for the client (P10, 35 years).

Erm...it depends on the level of communication of the relatives maybe language barrier you’ve to explain things to their understanding but at times you’ve to seek the patients consent rather so that she can relay the information to relatives to her satisfaction (P2, 37 years).

Midwives’ recommendation for improving respectful communication

Peer monitoring.

From the study, the midwives mentioned that there is a possibility for their colleagues to sometimes act unprofessionally and compromise respectful communication. Therefore, to remediate this, it is essential for them to be each other’s keeper through peer monitoring.

Hmm … for now I think we have to be each other’s keeper. There may be somethings that you will do and it will feel odd. But if we check on each other and become each other’s keeper, then we will be able to help ourselves at the ward. We can talk to ourselves, and also involve the senior midwives so that each student nurses and rotational nurses will be practicing professionalism in communicating to patients when they come here to give birth. All these are taught in school and doesn’t need any workshop or training. If you treat a patient right, they deem it much offer you’ve done them. (P2, 37 years).

No but with respectful maternal care we’ve to be each other’s keeper so patients should take it easy with us in order for us to deliver care to them (P3, 35 years).

Demonstrating good attitudes

The midwives also mentioned that in order to ensure respectful communication in course of delivering RMC, it essential for all midwives to demonstrate attitudes that are supportive and not disrespectful. This is reflected in the quote below:

We don’t need anything special but it is up to us to have good attitude and know how to deal with patients. We have to educate them on when to ask questions it may seem emergency to them but they’ve to bear with us. Most of the problem is our attitude so no matter what we’ve to portray good attitude towards our patient (P3, 35 years).

This study sought to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility in Ghana. The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication. For each of the themes, the current actions taken to promote it, its challenges and recommendations were captured. Overall, the current actions that promoted RMC included the provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, and logistics for provision of alternative birthing positions and privacy. Also, they requested continuous training and capacity building.

Our study revealed that performing sacral massages and responding timely to the needs of the childbearing women are ways midwives provide emotional support to clients. This result is corroborated by previous studies [ 18 , 19 ] that have found the use of sacral massages as a means of providing emotional support to women in labour. A plausible explanation for this observation could be that, during labour, women experience excruciating pains that tends to push them to a state of anxiety. However, the application of sacral massages significantly reduces labour pain and feelings of anxiety while simultaneously enhancing women’s satisfaction with labour [ 18 ]. From the study, midwives occasionally allowed birth companions into the labour rooms as a way of ensuring the emotional stability of clients. This finding is synonymous to that of a related study [ 20 ] that revealed that the presence of birth companions provided emotional support to labouring women.

Consistent with the findings of previous studies [ 21 , 22 ], we observed that midwives considered asking sensitive questions only when they are alone with the client in their cubicle, providing information and seeking consent as actions that promoted dignified care. Similar result was reflected in our findings that, asking relatives to excuse women and service providers during professional conversations was an action implemented to promote respectful communication. A plausible explanation for this observation could be that, non-consented and non-confidential care are basic elements of disrespectful care and undermine the dignity of women in labour [ 23 ]. Therefore, ensuring confidentiality and consented care becomes paramount in promoting dignified care. Nevertheless, providing information and explanation of procedures to gain consent was not always done by midwives due to workload of midwives. This concurs with the findings of a qualitative study conducted in Ethiopia [ 24 ].

Although the midwives alluded to the existence of certain supportive actions that promote emotional support, dignified care and respectful communication, they expressed concerns about some existing challenges. Notable among the challenges identified was inadequate logistical support for promoting alternative birthing positions and ensuring privacy. This finding is synonymous to an earlier study conducted in Ghana [ 17 ] that found logistical constraints for alternative birthing positions and limited resources to ensure privacy for childbearing women as one of the major challenges confronting midwives in their quest to promote RMC. Thus, emphasising the need for the hospital management to ensure sufficient resources such as drapes and screens are provided towards ensuring privacy of women who come there for childbirth. Also, the midwives recommended that in addition to the provision of equipment needed to support alternative birthing positions, it is imperative for the hospital management to provide capacity building and continuous training for midwives about alternative birthing positions. This finding is supported by a related study conducted in Tanzania [ 25 ].

Another challenge that emerged from our analysis was the low staff strength at the hospital. Midwives in this study asserted that the low staff strength made it difficult for them to sufficiently provide emotional support to women in labour. The result is analogous to that of an earlier study in Kenya [ 26 ] wherein the authors found staff shortages as a principal challenge to providing RMC. As such, the participants recommended that the hospital management need to increase the number of midwives in order for them to provide sufficient emotional support to women in labour. Our findings also showed that there were times that clients had to be detained because they could not afford their bills; this corroborates with previous studies in Nigeria [ 27 ], sub-Saharan Africa [ 28 ] and among low-and-middle income countries [ 29 ]. Probably, when the midwife allows the woman to leave the facility without settling their bills, then they (the midwife) will be responsible for paying of the woman’s bills. This may explain why women who cannot afford their bills are sometimes detained.

The present study showed that the clients’ condition limited their capacity to move freely at the hospital, and this was considered a challenge to the provision of dignified care in the continuum of RMC. Women who had ruptured their membranes were restricted from moving for fear of cord prolapse and other complication. Existing literature [ 27 , 28 ] has documented similar findings where the condition of women in labour has restricted them to their bed space for fear of cord prolapse and other complication such as foetal distress. We postulate that such immobility can be a trigger for disrespectful abuse. This is because, midwives in their quest to prevent cord prolapse and other complications among women at that stage of labour, may be tempted to shout, physically restrain women or even use abusive tone and words to dissuade women from moving around [ 27 ].

We also found that some midwives demonstrated unprofessionalism and unsupportive attitudes that hampered the provision of respectful communication and dignified care. Some midwives called women by their conditions and this is a clear demonstration of disrespectful maternity care. This substantiates findings from previous studies conducted in Nigeria [ 29 , 30 ] and Ghana [ 31 ]. The observed disrespectful maternity care could be explained from the perspective that, midwives may have premeditated or preconceived perceptions about how women in labour should behave. As such, women who are considered uncooperative with procedure become a source of stress for midwives; that frustration can lead them to maltreat or be disrespectful towards childbearing women [ 27 , 32 ].

Policy wise, our study has some implications. The findings from the study indicate that there are micro, meso and macro level factors that either facilitate or challenge midwives’ capacity to promote RMC. This calls for Ghana to consider RMC intervention implementation modules that takes into account the various levels of challenges and opportunities to be leveraged. Perhaps, Ghana can take cue from Kenya’s Heshima Project [ 33 ], or Tanzania’s Staha Intervention [ 34 ]. Both interventions acknowledge that RMC is beyond the interpersonal and clinical components of care. It requires structural/institutional commitments, policy backing, and human resource recalibration. Hence, continuous professional development would be to be implemented in order to reduce the occurrence of disrespect [ 35 ]. Our findings also emphasise the need to champion patient-centred care and a rights-based approaches in promoting RMC.

Strengths and limitation

The rich description of the study context is one of the strengths of the study, as it allows it to be transferrable. Also, the contributions of two experienced nurse-midwives, VMD and ABBM, in the study ensured the validity of the interviews conducted and the results generated. Thus, the credibility of our findings would be difficult to override. Nonetheless, there are some limitations that are worth mentioning. First, the sample frame used was limited to midwives who had participated in prior RMC trainings. Also, the use of only a qualitative method to explore the phenomenon does not provide the capacity of the study to be generalised to all midwifery contexts. Given that the interviews were conducted at the hospital setting, there is the possibility of social desirability bias because they may want to tread cautiously with their responses in order not to implicate themselves or their colleagues. We were able to minimise the likelihood of social desirability bias by reaffirming the confidentiality and anonymity clauses in the execution of the study. Irrespective of the limitations, the study was able to elucidate the current actions, challenges and recommendations for promoting RMC.

The goal of this study was to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility in Ghana. We conclude that in order for midwives to be able to provide undiluted RMC services through the provision of emotional support, dignified care and respectful communication, there should be continuous training and capacity building, motivation of midwives, as well as provision of logistics and equipment necessary for supporting alternative birthing positions, privacy and free movements of women in labour. We therefore recommend that, policies and programmes aimed at enhancing RMC delivery must address the various shortcomings while strengthening existing facilitating practices such as the provision of sacral massages and reassurance, ensuring confidentiality and consented care.

Availability of data and materials

All transcripts of the interview that was used for the analyses in this study are available from the corresponding author on reasonable request.

Abbreviations

Disrespectful Maternity Care

Obstetrics and Gynaecology

Research Assistants

Respectful Maternity Care-Module

Respectful Maternity Care

Sustainable Development Goals

Sub-Saharan African

Ahinkorah BO, Ameyaw EK, Seidu AA, Odusina EK, Keetile M, Yaya S. Examining barriers to healthcare access and utilization of antenatal care services: evidence from demographic health surveys in sub-Saharan Africa. BMC Health Serv Res. 2021;21(1):1–6.

Article   Google Scholar  

World Health Organization (WHO). Maternal mortality. 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality . Accessed 4 Apr 2022.

Waniala I, Nakiseka S, Nambi W, Naminya I, Osuban Ajeni M, Iramiot J, et al. Prevalence, indications, and community perceptions of caesarean section delivery in Ngora District, eastern Uganda: mixed method study. Obstet Gynecol Int. 2020;2020:5036260.

Article   PubMed   PubMed Central   Google Scholar  

Nuamah GB, Agyei-Baffour P, Mensah KA, Boateng D, Quansah DY, Dobin D, et al. Access and utilization of maternal healthcare in a rural district in the forest belt of Ghana. BMC Pregnancy Childbirth. 2019;19(1):1–1.

GSS G. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF. 2017. Ghana Malaria Indicator Survey. 2016.

Dzomeku VM, Boamah Mensah AB, Nakua EK, Agbadi P, Lori JR, Donkor P. “I wouldn’t have hit you, but you would have killed your baby:” exploring midwives’ perspectives on disrespect and abusive Care in Ghana. BMC Pregnancy Childbirth. 2020;20(1):1–2.

Dzomeku VM, van Wyk B, Lori JR. Experiences of women receiving childbirth care from public health facilities in Kumasi, Ghana. Midwifery. 2017;55:90–5.

Wilson G, Bryan J, Cranston K, Kitzes J, Nederbragt L, Teal TK. Good enough practices in scientific computing. PLoS Comput Biol. 2017;13(6):e1005510.

Freedman LP, Kruk ME. Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. Lancet. 2014;384(9948):e42–4.

Article   PubMed   Google Scholar  

World Health Organization. WHO recommendation on respectful maternity care. 2018;3:2020.

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015;12(6):e1001847.

Afulani PA, Kirumbi L, Lyndon A. What makes or mars the facility-based childbirth experience: thematic analysis of women’s childbirth experiences in western Kenya. Reprod Health. 2017;14(1):1–3.

Moyer CA, McNally B, Aborigo RA, Williams JE, Afulani P. Providing respectful maternity care in northern Ghana: a mixed-methods study with maternity care providers. Midwifery. 2021;94:102904. https://doi.org/10.1016/j.midw.2020.102904 .

Dzomeku VM, Mensah AB, Nakua EK, Agbadi P, Lori JR, Donkor P. Midwives’ experiences of implementing respectful maternity care knowledge in daily maternity care practices after participating in a four-day RMC training. BMC Nurs. 2021;20(1):1–9.

Balde MD, Bangoura A, Sall O, Balde H, Niakate AS, Vogel JP, et al. A qualitative study of women’s and health providers’ attitudes and acceptability of mistreatment during childbirth in health facilities in Guinea. Reprod Health. 2017;14(1):1–3.

Creswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches: Sage publications; 2016.

Google Scholar  

Amoah VM, Anokye R, Acheampong E, Dadson HR, Osei M, Nadutey A. The experiences of people with diabetes-related lower limb amputation at the Komfo Anokye teaching hospital (KATH) in Ghana. BMC Res Notes. 2018;11(1):1–5.

Karaduman S, Akköz ÇS. The effect of sacral massage on labor pain and anxiety: a randomized controlled trial. Jpn J Nurs Sci. 2020;17(1):e12272.

Maputle MS. Support provided by midwives to women during labour in a public hospital, Limpopo Province, South Africa: a participant observation study. BMC Pregnancy Childbirth. 2018;18(1):1–1.

Linyama YE. Experiences of birth companions as they provide support to labouring women at Queen Elizabeth Central Hospital, Blantyre. PhD [dissertation]. Malawi: University of Malawi; 2020. http://nkhokwe.kuhes.ac.mw/handle/20.500.12845/233 .

Molina RL, Patel SJ, Scott J, Schantz-Dunn J, Nour NM. Striving for respectful maternity care everywhere. Matern Child Health J. 2016;20(9):1769–73.

Sacks E. Defining disrespect and abuse of newborns: a review of the evidence and an expanded typology of respectful maternity care. Reprod Health. 2017;14(1):1–8.

Tekle Bobo F, Kebebe Kasaye H, Etana B, Woldie M, Feyissa TR. Disrespect and abuse during childbirth in Western Ethiopia: should women continue to tolerate? PLoS One. 2019;14(6):e0217126.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Dullo AG, Hailemariam NW, Fulasa TB, Feyissa DW, Tessema TT, Debela FA, et al. Respectful maternity care: a qualitative study on the experience of health providers in public health facilities of north Shewa zone, Oromia, Ethiopia. Ethiopian journal of. Reprod Health. 2019;11(1):10.

Mselle LT, Eustace L. Why do women assume a supine position when giving birth? The perceptions and experiences of postnatal mothers and nurse-midwives in Tanzania. BMC Pregnancy Childbirth. 2020;20(1):1.

Warren CE, Ndwiga C, Sripad P, Medich M, Njeru A, Maranga A, et al. Sowing the seeds of transformative practice to actualize women’s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research. BMC Womens Health. 2017;17(1):1–8.

Ige WB, Cele WB. Provision of respectful maternal care by midwives during childbirth in health facilities in Lagos state, Nigeria: a qualitative exploratory inquiry. Int J Afr Nurs Sci. 2021;15:100354.

Kassa ZY, Tsegaye B, Abeje A. Disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa: a systematic review and meta-analysis. BMC Int Health Hum Rights. 2020;20(1):1–9.

Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynecol Obstet. 2015;128(2):110–3.

Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye MA, Olutayo AO, et al. Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers. Reprod Health. 2017;14(1):1–3.

Maya ET, Adu-Bonsaffoh K, Dako-Gyeke P, Badzi C, Vogel JP, Bohren MA, et al. Women’s perspectives of mistreatment during childbirth at health facilities in Ghana: findings from a qualitative study. Reprod Health Matt. 2018;26(53):70–87.

Asefa A, Bekele D. Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia. Reprod Health. 2015;12(1):1–9.

Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth. 2015;15(1):1–4.

Kujawski SA, Freedman LP, Ramsey K, Mbaruku G, Mbuyita S, Moyo W, et al. Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga region, Tanzania: a comparative before-and-after study. PLoS Med. 2017;14(7):e1002341.

Asefa A. Unveiling respectful maternity care as a way to address global inequities in maternal health. BMJ Glob Health. 2021;6(1):e003559.

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Acknowledgments

We acknowledge the midwives who participated in this study and shared their perspectives about challenges faced and prospects available for promoting RMC.

The research reported in this publication was supported by a grant awarded by the National Institutes of Health through the Fogarty International Center under Award Number K43TW011022 to VMD. The content is solely the responsibility of the authors and does not represent the official view of the funder. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Veronica Millicent Dzomeku, Adwoa Bemah Boamah Mensah, Pascal Agbadi & Joshua Okyere

Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Emmanuel Kweku Nakua

Department of Population and Health, University of Cape Coast, Cape Coast, Ghana

Joshua Okyere

Department of Sociology and Social Policy, Lingnan University, 8 Castle Peak Road, Tuen Mun, Hong Kong

Pascal Agbadi

Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Peter Donkor

University of Michigan School of Nursing, Ann Arbor, USA

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Contributions

DVM, DP, and LRJ are the project leads, and they contributed to the conceptualization, data curation, formal analyses, writing of the original manuscript, as well as editing and review of the final manuscript. ABBM and NKE contributed to the data curation, formal analyses, writing of the original manuscript, editing, and review of the final manuscript. AP and JO contributed to formal analyses, writing of the original manuscript, editing, and review of the final manuscript. All authors have read and approved the manuscript.

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Correspondence to Veronica Millicent Dzomeku .

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All methods were performed in accordance with the relevant guidelines and regulations. Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics (CHRPE) at the Kwame Nkrumah University of Science and Technology (KNUST) (reference number: CHRPE/AP/181/18) and the Komfo Anokye Teaching Hospital Institutional Review Board (reference number: RD/CR17/289). We anonymised information by giving pseudonyms to the participants in order to protect their identities and prevent third parties from tracing data back to participants. Written informed consent was provided to participants in order for them to voluntarily participate in the study after having read and understood the terms, risks and benefits associated with their participation. Also, the recorded interviews were encrypted to prevent third parties from having access to it. After debriefing each participant, each of them requested that the place of the interview should be near their place of work, which we consented to.

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Dzomeku, V.M., Mensah, A.B.B., Nakua, E.K. et al. Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana. BMC Pregnancy Childbirth 22 , 451 (2022). https://doi.org/10.1186/s12884-022-04786-w

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Nurses and midwives demographic shift in Ghana—the policy implications of a looming crisis

• James Avoka Asamani   ORCID: orcid.org/0000-0003-0620-6010 1 ,
• Ninon P. Amertil 2 ,
• Hamza Ismaila 3 ,
• Akugri Abande Francis 2 ,
• Margaret M. Chebere 3 &
• Juliet Nabyonga-Orem 1  

Human Resources for Health volume  17 , Article number:  32 ( 2019 ) Cite this article

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As part of measures to address severe shortage of nurses and midwives, Ghana embarked on massive scale-up of the production of nurses and midwives which has yielded remarkable improvements in nurse staffing levels. It has, however, also resulted in a dramatic demographic shift in the nursing and midwifery workforce in which 71 to 93% of nurses and midwives by 2018 were 35 years or younger, as compared with 2.8 to 44% in 2008. In this commentary, we examine how the drastic generational transition could adversely impact on the quality of nursing care and how the educational advancement needs of the young generation of the nursing and midwifery workforce are not being met. We propose the institution of a national nursing and midwifery mentorship programme and a review of the study leave policy to make it flexible and be based on a comprehensive training needs assessment of the nursing and midwifery workforce. We further advocate that policymakers should also consider upgrading all professional nursing and midwifery programmes to bachelor degrees as this would not only potentially enhance the quality of training but also address the phenomenon of large numbers of nurses and midwives seeking bachelor degree training soon after employment—sometimes putting them at the offending side of organisational policy.

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Introduction

The global community is increasingly recognising the contribution of nurses and midwives to health service delivery and the need to harness the nursing and midwifery potential towards the attainment of Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) especially goal 3. In leaving no one behind as enshrined in the UHC effort, nurses and midwives who undoubtedly have been the bedrock of most healthcare systems and form the bulk of the health workforce [ 1 , 2 ] would have to be a greater part of the efforts.

The 2006 World Health Report classified Ghana among 36 countries in sub-Saharan Africa facing Human Resources for Health (HRH) crisis [ 3 ] which became a clarion call for concerted efforts to address a myriad of health workforce challenges notably, inadequate production, excessive out-migration and low wages among others. Consequently, the Ministry of Health developed the HRH strategy, 2007–2011 [ 4 , 5 ] which outlined a number of strategic interventions including the expansion and liberalisation of the training of health workers, the reintroduction of auxiliary nursing programmes, the establishment of postgraduate specialist training colleges (for doctors, pharmacist, nurses and midwives), review of health workers salary structure and the introduction of staff vehicle hire purchase scheme, to name a few. It would appear that these efforts to a large extent yielded some fruits as the density of doctors, nurses and midwives dramatically improved from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017 [ 6 ]. These efforts have not only resulted in improved service coverage towards UHC, but also the country is being cited as a leading producer of physicians, nurses and midwives in sub-Saharan Africa [ 7 , 8 ].

Out of about 115 650 health workers employed in the public sector in 2018, 58% were nurses and midwives whose numbers increased by 370% between 2008 and 2018 [ 9 ]. Among the nursing and midwifery workforce, 31% and 22% are enrolled nurses and community health nurses respectively (who are trained for 2 years). Nevertheless, empirically, there exist lingering workforce shortages and inequitable distribution [ 10 , 11 ] alongside a publicly acknowledged challenge of trained but unemployed nurses and midwives [ 12 , 13 ]. Although the aforesaid issues continue to preoccupy the health sector policymakers, an examination of the nursing and midwifery demographic transition over the last decade shows a massive youth bulge which must be taken into account in the health workforce policy discourse. Based on the annual operational report of the Ghana Health Service (GHS), we examine the changing age dynamics of the nursing and midwifery workforce in Ghana and advocate for a policy response in terms of mentorship and in-service education management.

Demographic shift among nurses and midwives—2008 and 2018 compared

Since the last decade, there has been a far-reaching shift in the age profile of the nursing and midwifery workforce in Ghana which appears to have been unaccounted for in the health workforce policy discourse. For example, in 2008, less than 3% of midwives were younger than 35 years with at least 88% being older than 46 years, most of whom were set to exit the active workforce (Fig.  1 ). This certainly rang the alarm bell [ 14 ] resulting in the introduction of direct Midwifery Program for Secondary School leavers which was hitherto restricted to only serving nurses. In contrast to the 2008 situation, about 71% of midwives in 2018 were between 25 and 35 years. Only 12% of the midwives were older than 46 years compared with 88% in 2008. This implies that during the last decade, there were literally too many experienced midwives with fewer younger ones to mentor, a situation which the opposite is currently prevailing whereby the bulk of the current generation of midwives are relatively inexperienced while there are too few clinical mentors to guide them.

Age profile of nurses and midwives in the public sector of Ghana, 2008 vs 2018

Similarly, in 2008, there were two distinct generational cohorts of professional nurses; 43% of whom were young (25–35 years) and were being mentored by 36% who were aged 45 years or older. Compared to the situation in 2018, 81% of professional nurses are younger than 35 years who are expected to be mentored by only 7% experienced ones who are 46 years or older (Fig.  1 ).

Also, the pattern of the demographic shift in the ages of the auxiliary nursing categories has been like that of the midwives. By 2018, enrolled nurses and community health nurses who were older than 45 years were almost extinct in the public health sector (less than 3% in both cases), as 93% and 90% of enrolled and community health nurses respectively were younger than 35 years. Indeed, the median range of working experience of these categories of nurses is also 3–5 years.

Policy implications

The foregoing demographic shift in terms of the age profile of nurses and midwives brings to fore several policy implications, some of which we discuss with the view of advocating for operational policy reforms at the MOH and its agencies.

Institute nursing and midwifery mentorship programme to improve quality of care

Whilst some have lauded the improvement in the stock of nursing and midwifery workforce, there are also concerns about the quality of nurses and midwives being produced and the impact of same on quality of care [ 15 , 16 ]. Undoubtedly, a situation where the care of patients is shifted from quite experienced to relatively inexperienced hands should adversely affect the technical quality of patient care, especially when there are no structured clinical mentorship programmes for midwives and nurses in Ghana beyond the required internships which are seldom monitored and virtually no one gets deferred. In the case of midwives, cultural issues may hinder older mothers from delivering in health facilities because they feel the young midwives are of the age of their children. Under the circumstance, it would be imperative for the MOH and its agencies to institute a mentorship scheme for nurses and midwives and if necessary, re-engage retired but fit-to-practice nurses and midwives to mentor young nurses and midwives.

Also, it has been documented that professional nurses of junior ranks (such as staff nurse and senior staff nurse—those with 1–3 years of working experience) have in many instances been made nurse managers in-charge of service delivery units/wards without adequate preparations [ 17 , 18 , 19 ]—roles which are significantly supervisory, clinical leadership and mentorship in nature. This ill-preparedness of the nurse managers could have an adverse consequence on both staff and patient outcomes [ 20 , 21 , 22 , 23 , 24 ]. Beyond concerns of the technical quality of patient care associated with limited clinical experience of the young generation of nurses and midwives, another source of concern is the potential for them to get stressed and burnout due to high workload levels in the roles that are relatively above their level of experience and capacity, a situation which could culminate in increased turnover and ultimately higher vacancy rates. Therefore, the Ministry of Health and its agencies need to explicitly define the criteria to be met, preferably competitive and managerial in nature, for appointment as nurse/midwife manager.

Review in-service training and education policy

It has been observed that, in recent years, large numbers of young health workers especially nurses and midwives are pursuing further training and education because most of them are initially trained at level of a 2-year certificate or a three-year diploma who are seeking for opportunities to obtain bachelor degrees—a testament that many nurses and midwives are unsatisfied with their non-bachelors level of training. Indeed, evidence from the international literature suggests that patients are much more safer under the care of nurses and midwives who are highly trained at least at the level of bachelors [ 25 , 26 ]. Under the prevailing dispensation of study leave policy, the official opportunities given to nurses and midwives to embark on further studies for bachelor degrees appears to be too restrictive which some nurses and midwives even wonder if it will ever get to their turn if they continue to wait in the queue for study leave. Consequently, some nurses and midwives have resorted to flexible modes of education such as weekends, evening and sandwich studies (with or without approval from their employer) which sometimes put them at the offending side of organisational policies.

It is imperative that Ministry of Health and its agencies view the aforesaid as a clarion call to review the policies on study leave which is neither efficient nor meeting the professional needs of the current generation of nurses and midwives. For instance, in 2018, 67% of GHS’ staff education programme focused on full-time studies with only 32% focusing on weekend, evening and sandwich modes of education combined [ 9 ]. The study leave policies should be reviewed to allow flexibility to accommodate the needs of the young generation of nursing and midwifery workforce to eschew resentment and demotivation which is adversely affecting staff performance and service delivery. We advocate for periodic comprehensive training needs assessment of all staff to facilitate the development of a master training plan based on which annual study leave plans can be developed using a bottom-up approach. This should be accompanied with greater emphasis on flexible modes of education (such as weekends, sandwich and evening studies) which tend to be cost-effective from the employer’s perspective as these flexible modes of education would allow the employees to continue to provide services whilst pursuing further studies. Finally, it might be worth considering upgrading all professional nursing and midwifery programmes to the level of first degree (baccalaureate programmes) as is the case in some countries in bid to improve the quality of training and also mitigate against the mass agitations by nurses and midwives for study leave to undertake degree programmes in nursing and midwifery soon after their employment.

Escalation of the production of nurses and midwives in Ghana over the last decade has resulted in a drastic shift in the age structure of nurses and midwives. This demographic shift appears to have been without appropriate mechanisms for mentorship which could adversely affect the quality of health care. The nursing and midwifery youth bulge has increased pressure on the administration of the study leave policy of the Ghana health sector. We reckon that these have necessitated the institutionalisation of a nursing and midwifery mentorship programme and a review of the study leave policy as well as to consider upgrading all professional nursing and midwifery programmes to first degrees soon after their employment.

Abbreviations

Human Resource for Health

Health Workforce

Ministry of Health

Sustainable Development Goals

Universal Health Coverage

World Health Organization

Boniol M, McIsaac M, Xu L, Wuliji T, Diallo K, Campbell J. Gender equity in the health workforce: analysis of 104 countries. Geneva: World Health Organ; 2019. p. 8.

George A. Human resources for health: a gender analysis. 2007. p. 57. https://www.who.int/social_determinants/resources/human_resources_for_health_wgkn_2007.pdf?ua=1

WHO. The world health report: 2006: working together for health. 2006; Available from: http://apps.who.int/iris/handle/10665/43432 . [Cited 10 Oct 2016]

Google Scholar  

MOH. Human resource policies and strategies for the health sector, 2007–2011 [Internet]. Ghana: Ministry of Health; 2007. Available from: www.moh.gov.gh

Sagoe K. Human resources for health - challenges and strategies to address them in sub-Saharan Africa. 2013. Available from: http://www.fatoafrique.org/congres2013/IMG/pdf/sagoe_kenneth_ppt_fr.pdf . [cited 24 Mar 2019]

GHS. Human resource directorate annual report for 2017. Accra: Ghana Health Service, Human Resource Directorate; 2018.

Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Org. 2013;91(11):853–63 Available from: http://www.scielosp.org/scielo.php?pid=S0042-96862013001100853&script=sci_arttext . [cited 29 Jan 2017].

Article   Google Scholar  

WHO. Equitable access to functional health workforce and community health workers in the africa region [Internet], WHO Regional Forum on Strengthening Health Systems for the SDGs and UHC. Windhoek; 2016.

GHS. Human resource annual report - 2018. Accra: Ghana Health Service; 2019.

Asamani JA, Chebere MM, Barton PM, D’Almeida SA, Odame EA, Oppong R. Forecast of healthcare facilities and health workforce requirements for the public sector in Ghana, 2016–2026. Int J Health Policy Manag. 2018;0(0) Available from: http://www.ijhpm.com/article_3525.html . [Cited 7 Aug 2018].

Scheffler RM, Mahoney CB, Fulton BD, Dal Poz MR, Preker AS. Estimates of health care professional shortages in sub-Saharan Africa by 2015. Health Aff (Millwood). 2009;28(5):w849–62 Available from: http://content.healthaffairs.org/cgi/doi/10.1377/hlthaff.28.5.w849 . [Cited 3 Jun 2016].

Amadu H. The rising trend in nurses unemployment: the need to include entrepreneurship in our nursing colleges curriculum [Internet]: Modern Ghana; 2018. Available from: https://www.modernghana.com/news/886516/the-rising-trend-in-nurses-unemployment-the-need-to-include.html . [cited 24 Mar 2019]

Elorm. Bonded nurses and midwives demand postings to health facilities [Internet]: Ghana Business News; 2018. Available from: https://www.ghanabusinessnews.com/2018/09/07/bonded-nurses-and-midwives-demand-postings-to-health-facilities/ . [Cited 24 Mar 2019]

Appiah-Denkyira E, Herbst CH. Toward evidence-based interventions for HRH. 2013 . Available from: http://elibrary.worldbank.org/doi/abs/10.1596/9780821396674_CH01 . [Cited 29 Jan 2017].

Book   Google Scholar  

Dzomeku MV. Maternal satisfaction with care during labour: a case study of the Mampong-Ashanti district hospital maternity unit in Ghana. Int J Nurs Midwifery. 2011;3(3):30–4 Available from: http://www.academicjournals.org/journal/IJNM/article-full-text-pdf/154DAFD809 . [cited 17 Nov 2016].

Moyer CA, Rominski S, Nakua EK, Dzomeku VM, Agyei-Baffour P, Lori JR. Exposure to disrespectful patient care during training: data from midwifery students at 15 midwifery schools in Ghana. Midwifery. 2016;41:39–44 Available from: http://www.sciencedirect.com/science/article/pii/S026661381630119X . [Cited 18 Dec 2016].

Asamani JA, Kwafo EO, Ansah-Ofei AM. Planning among nurse managers in district hospitals in Ghana. Nurs Manag (Harrow). 2013;20(8):26–31 Available from: http://journals.rcni.com/doi/full/10.7748/nm2013.12.20.8.26.e1151 . [Cited 18 Apr 2016].

Ofei AM, Sakyi EK, Buabeng T, Mwini-Nyaledzigbor P, Atindanbila S. Perceived and preferred leadership behavior of nurse managers at the unit level in the Greater Accra Region: a mixed method approach. Int Rev Soc Sci. 2014;2(2):42–61.

Peter Adatara JA. Challenges of being a hospital nurse manager in the Volta region of Ghana: a qualitative study. Nusing Manag Harrows. 2019;25(5):35–42 Available from: https://journals.rcni.com/nursing-management/evidence-and-practice/challenges-of-being-a-hospital-nurse-manager-in-the-volta-region-of-ghana-a-qualitative-study-nm.2018.e1773/print/abs . [Cited 24 Mar 2019].

Azaare J, Gross J. The nature of leadership style in nursing management. Br J Nurs. 2011;20(11):672–80 Available from: https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2011.20.11.672 . [Cited 27 Sep 2013].

Asamani JA, Naab F, Ofei AMA. Leadership styles in nursing management: implications for staff outcomes. J Health Sci. 2016;6(1):1–14 Available from: https://www.jhsci.ba/ojs/index.php/jhsci/article/view/533 . [Cited 18 Apr 2016].

Cummings GG, MacGregor T, Davey M, Lee H, Wong CA, Lo E, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2010;47(3):363–85 Available from: http://www.sciencedirect.com/science/article/pii/S0020748909002831 . [Cited 27 Sep 2013].

Cummings GG, Midodzi WK, Wong CA, Estabrooks CA. The contribution of hospital nursing leadership styles to 30-day patient mortality. Nurs Res [Internet]. 2010;59(5):331–9 Available from: https://www.ncbi.nlm.nih.gov/pubmed/20686431 . [Cited 25 May 2016].

Wong CA, Cummings GG. The relationship between nursing leadership and patient outcomes: a systematic review. J Nurs Manag. 2007;15(5):508–21 Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2007.00723.x/full . [Cited 27 Sep 2013].

Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195 Available from: https://journals.lww.com/lww-medicalcare/Abstract/2007/12000/The_Association_of_Registered_Nurse_Staffing.11.aspx . [Cited 6 May 2019].

Aiken LH, Sloane DM, Bruyneel L, den HKV, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931):1824–30 Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62631-8/abstract . [Cited 6 May 2019].

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Acknowledgements

We are profoundly grateful to Mr. Francis Victor Ekey for assisting us to retrieve historical age profile of Ghanaian public sector nurses.

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JAA conceived and designed the analysis; JAA and HI carried out the data collection and analysis and drafted the manuscript. NPA, AAF, MMC and JN contributed to the writing of the manuscript. All authors read, edited and approved the manuscript.

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Asamani, J.A., Amertil, N.P., Ismaila, H. et al. Nurses and midwives demographic shift in Ghana—the policy implications of a looming crisis. Hum Resour Health 17 , 32 (2019). https://doi.org/10.1186/s12960-019-0377-1

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The experiences of nurses and midwives regarding nursing education in Ghana: A qualitative content analysis

Affiliations.

• 1 School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus, Nosrat st. Tohid sq., Tehran 141973317, Iran; Tamale Teaching Hospital, Tamale, Ghana.
• 2 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. Electronic address: [email protected].
• 3 Nursing and Midwifery Training College, Gushegu, Ghana.
• 4 School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus, Nosrat st. Tohid sq., Tehran 141973317, Iran.
• PMID: 32574948
• DOI: 10.1016/j.nedt.2020.104507

Background: The nursing education in Ghana has only witnessed minimal advancement though one of the earliest in Africa. This study aimed to explore nursing education in Ghana at the bachelor degree level in terms of the program's strengths, weaknesses, opportunities, and threats from the perspectives of nurses and midwives.

Methods: A qualitative design based on the content analysis approach was used in this study. We purposefully sampled and interviewed thirty-five nurses and midwives at the Tamale Teaching in Ghana from September 2018 to May 2019.

Results: The data analysis revealed five main categories; professionally developed, diverse implementation, insufficient resources, applied opportunities, and threatening policies. The findings highlight the strengths, weaknesses, opportunities, and threats of nursing education at the bachelor degree level in Ghana.

Conclusion: The nursing education in Ghana has some internal capabilities in the form of strengths and weaknesses, such as the program being professionally regulated and operates on a well-developed curriculum, yet challenged with insufficient faculty and resources. The external opportunities and threats present as global recognition and career opportunities, amidst the proliferation of adjunct nursing programs. Recommendations have been highlighted.

Keywords: Content analysis; Ghana; Nursing education; Qualitative study.

Copyright © 2020 Elsevier Ltd. All rights reserved.

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Conflict of interest statement

Declaration of competing interest All the authors declare that they have no conflict of interest.

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Clinical learning environment of nursing and midwifery students in Ghana

• Florence Assibi Ziba 1 ,
• Vida Nyagre Yakong 2 &
• Zakari Ali 3 , 4  

BMC Nursing volume  20 , Article number:  14 ( 2021 ) Cite this article

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Data on student experience of the clinical learning environment in Ghana are scarce. We therefore aimed to assess students’ evaluation of the clinical learning environment and the factors that influence their learning experience.

This was a cross-sectional survey of 225 undergraduate nursing and midwifery students. We used the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale to assess students’ experience of their clinical placement. The association between student demographic characteristics and clinical placement experience was determined using t-test or ANOVA.

Most of the sampled students were Nurses (67%) and in the third year of training (81%). More students received supervision from a nurse (57%) during clinical placement and team supervision (67%) was the most common during clinical placement. Nursing students were more likely to rate their clinical experience better than midwifery students ( p =0.002). Students who had increased contact with private supervisors were also more likely to rate their experience higher ( p= 0.002). Clinical experience was also rated higher by students who received successful supervision compared to those who had unsuccessful or team supervision ( p =0.001).

Team supervision is high in health facilities where students undertake clinical placement in Ghana. Frequent contact with private supervisor and successful supervision are associated with better rating of clinical experience among Ghanaian undergraduate nursing and midwifery students.

Peer Review reports

Nursing care is pivotal in the health care services worldwide. Globally, nurses and midwives constitute 59% of the health workforce [ 1 ]. In Ghana, out of the 115, 650 health workers employed by the government, nurses and midwives account for 58% [ 2 ]. The axillary nurses (community and enrolled nurses; trained for 2 years) make up the majority (53%) of the total nursing and midwifery workforce whiles professional nurses (with at least 3 years of training resulting in the acquisition of diploma, undergraduate, postgraduate qualifications, or specific speciality areas of study) account for 47% [ 2 , 3 ]. The nurse serves as the main vessel that convey most interventions and care necessary for individuals utilizing health care services. For nurses to efficiently perform the myriads of duties, it depends on their ability to apply theory to practice [ 4 , 5 ]. Hence, nursing training involves both theory and practical training. Each aspect of the training carries important weight.

The clinical skills acquisition of nurses is so important that the Nursing and Midwifery Council (NMC) of Ghana, a body mandated to regulate the training of nurses increased the clinical contact hours of students to 432 h, 624 h and 576 h for the first, second and third year of training respectively [ 6 ]. According to Benner [ 7 ], skills acquisition is not an event but a process where individual nurses start as novice and gradually become experts. Whiles the acquisition of knowledge on the theory is done in the classroom, the skills acquisition is done in the skills laboratory and clinical learning environment or setting depending on one’s level of study.

The clinical learning environment (CLE) is a complex and constantly changing setting [ 8 ]. The CLE can be influenced by several factors such as the kind of supervisor, the quality of feedback received by students, the context and the students [ 9 , 10 ]. Much of skills teaching are done by the nurses in clinical practice regardless of their level of education and expertise.

This implies that the quality of clinical teaching of students depends on the efficiency of the supervisor they meet in the clinical facility [ 11 , 12 ]. In Ghana, it is regarded the responsibility of every registered nurse or midwife to provide teaching or guidance for students who work with them on their shift without any specific training for that purpose. The registered nurses supervise students and do not receive payments by any of the institutions for this service. Some of these supervisors may not be adequately prepared or motivated for the task of clinical teaching [ 9 ]. According to Chan and Ip [ 13 ], their relationship is very key and determines the kind of learning environment created. A positive learning clinical environment is a result of good relationship between the supervisor and the students. Nursing students will always be motivated to learn in environments where there is mutual respect and students are involved in the team and supported with their decision making [ 4 ].

Constructs of the clinical learning environment positively influence students’ satisfaction with their learning activities [ 14 ]. The pedagogical atmosphere, ward manager leadership style and supervisory relationship are important factors that contribute to satisfaction with the clinical environment. Students who have the chance to meet a supervisor on more regular basis tend to well appreciate the contribution of the clinical environment to their skills learning. Having access to a supervisor or mentor allows the student to learn more and improve the skills learning.

Despite the importance of clinical learning for nursing students, it comes with some challenges to students, faculty and supervisors. For students, depending on the level of study it can be demanding especially when students feel, they lack the right skills for a particular assigned task [ 15 ]. They worry about the probability of supervisors holding negative perceptions about them which could affect their grading and therefore may come under “pressure” to please their supervisors [ 9 ].

Crowding of students in the clinical setting is a major challenge to clinical teaching and learning [ 16 , 17 ]. Overcrowding in the ward makes it difficult for both students and clinical supervisors to engage meaningfully. When student numbers are high it means student-preceptor ratios will be higher than required for effective clinical learning. When students are more than the physical space can accommodate it becomes very difficult for staff to even assist them to learn clinical skills [ 18 ]. In Ghana, the ration of a supervisor to student is approximately 1: 10 or more students in a shift [ 19 ]. This is because students are required to do their clinical placement only in the hospital setting. Therefore, the need to improve clinical nursing education is an important aspect of training of nurses. Thematic areas of importance in improving clinical nursing education include having positive clinical environment, effective clinical supervision, adequate assessment of students and clinical-academic collaborations [ 20 ]. However, there are no current studies reporting the student evaluation of their clinical placement experience in Ghana. We examined nursing and midwifery students’ evaluation of their clinical placement using the CLES+T.

Study design and setting

This was a cross-sectional study involving undergraduate nursing and midwifery students of the University for Development Studies on clinical placement in health facilities in the Tamale Metropolis.

The Tamale Metropolitan Assembly (normally of a population of ≥250, 000) is one of the 260 Metropolitan, Municipal (normally of a ≥95,000 population) and District (normally of a ≥75,000 population) Assemblies in Ghana. Tamale is the capital town of the metropolis and the Northern region of Ghana. Until 2004, it was a municipality. It is the largest of the 16 metropolitan, municipal and district assemblies in the northern region of Ghana. According to the 2010 population and housing census, the metropolis has a population 223,252 made up of 49.8 and 50.2% males and females respectively. Though the main language of the people is Dagbani, due to its cosmopolitan nature, all the different Ghanaian languages can be heard in the municipality [ 21 ].

Apart from the University for Development studies which trains nurses and midwives among other health professionals, the metropolis has two of the oldest nursing training institutions in Ghana; the Tamale Nursing and midwifery training college and the Tamale community health nursing school. One of the three teaching hospitals in Ghana- The Tamale Teaching Hospital, is located in this metropolis. Students are, therefore, placed in this hospital and three other public hospitals (Tamale Central, West and the Seventh Day Adventist hospitals) for the clinical practicum.

Sampling and clinical placement

Purposive and convenient sampling techniques were used. Purposive, because only students who were toward the end of their studies (third and fourth years’ students) for nursing and midwifery degree were selected to participate in the study. Undergraduate education in Ghana is for 4 years and range from level 100 to level 400. The clinical supervisors sign off the clinical assessment of the students. This assessment constitutes 40% of the mark a student will score in his or her practical exams for the semester. The rest of the 60% is from Objective Structured Clinical Examination (OSCE) conducted by the training institutions (the school). The clinical placement of undergraduate students is divided into intra semester (students are placed for 1 day each week whiles they continue with their lectures and academic activities) and after semester (when students are done with their lectures and examination for the semester and proceed to spend the rest of it clinical placement. This comprise of four to ten weeks block for first and second semesters respectively). This was to ensure that students had enough exposure to clinical placement to enable them to evaluate their experience. However, it was convenient because students in these year levels who were available and willing to participate were selected.

The questionnaire was administered to students by the researchers in the university campus. The questionnaire was self-administered and participants were allowed to take the questionnaires home and return completed copies to the researchers.

The study questionnaire

We used the English version of the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale [ 22 ] with prior permission. This psychometric testing scale consists of a total of 34 items within five sub-dimensions. The sub-dimensions are: pedagogical atmosphere on the ward (nine items), leadership style of the ward manager (four items), premises of nursing on the ward (four items), supervisory relationship (eight items), and role of the nurse teacher in clinical practice (nine items). The questions were scored on a five-point Likert scale of 1 to 5. The scores were as follows: 1=fully disagree, 2=disagree to some extent, 3=neither agree nor disagree, 4=agree to some extent and 5=fully agree. We added questions on programme of study and level.

Statistical analysis

Statistical analyses were done using SPSS version 21. Demographic characteristics of students are presented as frequencies and percentages. Internal consistency was checked for the overall scale and each of the five dimensions using Cronbach’s alpha. There was high internal consistency of the overall CLES +T (Cronbach’s alpha = 0.904). The five dimensions also showed high internal consistency with Cronbach’s alpha values ranging from 0.713 to 0.903 which showed the suitability of the use of this scale (Additional file  1 ). The method of supervision was categorised into three based on responses to six questions. Unsuccessful supervision was assigned based on a combination of three alternative questions: (i) the student did not have a named supervisor; (ii) a personal supervisor was named, but the relationship with this person did not work; and (iii) the named supervisor changed during the training course. Team supervision was assigned based on a combination of: (i) the supervisor varied according to shift or place and (ii) the supervisor had several students. Successful supervision was where students had a named mentor and the relationship worked in practice [ 23 , 24 ].

An overall mean score of the questionnaire was calculated for each student by calculating the mean score of all questions. Scores on the five sub-dimensions were also calculated for each student using scores of the questions that make up those dimensions. Higher scores indicate more agreement with the statements.

The association between student demographic characteristics and clinical placement experience and mean scores was determined using t-test or ANOVA as appropriate. We determined associations of the overall mean score on CLES+T and the sub-dimensions using the mean scores (continuous) as dependent variable and demographic characteristics (binary/categorical) and clinical experience (binary/categorical) as independent variables.

Background characteristics and clinical experience of students

Majority of the sampled students were undergraduate nursing students (67%) and were in their third year (81%) of study. More than five in ten students received supervision from a nurse (57%) during clinical placement while nurse specialists (4%) provided least supervision. Team supervision (where students are not assigned to specific supervisor but are qualified or registered nurses on duty for the shift do the supervision) (67%) was the most common supervision students received during clinical placement. About three in ten students reported unsuccessful supervision (29%) while only 4% received successful supervision during clinical placement. Moreover, most students did not have one on one contact with their supervisor (46%) and the most frequent private contact with clinical supervisor was once or twice during the course of placement (27%) (Table  1 ).

Mean scores on the overall scale and sub-dimensions

Students had good perceptions of their clinical placement (mean CLES + T = 3.24). Student perceptions on the sub-divisions of CLES + T varied considerably. The highest score was for the Leadership style of the ward manager (3.6) while Role of the nurse teacher in clinical practice (3.06) dimension of CLES + T was least scored (Table  2 ).

Association between student demographics, clinical experience and mean CLES + T score

The results show that mean CLES + T score was not associated with year of study even though third year students had a little higher scores than fourth year students (3.3 vs 3.2, p =0.405). Mean CLES + T score associated weakly with the title of assigned clinical supervisor ( p =0.063). There was evidence of association between mean score and student programme of study, with nursing students scoring a little higher than midwifery students ( p =0.002); hence, nursing students perceived their clinical learning environments better than midwifery students. Students who had successful supervision were more likely to have higher scores than those who did not ( p =0.001). Students who reported increased contact with their private supervisors had higher mean scores ( p= 0.002) (Table  3 ).

Association between student demographics, clinical experience and mean score of the dimensions of CLES + T

We investigated the relationship between mean scores of the five dimensions of CLES + T and student’s demographic factors and clinical placement experience. The data show that method of supervision and frequency of private contact with supervisor were associated with the Pedagogical atmosphere dimension of CLES + T. For example, while students who received successful supervision (3.6) had better perceptions of the Pedagogical atmosphere, those who had unsuccessful supervision (3.1) and those who received team supervision (3.4) had poor perceptions. Only the method of supervision students received was associated with the Leadership style of the ward manager dimension of CLES +T ( p =0.023). Premise of nursing on the ward dimension was associated with the programme of study of students and their frequency of private contact with supervisor (Table  4 ).

In addition, Supervisory relationship was associated with programme of study ( p =0.002), frequency of contact with private supervisor ( p =0.001) and method of supervision received ( p < 0.001). The last dimension of CLES + T: Role of nurse teacher in clinical practice was also associated with programme of study ( p =0.010) and method of supervision ( p =0.015) (Table  5 ).

In this cross-sectional study among undergraduate nursing and midwifery students in the Tamale metropolis of Ghana, we assessed students’ evaluation of their clinical experience in health facilities using the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale. The main findings are that; more students received supervision from nurses during clinical placement and team supervision was the most common supervisory type. Nursing students were more likely to rate their clinical experience better than midwifery students and students who had increased contacts with private supervisors were more likely to rate their experience higher. Clinical experience was also evaluated better by students who received successful supervision compared to those who had other forms of supervision.

The higher likelihood of nurses than other health professionals such as midwives to provide supervision to students on clinical placement in this setting may be explained by the type of skills and competencies students are placed to acquire. This is because many basic skills for both nursing and midwifery as well as advanced skills are taught by nurses as most of those skills are general until students, such as the midwifery students move on to perform specific midwifery skills. The higher rating of clinical placement by nursing students than midwifery students in the present study could mean that midwifery students were expecting that since they are midwives they needed to have been supervised by only midwives; there is also the tendency to view midwifery practice totally separate from nursing practice, which in fact, should not be the case because most basic skills performed in midwifery practice also occur in nursing practice. This is a perception that needs more exploration to inform students’ experience and appreciation of their practice and skills acquisition. It is, therefore, useful for students to be made aware of this ahead of their clinical placement to avoid being unsatisfied with the initial nurse dominant supervision they receive.

We find that frequency of contact with private supervisor was associated with high evaluation of clinical experience by both nursing and midwifery students. These findings are consistent with the results from Cyprus [ 14 ], Slovakia [ 25 ], northern Italy [ 26 ] and Sweden [ 27 ] where nursing students evaluated their clinical experience better with private supervision. As team supervision was higher and likely to be poor among students, it is reasonable that contact with private supervisors with a high tendency for tailored training to receive high rating. There is high need for private supervision as revealed in the study and calls for students to make more efforts and make good use of this opportunity whenever available to gain the needed skills. We recommend that clinic or ward staff also endeavour to provide private supervision to increase the quality of clinical experience of students.

Consistent with previous findings [ 14 , 23 , 26 ], successful supervision was associated with higher evaluation of student clinical experience. However, this has not always been the case in all studies [ 28 ]. Successful supervision constitutes having a named mentor and a perception of the relationship having worked out. Therefore, it is understandable that students who had successful supervision rated their overall clinical experience better. For improved clinical experience of students, mentors and students should work together to achieve a successful supervision.

To the best of our knowledge, this is the first attempt to report nursing and midwifery students’ evaluation of their clinical placement in Ghana. The findings could be useful to health institutions and providers such as hospitals and clinics involved in the training of nursing and midwifery students to achieve better clinical experience and skills acquisition. However, the results of the study should be interpreted keeping some limitations in mind. First, our sample consisted of more nursing students than midwifery students, so the generalizability of the findings may be less applicable to midwifery students. Second, most supervisors at the ward level were often of a lower educational level than the students which could affect the quality of supervision and supervisory relationship. While this is not a typical limitation of the study, it may have influenced the evaluation of student experience of their clinical placement. Third, the CLES+T questionnaire has not been validated in this setting. However, we do not think this would have affected our results greatly, as the questionnaires were administered in the original English language not translated into a different Ghanaian language. The tests for reliability of the CLES+T using Cronbach’s alpha were also within acceptable ranges indicating its suitability. In spite of these limitations, our results provide important insights into the experiences of nursing and midwifery students during clinical placement in Ghana.

Team supervision is high in health facilities where students undertake clinical placement in Ghana; nursing students are more likely to rate their clinical experience better than midwifery students and students with increased contacts with private supervisors were more likely to rate their experience better. Frequent contact with private supervisor and successful supervision are associated with better rating of clinical experience among Ghanaian undergraduate nursing and midwifery students.

Availability of data and materials

The data supporting the conclusions of this article are included within the manuscript. The datasets could be obtained from the corresponding author upon reasonable request.

Abbreviations

Clinical Learning Environment and Supervision + Nurse Teacher evaluation scale

WHO: State of the world's Nursing 2020 Investing in education, jobs and leadership. 2020.

Google Scholar  

Asamani JA, Amertil NP, Ismaila H, Francis AA, Chebere MM, Nabyonga-Orem J. Nurses and midwives demographic shift in Ghana—the policy implications of a looming crisis. Hum Resour Health. 2019;17(1):32.

Article   PubMed   PubMed Central   Google Scholar  

Ghana Health Service: The health sector in Ghana Facts and figures 2018. 2018.

Ali WG, Banan SHAE, Al Seraty WH. Effective clinical learning environment as perceived by nursing students at Al Dawadmi, applied medical sciences college: actual versus preferred characteristics. Int J Nurs Didactics. 2015;5(05):01–6.

CAS   Google Scholar  

Eta VE, Atanga MB, Atashili J, D’Cruz G. Nurses and challenges faced as clinical educators: A survey of a group of nurses in Cameroon. Pan Afr Med J. 2011;8(1).

Nursing and Midwifery Council of Ghana. Curriculum for the Registered General Nursing (RGN) Programme. Accra Ghana: NMC; 2015.

Benner P. From novice to expert. Am J Nurs. 1982;82(3):402–7.

CAS   PubMed   Google Scholar  

Friendly L, Roos L. The challenges nurses face regarding professional and personal responsibilities; 2008.

Dale B, Leland A, Dale JG. What factors facilitate good learning experiences in clinical studies in nursing: bachelor students’ perceptions. ISRN Nurs. 2013;2013.

Mwale OG, Kalawa R. Factors affecting acquisition of psychomotor clinical skills by student nurses and midwives in CHAM nursing colleges in Malawi: a qualitative exploratory study. BMC Nurs. 2016;15(1):30.

Upton P, Scurlock-Evans L, Williamson K, Rouse J, Upton D. The evidence-based practice profiles of academic and clinical staff involved in pre-registration nursing students' education: a cross sectional survey of US and UK staff. Nurse Educ Today. 2015;35(1):80–5.

Article   PubMed   Google Scholar  

Walker S, Dwyer T, Moxham L, Broadbent M, Sander T. Facilitator versus preceptor: which offers the best support to undergraduate nursing students? Nurse Educ Today. 2013;33(5):530–5.

Chan DS, Ip WY. Perception of hospital learning environment: a survey of Hong Kong nursing students. Nurse Educ Today. 2007;27(7):677–84.

Papastavrou E, Dimitriadou M, Tsangari H, Andreou C. Nursing students’ satisfaction of the clinical learning environment: a research study. BMC Nurs. 2016;15(1):44.

Sharif F, Masoumi S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs. 2005;4(1):6.

Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students' experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127–32.

Jamshidi L. The challenges of clinical teaching in nursing skills and lifelong learning from the standpoint of nursing students and educators. Procedia Soc Behav Sci. 2012;46:3335–8.

Article   Google Scholar  

Hanson SE, MacLeod ML, Schiller CJ. ‘It's complicated’: Staff nurse perceptions of their influence on nursing students' learning. A qualitative descriptive study. Nurse Educ Today. 2018;63:76–80.

Bell SA, Rominski S, Bam V, Donkor E, Lori J. Analysis of nursing education in G hana: priorities for scaling-up the nursing workforce. Nurs Health Sci. 2013;15(2):244–9.

Asirifi M, Ogilvie L, Barton S, Aniteye P, Stobart K, Bilash O, Eliason C, Achempim-Ansong G, Kwashie A, Aziato L. Reconceptualising Preceptorship in clinical nursing education in Ghana; 2019.

Book   Google Scholar  

Ghana Statistical Service. 2010 Population and Housing Census Distric analytical report Tamale Metropolis. Accra; 2014.

Saarikoski M, Isoaho H, Warne T, Leino-Kilpi H. The nurse teacher in clinical practice: developing the new sub-dimension to the clinical learning environment and supervision (CLES) scale. Int J Nurs Stud. 2008;45(8):1233–7.

Papastavrou E, Lambrinou E, Tsangari H, Saarikoski M, Leino-Kilpi H. Student nurses experience of learning in the clinical environment. Nurse Educ Pract. 2010;10(3):176–82.

Saarikoski M, Warne T, Kaila P, Leino-Kilpi H. The role of the nurse teacher in clinical practice: an empirical study of Finnish student nurse experiences. Nurse Educ Today. 2009;29(6):595–600.

Gurková E, Žiaková K, Cibríková S, Magurová D, Hudáková A, Mrosková S. Factors influencing the effectiveness of clinical learning environment in nursing education. Cent Eur J Nurs Midwifery. 2016;7(3):470–5.

Cremonini V, Ferri P, Artioli G, Sarli L, Piccioni E, Rubbi I. Nursing students’ experiences of and satisfaction with the clinical learning environment: the role of educational models in the simulation laboratory and in clinical practice. Acta Bio Medica Atenei Parmensis. 2015;86(3Supp):194–204.

PubMed   Google Scholar  

Carlson E, Idvall E. Nursing students' experiences of the clinical learning environment in nursing homes: a questionnaire study using the CLES+ T evaluation scale. Nurse Educ Today. 2014;34(7):1130–4.

Dimitriadou M, Papastavrou E, Efstathiou G, Theodorou M. Baccalaureate nursing students' perceptions of learning and supervision in the clinical environment. Nurs Health Sci. 2015;17(2):236–42.

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Acknowledgements

We are grateful to all the participants of the study. We also thank the original authors of CLES+T for giving the permission to use the questionnaire for this study.

We did not receive external funding for this study.

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Florence Assibi Ziba

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FAZ conducted the interview and wrote the manuscript. VNY Planned and designed the study. ZA entered, performed data analysis, results interpretation and wrote manuscript. All authors reviewed the final manuscript draft and approved the final version for publication.

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Correspondence to Florence Assibi Ziba .

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The study was granted ethical approval by the Research and Ethical Committee of the School of Allied Health Sciences of the University for Development Studies, Tamale, Ghana. Participation was purely voluntary. Participants verbally agreed to participation and provided written informed consent for participation. Participants were told they could decide to withdraw from the study anytime without any consequences. The purpose of the study and the assurance of confidentiality of information were explained to participants. They were also told they could decide not to answer any question they felt uncomfortable with.

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Additional file 1..

Test for internal consistency of CLES + T (Cronbach’s alpha).

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Ziba, F.A., Yakong, V.N. & Ali, Z. Clinical learning environment of nursing and midwifery students in Ghana. BMC Nurs 20 , 14 (2021). https://doi.org/10.1186/s12912-020-00533-8

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Nurses and midwives demographic shift in Ghana—the policy implications of a looming crisis

James avoka asamani.

1 World Health Organization, Regional Office for Africa, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe

Ninon P. Amertil

2 School of Nursing and Midwifery, Valley View University, Oyibi, Accra, Ghana

Hamza Ismaila

3 Human Resources Division, Ghana Health Services, Accra, Ghana

Akugri Abande Francis

Margaret m. chebere, juliet nabyonga-orem, associated data.

The datasets supporting our conclusions will be provided upon request.

As part of measures to address severe shortage of nurses and midwives, Ghana embarked on massive scale-up of the production of nurses and midwives which has yielded remarkable improvements in nurse staffing levels. It has, however, also resulted in a dramatic demographic shift in the nursing and midwifery workforce in which 71 to 93% of nurses and midwives by 2018 were 35 years or younger, as compared with 2.8 to 44% in 2008. In this commentary, we examine how the drastic generational transition could adversely impact on the quality of nursing care and how the educational advancement needs of the young generation of the nursing and midwifery workforce are not being met. We propose the institution of a national nursing and midwifery mentorship programme and a review of the study leave policy to make it flexible and be based on a comprehensive training needs assessment of the nursing and midwifery workforce. We further advocate that policymakers should also consider upgrading all professional nursing and midwifery programmes to bachelor degrees as this would not only potentially enhance the quality of training but also address the phenomenon of large numbers of nurses and midwives seeking bachelor degree training soon after employment—sometimes putting them at the offending side of organisational policy.

Introduction

The global community is increasingly recognising the contribution of nurses and midwives to health service delivery and the need to harness the nursing and midwifery potential towards the attainment of Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) especially goal 3. In leaving no one behind as enshrined in the UHC effort, nurses and midwives who undoubtedly have been the bedrock of most healthcare systems and form the bulk of the health workforce [ 1 , 2 ] would have to be a greater part of the efforts.

The 2006 World Health Report classified Ghana among 36 countries in sub-Saharan Africa facing Human Resources for Health (HRH) crisis [ 3 ] which became a clarion call for concerted efforts to address a myriad of health workforce challenges notably, inadequate production, excessive out-migration and low wages among others. Consequently, the Ministry of Health developed the HRH strategy, 2007–2011 [ 4 , 5 ] which outlined a number of strategic interventions including the expansion and liberalisation of the training of health workers, the reintroduction of auxiliary nursing programmes, the establishment of postgraduate specialist training colleges (for doctors, pharmacist, nurses and midwives), review of health workers salary structure and the introduction of staff vehicle hire purchase scheme, to name a few. It would appear that these efforts to a large extent yielded some fruits as the density of doctors, nurses and midwives dramatically improved from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017 [ 6 ]. These efforts have not only resulted in improved service coverage towards UHC, but also the country is being cited as a leading producer of physicians, nurses and midwives in sub-Saharan Africa [ 7 , 8 ].

Out of about 115 650 health workers employed in the public sector in 2018, 58% were nurses and midwives whose numbers increased by 370% between 2008 and 2018 [ 9 ]. Among the nursing and midwifery workforce, 31% and 22% are enrolled nurses and community health nurses respectively (who are trained for 2 years). Nevertheless, empirically, there exist lingering workforce shortages and inequitable distribution [ 10 , 11 ] alongside a publicly acknowledged challenge of trained but unemployed nurses and midwives [ 12 , 13 ]. Although the aforesaid issues continue to preoccupy the health sector policymakers, an examination of the nursing and midwifery demographic transition over the last decade shows a massive youth bulge which must be taken into account in the health workforce policy discourse. Based on the annual operational report of the Ghana Health Service (GHS), we examine the changing age dynamics of the nursing and midwifery workforce in Ghana and advocate for a policy response in terms of mentorship and in-service education management.

Demographic shift among nurses and midwives—2008 and 2018 compared

Since the last decade, there has been a far-reaching shift in the age profile of the nursing and midwifery workforce in Ghana which appears to have been unaccounted for in the health workforce policy discourse. For example, in 2008, less than 3% of midwives were younger than 35 years with at least 88% being older than 46 years, most of whom were set to exit the active workforce (Fig.  1 ). This certainly rang the alarm bell [ 14 ] resulting in the introduction of direct Midwifery Program for Secondary School leavers which was hitherto restricted to only serving nurses. In contrast to the 2008 situation, about 71% of midwives in 2018 were between 25 and 35 years. Only 12% of the midwives were older than 46 years compared with 88% in 2008. This implies that during the last decade, there were literally too many experienced midwives with fewer younger ones to mentor, a situation which the opposite is currently prevailing whereby the bulk of the current generation of midwives are relatively inexperienced while there are too few clinical mentors to guide them.

Age profile of nurses and midwives in the public sector of Ghana, 2008 vs 2018

Similarly, in 2008, there were two distinct generational cohorts of professional nurses; 43% of whom were young (25–35 years) and were being mentored by 36% who were aged 45 years or older. Compared to the situation in 2018, 81% of professional nurses are younger than 35 years who are expected to be mentored by only 7% experienced ones who are 46 years or older (Fig.  1 ).

Also, the pattern of the demographic shift in the ages of the auxiliary nursing categories has been like that of the midwives. By 2018, enrolled nurses and community health nurses who were older than 45 years were almost extinct in the public health sector (less than 3% in both cases), as 93% and 90% of enrolled and community health nurses respectively were younger than 35 years. Indeed, the median range of working experience of these categories of nurses is also 3–5 years.

Policy implications

The foregoing demographic shift in terms of the age profile of nurses and midwives brings to fore several policy implications, some of which we discuss with the view of advocating for operational policy reforms at the MOH and its agencies.

Institute nursing and midwifery mentorship programme to improve quality of care

Whilst some have lauded the improvement in the stock of nursing and midwifery workforce, there are also concerns about the quality of nurses and midwives being produced and the impact of same on quality of care [ 15 , 16 ]. Undoubtedly, a situation where the care of patients is shifted from quite experienced to relatively inexperienced hands should adversely affect the technical quality of patient care, especially when there are no structured clinical mentorship programmes for midwives and nurses in Ghana beyond the required internships which are seldom monitored and virtually no one gets deferred. In the case of midwives, cultural issues may hinder older mothers from delivering in health facilities because they feel the young midwives are of the age of their children. Under the circumstance, it would be imperative for the MOH and its agencies to institute a mentorship scheme for nurses and midwives and if necessary, re-engage retired but fit-to-practice nurses and midwives to mentor young nurses and midwives.

Also, it has been documented that professional nurses of junior ranks (such as staff nurse and senior staff nurse—those with 1–3 years of working experience) have in many instances been made nurse managers in-charge of service delivery units/wards without adequate preparations [ 17 – 19 ]—roles which are significantly supervisory, clinical leadership and mentorship in nature. This ill-preparedness of the nurse managers could have an adverse consequence on both staff and patient outcomes [ 20 – 24 ]. Beyond concerns of the technical quality of patient care associated with limited clinical experience of the young generation of nurses and midwives, another source of concern is the potential for them to get stressed and burnout due to high workload levels in the roles that are relatively above their level of experience and capacity, a situation which could culminate in increased turnover and ultimately higher vacancy rates. Therefore, the Ministry of Health and its agencies need to explicitly define the criteria to be met, preferably competitive and managerial in nature, for appointment as nurse/midwife manager.

Review in-service training and education policy

It has been observed that, in recent years, large numbers of young health workers especially nurses and midwives are pursuing further training and education because most of them are initially trained at level of a 2-year certificate or a three-year diploma who are seeking for opportunities to obtain bachelor degrees—a testament that many nurses and midwives are unsatisfied with their non-bachelors level of training. Indeed, evidence from the international literature suggests that patients are much more safer under the care of nurses and midwives who are highly trained at least at the level of bachelors [ 25 , 26 ]. Under the prevailing dispensation of study leave policy, the official opportunities given to nurses and midwives to embark on further studies for bachelor degrees appears to be too restrictive which some nurses and midwives even wonder if it will ever get to their turn if they continue to wait in the queue for study leave. Consequently, some nurses and midwives have resorted to flexible modes of education such as weekends, evening and sandwich studies (with or without approval from their employer) which sometimes put them at the offending side of organisational policies.

It is imperative that Ministry of Health and its agencies view the aforesaid as a clarion call to review the policies on study leave which is neither efficient nor meeting the professional needs of the current generation of nurses and midwives. For instance, in 2018, 67% of GHS’ staff education programme focused on full-time studies with only 32% focusing on weekend, evening and sandwich modes of education combined [ 9 ]. The study leave policies should be reviewed to allow flexibility to accommodate the needs of the young generation of nursing and midwifery workforce to eschew resentment and demotivation which is adversely affecting staff performance and service delivery. We advocate for periodic comprehensive training needs assessment of all staff to facilitate the development of a master training plan based on which annual study leave plans can be developed using a bottom-up approach. This should be accompanied with greater emphasis on flexible modes of education (such as weekends, sandwich and evening studies) which tend to be cost-effective from the employer’s perspective as these flexible modes of education would allow the employees to continue to provide services whilst pursuing further studies. Finally, it might be worth considering upgrading all professional nursing and midwifery programmes to the level of first degree (baccalaureate programmes) as is the case in some countries in bid to improve the quality of training and also mitigate against the mass agitations by nurses and midwives for study leave to undertake degree programmes in nursing and midwifery soon after their employment.

Escalation of the production of nurses and midwives in Ghana over the last decade has resulted in a drastic shift in the age structure of nurses and midwives. This demographic shift appears to have been without appropriate mechanisms for mentorship which could adversely affect the quality of health care. The nursing and midwifery youth bulge has increased pressure on the administration of the study leave policy of the Ghana health sector. We reckon that these have necessitated the institutionalisation of a nursing and midwifery mentorship programme and a review of the study leave policy as well as to consider upgrading all professional nursing and midwifery programmes to first degrees soon after their employment.

Acknowledgements

We are profoundly grateful to Mr. Francis Victor Ekey for assisting us to retrieve historical age profile of Ghanaian public sector nurses.

No funding was received for this work.

Availability of data and materials

Abbreviations.

Authors’ contributions

JAA conceived and designed the analysis; JAA and HI carried out the data collection and analysis and drafted the manuscript. NPA, AAF, MMC and JN contributed to the writing of the manuscript. All authors read, edited and approved the manuscript.

Ethics approval and consent to participate

The work is based on publicly available data and did not involve the use of human subjects or animals. No ethical approval was required but permission was sought from the Ghana Health Service.

Consent for publication

All authors have approved the manuscript for submission.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Open Access

Peer-reviewed

Research Article

Prevention and management of anaemia in pregnancy: Community perceptions and facility readiness in Ghana and Uganda

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Department of Family Medicine and Community Practice, Mbarara University of Science and Technology, Mbarara, Uganda

Roles Data curation, Methodology, Writing – review & editing

Affiliation Research, Planning, Monitoring & Evaluation Department, National Blood Service Ghana, Accra, Ghana

Roles Data curation, Investigation, Methodology, Validation, Writing – review & editing

Affiliation Community Health Department, Mbarara University of Science and Technology, Mbarara, Uganda

Roles Data curation, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Health Policy Planning and Management, University of Ghana School of Public Health, Accra, Ghana

Roles Formal analysis, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

Roles Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing

Affiliation Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda

• Tara Tancred, 
• Vincent Mubangizi, 
• Emmanuel Nene Dei, 
• Syliva Natukunda, 
• Daniel Nana Yaw Abankwah, 
• Phoebe Ellis, 
• Imelda Bates, 
• Bernard Natukunda, 
• Lucy Asamoah Akuoko

• Published: August 26, 2024
• https://doi.org/10.1371/journal.pgph.0003610
• Peer Review
• Reader Comments

Anaemia is one of the most common conditions in low- and middle-income countries, with prevalence increasing during pregnancy. The highest burden is in Sub-Saharan Africa and South Asia, where the prevalence of anaemia in pregnancy is 41.7% and 40%, respectively. Anaemia in pregnancy can lead to complications such as prematurity, low birthweight, spontaneous abortion, and foetal death, as well as increasing the likelihood and severity of postpartum haemorrhage. Identifying and mitigating anaemia in pregnancy is a public health priority. Here we present a mixed-methods situational analysis of facility readiness and community understanding of anaemia in Ghana and Uganda. Quantitative health assessments (adapted from service availability and readiness assessments) and qualitative key informant interviews (KIIs) with district-level stakeholders, in-depth interviews (IDIs) with maternity staff, and focus group discussions (FGDs) with community members were held in 2021. We carried out facility assessments in nine facilities in Ghana and seven in Uganda. We carried out seven KIIs, 23 IDIs, and eight FGDs in Ghana and nine, 17, and five, respectively, in Uganda. Many good practices and general awareness of anaemia in pregnancy were identified. In terms of bottlenecks, there was broad consistency across both countries. In health facilities, there were gaps in the availability of haemoglobin testing—especially point-of-care testing—staffing numbers, availability of standard operating procedures/guidelines for anaemia in pregnancy, and poor staff attitudes during antenatal care. Amongst community members, there was a need for improved sensitisation around malaria and helminth infections as potential causes of anaemia and provision of education around the purpose of iron and folic acid supplementation for preventing or managing anaemia in pregnancy. Anaemia in pregnancy is a persistent challenge, but one with clear opportunities to intervene to yield improvements.

Citation: Tancred T, Mubangizi V, Dei EN, Natukunda S, Abankwah DNY, Ellis P, et al. (2024) Prevention and management of anaemia in pregnancy: Community perceptions and facility readiness in Ghana and Uganda. PLOS Glob Public Health 4(8): e0003610. https://doi.org/10.1371/journal.pgph.0003610

Editor: Marie A. Brault, NYU Grossman School of Medicine: New York University School of Medicine, UNITED STATES OF AMERICA

Received: April 3, 2024; Accepted: July 25, 2024; Published: August 26, 2024

Copyright: © 2024 Tancred et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data can be found in the manuscript and supporting information files.

Funding: This work was wholly funded by the Medical Research Council, UK (reference MR/T00326X/1) as part of the Public Health Intervention Development scheme, awarded to IB. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Competing interests: The authors have declared that no competing interests exist.

Introduction

Anaemia occurs when there are insufficient red blood cells or haemoglobin to carry oxygen to the tissues of the body. The prevalence of anaemia in women of reproductive age has been slow to improve. A review found the pooled prevalence of anaemia across 24 low-resource countries amongst women aged 15–24 was 42% [ 1 ]. Anaemia in pregnant women—sometimes called maternal, obstetric, or prepartum anaemia—is defined as a haemoglobin less than 110 g/L. It is an indicator of both poor nutrition and poor health. Globally, 36.8% of pregnant women are anaemic. The highest burden is in Sub-Saharan Africa and South Asia, where the prevalence of anaemia in pregnancy is 41.7% and 40% respectively [ 2 ].

Anaemia in pregnancy is associated with adverse outcomes for the mother and baby. These include preterm delivery, low birthweight infants, and impaired child development [ 3 ]. Severe anaemia, defined as haemoglobin below 60 g/L, can further result in spontaneous abortions, puerperal sepsis, and foetal death [ 4 , 5 ]. A review of anaemia in pregnancy in low-resource settings found that 12% of low birthweight births, 19% of preterm births, and 18% of perinatal mortalities were attributable to anaemia in pregnancy [ 6 ]. Severe anaemia also presents a risk to the mother, increasing the odds of postpartum haemorrhage by approximately 3.5 times [ 7 ].

Anaemia has multiple causes including: nutritional deficiencies (iron, folate, vitamin A); parasitic infections (malaria, hookworm, schistosomiasis); bleeding; underlying chronic conditions (tuberculosis, human immunodeficiency virus); and haemoglobinopathies such as sickle-cell disease [ 8 ]. The most common cause of anaemia in pregnancy is iron deficiency anaemia, though this may be proportionally less prevalent in malaria-endemic areas [ 5 ]. Iron deficiency can be caused by inadequate iron-rich food in the diet, or by blood loss, including secondary blood loss to helminth infections [ 9 , 10 ]. Women infected with intestinal parasites are 3.59 times more likely than uninfected women to develop anaemia, and women who have no iron and folic-acid supplementation are 1.82 times more likely to develop anaemia than supplemented women. Anaemia tends to worsen as pregnancy progresses, such that women in their third trimester are 2.37 times more likely to develop anaemia than those in the first and second trimesters [ 5 ].

Anaemia in pregnancy is a complex public health challenge, though there are many points from community-to-facility where helpful interventions may be put in place [ 11 ]. During pregnancy, antenatal care (ANC) is the main platform through which anaemia is identified, prevented, and treated. During antenatal visits, anaemia is assessed clinically or through the measurement of haemoglobin. Iron and folate supplements are generally prescribed, and, where appropriate, antimalarial prophylaxis and anti-helminth medication may be advised. With good adherence, this approach can improve iron stores and prevent or resolve anaemia in pregnancy [ 12 ]. Counselling on nutrition and malaria prevention, and encouragement to eat iron-rich foods, are also provided. For severe anaemia unresponsive to oral treatment, iron infusions, and occasionally, blood transfusions, may be warranted [ 5 ]. To meaningfully prevent or manage anaemia in pregnancy, it is critically important that ANC is accessible and of high quality, uptake is consistent, and that adherence to prescriptions and counselling is followed.

To strengthen health systems to catalyse reductions in anaemia in pregnancy, it is crucial to understand both facilitators and bottlenecks of anaemia care from multiple perspectives. With the aim of identifying good practices and areas for improvement, this study focused on perspectives about the prevention and management of anaemia in pregnancy amongst pregnant (or recently pregnant) women, male partners, community influencers, health services staff, and decision-makers who influence anaemia care policy and practice in Ghana and Uganda.

Materials and methods

Study design.

We carried out a cross-sectional mixed methods situational analysis of factors from community-to-district that impact the prevention, management, and treatment of postpartum haemorrhage in Uganda and Ghana from March–May of 2021. The results here are derived from an embedded sub-study that focused on anaemia in pregnancy, given that it is a key and persistent factor influencing the likelihood and severity of postpartum haemorrhage.

Study sites

Ghana and Uganda were selected as our study countries to maximize the diversity of contexts studied. As such, we wanted to select a country from West Africa and one from East Africa with different models of health system financing and governance. Due to longstanding research relationships in Ghana and Uganda across our study team, we selected these two countries. In both countries, we collected data from two districts. We piloted tools in an additional district in Ghana and an additional facility in Uganda. To facilitate the transferability of our findings, these districts were chosen to be “mid-range” in terms of population and geography compared to others in their respective countries. Among all the health facilities within each district—including private, public and faith-based—we selected only those that provided caesarean sections and blood transfusions, as we were interested in understanding readiness to support prevent, manage, and treat postpartum haemorrhage in referral-level facilities which are most likely to receive such cases. Our findings therefore reflect a census across all facilities in each study district meeting these criteria.

Data collection

Quantitative data collection..

The study involved a quantitative health facility assessment based on adapted “health facility service availability and readiness assessments” [ 13 ]. This assessment had three different modules: one for anaemia, one for postpartum haemorrhage management, and one for blood transfusion—the one for anaemia is presented here. This module asked a comprehensive set of questions to determine the availability of appropriate standards or protocols, drugs, equipment, trained staff, and infrastructure to support anaemia prevention and management. Certain practices that are documented—or were expected to be documented—in patient files were also captured, for example, the measurement of haemoglobin at the time of labour. For such measures, we typically assessed all relevant patient files in the preceding three months. Within each health facility, different questions within the module were administered to maternal health care providers, laboratory technicians, or pharmacists as relevant, and where needed, observation (e.g. physically viewing a protocol) took place. No processes of care, however, were observed.

Qualitative data collection.

Qualitative data were derived from community focus group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs). FGDs were held in each district with: currently pregnant or recently delivered women; male partners of currently pregnant or recently delivered women; community leaders and elders (referred to hereafter as “community influencers”); and blood donors. FGD participants were recruited from communities within the catchment area of study sites in the health facility assessment. Study information was shared with community leaders, who then advertised it and helped identify prospective participants meeting study inclusion criteria in their communities to ensure 6–10 eligible persons would be available per focus group. Other than the provision of refreshments and transport reimbursements, participants were not unduly incentivised to participate. FGDs explored perceptions about anaemia (how it is locally understood, what causes it, what its consequences are, how it can be prevented or managed) and ANC (why women do or do not attend, what occurs during ANC, its importance, and its role in anaemia prevention and management). IDIs were conducted with maternity in-charges and the heads of the participating health facilities to understand perceived facilitators and barriers to good practice in anaemia prevention and management. Laboratory technicians were also involved in IDIs to understand testing for anaemia and ordering blood for transfusion. There were typically only one or two people fulfilling each role in each participating facility, and we identified and interviewed them where possible. KIIs were carried out with key district- or national-level informants who play a role in supporting maternal and/or blood transfusion services in each participating district, including district health officers, district heads of maternity/reproductive health services, district heads of laboratory services, and regional or zonal blood transfusion leads. IDIs and KIIs were complementary to the health facility assessments, serving also to explain any gaps identified. All participants were purposively sampled based on their role in their community, health facility, or district and their lived experiences. Each participant participated in only one interview or group discussion.

FGDs took 60–90 minutes to complete, and IDIs and KIIs took 20–60 minutes to complete and were audio recorded. FGDs took place in convenient locations in each community where participants were derived from. To minimize the ask on participant time and travel, IDIs took place in the health faciltiies where the assessments were carried out with the relevant members of staff and KIIs were carried out in the offices of the key informants. All IDIs and KIIs were carried out in English, whilst FGDs were carried out in local languages as appropriate (Twi or Ga in Ghana and Runyankore in Uganda). All qualitative data were collected by skilled research assistants. They were registered nurses trained in maternal health, and in Ghana, they were also supported by staff from the National Blood Service for aspects pertaining to blood transfusion. They had at least three-years’ of experience conducting health research within the study districts.

Our study team included clinicians specialising in obstetrics, haematology and blood transfusion, nurses, and social scientists, all with extensive experience in low- and middle-income country health services research. We developed our data collection instruments to explore some of the themes identified in the qualitative review of postpartum haemorrhage prevention by Finlayson et al [ 14 ] and the general processes described in the protocol by Akter et al [ 15 ]. We tailored them to the purpose and context of our study. Since tools needed minimal revision following piloting, we included data from the pilots in our analysis. Our data collection instruments can be found in “ S1 Data Collection Instruments”.

Quantitative data were analysed in Excel to generate basic descriptive statistics (counts, averages, percentages). Qualitative data were read and re-read for familiarity. Framework analysis [ 16 ] was used to generate higher-level categories around specific pre-determined aspects of anaemia in pregnancy prevention and management. Data within each category were analysed thematically, being coded inductively, line-by-line in NVivo. These codes were grouped into increasingly higher-level codes to develop sub-themes to reflect key findings.

Quantitative data from the health facility assessments and qualitative data were then triangulated to present an overall picture of the key strengths and barriers to anaemia in pregnancy prevention and management across our study sites in Ghana and Uganda.

Ethical considerations.

We obtained ethics approvals from the Ghana Health Service Ethics Review Committee and, in Uganda, from the Research Ethics Committee of Mbarara University of Science and Technology and the Uganda National Council for Science and Technology. In the UK, research ethics approval was obtained from the Liverpool School of Tropical Medicine.

Permission to carry out the research was obtained from district health offices and the head of each participating health facility. All participants provided written informed consent before proceeding with data collection.

Data were collected from a total of nine health facilities (inclusive of one pilot facility) in Ghana and seven (also inclusive of a pilot facility) in Uganda. As seen in Table 1 , in Ghana, facilities from District 1 were generally larger than in other districts, with more patient traffic. Health facilities in Uganda had smaller overall patient numbers and tended to have facilities with larger capacity (as reflected by number of beds).

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https://doi.org/10.1371/journal.pgph.0003610.t001

Qualitative data collection is summarised in Table 2 below. Data were collected from 84 participants in Ghana and 63 in Uganda.

https://doi.org/10.1371/journal.pgph.0003610.t002

Diagnosing anaemia in pregnancy

Standard operating procedures or guidelines for assessing anaemia in pregnancy were not present in 7/9 (78%) facilities in Ghana, and in the other two facilities, respondents stated “unsure/don’t know”, or they were reported available but not seen. In Uganda, 5/7 (71%) facilities did not have these in place, and in the two other facilities, they were reported available but not seen ( Table 3 ).

https://doi.org/10.1371/journal.pgph.0003610.t003

The health facility assessments reported various methods for testing women’s haemoglobin concentration. The use of an automated haematology analyser for doing a full blood count was the most common method by far, being stated by participants across all facilities in the assessment in Ghana and in 6/7 (86%) facilities in Uganda. Only two facilities each in Ghana and Uganda also used non-automated methods (e.g. colorimeter, haematocrit) for measuring or estimating haemoglobin concentration. In Uganda, only one facility reported the use of Hemocue and another reported the use of DiaSpect, both of which can be point-of-care tests. However, no facilities in either country reported having haemoglobin measurement that was explicitly for point-of-care use ( Table 3 ).

In the facility assessment, in Ghana, only 5/9 (56%) of facilities had available documentation on assessment of haemoglobin at the time of labour, and this was reportedly done for all women in two of those three facilities (1029/1029 women in one facility, and 6/6 women in another), for 6/10 women coming to the facility for childbirth in the third, and for zero women in the other two. In Uganda, these data were available in 6/7 (86%) facilities, but of the 1161 women presenting during labour in the three months prior to the assessment across these six facilities, only 235 (20%) of women had their haemoglobin assessed at the time of labour. However, most of these came from one facility, where 116/156 (74%) of women had haemoglobin assessed during labour—the range across facilities was 0–74%, with three facilities at roughly 10% and one at 59% of women ( Table 3 ).

Maternity staff in Uganda noted that haemoglobin testing was done at various times and frequencies during pregnancy. Only one IDI participant in Uganda mentioned measuring haemoglobin during labour. At the facilities in Ghana, most or all women had their haemoglobin measured during labour as routine practice, which was confirmed in IDIs.

Yes it’s a routine thing we do here, all [labour] admissions that come, they go through the lab, do full blood count, then we know your haemoglobin level before any other thing. (IDI, matron in-charge, Ghana)

In community FGDs, especially those with women, in both countries, participants did note that their “blood is measured” during ANC.

It was also mentioned in both countries—though considerably more in Uganda—that, in the absence of haemoglobin testing, anaemia would be clinically assessed by pallor. Some district-level key informants in Uganda noted that lab-based haemoglobin testing is not always available, leading to this reliance on clinical assessment, which may not be as objective.

Clinical assessment depends entirely on the clinical acumen of the individual and it is highly subjective, so we want to beef it up, we want to support the clinical assessment with the laboratory confirmation, you cannot depend on just clinical assessment. (KII, district official, Uganda)

In Uganda, some facility-based participants also reported that a barrier to the laboratory diagnosis of anaemia in pregnancy was that sometimes error—human or technical—could lead to inaccuracies, for example, through documentation or equipment errors.

Respondent: When they mix the results, they may end up giving low blood count to the patient who is actually okay… [Or] when the machine for measuring haemoglobin is not working very well, it can give a false haemoglobin and we end up transfusing blood. (IDI, midwife, Uganda)

Anaemia in pregnancy is taken seriously by healthcare providers

In both countries, it was recognised that a woman should not be anaemic at the time of birth. Iron supplementation and nutritional counselling were cited as key ways to prevent or manage anaemia, though it was recognised by many participants that more severe anaemia may require blood transfusion.

When [haemoglobin] is 10 [g/L], they are being given haematinics for one month but when its nine and below, they are being referred to doctor to be given haematinics, mostly tot’hema [oral iron solution]. But if it’s seven, seven and below, they are being counselled on transfusion, yes. (IDI, matron in-charge, Ghana)

In both countries, maternity care providers commented on their commitment to following up with women they have identified as anaemic.

Once we see [anaemia], during the antenatal, we make sure that you don’t go down . Once you come here and I see you , I monitor you seriously . At least every week or two; at-least two weeks or third week , we do the blood test again to see if it has come up . And we have been successful in those cases . (IDI, matron in-charge, Ghana)

These participants noted difficulties in ensuring continuity of care, which acted as a barrier to effective anaemia in pregnancy management, often due to gaps in ANC attendance by pregnant women, including those with anaemia.

…ones who just came with maybe anaemia in pregnancy, those are actually the hardest to come back, but these others to them they think there are justifiable causes, like maybe I ruptured my uterus or something, those ones will come back. (IDI, matron in-charge, Uganda)

To encourage attendance at ANC, providers usually give women the details of their next ANC appointment at their current one so that women are aware of the importance of coming back and know when they should next attend. In Ghana, maternity staff and community members noted that women are provided with midwives’ contact details. This practice enabled better organisation of appointments, shorter waiting times, and provided a communication channel to address women’s needs, particularly for those who struggle to access care.

They also tell her days on which she should keep coming back to the hospital to check the status of her pregnancy until she gives birth. (FGD, community influencers, Uganda) The staff , most of them give their numbers out , and with a good relationship , a client will always call . (KII, district official, Ghana)

Localised understanding of anaemia in pregnancy

Anaemia is understood according to its symptoms..

In Ghana, some community FGD participants had a good understanding of the symptoms of anaemia. In Uganda, the term anaemia was recognised but was again understood in terms of its symptoms. These included being pale, having low energy, and dizziness. Anaemia was generally understood to mean a “low amount of blood” or “low blood volume” and was typically thought to be caused by not eating and sleeping well. In Uganda, community FGD participants also regularly talked about swelling, and in the FGD with pregnant or recently delivered women, anaemia was also linked to weight loss and loss of appetite.

Respondent 4: I know anaemia is when you don’t have enough blood, or your blood level is low. Respondent 3: Please I don’t know. Respondent 2: I haven’t heard of anaemia before. Respondent 1: I haven’t also heard it before. Respondent 5: Same. Respondent 6: Same. Interviewer: What are some of the symptoms of anaemia? Respondent 6: Sometimes you feel dizzy and not feel okay. Respondent 2: Your heart beats faster and you easily get tired. (FGD, pregnant or recently delivered women, Ghana)

Anaemia was seen as dangerous by participants in all community FGDs, especially to the developing fetus, leading to foetal death or premature childbirth. Some participants also noted it was potentially life-threatening to the mother, though this was given less focus. In one FGD in Uganda, a male partner specifically noted anaemia means “less oxygen and nutrients for the baby.”

Most FGD participants were aware of haemoglobin testing as a way to detect “blood volume”—i.e. anaemia. Male partners in Ghana and community influencers in Uganda also noted that there is a normal haemoglobin range or a “cut-off” and that falling below these indicates anaemia.

Reflecting on what was noted by facility- and district-level participants, some women in Uganda also described how a clinical assessment for anaemia is done during ANC.

The doctors instructs you to look up and looks into your eyes and looks into your hands to see if you have blood. (FGD, pregnant or recently delivered women, Uganda)

There is understanding of local foods associated with “improving blood”.

In Ghana, participants across community FGDs could describe many local foods that were useful in combatting anaemia to “help their blood”, including leafy greens, legumes, plantains, cabbage, milk, dried fish, meat, and eggs. Tomato paste and coke were also mentioned. Community influencers in Ghana also made a link between anaemia and vitamin C deficiency, noting the importance of fruit for preventing anaemia. Pregnant or recently delivered women also mentioned multivitamins and “iron 3 [a hematinic oral solution]—it’s a blood tonic” (FGD, pregnant women, Ghana).

Key informants in Ghana described several successful programmes to educate pregnant women and community members about anaemia in pregnancy. These include pregnancy schools—which are educational sessions run outside of routine antenatal appointments—and dietary education provided through two community-based nutrition programmes.

… we used to have anaemia quite bad in pregnant women, so we put in two major programs. Food demonstration and food bazaars. (KII, district official, Ghana)

In Uganda, local foods widely understood to prevent anaemia or to be consumed by women with anaemia in pregnancy are fruits (mango, banana, watermelon, pawpaw, pineapple, avocado), vegetables (eggplant, amaranth leaves and other greens), maize meal porridge, ground nuts, beans, and meat.

ANC and the prevention and management of anaemia in pregnancy

Perceptions towards anc are very positive..

Across all community FGD participants, ANC was seen as important.

There are many diseases that come up in the pregnancy period … the baby can even die at the point of birth if these things are not taken care of, so it is necessary to go for ANC . (FGD, male partners, Ghana)

We are firm in knowing we won’t meet any complications because we have been attending ANC . (FGD, male partners, Uganda)

Across community FGDs in Ghana, services referred to as part of ANC included: checking the baby’s growth and position; checking the mother’s weight, blood pressure, and temperature; as well as doing tests for infections and providing treatment where necessary. The provision of counselling, especially around nutrition and hygiene, was also noted frequently. A few participants in Ghana also mentioned that screening for Rhesus factor and sickle cell disease would be done. Male partners in Ghana were divided into those who were unsure about what ANC entails and those who had more knowledge as they had participated in ANC or asked their wives about it and reviewed ANC booklets. Only community influencers suggested that couples receive preferential treatment if a male partner accompanies a woman to ANC. However, mandatory HIV testing during ANC was mentioned as a deterrent to male partner involvement.

I have no idea…no, because I am not allowed inside. (FGD, male partners, Ghana) My wife said they tested her [haemoglobin] and was told her blood level is low , so I called the nurse and asked her because I didn’t see it in the antenatal book , so the nurse confirmed and said yes , she was told , but they didn’t write it in the book . (FGD, male partners, Uganda)

Community participants in Uganda were quite specific about what ANC covers, including measuring the “quantity of your blood” (to test for anaemia), screening for infections like HIV and syphilis and treating these, providing an expected due date, checking for blood pressure and blood sugar, counselling on nutrition and hygiene, the position and health of the baby, the amount of amniotic fluid, counselling on the place of childbirth, and education on understanding what different pains in pregnancy mean. Some also mentioned “mama kits” that include labour and childbirth supplies as well as newborn necessities that are given depending on the health facility they visited—it was expressed that they would like to see this given at all public facilities.

ANC timing and frequency are not always understood.

Guidelines in both contexts indicate that there should be eight ANC visits throughout pregnancy and that the first visit should be initiated within the first trimester to ensure that interventions are offered at the appropriate time. FGDs with pregnant or recently delivered women in Ghana highlighted variable knowledge about the timing and number of ANC visits, with only one participant noting that there should be “seven or eight” ANC visits throughout pregnancy. Timing of ANC initiation varied from two weeks to six months, though of the 23 pregnant women participating across three FGDs, 16/23 (70%) noted starting ANC in the first trimester. Women who sought care very early (within the first or second month of pregnancy) often commented that they had felt particularly unwell or that they had a history of miscarriage, which prompted them to seek care.

This variability in knowledge about ANC visits was also reflected in male partner FGDs in Ghana, but there seemed to be a stronger sense that going early was not required if there were no issues and that most women went after six months. However, when asked when women should go for ANC, there was consensus that starting at around three months, though a handful of participants noted that ANC attendance should begin as soon as the pregnancy is identified. When asked how often ANC occurs, there was a wide range of responses, from every two or three weeks to monthly, for a total number of visits ranging from 6–18 over the course of pregnancy. There was the sense amongst participants that ANC attendance is increasing, primarily due to policies supporting free care.

In FGDs with community influencers in Ghana, there was broad agreement around the start of ANC being from two-to-three months up until the pregnancy is visible. They expressed that women might delay going so that the pregnancy is more advanced, so they only have to pay for one ultrasound.

Interviewer: How many times [should a pregnant woman attend ANC] …? Number 3. Respondent 3 : 3 times . Interviewer : 3 times . Number 4 how many times … ? Respondent 4 : It can be 6 times . Interviewer : 6 times ? Number 6 how many times ? Respondent 6 : 9 times . (FGD, community influencers, Ghana)

Across all community FGD participants in Ghana, there was the perception that strong women and those with healthy pregnancies do not need ANC, and those who are “weaker” or with obvious health issues are the ones who need ANC earlier.

It depends on the individual. Some people are physically strong when they are pregnant. Others aren’t that strong, so they visit the hospital in their first week. (FGD, community influencers, Ghana)

In Uganda, most participants in the FGD with pregnant or recently delivered women spoke about the timing of the first ANC visit as 1–3 months, and it was clear that “eight ANC visits” was correctly understood as being the desired number of visits. However, in the FGD with male partners and both FGDs with community influencers, this ranged from four-to-eight. There was a shared understanding that most women would be likely to seek out ANC as soon as they have a positive pregnancy test but that there would be women who might go later in the absence of complications.

They go for antenatal on the sixth month of pregnancy…because until then there have not been any complications, so there would not be a need to go for antenatal . (FGD, male partners, Uganda)

However, community influencers suggested that most women start care from three-to-five months’ gestation and associated women coming later with a lack of responsibility.

[Coming at five months for the first ANC] is for a mother that has delayed or…doesn’t care…at three months, a responsible mother should be coming from ANC. (FGD, community influencers, Ghana) Doctors taught them [women in communities] that when you get pregnant , you start coming for ANC . (FGD , community influencers , Uganda)

Persistent barriers to ANC uptake exist.

All community FGD participants in both countries described recurring barriers to ANC care. These largely centred distance to the health facility, difficulty finding and paying for transportation—especially in remote areas—and other financial barriers, including “hidden costs” for equipment or medication that are expected to be free of charge. These barriers are exacerbated when repeated visits are required.

Some pregnant or recently delivered women in Ghana—especially those who already have children—suggested that expenses are increasing. There is a small charge for each visit (10 cedis (~1.7 USD at the time of data collection)) and two cedis (~0.34 USD) for some medications, even with health insurance. Male partners in Ghana agreed that there are many costs associated with ANC and pregnancy, mainly linked to drugs and transportation, and estimated total expenses throughout pregnancy and childbirth as high as 1500 cedis (~255 USD). Although Ghana’s National Health Insurance should cover costs, community-based participants regularly cited cost-related barriers. For example, if medication is required, as they explained, there are hidden costs that can influence the decision to seek care. In Uganda, it was widely agreed across community participants that ANC in public facilities is free, though payment is expected in private facilities. However, costs may still be incurred, as women might be sent to another facility if certain equipment is unavailable (e.g. an ultrasound machine), or they may be asked to buy medications.

They also like to take money too much, whether you have insurance or not. Medicine that will cost 20 cedis you end up spending 100 cedis. (FGD, community influencers, Ghana) Respondent 1: It comes down to a money issue and fatigue. Respondent 3 : I want to buttress that point . If you go today to do laboratory work , you would be expected to pay . After three days’ time , when you are scheduled to come back , you would be asked to go and do another . So if that continues , then you find out that your money is getting finished…if you have money , then you go and give birth . They say it’s free , but it’s actually not . (FGD, pregnant or recently delivered women, Ghana).

Many participants in both countries reiterated that the cost of ANC sometimes results in delays in women seeking and accessing anaemia in pregnancy diagnosis and management.

When they go early they will do so many scans, so if you go late in the last trimester that means you will do like just one scan and you leave. So, I think it’s the financial obligation that makes them stay longer at home. (FGD, community influencers, Ghana)

Poor attitudes of ANC staff were extensively highlighted in both countries by pregnant women and male partners, as well as long wait times in Ghana. These prevented women from taking up ANC and also from giving birth in a health facility. Community influencers also noted that healthcare providers do not consistently provide good quality care and can be unhelpful and unkind. However, some women stated they were satisfied with the care provided and the relationship with their midwives. It was understood that this may affect the reputation of the health facility in positive or negative ways as women share information about their experiences.

If I brought my wife here and if she wasn’t treated well—or even if she was treated well—now they are advising [other women]…which will cause a change of heart on the other person. (FGD, male partners, Uganda)

Local perceptions of having safely had children previously without seeking ANC or skilled attendance at birth may reinforce this idea among those women or women close to them.

Some people have given birth safely without antenatal, so they don’t see the need. (FGD, pregnant or recently delivered women, Ghana)

In Uganda, the perception of having lower socioeconomic status was seen as a barrier to some women. Lack of permission or support from husbands or mothers-in-law was also repeatedly cited across community participants.

Lack of proper clothes to wear to come to the hospital…they fear being seen in torn clothes and decided to keep home. (FGD, pregnant or recently delivered women, Uganda)

The use of traditional care was frequently mentioned by community-based participants in Ghana. Traditional care was appreciated as it lacked many of the barriers of formal ANC, such as cost and distance. Traditional medicine was also sometimes viewed as more effective.

Respondent: It is because sometimes traditional/herbal medicine is more potent than orthodox medicine…that is also a contributing reason. (FGD, pregnant or recently delivered women, Ghana)

Facility-based participants and key informants explained that inadequate staffing is sometimes a barrier to adequate ANC and, therefore, to anaemia in pregnancy diagnosis and management, as laboratory personnel were in particularly short supply.

Interviewer: So currently staff is a challenge? Respondent : It’s a huge problem , it’s a huge problem . (KII, district official, Ghana)

Staff training on anaemia in pregnancy appeared to be infrequent in both countries, though there was training before qualifying and on-the-job. Facility-based participants communicated gaps in training, particularly for training on attitude and conduct.

Apart from training on certain topics, ours have been informal discussions when we go on rounds, we talk a lot and try to educate them on transfusion, that has been my approach, I don’t normally run a lot of formal workshops and those things, we see a patient we just discuss it. (IDI, midwife, Ghana)

Some district-level key informants in Uganda also noted the importance of continuing medical education for anaemia in pregnancy.

Preventing and managing anaemia are well-understood by healthcare providers and less well understood by community members.

In IDIs with maternity staff in both countries, alongside haemoglobin measurement, routine practices during ANC—including preventing and treating malaria, providing deworming medication, giving iron and folate supplements, and providing nutritional counselling—were described as important for preventing and managing anaemia in pregnancy. The use of insecticide-treated bednets was also mentioned by maternity staff and community-based participants. In Ghana, maternity staff reported that women are supervised in taking malaria medication to increase adherence. Women across FGDs in both countries noted that many women did not always like taking antimalarials or iron and folate supplements due to side effects.

Yeah, we are doing it actually in antenatal, we start from antenatal, we first do haemoglobin, then on subsequent visits, we do it, and then that’s why we give them ferrous and folic, whatever we have in place, even the minister of health, that’s what she is advocating for, even the [intermittent preventative treatment for malaria] we are giving, if the woman does not have malaria, if she is dewormed and worms are not sucking blood, if she is given these to supplement her blood, then there is nothing that should stop her from fighting anaemia. Then also advising her on what to eat, nutritional status . (IDI, matron in-charge, Uganda) I want to find out why they give us the malaria drug . When I went , they ask us to take the medicine right there . But when I came home I had adverse reactions; my mouth area was itching and when I touched it , rashes developed . (FGD, pregnant or recently delivered women, Ghana)

These findings are echoed in facility assessments, where intermittent malaria prophylaxis is routinely given to all women across all participating facilities in both countries and iron and folate supplements are provided to all women during ANC. In Ghana, the provision of anti-helminth medications was offered to all women in ANC in 5/9 (56%) facilities and only to women in higher-risk areas in 4/9 (44%) facilities. In Uganda, these medications were offered to all women attending ANC ( Table 3 ).

Participants in the FGDs with pregnant and recently delivered women in Ghana linked iron and folate supplements to the development of the baby’s blood and bones rather than with their own anaemia. “I think folic acid supports blood cells…about iron? I have no idea” (FGD, male partners, Ghana). In Uganda, pregnant or recently delivered women knew pills could be given for anaemia but did not refer to these by name.

They give us those red tablets to increase our blood levels…and…add on our blood levels and [ensure we] have enough blood to take care of the baby in the womb. (FGD pregnant women, Uganda)

Iron and folate supplements were known by a few male partners and community influencers in Uganda to help women “gain blood”. However, it was mostly understood as being important for health in general and not linked to resolving anaemia.

Although malaria and helminth infections were understood as bad for the baby and mother, they were not associated with anaemia in FGDs with pregnant or recently delivered women in Ghana. Only one pregnant or recently delivered participant in Uganda noted, “deworming prevents [pregnant women] from being anaemic”. However, some male partners and community leaders in Ghana did note the association between malaria and “reducing blood”, and one community influencer in Uganda noted malaria causes “blood loss and complications” and was therefore linked to anaemia. Only one male partner in Uganda noted that worms “take nutrients”, resulting in the mother becoming malnourished and then anaemic (Male partner FGD, Uganda).

Blood transfusion was sparingly mentioned in both countries by community participants as a treatment for severe anaemia.

This mixed methods assessment explored facility readiness and diverse stakeholder perspectives to identify many good practices in Ghana and Uganda around the diagnosis, prevention, and management of anaemia in pregnancy, as well as several gaps.

Standard operating procedures or guidelines specific to anaemia in pregnancy were reported as sparingly present in both countries but were never seen. Ensuring that these are available, widely publicised, and used for continuing medical education would help to promote better practice and reduce anaemia in pregnancy and its consequences for the mother and baby. Such guidelines could be adapted from the “World Health Organization recommendations on ANC for a positive pregnancy experience”, which recommend daily (or intermittent if side effects are intolerable) oral iron and folic acid supplementation and for pregnant women to be advised about food sources of vitamins and minerals, and dietary diversity [ 5 ].

Community participants widely understood the use of haemoglobin testing for detecting anaemia. Haemoglobin measurement around the time of labour did not appear to be routine in many facilities in Uganda, but is very important so that anaemia can be corrected prior to delivery, especially where women may have had inconsistent attendance of ANC and do not have a recent measure [ 17 ]. Doing so may reduce the occurrence and severity of peripartum haemorrhage [ 18 ]. In both countries, automated analysers were by far the most common way to measure haemoglobin; this is the recommended method for diagnosing anaemia in pregnancy [ 5 ]. However, the limited availability of laboratory personnel and equipment sometimes necessitated the use of manual haemoglobin measurements or clinical assessment of anaemia, even though clinical examination is inadequately sensitive and specific for diagnosing anaemia [ 19 ]. Point-of-care haemoglobin tests may be useful in this situation as they can be performed by non-laboratory personnel and can yield timely, reliable results for quick decision-making [ 20 , 21 ]. However high volume use of these tests can be expensive [ 20 , 22 ], limiting their availability in many contexts, as was also reflected in our assessment.

Overall, there was a good level of understanding of some critical aspects of anaemia. Community participants in both countries recognised the symptoms and consequences of anaemia but knew less about the causes. Its implications on the developing foetus, and to a lesser extent on the mother, were acknowledged by community participants. There was wide general knowledge about local foods that may help in preventing or reducing anaemia across both countries, including an emphasis on vitamin C-rich foods, which can increase the absorption of iron, especially from plant foods [ 23 , 24 ]. Dietary factors can play an important role in reducing the risk of anaemia [ 25 ]. Positively, it was clearly noted by participants in both contexts that nutrition education for anaemia prevention or mitigation is a common aspect of ANC.

Community participants unanimously understood ANC to be very important. The timing of uptake and frequency of ANC visits were less well-understood, especially among Ghanaian participants. In both countries, initiation of ANC was frequently (and correctly) cited by participants as being within the first three months of pregnancy. However, literature from both Uganda and Ghana suggest this is not typical of most women, for whom early initiation of ANC and regular attendance is a persistent challenge due to gaps in knowledge and social, financial, and geographical barriers to accessing care [ 26 – 29 ]; achieving all eight ANC contacts occurs for a minority of women [ 30 – 32 ]. Community education about the importance of early and consistent ANC uptake may, therefore, be beneficial in managing anaemia in pregnancy [ 33 , 34 ].

Anaemia in pregnancy was taken seriously by maternity staff, with efforts being made to follow-up with patients identified as anaemic, including providing personal phone numbers and appointment reminders. However, despite efforts made, this follow-up was sometimes difficult due to women’s reluctance to take up care. In both countries, there were common barriers around ANC uptake, largely stemming from long distances to the health facilities, difficulty finding or paying for transportation, other costs, especially for medications, and poor staff attitudes. From the health providers’ perspectives, staff shortages and a lack of anaemia in pregnancy-specific training were noted in both countries. All of these resonate with findings from other lower-resource settings [ 35 , 36 ]. Without early and consistent uptake of ANC, women miss opportunities for interventions that can prevent or mitigate anaemia in pregnancy, potentially leading to poorer health outcomes for the mother and the baby [ 37 ]. It is, therefore, important that initiatives to reduce barriers to accessing ANC are implemented. For example, in other African settings, women have been provided with transportation vouchers that they can use in exchange for bus or motorcycle transport, which helps to overcome some of the transportation barriers related to attending ANC [ 38 – 40 ].

Finally, though the provision of antimalarials, iron and folate supplements, and deworming are routine during ANC in both countries, very few community participants understood their link with preventing or managing anaemia in pregnancy. Even where the link was made, it was not fully understood—for instance, helminth infections can cause anaemia due to red cell destruction or intestinal bleeding [ 41 ], but the women associated them with causing malnutrition. Iron and folate supplements are very effective in reducing anaemia if taken consistently during pregnancy [ 42 , 43 ] and ANC clinic consultations are a critical point through which iron and folate supplements are provided. Delays in care may, therefore, exacerbate the risk of developing anaemia [ 44 ]. Further, across many contexts, knowledge about iron and folate supplements and their importance supported significant improvements in adherence throughout pregnancy [ 45 – 47 ]. In a recent systematic review of iron and folate supplement adherence, the most significant contributor to compliance was knowledge of anaemia and the role of iron and folate supplements in preventing or managing it [ 47 ]. As participants highlighted the importance of counselling on various topics in ANC and noted a clear understanding of anaemia as dangerous for the developing foetus and mother, emphasising the link between iron and folate supplements, antimalarials, deworming, and anaemia within this counselling is an easy-to-action and likely highly effective step in promoting adherence to these treatments given during ANC.

Strengths and limitations

This study benefitted from having both quantitative and qualitative components, drawing insights across a wide range of respondents. Collecting data from two countries enabled comparison around the many similarities and few differences. Our study focused on surgery- and blood transfusion-capable facilities, so the findings may not apply to lower-level facilities, which may be less well-resourced and have less experienced or knowledgeable staff. Further, as we only collected data from 2–3 districts (and 16 facilities total) across both countries, our findings may not be generalizable. However, the many similarities across both countries suggest that our findings may be applicable to other facilities providing comprehensive obstetric care across Sub-Saharan Africa.

Conclusions

Limited capacity for haemoglobin testing, difficulties in accessing ANC, and staffing issues were raised by participants in both countries. Improved education for pregnant women, their families, and communities on anaemia, including its importance, causes, treatment and prevention, may support better uptake of anaemia prevention and treatment strategies. Understaffing, insufficient resources, and provision of and training on standards of care for anaemia in pregnancy should be addressed by the health service at the district or national levels.

Supporting information

S1 checklist. checklist—contains our human subject research checklist..

https://doi.org/10.1371/journal.pgph.0003610.s001

S1 Data. Data collection instruments—contains our data collection instruments.

https://doi.org/10.1371/journal.pgph.0003610.s002

Acknowledgments

We thank all of the participating health facilities, staff, and community members for their insights and cooperation.

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• PubMed/NCBI
• 13. World Health Organization. Service availability and readiness assessment (SARA): an annual monitoring system for service delivery: implementation guide. Geneva: World Health Organization; 2013.

SCOPE OF PRACTICE FOR NURSES AND MIDWIVES IN GHANA

General roles and responsibilities for nurse/midwife specialists 2022-05-09, general roles and responsibilities for nurse/midwife specialists.

Communication and Working relationships

Be an advocate for patient rights.

Communicate effectively with staff and clients/patients to enhance optimum customer care and quality of service.

Cooperate and collaborate effectively with all other health professionals in the service delivery area to ensure holistic patient care.

Be diligent, accessible and available for consultation at all times

Personal and People Development

Develop and maintain continuing personal and professional development to meet the changing demands in the area of addictions nursing services.

Monitor own performance against agreed objectives and standards.

Keep up-to-date on job related issues as appropriate.

Play active role in the induction of new personnel.

Conduct continuous professional education.

Take responsibility to ensure personal professional development plans are agreed with senior management.

Promote an enabling environment for staff development and training to meet required standards.

Provide leadership and mentorship for nursing, other health care professionals and trainees

Maintain a stable and enthusiastic learning environment .

Ensure accurate documentation and utilisation of specialty materials to promote accountability.

Participate in the preparation of proposals, concept notes, annual plans and budget for the institution.

Contribute to the determination of equipment and logistical needs of the unit.

Identify innovations towards improved job efficiency.

Utilize the nursing process (problem solving approach) to providing individualised and holistic care to patients/clients.

Identify, plan, conduct and or participate in operational research

Apply evidence-based clinical practice.

Participate in mobilizing funding for research.

Disseminate research finding.

Health and Safety Responsibilities

Ensure and comply with existing health and safety policies and procedures of GHS/MOH.

Ensure personal, staff and clients/patients’ safety.

Observe the Standard Precaution guidelines for infection prevention and control.

Quality Assurance

Act as a role model in quality improvement.

Institutionalise quality management systems in the unit.

Promote and participate in quality improvement measures such as multidisciplinary audit and quality initiatives.

Regularly monitor activities against quality standards and take effective action to address them.

Scope of Practice for Clinical Nurse/Midwife Specialist Addictions Nurse Specialist 2022-05-09

Scope of practice for clinical nurse/midwife specialist addictions nurse specialist.

To provide comprehensive specialist, evidence-based addictions nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Addiction Nurse Specialist:

provides quality specialised and evidence-based addictions nursing care

manages clients with complex health problems related to substance use utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse-led specialised clinics to cater for individuals with substance use disorders

participates in inter/multi-professional clinical sessions to promote inter-professional learning

initiates and implement regular clinical/technical meetings/updates in addictions nursing

provides mentorship and supportive supervision in the area of addiction care

provides follow up care (clinical and community-based)

evaluates addictions nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in addictions nursing care

organize/facilitates continuing professional development in addictions nursing

collaborates with other health professionals to promote mental health and wellbeing including the provision of community-based addictions nursing services

participates in the development of policies, guidelines, protocols and standards of care in addictions nursing

participates in monitoring and evaluation

undertakes research in the area of addictions nursing and disseminate findings

conducts performance appraisal of junior colleagues under his/her supervision

makes input into planning and budgeting of the facility

documents, and/or ensure proper documentation of all activities performed

performs any other official duties that may be assigned

Scope of Practice for the Emergency Nurse Specialist 2022-05-09

Scope of practice for the emergency nurse specialist.

To provide comprehensive specialist, evidence-based emergency nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Emergency Nurse Specialist:

provides quality specialised and evidence-based emergency nursing care

manages clients with complex health problems related to emergencies which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols.

conducts nurse-led specialised clinics to cater for individuals with emergencies

initiates and implement regular clinical/technical meetings/updates in emergency nursing

provides mentorship and supportive supervision in the area of emergency care

evaluates emergency nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in emergency nursing care.

organize/facilitates continuing professional development in emergency nursing

collaborates with other health professionals to promote health and wellbeing including the provision of community-based emergency nursing services

participates in the development of policies, guidelines, protocols and standards of care in emergency nursing

undertakes research in the area of emergency nursing and disseminate findings

Scope of Practice for the Oncology Nurse Specialist 2022-05-09

Scope of practice for the oncology nurse specialist.

To provide comprehensive specialist, evidence-based oncology nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Oncology Nurse Specialist :

provides quality specialised and evidence-based oncology nursing care

manages clients with complex health problems related to cancers which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse-led specialised clinics to cater for individuals with cancers.

initiates and implement regular clinical/technical meetings/updates in oncology nursing

provides mentorship and supportive supervision in the area of oncology nursing care

evaluates oncology nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in oncology nursing care.

organize/facilitates continuing professional development in oncology nursing

collaborates with other health professionals to promote health and wellbeing including the provision of community-based oncology nursing services

participates in the development of policies, guidelines, protocols and standards of care in oncology nursing

participates in monitoring and evaluation.

undertakes research in the area of oncology nursing and disseminate findings

documents, and/or ensure proper documentation of, all activities performed

Scope of practice for the Palliative Care Nurse Specialist 2022-05-09

Scope of practice for the palliative care nurse specialist.

To provide comprehensive specialist, evidence-based palliative care nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Palliative Care Nurse Specialist:

provides quality specialised and evidence-based palliative nursing care

manages clients with complex health problems related to palliative care needs utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conduct nurse-led specialised clinics to cater for individuals with palliative care needs

initiates and implement regular clinical/technical meetings/updates in palliative care nursing

provides mentorship and supportive supervision in the area of palliative care

evaluates palliative nursing practice and develop innovative strategies for better outcomes

promote quality improvement in palliative nursing care.

organize/facilitates continuing professional development in palliative care nursing

collaborates with other health professionals to promote health and wellbeing including the provision of community-based palliative care nursing services

participates in the development of policies, guidelines, protocols and standards of care in palliative care nursing

undertakes research in the area of palliative nursing and disseminate findings

Scope of Practice for the Paediatric Nurse Specialist 2022-05-09

Scope of practice for the paediatric nurse specialist.

To provide comprehensive specialist, evidence-based paediatric nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Paediatric Nurse Specialist:

provides quality specialised and evidence-based paediatric nursing care

manages clients with complex health problems related to children and adolescents utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse-led specialised clinics to cater for children and adolescents

initiates and implement regular clinical/technical meetings/updates in paediatric nursing

provides mentorship and supportive supervision in the area of paediatric care

evaluates paediatric nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in paediatric nursing care

organize/facilitates continuing professional development in paediatric nursing

collaborates with other health professionals to promote mental health and wellbeing including the provision of community-based paediatric nursing services

participates in the development of policies, guidelines, protocols and standards of care in paediatric nursing

undertakes research in the area of paediatric nursing and disseminate findings

Scope of Practice for the Haematology Nurse Specialist 2022-05-09

Scope of practice for the haematology nurse specialist.

To provide comprehensive specialist, evidence-based haematology nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Haematology Nurse Specialist:

provides quality specialised and evidence-based haematology nursing care

manages clients with complex health problems related to blood disorders utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse-led specialised clinics to cater for individuals with blood disorders

initiates and implement regular clinical/technical meetings/updates in haematology nursing

provides mentorship and supportive supervision in the area of haematology care

Evaluate haematology nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in haematology nursing care.

organize/facilitates continuing professional development in haematology nursing

collaborates with other health professionals to promote health and wellbeing including the provision of community-based haematology nursing services

participates in the development of policies, guidelines, protocols and standards of care in haematology nursing

undertake research in the area of haematology nursing and disseminate findings

Scope of Practice for the Neuroscience Nurse Specialist 2022-05-09

Scope of practice for the neuroscience nurse specialist.

To provide comprehensive specialist, evidence-based neuroscience nursing services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Neuroscience Nurse Specialist:

provides quality specialised and evidence-based neuroscience nursing care

conducts nurse-led specialised clinics to cater for individuals with neuroscience related disorders.

initiates and implement regular clinical/technical meetings/updates in neuroscience nursing.

provides mentorship and supportive supervision in the area of neuroscience nursing care

evaluates neuroscience nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in neuroscience nursing care.

organize/facilitates continuing professional development in neuroscience nursing

collaborates with other health professionals to promote health and wellbeing including the provision of community-based neuroscience nursing services

participates in the development of policies, guidelines, protocols and standards of care in neuroscience nursing

undertakes research in the area of neuroscience nursing and disseminate findings

Scope of Practice for the Neonatal Nurse Specialist 2022-05-09

Scope of practice for the neonatal nurse specialist.

To provide comprehensive specialist, evidence-based neonatal nursing care services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Neonatal Nurse Specialist :

provides quality specialised and evidence-based neonatal nursing

manages clients with complex health problems related to neonatal nursing utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse/midwife-led specialised clinics to cater for individuals with neonatal disorders

initiates and implement regular clinical/technical meetings/updates in neonatal nursing

provides mentorship and supportive supervision in the area of neonatal nursing care

evaluates neonatal nursing practice and develop innovative strategies for better outcomes

promotes quality improvement in neonatal nursing care.

organize/facilitates continuing professional development in neonatal nursing care

collaborates with other health professionals to promote neonatal care and wellbeing including the provision of community-based Neonatal nursing services

participates in the development of policies, guidelines, protocols and standards of care in Neonatal nursing

undertakes research in the area of Neonatal nursing and disseminate findings

Scope of Practice for the Women’s Health Specialist 2022-05-09

Scope of practice for the women’s health specialist.

To provide comprehensive specialist, evidence-based Women’s Health services and facilitate capacity building programmes for nursing or midwifery residents/students and other health professionals.

The Women’s Health Specialist:

provides quality specialised and evidence-based women’s health care

manages clients with complex health problems related to women’s health utilising the nursing process which includes assessment, diagnosis, prescription and administration of appropriate treatments according to standards and protocols

conducts nurse/midwife-led specialised clinics to cater for individuals with women’s health disorders

initiates and implement regular clinical/technical meetings/updates in women’s health care

provides mentorship and supportive supervision in the area of women’s health

evaluates women’s health practice and develop innovative strategies for better outcomes

promotes quality improvement in women’s health care

organize/facilitates continuing professional development in women’s health.

collaborates with other health professionals to promote women’s health and wellbeing including the provision of community-based midwifery services

participates in the development of policies, guidelines, protocols and standards of care in women’s health care

undertakes research in the area of women’s health and disseminate findings

conduct performance appraisal of junior colleagues under his/her supervision

PRACTICE OF NURSES 2022-05-09

Practice of nurses.

Treatments which a Nurse may perform without instructions from a Doctor

Care and cleanliness of all nursing equipment

Sterilization of surgical equipment

Washing of patient

Prevention and treatment of bedsores

Cleaning patient of pediculi

Making of patient’s bed

Cooking and serving patient’s food

Cleaning mouth of patient. Administration of mouth washes and gargles

Giving treatments for reduction of pyrexia, tepid and cold sponging but not administration of anti-pyretic drugs, except aspirin, phenacetin

Administration of evacuant enemata, soap and water, olive oil, glycerine

Administration of evacuant suppository, viz: glycerine but not of suppositories containing dangerous drugs or poisons

Administration of drugs for relief of flatulence.

Administration of common drugs for the relief of pain – aspirin, but not of any drug listed in the Pharmacy and Drugs Act as a dangerous drug

Giving of moist inhalation for laryngititis, tracheitis, pharyngitis or nasal sinus infections.

Application of simple liniments

Irrigation of eyes

Application of cold to a part – cold compress, ice bag

Application of heat to a part – hot water bottles, electric pad, medical fomentation

Surgical fomentation

Preparation of any part of the body for an operation

Make blood films for diagnosis of malaria. (The nurse may not, without sanction of a Doctor, withdraw blood through a hollow needle or any other contrivance for the purpose of making blood tests)

Disinfection of utensils, clothing, bedding, furniture, excreta of patients

Give usual nursing and first aid treatments for relief of shock – warmth; elevation of legs

Withdraw urine by rubber catheter

Arrest haemorrhage by use of pad and bandage, digital pressure or tourniquet

Give first aid treatment for cleaning of a wound

Apply first aid to fractures, sprains, muscle injuries, by using splints, slings, bandages or sandbags

Performance of artificial respiration in an emergency

First aid treatment for removal of foreign body from eye

Giving of first aid treatment for snake bite or insect stings

Giving of first aid to a woman in labour if no midwife or Doctor is available

Giving of first aid to patients having fits or convulsions

Administration of demulcent drinks; common antidotes and antagonists against poisons and administration of such stimulants as coffee in cases of collapse following poisoning

Giving first aid treatment for burns but not applying sclerosing agents to burnt areas without sanction of Doctor

Performance of last offices

Keeping of the various charts and records

Treatment which a Nurse may perform only with sanction of a Registered Medical Practitioner (not necessarily in his presence), given in writing and dated on the patient’s treatment form

Artificial feeding by oesophageal or nasal routes

Administration of any drug ordered by a Registered Medical Practitioner. This includes:

oral and rectal administration

hypodermic, intra-muscular and intravenous injection;

applications to eyes, ears, throat, vagina, uretha and skin;

administration by inhalation (but not anaesthetics except in the presence of a Registered Medical Practitioner)

A nurse may not administer drugs or anaesthetics by the intrathecal route.

Obtaining of specimens of infective material from throat, nose, eyes, urethra, cervix; using appliances for the purpose

Examination of urine with a view to providing data for doctor to form a diagnosis

Performance of minor operations such as incision of boils or insertion of sutures in wounds

Application of strapping or Elastoplast or other skin adherent for temporary treatment of fractures. Putting on of Plaster of Paris

Application of radiant heat

Lavage of stomach, colon, bladder

Vaginal douching

Dressing of operation and other wounds including removal of stitches, clips, drainage tubes, etc.

Treatment which Nurses may perform only in presence of a Registered Medical Practitioner and with his sanction

Administration of anaesthetics

Practice of Public Health Nurses 2022-05-09

Practice of public health nurses.

To supervise the welfare of infants from seven days old (when the Midwife ceases to visit) to five years old; each infant to be visited monthly for first twelve months, then at three monthly intervals until the age of three years and at six monthly intervals from three years to five years.

To attend and supervise Child Welfare Centres where children are weighed and inspected; to give mothers advice on feeding, weaning and dietary requirements of the growing child and so to encourage mothers to make full use of the Welfare Centre by attending regularly.

To advise with regard to domestic and personal hygiene when visiting mothers in their homes.

To teach mothers to recognize and notice early signs and symptoms of disease and to obtain early medical advice.

To advise parents and expectant mothers as to the best means of promoting their health and that of their families.

To organize and attend ante-natal and family planning clinics and to advise mothers on general pre-natal care and diet.

To organize and attend school clinics, carrying out general inspection of all scholars; to supervise minor ailments clinics and to visit school children at home when occasion demands.

To organize and give nursing services to sick persons, invalids and those requiring nursing in their own homes.

To prevent infection by immunization and vaccination programmes.

To follow-up cases of infectious diseases and give advise with regard to prevention of spread of diseases; special emphasis on “follow-up” of contacts of Tuberculosis. Veneral Disease and Leprosy.

To refer to the appropriate authorities persons suffering from mental illness or subnormality and to advise and assist such persons in recuperation and rehabilitation.

To follow up cases of mental illness and subnormality discharge from hospitals and treatment centres.

To visit and inspect all motherless and orphaned children monthly up to five years and then at three monthly intervals to the age of ten years.

To follow-up children discharged from hospital, to give advice regarding diet and general after-care etc.

To keep all the necessary records and ledgers and to send in monthly returns to the Medical Officer of Health.

Scope of Practice for the Registered Mental Health Nurse (RMN) 2022-05-09

Scope of practice for the registered mental health nurse (rmn).

The scope of practice for the Registered Mental Health Nurse is based on the WHO’s QualityRights of patients and ICN competences for Mental health nursing. The RMN:

assesses client for relevant health history, with emphasis on mental health issues

observes and document changes in mood, perception and behavior etc. (mental status examination)

applies standardized taxonomy systems to the nursing diagnosis of mental health problems and interventions using the current ICD and DSM

facilitates proper communication with the patient/relatives and build a therapeutic relationship

demonstrates ability for continuous professional development and life-long learning in a changing society

conducts admission and discharge procedures of patients

monitors patients’ health status and note changes where necessary

administers psychotropic and related medications, monitor its side effects, adverse reactions, changes in patient's mood or behavior and follow procedures regarding the documentation and storage

practices pharmacovigilance

de-escalate/administers PRN medications to aggressive patients when the nurse considers the likelihood of the patient harming self or others

facilitates the protection of patient and others against any form of stigma, abuse or harm

engages patient in coaching through advocacy, mentoring and teaching

facilitates the care of patients with specific needs such as Dementia, Suicidal ideations, Epilepsy, Eating Disorders, Violent Behavior and Intellectual Disabilities

develops and implement social, individual, group and family psychotherapeutic interventions including that of child protection and abuse

encourages patients to take part in art, drama or occupational therapy where appropriate

organizes social events aimed at developing patient’s social skills and helping to reduce feelings of isolation

formulates and implement interventions in areas of physical need to promote personal hygiene, nutrition, sleep, exercise etc. as well as managing any related physical ailments

prepares patient for therapies e.g. ECT, CBT and provide care for patient during and after recovery from therapy

supports the patient to develop a sense of purpose and hope in his/her current life experience

initiates mental health practices, support and educate communities, schools, workplaces and manage or refer where necessary

cares for patients experiencing acute and chronic mental disorders

demonstrates leadership and administrative capabilities in managing health care units within the framework of the national health policy and the regulatory framework using reflective/journaling practice

contributes to policy formulation, implementation and supervision for mental health services

educates trainee nurses/midwives in mental health care practices, enforce sanctions and documentation where necessary

participates in the conduct of research in mental health related issues

demonstrates and apply entrepreneurial skills in Nursing

works with patient’s family and other caregivers, helping to educate them and the patient about their health problems and promote recovery based approach to care

incorporates the use of nursing informatics using the latest versions of available software in the care of patients and the analysis of data generated to improve care outcomes

demonstrates and apply innovation in practice

collaborates with other health professionals to ensure continuity of care

cares for the dying in accordance with nursing standards

Scope of Practice for the Registered Midwife (RM) 2022-05-09

Scope of practice for the registered midwife (rm).

The scope of practice as prescribed for the Registered Midwife is premised on the WHO’s Labour Care Guide and Respectful Maternity Care within the landscape of Midwifery Services Framework and the ICM competencies. The midwife:

obtains client’s medical and obstetric history and conduct physical examination

promotes and maintain an environment which assures physical and mental well-being of mother and child by reassurance of mother, father, child, family, group and community

promotes and maintain hygiene and physical comfort; care and cleanliness of all midwifery equipment and sterilization of surgical equipment

provides pre-conceptual care

provides pre-natal and family planning services

monitors progress of pregnancy, identify and manage minor disorders, medical conditions and complications of pregnancy and refer when necessary

provides intra partum care; monitor progress of labour, identify complications and refer to a higher level of care

provides post-partum care; monitor progress of puerperium; identify and manage post- partum complications or refer when necessary

prevents complications relating to labour and puerperium by performing

episiotomy, suturing first and second degree tears or episiotomy and administration of local anaesthetics/anaesthesia

performs emergency life-saving procedures including augmentation of

labour, vacuum delivery and manual removal of placenta

provides child care including resuscitation and examination of the new born (head to toe) and promotion of breast feeding

monitors and manage reaction of mother and child to condition, trauma, stress,

medication and other forms of treatment

provides care for mother and child in obstetric emergencies; and refer complications of pregnancy

provides Comprehensive Abortion Care (CAC) and Post Abortion Care (PAC)

identifies abnormal obstetrical condition and seek prompt medical interventions to a higher level of care

administers medicine used in midwifery to mother and child and monitor its effects

educates and counsel individuals, families and communities to prevent maternal and infant morbidity and mortality

promotes antenatal and postnatal exercises

administers and monitor supply of oxygen to the mother and child

maintains fluid, electrolyte and acid base balance of mother and child

improves and maintain the nutritional status of mother and child

promotes effective communication between care givers, clients and significant others

ensures infection prevention while carrying out clinical procedures

prepares and assist surgical operation, diagnostic and therapeutic interventions for mother and child

keeps accurate records of all activities or interventions performed on mother and child

obtains specimen for diagnostic investigations (blood, urine, stool etc.)

advocates for mother and child to obtain optimum quality health care including child protection and abuse

collaborates with other health personnel to provide care for mother and child

identifies training needs of students and staff and impact knowledge, skills and principles of reproductive health to meet those needs

plans and coordinate the use of supplies and services

prescribes medication within her jurisdiction

administers medication ordered by a Registered Medical Practitioner

initiates research, share relevant research findings and provide evidence-based practice

demonstrates and apply entrepreneurial skills in Nursing and Midwifery

observes and report behavioural changes in patients

notifies births, maternal and neonatal death and conduct maternal and neonatal death audit

cares for stillborn infants and dead neonates

cares for the dying in accordance with midwifery standards

Scope of Practice for the Public Health Nurse (PHN) 2022-05-09

Scope of practice for the public health nurse (phn).

The scope of practice for the Public Health Nurse among others is anchored on the concepts of the Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). The PHN:

performs professional core functions as a member of the District Health Management Team (DHMT)/Sub District Health Team (SDHT)

contributes to and promote Primary Health Care Services/CHPS in the community especially the vulnerable population and high-risk groups

conducts community assessment, diagnosis, plan, implement and evaluate community programmes towards preventive, promotive and rehabilitative services

provides emergency obstetric care and refer patients/clients with conditions beyond his/her competence to appropriate authority

plans and conduct health promotion programmes based on community diagnosis and prevailing health issues

implements national health policies and apply its relevance to nursing and midwifery

participates in the disease surveillance in the community

collaborates with other members of the SDHT and other health related agencies in the community to plan, implement and monitor health activities

provides Family Planning, Testing and Counseling, STI’s/HIV and AIDS, Adolescent, Geriatric, Maternal and Child health services

assesses the physical and mental health needs of individuals, diagnose and treat specified diseases and make referrals when necessary

identifies nutritional needs, health and social resources available in the community and mobilize the community to utilize them

undertakes logistics management

plans, organize, coordinate and implement national immunization programmes and Child Welfare Clinics

plans and implement School Health Programmes/Services

manages financial resources in accordance with relevance financial regulations

liaises with stakeholders and community leaders to advocate for Positive behavioural change in harmful cultural practices

implements rehabilitative activities in the community

plans and conduct routine and special home visits to families

supervises the work of Nurse Assistants (Preventive)

participates in the conduct of research in public health related issues

keeps all necessary records, ledgers and transmit accordingly

offers end of life palliative care in accordance with nursing standards

Scope of Practice for the Registered General Nurse (RGN) 2022-05-09

Scope of practice for the registered general nurse (rgn).

The scope of practice for the Registered General Nurse is basically premised on the International Council of Nurses (ICN) competencies for patient care and the Practice for Nurses as enshrined in the Nurses Regulation LI 683, 1971. The RGN, in addition to the forty-seven (47) practice of nurses/functions stated in the Nurses Regulation LI 683, 1971:

uses knowledge acquired in the principles of homeostasis to meet patients’ needs by monitoring vital signs of patient and their reaction to disease conditions, trauma, stress, anxiety, medication, treatment and documentation

administers prescribed medication to patients

practice pharmacovigilance

demonstrates skills and abilities for imparting knowledge and principles of health to student nurses, patients and relatives by participating in the teaching of patients and mentoring nursing students

contributes to, and promote primary health care services, child protection and abuse in the community; recognize, manage and refer clients/patients where necessary

plans and carry out health education based on identified health needs of the community by teaching and counseling individuals and groups of persons

demonstrates understanding of national policies and their relevance to nursing

coordinates the health care activities provided for the patient by other categories of health care providers

facilitate proper communication with the client and build therapeutic relationship

assists patients family through the grieving process

Scope of Practice for the Registered Community Mental Health Nurse (RCMN) 2022-05-09

Scope of practice for the registered community mental health nurse (rcmn).

The scope of practice for the RCMN is birthed on the WHO’s QualityRights of patients, UHC, SDGs and ICN’s competencies. The RCMN:

assesses client for relevant health history, with emphasis on mental health

observes and document changes in mood, perception and behavior

facilitates proper communication with the client and build a good relationship

monitors clients’ health status and note changes and refer where necessary

conducts community diagnosis, plan, implement and evaluate community programmes towards preventive, promotive and rehabilitative services

administers prescribed psychotropic and related medications, monitor its side effects, adverse reactions, changes in patient's mood or behavior and refer for follow procedures regarding the documentation and storage

participates in disease surveillance in the community

collaborates with other members of the SDHT and other health related agencies and the community to plan, implement and monitor health activities at the community level

de-escalates aggressive patients and refer client and family when the nurse considers the likelihood of the client harming self or others

facilitates the protection of client and others against any form of abuse

engages client in coaching through advocacy, mentoring, and teaching

facilitates the care of clients with specific needs such as Dementia, Suicidal ideations, Epilepsy, Eating Disorders, Violent Behavior, Intellectual Disabilities and Substance use

develops and implement social, individual, group and family psychotherapeutic interventions

encourages clients to take part in art, drama or occupational therapy where appropriate

organizes social events aimed at developing client’s social skills and helping to reduce feelings of isolation

formulates and implement interventions in areas of physical need to promote personal hygiene, nutrition, sleep, exercise etc. as well as manage any related physical ailments

initiates mental health practices, support and educate communities, schools and workplaces and manage or refer where necessary

educates trainee nurses in mental health care practices and enforce sanctions and documentation where necessary

participates in the conduct of research in community mental health related issues

work with client’s family and other caregivers, helping to educate them and the client about their health problems and promote recovery based approach to care

requests and manage supplies, commodities and services

plans and implement school health programmes/services

manages financial resources in accordance with relevant financial regulations

advocates for Positive behavioural change in harmful cultural practices

plans and conduct routine and special home visits

demonstrates ability for CPD and life-long learning

collaborates with stakeholders to care for the dying in accordance with nursing standards

Scope of Practice for Registered Nurse Assistant (Clinical) (RNAC) 2022-05-09

Scope of practice for registered nurse assistant (clinical) (rnac).

The Registered Nurse Assistant (Clinical) under the supervision of a Registered Nurse/Midwife:

assists in admission and discharge procedures of patients on the ward

assists in giving all forms of medication ordered

observes and report adverse events of medications

carries out spoon feeding of patient

demonstrates ability for continuous professional development and life-long learning in a

changing society

maintains personal hygiene of patient

maintains clean ward and clinical environment

checks vital signs, records and reports appropriately

assists in carrying out pain assessment and management of patients

ensures client/patient safety on the ward

processes used equipment, instruments and medical devices

assists in the conduct of health related research

receives and orient patients and relatives to the ward

conducts emergency deliveries and refer patients/clients to appropriate authority

carries out other nursing duties within their regulatory competence as assigned by the

Registered Nurse/Midwife

Scope of Practice for the Registered Nurse Assistant (Preventive) (RNAP) 2022-05-09

Scope of practice for the registered nurse assistant (preventive) (rnap).

The Registered Nurse Assistant (Preventive) under the supervision of the Public Health nurse:

works with members of the Sub District Health Team (SDHT) and the community to plan, implement and monitor health activities at the community level

assists in the conduct of community diagnosis, planning, implementing and evaluating community programmes towards preventive, promotive and rehabilitative services

provides first aid services and refer patients/clients to appropriate authority

assists in the planning and conduct of health promotion programmes

assists in the management of health care units

participates in the implementation of national health policies and apply its relevance to practice

performs routine data collection on health activities

participates in identifying health problems in the community

participates in the provision of Family Planning, STI’s, HIV and AIDS, Adolescent, Maternal and Child health services

participates in the implementation of national immunization programmes

participates in the planning and implementation of school health programmes

facilitate proper communication with the client and build a good relationship

assists in planning and conducting of routine and special home visits

documents and report all activities to the Public Health Nurse (appropriate authority)

carries out other nursing duties within their regulatory competence as

assigned by the Public Health Nurse

Scope of Practice for Public Health Nurses ed : 2023-08

Scope of practice for public health nurses.

1. Apply nursing process within their scope in the care of individuals, families and communities

2. Organize and run clinics (Child Welfare, School Health Services, Adolescent Health Clinics, Maternal Health, Family Planning and Testing and Counselling (TC) Services) in the health facilities and communities

3. Promote Primary Health Care Services in the community

4. Work in partnership to support and empower individuals, their families/groups and communities to participate in decisions concerning their health

5. Conduct community needs assessment, diagnose, plan, implement and evaluate programmes towards preventive, promotive, rehabilitative and regenerative services

6. Provide emergency obstetric care and refer patients/clients with conditions beyond their capacity to the appropriate authority

7. Provide basic emergency procedures, prescribe and administer emergency therapies

8. Encourage community participation and work in partnership with voluntary workers in health enhancing activities

9. Assume administrative and leadership roles in managing health care units

10. Demonstrate an understanding of national health policies and apply its relevance to Public Health Nursing

11. Collect, analyse and interpret routine data on health events in the community for an informed decision

12. Work with other members of the Health Team and the community to plan, implement and monitor health activities at the community level

13. Assess the physical and mental health needs of individuals, diagnose and treat specific diseases and make appropriate referrals

14. Interpret services and resources available in the community to the people to help them maintain maximum health standards, prevent disabilities and premature deaths

15. Design programmes and activities to train health workers and non-health workers in the community

16. Assess the health and social needs of the school child and use the resources available to meet such needs

17. Attend to the health needs of the adolescent, the aged and clients with special needs

18. Provide counselling services to clients

19. Foster patient advocacy and patient safety roles

20. Demonstrate knowledge and skills in the prevention and control of communicable and non-communicable diseases

21. Demonstrate responsibility, accountability and ethical behavior in the performance of roles

22. Create and keep proper records of patient care, administrative and managerial activities in collaboration with other team members

23. Develop, implement, evaluate health promotion and health education strategies

24. Collaborate with other health professionals to design and implement various educational programs aimed at addressing emerging health issues in the area of practice

25. Conduct appraisal of immediate supervisees, analyse outcomes and make appropriate recommendation for training/capacity building

26. Make inputs into the development and review of protocols, standard operating procedures and other relevant manuals

27. Serve as a preceptor for the training of public health nurses

28. Recognize the need for life-long learning and continued professional growth

29. Conduct research in nursing and use findings in the delivery of population-focused care

Scope of Practice for Nurse Practitioners 2023-08-29

Scope of practice for nurse practitioners.

1. Apply nursing process within their scope in the care of individuals and families

2. Provide out-patient Nurse-Led consultation for patients of all age groups

3. Serve as a resource person in the provision of advanced nursing care in health facilities

4. Set up a General Practice Clinic and use leadership and managerial skills to manage the clinic in the delivery of health care to clients with diverse conditions

5. Conduct advanced health assessment of patients

6. Assess, diagnose, treat and evaluate patients with disorders

7. Obtain specimen for laboratory investigations

8. Request diagnostic imaging such as x-rays, ultrasound, CT scan, MRI, etc.

9. Analyse and interpret laboratory and other diagnostic results and put in appropriate interventions

10. Establish primary and differential diagnosis

11. Prescribe pharmacologic and non-pharmacologic treatment and interventions

12. Detain or admit patients to hospital for purposes of management of their condition

13. Refer patients to other healthcare team members or higher levels of care as required

14. Undertake minor surgical procedures such as incision of boils and suturing of minor wounds among others

15. Provide basic emergency procedures and administration of emergency therapies

16. Administer medical, nursing, pharmacological and other forms of therapy to patients

17. Review patients and conduct follow-up care as appropriate

18. Prescribe essential medicines and drugs in levels B1, B2 and C

19. Prescribe blood or blood products for patients as may be required

20. Provide care to patient with mental health disorders and behavioural problems and refer as appropriate

21. Provide pre-conceptional, antenatal, maternal, child health and family planning services

22. Conduct/participate in ward rounds, clinical meetings, morbidity/mortality meetings and staff durbars where appropriate

23. Demonstrate responsibility, accountability and ethical behavior in the performance of roles

24. Offer public health services such as health education and promotion to individuals, families and communities

25. Provide counselling services to clients

26. Foster patient advocacy and patient safety roles

27. Create and keep proper records of patient care, administrative and managerial activities in collaboration with other team members

28. Collaborate with other health professionals to design and implement various educational programs aimed at addressing emerging health issues in the area of practice

29. Conduct appraisal of immediate supervisees, analyse outcomes and make appropriate recommendation for training/capacity building

30. Make inputs into the development and review of protocols, standard operating procedures and other relevant manuals

31. Establish and maintain effective collaboration with public health units to ensure effective contact tracing

32. Serve as a preceptor for the training of nurse practitioners

33. Recognize the need for life-long learning and continued professional growth

34. Conduct research in nursing and use findings in the delivery of population-focused care

Scope of Practice for Ear, Nose and Throat Nurses 2023-08-29

Scope of practice for ear, nose and throat nurses.

2. Make technical input in the setup of ENT clinic where appropriate

3. Set up an ENT Clinic and use leadership and managerial skills to manage the clinic in the delivery of health care to clients with ENT conditions

4. Provide out-patient clinic Nurse-Led consultation

5. Perform physical examination of the ear, nose and throat of clients

6. Obtain specimen for laboratory investigations

7. Assess, diagnose, treat and evaluate patients with ENT disorders

8. Analyse and interpret laboratory and other diagnostic results and put in appropriate interventions

9. Prescribe medications for minor ENT disorders

10. Conduct/participate in ward rounds, clinical meetings, morbidity/mortality meetings and staff durbars where appropriate

11. Identify and manage ENT emergencies, and refer where appropriate

12. Perform non-invasive removal of foreign bodies from the ear, nose and throat

13. Prepare patients for surgeries

14. Assist in the performance of surgical procedures

15. Serve as ENT Scrub Nurse during major surgeries

16. Perform wicking of the ear to prevent stenosis

17. Instill/administer ENT, head and neck medications

18. Review patients and conduct follow-up care as appropriate

19. Collaborate with other health professionals to design and implement various educational programs aimed at addressing emerging health issues in the area of practice

20. Conduct appraisal of immediate supervisees, analyse outcomes and make appropriate recommendation for training/capacity building

21. Make inputs into the development and review of protocols, standard operating procedures and other relevant manuals

22. Establish and maintain effective collaboration with public health units to ensure effective contact tracing

23. Provide pre and post-operative management of ENT patients

24. Perform incision and drainage of minor E.N.T, head and neck abscesses

25. Perform minor ENT Surgeries

26. Carry out outreach clinics such as School Health Services

27. Identify ‘at-risk’ group, discuss problems with parents/teachers and refer for further management

28. Serve as a preceptor for the training of ENT nurses

29. Provide counselling services to clients

30. Foster patient advocacy and patient safety roles

31. Create and keep proper records of patient care, administrative and managerial activities in collaboration with other team members

32. Plan, organize and participate in rehabilitation of the early hearing, speech and language impairment

33. Demonstrate responsibility, accountability and ethical behavior in the performance of roles

34. Offer public health services such as health education and promotion to individuals, families and communities

35. Train other health personnel to assist in the delivery of ENT Healthcare

36. Recognize the need for life-long learning and continued professional growth.

37. Conduct research in ENT Nursing and use findings in the delivery of population-focused care

Scope of Practice for Ophthalmic Nurses 2023-08-29

Scope of practice for ophthalmic nurses.

2. Set up an Eye Clinic and use leadership and managerial skills to manage the clinic in the delivery of health care to clients with eye conditions

3. Make technical input in the setup of eye clinic where appropriate

4. Provide out-patient clinic Nurse-Led consultations

5. Assess, diagnose manage and evaluate patients with common eye conditions

7. Analyse and interpret laboratory and other diagnostic results and put in appropriate interventions

8. Prescribe medications for minor eye disorders

9. Conduct/participate in ward rounds, clinical meetings, morbidity/mortality meetings and staff durbars where appropriate

10. Select and prepare patients who require intra-ocular surgeries

11. Plan, organize and participate in rehabilitation of the visually challenged persons

12. Assist the Ophthalmologist during surgery

13. Serve as a Scrub Nurse during major surgeries

14. Carry out pre and post-operative management of clients

15. Administer topical eye medications

16. Administer periocular injections

17. Identify and manage ophthalmic emergencies, and refer where appropriate

19. Carry out patient/family teaching and counselling

20. Foster patient advocacy and patient safety roles

21. Set various types of trolleys for ophthalmic procedures

22. Manage minor clinical/surgical eye health conditions such as lid surgery and evisceration

23. Carry out outreach clinics such as School Health Services

24. Participate as a member of a multidisciplinary health team to coordinate and/or manage the care of a community with eye health conditions

25. Demonstrate responsibility, accountability, and ethical behavior in the performance of roles

26. Educate the public on eye care, health promotion and prevention of preventable eye diseases

27. Train other health personnel to assist in the delivery of eye healthcare

29. Promote national health policies and their relevance to eye health care

30. Conduct appraisal of immediate supervisees, analyse outcomes and make appropriate recommendation for training/capacity building

31. Make inputs into the development and review of protocols, standard operating procedures and other relevant manuals

32. Establish and maintain effective collaboration with public health units to ensure effective contact tracing

33. Create and keep proper records of patient care, administrative and managerial activities in collaboration with other team members

34. Train and supervise primary eye care personnel

35. Serve as a preceptor for the training of ophthalmic nurses

36. Conduct research in Ophthalmic Nursing and use findings in the delivery of population-focused care

Scope of Practice for Peri-Operative Nurses 2023-08-29

Scope of practice for peri-operative nurses.

2. Make technical input to the setup of theatres in the hospitals

3. Prepare and set up the operating theatre for surgery

4. Manage theatre hygiene, asepsis and the different methods of disinfection and sterilisation

5. Conduct pre-operative assessment and ensure patient preparation throughout the peri-operative periods

6. Use systematic observation and assessment to identify an elevated risk or actual health decline at an early stage

7. Implement measures to prevent further development of deteriorating health and illness

8. Protect the patient against complications and injury in connection with assessment and treatment

9. Perform focused assessment of level of consciousness

10. Analyse and interpret laboratory and other diagnostic results and put in appropriate interventions

11. Demonstrate skillful techniques and safe maintenance in the use of surgical instruments and devices in the operating theatre

12. Demonstrate competence in the circulating and scrub roles in the operating theatre

13. Assess, diagnose and prescribe pharmacologic and non-pharmacologic treatment and interventions

14. Perform minor suturing of lacerations, wound toileting and surgical wound dressing under strict aseptic principles

15. Collaborate and liaise with other units and multidisciplinary team in the plan of care

16. Foster patient advocacy and patient safety during peri-operative care

17. Incorporate specialized PON nursing knowledge and skills into the care of patients undergoing operative and other invasive procedures and of their designated support persons

18. Provide basic emergency procedures and administration of emergency therapies

19. Initiate diagnostic studies relevant to the patient’s current status and plan operative or invasive procedures

20. Provide supportive and compensatory assistance in case of failure of the patient’s vital functions

21. Administer medical, nursing, pharmacological and other forms of therapy to patients in the recovery ward

22. Participate in recovery ward rounds

23. Demonstrate responsibility, accountability, and ethical behavior in the performance of roles

24. Take part in the administration and organisation of the theatre and in the management of multidisciplinary team

25. Offer public health services such as health education and promotion to individuals, families and communities

26. Provide counselling services to clients and significant others

30. Make inputs into the development and review of protocols, standards operating procedures and other relevant manuals

31. Serve as a preceptor for the training of peri-operative nurses

32. Recognize the need for life-long learning and continued professional growth

33. Conduct research in nursing and use findings in the delivery of population-focused care

Scope of Practice for Critical Care Nurses 2023-08-29

Scope of practice for critical care nurses.

2. Use systematic observation and assessment to identify an elevated risk or actual health decline at an early stage

3. Implement measures to prevent further development of deteriorating health and illness

4. Protect the patient against complications and injury in connection with assessment and treatment

5. Facilitate a health-promoting environment for the critical care patient and encourage well-being and quality of life

6. Assess, diagnose and prescribe pharmacologic and non-pharmacologic treatment and interventions

8. Perform focused assessment and level of consciousness

9. Provide supportive and compensatory assistance in case of failure of the patient’s vital functions

10. Offer palliative and comfort measures to relieve symptoms and limit the patient’s burden in association with illness, injury and treatment

11. Provide counselling services to clients and significant others

12. Conduct/participate in ward rounds, clinical meetings and morbidity/mortality meetings

13. Set up systems to manage the transportation/evacuation of critically ill patients

14. Perform 12-lead ECG, interpret and intervene as appropriate

17. Operate various types of technology in the Critical Care Setting for the care and

management of critically ill patients

18. Execute appropriate critical care nursing to special patient populations when confronted with such in the critical care practice/setting

19. Determine readiness, prepares for and perform weaning of critically ill patients from assistive technological devices in accordance with institutional protocols e.g. mechanical ventilation

20. Initiate diagnostic studies relevant to the patient’s current status and plan operative or invasive procedures

21. Provide specialized Nurse-Led care to the terminally ill or convalescent clients at home

22. Evaluate patients’ resources, conduct follow-up care as well as assist in rehabilitation

23. Establish a patient-and family-centred treatment environment in connection with critical care treatment

24. Demonstrate responsibility, accountability, and ethical behavior in the performance of roles

32. Serve as a preceptor for the training of critical care nurses