Quality in Primary Care Open Access

The Perception of Midwives on the Implementation of South Africa's Maternal Care Guidelines in Postnatal Health in KwaZulu-Natal Province: A Qualitative Study

Ngozichika Obiageli Okeke^* and Roinnah Ngunyulu Department of Nursing, University of Johannesburg, South Africa
^*Correspondence: Ngozichika Obiageli Okeke, Department of Nursing, University of Johannesburg, South Africa, Email:

Received: 31-May-2023, Manuscript No. IPQPC-23-16885; Editor assigned: 02-Jun-2023, Pre QC No. IPQPC-23-16885 (PQ); Reviewed: 16-Jun-2023, QC No. IPQPC-23-16885; Revised: 21-Jun-2023, Manuscript No. IPQPC-23-16885 (R); Published: 28-Jun-2023, DOI: 10.36648/14791064.23.31.23

Introduction

Healthcare workers worldwide have played significant roles in saving lives by rendering services even during difficult times. Doctors, nurses (including midwives), and other paramedical professionals have continued to save lives and ensure that human beings live better lives. In particular, nurses and midwives are a critical part of the health sector of every society. The International Confederation of Midwives (2017) agrees that Midwives provide maternity care throughout childbirth. The predominant focus of their care is the health and wellbeing of the mother and her infant. Wynter et al. reasoned that considering that midwives, in most cases, have more contact hours with women and their families than other health professionals during pregnancy and the immediate postnatal period, they may also have the special opportunity to engage further, perhaps, with fathers too. However, the role midwives are supposed to play often suffers a series of setbacks due to policy inconsistencies, such as a lack of proper implementation. Fenwick et al. (2010) observed that one important aspect of maternity service is the provision and care midwives provide, especially in the immediate postpartum period. Fenwick et al. further remark that evidence shows that postpartum morbidity and its impact on women’s health after childbirth is an area of great concern. MacArthur et al. argued further that present care does not address much postpartum physical and psychological morbidity, which tends to focus on routine examinations.

The State of the world midwifery Report (SoWMR) (UNFPA, 2017a), in their report successfully examined 73 of the 75 low and middle-income nations, including South Africa, and discovered that 92% of significant maternal and newborn deaths worldwide take place in the 73 nations. But just 42% of the world’s nursing, medical, and midwifery professionals are accessible to give care in these nations (NDoH,2017: UNFPA 2017a, UNFPA, 2017b).

The WHO (2017a) agrees with SoWMR that healthcare organisation can only operate with the help of healthcare professionals, who rely on four of the following key aspects: Accessibility, acceptability, availability, and effectiveness. These components significantly impact maternal mortality and facilitate care for mothers and families with young infants. The WHO (2017a) emphasises further that only having health workers available is insufficient; only when they are equally dispersed, reachable by the public, have the necessary skills, and are driven to provide appropriate, acceptable treatment, can theoretical coverage become a reality [1,2].

The Consortium of International Midwives (ICM) (2016, 2019) and the Saving Mothers Report (NDoH, 2017) both describe a midwife as an individual who has completed a midwifery training programme that is duly recognised in the nation where it is located. Similarly, it is premised on the ICM’s essential qualifications for foundation midwifery and the guidelines of the ICM Global regulations for midwifery training who has acquired the correct expertise to be registered as a midwife. The ICM goes on to say that only midwives can practice midwifery and that midwifery is their profession. It has a distinct set of knowledge, abilities, and perspectives drawn from fields like science and sociology and used by midwives in the context of professional autonomy, partnership, ethics, and responsibility (International Confederation of Midwives 2016, 2019).

Midwives contribute a significant role in the health care delivery system by rendering maternal care services to women and their newborns. However, their roles and views are sometimes not acknowledged. There are different types of maternal health care services delivered by midwives. These include antenatal or antepartum care, intrapartum care, and postnatal or postpartum care. Others include new born care, family planning, counselling, Prevention of Mother-to-Child Transmission (PMTCT), Expanded Program on Immunisation (EPI), and Antiretroviral testing (ARV) (South African National Department of Health, 2018; National Committee for Confidential Enquiry into Maternal Deaths, 2019 Moodley, Fawcus, and Pattison). However, little attention is paid to the postnatal period, and most times, the postnatal period might not be considered an essential maternal care service (American College of Obstetricians and Gynecologists, 2018).

Midwives and Maternal Health Care in South Africa

The South African maternal care guideline provides midwives framework for implementing safe postpartum care to newborns and mothers (South African Department of Health, 2015). This recommendation assesses health system factors and midwives duties in the care and management of women during the postnatal period. The maternal care guidelines for postnatal care explored characteristics such as midwives responsibilities in caring and managing women and their babies post-delivery, practices like discharging of patients within 6 hours post-normal vertex delivery in satisfactory condition based on health providers’ discretion and follow-up care (South African National Department of Health, 2018). Also, among these factors are the management of episiotomies, checking vital signs, and midwives knowledge, competence, and skills during postnatal emergencies. These factors may have changed over the years but have not been adequately explored due to limitations in implementing these guidelines.

Commitments to adequate care and appropriate follow-up, especially during the postnatal periods, have been poorly reported (Saving Moms Report, 2018). The health system continuity of care should be such that the management of patients is appropriate irrespective of where they enter the health system. According to Saving Mothers Report, 25% of preventable maternal deaths are often associated with a lack of skilled midwives providing a continuum of care in postnatal periods (South African National Department of Health, 2018; Report from Saving Mothers, 2018). Also, there is a scarcity of information on the benefits of the implementation of the South African Maternal Guideline related to postnatal care.

Despite the reality and the crucial stage in postnatal care for women and infants, maternal care guidelines are poorly implemented in South Africa, especially during the postnatal period (South African National Department of Health, 2018; Saving Mothers Report, 2018). This has led to subpar care as observed in midwives knowledge, competence, and skills in implementing postnatal care National Health Act, 2015; Department of Health 2015. Women who gave birth without complications were discharged within 6 hours or sometimes too soon in “satisfactory condition” based on midwives knowledge and discretion, although these criteria of judgment might not be clearly defined (South African National Department of Health, 2018; Saving Mothers Report, 2018). Also, postnatal care is mainly focused on the infants, counselling on breastfeeding, and immunisation, while limited attention is given to mothers’ health (South African Department of Health, 2015; Khaki, 2019).

Furthermore, early discharge of mothers post-delivery and the lack of follow-up in the postnatal care period are often overlooked. According to the South African Statistics Department (2018), the department has reported that 20% of maternal deaths occurred outside hospital facilities (Statistics South Africa (Stats SA), 2018). However, contributing factors to these occurrences were related to those factors within the hospital setting, especially during the postnatal period. Many women whose death occurred away from the hospital were discharged early, resulting in deterioration in their health condition (Saving Mothers Report, 2018).

According to the Demographic Health Survey (2017), the survey has shown that the majority of women 96% of them give birth in the hospital. A given proportion of about 36% of such women died during the postnatal period (South Africa Demographic and Health Survey, 2017). However, studies have shown that the causes of these deaths were due to poor monitoring during the postnatal period resulting in late detection of complications and delayed response to deteriorating health conditions. Most of these deaths were potentially preventable (Saving Mothers Report, 2018; Bradshaw and Dorrington).

The South African Maternal Care Guideline (2015) is a framework for caring for mothers and their babies during the postnatal period. Furthermore, the failure to implement these guidelines has specifically affected women physically, psychologically, and socio-economically (Department of Health, 2018; Department of Health, 2015). Also, studies have shown that infants usually suffer long-term disabilities and poor development during early postnatal periods due to failure to implement these guidelines (Stats SA, 2018; Demographic Health Survey, 2017; United Nations, 2018).

Interestingly, the survey has shown that to implement maternal care guidelines, however, there is usually a lack of clear indicators of its effectiveness (Demographic Health Survey, 2017). The assumptions made by some surveys are that most of the women who have hospital births automatically receive postnatal care. However, based on an analysis of Demographic and Health Surveys (2017), only a few women receive adequate postnatal care. The South African maternal care guideline gives a standard principle on midwives role in implementing effective postnatal care to mothers and newborns (Department of Health, 2015).

The African Midwifery Industry is facing several challenges. Midwives in many countries frequently deal with maternal and neonatal mortality and morbidity without receiving competent psychological support [3]. Poor evidenced-based intervention implementation and low quality of maternal and new born care are strongly associated with a lack of resources, leadership, and skills [4]. Additionally, they are mandated to work in unconductive settings, which lowers their capacity to respond to demand [3,5].

A complicated problem requiring various interventions is adjusting midwifery education to the global context and evidenced- based practices [3]. The difficulties of being frontline professionals include financial struggles coupled with disrespect from the general public and other important team members of the maternal healthcare system [3,6]. The continent is severally lacking in midwives as a result of the “brain drain” (exodus to Western nations) and illness/death owing to HIV/ AIDS [5,7]. Furthermore, a significant portion of the population lacks access to expert maternal health care, and midwives lack the backing and medical resources needed to handle the challenge [3,8].

The number of preservice midwives trained can be increased, as can the knowledge and skills of the existing cadres of staff to enable them to provide early neonatal and postnatal care, including through task shifting [9,10]. These strategies are crucial to increasing the availability of health providers. Additionally, studies have indicated that African and Asian countries anticipate a broad range cadre of healthcare personnel to offer postnatal care [2,6]. Unfortunately, not all are supported, legislated, or trained to the necessary standard to perform all tasks they need following the international criteria [2,6]. In addition to receiving the necessary training, midwives should also be given access to an “enabling environment” that includes medications, supplies, suitable policies, and a working referral system [5,11]. Only when an enabling environment is present is a midwife available to work and give their best [5].

According to UNFPA (2017a) yearly survey, midwives should receive an education based on fundamental competencies and be subject to international regulatory standards. However, it cannot be easy to recognise a midwife in South Africa because their position and identity are not well defined. Additionally, it is stated that neither midwives nor enrolled nurses have an exact count. Approximately 1284 licensed midwives plus 124045 enrolled nurses are found in South Africa, according to the most recent SoWMR data from South and Eastern Africa (UNFPA,2017a) [1]. If the SDG targets are to be achieved by 2030, a significant hurdle that must be quickly addressed is the shortage of nurses and midwives [12].

If fully implemented and widely used in different healthcare institutions, the maternity strategy may substantially decrease the iMMR further to 29.3. The number of maternal deaths in South Africa decreased over the 2014 to 2016 triennium, yet several fatalities were still blamed on poor care services. The assessors identified 61% of the total maternal fatalities during the previous three years as potentially avoidable. For 25% of maternal deaths with preventable causes, a shortage of qualified midwives was deemed to be a contributing factor (NDoH, 2017).

The competency of health professionals is one of the critical determinants of service quality, according to UNFPA (2017a). Focusing on the skills of both midwives and physicians and keeping an eye on the implementation at different levels of the health institution are some of the current pertinent recommendations in various levels of the health institution. These are some of the existing relevant recommendations made by the Saving Moms Report (NDoH, 2017) to further reduce preventable maternal mortality and postpartum complications.

According to the SMR’s recommendations (NDoH, 2017), midwifery and medical programs should coordinate their efforts by increasing education and adopting regulations that adhere to worldwide standards. This would improve maternal healthcare and help to meet the objectives of ending maternal and newborn fatalities that could have been prevented. Preservice and ongoing education should be maximised because the midwifery component of maternal healthcare is typically in the spotlight [12].

Therefore, the study aimed to address the gap in the literature by exploring and describing midwives views on implementing the maternity guidelines on postnatal care to improve postnatal policy implementation and facilitate patients’ access to postnatal care services.

Methods

Description of the Research Demographics

The research was carried out at a Durban District Hospital, Went-Worth Hospital. This hospital is located in the eThekwini municipality of Durban, South Africa, and serves as the research site. This was chosen because it is a well-known hospital in South Africa that provides comprehensive care to its patients. Dietetics, family medicine, physiotherapy, mental health, an emergency unit, and surgical, medical, and maternity units are all available at the hospital. The hospital offers a range of services: Maternal and child health care, paediatrics, family health care, antiretroviral treatment, counselling services, psychosocial support, nutrition, and medical and surgical care.

The maternity unit and postnatal wards were the focus of the research. The maternity unit is divided into 5 sections: Antenatal clinic, gynaecology ward, labour ward, new born unit, and postnatal ward. The antenatal ward has 5 beds, the gynaecology ward does have 15 beds, the labour has 8 beds, the new born unit has 10 beds, and the postnatal ward has 20 beds (Kwazulu-Natal Department of Health, 2021). The number of deliveries performed in the maternity units is approximately 15 per month (Department of Health, 2021). Professional midwives, doctors, and other healthcare specialists work in these units.

The midwives and midwives managers who rendered postpartum care services to women and their babies were the target respondents of interest. At the time of the study, the registered midwives assigned to the maternity unit for the day and night shifts were 22 permanently employed females and two midwives managers. The midwives who took part in the study were interviewed in the maternity units. At data saturation, 17 midwives and two midwives managers were interviewed. 5 midwives worked in the postnatal ward, 5 in the labour unit, 5 in the gynaecology ward, two in the newborn unit, and none in the antenatal clinic. The midwives experience ranged from 3-15 years in the field of midwifery, with their most recent experience caring for babies. Their direct experience caring for women and babies after delivery ranged from two to 28 months. Based on the study’s criteria, midwives were included in the study. Table 1 shows the demographics of midwives and midwives managers interviewed at data saturation.

Table 1: Displays the demographic information for the participants

Overview of Study Context

Prior to the commencement of the study, the institution, health district, and hospital management provided ethical clearance and authorisation letters. The midwife manager acted as a gatekeeper, allowing the researcher access to the midwives in the respective maternity and postnatal wards. The participants were given a written consent form to indicate their willingness to participate in the interview and be audio recorded.

An in-depth phenomenological interview was conducted with participants to gather information about how to promote their roles and perspectives in implementing maternal care guidelines during the postnatal period. The participants who met the study criteria were chosen using a purposive non-probability sample. The researcher used a variety of interview techniques; probing, active listening, silence, paraphrasing, summarising, and reflection (Holloway and Galvin). This allowed the researcher to fine-tune the logical flow of questions, probe more profoundly, and elicit more information from the participants. Data was collected over a 12 week period from May 17^th, 2022, to August 1^st, 2022, with interview sessions lasting approximately 40 to 60 seconds.

The interview procedure was guided by a structured interview. The research question was reiterated to the participants. Tell me about your roles as midwives in providing postnatal care services to women and babies. Utilising the maternal care guidelines was the main query for the midwives. The possible starter inquiries included.

• Tell me about your experience as a midwife working in the postnatal care unit and having to support women and their babies during the postnatal period.

• Tell me about your roles in the provision of postnatal care to mothers and their babies in your unit.

• Tell me more about post-delivery complications identified or observed during postnatal care of women and their newborns.

• Tell me about the challenges you have experienced in your role while providing postnatal care to women and their babies in your unit.

• Based on your role, what support did you get in the provision of postnatal care services

• Tell me about your experience of the resources used to support midwives during the postnatal care provision.

• Tell me about the process or application of midwifery legislation and guidelines that support midwives in the provision of postnatal care services.

• Based on your experience in providing care, which role has been most meaningful?

Presentation of findings: Themes and categories were found and articulated on the measures to promote the participants’ roles and opinions in implementing maternal care recommendations during the postnatal periods after thorough data analysis and collaboration between the coder and the researcher. These were displayed as tables as illustrated in (Tables 2 and 3). The formatted citations were listed and enclosed by inverted commas.

Table 2: Summary of the themes and categories of midwives roles in implementing maternal care guidelines during postnatal periods

Table 3: Summary of the themes and categories of midwives' manager's views in implementing Maternal Care Guidelines (MCG) during the postnatal periods

Central theme: There is a lack of understanding and detailed information about implementing maternal care guidelines during the postnatal period. Midwives encountered difficulties in carrying out the maternal guidelines during the postnatal period. The problems included a shortage and poor retention of midwives in maternity units, insufficient funding and capacity building, limited resources and equipment, poor orientation and training of midwives, and unmotivated midwives; they expressed a desire for assistance from management, stakeholders, and professional organisation.

According to the managers of the midwives, there is awareness of MCG, but there are still no clear indicators of its effectiveness in execution and limitations in its core information. Managers reported that the MCG provided quality and holistic maternal care, increased the number of competent and skilled midwives, reduced costs and legal actions, increased safety, and favourable health outcome, prevented complications, and improved the health system. Furthermore, midwives managers reported that promoting midwives roles in delivering quality postnatal care depends on the following measures: Increasing human resources by hiring and retaining more midwives in maternity units, providing evidenced-based practice midwifery, team building, on-going education, and midwife empowerment. It was additionally fostering a supportive environment, providing enough resources and equipment, competent leadership, enabling policies, the participation and collaboration of stakeholders, and an efficient referral system.

Themes and Categories

The themes and categories identified from the interviews with the midwives and midwives managers are outlined in (Tables 2 and 3).

Discussion

This study has examined midwives views on implementing maternal care guidelines in postnatal health in the province of KwaZulu-Natal, South Africa. Responses from respondents indicate that there are many challenges, especially regarding policy implementation and the welfare of midwives. Respondents revealed that they rarely receive support in terms of their work from the South African Nursing Council (SANC). Oftentimes, they are left alone to fight for their rights. In most industrialised societies, midwives provide a significant majority of care to women during and after their pregnancies. Homer observed that for effective high-quality service delivery and improved patient experiences, the essential elements of healthcare policy must be implemented, as evident in many industrialised societies. This undoubtedly underscores the importance of effective policy implementation for maximum and tangible results.

With regard to awareness and in-depth information about Maternal Care Guidelines (MCG), midwives acknowledged being aware of MCG; however, there is currently a lack of knowledge regarding its implementation and its efficacy. There are a number of studies that shown that South Africa has poor performance of maternal care guidelines, particularly during the postnatal stage (South African National Department of Health, 2018, Saving Mothers Report, 2018), concur with these findings. As evidenced by the midwives knowledge and abilities to implement postnatal care (National Health Act, 2015; Department of Health, 2015; this has resulted in subpar care.

Admittedly, most midwives acknowledged awareness of MCG, but there are still limitations to the guideline application, particularly during the postnatal stage, due to staff shortage. The study also reiterates that despite efforts to implement recommendations for maternal care, there are frequently no apparent signs of success (Demographic Health Survey, 2017; Bradshaw, Dorrington, Saving Mothers Report, 2018).

During this study, midwives revealed in detail and identified several obstacles that affect their ability to implement MCG during the postnatal period. Prominent among these obstacles include a lack of midwives in the maternal care unit, poor retention rates, insufficient orientation, training, poor skill acquisition, and lack of empowerment. Others include a lack of motivation and a supportive environment, poor infrastructure, adequate supplies and tools, poor compensation and salaries, insufficient funding for capacity building, and insufficient resources and equipment.

The midwives stated that they could not give individualised care because of higher turnover. Similarly, Alkema et al. concur with the findings that increased patient rates make it difficult for midwives to implement the recommendations. In addition, Lodeka and Hazfiarini suggest that increasing workloads and burnout negatively impact midwives roles.

The lack of personnel and supplies was the major issue raised by the midwives. Similarly agree with both findings that midwives utilisation of MCG in the postpartum phase is frequently influenced by health system challenges such as resources, equipment, essential supplies, and drugs. The current staff shortage, according to midwives, means that many regulations may not be put into effect because staff members will not be able to follow them. In addition, studies have shown that shortage of midwives who are trained, competent, skilled, and motivated, as well as a low retention rate, invariably prevent midwives from implementing the guidelines. It was further revealed in the data that midwives are not sent for in-service training. Lack of in-service training hinders midwives from acquiring the latest skill set and knowledge to respond to modern challenges associated with midwifery. There is also the problem of Poor role definition, delegation, and supervision which have all been identified as impediments to a midwife’s responsibilities. A careful look into this could be attributed to a lack of training, education, or orientation, or it could also be due to poor adaptation to midwifery education. As a result, midwifery education, staff training, and clinical evaluation must be improved for effective service delivery in the province of KwaZulu-Natal and, by extension, the entire republic of South Africa (Yakubu).

Due to the high volume of patients, staff shortage, lack of equipment, and delays in the health system, midwives are unable to carry out their responsibility effectively. Midwives mentioned that working could be traumatising. According to delays in the health system, as such resulting in poor system coordination, planning, and intervention, have often been identified to hamper midwives functions. This agrees with the findings of this study.

There is a mention where midwives have complained of how management’s lack of support hindered their roles. Similarly, Simona et al. and Petterson affirm that lack of support undoubtedly hampers midwives roles in implementing the recommendations. These difficulties may be the result of inadequate leadership and governance in the health system. The fact that midwives worked underappreciated and frequently worked in unfriendly environments was also mentioned. Petterson also agrees that midwives frequently face challenges such as poor health conditions impeding their efficiency in providing quality care to mothers and their newborns. The author also claimed that midwives often struggle in their roles due to burnout and financial difficulties. In addition, midwives were found to be unmotivated due to disregard from the public and health team.

Data from this study, as evident from the responses of respondents, indicate that encouraging environments and midwives motivation, hiring and keeping more midwives in the maternity units, continuing education, and developing midwifery skills were all factors that helped them in their postnatal roles. Others include the development of infrastructure, the availability of resources and equipment, the payment of incentives and salary increases, and assistance from management and legislative bodies. The retention of more midwives in the maternity and postnatal units, according to the midwives, would enhance their roles in putting the recommendations into practice. Therefore, midwives believe they need more compensation and incentives to support their role as midwives in delivering postnatal care and working effectively. Midwives further stated that they require more financial support from the management in the form of higher salaries.

Conclusion

This study has examined midwives perceptions of implementing maternal care guidelines in postnatal health in Durban, the biggest city in the province of KwaZulu-Natal, South Africa. The study was conducted in a District Health Hospital, which met the requirement for this study. Midwives in the maternity ward of the Wentworth Hospital constitute the sampled population, and the qualitative research adopted a structured interview to assess midwives views regarding the implementation of maternal care guidelines in postnatal health in Durban, South Africa. This study revealed that the implementation of maternal care guidelines in postnatal health in Durban had been constrained by a myriad of factors, among which include poor working environment and conditions, lack of provisions for in-service among midwives, poor remunerations, lack of support from the South African Nursing Council (SANC) toward midwives, staff shortage, lack of equipment, and delays in the health system etc. To address these problems, therefore, this study recommends that government review its policies regarding the roles midwives should play across all districts of hospitals.

Similarly, proper attention should be paid to the midwives with regard to their welfare, remuneration, conducive working environment, constant training and retraining, and provision of quality equipment in the maternity wards, among others. Above all, midwives should equally be rewarded through promotion, motivation and other things that would boost their morals to work better. That way, they will work to ensure that the best services are rendered, and more lives can be saved.

Ethical Declaration

Ethics Approval and Consent to Participate

This article is part of a PhD Nursing thesis, which is being currently conducted in accordance with the permission from the Faculty of Health Sciences Research Ethics Committee of the University of Johannesburg, South Africa (NHREC), under the protocol reference number REC 241112-035. Gatekeepers’ approval was obtained from the district’s Department of Health. Also, approval was obtained from the hospital’s research ethics committee. The institutions ethical standards were met in this review.

Consent for Publication

Not applicable.

Competing Interest

The authors declare that they have no competing interest.

Funding

This work was financially supported by the University of Johannesburg, South Africa.

Acknowledgement

The authors would like to thank the Department of Nursing, University of Johannesburg to have supported this project. The University of Johannesburg Library Department for the provision of the resources towards this review.

Contribution

No conceptualised the study under the supervision of RN. RN contributed to the writing of the manuscript, provided substantive revision and approved the final manuscript.

References

1. Day-Stirk F, Fauveau V (2017) The state of the world’s midwifery: Making the invisible visible. Int J Gynaecol Obstet 119: S39–S41.

   [Crossref] [Google Scholar]

2. World Health Organization (WHO) (2017). WHO recommendations: Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting.

   [Google Scholar]

3. Pettersson KO (2018) Major challenges of midwifery in Africa. Afr J Midwifery Womens Health 2(2): 100-103.

   [Crossref] [Google Scholar]

4. Ameh CA, Broek NVD (2017) Making it happen: Training health-care providers in emergency obstetric and newborn care. Best Pract Res Clin Obstet Gynaecol29(8): 1077–1091.

   [Crossref] [Google Scholar]

5. Adegoke A, Bettina UTZ, Msuya SE, Broek NVD (2017) Skilled Birth Attendants: Who is who? A descriptive study of definitions and roles from nine Sub Saharan African countries. PlosOne 7(7): e40220.

   [Crossref] [Google Scholar]

6. Nyamtema AS, Urassa DP, Roosmalen JV (2017) Maternal health interventions in resource limited countries: A systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth 11(33): 12.

   [Crossref] [Google Scholar]

7. Bettina Utz, Siddiqui G, Adegoke A, Broek NVD (2017). Definitions and roles of a skilled birth attendant: A mapping exercise from four South‐Asian countries. Acta Obstet Gynecol Scand 92(9): 1063-1069.

   [Crossref] [Google Scholar]

8. Wall SN, Lee ACC, Carlo W, Goldenberg R, Niermeyer S, et al. (2018) Reducing intrapartum-related neonatal deaths in low-and middle-income countries what works? Semin Perinatol 34(6): 395-407.

   [Crossref] [Google Scholar]

9. Dogba M, Fournier P (2019) Human resources and the quality of emergency obstetric care in developing countries: A systematic review of the literature. Hum Resour Health 7(1) 1-12.

   [Crossref] [Google Scholar]

10. Ameh C, Msuya S, Hofman J, Raven J, Mathai M, et al. (2017) Status of emergency obstetric care in six developing countries five years before the MDG targets for maternal and newborn health. PlosOne 7(12): e49938.

    [Crossref] [Google Scholar]

11. Graham WJ, Bell JS, Bullough CHWB (2017) Can skilled attendance at delivery reduce maternal mortality in developing countries? Safe Motherhood Strategies: A Review of the Evidence.

    [Google Scholar]

12. Sewnunan A, Puckree T (2022) Implementing essential steps to manage obstetric emergencies in South Africa: Midwives’ perspectives. Afr J Midwifery Womens Health 16(4): 1–9.

    [Crossref] [Google Scholar]