CLINICAL DECISION-MAKING AND REFERRAL OF OBSTETRIC EMERGENCIES: A CASE OF EmONC TRAINED AND UNTRAINED NURSES AND MIDWIVES IN MPIKA DISTRICT, ZAMBIA

Abstract

Background: Prompt decision-making in referring women with obstetric complications to the next level of care for further management by nurses and midwives is critical in reducing the maternal mortality rate. The study was conducted to determine whether there was a difference in clinical decision-making between nurses and midwives trained in Emergency Obstetric and Neonatal Care (EmONC) and the untrained in referral of obstetric emergencies. The total maternal mortality for Mpika District in 2014 was 12, and out of the twelve (12) recorded deaths, ten (10) were from the referred cases. There is still high maternal mortality in Zambia despite strategies like EmONC being implemented, whose goal is to provide knowledge and clinical and decision-making skills to nurses and other relevant staff to respond appropriately to obstetric emergencies. Objective: The main objective of the study was to determine the differentials in clinical decision-making and referral of obstetric emergencies between nurses and midwives who had undergone training in EmONC and those who had not. Materials and Methods: This was a cross-sectional survey conducted in Mpika District. A sample size of 18 nurses and midwives was selected using the census method, and 111 obstetric referral records were purposively sampled. A pre-tested self-administered questionnaire and checklists were used to collect and record the information. Data was analysed using SPSS for Windows statistical software version 22.0. The chi-square test was used to test associations between the dependent and independent variables. Results: The findings revealed that out of the 18 nurses and midwives who participated in the study, (44%) 8 were trained in EmONC while (56%) 10 were not. The findings showed no difference in timely referral of obstetric emergencies (χ2 = .407; p>0.005). The findings did not show a strong relationship between being trained in EmONC and the outcome of an obstetric emergency (χ2 =0.644 p> 0.005). However, Environmental and organizational contexts of decision-making, such as availability of transport by the referring unit (95% CI, P- Value 0.002), going to the hospital with a referral letter (95% CI, P-value = 0.016) and documentation of pre-referral treatment on the referral form (95% CI, P-value = 0.019) were significantly related to being referred by EmONC trained nurse or midwife. Conclusion: The results indicate that there was no difference in clinical decision-making between the EmONC-trained and the untrained nurses and midwives in relation to timely referral, foundational knowledge and outcome of referred obstetric emergencies. However, the availability of transport has been seen to have an influence on the number of cases referred. This study highlights the fact that given all the logistics, nurses and midwives can make timely decisions on the referral of obstetric emergencies. Recommendations: There is a need for MoH to consider making transport available at rural health facilities and possibly establish Zonal health facilities that can help in both referral and management of obstetric emergencies.