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Table 1 Main table with all included studies (n = 35)

From: Healthcare workers’ behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review

Study/Country Sample Design Outcome Determinant / summary measures
Tilahun et al. (2012)/Ethiopia [17] Physician and nonphysician obstetric care workers (n = 423) Cross-sectional study Attitude toward provision of SRH to unmarried adolescents Negative attitude toward provision of SRH services to adolescents was significantly associated with healthcare workers’ being married (OR: 2.15; 95% CI 1.44 – 3.06), lower levels of education (OR: 1.45; 95% CI 1.04 -1.99), being a health extension worker (OR: 2.49; 95% CI 1.43 – 4.35), lack of training on RH services (OR: 5.27; 95% CI 1.51 – 5.89), and non-use of family planning (OR: 1.77; 95% CI 1.05 – 2.77).
Okokon et al. (2014)/Nigeria. [22] Nonphysician obstetric care workers (n = 290) Cross-sectional study Utilization of the partograph Knowledge of the partograph had a significant relationship with its utilization in teaching hospital (Χ 2 = 38.96, p ≤ 0.0001) and general hospital (χ2 = 12.05, p ≤ 0.0001), but not in primary healthcare centers (Χ 2 = 0.08, p = 0.778)
Fawole et al. (2008)/ Nigeria [23] Physician and nonphysician obstetric care workers (n = 719) Cross-sectional study Knowledge and utilization of the partograph Utilization of partograph was reported more frequent by responded working in tertiary levels of care compared to those on primary and secondary levels (χ2 = 214. 6, p ≤ 0.0001). 37.3% of respondents who were predominantly from the tertiary level of care could correctly mention at least one component of the partograph (χ2 = 139.1, p < 0.0001). The partograph is utilized mainly in tertiary health facilities; knowledge about the partograph is poor.
Fawole et al. (2010)/ Nigeria [24] Physician and nonphysician obstetric care workers (n = 275) Exploratory study Knowledge of the partograph Knowledge of partograph components was poor among auxillary nurse/midwives at 0% median score. Knowledge about assessment that could be made by the use of partograph was poor on both settings (private and primary/public care facilities). More responded in the private sector correctly mention the function of the alert line on the partograph than those on the public sector (χ2 = 4.43, p < 0.05). Previous training on partograph was associated with knowing at least one component of the partograph (χ2 = 49.2, p < 0.05). Knowledge about assessment of women during labour was also poor.
Yisma et al. (2013)/Ethiopia [25] Physician and nonphysician obstetric care workers (n = 202) Cross-sectional study Utilization of the partograph Knowledge about partograph was significantly higher among obstetric care workers working in hospitals compared to those working in health centers (OR: 2.0; 95% CI 1.1 – 3.9). However, utilization was significantly more frequent in health canters than in hospitals (χ2 = 19.2, p < 0.01). Lack of positive attitude toward partograph was associated with poor utilization of the partograph by obstetric care workers (OR: 0.10; 95% CI 0.01 – 0.81). Nonphysician obstetric care workers had lesser likelihood of having a good level knowledge about partograph (OR: 0.10; 95% CI 0.03 – 0.97). Knowledge about partograph was significantly associated with previous training on partograph (OR: 2.80; 95% CI 1.19 – 6.70)
Wakgari et al. (2015)/ Ethiopia [26] Physician and nonphysician obstetric care workers (n = 403) Cross-sectional study Utilization of partograph 40.2% utilized partograph during labor. Those who were midwives by profession were about 8 times more likely to have a consistent utilization of the partograph than general practitioners (AOR = 8. 13, 95% CI: 2.67, 24.78). Similarly, getting on job training (AOR = 2. 86, 95% CI: 1.69, 4.86), being knowledgeable on partograph (AOR = 3. 79, 95% CI: 2.05, 7.03) and having favorable attitude towards partograph (AOR = 2. 35, 95% CI: 1.14, 4.87) were positively associated with partograph utilization.
Opiah et al. (2012)/ Nigeria [27] Nonphysician obstetric care workers (n = 165) Descriptive cross-sectional study Knowledge and utilization of the partograph Knowledge of partograph was significantly associated with is utilization ((χ2 = 32.29, p < 0.05), and between the obstetric care workers’ years of experience and partograph utilization ((χ2 = 4.82, p < 0.05).
Hussein, et al. (2004)/ Ghana [28] Physician and nonphysician obstetric care workers (n = 416 deliveries) Retrospective study Obstetric skills For all deliveries, 32.6% to 93.0% of criteria were met for “standard care” (defined by Section A criteria), with a mean of 65.5%. No delivery met all of the criteria. Doctors, with a mean score of 76.1%, appear to satisfy more criteria than mid- wives at 67.4%, who in turn satisfy more criteria than assistant midwives, a non-professional grade of staff in private facilities in Ghana.
Nyango et al. (2010)/Nigeria [29] Nonphysician obstetric care workers (n = 54) Descriptive cross-sectional study Knowledge and skills among birth attendants A minority of the obstetric care workers routinely performed basic ANC services. EmOC services provided, including the use of partograph by the respondents were below optimal levels as prescribed by WHO.
Mirkuzie et al. (2014)/Ethiopia [30] Nonphysician obstetric care workers (n = 49) Health facility-based intervention Knowledge and skills of basic EmOC Obstetric care workers’ knowledge on basic EmOC was poor both in 2008 respondents as well as in 2013 respondents.
Ameh et al. (2012)/ Somalia [31] Physician and nonphysician obstetric care workers (n = 222) Descriptive study Knowledge and skills of life-saving EmOC, provision of EmOC Availability and quality of EmOC There was a significant improvement in knowledge (50%) and skills (100%) among the obstetric care workers. Confidence in EmOC provision was improved.
Haile-Mariam et al. (2012)/Ethiopia [32] Nonphysician obstetric care workers (n = 711) Cross-sectional study Knowledge of EmOC, resuscitation Half of the midwives interviewed reported having performed neonatal resuscitation in the past three months compared to only 20% of the nurses. Key predictors of a high knowledge score among providers were recent performance of neonatal resuscitation and geographic region. Whether the provider was a nurse or a midwife, was not associated with a higher knowledge score.
Vivio et al. (2010)/ Zambia [33] Nonphysician obstetric care workers (n = 62) Observational cross-sectional study Knowledge of the active management of the third stage labour (AMTSL), provision of AMTSL Majority of the obstetric care workers knew that AMTSL was associated with the administration of a uterotonic drug. More than half of the participants were aware of the controlled cord tracting (CCT) as a strategy to promote placenta delivery, while a few reported early cord clamping and cutting as a component of the AMTSL protocol, and were observed to use it as a standard practice. A third of the responded were aware of the fundal massage as a component of the AMTSL protocol.
Kimberly et al. (2010)/ Zambia [34] Nonphysician obstetric care workers (n = 21) Observational study Knowledge and skills (use) of maternal ultrasound Clinical decision-making Paired OSCE scores showed a slight overall improvement in the midwives ability to scan at 2 months of 10.0/14, SD 3.9 (71%) and at 6 months of 11.6/14, SD 1.8 (83%). Paired t-test showed no significant difference between OSCE 1 and OSCE II with p = 0.15
McAuliffe et al. (2013)/ Malawi, Tanzania, Mozambique [35] Nonphysician obstetric care workers (n = 1561) Cross-sectional study Intention to leave obstetric services (job satisfaction) Not receiving any supervision appeared to be most strongly linked to decrements in intentions to leave and job satisfaction. In particular, intentions to leave were substantially increased when no supervision system was in place in Malawi (b = 1.09, SE = 0.31, t = 3.52, p < 0.01), Tanzania (b = 0.82, SE = 0.3, t = 2.73, p < 0.01), and Mozambique (b = 1.04, SE = 0.39, t = 2.67, p < 0.01). There was also clear evidence of a link between the absence of supervision and diminished job satisfaction in all countries. In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave.
Maramagi et al. (2004)/ Uganda [36] Nonphysician obstetric care workers (n = 37) Cross-sectional study Counseling skills in IMCI programme Older health providers (50-59 years) were more likely to advise caregivers on medication than younger health providers (χ2 = 15.64, p = 0.016). Male health providers (χ2 = 6.22, p = 0.045) and those aged 30-39 years (χ2 = 19.244, p = 0.004) were more likely to explain the feeding problem to the caregivers. Health providers aged 30 or more years were more likely to give feeding advice than younger health providers (Χ 2 = 9.62, p = 0.022).
Tita et al. (2006)/ Cameroon [37] Physician and nonphysician obstetric care workers (n = 328) Cross-sectional study Awareness of evidence-based obstetric care A total of 15.5% (50/322) of health workers were aware of all the four interventions while only 3.8% (12/312) reported optimal practice. Evidence-based awareness was strongly associated with practice (PR = 15.4; 96% CI: 4.3–55.0). Factors significantly associated with awareness were: attending continuing education, access to the WHO RHL, employment as an obstetrician/ gynaecologist and working in autonomous military or National Insurance Fund facilities. Controlling for potential confounding, working as an obstetrician was associated with increased awareness (adjusted prevalence odds ratio [aPOR] = 8.3; 95% CI: 1.3–53.8) as was median work experience of 5–15 years (aPOR = 2.0; 95% CI: 1.0–3.8). Internet access was associated with increased practice (aPOR = 3.4; 95% CI: 1.0–11.8).
Ijadunola et al. (2010)/ Nigeria [38] Physician and nonphysician obstetric care workers (n = 152) Descriptive study Knowledge of EmOC Knowledge of EmOC was poor among the respondents, and no difference across age groups. Doctors had a fair knowledge compared to other profession.
Ersdal et al. (2008)/ Zimbabwe [39] Physician and nonphysician obstetric care workers (n = 80) Cross-sectional study Knowledge, attitude and practice of symphysiotomy Seventy-nine of the 80 participants knew about symphysiotomy, and 76 could describe the technique, including 16 of the 17 midwife instructors. One junior doctor was not aware of the intervention. One of the ten obstetricians had occasionally performed a symphysiotomy the other nine did not practice the intervention, but indicated that they would be able to carry it out. All the rural midwives (n = 13) regarded symphysiotomy as a lifesaving operation appropriate for remote areas, and 23 of the 39 midwives (59%) thought that the procedure should be taught to midwives.
Ndikom & Onibokun (2007)/ Nigeria [40] Nonphysician obstetric care workers (n = 155) Cross-sectional study Knowledge and behaviour towards PMTCT Nurse/midwives had moderate level of knowledge with mean score of 51.4%. Hypotheses tested revealed that there is a positive relationship between knowledge and behaviour (r = 0.583, p = 0.00). Knowledge level of nurse/ midwives who had educational exposure was not different from those who did not (t = 1.439, p = 0.152). There was a significant difference in the knowledge of nurse/midwives who had experience in managing pregnant women living with HIV/AIDS and those who did not (t = 2.142, p = 0.03). Also, there was a significant relationship between behaviour and availability of resources (r = 0.318, p = 0.000).
Chi et al. (2004)/ Zambia [41] Physician and nonphysician obstetric care workers (n = 225) Cross-sectional study… Perceptions toward HIV screening and treatment Providers reported widespread stigma associated with HIV. Physicians (OR = 1.9), providers with research affiliations (OR = 2.3), and those located in Lusaka (OR = 9.0) were more likely to offer HIV testing. Only 30% routinely prescribed antiretroviral treatment (ART) to reduce MTCT. Practitioners from district facilities, and those employed at research facilities were more likely to prescribe ART routinely (OR = 2.8, 10.1 and 3.4 respectively). Among those never prescribing ART, most cited a lack of availability (83%).
Byamugisha et al. (2007)/ Uganda [42] Physician and nonphysician obstetric care workers (n = 247) Cross-sectional study Knowledge, attitude and practice of EC Most of the participants had heard about EC (79.4%). 1 in 4 (24.1%) of the participants did not know the time limit within which EC is effective. slightly more than half (53.3%) wanted to make the population sensitized about EC issues. About 28% wanted EC available and accessible in convenient places for all. Some HCWs expressed the need for more training, such as seminars in FP methods. Almost half (49%) of the participants who knew about EC had prescribed it in one form or another and 1 in every 10 had prescribed ECPs in the previous 12 months (11.9%).
Traore et al. (2014)/ Mali [43] Physician and nonphysician obstetric care workers (n = 196) Cross-sectional study Knowledge and skills of EmOC Bivariate analysis showed an association between competency score and type of health worker (p < 0.05). Knowledge was most deficient for postpartum infection and hypertensive complications. Type of health worker, years of experience, number of days absent, and avail- ability of guidelines for management of obstetric complications within the health center were positively associated with test score (p < 0.05). Availability of guidelines was associated with higher competency of physicians, health technicians, and obstetric nurses (p < 0.001), and seemed to influence the competency of healthcare workers with fewer than 10 years of experience in particular.
Ehiri et al. (2005)/Nigeria [44] Nonphysician obstetric care workers (n = 252) Cross-sectional descriptive study Quality of child health services Facilities were adequately equipped with immunization supplies. Essential drugs supply was inadequate in all centers; as well as emergency care facilities. 68.3% of the respondents had adequate training in immunization with high knowledge scores on immunization issues. Use of the national case management algorithm was low among the respondents.
Worku et al. (2013)/Ethiopia [45] Nonphysician obstetric care workers (n = 38) Population-based survey Availability of MCH services, Obstetric care workers skills, and the quality of MCH services Availability of essential drugs, equipment and other supplies was unsatisfactory. A small proportion of obstetric care workers had adequate training and experience on important obstetric procedures. Only 24% of the obstetric care workers used partograph frequently and consistently. Majority of the facilities did not function fully for emergency obstetric care (EmOC) as per their level. Important ANC components were incomplete and unsatisfactory.
Mngadi et al. (2008)/ Swaziland [48] Physician and nonphysician obstetric care workers (n = 56) Exploratory study Attitude towards adolescents’ SRH service provision 78% respondents reported that they provided contraceptives to the adolescents when they asked for them and when they were available. Some reported that contraceptive use was against their religion and that youth should not indulge in sex. Half of the nurses/midwives had no continued education and lacked supervision on adolescent sexual and reproductive health care. The majority had unresolved moral doubts, negative attitudes, values and ethical dilemmas towards abortion care between the law, which is against abortion, and the reality of the adolescents’ situation. Forty-four wanted to be trained on post-abortion care while eight on how to perform abortions. Twenty-six wanted the government to support adolescent-friendly services and to train healthcare providers in adolescent sexual and reproductive health services.
Oduro-Mensah et al. (2013)/ Ghana [49] Physician and nonphysician obstetric care workers (n = 65) Cross-sectional descriptive study Decision making for clinical care Printed protocols and guidelines were the most commonly selected (96%) aids used in decision-making. However workshop materials (92%), expert advice (90%) and telephone calls for advice (85%) were also frequently selected as aids in daily decision making. The majority of respondents (80%) said they had access to various local (institutionally) modified or developed guidelines and protocols e.g., management of postpartum haemorrhage, management of pre-eclampsia / eclampsia, etc. Health system constraints such as availability of staff, essential medicines, supplies and equipment; management issues (including leadership and interpersonal relations among staff), and barriers to referral were important influences in decision-making.
Leon, Lundgren, & Jennings (2006)/ Rwanda [50] Nonphysician obstetric care workers (n = 40) Observational study Guidelines utilization for Provision of contraceptives Providers implemented less than one third of the guideline set, but they addressed, more frequently than other guidelines, items categorized as essential by expert opinion (p <0.01). Rwandan providers emphasized contraindications in 29-min sessions. Within this set, items previously classified as essential were addressed more frequently than guidelines classified as less important in Rwanda (3:2). Use instructions were not addressed frequently than other guideline categories in Rwanda, where contraindications were more prevalent than use instructions. Contraindications ranked above use instructions in both locations in Rwanda.
Warenius et al. (2006)/ Kenya/Zambia [46] Nonphysician obstetric care workers (n = 707) Cross-sectional study Attitude towards adolescents’ SRH service provision Nurse-midwives disapproved of adolescent sexual activity, including masturbation, contraceptive use and abortion, but also had a pragmatic attitude to handling these issues. Those with more education and those who had received continuing education on adolescent sexuality and reproduction showed a tendency towards more youth- friendly attitudes. About two-thirds (69%) of Kenyan and about half (52%) of Zambian respondents disagreed that “16-year-old out-of-school girls should be encouraged to use condoms”. However, both Kenyan (55%) and Zambian (67%) nurse-midwives agreed that “if a schoolgirl was sexually active she should be allowed to use contraceptives”.
Evens et al. (2014)/ Kenya [51] Nonphysician obstetric care workers (n = 20) Descriptive post-intervention study Attitude towards post-abortion care (PAC) service and quality of the service provision Majority of healthcare providers’ were in favour of equal treatment for PAC regardless of age/marital status of clients. All healthcare providers deemed PAC services important. Sexual activity after marriage was supported by 45% of the providers.
Chalmers, McIntyre & Meyer, (1992)/ SA [52] Physician obstetric care workers (n = 203) Hospital-based survey Attitude toward caesarean section Private doctors consider CS safer than a “normal” delivery. Public doctors believe that CS are performed by obstetricians duet of lack of proper (training) management of complication/difficult delivery.
Sidze et al. (2014)/Senegal [47] Physician and nonphysician obstetric care workers (n = 637) Health facility survey Access to and use of contraceptives Obstetric care workers had a minimum age restriction, as well as restrictions according to clients’ marital status, for the provision of contraceptives to young women in Senegal.
Chaibva et al. (2010)/ Zimbabwe [13] Nonphysician obstetric care workers (n = 52) Descriptive study Utilization of prenatal services by adolescents Socio-demographic and cultural factors influenced adolescents’ utilization of prenatal services according to the midwives. Almost all of the midwives (n 1⁄4 49; 94.2%) considered financial constraints to be a factor limiting adolescents’ utilization of prenatal services. 71.2% agreed that health workers’ attitudes could influence adolescents’ decisions. Most midwives (n 1⁄4 45; 86.5%) reported that the quality of prenatal services could influence adolescents’ decisions to utilize prenatal services; 29 (55.8%) felt that adolescents perceived prenatal care to be beneficial because they realised that obstetric problems could be detected and addressed during the prenatal period.
Mane et al. (2014)/Senegal [57] Physician and nonphysician obstetric care workers (n = 163) Descriptive study Provision of emergency contraceptives (EC) Knowledge gaps about EC among obstetric care workers were found. They also reported reluctance in providing counseling and consequently the service/availability of the service thereof. The workers also carried judgment towards EC users. A larger proportion of the obstetric care workers indicated unwillingness to provide EC to adolescents- only 37% indicated they would provide EC to adolescents who require it.
Lawani et al. (2014)/ Nigeria [58] Physician obstetric care workers (n = 151) Cross-sectional study Provision of obstetric analgesia A total of 74 (49.0%) participants offered obstetric analgesia to parturients in labour that were either non- assisted or assisted with instruments. Among users, only 20 (13.3%) offered obstetric analgesia routinely to parturients, 44 (29.1%) sometimes and 10 (6.6%) on patients’ requests. The comparison between the younger and older age groups was statistically significant with Odds Ratio of 4.37 (1.18-16.18) at 95% CI, p = 0.018, while that between urban and rural practitioners was 4.77 (0.99-22.85) at 95% CI, p = 0.034.