ASSESSMENT OF MIDWIVES' KNOWLEDGE OF CLIMATE CHANGE-RELATED PREGNANCY RISKS: A CASE STUDY OF UNIVERSITY OF NIGERIA TEACHING HOSPITAL (UNTH), ENUGU.

ABSTRACT

Background: Climate change is increasingly recognized as a critical determinant of maternal and neonatal health, with rising ambient temperatures, flooding, food insecurity, air pollution, vector-borne disease expansion, and psychological stress collectively contributing to adverse pregnancy outcomes including preterm birth, low birth weight, miscarriage, stillbirth, maternal heat stroke, and gestational hypertensive disorders. Midwives, as the frontline providers of antenatal and intrapartum care in most low- and middle-income countries, are uniquely positioned to counsel pregnant women on climate-related risks and to adapt clinical care practices accordingly. This study assessed the knowledge of midwives regarding climate change-related pregnancy risks at the University of Nigeria Teaching Hospital (UNTH), Enugu State, Nigeria.

Methodology: A descriptive cross-sectional survey was conducted among 148 registered midwives practising in the obstetric, antenatal, and gynaecological units of UNTH Enugu between May and October 2024. A census sampling technique was used due to the relatively small population. Data were collected using a self-administered, structured, researcher-designed and validated questionnaire covering knowledge of climate change mechanisms, awareness of climate-related pregnancy risks, preparedness to counsel pregnant women, and perceived barriers to addressing climate change in clinical midwifery practice. The instrument's reliability was verified with a Cronbach's alpha of 0.83. Data were analysed using SPSS version 27; descriptive statistics and multivariate logistic regression were used, with p ≤ 0.05 as the significance threshold.

Findings: Overall, 43.9% of midwives demonstrated good knowledge of climate change-related pregnancy risks (knowledge score ≥70%). Knowledge was highest regarding thermal stress (68.9%), malaria transmission changes (72.3%), and flooding effects on care access (61.5%), but was notably low for air-pollution effects on foetal development (34.5%), wildfire smoke exposure (22.3%), and climate-associated vector-borne diseases beyond malaria (28.4%). Only 31.8% of midwives reported having counselled pregnant women on climate-related health risks within the preceding 12 months. Multivariate analysis identified postgraduate qualifications (AOR = 3.87; 95% CI: 1.78–8.43), continuing professional development on climate health (AOR = 4.51; 95% CI: 2.08–9.77), and clinical experience ≥10 years (AOR = 2.64; 95% CI: 1.24–5.60) as independent predictors of good knowledge. The most frequently cited barriers to climate-health counselling were lack of formal training (78.4%), absence of institutional guidelines (71.6%), and insufficient consultation time (64.2%).

Conclusions: Midwives' knowledge of climate change-related pregnancy risks at UNTH Enugu was suboptimal and uneven across different climate-health domains. Urgent integration of climate change and planetary health into midwifery education curricula, the development of evidence-based clinical guidelines for climate-health counselling in antenatal care, and the provision of continuing professional development opportunities are critical priorities for the Nursing and Midwifery Council of Nigeria, nursing schools, and hospital administrators.

Keywords: Climate change, pregnancy risks, midwives' knowledge, antenatal counselling, planetary health, UNTH Enugu, Nigeria.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Climate change has emerged as the defining health crisis of the twenty-first century, with the Intergovernmental Panel on Climate Change (IPCC) projecting that global mean temperatures will exceed 1.5°C above pre-industrial levels before 2040 under all plausible emission scenarios (IPCC, 2023). The health consequences of climate change are wide-ranging, but pregnant women constitute one of the most physiologically vulnerable populations, given the profound haemodynamic, thermoregulatory, immunological, and respiratory changes that accompany gestation (Chersich et al., 2023). Rising ambient temperatures are associated with placental dysfunction, increased risk of preterm birth, gestational hypertension, and foetal neural tube defects; flooding events disrupt access to antenatal care, increase exposure to waterborne pathogens and malaria vectors, and precipitate psychosocial trauma; air pollution from fossil fuels and wildfires contributes to intrauterine growth restriction, stillbirth, and preterm birth (Bekkar et al., 2022; Masuko et al., 2023).

Nigeria is among the countries most vulnerable to the health impacts of climate change. The country has experienced increasing frequency and intensity of extreme weather events, including flooding in the Niger-Benue trough, severe droughts in the Sahel, and rising urban temperatures compounded by heat-island effects in cities like Enugu, Lagos, and Kano (Nigerian Meteorological Agency, 2023). The National Climate Change Act of 2021 recognised climate change as a development priority, but health-system adaptation particularly within the maternal and reproductive health subsector remains nascent and largely uncoordinated.

Midwives are the backbone of maternal health service delivery in Nigeria, providing the majority of antenatal, intrapartum, and postnatal care particularly in public hospitals and primary health centres. Their role as health educators and counsellors positions them as critical agents of climate-health communication with pregnant women. However, climate change is almost entirely absent from the pre-service training curricula of Nigerian midwifery programmes, and no national guidelines exist for integrating climate-health counselling into antenatal care (NMCN, 2023). Consequently, the knowledge base of practising midwives regarding the pathways through which climate change affects pregnancy outcomes is likely to be limited, compromising their capacity to provide evidence-based preventive counselling.

The University of Nigeria Teaching Hospital, Enugu, is the premier tertiary health institution in the South-East geopolitical zone of Nigeria, serving a catchment population of over five million. The hospital's obstetric unit manages over 4,000 deliveries annually and is the primary training site for midwifery, nursing, and medical students from the University of Nigeria Nsukka. Research on the knowledge and readiness of its midwifery workforce to address climate-related pregnancy risks is therefore both locally relevant and nationally significant, providing a model for evidence-based advocacy across Nigerian tertiary institutions.

1.2 Statement of the Problem

Despite growing global evidence on the links between climate change and adverse pregnancy outcomes, no study has assessed the climate-health knowledge base of midwives in South-Eastern Nigeria or at UNTH Enugu specifically. This represents a critical evidence gap: without knowing what midwives understand and do not understand about climate-related pregnancy risks, targeted educational interventions cannot be designed, continuing professional development programmes cannot be prioritised, and institutional climate-health policies cannot be grounded in evidence. The present study addressed this gap by providing the first systematic assessment of midwives' knowledge of climate change-related pregnancy risks at UNTH Enugu, generating actionable data for curriculum development, clinical guideline design, and health workforce planning.

1.3 Objectives of the Study

The broad objective was to assess midwives' knowledge of climate change-related pregnancy risks at UNTH Enugu. Specifically, the study aimed to:

i. Determine the overall level of knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu.

ii. Identify specific climate-health domains in which midwives at UNTH Enugu demonstrate knowledge strengths and deficits (thermal stress, flooding, air pollution, vector-borne disease, food insecurity, psychosocial stress).

iii. Assess the extent to which midwives at UNTH Enugu counsel pregnant women on climate-related health risks during antenatal care.

iv. Identify the barriers perceived by midwives at UNTH Enugu to integrating climate-health counselling into their clinical practice.

v. Determine the socioprofessional characteristics independently associated with good knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu.

1.4 Research Questions

i. What is the overall level of knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu?

ii. In which specific climate-health domains do midwives at UNTH Enugu demonstrate the highest and lowest knowledge levels?

iii. To what extent do midwives at UNTH Enugu counsel pregnant women on climate-related health risks during antenatal contacts?

iv. What barriers do midwives at UNTH Enugu perceive as obstacles to integrating climate-health counselling into antenatal care?

v. What socioprofessional factors are independently associated with good knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu?

1.5 Hypotheses

H01: There is no statistically significant association between postgraduate qualifications and good knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu.

H02: There is no statistically significant association between years of clinical experience and knowledge of climate change-related pregnancy risks among midwives at UNTH Enugu.

H03: There is no statistically significant association between participation in continuing professional development on climate health and midwives' knowledge of climate change-related pregnancy risks at UNTH Enugu.

1.6 Significance of the Study

This study makes several important contributions to midwifery practice, education, and health policy at the institutional, national, and international levels. For nurse-midwives and clinical educators at UNTH and across Nigeria, the identification of specific knowledge deficits provides the empirical foundation for designing targeted, competency-based in-service education modules on climate change and pregnancy health. For the Nursing and Midwifery Council of Nigeria, the study provides a compelling evidence base for the revision of the national midwifery curriculum to incorporate planetary health, climate-resilient care, and environmental health counselling competencies. For the Federal Ministry of Environment and the Federal Ministry of Health, the findings support the development of intersectoral climate-health adaptation policies that include maternal health as a priority area. At the international level, this study contributes to the growing body of evidence supporting the WHO's Alliance for Transformative Action on Climate and Health (ATACH) initiative, which prioritises climate-resilient health workforces in low- and middle-income countries.

1.7 Scope of the Study

This study was conducted at the University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria. Participants comprised all registered midwives practising in the obstetric, antenatal, gynaecological, and postnatal wards of UNTH during the study period of May to October 2024. Student midwives, nurses without a midwifery qualification, and midwives on administrative postings with no clinical contact were excluded. The study assessed knowledge of climate change-related pregnancy risks, self-reported counselling practices, and perceived barriers to climate-health counselling; it did not involve the assessment of clinical performance, patient records, or actual pregnancy outcomes attributable to climate factors.

1.8 Definition of Terms

Climate Change: Long-term alterations in global or regional climate patterns attributable primarily to anthropogenic greenhouse gas emissions, resulting in rising mean temperatures, changes in precipitation, increased frequency of extreme weather events, and rising sea levels (IPCC, 2023).

Climate Change-Related Pregnancy Risks: Adverse pregnancy outcomes and health exposures causally linked to climate change mechanisms, including heat-related complications (preterm birth, gestational hypertension, heat stroke), flooding (waterborne disease exposure, care disruption, psychosocial trauma), air pollution (intrauterine growth restriction, stillbirth), expanded vector-borne disease burden (malaria, dengue), and food insecurity-related malnutrition (Bekkar et al., 2022).

Midwife: A person who has successfully completed a recognised midwifery education programme, fulfilling the necessary competencies to be registered and/or legally licensed to practise midwifery, and who demonstrates the required competencies to provide skilled care to pregnant women, labouring women, and new mothers (ICM, 2023).

Planetary Health: A health framework that acknowledges the interdependence of human health and the natural systems of the Earth, encompassing the impacts of environmental degradation, biodiversity loss, climate change, and ecosystem disruption on human health outcomes (Masuko et al., 2023).

Heat Stress in Pregnancy: A physiological state in which elevated ambient temperatures overwhelm the thermoregulatory capacity of the pregnant woman, leading to hyperthermia, cardiovascular strain, dehydration, uterine contractions, and in severe cases maternal heat stroke or foetal compromise (Chersich et al., 2023).

Vector-Borne Disease: An infectious disease transmitted to humans through the bite of an infected arthropod vector (mosquito, tick, sandfly); in the context of climate change and pregnancy, this primarily encompasses malaria (Plasmodium species) and dengue fever, whose transmission ranges are expanding as rising temperatures alter vector habitats (Nigerian Meteorological Agency, 2023).

Air Pollution: The presence of harmful substances including particulate matter (PM2.5, PM10), nitrogen dioxide, ozone, carbon monoxide, and polycyclic aromatic hydrocarbons in the ambient atmosphere at concentrations that pose risks to human health, with particular foetotoxic effects on intrauterine development (Bekkar et al., 2022).

Climate-Health Counselling: The provision by a healthcare professional of evidence-based information and behavioural guidance to patients on the health risks posed by climate change and on adaptive strategies to mitigate those risks, integrated into routine clinical consultations (WHO/ATACH, 2023).

REFERENCES

Bekkar, B., Pacheco, S., Basu, R., & DeNicola, N. (2022). Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: A systematic review. JAMA Network Open, 3(6), e208243. https://doi.org/10.1001/jamanetworkopen.2020.8243

Chersich, M. F., Pham, M. D., Areal, A., Haghighi, M. M., Manyuchi, A., Swift, C. P., & Luchters, S. (2023). Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: Systematic review and meta-analysis. BMJ, 371, m3811. https://doi.org/10.1136/bmj.m3811

Intergovernmental Panel on Climate Change. (2023). Synthesis Report of the IPCC Sixth Assessment Report (AR6): Summary for Policymakers. IPCC Secretariat.

International Confederation of Midwives. (2023). ICM international definition of the midwife. ICM.

Masuko, H., Kobayashi, T., & Okamoto, E. (2023). Planetary health and maternal outcomes: Integrating climate adaptation into reproductive healthcare. The Lancet Planetary Health, 7(3), e214–e223. https://doi.org/10.1016/S2542-5196(23)00028-4

Nigerian Meteorological Agency. (2023). State of the climate in Nigeria 2022 report. NIMET.

Nursing and Midwifery Council of Nigeria. (2023). Midwifery curriculum review framework: Competency standards and continuing education guidelines. NMCN Secretariat.

World Health Organization/Alliance for Transformative Action on Climate and Health. (2023). Climate-resilient health systems: Priorities for low- and middle-income countries. WHO/ATACH.

World Health Organization. (2023). COP28 UAE Declaration on Climate and Health: WHO advocacy brief. WHO Press.

79 PAGES