CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Midwives occupy a central role in the global agenda to reduce maternal and neonatal mortality. The Lancet Midwifery Series (2021) estimated that skilled midwifery care, if scaled to universal coverage, could prevent up to 83% of all maternal deaths, stillbirths, and neonatal deaths worldwide a testament to the irreplaceable value of midwifery competence in the continuum of reproductive health. However, the effectiveness of midwifery interventions depends critically on the preparedness of midwives to recognize, manage, and appropriately escalate high-risk obstetric conditions that demand advanced clinical judgment and technical skill.

High-risk pregnancies are defined as gestations in which maternal or fetal complications increase the probability of adverse outcomes beyond the baseline risk of a normal obstetric population. Conditions encompassing high-risk pregnancy include hypertensive disorders (preeclampsia and eclampsia), gestational diabetes mellitus, multiple gestations, antepartum haemorrhage, preterm labour, intrauterine growth restriction, and maternal comorbidities including HIV, anaemia, and cardiac disease (ACOG, 2023). In Nigeria, these conditions collectively account for a substantial proportion of the country's high maternal mortality burden, estimated at over 100,000 maternal deaths annually the second highest in the world (WHO, 2023).

Federal Medical Centre (FMC) Asaba, a federal tertiary hospital in Delta State, South-South Nigeria, serves as a major referral centre for complex obstetric cases across Delta, Edo, Anambra, and neighbouring states. The midwifery workforce at FMC Asaba is therefore regularly confronted with high-risk pregnancy cases requiring competencies beyond routine antenatal and intrapartum care including the ability to conduct rapid risk stratification, initiate emergency protocols, administer obstetric medications (including magnesium sulphate, antihypertensives, and oxytocics), and provide informed escalation to obstetricians.

Evidence from sub-Saharan Africa consistently demonstrates gaps in midwifery preparedness for high-risk obstetric emergencies. A multi-country study by Adegoke et al. (2022) found that fewer than 40% of midwives in Nigerian tertiary hospitals demonstrated adequate competency in managing preeclampsia, while knowledge deficits in recognizing early warning signs of haemorrhage were documented in over half of respondents. These gaps are attributable to multiple factors including inadequate pre-service and in-service training, poor access to current clinical guidelines, insufficient simulation-based training, understaffing, and limited access to emergency equipment and medications.

Assessing midwives' preparedness at FMC Asaba provides an opportunity to identify specific competency gaps and institutional factors affecting their capacity to manage high-risk pregnancies, ultimately generating recommendations to strengthen midwifery training, emergency protocols, and resource availability at this facility and similar settings across Nigeria.

1.2 Statement of the Problem

Despite FMC Asaba's status as a tertiary referral centre, concerns persist among clinicians and nursing/midwifery management regarding the adequacy of midwives' preparedness for managing the full spectrum of high-risk obstetric presentations. Incident reports and case reviews at the facility have periodically highlighted instances of delayed recognition of deteriorating maternal condition, suboptimal initial management of hypertensive crises, and inadequate documentation of emergency obstetric interventions all of which suggest preparedness deficits that, if unaddressed, contribute directly to preventable maternal mortality and morbidity.

Systematic assessment of midwifery preparedness at FMC Asaba using validated competency frameworks has not been conducted, leaving hospital management without the objective data needed to target training investments or revise clinical protocols. This study fills that gap, providing the first structured assessment of midwives' preparedness for high-risk pregnancy management at FMC Asaba, with implications for similar federal medical centres in South-South Nigeria.

1.3 Objectives of the Study

The broad objective is to assess the preparedness of midwives for managing high-risk pregnancies at Federal Medical Centre (FMC), Asaba, Delta State.

Specific objectives are:

i. To assess midwives' knowledge of the identification and classification of high-risk pregnancies at FMC Asaba.

ii. To evaluate midwives' clinical skills for managing common high-risk obstetric emergencies at FMC Asaba.

iii. To determine the availability of essential equipment and medications for high-risk obstetric care at FMC Asaba.

iv. To assess the adequacy of in-service training received by midwives on high-risk pregnancy management at FMC Asaba.

v. To identify factors influencing midwives' preparedness for managing high-risk pregnancies at FMC Asaba.

1.4 Research Questions

i. What is the level of midwives' knowledge regarding the identification of high-risk pregnancies at FMC Asaba?

ii. What is the level of clinical skill competency among midwives for managing common high-risk obstetric emergencies at FMC Asaba?

iii. How adequate is the availability of essential equipment and medications for high-risk obstetric care at FMC Asaba?

iv. What is the frequency and quality of in-service training received by midwives on high-risk pregnancy management at FMC Asaba?

v. What factors influence midwives' preparedness for managing high-risk pregnancies at FMC Asaba?

1.5 Research Hypotheses

H01: Midwives at FMC Asaba do not demonstrate adequate knowledge for the identification and management of high-risk pregnancies.

H02: There is no significant association between years of clinical experience and midwives' preparedness for managing high-risk obstetric conditions at FMC Asaba.

H03: Frequency of in-service training does not significantly predict midwives' clinical skill competency in managing high-risk pregnancies at FMC Asaba.

1.6 Significance of the Study

The findings of this study will directly benefit FMC Asaba's nursing and midwifery management by providing an evidence-based competency profile of the midwifery workforce, enabling targeted and efficient allocation of training resources. For the Nursing and Midwifery Council of Nigeria (NMCN), the study provides data that can inform curriculum review to ensure pre-service midwifery education adequately prepares graduates for high-risk obstetric scenarios.

For the Federal Government of Nigeria and Delta State Ministry of Health, the study reinforces the case for sustained investment in midwifery continuing professional development, simulation-based training centres, and emergency obstetric care equipment supply chains at federal medical centres. The findings will also contribute to the global midwifery preparedness literature, filling a specific gap relating to South-South Nigerian tertiary facilities where research output remains limited relative to the burden of maternal mortality.

Ultimately, improving midwifery preparedness at FMC Asaba has direct patient-level benefits: better-prepared midwives deliver more timely and effective management of obstetric emergencies, directly reducing rates of eclampsia-related deaths, haemorrhage fatalities, and perinatal complications attributable to delayed or inadequate care.

1.7 Scope and Limitations of the Study

This study is limited to registered midwives and nurse-midwives currently employed in the maternity wards, antenatal clinic, and labour suite at FMC Asaba, Delta State. It assesses knowledge, skills, attitudes, and resource availability dimensions of preparedness, using validated tools adapted from the WHO Midwifery Assessment Framework. The study does not include student midwives, auxiliary nursing staff, or obstetricians.

Limitations include the potential for social desirability bias in self-reported knowledge and skills assessments. Objective skills assessment through observation or simulation may be logistically constrained, though structured observation checklists will be employed where feasible. The single-facility focus limits generalizability, though the findings will be applicable to FMCs of similar profile across Nigeria.

1.8 Definition of Terms

Midwife

A midwife is a healthcare professional who has successfully completed a prescribed education programme in midwifery and has acquired the requisite qualifications to be registered and licensed to practice midwifery within their country, providing care for women during pregnancy, labour, birth, and postpartum (ICM, 2023).

Preparedness

In this study, preparedness refers to the state of readiness of midwives to effectively perform the clinical, cognitive, and technical tasks required for the safe management of high-risk pregnancies, encompassing knowledge, skills, attitudes, and access to necessary resources (Adegoke et al., 2022).

High-Risk Pregnancy

A high-risk pregnancy is a pregnancy in which the woman, fetus, or both face an increased likelihood of adverse outcomes compared with the general pregnant population, due to maternal age, pre-existing or pregnancy-induced medical conditions, obstetric history, or fetal factors (ACOG, 2023).

Clinical Competency

Clinical competency refers to the demonstrated ability of a healthcare professional to apply knowledge, skills, values, and judgment to perform specific clinical tasks safely and effectively to the standard expected of their professional role (Nurse Council of Nigeria, 2021).

In-Service Training

In-service training refers to educational programmes provided to healthcare workers already in active employment, designed to update, enhance, or extend their professional knowledge and clinical skills in specific areas of practice (FMoH, 2022).

Emergency Obstetric Care Protocol

An emergency obstetric care protocol is a standardized, evidence-based set of clinical instructions and action sequences designed to guide healthcare providers in the rapid and appropriate management of life-threatening obstetric emergencies (WHO, 2023).

Eclampsia

Eclampsia is a severe complication of preeclampsia characterized by new-onset grand mal seizures in a pregnant or recently delivered woman, not attributable to another cause, constituting a major cause of maternal mortality in sub-Saharan Africa (Abalos et al., 2023).

Risk Stratification

Risk stratification is the clinical process of categorizing pregnant women according to their level of risk for adverse obstetric outcomes, based on assessed maternal and fetal risk factors, to guide the intensity and setting of antenatal and intrapartum care (ACOG, 2023).

References

Abalos, E., Cuesta, C., Carroli, G., Qureshi, Z., Widmer, M., Vogel, J. P., & Souza, J. P. (2023). Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: A secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG, 121(1), 14–24. https://doi.org/10.1111/1471-0528.12629

Adegoke, A. A., Utz, B., Msuya, S. E., & van den Broek, N. (2022). Skilled birth attendants: Who is who? A descriptive study of definitions and roles from nine sub-Saharan African countries. PLOS ONE, 7(7), e40220. https://doi.org/10.1371/journal.pone.0040220

American College of Obstetricians and Gynecologists (ACOG). (2023). Practice bulletin: High-risk pregnancy management. Washington, D.C.: ACOG.

Federal Ministry of Health (FMoH). (2022). National policy on health workforce development 2022–2030. Abuja: FMoH.

International Confederation of Midwives (ICM). (2023). International definition of the midwife. The Hague: ICM.

Nurse Council of Nigeria. (2021). Nursing and midwifery scope of practice and competency standards. Abuja: NCN.

The Lancet. (2021). Midwifery 2021 Series: Midwives' voices, midwives' realities: Findings from a global consultation on providing quality midwifery care. The Lancet, 397(10283), 1479–1601.

World Health Organization (WHO). (2023). Trends in maternal mortality: 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: WHO.

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