EVALUATION OF INFECTION PREVENTION PRACTICES AMONG MIDWIVES IN LABOUR WARDS OF RIVERS STATE UNIVERSITY TEACHING HOSPITAL (RSUTH), PORT HARCOURT.

CHAPTER ONE

ABSTRACT

Background: Infection prevention and control (IPC) in labour wards represents one of the most critical dimensions of maternal and neonatal safety in intrapartum care settings. Healthcare-associated infections (HAIs) during labour and delivery contribute significantly to maternal sepsis, puerperal fever, surgical site infections following caesarean section, and neonatal sepsis all of which are leading causes of preventable maternal and neonatal morbidity and mortality in Nigeria. Rivers State University Teaching Hospital (RSUTH) in Port Harcourt, as a high-volume tertiary referral centre in the South-South zone, manages thousands of deliveries annually under conditions that place significant demands on midwives' infection prevention practices.

Objective: This study evaluates infection prevention practices among midwives in the labour wards of Rivers State University Teaching Hospital, Port Harcourt.

Methods: A descriptive cross-sectional design was used. Using total population sampling, all consenting midwives working in the labour ward at RSUTH (estimated n=100) were recruited. Data were collected using a validated structured questionnaire and a structured observational checklist. SPSS version 26 was used for analysis.

Expected Findings: The study expects to find that midwives demonstrate satisfactory knowledge of IPC principles but inconsistent practice, particularly in hand hygiene compliance, use of personal protective equipment, and disposal of sharps and clinical waste.

Conclusion: Sustained IPC training, improved access to IPC supplies and infrastructure, and strong institutional IPC governance are essential to achieving consistent infection prevention practice among midwives in RSUTH's labour wards.

Keywords: Infection prevention and control, labour ward, midwives, RSUTH, Port Harcourt, hand hygiene, healthcare-associated infections, Nigeria.

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Infection prevention and control in healthcare settings is a foundational patient safety discipline that aims to prevent the transmission of infectious agents between patients, healthcare workers, and the care environment. In the labour ward a setting uniquely characterised by the simultaneous management of open wounds, blood and body fluid exposure, invasive procedures, and vulnerable patient populations including immunocompromised mothers and physiologically immature neonates adherence to evidence-based IPC practices is of paramount importance (WHO, 2018a).

Healthcare-associated infections represent a major global public health burden. The WHO (2022) estimates that approximately 15% of hospitalised patients in developing countries acquire a HAI during their hospital stay, compared to 7% in developed countries. In obstetric settings, HAIs manifest as maternal sepsis (including Group A Streptococcus infection), endometritis, wound infections following episiotomy or caesarean section, chorioamnionitis, and neonatal sepsis conditions that collectively constitute a leading cause of preventable maternal and neonatal mortality in LMICs (WHO, 2018b). Nigeria's high maternal mortality burden is in part driven by sepsis, which accounts for an estimated 10–15% of direct maternal deaths nationally (Say et al., 2014).

Rivers State University Teaching Hospital is one of Nigeria's newer federal teaching hospitals, established in 2017 following the renaming and upgrading of the former Rivers State University Teaching Hospital. It serves as the principal tertiary referral institution for Rivers State and receives obstetric referrals from across the South-South geopolitical zone. Its labour ward manages a high volume of deliveries, including a significant proportion of complicated cases involving ruptured membranes, prolonged labour, operative vaginal delivery, and emergency caesarean section all of which create elevated risks of both endogenous and exogenous infection (Onyeka et al., 2021).

Midwives in the labour ward at RSUTH are the frontline professionals responsible for implementing IPC practices on a moment-to-moment basis. Their adherence to hand hygiene protocols, appropriate use of personal protective equipment (PPE), aseptic technique during invasive procedures, proper decontamination and sterilisation of instruments, and safe handling and disposal of sharps and clinical waste directly determines the infection risk experienced by their patients (Onyeka et al., 2021; Erhabor et al., 2020). Understanding the actual state of IPC knowledge and practice among this cadre is therefore a prerequisite for targeted quality improvement in labour ward infection prevention at RSUTH.

The global patient safety movement, led by the WHO World Alliance for Patient Safety since 2004, has placed IPC at the centre of healthcare quality improvement initiatives worldwide. The WHO's core components of IPC programmes encompassing institutional governance, training, surveillance, multimodal strategies, monitoring and audit, physical infrastructure, and workload management provide a comprehensive framework for assessing and improving IPC performance in healthcare institutions (WHO, 2016). Within this framework, hand hygiene occupies a position of singular importance: the WHO's "Five Moments for Hand Hygiene" model identifies the critical junctures at which hand hygiene must be performed to interrupt the chain of infection transmission in clinical settings.

In Nigeria, studies from various states and healthcare institutions have documented significant deficits in IPC practice in labour ward settings. A study by Erhabor et al. (2020) from Sokoto found that less than 40% of observed clinical procedures in the maternity unit were preceded by adequate hand hygiene. A study from Lagos by Nwaneri et al. (2020) reported that fewer than 60% of midwives consistently used appropriate PPE during deliveries, with cost, availability, and time pressure cited as primary barriers. A systematic review of IPC practices among maternity care providers in sub-Saharan Africa by Aiken et al. (2020) confirmed that knowledge-practice gaps in IPC are widespread across the region and are associated with healthcare facility-level infections.

In the Niger Delta context, Rivers State's healthcare facilities face additional challenges including climate-related infrastructure demands, water supply intermittency (which directly affects hand hygiene compliance), supply chain disruptions for IPC consumables, and the high volume of unbooked and emergency admissions that creates sudden surges in labour ward activity. These factors interact with individual midwife-level knowledge, attitudes, and behaviours to determine the actual standard of IPC practice in RSUTH's labour ward. No published study has systematically evaluated this standard at RSUTH, making the present study both timely and necessary.

1.2 STATEMENT OF THE PROBLEM

Despite the well-established evidence base linking IPC practices to maternal and neonatal infection outcomes, and despite global and national standards for IPC in healthcare settings, systematic evaluation of actual IPC practice among midwives in the labour ward of RSUTH has not been conducted. Anecdotal reports from senior midwifery staff and IPC nurse leads at RSUTH suggest that hand hygiene compliance is suboptimal, that PPE use is inconsistent particularly during emergency procedures and that sharp disposal and waste segregation practices do not consistently meet WHO and Federal Ministry of Health standards.

The absence of empirical data on IPC practice at RSUTH's labour ward prevents the institution from identifying the most significant gaps, designing targeted interventions, or monitoring progress toward IPC performance standards. Given that maternal sepsis and neonatal sepsis contribute to mortality outcomes in the RSUTH catchment area, this evidence gap has real patient safety consequences. The present study addresses this gap by providing the first systematic evaluation of IPC knowledge and practice among midwives in RSUTH's labour ward, using a combination of validated self-report instruments and observational checklists to generate actionable evidence for institutional quality improvement.

1.3 OBJECTIVES OF THE STUDY

The general objective is to evaluate infection prevention practices among midwives in the labour wards of Rivers State University Teaching Hospital, Port Harcourt.

Specific objectives are to:

1. Assess the level of knowledge of infection prevention and control principles among midwives in the labour wards of RSUTH.
2. Evaluate the practice of infection prevention by midwives in RSUTH's labour ward, with particular attention to hand hygiene, PPE use, aseptic technique, and waste disposal.
3. Identify specific IPC practice domains in which significant deficits exist among midwives in the RSUTH labour ward.
4. Determine the factors individual, institutional, and environmental associated with suboptimal IPC practice among midwives at RSUTH.
5. Assess the relationship between IPC knowledge and IPC practice among midwives in RSUTH's labour ward.

1.4 RESEARCH QUESTIONS

1. What is the level of knowledge of IPC principles among midwives in the labour wards of RSUTH?
2. What is the practice of infection prevention among midwives in RSUTH's labour ward?
3. In which IPC domains do the most significant practice deficits exist among midwives in RSUTH's labour ward?
4. What individual, institutional, and environmental factors are associated with suboptimal IPC practice among midwives at RSUTH?
5. Is there a significant relationship between IPC knowledge and IPC practice among midwives in RSUTH's labour ward?

1.5 RESEARCH HYPOTHESES

H01: There is no significant relationship between midwives' knowledge of IPC principles and their practice of infection prevention in the labour ward at RSUTH.

H02: There is no significant association between availability of IPC supplies and hand hygiene compliance among midwives in RSUTH's labour ward.

H03: There is no significant relationship between in-service IPC training and infection prevention practice scores among midwives at RSUTH.

1.6 SIGNIFICANCE OF THE STUDY

The significance of this study spans clinical quality improvement, patient safety, institutional policy, professional development, and public health advocacy. For midwives at RSUTH, the study provides an evidence-based assessment of their IPC practice that can serve as the foundation for targeted in-service training, skills update workshops, and reflective practice improvements. For hospital management and the IPC committee at RSUTH, the findings will identify specific IPC system weaknesses including supply gaps, infrastructure deficits, and training needs that require institutional resource allocation and policy attention.

For the Rivers State Ministry of Health and the Federal Ministry of Health, the findings contribute to the evidence base for IPC programme development in tertiary obstetric settings, supporting the implementation of the National Infection Prevention and Control Policy and the WHO core components framework at the institutional level. For the midwifery profession and education sector, the study highlights the importance of robust IPC training in both pre-registration midwifery curricula and continuing professional development, supporting advocacy for NMCN curriculum updates and mandatory IPC competency assessments.

At the patient safety level, the study's most significant contribution lies in its potential to trigger improvements in IPC practice that directly reduce the incidence of maternal sepsis, puerperal fever, and neonatal sepsis in RSUTH's labour ward, thereby contributing to improved maternal and neonatal outcomes in Rivers State.

1.7 SCOPE OF THE STUDY

This study is confined to midwives working in the labour wards of Rivers State University Teaching Hospital, Port Harcourt. It focuses specifically on IPC knowledge and practice, encompassing hand hygiene, use of personal protective equipment, aseptic technique during invasive procedures, decontamination and sterilisation of instruments, and management of clinical waste and sharps. The study does not extend to other wards or units within RSUTH, to other cadres of healthcare workers, or to patients' experiences of infection outcomes. Direct observation of IPC practices during clinical procedures is limited to observational windows during the data collection period and may not capture all aspects of routine practice.

1.8 LIMITATIONS OF THE STUDY

The Hawthorne effect is the primary methodological limitation, as midwives' IPC practices during observed sessions may not accurately reflect their habitual practice when not being observed. Self-report bias in questionnaire responses may lead midwives to overstate their IPC knowledge and compliance. Restriction of the study to RSUTH limits generalisability to other hospitals in Rivers State or the South-South zone. Seasonal and temporal factors including fluctuations in patient volume, supply availability, and staffing levels may influence IPC practices during the specific data collection period in ways that are not representative of year-round performance. These limitations will be mitigated through extended observation periods, anonymous questionnaire administration, and triangulation of observational and self-report data.

1.9 DEFINITION OF TERMS

Infection Prevention and Control (IPC): A practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infections, delivered through a set of standard and transmission-based precautions (WHO, 2016).

Hand Hygiene: The act of cleaning the hands with soap and water or an alcohol-based hand rub to remove or destroy microorganisms on the hands, regarded as the single most effective measure for preventing healthcare-associated infections (WHO, 2009).

Personal Protective Equipment (PPE): Specialised clothing or equipment worn by healthcare workers to protect themselves and their patients from infectious agents, including gloves, gowns, aprons, masks, goggles, and face shields (WHO, 2018a).

Aseptic Technique: A collection of practices and procedures used to minimise the introduction of pathogenic microorganisms into the clinical environment during invasive procedures, including the use of sterile instruments, sterile fields, and non-touch techniques (Onyeka et al., 2021).

Healthcare-Associated Infection (HAI): An infection occurring in a patient during the process of care in a hospital or other healthcare facility which was not present or incubating at the time of admission (WHO, 2022).

Sharps Disposal: The safe containment and disposal of used needles, lancets, scalpels, and other sharp instruments in puncture-resistant containers, in accordance with national waste management guidelines, to prevent needlestick injuries and bloodborne pathogen transmission (Federal Ministry of Health Nigeria, 2021).

Standard Precautions: A set of IPC practices used for all patients, regardless of infection status, based on the assumption that all blood, body fluids, non-intact skin, and mucous membranes may contain transmissible infectious agents (WHO, 2016).

Labour Ward: The dedicated clinical area within a hospital maternity unit where women are admitted for the active phase of labour, management of intrapartum complications, and delivery (RSUTH, 2022).

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