Introduction

The Perinatal Problem Identification Programme (PPIP) produced reports which highlighted the preventable deaths in South Africa. Every year about 23,000 new-born babies die in South Africa, with an additional estimated 20,000 stillbirths [1]. Forty-five percent of these babies die from preterm-related complications [1]. In the 2006–2007 Perinatal Care Report of South Africa, preterm birth (PTB) was found to be responsible for 46% of all neonatal deaths followed by 29.8% of asphyxia [2]. This observation was supported by the Department of Health 2012–2013 Saving Babies Report, Pattinson and Rhoda [3]. Pattinson alluded to the lack of adequate neonatal facilities in rural areas as one of the challenges in the management of preterm infants; wherein, women arrive at health care facilities being in advanced labour and the suppression of labour is no longer an option [4]. Delivery of the preterm baby becomes imminent. The prevention of preterm labour is one of the greatest challenges for midwives [5]. Patel et al. recommended that child survival strategies should direct resources toward the leading causes of child mortality which are pneumonia and preterm birth complications [6]. According to a study conducted in Limpopo Province in 2003 by UNICEF to ascertain the status and availability of new-born care services and infrastructure, it was found that none of the health facilities had level 2 new-born care units, few nursing staff were trained in new-born care and many health facilities had inadequate equipment to provide standard quality of care to new-borns [7]. These factors lead to midwives’ challenges as reflected in the Saving Babies 2012–2013 report [8]. There were delays in seeking medical attention which accounted for most immaturity deaths (10.5%), never initiated ANC (8.8%), late booking (3.1%), inappropriate response to poor foetal movements (2%), inadequate neonatal care management plan (2%), and not giving antenatal steroids (1.2%) [3]. Midwives could play a major role in the prevention of these factors. Pattinson found that lack of adequate neonatal facilities were the most common administrative problem that caused deaths amongst preterm babies [9]. In low income countries with limited resources, over 90% of preterm babies die within few days of life [10]. Preterm Birth (PTB) is the first leading cause of child death after pneumonia [10]. This was supported by WHO, that 15 million babies are born too soon every year and over 1 million children die each year due to complications of PTB [10]. PTB is the significant cause of short and long-term morbidity which increases the demand for neonatal intensive care services. A large number of surviving preterm babies tend to end up with deficits such as blindness, neurological impairment and chronic respiratory distress [11].

Preterm babies lose heat very rapidly after birth [12]. These babies need simple essential care such as warmth, feeding support, safe oxygen use and prevention of infection which can be achieved by use of chlorhexidine and avoiding sharing of incubators for neonates [11]. However, in a limited resource setting there are limited incubators. Premature babies are vulnerable to temperature instability, feeding difficulties, low blood sugar, infections and breathing complications [11]. About 10% are born in low income settings with limited physical and human resources barely [12]. Midwives caring for preterm infants receiving mechanical ventilation, faces many challenges. Important aspects of care to be carried out by midwives include thermoregulation, optimal positioning, airway clearance, stable haemodynamic status, and adequate nutrition for growth and development [13]. Midwives face challenges of staff shortage when working at the state hospitals [14]. This was evidenced by findings of a study entitled “Occupational challenges faced by nursing personnel at a state hospital in Cape Town, South Africa” by Brophy who found that midwives face challenges of providing quality maternal and neonatal care due to poor working conditions, feeling of insecurity and frustration at work [14]. Thommesen revealed that most midwives in Ethiopia started in midwifery without a passion and they do not show urgency in emergency situations [15]. Brophy reflected on a challenge of lack of resources [15]. It was found that if a hospitals’ resources were not well managed, the service delivery to patients would be negatively affected. The use of open multi-patient rooms posed a challenge in a manner that it increases the costs of care for preterm babies who are kept in NICU. The use of private and semi-private rooms for neonates allows for improved care resulting in reduced hospital stay and lower costs for NICU. Prolonged length of hospital stay was one factor that attributed to this increased NICU costs. Complications that increase the length of stay adversely affected costs. However, therapies that reduce the intensity of illness decrease the costs of care. Reduction of length of hospital stay can be achieved by minimising hospital-acquired infections which usually occurs during close contact between patients, preterm babies in this case and accidentally using the same equipment in infants.

Shortage of nurses in neonatal care is also a challenge [16]. Perinatal deaths from spontaneous preterm labour is sometimes caused by lack of adequate neonatal facilities in rural areas wherein the woman arrives to the institution in advanced labour and the baby is delivered shortly thereafter, the opportunity for interventions by suppressing labour and giving corticosteroids is therefore low [17, 18]. This study was conducted in the Mopani District which is one of the five districts of the Limpopo Province. The statistics of January–June 2016 showed that the perinatal mortality rate per 1,000 in Mopani hospitals were as follows: 59.7% in Maphutha Malatji; 37% in Letaba; 36.1% in Sekororo; 35.6% in CN Phathudi, 44.1% in Kgapane; 34.8% in Nkhensani and 30.9% in Van Velden Hospital [17]. Hence, this research focused on describing the challenges encountered by midwives when providing care to preterm infants.

Methodology

Ethical considerations

The ethical clearance SHS/17/PDC/04/1403 was approved by Ethics Committee of University of Venda. Permission (Ref: 4/2/2) to access the selected hospitals was obtained from Limpopo Department of Health. Informed consent to participate in the study was obtained from each participants. An informed consent form was completed by all participants, which evidenced that they participated in the study willingly without being coerced. Emphasis was on confidentiality and anonymity which indicate that only the researcher and the research team during the research process should be aware of the identity of the participants.

Findings

Twenty-three midwives who had an experience of at least two years of working in maternity ward were interviewed from three selected hospitals with limited resources. Distribution of participants were as follows; 8 from hospital A, 8 from hospital B and 7 from hospital C. The results revealed one theme with sub-themes as presented in Table 1.

Theme 1: Preterm condition and expected care

Preterm infants experienced multiple complications and midwives encountered challenges when managing those conditions due to limited resources. This was evidenced from the interviews.

“There is only one ventilator machine, four duopaps and two nasal Continuous Positive Airway Pressure (nCPAP) machines; and the Neonatal Intensive Care Unit (NICU) is having eight beds and only very ill babies are admitted in that unit. Most of the babies being admitted are preterm babies with severe respiratory distress syndrome (RDS) and they will need to be assisted by these machines for them to be relieved from RDS. When a preterm baby is not coping on duopap and nCPAP machines, they should be initiated on a ventilator machine, but it is a challenge because the machine is only one. The unavailability of ventilator machine poses a challenge because care for another baby will be compromised” (Participant G from hospital A).

Sub-themes which are presented in Table 1, emerged from this theme.

Discussion of Findings

There was higher incidence of perinatal mortality amongst severely preterm babies (61.4%) as compared to moderately preterm babies (22.46%) [5]. Twenty-three midwives who were working in the maternity units of the low resource hospitals shared challenges they faced. They further shared experiences of care provided to preterm infants with the limited resources in the facilities. Midwives displayed knowledge and understanding on what contributory causes of preterm deaths and prevention of complications were. Common complications cited by participants were infections, RDS, hypothermia, hypoglycaemia and jaundice. Participants cited that preterm babies were at high risk of acquiring infection; due to their immature immune system. Midwives ensured that preterm babies were protected from infection through limited contact with other individuals, handwashing and promotion of exclusive breastfeeding [23]. Preterm babies were losing heat very rapidly after birth [12]. The evaporative heat loss in preterm infants during the first week of life is said to be due to the increase in trans-epidermal water losses as a result of their poorly developed epidermis and a relatively large surface area in relation to body weight [24]. Hypothermia has been independently associated with increased energy consumption, neonatal cold injury, poor weight gain and susceptibility to infection that may jeopardise the condition of a neonate [13]. Preserving warmth was accurately maintained by KMC, but when babies need incubators, that was a challenge. In the clinical setting, preterm infants of less than 28 weeks gestation were nursed under a radiant warmer which provides unobstructed access for medical and nursing staff to treat and care for these infants [25]. However, the findings of this study revealed that there was lack of adequate radiant warmers, incubators and KMC rooms were overcrowded. Insufficient KMC rooms is common in most low income countries [26].

Preterm babies were found to be suffering from RDS which is a condition related to prematurity and accounts for 15% morbidity in infants born at 34 weeks and 3.2% in those born at 36 weeks [22]. While most premature babies were born just a few weeks early. These babies could be saved by the skill and competency of the staff, however, midwives who were involved in the provision of care were not trained as neonatal nurses or on Limpopo Initiative New-born Care (LINC). About 50% of preterm babies with a gestational age of 24 to 28 weeks may require intubation and mechanical ventilation to maintain extra-uterine life [13]. This was also supported by Lawn et al., that extreme premature babies, require additional skills, equipments and commodities that are critical, ranging from bag and mask, controlled intravenous fluid-giving sets, to nCPAP and surfactant [27]. For babies with RDS, safe monitoring of oxygen saturation was required to be monitored with pulse oxymeter However, these equipments were often unavailable. The equipments necessary to care for preterm babies are incubators, wall suction units, transcutaneous bilirubin meter, ventilators, nasal nCPAP, head boxes, pulse oxymeters, apnoea monitors, oxygen blenders, intravenous infusion controller, resuscitation equipments and feeding equipments [23]. Findings of this study were similar to the study by Thommesen who found midwives’ challenges in providing quality maternal and neonatal care as poor working conditions, feeling of insecurity and frustration at work [15].

It was clear from findings that preterm babies needed individualised care, by competent human resources. When providing care to preterm babies the individualised care was preferred, however, the structure of the unit, shortage of staff and equipments was a barrier. McNamara indicated that there are various challenges to the management of preterm labour which may require individualised approaches for different patients, using expert committees or guidelines as the backbone of the management plan [22]. In this study, it was difficult to achieve individualised care because of shortage of competent staff, limited equipments, and the required sizes of the equipments and overcrowded units. Reduction of length of hospital stay can be achieved by minimising hospital acquired infections which usually occurs during close contact between patients, preterm babies in this case and accidentally using the same equipment in infants. The use of semi-private rooms for neonates who are critically ill for individualized [16].

A study conducted in the United Kingdom indicated that across nine countries in sub-Saharan Africa and South East Asia, in each country setting and for each cadre of health care provider, there was a significant improvement in knowledge and skills after receiving a short competency-based training package in emergency obstetrics and early newborn care [28]. The findings by show that there is a need for continuous training of midwives in newborn care [28]. In South Africa, Emergency Obstetric and Neonatal Care (EmONC) was adopted to include a substantial module on intubation as part of the resuscitation module; the package is known as Essential Steps in Managing Obstetric Emergencies (ESMOE), and it is compulsory for all maternity staff in improving knowledge and skills [29]. Again, the Limpopo Department of Health, was providing the course on Limpopo Initiative Neonatal Care to all those working in maternity and neonatal units. The LINC provides health care personnel with knowledge and skills on the diagnosis and management of different conditions of small and sick neonates. However, midwives who participated in this study were not trained as neonatal nurses, paediatric nursing or on Limpopo Initiative New-born Care (LINC). Researchers noted that to provide capacity for staff, continuous in-service education were scheduled but attendance was poor due to staff shortage especially when the unit was busy.

Conclusion

The findings of the study revealed that midwives who are working at resource limited health facilities were encountering challenges when providing care to preterm babies. This was due to staff shortage and lack of necessary and appropriate equipments when caring for preterm babies, Due to inadequate equipments, the standard of care was compromised. Preterm babies developed complications which needed specialised care by skilled and knowledgeable midwives. It was recommended that to save the lives of the preterm babies it is of great importance to improve the skills and competence of midwives through training on LINC, HBB and NICU. The health facilities need to plan and send at least one midwives for LINC training every year and one nurse for NICU every two years. Operational managers should be involved in the ordering and supply of necessary equipment and the correct sizes to use on preterm babies. In-service trainings should be conducted weekly within the facility to equip nurses with updated knowledge and skills on management of different conditions and the use of available machines. Mothers should be taught on measures to prevent infection in the neonatal unit such hand washing, using of surgical spirit for cord care; and also to teach them about the importance of practicing KMC (Kangaroo Mother Care). Future research should be conducted on the same topic in different settings to generate more knowledge on the phenomenon.

Additional File

The additional file for this article can be found as follows: