Introduction: This study evaluated the application of infection prevention and control (ICP) measures by midwives in the delivery rooms and maternity suites at the five district hospitals in the Region of Hauts Bassins, Burkina Faso.

Methods: This was a cross-sectional study conducted from 02 August 2015 to 12 June 2016. The data collected were: socio-professional characteristics, knowledge of ICP, attitudes towards handwashing, ICP practices, and service organization.

Results: Of the 65 agents surveyed, 60.0% were untrained about ICP after basic training, and 78.5% with no supervision for at least four years.

The scores were : knowledge (64.7%), attitude (68.1%), domains of practice (<85%). None of the maternity hospitals had the four bins for instrument processing. The organization of services was insufficient.

Conclusion: The infection prevention and control is insufficiently implemented, requiring capacity building and reorganization of services in a spirit of quality assurance.

Care incidents, iatrogenic problems, incidence of complications and emergence of nosocomial infections are become unavoidable and universal concerns related to patient safety, one of criterion choice for analyzing health system performance [1]. Patient safety is considered by the World Health Organization (WHO) as a quality component for improving the overall quality of care [2]. From this perspective, all health workers, regardless of their role and work environment, must be involved in infection prevention and control (IPC) [3].

Infection prevention and control (IPC) is defined as all material and technical means intended to prevent the penetration and development of pathogens in the body [4]. To this end, healthcare associated to infections (HCAIs) and nosocomial infections (NIs) must be avoided. HCAIs are a major concern for health professionals [5].

The WHO estimated that 1.4 million people were sick worldwide as a result of infections contracted in hospitals. In developed countries, these infections affected 5 to 10% of patients [6]. The prevalence of nosocomial infections (INs) was 4.5% in the USA, 10.5% in Canada, 6.7% in France, and 6.2% in Belgium [6, 7]. In Africa, the prevalence of NIs varied between 10 and 60% and they represented the third cause of maternal mortality, the second cause of early neonatal mortality, and the first cause of post-operative morbidity. This prevalence was estimated at 10.9% in Senegal, 12% in Côte d'Ivoire, 10% in Benin, 14% in Mali, and 23.7% in Burkina Faso [8].

The occurrence of HCAIs in hospitals is driven by many factors including patient-related factors, the exposures to invasive medical devices and deficiencies in the quality of care [9, 10], and the defects in cleaning, the disinfection and the sterilization [11-13]. The HCAIs lead to prolonged hospital stays [2-5], excess costs [4, 6], high resistance of microorganisms to antibacterial agents and high mortality rates [7-11]. For reducing these consequences, the present study accessed the implementation of the infection prevention principles’s in maternity wards from the functional health district hospitals of the Region of Hauts Bassins (RHBS), Burkina Faso.

Materials and methods

Study setting

Capital Bobo Dioulasso, the Region of Hauts Bassins (RHBS) is located in the West part of Burkina Faso. There are eight (8) health districts (HD) from the Health Region of Hauts Bassins (RHBS). As the referral structure of the health district, the district hospital therefore provides a complementary care package to those provided at the level of peripheral health centres [14]. The maternity wards of the five (5) functional HD were the setting of the present study : Orodara HD, Do HD, Dafra HD, Dandé HD and Houndé HD.

Type, period and method of the study

This was a cross-sectional study on the application of the infection prevention principles’s in the study setting. The study took place from August 02, 2015 to June 12, 2016. The participants were midwives working in the delivery rooms and maternity suites of the HD, present during study period, and accepting to participate to the study.

The study method was the survey that used face-to-face individual interview and observation of practices as data collection techniques. The  tools used were a semi-structured questionnaire and an observation grid.

Sample size and sampling method

Considering the total number of 99 midwives from the maternity wards of he HD in the RHBS (table I), the expected sample was 79 agents with a 5% margin of error, an assumed distribution of 50%, and a power β of 80 [15]. The sampling method was the simple random one, without handing over the 79 agents, and this, per maternity of each HD of the RHBS.

Table I : Number of midwvies per functional health district in the Region of Hauts Bassins, and sample size expected

Variables and data collection

Five (5) interviewers (one by HD) were recruited and trained for data collection. Data collected were socio-professional characteristics of the midwives (table II), knowledge (table III), attitudes towards handwashing (table IV), practices about ICP (table V), and the organization of maternity services.

 Data analysis

The data were recorded on a microcomputer using the SPSS software (version 23) with a double checking of the data before data analysis. To assess the level of knowledge, attitudes and practices of the agents surveyed, a score of 0 for « yes » and 1 for « no » corresponding to the answers was defined for each question. When the percentage of scores calculated was equal or greater than to 85,0%, the item was considered having a good level. The level was considered medium when the percentage of scores ranged from 60,0% to 85,0%; and the level was considered low when the percentage of scores was less than 60,0%.

Ethical considerations

To carry out this study, the study authorization was obtained from the Health Regional Director of the Hauts Bassins and with the agreement from the Head medical Doctor of the health district teams concerned. The informed and written consent was filled out before the data collection. The confidentiality of the information collected was ensured by limiting access to the data to investigators only and to the need for the investigation.

A total of 88 agents were present during data collection period and eligible for the study, of which 65 midwives were included in the study with participation rate of 74.0%.

Socio-profesional characteristics

Of the 65 participants included, 63.1% were female (41), for a sex ratio of 1.7. The average age was 33.3 (95%CI: 31.1-35.5) years-old. The age group 30-34 ar-old accounted for 38.5% of respondents, followed by the age group 35-39 years-old with 29.2% (table II). The proportion of respondents with profesional experience between 4 and 10 years was the most represented with 50.8% (table II). The respondents with a maximum of 3 years' seniority in the actual position represented 67.7% (table II). And 40.0% of the participants received training or retraining on IPC after their basic training (table II). The proportion of respondents who had not received supervision for at least four years was 78.5% (Table II).

Table II: Socio-profesional characteristics of the study participants

Knowledge of midwives abt the IPC

The proportions of agents surveyed who were familiar with the definitions were: 80.0% for the IPC definition, 76.9% for the nosocomial infection definition, and 90.3% for the handwashing definition (table III). The hand hygiene was the most frequently cited precaution by 76.9% of the respondents (table III).

The purpose of handwashing was known by 76.9% of respondents (table III). The different types of handwashing were known by only 38.5% of respondents. The indications for surgical washing were best known at 49.4%, followed by those for simple washing at 49.4% (table III). As well, 93.8% of respondents were aware about the different types of gloves used for IPC application.

With respect to the usefulness of the flaps, 86.2% of respondents used the flaps to protect health workers from splashes and 27.7% of respondents used them to protect the client from microorganisms emitted by the provider. The proportion of respondents who were familiar with the three procedures for the maintenance and treatment of soiled instruments was 90.5% (table III). A proportion of 62.5% of respondents cited 10 minutes as the decontamination time. Among the respondents, 50.8% gave one hour as the duration of sterilization of the equipment with the poupinel at 1700c. For a standard of 20 to 30 minutes for sterilizing equipment in an autoclave, 47.7% of respondents cited 60 minutes as the duration of the equipment in an autoclave at 1340c (table III). Knowledge of high-risk areas in the maternity wards of the HD from the Region of Hauts Bassins was cited: 80.0% for the delivery room, 66.7% for the bed suite room, 53.9% for the pregnancy and infectious disease room, 23.8% for the consultation room, 9.5% for the guard room, and 1.2% for the pregnancy and non-infectious disease room. For the cleaning of the delivery room, the agents surveyed said that both disinfectant and detergent were required for 84.6% of cases, detergent alone for 7.7%, and disinfectant for 7.7%. The overall score for knowledge on IPC was 64.7%.

Table 3

Table III : Results related to midwives knowledge on  infection prevention and control (IPC)
 

Attitude of the midwives about the handwashing

For handwashing, 86.2% said that it is often and always necessary to wash hands for care  between two patients (table IV). Also 47.7% of the 65 respondents stated that they were always and often influenced by their peers about their non-compliance with handwashing (table IV). And 86.2% of the respondents reported that they always and often washed their hands before and after removing gloves (table IV). From the 65 people surveyed, 52.3% of them said that they always and often reminded their colleagues to wash their hands before and after all actions (table IV). The overall score of the attitude towards handwashing was 68.1%. Finally and 73.8% of respondents said they used cans to supply themselves for water ; and 23.0% of them used kettles, as alternatives when haing water shortage.

Table IV : Results of midwives attitude on hanswashing

Midwives practices and IPC

No domains of practice by midwives were at a satisfactory level (table V). The medium-level areas of practice were: glove wearing (69.2%) and instrument maintenance (72.7%). The areas of low-level practice were: clean service provider dress and use of personal protective equipment (53.1%), simple handwashing (56.9%), biomedical waste management (56.2%), behaviour change communication (49.5%). None of the maternity hospitals had the four (4) tanks for processing instruments.

The table V shows the summary of midwives' practices on the application "standard" precautions of about infection prevention and conrol (IPC) and aspects to be improved.

Table V : Summary of midwives' practices on the application "standard" precautions of about infection prevention and conrol (IPC) and aspects to be improved
 

Organization of the services and IPC

When accessing the five (5) maternity hospitals, there was nowhere was there is a committee to fight nosocomial infections. The proportion of agents who reported the existence of an adequate water point in the service was 85.9%. Among the participants, 95.3% said that running water had been suspended in their service. Concerning the maintenance of soiled instruments, the availability of "bleach" (or chlorinated water) was reported by 98.4% of agents. Also, the sources of bleach supply were staffing and internal production at more or less equal proportions 47.6% and 52.4% respectively. The proportion of midwives who had never received a supervisory visit was 72.3%. The respondents who had been supervised were mainly supervised when they were in the health district in 50.0% of all supervised (n=18), by the regional level in 22.2% of cases, by their maternity managers in 16.7% of cases, and by the national level in

5.6% of cases. Also, the proportion of midwives who supervised at least once said that supervisions addressed PCI in 83.3% of cases. And 69.8% of the agents surveyed said they had a distribution of workstations at their disposal.

When the job description existed (100%), the job description was only displayed in 2 of the 5 maternity units evaluated.

Of the existence of the various managers involved in te IPC, 98.4% appointed a manager of the maternity department, 20.0% appointed a IPC manager in the maternity department, 38.4% appointed a IPC manager of the HD, and 61.9% appointed a IPC manager of the health district. Of the 65 respondents, 92.3% of them said they had never had a manager for compliance with handwashing practices.

For the 65 respondents, it emerged that:

69.2% stated that protocols on handwashing procedures were never posted; upon observation, simple handwashing protocols, precautions to be observed in case of exposure to biological fluids (EBF) and those for the maintenance of reusable soiled instruments were not posted in any care rooms;

34.4% said that handwashing products were often accessible; and 41.9% said they still had access to handwashing facilities.

Of the five maternity hospitals surveyed, there were the following elements: supervision booklet (2/5), weekly or monthly equipment supply booklet (5/5), apron for maternity staff (5/5), individual glasses (2/5), individual boots (5/5), individual bibs (3/5), water in care rooms (5/5), soap and detergent (5/5), safety boxes (5/5), waste collection tools comply with WHO coding (0/5), signage to allow customers to distinguish waste collection tools (0/5), baby doll (5/5), autoclave (0/5), functional incinerator (3/5). The sterilization method used by all five maternity hospitals was the poupinel. Feedback on care-related infection rates was reported by 76.9% of respondents. Handwashing facilities were rated as rarely or never functional by 38.4% of respondents. Since basic training, 83.1% of respondents said they had never done any internships about handwashing practice. Also, 84.6% of respondents said they had never been evaluated on handwashing practice.

The objective of this study accessed the implementation of the infection prevention principles’s in maternity wards from the functional health district hospitals. As main finding, the level of knowledge on IPC was 64.7%. Also, the attitude score on handwashing was 68.1%. In addition, no areas of practice by midwives were of a satisfactory level. Finally, the organisation of services remains insufficient.

The methodological limitations of this study are mainly based on its cross-sectional type of study and the single passage for observing practices. Indeed, it would have taken several passages to be sure to capture the real practices of the health professionals surveyed.

Socio-profesional characteristics

In this study, the 30-39 age group was the most representative. Zabsonré et al showed that agents over 40 years of age were less likely to be involved in accidents involving exposure to biological fluids (EBF), which were more frequent among agents between 30 and 39 years-old.

[16].

Knowledges on IPC

In this study, the level of knowledge was medium about the definition of nosocomial infection being the least known amongst the definitions. Already in 2008, Hien et al showed that only 30.04% of respondents were aware about the definition of a nosocomial infection [17]. And yet the healthcare associated infections (HCAIs)  were the consequences of the lack of IPC. In their study, Boni-Cissé et al showed that 25.7% of the agents were unaware that carew could contract a nosocomial disease [18].

While the purpose of handwashing was known, the different types of handwashing were only known by 38.5% of respondents, such as the 48% results found in Senegal [8]. The results of this study showed that there is a need to improve knowledge about the indications for surgical and simple hand washing. The present results are similar to those observed in Senegal where 62% of respondents do not know the indications for handwashing [8]. As for the different types of gloves used for the application of the IPC, it is noted that this was quite well known in this study. With respect to the usefulness of the bibs, the respondents said that they protected the health worker from splashes and almost not to protect the client from emitted microorganisms. This would show that health workers did not take into account their client's other means of protection. Moreover, Benboubker et al in Morocco, the individual protection measures were poorly cited in several high-risk situations [19]. According to Hien et al, only 44.4% reported that the hand of caregivers when having absence of hygiene was the main mode of cross-transmission of germs between patients [17]. Therefore, it is important to remember that microorganism reservoirs are made up of long nails, fake nails, nail polish, jewellery and long-sleeved clothing ; their use should therefore be avoided during treatment [20].

Whilst the review studies did not address aspects related to instrument processing and risk areas, it was found that the times of decontamination, sterilization of the equipment with the 1700c nursery, and sterilization of the equipment in an autoclave were not well known. It is recommended to decontaminate in 10 minutes, to sterilize the equipment with the poupinel at 1700c in one hour, and to sterilize the equipment in an autoclave in at least 18 minutes [21, 22].

The Knowledge on high-risk areas was not well known. This is essential to be considered when circulating in the rooms of a hospital. Care rooms, intensive care, oxygen bottles, delivery rooms are classified in zones D or zone 3, hving severe risks [21, 22]. As for cleaning the delivery room, three-quarters of the agents surveyed said that both disinfectant and detergent were required in 84.6% of cases. This is recommended depending on the nature and surface to be cleaned [22].

If the knowledge is generally fairly well mastered [23], been in medium level in this study, the knowledge does not lead to practical translation and there is a constant gap between words and deeds [24].

Midwives attitude and their pratiques about IPC

While at least three-quarters of the participants often and always said they wash their hands between the care of two patients, it is noted that almost half of them said they were always and often influenced by their peers about their non-compliance with handwashing and always and often reminded their colleagues to wash their hands before and after all actions in this study. Already in 2008, Hien et al showed that hospital hygiene practice by health professionals was low (36.9%) [17]. In the context of activities promoting peer experience, the data showed the need for more continuing training and supervision sessions, more consultation frames on IPC including compliance with standard precautions. 

As in this study, 87.7% of respondents reported handwashing between two patients according to Benboubker et al [19]. On the other hand, in practice, there is a systematic failure to carry out simple handwashing or hand friction with a hydroalcoholic solution for care between two patients by 56.9% of the respondents. The same observation was made in Côte d'Ivoire where 21.1% of respondents confirmed that they did not perform this procedure and any about midwives [18]. In Algeria, only 30% of respondents observed handwashing practice before the treatment [8]. As Boni-Cissé et al pointed out, despite the presence of washbasins confirmed by 87.5% of respondents, and liquid soap dispensers confirmed by 50.5% of respondents, the respondents rarely performed simple handwashing at the start of the shift an about midwives [18]. According to the standards, staff must wash their hands as soon as they arrive at work, before and after each client's examination; after touching any object likely to be contaminated; after handling samples; before putting on gloves for clinical procedures; after removing gloves; after using the toilet; before leaving work [3].

In this study, 69.2% of the agents observed had worn gloves as previously noted by Laraquib et al (65.6%) [25]. Among nurses, gloves are not systematically worn by many agents, as evidenced by glove wearing rates of 64% for samples and 65.5% for infusion sets [16]. And 75.7% recognized the need to change gloves between two patients [19].

The systematic wearing of personal protective equipment was unsatisfactory for Bambenongama et al [26]. Only 20% of caregivers reported regular use of personal protective equipment [27]. As noted by Zabsonré et al, where 52.3% of the participants had never worn protective glasses when performing acts at risk of blood spatter, and although the health workers were aware of the risk of exposure to biological fluids (EBF), and the rules governing the application of the IPC are not respected [16]. This would be due to the attitude of the agents or their access to protective equipment. In this study, there was no wearing of aprons, glasses or flaps. In addition, it is noted that the same pair of gloves is worn to examine at least two women, while it is recommended that gloves be changed between patients [21, 22]. Although recapping needles after care was a practice not found in this study, it was noted in 55% of cases according to Bambenongama et al [26], in 51.2 % about Laraquib et al [25], and 25.7% according to Aké-Tano [28].

The client or patient/sick person was not taken into account because they were not oriented for a change in behaviour conducive to their safety: no explanation given to parents on how to repair the bed; no explanation given to the woman on how to change sheets and cloths when those used are wet because humidity maintains the proliferation of germs; and cloths contaminated with blood and/or biological liquids not decontaminated or not soaked in disinfectant before being given to the woman's caregivers.

Finally, the present results showed that no area of practice by agents was of a satisfactory level. In his study, d'Alessandro pointed out that there are many dysfunctions in care practices and that carers largely neglect hygiene recommendations [24].

Service organization and IPC

Through the present results, the organization of services was unsatisfactory. As in this study, only 33.9% of the staff interviewed had received training in hospital hygiene according to Boni-Cissé et al [18], and 28.7% from Benboubker et al [19]. While the proportion midwives who disposed of each type of solid waste in the containers placed in the rooms for this purpose was 96.8%, the bins did not meet WHO standards. It is recommended to respect the sorting of biomedical waste through garbage bags of different colours (yellow, red and black) [21, 22].

In this study, it was found that there was no committee to control nosocomial infections. Although existing, the nosocomial infection control committee of the Centre hospitalier universitaire (CHU) de Yopougon did not really carry out its tasks ; moreover, 71.6% of the staff interviewed were unaware of the existence of this hygiene committee [18].

As already pointed out by Zida et al in Burkina Faso [8], the following facts were also observed in this study: poor compliance with handwashing instructions by health professionals; resistance to change despite training; lack of sewage systems for liquid waste in most hospitals; misuse of incinerators, frequent breaks in antiseptics; obsolescence and exiguity of rooms; lack of knowledge of basic hygiene rules; malfunction of laundries; failure to sterilize; and use of artisanal incinerators. And yet, according to the Basel Convention, medical waste produced in health care facilities must always follow an appropriate and clearly identified route from its production points to its final disposal. This route consists of several steps that include: production, sorting, collection, on-site collection, transport and storage, off-site transport and storage, treatment and disposal  [29]. For Hien et al, the determinants of these infectious risks associated with care in developing countries include lack of infrastructure, inadequate equipment, inadequate hygiene conditions, non-implementation of protocols, inappropriate use of antibiotics, lack of hygiene compliance and insufficient knowledge of health professionals that could be due to lack of initial training [17].

Implications for public health

The purpose of this study is to contribute to a significant reduction in the risk of spreading infections among clients, providers and other staff. The responsibility for IPC lies with everyone working in sanitation facilities, regardless of their role, size or type of facility or facility. [21]. The Global Patient Safety Alliance advocates the use of systemic interventions and organizational culture changes to improve patient safety, rather than individual denunciation of health practitioners and administrators [1]. As a result, risk management is increasingly becoming a priority for governments [30]. Poorly managed risks result in significant costs related to complications, inappropriate use of services, adverse events and deaths [1]. Calling for action, the quality of care and patient safety approach must take into account the dimension of training and a change in the behaviour of health professionals [17].

This study accessed the application of infection prevention and control measures by midwives in delivery rooms and maternity suites at the district hospital level. Our findings indicate that infection prevention and control is not sufficiently implemented in these district hospitals, as several studies in developing countries have noted. It is therefore necessary to strengthen staff skills and reorganize maternity services in the field of IPC using quality assurance.