World Health Organization (WHO) defines maternal death as “a death occurring in a woman during pregnancy or within 42 days after delivery or miscarriage the location and gestation notwithstanding, as long as it is due to factors that are related to or worsened by pregnancy or its management but not due to accidental or incidental causes” [1]. In 2017, 295,000 maternal deaths occurred globally out of which about two-thirds (66%) occurred in sub-Saharan Africa [2].

Although there has been a reduction in maternal mortality ratio (MMR) over the years since the year 2000, the level is still below that envisioned in the sustainable development goal target 3.1 of reducing MMR to less than 70 per 100,000 live births by 2030 [2]. In Kenya, the current MMR is 362 maternal deaths per 100,000 live births, which is way below the target of 147 maternal deaths per 100,000 live births [3]. More than half of the maternal deaths arise from hemorrhage, hypertensive disorders, and sepsis which are preventable through use of appropriate strategies [4].

One of the strategies that have been adopted in Kenya is increasing access to skilled attendants through the introduction of maternity services free of charge by the government in June, 2013. This covered all public health facilities across the country and increased the number of facility based deliveries by 26.8% [5] [6]. However, increasing access alone may not be adequate in achieving the desired maternal health outcomes [7]. Indeed, a review of 2014 maternal death case notes in Kenya found that in 75.4% of the cases one or more health worker-related factors were to blame [8].

Quality maternal health care can be accomplished through the use of maternal and newborn care guidelines detailing best practices that are known to produce desirable outcomes [9]. One such guideline is the “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities” developed by WHO in 2016 [10]. This document has a set of standards containing eight domains of quality of care to guide health facilities in assessing and continually improving the quality of care provided [10].

In Kenya, 61% of the deliveries occur in a health facility and 46% occur in a public sector facility. Targeting the nurse-midwives is likely to produce favorable outcomes in maternal health care since they conduct seventy percent of deliveries in public sector facilities [3]. This study thus sought to determine the knowledge and attitude of nurse-midwives regarding the use of maternal health care standards and guidelines which are some of the factors that may influence their utilization.

In this study, majority of the participants (84.7%) were females and most of them were married. This finding may be because nursing originated as a caring profession. In most cases, it is the women who are involved in caring for the sick. This is consistent with a study finding by Ndirangu et al. that the majority of the nurse-midwives are female [11]. Regarding the age of the participants, the majority of the participants were aged between 20 - 29 years. This might be due to the deployment pattern in the hospital. Maternity being a labor-intensive department the management tends to place younger nurses there since they are considered more energetic. However, this finding differs from the findings of Gitonga which showed that the majority of the nurse-midwives in maternity are aged 30 - 35 years [12]. Most of the participants in this study were diploma holders. This can be explained by the fact that the number of certificate training programs in Kenya decreased as up-grading programs from certificate to diploma were being introduced as well as the presence of many medical training colleges offering diploma training as opposed to those offering degree-level training. This finding is in tandem with that by Tallam et al. who in their study on Midwives’ self-perceived confidence in their knowledge and skills in Kenya indicated that the majority of the participants were diploma holders [13]. Most of the participants had practiced for between 1 - 9 years. This may be because most of the nurse-midwives deployed in maternity are young.

Only 42.3% of the participants correctly specified that quality maternal health care is care that met the laid down standards with the majority indicating it refers to care that responds to the needs of the client. This could be due to the lack of training of nurse midwives on maternal health care quality and quality standards. Training in-service nurse-midwives is an important undertaking to ensure that they are abreast with the best practices. Incidentally, this study identified that only 38.8% of the nurse-midwives are trained on the maternal health care standards and most of these were trained in college. Furthermore, only 30.6% demonstrated adequate knowledge about maternal health care standards. This finding concurs with the assertion by WHO et al. that only 18.5% of health care workers are equipped with the necessary knowledge and skills to provide quality obstetric care [14]. Most of the in-service training is carried out by Non-Governmental Organizations which has dwindled since the inception of devolution in Kenya [12].

The majority of the nurse-midwives interviewed in this study supported the use of maternal health care standards since they standardized the quality of maternal care. This finding is consistent with several other studies such as those by Wahabi et al, Melanie, and Hendaus et al. [15] [16] [17]. Most of the participants who do not support the use of the standards indicated that it would be time-consuming. This is maybe because a nurse-midwife is required to follow every step as stipulated in the guidelines. With the current nurse-to-patient ratio of 25:10,000 as opposed to the required ratio of 83:10,000, this becomes an issue. This finding is different from that of Zheng et al. [18].

The level of knowledge about maternal health care quality standards among nurse-midwives is inadequate though their attitude towards them is positive. There is a need to carry out in-service education and training on maternal health care quality standards and specifically on the use of WHO (2016) standards for improving the quality of maternal health care. Maternal health care standards for quality improvement should also be added as content to the training curricula for diploma and bachelor nursing students.

The authors would like to thank Mr. Dan Musau for helping with data analysis.

The authors declare no conflicts of interest regarding the publication of this paper.

Impwii, D.K., Kivuti-Bitok, L. and Karani, A. (2022) Knowledge and Attitude of Nurse-Midwives Regarding Maternal Health Care Quality Standards in Two Regional Teaching and Referral Hospitals in Kenya. Open Journal of Obstetrics and Gynecology, 12, 914-926. https://doi.org/10.4236/ojog.2022.129076