Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana.
To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities.



Cross-sectional Health Facility Assessment linked to population-based surveillance data.



7 districts in Brong Ahafo region, Ghana.



Most experienced delivery care providers in all 64 delivery facilities in the 7 districts.



Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant.



Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores.



Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care.



NCT00623337.
Department of Public Health, University of Helsinki, Helsinki, Finland Institute of Public Health, Heidelberg University, Heidelberg, Germany.
Terhi Johanna
TJ
Lohela
Institute of Public Health, Heidelberg University, Heidelberg, Germany.
Robin Clark
RC
Nesbitt
Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
Alexander
A
Manu
Innovations for Maternal, Newborn and Child Health, Concern Worldwide US, New York, New York, USA Health Section, Programme Division, UNICEF Headquarters, New York, New York, USA.
Linda
L
Vesel
Department of Public Health, Flinders University, Adelaide, South Australia, Australia Ghana Health Service, Kintampo Health Research Centre, Kintampo, Ghana.
Eunice
E
Okyere
Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Betty
B
Kirkwood
Institute of Public Health, Heidelberg University, Heidelberg, Germany.
Sabine
S
Gabrysch
D002983:Clinical Competence / Q000592:standards*; D003430:Cross-Sectional Studies; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D005869:Ghana; D006268:Health Facilities / Q000145:classification / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000145:classification*; D006801:Humans; D016014:Linear Models; D009774:Obstetrics; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D011787:Quality of Health Care; D016526:Workload
Clinical vignettes; Emergency obstetric care; Health facility assessment; Quality of care; Signal functions