Factors influencing knowledge and practice on helping babies breathe among Skilled Birth Attendants in rural areas in Lake Zone in Tanzania

Background It is estimated that 1 million babies die each year due to birth asphyxia. Globally, it is approximated that 10 million babies cannot do it by themselves and need assistance. Helping babies breathe is a key component in reducing neonatal mortality due to birth asphyxia. Methods A cross-sectional design was used, A total of 330 respondents included in the study. Simple random sampling by lottery was used to select the 2 regions and health facilities. The participants were selected through convenient. Data were collected using standard semi-structured questionnaire. Chi-square and Binary logistic regression were used to analyse the data. Results Out of 330 participants, Those who working in hospital and were more likely to have adequate knowledge (AOR= 3.227, P< 0.001) and practice (AOR= 43.807, P<0.001) than those working in Health Centers; Enlored nurses were more likely to have adequate knowledge (AOR= 3.118,P<0.05) than AMO/MD;Those with 1 year and above of experience in labor ward were more likely to have adequate practice(AOR=15.418,P<0.001) than those with less than 1 year of experience in labor ward; those who attended once on neonatal resuscitation training were adequate knowledge (AOR=1.778,P<0.05) than those who had never attended. Those with Enough equipment of neonatal resuscitation had adequate practice (AOR=4.355, P<0.001) than with no enough equipment. Conclusion Regarding the findings of the current study, it was revealed that working facility, Professional/ qualification, and training was significant predictor of knowledge while working facility, experience, and equipment was significant predictor of practice. There is a need to find effective measures on how to reduce those factors which affect knowledge and practice on helping babies breathe.


INTRODUCTION
The health of new born babies is very important during delivery in daily life, and it is estimated that more than 100 million babies are born annually worldwide (1). During the process of birth, babies can make the transition from the intrauterine life to extra uterine life. During the intrauterine life, the baby can use the placenta as an organ for gaseous exchange, and soon after birth, the fetus can use their own cardiopulmonary system independently within the minutes of survival.
It is estimated that all babies do not establish their own spontaneous breathing during birth, so helping babies breathe is needed as an intervention for neonatal resuscitation during delivery and can be done by skilled birth attendants (1).
Almost 99% of all the deaths take place in resource-poor settings (2), A major factor contributing to the high mortality is a global lack of trained providers in neonatal stabilization and/or resuscitation which is most acute in Sub-Saharan Africa with the highest neonatal mortality (2).
Helping babies breathe is an evidence-based education programme that was developed by the American -Academy of Pediatrics in consultation with the WHO and its collaborative partners to teach neonatal resuscitation technique in resource-limited areas to health care providers in developing countries (3).The goal is to have at least one skilled birth attendant at each delivery and to reduce the neonatal mortality rate due to birth asphyxia. This essential intervention is useful by providing them with stimulation to breathe, within one minute hence many babies can be saved (4).
Estimated that one million of babies die each year due to birth asphyxia (3), Birth asphyxia is the inability of a new born baby to breathe immediately after birth. Globally, it is approximated that 10 million babies cannot do it by them and need some assistance at birth (3).Therefore helping babies breathe can focus on helping them initiate breathing. It was found that 99% of babies need this intervention, almost 80-90% who need this will be sufficient (WHO, 2012) as cited by (4).
Globally, about one-quarter of all neonatal deaths are caused by birth asphyxia and is among of the leading cause of those neonatal deaths, which account 23%( Lawn et al.) as cited by (5). The neonatal resuscitation has the potential to prevent perinatal mortality caused by birth asphyxia for almost two million babies annually (Lawn et al.) as cited by (5),and it is estimated that 8. The main causes of these deaths are an infection (25%), birth asphyxia (24%) and complication of pre-term 25 % (6). In Tanzania, the neonatal mortality rate due to birth asphyxia accounts for 31% (7). This unacceptably high rate must be reduced if the success in achieving better child survival is to be reached. In low -income countries, nearly half of all new born do not receive skilled care during and immediately after birth (7) .However, two thirds of new born deaths can be prevented if effective measures are taken (7).Neonatal resuscitation (NR) is a simple, inexpensive intervention that has been shown to reduce neonatal mortality (7).
Due to the slow decline of the Millennium Development Goal 4 which ended in 2015 to reduce the neonatal mortality rate, the Sustainable Development Goal targets 3.2, strategies aimed to reduce new born deaths at least to 12 deaths per 1000 live births by 2030 ( Lawn et al) as cited by (5).
The Helping Babies Breathe programmes offer standardized training, knowledge, and skills in essential new born resuscitation to providers and have the potential to significantly reduce global neonatal mortality. Since its introduction in 2010, HBB has been taught in 77 countries to approximately 300 000 birth attendants and is currently being implemented throughout sub-Saharan Africa, Asia, and Latin America (8).
However, the data on its effectiveness at reducing neonatal mortality are interpreted differently.
The falloff of skills and knowledge after training in new born resuscitation has been well documented in high-income countries (8).Nevertheless, in the low-income countries, there are few data. Furthermore, there is poor retention of knowledge and skills after training courses which represent a significant barrier to improving neonatal mortality worldwide (8).
Helping Babies Breathe is initiated soon after delivery where all new-borns are evaluated for crying. That is, if the baby doesn't cry, it will need basic resuscitation. The intervention includes thoroughly drying the baby and stimulating it to breathe, cleaning the airway starting from the mouth then to the nose to avoid aspiration. This is followed by the bag and mask ventilation.
However, few babies' approximately one percentage will need advanced resuscitation including specific medications and cardiac resuscitation. However, this intervention has been underutilized due to a shortage of well-trained staff and a shortage of equipment in the resourcelimited area, which includes Tanzania (9).
In 2009, a simulation programme of helping babies breathe was implemented to eight hospitals in Tanzania. These included three major referral hospitals (Muhimbili National Hospital, Bugando Medical Centre and Kilimanjaro Christian Medical Centre), four regional hospitals (Amani, Burunguni, Sekou Toure and Mawenzi), and one district hospital (Haydom Lutheran Hospital). These hospitals were successful in reducing new born deaths within 24 hours as well as reducing stillbirth (9) In April 2010, the initial one-day HBB course was held at Hydom Lutheran Hospital. Only half of the birth attendants were able to attend and no local Master Instructors were trained to facilitate the continuation of HBB re-trainings. An evaluation of data from Hydom Lutheran Hospital revealed no improvements in mortality during the first months after the initial HBB course (2).
An additional study on testing skills and knowledge among birth attendants at Hydom Lutheran Hospital showed that both knowledge and technical skills improved when rated in a simulated setting seven months after the initial one-day HBB course compared to what it was before.
However, this improvement did not transfer into clinical practice (10).
Despite the neonatal resuscitation programme which was successfully initiated, birth attendants (BAs) must be assessed on their knowledge and practice to perform appropriate and adequate neonatal resuscitation in the critical first minutes after birth (11).

Research Design
The analytical cross-sectional study was used with quantitative approach. This is because the analytical cross-sectional study was used to investigate the relationship between exposure and outcome of interest .The data were collected at one point in time.

Research Setting/Area
This study was conducted in rural areas in Lake Zone in Tanzania Mainland. Lake Zone consists of 4 regions namely Kagera, Mwanza, Mara, and Geita. In particular, 2 regions namely, Mwanza and Kagera Region were used for the study. Specifically, 5 district hospitals from each Region and 10 Health Centre's located in a rural area were studied. The study was also conducted in Kagera Region, whereby 5 districts namely Ngara, Karagwe, Bukoba Rural, Kyerwa, and Muleba were involved. According to Tanzania Population and Housing Census (2012), the region has a total population of 2,458,023. Health services are being provided to all the regional population with about 15 hospitals available in the region distributed in all districts.Also in Kagera region,1 district hospital and 2 health centers were used in each district.(13).

Study Population
The study population included the skilled birth attendants who were conducting deliveries in the labor ward.

Inclusion Criteria
The inclusion criteria focused on all skilled birth attendants such as AMO, medical doctors and nurses midwives with certificate, diploma, undergraduate and master degree, who were conducting deliveries in labor ward within the time of data collection and who gave their informed consent by agreeing to participate in the study.

Exclusion Criteria
The exclusion criteria focused on those skilled birth attendants who were sick, absent, student nurses and doctors and those who did not agree to participate during the data collection day.

Sample Size
The sample size was estimated using the Kish Leslie's formula for quantitative studies (14) and the prevalence of current evaluation of birth asphyxia in Tanzania 31% (7). Simple random sampling by lottery was used to select 2 regions (Mwanza and Kagera). A total of 5 district hospitals from rural Kagera and 5 of them from rural Mwanza were selected by simple randomly by lottery. Also, a total of 10 district health centres from rural Kagera and 10 of them from rural Mwanza were selected randomly and through lottery selection in all districts.
The researcher prepared written small pieces of paper and then the research assistant picked them. (That is, 2regions, 5 district hospitals in each region and 2 health centres from each district in both regions).
The participants were selected through convenient sampling from those district hospitals and health centres in both Mwanza and Kagera Region, the number of participants in each region was estimated according to the number of health facilities, and staff working in the labour ward, where 17 participants in each hospital and 8 participants in each health centre in Kagera and Mwanza region were involved (Table 1).

Data Collection Methods/Tool
The standard Semi-structured questionnaire was developed to address socio-demographic, theoretical and practical aspects of the knowledge and practice of the participants about helping babies breathe. The questionnaire was validated and pilot tested in other hospitals and changes were made before the study.
The skilled birth attendants were assessed on knowledge, practice and demographic data of participants by using questionnaire with both closed-ended and open-ended questions. The standard questionnaires from American Heart Association were adopted and modified. The selfadministered questionnaire which were composed of questions of knowledge and practice on helping babies breathe among skilled birth attendants, they also included and demographic variables like age, sex, professions, and working experiences. (1).
Practice: it is when she/he is able to perform and follow the procedures regarding helping babies to breathe Practice level measurement: The subjects were given the questions on HBB practices. The section contained 15 questions pertaining to practice and was classified into two groups that are, adequate and inadequate practice. These 15 questions were used to assess the level of practice and each correct answer was given one point. The adequate practice was for skilled birth attendants who answered correctly at least 9 out of 15 questions. With regard to inadequate practice, this involved skilled birth attendants who correctly answered less than 9 of the 15 questions(Adopted and modified from American Heart Association 2005 (AHA) accreditation criteria (15).

Independent variable
Are those demographic factors such as age, sex, marital status, education level, experience, professional/ qualification, working facility, and training. They were measured by Descriptive measurements.

Data Analysis Procedures
Data were analysed using SPSS version 20. Before the analysis, the cleaning of the data was done for the missing data and for checking the completeness and accuracy manually.
Descriptive statistics were used to describe the demographic characteristics of the respondents and to assess the level of knowledge and practice among skilled birth attendants in rural areas of Lake zone of Tanzania. Chi-square test was used to test for association of knowledge and practice with demographic characteristics. Binary logistic regression with both odds ratios (OR) and adjusted odds ratios (AOR) was used to identify the significant factors influencing the knowledge and practice among skilled birth attendants.

Validity and Reliability of Data
Validity: Randomly selected sample and employed use of a standardized questionnaire in measuring the outcome variable. Data on possible confounder was collected and adjusted during analysis.
Reliability: Pre-testing of the tools was done before conducting the study, to test for accuracy of the tool to yield valid information. The pilot study was carried out at Makole health center one month before the actual study. The aim of the piloting was to see how long it will take to assess skilled birth attendants and also be able to identify flows such as ambiguity in questions and establish whether or not the instructions were understandable.

Ethical Issues
Due to the fact that the data were collected from nurses, the ethical consideration was taken into account in this study. One of the aspects of research ethics is autonomy which is about recognising the participants' right. This was done by obtaining the informed consent of the respondents where the reasonable balance was achieved in over informing and under-informing the participants about the study exercises to be taken. It also implies that the participants exercised their autonomy to voluntarily accept or refuse to participate in the study.
The study protocol was approved by the College of Health Research Ethics Committee of the Dodoma University. Verbal and written informed consent was obtained from all participants including skilled birth attendants who were working in labour wards before the interview in voluntary basis with no compensation. The participants were informed about the purpose of the study, benefits, and risks of participating in the study and then were asked to sign. The permission to visit the health facilities was also obtained from the facility directors. The description of the study was to skilled birth attendants from the selected district hospitals and health centres in Kagera and Mwanza Region to gain access and collaboration.

Respondents Socio-Demographic Characteristics
The participants who participated in the study were all skilled birth attendants from the selected health facilities including district hospitals and health centers in each selected district. They all fell in the age category of 25-60years.
Data collected were generated from a total number of 330 respondents both males and females who participated in this study.

Factors Influencing Knowledge Level on Helping Babies Breathe among Skilled Birth
Attendants.
Chi square test and binary logistic regression were used to assess the factors associated with the knowledge level of helping babies breathe.

Bivariate Analysis of Factors Associated with the Knowledge Level on Helping Babies
Breathe among Skilled Birth Attendants.  ( Table 3). Binary logistic regression was used to identify significant predictors of knowledge among skilled birth attendants in a rural area of Lake zone of Tanzania.
The results show that working facility, professional/ qualification, and training were significant predictors of knowledge of skilled birth attendants. The odds ratios (OR) show that; birth attendants working in hospitals were 3.065 times more likely to have adequate knowledge than those working in health centers; Those who had attended training once and more than once were 1.799 and 3 respectively. Therefore, they were 185 times more likely to have adequate knowledge than those who had never attended any training; for professional/qualification. Enrolled nurses were 3 times more likely to have adequate knowledge than AMO/MD.
After adjusting for other confounders, the results show that the level of the facility, professional/ qualification, and training were significant predictors of knowledge level; the adjusted odds ratios (AOR) indicate that birth attendants working in the hospital were 3.227 times more likely to have adequate knowledge than those working in health center's. For professional qualification, enrolled nurses were 3.118 times more likely to have adequate knowledge than other categories of birth attendants (registered and AMO/MD). For training, those who had attendant training once and more than once were each 1.778 and 3.102 times more likely to have adequate knowledge compared to those who had never attended such training.
These results are presented in ( Table 4).

Factors Influencing Practice Level on Helping Babies Breathe among Skilled Birth Attendants.
Chi square test and binary logistic regression were used to assess the factors associated with the practice level of helping babies breathe.

Bivariate Analysis of Factors Associated with the Practice Level on Helping Babies Breathe among Skilled Birth Attendants.
The results show that only working facility, experience in the labor ward and the availability of equipment, were statistically significantly associated with the practice of birth attendants among skilled birth attendants (P< 0.001). The findings further indicate that the proportion of nurses with adequate practice was high for birth attendants working in hospitals (59.4%) compared to those working in the health centers (3.8%). For experience regarding both groups, a large proportion of birth attendants had inadequate practice with those with at least one year and above of experience in labor ward (44.8%) higher than those with less than one year of experience (4.0%). For availability of equipment (49.0%) had adequate practice compared to (18.1%) with no enough equipment. The results are presented in (Table 5).

Factors Influencing Knowledge Level on Helping Babies Breathe among Skilled Birth
Attendants.
The results show that, working facility, professional/ qualification and training on neonatal resuscitation were statistically significantly associated with the knowledge of helping babies breathe among skilled birth attendants (p< 0.05).
The factor which was observed to contribute to this problem was a shortage of staff working in the labour ward, low frequency of neonatal training, lack of refresher training on helping babies breathe. This could be due to lack of skilled birth attendants working in labor ward and majority did not attend training on neonatal resuscitation. So the regular training and increasing number of skilled birth attendants in labor ward was needed.
The current study was similar with other findings by (16) show that acquisition of knowledge and skills was associated with the level of training and the facility type in which birth attendants were working. They also showed that birth attendants from lower cadres (e.g., midwives) improved significantly more from pre-training to post-training than those from higher cadres (e.g., physicians).This could be due to majority of skilled birth attendants were working in labor ward and those who attending training on neonatal resuscitation have adequate knowledge on neonatal resuscitation as compared to physician.
The findings of this study are linked with the study done in Afghanistan by (17) whose results showed that; facility type, infrastructure, years of experience offering, training on new-born resuscitation, and confidence in performing new-born resuscitation had a statistically significant association with knowledge of health professionals on neonatal resuscitation. Trained health professionals (respondents) had more than 26 times sufficient knowledge on neonatal resuscitation than untrained health professionals or untrained health professionals. This might be due to those who attending training on neonatal resuscitation had sufficient knowledge also those with more experience they practice more on neonatal resuscitation as compare to those with less experience in labor ward.
Our findings are consistent with (18) who also found that lack of neonatal resuscitation training was among factors that influence knowledge. This might be due to shortage of staff.

Factors Influencing Practice Level on Helping Babies Breathe among Skilled Birth
Attendants.
The findings of the current study show that working facility, experience in the labour ward and availability of equipment was statistically significantly associated with the practice level on helping babies breathe among skilled birth attendants. The factor which was observed to contribute to this problem was a low number of staff working in the labour ward, inappropriate space for neonatal resuscitation, not enough time to practice due to many activities. This could be due to failure to follow guideline for neonatal resuscitation and lack of adequate knowledge on neonatal resuscitation.
Furthermore, the current study was similar with a study done by (19) shown that lack of equipment is common the reason for not being able to practice helping babies breathe. These observed that those with enough equipment have appropriate practice as compared to those with no enough equipments.
These findings are consistent with a study done in Ethiopia which reported that training and well equipped health faculty had a statistically significant association with the practice of health professionals on neonatal resuscitation. Untrained health professionals were 7 times with less practice level than trained respondents (health professionals) on neonatal resuscitation and well equipped health facility had a statistically significant association with the practice of health professionals on neonatal resuscitation well equipped health facility were 4 times better practice level than unwell equipped health facility on neonatal resuscitation (20).

CONCLUSSION:
Regarding the findings of the current study, it was revealed that working facility, Professional/ qualification, and training was a significant predictor of knowledge while working facility, experience and equipment's was significant predictor of practice. There is a need to find effective measures on how to reduce those factors, which affect knowledge and practice on helping babies breathe.