Prevention and Control of Healthcare-Associated with Infections in Birth Rooms of Referral Hospitals in Ouagadougou: Availability of Equipment, Knowledge and Practices of Health Workers

Objective: The neonatal mortality rate remains a serious problem in most countries in sub-Saharan Africa such as Burkina Faso, where, in 2010 this mortality rate was 28 per 1000 live births [1] [2]. Its reduction is possible and passes first by the strict prevention of infections in birth rooms. The objective of this study was to describe the practices of infection prevention in the birth rooms of seven referral hospitals in Ouagadougou from April 1 to July 31, 2016. Materials and Methods: This was a cross-sectional study on the knowledge, attitudes and practices of the rules of prevention and control of healthcare associated infections (PCHAI) among 123 consenting health workers who provided birth room care in 7 hospitals in Ouagadougou. Data were collected through individual interviews and direct observations. The study was authorized by the Institutional Ethics Committee in 2015 under the number 32. The data analysis was done with the Epi Info software version 2000. Results: The “five clean in the birth room” were known by 26.83%. Regarding the equipment used for PCHAI, sterile gloves were mentioned by 75.61% of the agents, the source of clean water by 62.60% and soap by 57.11%; in practice, 17.07% of the respondents had not washed their hands and 42 providers (34%) had not performed with complete mastery the wearHow to cite this paper: Some, D.A., Tougma, P.A., Ouattara, S., Yonaba Okenge, C., Poda, G.A.E., Yameogo, R.B., Kam, S.P., Traore, B., Sib, S.R., Thieba Bonane, B. and Dao, B. (2020) Prevention and Control of Healthcare-Associated with Infections in Birth Rooms of Referral Hospitals in Ouagadougou: Availability of Equipment, Knowledge and Practices of Health Workers. Open Journal of Obstetrics and Gynecology, 10, 135-150. https://doi.org/10.4236/ojog.2020.1010012 Received: November 25, 2019 Accepted: January 10, 2020 Published: January 13, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
The determinants of neonatal mortality are known.They are multifactorial and classified into three groups.The group of direct causes includes medical pathologies, mainly severe infections (38%) such as pneumopathy/septicemia (28%); tetanus (6%) and diarrhea (4%).In the second group of indirect causes, there is prematurity (25%), asphyxia (24%) and congenital malformations (6%) [3].But at the center of all these pathologies is low birth weight, which is the third leading cause of neonatal death [4].PCHAI rules during childbirth or newborn care are a possible determinant of neonatal death if these rules are not known and followed.
The actions carried out have enabled Burkina Faso to be ranked among the six (06) low-income countries that have succeeded in significantly reducing the neonatal death rate.Nevertheless, sub-Saharan Africa remains the most dangerous region in the world for an unborn child [5].However, the rules for effectively preventing infections in the birth room are simple.These include above all the use of protective measures and respect for "the five clean".This cleanliness concerns 1) the hands, 2) the surfaces and linens, 3) the scissors and blades, 4) the ligation of the cord and 5) the condition of the cord until it is scarred.The purpose of this study was to learn about the practices of health workers in Ouagadougou's referral hospitals regarding neonatal PCHAI in order to propose corrective measures.

Type, Period and Location of the Study
This was a cross-sectional study with prospective data collection from September 2015 to July 2016.It took place in the maternity wards of 7 reference hospitals in the city of Ouagadougou, namely Yalgado Ouédraogo Hospital, Saint Camille Hospital, medical centers with surgical antenna (MCSA) of Kossodo, Bogodogo, Pissy, Paul VI and Shiphra.

-Inclusion criteria
The study aimed agents of health centers who were regularly involved in -Criteria of non-inclusion Trainees and other non-permanent health workers at the time of the study were not included.
-Sample and sampling Agents were randomly and systematically included.In fact, during the three months outings for investigations, agents who were on duty were informed of the study and then invited to participate by signing freely the informed consent form.A total of 151 of them were expected.

Methods, Techniques and Instruments
The data were collected through direct semi-structured individual interviews using a written questionnaire that was validated by a pre-test.In addition, three direct participatory observations were made by agents using a grid established for this purpose.The verification of infection prevention equipment in each department was done by referring to existing lists.

The Variables Sought
During the interviews, the socio-demographic and professional characteristics of the providers, the providers' knowledge of infection prevention equipment and consumables and their knowledge of infection prevention rules were sought.
When officers were observed, their practices were assessed using scores.The scores were derived from the benchmark for the ideal practice of essential newborn care, the reference manual on newborn care [5].The zero (0) score meant that the provider had not performed the act; the one (1) meant that the act was incorrectly performed; the 2 score was given when the act was performed without control; the 3 for the act well performed with good control and the 4 score for the act very well performed with perfect control.
With regard to equipment and medicines, the tasks were distributed as follows: a first investigator was responsible for checking the equipment in the delivery room and operating room and then for contacting the person in charge of the delivery room to find out how the service was organized; the second investigator was responsible for checking the medicines in the pharmacy.

Investigators and Supervisor
The survey was conducted by 14 resident physicians in obstetrics and gynaecology and midwives; they were trained in collection techniques and ethics and confidentiality for 2 days.Two investigators were assigned to each hospital.They divided up the duty and duty teams to be investigated, and then returned to hospitals according to the teams' schedule.Thus, the person who had observed a claimant once would see him again the other two times.He administered the Open Journal of Obstetrics and Gynecology questionnaire to that health worker after the third and final observation.
Throughout the data collection, these interviewers were supervised for data quality assurance.

Ethical Considerations
Authorization number 32 of October 31, 2015 from the Institutional Ethics Committee of Muraz Centre, as well as administrative authorizations from the hospital directorates to conduct the study, have been obtained.All study participants had freely signed the informed consent form.The anonymity and confidentiality of the content of the questionnaires were guaranteed throughout the study.

Data Analysis
The data were analyzed with the Epi Info software version 2000.

Results
The final sample consisted of 123 providers out of the 151 initially expected, representing a participation rate of 81.45%.

Population Characteristics
The health workers were between 30 and 39 years old, had been working as qualif at least one year, and had studied until secondary school.Most of them were from the Medical center with surgical antenna (MCSA) of KOSSODO.In Table 1 are presented the socio-professional characteristics of the respondents.

Detergents and disinfectants
Liquid soap and chlorinated water were available in all maternity wards.The hydro-alcoholic solution was available in two of the seven maternity hospitals, or 28.57% of the cases.

Sterile equipment and consumables
The sterile scissors, Baar clamps and clamps were available in the seven reference maternity units.Scalpels and sterile fields were present in 57.14% and 42.86% of cases respectively.

Material for the protection barrier
Coats, bibs, caps and hooves were available in all maternity hospitals, except for safety glasses.

High level sterilization or disinfection equipment
A nursery was present in six maternity wards, representing 85.71% of cases, and an autoclave in four, representing 57.14% of cases.High level disinfection equipment existed in 28.57% of cases.

Other materials and consumables used for infection prevention
Running water, sharp boxes and garbage cans were available in all maternity hospitals.
Hand towels were available in 3 maternity wards or 42.86%.Collective towels Open Journal of Obstetrics and Gynecology were used in one maternity ward or 14.29% and individual towels in two maternity ward or 28.57% of cases.

Knowledge of the Principles of Infection Control in the Neonatal Period
Knowledge of the "five clean" Among the 123 providers, 33(26.83%)knew at least one component of the "five clean".The level of knowledge of these providers on the component of the "five clean" is reported in Table 2.
The average level of knowledge of the components of the five clean ranged from 15.45% for "clean and dry cord until it heals" to 26.06% for "clean hands" and "clean surfaces and linens".

Means used for hand hygiene
Handwashing was cited by 115 providers (93.50%) and friction with a hydro-alcoholic solution, by 68 service providers (55.28%).

Competency check on infection control
The level of competence of providers in infection prevention is noted in Table 3.
The protection barrier had been used by all providers.Of these, 59 had used it without control.The maternal perineum had been cleaned, before the birth of the newborn by 55 providers, three of them had performed it with perfect control.

Discussion
Health workers receive continuous training once they have left training institutions.We note that none of the providers surveyed had received additional training in prevention and control of healthcare associated infections (PCHAI); however, these additional training sessions are necessary for upgrading and acquiring new skills.Tonleu in his study found that more than half of the providers did not remember an upgrading course [6].The training of a sufficient number of qualified providers must be based on the coordination of management policies, human resources in order to ensure equitable distribution and quality care [7].
Basic care must respect the infection prevention rules that recommend soap and chlorine solution in all maternity wards [8].But the hydro-alcoholic solution existed in only 28.57% of the maternity hospitals in our study.It is a non-irritating alcohol-based solution to which glycerin is added; it works effectively to prevent infections [9].To compensate for this deficiency, it is desirable that each maternity hospital produces its own hydro-alcoholic solution.It is easy to do and should not be missed in a maternity ward.
Also in the context of PCHAI, sterile equipment is essential in the birth room to ensure asepsis during delivery.In our study, sterile scissors and pliers were found in all maternity hospitals.However, scalpels and sterile fields existed but they were not in sufficient quantity [8].The lack of autoclaves in some reference maternity hospitals would explain this absence of sterile fields.Scalpels were also temporarily unavailable in some formations.This suggests a simple stock management problem!
As for the equipment for the protection barrier, it is the first means used in infection prevention.It is accepted that the wearing of gown, clogs, cap, and bib is mandatory in the delivery room [8].During our survey, all maternity hospitals had this equipment.However, protective glasses or visors were not available.
This could be due to lack of resources or visual discomfort when some health workers wear protective eyewear.
Sterilization of equipment as the most effective means of infection prevention must be a priority for any surgical facility [9].Indeed, not all maternity hospitals had an autoclave and high level disinfection (HLD) equipment.At the national level, an evaluation conducted as part of the implementation of emergency obstetric and neonatal care revealed that 87% of babies existed in the reference maternity units [8].This would be explained by its more affordable cost.With the exception of the poupinel, high-level sterilization or disinfection equipment is lacking in the reference maternity hospitals in the city of Ouagadougou.
However, the baby doll is no longer recommended for effective sterilization.Instead, steam sterilization, using an autoclave [10], should be preferred.The latter allows the sterilization of a greater number of materials, compared to the poupinel [9].It would therefore be more appropriate for all reference maternity hospitals to purchase them.
Other materials and consumables are used for infection prevention such as running water, cutting edge boxes and garbage cans, which were available in all the reference maternity hospitals in the city of Ouagadougou.In most publications, the findings were similar [6] [8] [11].The use of hand towels, collective and individual towels is low.Nennig in France in 2009, in her study on cord care, found that paper towels were used to dry hands by caregivers in 89% of cases [12].The collective cloth towel is to be avoided, as it can be a source of cross-infection.Indeed, a hand towel, in a hospital setting, should only be used once, in order to avoid transmission to users [13].In addition to the hand towel, it is recommended to dry your hands outdoors.Most of these measures are simple to apply to prevent infections, which are the cause of neonatal death in 38% of cases [2].
In terms of infection prevention, hand hygiene is a quality indicator, highlighting the safety of health care systems [14].Hand washing was known to providers as a way to make hands clean.But friction with a hydro-alcoholic solution was cited only in 55.28% of cases.This result is explained by the non-existence of this product in the reference maternity hospitals.
Knowledge of the five own and their components is insufficient.It is true that this is a new concept, but this inadequacy is confirmed by the high neonatal mortality rate linked to infections of 32% [15].It is therefore necessary to regularly update the knowledge and practices of providers.
While in our study, the level of competence for infection prevention appears to be good, on the other hand, few providers had performed the procedures with perfect control.Indeed, more than half of the sample performed gestures to prevent infections in the birth room; but only half among them executed gestures satisfactorily.This analysis suggests that level of infection prevention practices is average among agents who apply it.The lack of equipment and insufficient knowledge could explain this poor execution of prevention measures.This is one of the reasons why infections remain at the forefront.It is appropriate for providers' practices to change.The objective of the training must be based on social and behavioral change, because the agents work routinely and are therefore no longer effective.

Limits
The limits of this study could be related on the one hand, to the duration of three months for the investigation; this delay did not allow enlisting all the providers since some of them were on leave.On the other hand, the presence of the interviewer may have sometimes influenced the behavior and the responses of the providers.But the results obtained are interesting and have been discussed, commented and compared to the data of the literature.

Conclusion
Equipment and materials for infection prevention in the neonatal period remain

D
. A. Some et al.DOI: 10.4236/ojog.2020.1010012137 Open Journal of Obstetrics and Gynecology childbirth and the immediate essential care of newborns (IECN).Only those who were present at the time of the study and gave their free and informed written consent to be interviewed and observed were included.

Table 1 .
Distribution of the sample according to socioprofessional characteristics.
3.2.Training Received on Newborn CareAll providers (100%) had received basic training in essential newborn care and 42% had subsequently received additional training, including emergency obstetric and neonatal care (24%), neonatal resuscitation (11%) and essential newborn care (4%).None had received training in the prevention and control of healthcare-associated infections.

Table 2 .
Frequency of responses on the components of the "five clean" (n = 123).

Table 3 .
Distribution of providers' competence elements on infection control according to the quality of their execution (n = 123).