Factors Associated with Compliance with Infection Control Guidelines in the Management of Labour by Healthcare Workers at Mulago Hospital, Uganda

Globally, infections acquired during childbirth contribute to one tenth of the maternal deaths annually [1] [2]. Factors predisposing to high risks of puerperal infections include non-compliance with Standard Precautions of Infection Control (SPIC), unhygienic births by unskilled birth attendants, multiple vaginal examinations, prolonged labour and premature rapture of membranes [1]. The main purpose of this study was to determine factors associated with compliance to standard precautions of infection control the management of labour by healthcare workers in Mulago Hospital to generate in-formation, which may be used in infection control and prevention practices. A cross-sectional study utilizing a quantitative approach was conducted among 115 healthcare workers. Consecutive sampling was done to include respondents in the study. Data were collected by direct observation and researcher administered questionnaires. Data were coded and entered into the computer using SPSS version 20 with programmed quality control checks. Descriptive data analyses, frequencies, cross tabulations and logistic regression analysis were the major statistical methods used. 103 healthcare workers were involved in the study, where 74% were females. Overall compliance was at 52%, although it varied across domains. The majority of the healthcare workers (95.1%) did not comply with hand hygiene. Being a male was associated low compared to the Centre for Disease Control (CDC) recommendation. The findings in this study provide insight into individual and hospital related factors associated with compliance with standard precautions of infection control in the management of labour. There is an urgent need to put up interventions to improve on compliance with SPIC in management of labour among all healthcare workers.


Standard Precautions of Infection Control (SPIC) protocols replaced Universal
Precautions and were formulated to be used in the care of all patients regardless of their diagnosis [3] [4]. According to WHO (2016), SPIC include: hand hygiene, use of Personal Protective Equipment (PPE), observing aseptic non-touch technique, disinfection and sterilization of reusable equipment and clothing used during patient care, environmental control (e.g., surface cleaning), health service waste handling, appropriate waste segregation of sharps, waste segregation excluding sharps, and isolation of patient's in accordance to requirement levels as an infection transmission source.
Compliance with SPIC in the management of labour by all healthcare workers in all health care facilities and other health service centres is very crucial in preventing maternal peripartum infections [3] [5]. The WHO (2016) highly recommends practice of asepsis in six areas also known "the six cleans" which include clean delivery surface, clean hands of the birth attendant, clean perineum of the mother, clean cord cutting instrument, clean cord ligature and clean cord care. In spite of the long period since the introduction of the SPIC, full compliance is still a matter of concern in many healthcare facilities [6].
Globally, infections acquired during childbirth process contribute to one tenth of the maternal deaths annually [1] [2]. These infections are one of the leading causes of maternal mortality and morbidity, with sepsis accounting for as much as 15% of the 289,000 maternal lives lost globally every year [7] [8].
Factors predisposing to high risks of puerperal infections include non-compliance with SPIC, unhygienic births by unskilled birth attendants, multiple vaginal examinations, prolonged labour and premature rapture of foetal membranes home [1]. Other factors also include the flora of the delivery room, and the types of antibiotics used, [9].
The situation is worse in developing countries where resources for healthcare delivery are limited [10]. Sub-Saharan Africa contributes three quarters of the global estimate for maternal sepsis related deaths [1] [11]. If death does not occur, these infections have been identified as a leading cause of maternal morbid-ity, prolonged hospital stay, chronic disability, chronic pelvic pain and secondary infertility [12].
In Uganda, the second leading cause of maternal mortality after haemorrhage is sepsis, where the mortality rate stands at 14% (UDHS, 2016). Many hospitals reports have indicated a big number of mothers admitted in the hospital receiving care during labour and childbirth, develop puerperal sepsis [11]. Evidence has suggested that all deaths as a result of sepsis are preventable through hygienic practices and delivery environments and these have been historically well documented [13]. Healthcare workers have been identified to be in a key position in the prevention of hospital acquired infections [7] [14].
Non-compliance with standard precautions of infection on the side of healthcare workers has been linked to lack of adequate training in infection control protocols, lack of supplies in the healthcare facilities and work overload [15].
Other studies have suggested that lack of appropriate knowledge of SPIC, lack of Personal Protective Equipment (PPE), low-risk perception and low perception of institutional safety environment are frequent factors linked to non-compliance to SPIC (Gammon et al., 2008).
The WHO highly recommends compliance with the standard precautions of infections control during management of labour by all healthcare workers. Compliance with standard precautions on the part of Healthcare Workers (HCWs) has been emphasized as fundamental and efficient means of healthcare-associated infections for both patients and healthcare workers [16].
Mortality rate in Uganda due to sepsis has overwhelmingly increased to almost double from 8% and 14% between four years (UDHS, 2016; UDHS, 2012).
A recent study done in Mbarara regional referral and teaching hospital indicated that puerperal sepsis accounted for 30.9% of maternal deaths [11]. Yet healthcare workers are in a key position to preventing healthcare acquired infections [14]. This could be due to differences in professional background, inadequate training in SPIC, availability of standard operating procedures and work over load [15].
The existing evidence about the health care practitioners, infection control practices in the management of labour does not provide an in-depth insight about compliance with standard precautions of infection control.
In search for literature, there is paucity of data about this topic in maternity services although some studies have generally looked at general practices of SPIC in different areas of healthcare practice. Therefore, this study describes factors associated with compliance to standard precautions of infection control in the management of labour by healthcare workers at Mulago Hospital.

Study Design
specific point of time and the investigator measures the outcome and the exposure in the study participants at the same time (Gordis, 2009). Cross sectional study design is cheap and yet good at estimating the prevalence of the problem because data on the cause and outcome are collected at the same time [17]. This design was used because it is reliable at estimating the magnitude (compliance) and determinants of the phenomenon.

Study Site
The study was carried out in Mulago National Referral hospital, department of Obstetrics

Study Population
The study population comprised of HCWs (midwives, nurse midwives, intern nurses and midwives, senior house officers, obstetricians) who are 163 in total as per monthly duty roster (Hospital labour suite, statistics) at Mulago hospital working in the department of obstetrics and gynecology in labour suite units.

Inclusion Criteria
The study included HCWs (Nurses, midwives, intern nurses, nurse/midwives, intern doctors, obstetricians and senior house officers) who are involved in the management of labour.

Exclusion Criteria
The study excluded healthcare workers who are sick, those on leave and those busy with administrative work.

Sampling Procedure
The study utilized non probability quota sampling proportionate to size using convenience sampling. A fair representation of all cadres was considered by selecting a participant from all cadres to be included in the study. The first res-  The confidence level of the researcher in this study was at 95% (Hence z = 1.96).

Sample Size Determination
Compliance among healthcare workers in Tanzania stands at 49.7% [18].
The degree of precision in the study was estimated at 5% (Hence d = 0.05).
Substituting in the above formula, therefore:   Compliance means that the correct action has been taken. For example, for the domain of hand hygiene (Table 1 of the observation checklist), the indication "Before touching the patient" indicates the possibility that physical contact could lead to microbial transmission. The correct action corresponding to this indication is "Health-care worker washed his or her hands with soap and water or used an alcohol-based hand rub).

Independent Variables
Independent variables associated with compliance to SPIC include: socio-demographics variables include gender and professional category, qualification, cadre, work these were measured using a questionnaire (see Appendix II).

Data Collection Methods
This was a non-intrusive as the healthcare workers were left to do what they usually do while practicing infection control and prevention measures in labour suite unless there is a life-threatening event that forces the observer to intervene.
If this happened, then that case would be dropped, but this never happened throughout the study. During the direct observation by the principal investigator created a rapport with the study participant to pave a way to ask the few questions which are in the questionnaire indirectly in a manner that the respondent never considered this an observation of their practices. The observed data was

Data Collection Procedure
Administrative clearance from Mulago hospital institutional review board was sought. Institutional consent was obtained from the unit managers to minimize on the change of behavior. Healthcare workers were identified by use of a duty roster before a shift. Since the study was unobtrusive (covert) direct observation, deferred consent was sought after the study where the principal investigator debriefed the participants about the study and the findings and asked them whether they would allow their findings be used for data analysis. In addition, those who objected this their findings were not included for data analysis.

Data Collection Tools
An observation checklist was modified from CDC (2008) infection control assessment tool and a validated observation checklist of a study, which was done in Kenya, to assess compliance by practices of the HCWs on SPIC [5].
A pilot study of 10 HCWs was conducted at Naguru Regional Referral Hospital labour ward, which has similar characteristics as the study area to test the tool for validity and reliability.

Quality Control Measures
The Principal Investigator collected data in order to avoid bias by other researchers and directly observed the performance of HCWs to avoid change of The questionnaire was pretested before data collection on 10 HCWs from Naguru hospital since it has similar characteristics of being also a referral facility as Mulago national referral hospital.
To improve validity/reliability of data collection on observational studies, the principal investigator through participative observation offered an assistive role to the healthcare worker performing the procedure. Interviews were conducted alongside the participative by the principal investigator. This was adopted as strategy to minimize the Wharthone's effect.
Quality of data collected was ensured by cross checking completeness of the data checklist and the questionnaire, which was used to assess the individual and facility factors. The principal investigator also crosschecked all filled data collection tools at the end of each data collection shift.

Data Management and Analysis
Data collected was entered, cleaned and analyzed using SPSS version 20 to generate descriptive statistics.
Overall compliance and non-compliance was calculated by adding up all percentages from each domain then divided by the total number of domains which was 6 this method was obtained from different studies which were conducted on compliance with infection control practices [5].
A binary score of yes (performed) and no (not performed) were used for the six domains of SPIC.
In addition, to generate descriptive statistics, categorical variables were described in form of frequencies, percentages and texts.
For objective one, data was analyzed to yield percentages of compliance of respondents and was be presented in form of a table and pie chart.
The objective two and three data were analyzed by chi square test/cross tabulation to yield frequencies, percentages and p-values for each SPIC domain. This method was utilized because the some of the data had no values hence this would not yield the Odds Ratios (OR) and Confidence Intervals (CI).

Ethical Considerations
Approval to do the study was sought from the School of Health Sciences Re-

Social Demographic Characteristics/Individual Factors of the Respondents
The study involved 115 but only data for 103 respondents who offered differed consent were analyzed. Majority of the participants were females (74%). Most of the respondents were midwives (44%) and almost a half of the respondents (48%) were bachelor's degree holders as a level of academic qualification. Half of the study participants (51%) worked in other health facilities/multiple places.
Other characteristics are presented in Table 1 below.
In Table 2, majority (84%) of the healthcare workers had not seen the standard operating procedures (SOPs) at the facility. Moreover, majority (65%) had not had an in-service training on SPIC. Table 3, shows proportions of compliance with SPIC by health care workers in management of labour in the six domains which are hand hygiene, personal protective equipment, equipment processing and surfaces, waste segregation of sharps, waste segregation excluding sharps and the non-touch technique. Study results show that the majority (95.1%) of the HCWs did not comply with hand hygiene compared to other domains of SPIC in the management of labour. However, the observation tool captured that majority (94.2%) of the HCWs complied with use of PPE and 77.7% complied with waste segregation of sharps.    likely to comply than other levels of qualification. Results also indicate that work in different places was statistically associated with compliance to hand hygiene (p-value 0.018). In the same Table 4 below results indicate that majority of the females (73%) used Personal Protecting Equipment (PPE).
In Table 5, results indicate majority of the females complied to equipment processing compared to their male counterparts and gender was significantly  associated with compliance to equipment processing (p-value 0.049). In the same   respectively). In the same Table 6 results indicated, that and observing the non-touch technique was statistically associated with professional cadre and level of qualification with p-values of 0.007 and 0.009 respectively. Table 7 shows the Hospital/Facility related factors associated with standard precaution of infection control in management of labour among healthcare workers. It is indicated that having had an in-service training was significantly associated with complying to hand hygiene (p = 0.018).   In Table 9, results show that majority of the people (74%) who complied with wate segregation excluding sharps had had an inservice training.

Bivariate Analysis
Individual factors associated with compliance to standard precautions of infection control in management of labour among healthcare workers at bivariate analysis was done for those variables that had numbers that can be computed to get the odds ratios and confidence intervals and aggregated results are shown in Table 10.
The results indicated in   experience of 5 years and below were two times more likely to comply with hand hygiene and disinfection of re-usable equipment than those with more than five years work experience. In

Multivariate Analysis
Multivariate analysis was carried out to control for confounders using only   Table 13 below. Results in Table 13 below indicate that, having had an in-service training was statistically associated with compliance to hand hygiene. Table 14 below indicates results obtained from multivariate analysis of the association of waste segregation excluding sharps. Results show that being a female was statistically significant with waste segregation excluding sharps (p = 0.000).

Individual Factors Associated with Compliance to Standard Precautions of Infection Control in Management of Labour by Healthcare Workers
The social demographic characteristics in this study were also regarded as individual factors. Data from 103 study participants were analysed. Results indicate  This study demonstrated that compliance with standard precautions of infection control was generally highly associated with the above mentioned. Although the overall score was low, obstetricians in all the domains of SPIC had lower scores compared to other professional cadres for example in the hand hygiene domain where 100% of this cadre did not comply. This could have been as a result of work overload as it is indicated in Uganda the doctor patient ratio currently stands at 1:25,725 (UDHS, 2016).
It was found that majority of the medical intern (60%) were more compliant with hand hygiene compared to other professional cadres. The findings in this study were also congruent with those a study done in Jordan [19] which found out that nurses had significant higher compliance than physicians with mean = 4.91 (p = 004).
In our study, females scored higher than males in overall compliance with a statistically significance difference. This was in agreement with a study done in Jordan about factors influencing compliance with infection control precautions among 211 nurses and physicians from private and public hospitals, it was indicated that there was a significant positive correlation between compliance and individual factors such as gender where being a female was likely to be associated with compliance to SPIC. The female HCWs' compliance with SPIC might be due to the natural proneness of female employee to obey and execute institutional rules and regulations [10]. Moreover, in Uganda women take a major role in cleaning, cooking and caretaking this could make them cautious about infection control and prevention to their family. of their family Females are usually seen performing duties that require cleanliness as part of their gender roles.
In this study work experience of 2 -4 years was significantly (p value 0.043) associated with compliance with waste segregation of sharps. This is in contrast with pertinent studies where having more experience in clinical services was found to be significantly associated with compliance. For instance a study done in India [20] which indicated length of time was statistically significant with compliance (p = 0.014) where those who had longer stay on job had better compliance. Our study findings of a short work experience could be related to the fact that these healthcare workers are fresh graduates and inspired in applying knowledge into skills, this could also be explained by the Bloom's taxonomy of the learning domains, where the higher the level of learning, the more the learners will tend to apply more of the psychomotor domain. Results in this study, indicated that work in multiple places influenced compliance with hand hygiene and segregation of waste excluding sharps negatively.
It was apparent that respondents working in multiple places showed lower compliance scores compared to those who did not. Work overload has also been found to influence stress and hence decrease competence among healthcare workers [21]. This could be due to the fact that, Mulago as a national referral hospital, receives an overwhelmingly huge numbers of mothers in labour yet there is inadequate staffing. In Uganda currently the doctor-patient ratio stands at 1:25,725 and nurse-patient ratio at 1:11,000 (UBOS, 2012). The doctors tend to get involved in dual practice in order for them to cope with low pay in the public health facilities such as Mulago National Referral Hospital. The results from this study agree with previous studies such as study conducted in Brazil [22] and another study in China [23], while a study done in Italy [24] showed lower scores of 15% among healthcare workers who had a side job. This conforms to Piai-Morais et al. (2015) in his conclusion that work overload negatively affects compliance. In this study, aseptic non-touch technique showed statistical significance with professional cadre and level of education both at Univariate and at bivariate analysis. It was also indicated that Obstetricians were 6 times more likely to comply with the asepsis non-touch technique compared to the midwives. Aseptic non-touch technique is one of the core components of SPIC, which involves a set of actions, aimed at preventing transmission of pathogenic infections to the patient (CDC, 2010). Aseptic non-touch technique vocabulary has been used interchangeably with other words which changes meaning and causes confusion which could contribute to practice variability [25]. The results from this were in congruent with the findings from a study done on two London hospitals [25] where Physicians were more compliant than the nurses in observing the non-touch technique. This could be explained by the different training systems that could have an impact on the practice outcomes especially when it comes to clinical practice [26].

Hospital Related Factors Associated with Compliance to Standard Precautions of Infection Control in the Management of Labour
In this study, it was also found out that having had an in-service training on standard precautions of infection, control and having seen SOPs were associated to compliance with waste segregation of sharps, waste segregation excluding sharps and observing the Aseptic non-touch technique. The Odds Ratios at bivariate analysis indicated those who had seen SOPs and those who had gone through in-service training in SPIC were two times more likely to comply with these domains of standard precautions of infection control. The main purpose of standard operating procedures is to inform all healthcare workers of the correct steps to follow during the practice of SPIC this is also seen to improve knowledge on SPIC [27]. In a quasi-experimental study on the effectiveness of SOPs It was also apparent in a recent pragmatic evaluation study in 2 London hospitals [25] where a bigger proportion of staff (37/49, 76%), thought that their practice had greatly improved and 98% of these staff considered the training had helped to standardize aseptic technique practices.
Similar findings were shown in a study done in Brazil [22] where practice of SPIC was highly influenced by availability of standard operating procedures at the hospital and continuous medical training on SPIC. In contrary, an observation study on compliance with infection control and prevention in Kenya Bedoya et al., (2017), concluded that there was a weak association between compliance and availability of all infection control supplies. In service training to all healthcare workers, despite of their professional cadres and academic qualification is vital concerning infection control and prevention in labour suites in order to prevent hospital-acquired infections to all mothers who are in labour.
The results from this study reveal lack of strategic approach for infection control and prevention in the labour suites of Mulago national referral hospital. It was shown in this study that there are no standard operating guidelines in this institution, yet there are several strategies set by the WHO for infection control and prevention in maternal health facilities for developing countries [1]. These strategies include development of an institutional infection control programme which consist of use of infection control and prevention manuals, education and training of HCWs, infection control teams and committees and audit of maternal deaths [28].

Study Limitations
This study had the following limitations: Compliance was measured by direct observation, which would bring about the Hawthorne's effect among the study participants, to minimize on this the re-searcher utilized direct unobtrusive observation when the healthcare workers performed their procedures in care for mothers in labour.
The other limitation is that the study was cross-sectional in nature, which does not establish the definitive and effect of a relationship between the dependent, and independent variables, this was maximized by combining observation together with interviews from researcher-administered questionnaire.

Strengths of the Study
According to my understanding, this study was the first to determine compliance with standard precautions of infection control in management of labour by healthcare workers in Uganda and sub-Saharan Africa.
Compliance was measured by direct observation, which has been considered a gold standard to measure compliance by various researchers.

Conclusions
Overall compliance to standard precautions of infection control was low at 52% although it varied across domains.
The findings in this study provide insight into individual and hospital related factors associated with compliance with standard precautions of infection control in management of labour. These factors include: gender, professional cadre, level of education, having had n-service training and availability of supplies for infection control measures at the institution.

Recommendations
Based on the above findings in the study, the following recommendations were made 1) There is an urgent need to put up interventions to improve on compliance with SPIC in management of labour among all healthcare workers because mothers in labour are at very high risk to acquisition of infections during this course of childbirth.
2) Establishment of appropriate strategies and policies which include; accountable infection control committee/team, regular in-service training of HCWs in SP, adequate supply of PPE and provision standard operating procedures in all parts of the facility

Implications for Practice
As healthcare workers it is very important to observe compliance with standard precautions of infection control in the management of labour since were in the best position to control/prevent hospital-acquired infection. There's need to strengthen policies regarding infection control and prevent at all levels of management.

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