Determinants of healthcare providers' confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia

Background: Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals' knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia.

Methods: This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics.

Results: Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers' mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence.

Conclusions: Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.