International Journal of Public Health Science (IJPHS)

Vol. 12, No. 4, December 2023, pp. 1555~1561

ISSN: 2252-8806, DOI: 10.11591/ijphs.v12i4.22987  1555

Factors influencing healthcare workers' perceptions towards

comprehensive emergency obstetric and newborn care
Yusrawati1, Titik Respati2, Nanan Sekarwana3
1
Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Andalas, Padang, Indonesia
2
Department of Public Health, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia
3
Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia

Article Info ABSTRACT

Article history: In tertiary hospitals, comprehensive emergency obstetric and newborn care
(CEmONC) provides subspecialty care for high-risk maternal and neonatal
Received Jan 16, 2023 emergency cases. Healthcare workers (HCWs) play critical roles in hospital
Revised Aug 25, 2023 services, and their perception affects the quality of care they provide. Hence,
Accepted Sep 19, 2023 this study was conducted to analyze the factors influencing HCWs’
perception regarding CEmONC in a tertiary referral hospital. This cross-
sectional study used an electronic questionnaire distributed to 198 CEmONC
Keywords: team members. The sample was selected by convenience sampling, and
those who had worked for at least one year were included. The collected data
Emergency hospital services were then analyzed using bivariate and multivariate analysis. Among 119
Healthcare workers HCWs, 52.9% had a positive perception towards CEmONC implementation
Logistic regression at the hospital. The result of logistic regression analysis found that the
Obstetrics significant factors contributing to HCWs’ positive perceptions were good
Perception knowledge (AOR=33.484; p=0.001), good attitude (AOR=55.834; p=0.009),
Tertiary healthcare high motivation (AOR=12.579; p=0.005), high expectations (AOR =27.106;
p=0.002), and good actual performance (AOR=45.879; p=0.003). Age,
gender, professional background, and the length of work experience were
not associated with HCWs’ perceptions (p>0.05). Therefore, hospital
administrators must regularly evaluate these factors to improve the quality of
CEmONC services in the hospital so that maternal and infant mortality rates
can be reduced.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Yusrawati
Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine,
Universitas Andalas
Perintis Kemerdekaan No 94, Padang, West Sumatra, 25172, Indonesia
E-mail: [email protected]

1. INTRODUCTION
Reducing the global maternal mortality rate (MMR) to at least 70 deaths per 100,000 live births and
the infant mortality rate (IMR) to less than 12 per 1,000 live births by 2030 is one of the Sustainability
Development Goals (SDGs) targets [1]. In Indonesia, this target is still far from being achieved, where the
MMR is 305 per 100,000 live births, and the IMR is 24 per 1,000 live births [2]. To achieve this target, all
hospitals should provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services as
part of the integrated maternal and neonatal emergency care system [3]. This service must be available within
24 hours, which includes: i) administration of parenteral antibiotics, anticonvulsants, or uterotonics; ii) the
manual removal of the placenta; iii) manual vacuum aspiration, dilation or curettage for retained products; iv)
assisted vaginal delivery; v) resuscitation for newborns; vi) emergency delivery with a caesarean section; and
vii) blood transfusion [3], [4].

Journal homepage: http://ijphs.iaescore.com

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Based on the Indonesian National Guideline, the CEmONC program is implemented to prevent
maternal and neonatal death, with a different scope of services based on the clinical and management
performance standards criteria of each hospital type [3]. A tertiary hospital has higher capabilities in
managing complicated cases compared to other lower-level hospitals. This type of hospital must be able to
provide subspecialty care for high-risk maternal cases, such as pregnancy with multi-organ failure, which
must be handled by a fetomaternal consultant and needs inter-department consultation. In addition, it is also
responsible for addressing intensive neonatal care for high-risk newborns, such as critically ill neonates with
hemodynamic instability or severe respiratory distress who require advanced life support and are treated
under the supervision of a neonatologist [3], [5].
The success of hospital care depends on the performance of the healthcare workers (HCWs)
involved in providing the service [6]. Many factors affect performance, one of which is the HCWs’
perception of the program implemented in their workplace [7]. One study revealed that the perception of
health workers towards the CEmONC services in a hospital is the second most dominating factor influencing
their performance quality [8]. Robbins et al. [9] stated that perceptions could directly affect employees’
participation and commitment, which can further improve their work productivity. Perception is also related
to a person’s decision-making process and impacts their positive work behavior to achieve the expected goal
[10].
In the healthcare setting, HCWs’ perception is one of the determinant factors of patient safety
culture [11]. By having positive views, adverse medical occurrences could be prevented, and the mortality
rate could be reduced [12]. Hence, hospital administrators should consider the health workers’ perceptions to
improve the quality of patients’ care. However, there is no previous study concerning the factors affecting
HCWs’ perception regarding CEmONC services in the tertiary referral hospital. Therefore, this study was
performed to analyze the influencing factors of the HCWs’ perceptions towards the implementation of
CEmONC services in a tertiary hospital.

2. RESEARCH METHOD
This was a cross-sectional study used an electronic, self-administered questionnaire distributed to all
healthcare team members involved in providing CEmONC services at a tertiary hospital in Indonesia, with a
total population of 198 people. The sample in this study was selected using a convenience sampling method.
Those who had work experience for more than one year, agree to participate in this study, and are able to use
electronic questionnaire tools were eligible to be included in this survey. A total of 129 participants
submitted the questionnaire, of which 119 were included. Meanwhile, ten respondents who had worked as
CEmONC team members for less than a year were excluded. This study was approved by the Health
Research Ethics Committee of the hospital (Ethical Approval No. LB.02.02/5.7/151/2022).
The questionnaire was prepared by the researchers and validated by two supervisors, and was
presented in Bahasa Indonesia to minimize the risk of information bias. This self-developed questionnaire
was tested for validity and reliability using Pearson Correlation analysis and Cronbach's alpha method, before
being distributed to the participants. In this study, the researchers initially approached the participants with a
detailed explanation of research, and they were then asked to fill out an informed consent page before
answering the online questionnaire through Google Form (Google LLC, USA). To complete the survey, they
must provide personal characteristic data (age, gender, professional background, and the length of work
experience), as well as answer a total of twenty questions on five-point Likert scales that were used to assess
five variables affecting perceptions, which are: knowledge (6 items), attitude (3 items), motivation (4 items),
expectations (4 items), and actual performance (3 items). Furthermore, the perception was measured as the
total accumulation of those 20 items in the questionnaire. The online questionnaire was opened from June to
July 2022 until data saturation occured.
In this study, bivariate and multivariate analysis were performed to determine the factors influencing
HCWs’ perceptions. The data were analyzed using SPSS software version 23.0 (IBM Corp., USA). The
categorical data were calculated as frequencies (n) and percentages (%). Variable knowledge, attitude,
motivation, expectations and actual performance were measured by calculating the median score as the data
were non-normally distributed. If participants scored more than or equal to the median, it was categorized as
good/high, whereas if they scored less than the median, it was categorized as poor/low. So is perception; it
was categorized as positive if they scored more than the median and negative if they scored less than the
median. Bivariate analysis using the Chi-square test was initially conducted, and all variables with a
significance level p-value <0.25 were further analyzed using binary logistic regression for multivariable
analysis. Statistical significance was set at p-value <0.05.

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3. RESULTS AND DISCUSSION

The subjects’ characteristics, as well as the frequency and percentage of each variable, are shown in
Table 1. The majority of the participants were 31-40 years (48.7%), female (84.0%), worked as midwives or
nurses (70.6%), and had been providing CEmONC services for more than ten years (49.6%).

Table 1. Characteristics of participants (n=119)

Characteristics Groups n (%)
Age, years 20-30 23 (19.3)
31-40 58 (48.7)
41-50 22 (18.5)
>50 16 (13.4)
Gender Male 19 (16.0)
Female 100 (84.0)
Professional background Supporting staff 12 (10.1)
Midwives/Nurses 84 (70.6)
Non-Consultant doctors 11 (9.2)
Consultant doctors 12 (10.1)
Length of work, years 1-5 34 (28.6)
5-10 26 (21.8)
>10 59 (49.6)
Knowledge Poor 45 (37.8)
Good 74 (62.2)
Attitude Poor 41 (34.5)
Good 78 (65.5)
Motivation Low 42 (35.3)
High 77 (64.7)
Expectations Low 52 (43.7)
High 67 (56.3)
Actual Performance Poor 52 (43.7)
Good 67 (56.3)
n: frequency

The results of the bivariate analysis are provided in Table 2. The percentage of HCWs with positive
perception was higher in the age range 41-50 years than those who aged 31-40 years (72.7% versus 36.2%).
In addition, male participants (68.4%) had more positive perceptions than females (50%). Based on
occupational characteristics, HCWs who had professional backgrounds as consultant doctors were more
likely to positively perceive the CEmONC services implementation at the hospital (OR=1.429; 95% CI
0.271-7.518) than those who worked as supporting staff. Also, HCWs who had work experience for 5-10
years and more than ten years were almost twice more likely to have a positive perception than those who
worked for less than five years, with OR 1.948 (95% CI 0.692-5.485) and 1.943 (CI 95% 0.825-4.574)
respectively.
In the multivariate analysis, eight variables with p-value of less than 0.25 remained in the regression
model, in which the professional background variable was excluded in this step. The Hosmer and Lemeshow
Test showed a significance of 0.947, which indicates that the model tested is acceptable goodness of fit. A
Nagelkerke R Square of 0.841 means that the eight variables explained 84.1% of the factors influencing
HCWs’ perception. The Omnibus Tests results obtained a significance p-value (<0.001), so there is a
significant simultaneous effect of the remained variables on the HCWs’ perception. Based on the partial
analysis, five variables were defined as the significant factors influencing HCWs’ perception of the
CEmONC services at the hospital, which are knowledge (p=0.001), attitude (p=0.009), motivation (p=0.005),
expectations (p=0.002), and actual performance (p=0.003). The values of B (beta coefficient), the
exponential B/ Exp(B) (adjusted odds ratio/AOR), and the significance, are presented in Table 3.
This study was aimed to analyze the factors influencing healthcare team members’ perceptions
towards the implementation of CEmONC services at a tertiary hospital. As the highest referral healthcare
facility, the hospital must provide 24-hour subspecialty care to handle emergency cases of high-risk maternal
and neonatal patients to prevent the death of mothers and newborns [3], [7]. HCWs play critical roles in
emergency medical services, and their perception affects the quality of care they provide [7], [13]. Perception
is a series of psychological processes in understanding an object, which can be interpreted differently by each
individual [14]. In the workplace setting, perceptions could directly affect employees’ participation and
commitment, which can further improve their work productivity [9], [15].
This study found that only 52.9% of participants positively perceived the implementation of
CEmONC services, which indicates that the quality of care provided at the hospital is still not optimal. The
analysis found that knowledge, attitude, motivation, expectations, and actual performance were influencing

Factors influencing healthcare workers' perceptions towards comprehensive … (Yusrawati)

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HCWs’ perception, with p-value less than 0.05. These findings add evidence and strengthen previous studies
related to the affecting factors of health workers’ perception, which previously had been limited in the
primary healthcare setting [16].

Table 2. Factors influencing HCWs’ perceptions (bivariate analysis)

Perception
Variables p-value* Unadjusted OR (95% CI)
Negative n (%) (n=56) Positiven (%) (n=63)
Age
20-30 years (ref.) 8 (34.8) 15 (65.2) 1.00
31-40 years 37 (63.8) 21 (36.2) 0.021 0.303 (0.110-0.832)
41-50 years 6 (27.3) 16 (72.7) 0.587 1.422 (0.399-5.072)
>50 years 5 (31.2) 11 (68.8) 0.818 1.173 (0.301-4.579)
Gender
Male (ref.) 6 (31.6) 13 (68.4) 1.00
Female 50 (50) 50 (50) 0.147 0.462 (0.163-1.311)
Professional Background
Supporting staff (ref.) 5 (41.7) 7 (58.3) 1.00
Midwives/Nurses 40 (47.6) 44 (52.4) 0.700 0.786 (0.231-2.674)
Non-Consultant doctors 7 (63.6) 4 (36.4) 0.296 0.408 (0.076-2.193)
Consultant doctors 4 (33.3) 8 (66.7) 0.674 1.429 (0.271-7.518)
Length of Work
1-5 years (ref.) 20 (58.8) 14 (41.2) 1.00
5-10 years 11 (42.3) 15 (57.7) 0.207 1.948 (0.692-5.485)
>10 years 25 (42.4) 34 (57.6) 0.128 1.943 (0.825-4.574)
Knowledge
Poor (ref.) 37 (82.2) 8 (17.8) 1.00
Good 19 (25.7) 55 (74.3) <0.001 13.388 (5.308-33.771)
Attitude
Poor (ref.) 37 (90.2) 4 (9.8) 1.00
Good 19 (24.4) 59 (75.6) <0.001 28.724 (9.060-91.069)
Motivation
Low (ref.) 32 (76.2) 10 (23.8) 1.00
High 24 (31.2) 53 (68.8) <0.001 7.067 (2.995-16.672)
Expectations
Low (ref.) 44 (84.6) 8 (15.4) 1.00
High 12 (17.9) 55 (82.1) <0.001 25.208 (9.475-67.066)
Actual Performance
Poor (ref.) 31 (59.6) 21 (40.4) 1.00
Good 25 (37.3) 42 (62.7) 0.017 2.480 (1.180-5.213)
OR=odds ratio; CI=confidence interval; ref.=reference group
*Chi-square test, all variables with p<0.25 in the bivariate analysis using Chi-square test were included in the multivariate analysis

Table 3. Factors influencing HCWs’ perceptions (multivariate analysis)

95% CI
Characteristic B S.E. Wald df p-value† Adjusted OR
Lower Upper
Age -0.282 0.597 0.224 1 0.636 0.754 0.234 2.430
Gender 0.006 0.997 <0.001 1 0.995 1.006 0.143 7.096
Length of work 0.672 0.764 0.774 1 0.379 1.959 0.438 8.761
Knowledge 3.511 1.027 11.697 1 0.001 33.484 4.477 250.433
Attitude 4.022 1.536 6.857 1 0.009 55.834 2.750 1133.504
Motivation 2.532 0.901 7.903 1 0.005 12.579 2.153 73.501
Expectations 3.300 1.040 10.071 1 0.002 27.106 3.532 208.030
Actual performance 3.826 1.270 9.075 1 0.003 45.879 3.807 552.955
Constant -28.383 7.123 15.877 1 .000 .000
B=beta coefficient; S.E=standard error; df=degree of freedom; OR=odds ratio; CI=confidence interval
†Binary logistic regression test, significant if p <0.05. Eight variables were remained in the multivariate analysis, R² =0.841
(Nagelkerke)

The current study revealed that the most important factor affecting healthcare team members’
perception was attitudes, with an AOR of 55.834 (95% CI 2.750-1133.504). The attitude of HCWs was
assessed by their teamwork behavior, the sense of responsibility, and awareness of their competence in
providing the CEmONC services at the hospital. Karademirler et al. [17] stated that teamwork among
healthcare providers is an essential element in improving patient safety, which is a critical issue in pediatric
healthcare services. Basically, it is because the care of a patient does not only require the responsibility of one
person but is the responsibility of the entire team of health workers who coordinate with each other [18]. If it
is neglected, medical errors can occur, and newborns being the most vulnerable group affected by patient
safety incidents [17], [19].

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The second most essential factor affecting HCW’s perception is the actual performance
(AOR=45.879; 95% CI 3.807-552.955), defined as the factual activities of maternal and neonatal service
relative to the performance standard. An expert mentioned that experience is closely related to perception, in
which a person with a successful experience tends to have a positive perception [20]. In contrast, people will
have a negative perception when the expected goal is not achieved.
This study also found that a healthcare professional with good knowledge is about 33 times more
likely to perceive the implementation of CEmONC services positively (AOR=33.484; 95%
CI 4.477-250.433). This is supported by the result of a previous study that knowledge is the main factor
affecting nurses’ perception of the triage system, which contributes to their decision-making in providing
care for emergency patients [21]. These findings emphasize that being professionally trained is crucial for
HCWs to provide better care services [22]. The competence of healthcare professionals has a favorable
impact on patient satisfaction [23], which in turn affect patients' trust and clinical outcomes [24]. Thus, the
hospital management team should consider the importance of knowledge among CEmONC team members
and should provide continuing education to increase HCWs’ capacity in handling maternal and neonatal
emergency cases [8], [25]. The training can be carried out in collaboration with other institutions or by
competent speakers from the hospital [3], [26].
In addition, HCWs’ expectation regarding their supporting system was also found to have a strong
association with their perception (AOR 27.106; 95% CI 3.532-208.030). The results of this study are also in
line with a study conducted by Hanifah et al. [27] that there is a relationship between expectations and one’s
perception, in which individuals with high expectations tend to have good perceptions. Furthermore, the
individual’s expectation towards positive feedback that they receive will directly affect their performance
[28]. Similarly, Kiyici et al. [29] revealed that nurses who are highly satisfied with their work environment
would focus more on patient care and provide a higher quality of healthcare services.
This study also demonstrated that motivation was significantly correlated to the perception formed
by HCWs regarding the hospital healthcare services (AOR 12.579; 95% CI 2.153-73.501). This finding is in
line with the study conducted by Madiistriyatno et al. [30] that high motivation at the workplace will affect
health workers’ perceptions so that they will provide excellent service and good work productivity. Also,
Aduo-Adjei et al. [31] revealed that motivation is key to the work performance of healthcare professional.
The quality of the healthcare system is associated with the efficiency and effectiveness of services provided,
which depends on HCWs' motivation. Thus, hospital managers should be aware about the importance of
providing support for health workers [32]. HCWs’ motivation can be boosted when they have close
engagement with the managerial team, which will facilitate them to discuss challenges and find possible
solutions regarding patients’ care [33].
However, this study had several limitations. First, this study used a self-reported questionnaire, in
which participants might not fully understand the question and causing information bias. Second, the cross-
sectional design used in this study was not an ideal method for determining causal relationships. This study
was also only conducted in one hospital in Indonesia, which could not be generalized to the actual situation
in all tertiary referral hospitals in the country. Further studies, such as multi-center research with cohort
design or direct examinations, are suggested to better acknowledge the relations.

4. CONCLUSION
In conclusion, the influencing factors for HCWs’ perception towards the implementation of
CEmONC services at a tertiary-level hospital were knowledge, attitude, motivation, expectations, and actual
performance. Meanwhile, age, gender, professional background, and the length of work experience were not
significantly associated with the HCWs’ perception. Therefore, the hospital management team should
monitor and evaluate those affecting factors periodically to improve the quality of CEmONC services and
can further reduce the maternal and neonatal mortality rate.

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BIOGRAPHIES OF AUTHORS

Yusrawati is a professor of fetal and medicine, as well as an obstetrician who

provides fetomaternal services for the health of mothers and prospective babies by prioritizing
quality and patient safety. She is also a lecturer at the medical faculty of Universitas Andalas
Padang. Besides, she also focuses on hospital management at M. Djamil Padang Hospital,
Indonesia. She can be contacted by email: [email protected].

Titik Respati is a lecturer at the faculty of medicine and the master's program in
management at Universitas Islam Bandung. She is also responsible as the secretary of the
Institute for Research and Community Service at the same university. She is an author of many
international peer-reviewed publications, and her research interest mainly focuses on public
health. She can be contacted by email: [email protected].

Nanan Sekarwana is a pediatric nephrology professor who wrote a book related

to his expert entitled "Buku Ajar Nefrologi Anak". He is also a lecturer in the master's program
of midwifery at Universitas Padjadjaran and the dean of the medical faculty at Universitas
Islam Bandung. He has published a lot of scientific articles in reputable journals on the subject
of child health. He can be contacted by email: [email protected].

Factors influencing healthcare workers' perceptions towards comprehensive … (Yusrawati)