The neonatal death rate has generally declined globally by more than half from 1990 to 2018 (from 37/1000 to 19/1000 live births), yet neonatal deaths account for 47% of all under-5 child mortality (World Health Organization [WHO] 2019a). Ninety-eight per cent of new-born mortality occurs in low- and middle-income countries (LMICs), of which 78% occur in sub-Saharan Africa and Asia. The Saving Babies Report revealed that 2.2% of the neonatal deaths in South Africa are due to pregnancy-related infections, and 48.0% of unexplained intra-uterine deaths occurred in women with no obstetric complications (South Africa National Department of Health 2017).

Perinatal infection was reported by the WHO to be the third-highest death factor for maternal mortality rates in the world in 2013, and United Nations Children’s Fund (UNICEF) reported that primary causes of new-born deaths include premature births (35%), complications around the time of birth 24%), and infections such as sepsis and meningitis (15%) and pneumonia (6%) (UNICEF 2018). Inclusive of these infections is chorioamnionitis, which is defined as an inflammation (elicited by an immune response) or infection (elicited by bacterial infection) of the foetal sac, and is a cause of neonatal infections (El Malek, Embleton & Loughney 2015; Gantert et al. 2010).

A new name for chorioamnionitis was suggested by the National Institute of Child Health and Human Development expert panel: ‘Intrauterine inflammation or infection or both’, abbreviated as ‘Triple I’, which has been proposed to include all the parameters of chorioamnionitis that involve the amniotic fluid, foetus, umbilical cord or placenta as well as the foetal membranes (Peng et al. 2018). The inflammation or infection may extend to the placenta and the uterine muscle in more severe cases.

Chorioamnionitis is caused by ascending infections such as organisms that cause vaginitis, streptococcal infections (in the form of a urinary tract infection [UTI]) and other underlying infections, which ascend the vaginal tract to affect the foetal membranes. Allen and Yudin (2012) report that UTIs caused by the bacteria Escherichia coli, Ureaplasma urealyticum and group B streptococci were highlighted in research studies as culprits in ascending bacterial infections that cause chorioamnionitis. UTIs, bacterial vaginitis and other sexually transmitted infections, which are part of the burden of disease in South Africa, and a concern in pregnancy, were also culprits in ascending bacterial infection causing premature deliveries, maternal infections and intra-amniotic infections (Brocklehurst et al. 2013).

Clinical studies in South Africa emerged from the study of placentas of babies born with low Apgar scores. Moore, Arnold and Wright (2013) examined 72 placentas of premature infants who had surgery for necrotising enterocolitis. The results suggested that antenatal placental infection contributed to the pathology of necrotising enterocolitis of neonates.

Identifying intrapartum intraamniotic infection early and implementing treatment recommendations are essential steps to minimise morbidity and mortality for women and new-borns (Committee on Obstetric Practice 2017). Timely maternal management, together with notification of the neonatal healthcare providers, will facilitate appropriate evaluation and antibiotic treatment when indicated. Intraamniotic infection alone is rarely, if ever, an indication for caesarean delivery. Complications of chorioamnionitis include post-partum haemorrhage and uterine sepsis. Neonates who were exposed to chorioamnionitis showed signs of respiratory distress syndrome and post-partum infections, such as lung infections (Jones et al. 2013).

Maternal complications such as chorioamnionitis, premature birth and intra-uterine deaths are higher among populations within the lower socioeconomic and educational levels (WHO 2019b). The long-term health effects of chorioamnionitis and its complications have a negative impact on vulnerable socioeconomic populations who are at risk, and it escalates the healthcare cost related to treating the long-term health effects (Ventres, Dharamsi & Ferrer 2017). Anecdotal evidence, observed by obstetricians in a health district in the Eastern Cape province, South Africa, of an increase in hysterectomies in young women due to misdiagnosis of chorioamnionitis motivated the inquiry into screening for and management of women with chorioamnionitis.

Statistics for chorioamnionitis were not monitored in South Africa via the District Health Information System. Thus, the rates of occurrence of chorioamnionitis were assumed by healthcare professionals through inductive reasoning, based on commonly occurring complications of chorioamnionitis, such as premature birth (for unspecified reasons) and what, anecdotally, appeared to be high rate of post-partum removal of uteri because of complications related to infection after a normal vertex delivery. However, hospital patient records revealed that women who presented with a clinical picture that suggested chorioamnionitis were not referred. The complex nature of diagnosing chorioamnionitis further caused uncertainty amongst midwives over the management of these women.

Anecdotal evidence from healthcare professionals in a health district in the Eastern Cape province, South Africa, as observed by the first author, suggests that screening for risks of chorioamnionitis was lacking during antenatal care. Missing risks for chorioamnionitis would result in misdiagnosis and failure to provide timeous treatment to prevent maternal and neonatal complications (Committee on Obstetric Practice 2017). When searching for best practice guidelines on the screening and management of chorioamnionitis, none were found. This, it was assumed, added to the lack of comprehensiveness of the information on the management of chorioamnionitis in the Guidelines for Maternity Care in South Africa (South Africa National Department of Health 2015), which is the principal guideline used by midwives in primary health care.

The objective of the study was to explore and describe midwives’ knowledge and practices related to screening for and management of women who are at risk of or who are diagnosed with chorioamnionitis.

A qualitative research design was chosen for this study as little was known about midwives’ knowledge and practices relating to the screening and management of women who are at risk of or diagnosed with chorioamnionitis. The study aimed to produce knowledge and understanding of the knowledge and practices of midwives by conducting semi-structured individual interviews with them regarding screening and managing women who are at risk of chorioamnionitis and those who present with signs and symptoms of chorioamnionitis and who were therefore diagnosed with chorioamnionitis. An explorative, descriptive and contextual design was chosen as suitable for this study. The philosophical approach was based on the epistemic view of presumptions, and how it relates to arguments from a position of lack of appropriate knowledge (Bodlović 2019). The view that presumptions are inferred from basic facts – in this case, basic experience in the field of midwifery – provides a template for the belief that midwives would speak honestly and truthfully (sometimes called the ‘presumption of veracity’) (Bodlović 2019:580) about how they screen and manage chorioamnionitis.

The setting, study population and sampling strategy, data collection, data analysis, ethical considerations and steps taken to ensure the quality of research will now be discussed.

The 10 midwives that participated in the study had between 3 and 22 years of experience in the field of midwifery. The midwives had differing levels of experience and qualifications but had experience related to the antenatal, intrapartum and postpartum care of pregnant women. However, the midwives at PHCs had mainly antenatal and postnatal care experience. Four (n = 4) had basic 4-year nursing qualifications and six (n = 6) had postgraduate qualifications in advanced midwifery and neonatology. The demographics of the participants are provided in Table 2.

One main theme with four sub-themes that emerged from the data from the interviews with the midwives is set out in Table 3.

Chorioamnionitis is a complex condition and clinical signs and symptoms are not always accurate enough for diagnosing it. It is apparent that midwives’ insufficient knowledge results in incorrect practices regarding screening for and managing chorioamnionitis. Worldwide it is accepted that professional development bridges the gap between knowledge and evidence-based practice (Greenaway et al. 2019). There is an urgency to make concerted efforts to upscale the in-service training programmes to assist midwives in gaining specific knowledge related to conditions such as chorioamnionitis for better screening and management practices.

Midwives in this study expressed that there is a lack of screening for chorioamnionitis in antenatal clinics in the setting and revealed that there are no screening tools available for chorioamnionitis; screening for UTIs and vaginal infections are not linked to chorioamnionitis and treated inconsistently. For consistent and best practices in the screening and management of chorioamnionitis, it is therefore important to have these screening tools available as well as a linked treatment plan (American College of Obstetricians and Gynecologists 2017).

Because chorioamnionitis is an infection, it shares common clinical signs and symptoms such as an increased pulse rate, increased foetal heart rate, abdominal tenderness with a closed os, leukocytes in the urine and increase maternal temperature (Committee on Obstetric Practice 2017) with other infections, such as pyelonephritis or UTIs. Thus, the diagnosis is often missed for the woman at risk for chorioamnionitis, or signs and symptoms of chorioamnionitis is undiagnosed. This was confirmed by the National Institutes of Health (United States of America) who contributed this to the broad definition of chorioamnionitis, which refers to a heterogeneous group of various conditions including inflammation as well as infections of varying degrees of severity and duration (Higgins et al. 2016).

Participants reported that there is no different management during labour, birth and the postpartum period for women who were exposed to chorioamnionitis. There are no specific guidelines regarding treatment and follow-up of women with chorioamnionitis after birth. After birth, antimicrobials prescribed for women with chorioamnionitis are continued depending on the clinical condition of the woman, especially when there is ongoing fever (Committee on Obstetric Practice 2017).

Furthermore, Chapman et al. (2014) report that some studies supported longer than 6 weeks of postnatal follow-up but that, most importantly, it is necessary to check for additional symptoms of infection or relapse, defined as ‘a cure with subsequent wound infection, abscess or recurrent endometritis’. This further necessitates best practice guidelines for screening and managing chorioamnionitis not only to prevent postnatal maternal complications but also to prevent and detect chorioamnionitis in subsequent pregnancies, which could cause maternal and neonatal complications. However, as this research indicates, midwives do not use the current guidelines available to them. Midwives indicated they were not up-to-date with the guidelines, which could result in midwives neglecting to integrate theory and practice and to use the guidelines to guide their practice, which was indicated elsewhere as one of the common barriers to translate knowledge into practice (Ausmed 2018). Midwives also indicated to be demotivated to use the guidelines because doctors attached little value to the guidelines for chorioamnionitis in the Guidelines for Maternity Care in South Africa (South Africa National Department of Health 2015). This may have led to midwives incorrectly perceiving that the guidelines are not important or applicable or that the guidelines are not effective, because medical practitioners override the guidelines when consulted telephonically.

Guidelines should reflect evidence-based guidance for clinical decision-making and practice. When midwives forsake to pay attention to guidelines or omit to practice according to guidelines, it poses a risk for clinical decision-making errors, which could disadvantage the patient and health outcomes. It is not well understood why clinical practitioners do not follow guidelines. An analyst, Etienne (2010) reckoned that human responses to following rules could be an aspect of automatic behaviour – the product of habits and routines. Rycroft-Malone et al. (2010) assert that, in practice, practitioners are rarely bound to follow guidelines, protocols and standards.

Filipe et al. (2014), however, concluded that continuous educational development was identified as a major factor that influences clinical decision-making practice between nurses and midwives.

At a Maternal Care Quality Standards workshop that was held in Pretoria in April 2016 (Maternal Care Quality Standards in the South African Context 2016), it was said that it is expected that adherence to the guidelines would significantly influence maternal and new-born outcomes. Internationally, there seems to be more evidence-based guidance. For example, the American College of Obstetricians and Gynaecologists developed a guideline on Intrapartum Management of Chorioamnionitis, including intrapartum treatment of chorioamnionitis as well as postpartum and neonatal care (Wisner 2018).

In summary, a combination of factors in practice influences midwives’ lack of knowledge regarding chorioamnionitis, namely attitudes to professional development and in-service training and conflict between the guidelines and instructions from medical practitioners.

The first author’s presence during data gathering, which is unavoidable in qualitative research, could have affected the subjects’ responses in terms of the provided scenario as well as their general perceptions regarding the midwifery practices related to the screening and management of women who are at risk of or diagnosed with chorioamnionitis. The choice of research methodology could have been a possible limitation in so far as the semi-structured interviews might have sacrificed depth, allowing the possibility of superficial discourse. The use of a scenario for a certain group of participants may have unintentionally aided the perception that the research was seeking to apportion blame.

Findings of this research showed that midwives lacked knowledge regarding the screening and management of women with chorioamnionitis resulting in incorrect practices in this regard. Further, midwives in this study neglect to update their professional knowledge on the recommended midwifery practices related to the screening and management of women who are at risk of or diagnosed with chorioamnionitis updating their knowledge is thus a recommendation.

A literature review related to maternal mortality rates showed that training in essential management of obstetric emergencies could be effective, but needs the support of concerted efforts to upscale the in-service training programmes related to midwifery, obstetrics and neonatal care (Moran, Naidoo & Moodley 2015). With the implementation of the requirement for continuous development points for annual re-registration with the South African Nursing Council underway, universities and nursing colleges should focus on short learning programmes that include training on the diagnosis and management of chorioamnionitis. Findings of this study are applicable to midwifery practice, midwifery education and midwifery research.