Continuing Professional Development on Emergency Obstetrics and Newborn Care (Emonc): Assessment,training Intervention and Its Outcome in Embu and Merulevel 5 Hospitals, Kenya
Abstract
Introduction and Background
Each year, more than 536,000 women worldwide die from complications of
pregnancy and childbirth – that is one woman die every minute (Mirkuzie et al 2014).
The complications include Antepartum haemorrhage, postpartum haemorrhage,
obstructed labour as well as sepsis (WHO 2010) and many more survive but will
suffer ill health and disability as a result of these complications (Moxon et al 2015
2015). In addition, an estimated 4 million neonatal deaths occur each year accounting
for almost 40% of all under 5 deaths (WHO 2010). Moreover, more than ¾ of all
these deaths occur in Asia and sub-Saharan Africa (Fotso and Fogarty 2015).
Additionally, the health of the neonate is closely related to that of the mother and
majority of deaths in the first month of life could also be prevented if interventions
were in place to ensure good maternal health (Bluestone et al 2013). Over 80% of all
maternal deaths result from five well understood and readily treatable complications:
(1) haemorrhage, (2) sepsis, (3) eclampsia, (4) complications of abortion and (5)
obstructed labour. It is well known how to prevent these deaths – there are existing
effective medical and surgical interventions that are relatively inexpensive (Murphy et
al 2014). To reduce maternal mortality it is important that all women have access to
maternal health care services, particularly skilled attendance at birth and timely access
to Essential (or Emergency) Obstetric Care (EOC) when an obstetric complication
occurs (WHO 2010). Two levels of EOC can be distinguished, that is Basic Essential
Obstetric Care (BEOC) and Comprehensive Essential Obstetric Care (CEOC) (Ouma
et al 2010). BEOC has 7 signal functions: Parenteral Antibiotics, Parenteral oxytocics,
parenteral anti-convulsants, Manual removal of a retained placenta, Removal of
retained products of conception by Manual Vacuum Aspiration, Assisted vaginal
delivery (vacuum extraction) and Resuscitation of the newborn (using bag and
mask)(WHO 2010, Fotso and Fogarty 2015) CEOC– 9 signal functions: All 7 BEOC
functions (above), Caesarean Section and Blood Transfusion)(WHO 2010, Fotso and
Fogarty 2015).
Approximately 15% of expected births worldwide will result in life-threatening
complications during pregnancy, delivery, or the postpartum period (Mumtaz et al
2014). Providers skilled in Emergency Obstetric and Newborn Care (EmONC)
services are essential, particularly in countries with a high burden of maternal and
newborn mortality (Sipsma et al (2012). WHO (2015) has implemented three global
programs to enhance provider capacity to provide comprehensive EmONC services to
women and newborns in resource-poor settings. Providers have been educated to
deliver high-impact maternal and newborn health interventions, such as prevention
and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and
management of birth asphyxia, within the broader context of quality health services
(Lassi et al 2014)and this has been seen to reduce maternal and neonatal mortality.
Literature identifies gaps in knowledge and practice of EmONC skills to improve
maternal and neonatal care (Mwaniki et al 2014, Charsbin statistics Collector Team
2010). The status in Kenya has not been established. Lonkhuijzen et al (2010)
examined various articles in order to assess the effectiveness of training programs
aimed at improving emergency obstetric care in low resource environments and the
review revealed limitations which hamper their usefulness in evaluating the effects of
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postgraduate educational interventions to improve obstetric care in low resource
environments. Das et al (2014) stated that failure of most studies to underpin the
results with adequate evidence precludes valid pronouncements on the effectiveness
of the courses described. Furthermore, although the introduction of the Reproductive
Health Library and the Perinatal Education Program led to an improvement in
knowledge and skills, no positive effects on behaviour were reported and patient
outcomes were not evaluated (Das et al 2014). It is the responsibility of organizations
that initiate and fund training programs to make evaluation an integral part of
programs and ensure that the results, assessed by a proper peer-reviewed process, are
made available to those who stand to benefit the most from a successful program (Das
et al 2014). Large parts of the world are behind schedule in reaching the fourth and
fifth Millennium Development Goals (addressed in sustainable Development Goal 3).
Improving knowledge and skills through training can contribute to the attainment of
these Goals. In order to do so successfully, sound research is needed to provide
reliable evidence to support the implementation of effective training programs.
Otolorin (2015) stated that while remarkable progress has been made toward the
reduction of maternal and child mortality in many low-resource countries, critical
challenges remain in provision of high-quality EmONC services, particularly in Sub-
Saharan Africa and Southeast Asia (legale et al 2011). The global community must
focus on reaching the poorest and most vulnerable populations to address persistent
inequities. These inequities include, among other things, a shortage of skilled birth
attendants (SBAs) in the most vulnerable communities that is driven by lack of
targeted workforce planning strategies, for example matching deployment with the
competencies of providers and addressing well-known factors that discourage
workforce retention (Lassi et al 2014).
Objective
To assess, train and evaluate Continuing professional development training in
“Emergency Obstetric and Newborn Care” for midwives in order to improve the
availability of emergency obstetric and Newborn care (EmONC) in Embu and Meru
hospitals, Kenya.
Methods
Study design
The study adopted assessment (phase one), intervention (phase two) and evaluation
(phase three) exploratory design. The study participants were midwives from the
maternity units of Embu and Meru level five hospitals in Meru and Embu counties
respectively. The study was three phased. Phase one (June to November 2013)
involved a needs assessment survey of the perspectives of CPD among midwives
working in the above mentioned hospitals. A total of 113 midwives were involved in
the study (54 from embu hospital and 59 from Meru). During this phase, data was
collected using a questionnaire (knowledge, confidence and experience
questionnaire), interview checklist and case studies. The main objective of this phase
was to identify skills and knowledge gap in the area of maternal and neonatal health
among midwives in Meru and Embu hospitals respectively. Method triangulation
helped in yielding more valid data than if a single method was used. Quantitative data
was analyzed using SPSS version 20.0 and qualitative data was analyzed using the
themes that emerged. Pearson’s chi square was used to describe the associations
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between participant’s demographic characteristics and participation in CPD activities.
The findings of phase one formed the basis for phase two.
Phase two (December2013- September 2014) involved training of all the midwives in
Phase one based on the results of the analysis of the data obtained in phase one. The
training programme followed a modular format and competency-based approach. The
training content was prepared based on the findings of phase one in reference to the
WHO materials in the Integrated Management of Pregnancy and Childbirth
(IMPAC) series. In addition, it used relevant local guidelines and protocols developed
by the Division of Reproductive Health, Kenya and ministry of health, Kenya. There
were five modules in the package and each module described the learning objectives,
learning outcomes, course content, teaching methods, and evaluation methods. The
evaluation guidelines contained the data collection tools, data analysis templates and
guidelines on how to use each tool. Module one was introduction to maternal and
newborn health, module two on rapid initial assessment and emergency management;
module three on care during pregnancy; module four on care during labor and child
birth and module five on post partum maternal and newborn care.
This training was completed over three weeks period with 8 days classroom
theoretical sessions & practice on anatomical model and 10 days of clinical practice in
the two health facilities. The trained midwives were followed and monitored in the
study areas for three months as they cared for mothers and neonates.
Phase three (November 2014- December 2014) data collection from the trained
midwives’ evaluation of the impact of the knowledge and skills acquired during the
training using the model developed in phase one. Data was analyzed and results
compared with those obtained in phase one. Paired t-tests of mean differences
between participant’s scores and performance of CPD activities before and after
intervention were computed. Mean differences in performance of CPD activities
between the two hospitals and the nursing qualifications were analyzed using
ANOVA.
Results
Overall results showed marked improvements in midwives’ knowledge/skills in all
areas of antenatal care, normal labor, childbirth, immediate newborn care skills,
postpartum care and management of complications. Generally their skills in maternal
and newborn care skills improved after training. The results showed that knowledge
improved after the training from a pretest mean of 55.92 to a posttest mean of
86.003.This indicates 30% after training improvement. The results were further
subjected to paired samples test. The improvement in knowledge was statistically
significant with a T= 15.684 (P=0.001) .Therefore, the hypothesis that,’ there is no
relationship between an educational intervention on nursing essential maternal and
neonatal skills and knowledge in these skills was rejected.
Conclusion: The results in phase one identified gaps in knowledge/ skills, experience
and practice of EmONC in improving maternal and neonatal health in Kenya. The
training in phase two which was a CPD activity was associated with increased level of
practice of EmONC skills. The results indicated that respondents on assessment of
antenatal skills scored an average of 95.2% while on normal labor, childbirth and
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immediate newborn care skills they scored an average of 89.63% on postpartum care
(mother and baby) an average of 87.92%, on management of complications they
scored a mean of 88.22%.This indicated that midwives showed an improvement after
training and this implied that they were well prepared to solve various midwifery
related conditions and complications.
It is therefore confirmed that CPD activities are essential in engaging midwives in
practising EmONC skills according to laid down guidelines with the aim of reducing
maternal and neonatal mortalities in the country.
Recommendations: Based on the findings, CPD in EmONC should be provided to all
midwives at all levels of health care delivery in the country including incorporating
such activities in the induction programmes for midwives. There is need to review the
nursing curricula to be more focused on skills development and retention in the area
of EmONC. The findings lead to development of a framework to enhance provision of
CPD and also development of evaluation guidelines for assessing development of
competences in EmONC (see appendix 4 and 9). These guidelines should be used in
the country with the aim of improving maternal and newborn health.
Publisher
University of Nairobi