Improving MNH Nursing Care through Competency-Based Basic Emergency Obstetric and Newborn Care (BEmONC) Training in Ethiopia

Alemnesh Tekleberhan , Nega Tesfaw Wassie, Hannah Gibson, Hone Belete Fenta, Mintwab Gelagay

Presentation Outline
Background Project Description Results Challenges and Lessons Learned Conclusions Acknowledgment
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I. Country Background
Located in the horn of Africa Population: 87 million (PRB, 2012) 84% live in rural areas; agriculture accounts for 54% of GDP

Country Background
MNH status: MMR: 676/100,000 live births (CSA, 2011) NMR: 37/1,000 LB (CSA,2011) Skilled birth attendance: 10% (CSA, 2011) 0.05 midwife for every 100 expected deliveries
MMR per 100, 000 Live Births (Actual and Desired Trends for 19902015) (Source: MOFED, 2010) 4

National EMoNC Assessment (2008)

National EmONC assessment in 2008 revealed: Of the total 797 facilities, the greater majority were not fully functioning for EmONC (only 10% meet the criteria as per the signal functions). 51% of hospitals (vs. planned 87) provide full CEmONC services. Only 1% of health centers (vs. planned 100%) provide full BEmONC services. Scarcity of skilled health care providers and lack of equipment were critical.

EMoNC Assessment cont..

Only 17% of HCs meet the standard for staffing (2 midwives/HC). As a result, in most facilities, nurses are the primary MNH care providers. Assessment of providers knowledge and skill in MNH was generally low for all cadres; however, nurses had a relatively lower score compared to midwives and health officers.
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II. Project Description

In response to the knowledge and skill gaps identified, Jhpiego in collaboration with FMOH and other partners designed a competency-based BEmONC training to equip nurses and midwives with the necessary knowledge and skill to provide quality MNH care. Global evidences showed with greater task shifting effort undergoing it is possible to improve access to BEmONC services by training of midwives and nurses.
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Project Objectives
Establish standardized BEmONC training sites in 8 out of 11 regions Adapt a competency-based learning resource package Develop a pool of competent trainers Train skilled providers who will be competent in providing BEmONC Conduct post-training follow-up to strengthen the provision of BEmONC in hospitals and health centers
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Project Implementation Regions

Approach to Competency-Based Training

Learning by doing Has scientific basis Focus on the specific knowledge, skills and attitudes Competency is assessed objectively The role of the trainer is facilitating and encouraging learning Coaching is an essential component Integrated with adult learning, behavior modeling and humanistic teaching techniques
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Approach to Competency-Based Training

Planning a training
Do training needs assessment; identify performance gaps Prepare trainer, participant and reference books, anatomic models and skill lab materials

Site preparation

Site selection, standardization, staff training Trainer preparation ( KUSS, ETS, CTS)

Training

Use of adult learning, behavior modeling and humanistic techniques Post-training follow-up
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Skill Demonstration Session Using Anatomic Models

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III. Results
15 training sites established 88 qualified trainers developed To date, a total of 1,736 health care providers have been trained in BEmONC: 441 Nurses 1,108 Midwives 20 General practitioners 6 Health officers Post-training follow-up showed that: Most of them 194 (83.4%) were selected from health centers, followed by hospitals 34 (14.8%) how do these numbers (total of 228) relate to nos. in above bullet? Who is them?

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Results
Post training follow up showed BEmONC training brought a great change in confidence and quality of service provision as described by the health care providers. 80.7% of the providers remained in the facility where they were selected. They developed new skills (competencies) in providing MNH care:

Management of normal pregnancy and childbirth Use of the partograph Active management of third stage of labor (AMTSL) Newborn resuscitation Prevention and management of postpartum hemorrhage

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# of Cases Managed by Health Care Providers within 3 Month after Training Services Provided by Trained Health Workers, n=230 Cases Frequency % ANC 1100 >100 No case 120 >20 Not used 120 >20 No case 129 88 13 135 45 50 136 92 2 56.0 38.3 5.7 58.7 19.6 21.7 59.1 11.7 0.9

Use of partograph

Assist normal birth, including AMTSL and ENC

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# of Cases Managed by Health Care Providers within 3 Month after Training Services Provided by Trained Health Workers, n=230 Cases Frequency % Parenteral uterotonics 120 >20 No case 110 >10 No cases 110 >10 cases No cases 16 > 6 cases No cases 119 105 6 65 12 153 67 20 143 92 6 132 51.7 45.7 2.6 28.2 5.2 66.6 29.1 8.7 62.2 40.0 2.6 57.4
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Management of severe pre-eclampsia/eclampsia Manual vacuum aspiration

Breech delivery

# of Cases Managed by Health Care Providers within 3 Month after Training Services Provided by Trained Health Workers, n=230 Cases Frequency % Vacuum extraction 110 >10 No cases 16 >6 No cases 16 >6 No cases 130 > 30 No cases 70 14 146 126 17 87 112 28 81 149 59 22 30.5 6.1 63.4 54.8 7.4 37.8 52.6 12.2 35.2 64.8 25.7 9.6
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Manual removal of placenta

Newborn resuscitation

Postpartum care

Results
Increased MNH service provision Providers have given a wide range of BEmONC services in the last three months, the most frequent services provided being:
Focused antenatal care increased Assisting normal birth Use of the partograph AMTSL and immediate newborn care

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Table 1. Provision of MNH Service by Health Workers before and after BEmONC Training
Type of Services Provided Before Training (%) 77.4 33.5 54.8 63.9 27.8 64.8 13.9 55.7 29.6 22.1 31.3 32.2 53.5 After Training (%) 82.6 85.2 93.9 91.7 55.7 93.0 35.7 77.0 45.2 40.0 67.4 68.7 90.4 ANC Use of partograph Assessment of woman in labor Assist normal birth, including AMTSL and immediate newborn care Parenteral antibiotics Parenteral uterotonics Mgmt. of severe pre-eclampsia/eclampsia Perineal/Episiotomy repair Breech delivery Vacuum extraction Manual removal of placenta Newborn resuscitation Postpartum care

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Challenges and How They Were Overcome

Lack of equipment and materials in the facilities:
Introduction of performance quality improvement (PQI)approach

and resource mobilization activities

Lack/shortage of essential drugs at facilities, e.g., parenteral anticonvulsants and antibiotics:

Frequent discussions with Ministry of Health and Pharmaceutical

Fund and Supply Agency (PFSA) Revision of the Essential Drugs List for Health Centers helped to identify and resolve implementation challenges promptly
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Challenges and How They Were Overcome

Selection of inappropriate health care providers for training:
Use of criteria and consultation with RHBs helped to

select appropriate training sites

Low client flow in training facilities:

Demand generation activities community awareness,

pregnant women forums Partner and community leaders involvement use of Health Development Army (HDA) woman-friendly care

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Conclusion / The Way Forward

Ethiopia needs skilled providers to ensure quality care of women and infants during pregnancy and birth working toward Millennium Development Goals 4 and 5. Competency-based training is a key to ensure that trainees acquire the required knowledge and skills. Nurses can provide quality MNH care if they receive appropriate training and coaching and bridge the huge shortage of midwives that Ethiopia currently faces.
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Conclusion / The Way Forward

An adequate supply of drugs and equipment is mandatory to strengthen maternal and child health services. There should be an ongoing supportive supervision and support. There should be more staff deployed in MNH areas who are competent in BEmNOC to provide service 24 hours per day and seven days per week
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Thank You

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