Title Meeting the Millennium Development Goals 3 and 5: Do our midwives meet competence level?

Solange Mianda, MSc (PMPH), PhD student; School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal %mail& solange'(oe)*+gmail'com ,*-.,*,.-+u/(n'co'(a Phone n*& **,0 01.)*2-.1 Dr 3nna 4oce, senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal' %mail& voceas+u/(n'co'(a 5el& **,0 16,)*---1 7ord count& 6.** 3uthor biographic Solange Mianda is a PhD student at the department of public health medicine at the Universit of !"a#ulu$Natal' Dr 3nna 4oce& is a senior lecturer, School of Nursing and Public health, department of public health medicine, Universit of !"a#ulu$Natal' 8onflict of interest disclosure; and

Abstract S/illed attendance has increased "orld"ide to address the challenge of maternal and perinatal mortalit ' Ho"ever the provision of s/illed attendance onl reflects the presence of the health care "or/er and not their s/ills and /no"ledge' 5o e9plore the issue of s/illed attendance this stud "as designed' 5"ent five mid"ives of five district hospitals in a health district of !"a#ulu$Natal "ere assessed' :bstetric /no"ledge of the mid"ives from both shift (da and night) on the da of data collection "ere evaluated using multiple choice ;uestion on normal labour, cord prolapsed, prolonged labour, postpartum haemorrhage, pregnanc induced h pertension, H<4 and puerperal sepsis' 5he obstetric s/ills of mid"ives "ere assessed through the administration of an :b=ective Structured 8linical %9amination' Mid"ives abilit to& use the partogram as a decision$ma/ing tool in labour, plot information on a partogram and manage post$partum haemorrhage "ere assessed' 7hile the ma=orit of deliveries ma have been attended b a >s/illed health professional? these results are far from sho"ing' 5he presence of s/illed attendant is not necessaril the provision of s/illed care' Ke words: s!illed attendance" midwives" competence level" midwives s!ill an !nowledge

#ntroduction %ver ear "omen and babies die as a result of child bearing, "ith most of these deaths

occurring in sub$Saharan 3frica (@radsha" et al ,*6,)' 5he millennium development goals (MDAs) called for a t"o$third reduction in under$five mortalit and three$;uarter in maternal mortalit b ,*6. "orld"ide; an increased s/illed attendance at birth "as one of the strategies to achieve these goals (N ango et al ,*6*)' S/illed attendance comprises both the s/illed attendant and the environment "ithin "hich the care is provided' 5he health care "or/ers providing care must possess ade;uate s/ills defined as core s/ills to provide effective care during labour' 5he environment of care is defined in terms of re;uired e;uipment and supplies and ;ualit referral (3detoro et al ,*66) Having a s/illed professional attending birth is important in that it helps avoid maternal and perinatal deaths (3dego/e et al ,*66)' 7orld"ide births, attended b s/illed professionals have increased (3dego/e et al ,*66)' <n South 3frica eight four percent of births "ere attended b s/illed attendance as reported b the demographic health surve ; and births are mainl conducted b mid"ives' Despite the increase of s/illed attendance, maternal and perinatal deaths are still high in the countr ' Man of these deaths are associated health care "or/ers (substandard care) (@radsha" et al ,*6,); this sho"s that there is no progress to"ards meeting MDAs re;uirements (@radsha" et al ,*6,)' <n South 3fricaBs effort to"ards meeting this agreement is seen in the implementation of the perinatal problem identification (PP<); the national confidential en;uiries into maternal deaths (N88%MD) and the introduction of saving babies and saving mothers' 5hese reports reflect on the causes of maternal and perinatal deaths and suggest appropriate measures to avoid maternal and perinatal deaths (@radsha" et al ,*6,)' Despite national effort, maternal and perinatal deaths are still high in the countr as a "hole and in !"a#ulu CNatal in particular (@radsha" et al ,*6,; NaPeMM8o ,*66, Moodle D ,*6*)'

5he proportion of deliveries "ith s/illed attendance onl reflects on the presence of a health care provider but do not reflect on their competencies or the environment in "hich the "or/ (3dego/e et al ,*66)' 5his stud "as designed to investigate the provision of s/illed attendance in district hospitals "here the ma=orit of deliveries occur, in one health district of !"a#ulu$Natal; "ith the follo"ing ob=ectives& to assess the obstetric /no"ledge and s/ills of health care "or/ers attending births' 5o achieve the above ob=ectives& health care "or/ers obstetric /no"ledge and s/ills "ere measured' Mid"ives present on both shifts on the da of data collection "ere assessed using M8E ;uestionnaires and :S8% stations' Fesults sho"ed lo" level of mid"ives competence' Methods 5he stud "as conducted in one health district of !"a #ulu$Natal in ,**G' 3ll district hospitals ()) in the health district "ere selected for the stud e9cept for one hospital that did not consent to participate in the stud ' 3n e9plorator observational cross$sectional descriptive stud "as implemented; "hich evaluated the obstetric /no"ledge and s/ills of mid"ives in district hospitals' 5o evaluate obstetric /no"ledge and s/ills of mid"ives, all registered mid"ives present on both shifts (da and night) on the da of data collection "ere assessed' 3 total of ,. mid"ives "ere assessed' 5he obstetric /no"ledge of mid"ives "as assessed using 1* multiple choice ;uestions (M8E) adapted from the perinatal education programme (P%P) covering& normal labour, cord prolapse, prolonged labour, postpartum haemorrhage (PPH), pregnanc induced h pertension (P<H), H<4 and puerperal sepsis' 5he /no"ledge test "as administered in a "ritten form and a score "as allocated for ever correct ans"er and percentages "ere calculated' 5he obstetric s/ills of mid"ives "ere assessed through the administration of an :b=ective Structured 8linical %9amination (:S8%)' 5ools developed b the P%P "ere used to assess mid"ives abilit to& plot information on a partogram, and the use of the partogram as a decision$ma/ing tool in labour and manage post$partum haemorrhage' %ach mid"ife "as

assessed individuall ' 3 score "as allocated for ever correct ans"er and percentages "ere calculated' Median scores (H) "ere calculated for obstetric /no"ledge and s/ills; !rus/al 7allis non$ parametric test "as used to measure significance bet"een variables' 5he P%P manual set G*H as passing mar/' Permissions to underta/e the stud "ere obtained from the Universit of !"a#ulu$Natal biomedical ethic committee, the provincial Department of Health, and hospital managers' 8onsent "as obtained from mid"ives to participate in the obstetric /no"ledge and s/ill assessments' <t "as clearl stated to them that participation "as voluntar and "ithdra"al could happen at an stage of the stud "ithout an negative conse;uences' $esults

70 60 50 40 30 20 10 0 H 1 H 2 H 3 H 4 S kills s cores % H 5

K nowledg es cores %

Figure 1 Knowledge and skills median % scores

3ll hospitals sho"ed the same pattern in terms of obstetric /no"ledge "ith ver poor overall scores and no statistical significance difference bet"een hospitals (P value I*'**0)' 3ll hospitals scored poorl on the /no"ledge of normal labour, prolapsed cord, PPH, P<H and sepsis' 3ll hospitals had better scores on the /no"ledge of prolonged labour and H<4' 3ll hospitals performed poorl on the overall s/ills score, there "as ho"ever a statistical significant difference bet"een hospitals (P value I *'**,*' 5"o hospitals performed poorl on all s/ill subset'

80 70 60 50 40 30 20 10 0 H 1 H 2 H 3 Pa r og ra m! % H 4 Pa r og ra m !! % H 5

Figure 2 Par ogram e"ercises ! and !!

Jigure , sho"s all hospitals "ith high scores on partogram e9ercise <, compared to the standard set b the P%P manual, no hospital met the set standard' 3ll hospital performed similarl poorl on the partogram e9ercise <<'

80 70 60 50 40 30 20 10 0 H1 H2 H3 H4 H5

P P H kn nowled g e% P P H skills %

Figure 3 PPH Knowledge and skill median % score

Jigure 1 sho"s the PPH /no"ledge and s/ill median H scores "ith interesting information on the competence of mid"ives in these five district hospitals' Discussion 3n evaluation of the P%P programme in South 3frica sho"ed an increase in the /no"ledge and s/ills of mid"ives (Fundare, 3 and Aoodman S ,*6,)'5he P%P has set a standard of G*H as pass mar/ to the /no"ledge test'

Jrom the measure of s/illed attendance through the assessment of obstetric /no"ledge and s/ills of mid"ives all hospitals sho"ed poor scores on the /no"ledge and s/ills test and no mid"ife in the stud hospitals met P%P standard' Some studies identified in the literature measuring mid"ives competence sho"s differences in level of mid"ives /no"ledge and s/ills& 3 stud conducted in Ahana assessing the e9tent of s/illed attendance at birth using records /ept sho"ed onl ,)H of records in the stud meeting three$;uarter of the criteria for s/illed attendance (3hlu"alia et al ,**1)' 3 stud measuring mid"ivesB competence against 7H: guidelines sho"s onl ..'GH of the providers able to ans"er correctl the /no"ledge ;uestions and -GH performing the s/ills steps correctl (Harve et al ,**-)' Abangade et al (,**1); Mc8a"$@inns et al (,**-) and Harve et al (,**0) reported inade;uate mid"ives obstetric /no"ledge in Damaica, F"anda, %cuador and @enin supporting these findings' 5o get a better understanding of the situation a further loo/ at different subsets, the findings sho"ed better mar/s scored onl on items that tested /no"ledge of prolonged labour and H<4; the rest of subset (normal labour, Pepsis, PPH, P<H and cord prolaspe) "ere scored poorl ' 3ll hospitals sho"ed a similar level of poor performance on obstetric /no"ledge; this suggest that mid"ives in this health district do not have the minimum /no"ledge re;uired of mid"ives in identif ing and managing obstetric complications' Poor /no"ledge scores indicate inade;uate /no"ledge in mid"ives to monitor, manage and supervise labour, calling for in$service training and supervision initiatives for mid"ives in the management of labour' 7hile loo/ing at the s/ills test, all hospital scored poorl overall; and the stud b Harve et al (,**-) reported similar results' :nl three of the five hospitals reported high scores for the plotting of information on the partogram, ho"ever all hospitals had poor scores in interpreting information on a partogram and all hospitals performed at a similar level' :nl the s/ill test on the management of PPH sho"ed interesting data, as all hospitals performed poorl in the /no"ledge test so did the perform poorl on the s/ill test' :ne hospital "ith the lo"est median /no"ledge score, had the highest s/ill median score' Poor scores on plotting and interpreting information on a partograph in these hospitals indicate that there ma be other factors intervening but not e9plored in the stud as sho"n in figure 1 for H.' 5his suggests a need for further studies to e9plore the reason for the discrepancies bet"een plotting of information on a partograph and interpretation of information on a partograph' 5here is also a need for training and supervision interventions to

improve the capacit of mid"ives to interpret findings and ma/e management decisions' %ssential steps in managing obstetric emergencies (%SM:%) is currentl suggested and applied in the countr to improve health care professionals (Pattinson ,*6*)' %onclusion 5here are a number of interventions that can be performed b mid"ives to decrease maternal and perinatal deaths; and s/illed attendance is a /e strateg to achieve these goals' 5he above findings reveal ver lo" level of competence in mid"ives attending birth in this health district' 7hile the ma=orit of deliveries ma have been attended b a >s/illed health professional? these results are far from sho"ing that' 5he presence of s/illed attendant is not necessaril the provision of s/illed care'

$e&erence @radsha" D, 8hopra M, !erber !, Ka"n D, Moodle D, Pattinson Fet al' %ver death counts saving the lives of mothers, babies and children in South 3frica (,*6,)' 8ape 5o"n& MF8' N ango DD, Mutihir D5, Kaabes %P, !igbu DH, @uba M'S/illed attendance& the /e challenges to progress in achieving MDA$. in north central Nigeria' 3fr D Feprod Health' (,*6*); 6-(,)&6,2$1G' 3dego/e 33 et al, Hofman FN, !ongn u %D' Monitoring and evaluation of s/illed birth attendance& 3 proposed ne" frame"or/' Mid"ifer (,*66) (,0) 1.*C1.2 National Perinatal Morbidit and Mortalit 8ommittee (NaPeMM8o)' National perinatal mortalit and morbidit committee triennial report (,**G$,*6*)' ,*66' Moodle D' Status of Maternal and 8hild Health in !#N' ,*6*

Fundare, 3 L Aoodman S' 3n outcome evaluation of a perinatal education programme' S3 Dournal of Human Fesource Management (,*6,) 6*(1), -,-, G' Abangbade S, Harve S3, %dson 7N, @ur/halter @, 3ntona/os 8' Safe mother "ood studies results from @enin' 8ompetenc of s/illed attendants, the enabling environment for s/illed attendance at deliver , in hospital dela s in obstetric care (documenting the 1rd dela ) ;ualit assurance' Harve S3, 7ong @, Mc8a"$@inns 3, Snadino <, Urbina K, Fodrige( 8 et al L the Nicaraguan Maternal and Neonatal health ;ualit improvement group' 3re s/illed attendants reall s/illedM 3 measurement method, some disturbing results and a potential "a fo"rd' B7orld :rganisation @ulletin, (,**0) G. (6*)&01G$02*' MacDonagh S' 3chieving s/illed attendance for all, a s nthesis of current /no"ledge and recommended actions for scalling upB DJ<D health resources centre ,**.' 6$10 Mc8a"$@inns 3, @ar/hatler @, %dson 7, Harve S, 3ntona/os et 8' :peration research results' Safe mother"ood result from Damaica' 8ompetence of s/illed attendants, the enabling environment for s/illed attendance at deliver , in$ hospital dela s in obstetric care (documenting the 1rd dela ) (,**-)' Eualit 3ssurance pro=ect Hussein D, @ell D, Na((ar 3, 3bbe M, 3d=ei S, Araham 7 on behalf of the S3J% stud sub$ group' 5he s/illed birth attendance inde9& proposal for a ne" measure of s/illed birth attendance at deliver ' Feproductive health Matters, (,**-) 6, (6,)& 6)*$60* 3hlu"alia @, Schmid 5, !ouletio M, !anenda :''3n evaluation of a communit $based approach to safe motherhood in north "estern 5an(ania' <nternational Dournal of A naecolog and :bstetrics (,**1) G,, ,16C,-*' Harve S3, 3 abaca P, @ucagu M et al' S/illed birth attendant competence& an initial assessment in four countries, and implications for the safe motherhood movement' <nternational Dournal of A naecolog and :bstetrics (,**-) G0, ,*1C,6*' Aunathunga 7', Jernando DN' 3ssessment of communit maternal care performance of public health mid"ives of a province in Sri Kan/a& a multi$method approach' South %ast 3sian Dournal of 5ropical Medicine and Public Health (,***) 16,16*C16G'

Pattinson F8 @e Prepared& 5raining and on$going %ducational <nitiatives' <n 3 Monograph of the Management of Postpartum Haemorrhage' ,*6*